We are experiencing a unique period as a nation – where a number of historic events are unfolding contiguously. Just a few months ago, our lives were upended by a pandemic unprecedented in our lifetimes. As a result of COVID-19, the country is grappling with severe economic fallout. Then last month, the killing of George Floyd in Minneapolis underscored the continued need for discussion about systemic racial and ethnic inequities that persist in our society.

Like other health care providers across the nation, St. John’s Well Child & Family Center was blindsided by the COVID-19 pandemic when it first hit.

“We were responding, literally, minute by minute to something none of us had ever experienced before,” said Jim Mangia, CEO of St. John’s, which operates health clinics and community health centers that provide care for patients at 18 locations in South Los Angeles, Compton and Lynwood. “It was a horrendous situation. Everyone was out there fighting for themselves, without any support from the federal government. It was like having to build an airplane while you’re in flight.”

After the initial period of confusion and uncertainty, St. John’s mobilized quickly. In early March, St. John’s began erecting isolation tents at its health centers and implementing coronavirus screening and triage procedures. Administrators scrambled to procure personal protective equipment (PPE) and test kits as the number of patients seeking care began to climb. Rather than furloughing employees in service areas that were shut down due to the pandemic, St. John’s trained and redeployed them to support new telehealth services and perform screening for COVID-19 out in the community, including in homeless encampments. “We had to reorganize and retool our whole practice,” Mangia added. “It was a major undertaking.”

Fast Facts (Los Angeles Community Clinics
• 65+ clinics
• 350+ full-time sites
• 1.7 million patients served annually
• 50% of patients are below the poverty level and either on Medi-Cal or uninsured

Now, Los Angeles County health officials, hospitals and community health centers are coming together to discuss lessons learned and share
best practices from the opening phase of the pandemic. The goal is to better coordinate and improve their response for possible additional
waves – as well as to prepare for any potential future pandemics.

“We, in partnership with the community health centers, are a safety net system serving the most vulnerable populations in Los Angeles County,” said Anna Gorman, Director of Community Partnerships and Programs with the LA County Department of Health Services (DHS). Gorman oversees the county’s My Health LA program, which contracts with the community health centers to provide no-cost care for low-income patients who do not quality for public insurance. “We’ve always worked well together, but I think we’ve come together even more closely to respond to this crisis,” she added.

“Our 25-plus-year partnership with LA County has continued to grow, especially now,” said Louise McCarthy, MPP, President and CEO of
the Community Clinic Association of Los Angeles County and Chair of the California Primary Care Association. “We share common missions and patient populations. We’re a common network of care for the uninsured and underinsured.”

As part of this long-established relationship, the county contracts with the Community Clinic Association to provide a portion of the PPE it receives through the federal Hospital Preparedness Program to the community clinics. “Thanks to that partnership, our clinics are much better off than clinics in other counties around the state,” McCarthy said. “While we’ve had to get additional supplies from outside the county stockpile, the PPE we’ve gotten from the county has helped some of our clinics stay open.”

During the pandemic, the county is providing logistical support for COVID-19 testing, including vetting of commercial laboratories, and distributing communication materials to raise awareness of the coronavirus among disadvantaged populations, according to Clemens Hong, MD, MPH, MPH, Director of Whole Person Care at LA County DHS.

“The county has done a lot of work to ensure the testing quality is high,” Dr. Hong said. “As we move to a more mature stage of the pandemic, the county is working to move testing into clinical care, including building community test sites in community health centers. During the initial stage, we started testing sites where we could, including in malls, parking lots and fairgrounds. We’re trying to move testing to where patients go for care – to the clinic or hospital they trust.”

Community health centers, like St. John’s, have helped the county test some of the most difficult-to-reach populations during the pandemic.

“They’ve committed their staff to walk homeless encampments and conduct testing through mobile units,” Dr. Hong said. “Staff at other clinics also have done swabbing in people’s homes, rather than having them come to the drive-in sites. These are solutions to meet the need that is out there.”

Providing education and public messaging about COVID-19 also is a key role the county has played during the pandemic. “We’ve partnered with the clinics, different community organizations and other county agencies to get the word out to populations that are disproportionately affected,” said Gorman. For example, the county’s Office of Immigrant Affairs has developed and distributed materials such as flyers and posters in several different languages, including Spanish, Chinese, Korean and Khmer.

The materials give basic information about the coronavirus and stress the importance of sheltering in place, washing hands, wearing masks, and physical distancing. “It’s not just about doing testing,” said Dr. Hong. “Without wrapping education and counseling around it, a test is just a test.” As they plan for additional surges and the upcoming flu season, a closer collaboration among the county, community health centers and hospitals will be essential.

“Los Angeles County can serve as a model for other counties, big and small, that are trying to figure out how to work together to respond during this crisis, not just now, but as we move into new phases of the pandemic,” said Gorman.

For additional information about Communities Lifting Communities, contact Karen Ochoa, CLC Project Manager, at (213) 538-0765 or kochoa@hasc.org

COVID-19 has brought unprecedented changes and challenges to the health care workforce. Prior to the pandemic, physicians, nurses and other caregivers were already experiencing record rates of work related burnout or depression. Research on health care workers caring for COVID-19 patients during the pandemic shows an alarming increase in rates of anxiety, depression, insomnia and burnout.

“We’re living in a different world right now – everyone’s wearing masks, we can’t hug each other, everyone is guarded,” said Jeannine Loucks, MSN, RN-BC PMH, manager of the emergency clinical decision unit of the emergency care center at St. Joseph Hospital Orange. “We’re doing whatever it takes to get the job done for maintaining the safety of our patients but it’s the uncertainty, the fear of the unknown, that’s difficult. Staff are asking themselves, ‘Am I going to bring the coronavirus home to my family? How do I manage my own fears?’”

The Hospital Association of Southern California (HASC) and Communities Lifting Communities (CLC) invited three hospitals – St. Joseph Hospital Orange, MemorialCare Orange Coast Medical Center and Dignity Health California Hospital Medical Center – to share their efforts to address workforce burnout via a Nov. 9 webinar titled, A Workforce Burnout Crisis: Exploring Signs & Solutions.

ST. JOSEPH HOSPITAL ORANGE

When COVID-19 first hit California in March, St. Joseph Hospital Orange moved quickly to ensure the safety of patients and staff. “We started holding drills. We looked for best practices or developed our own best practices and were proactive in getting the most recent evidence-based information out to our staff on a daily basis,” Loucks said. “We obtained extra PPE and made sure our employees knew how to don and doff it correctly, through repeated drills.”

One way the hospital supports employees experiencing pandemic-related stress is through its Code Compassion team. “If someone’s having a bad day, a team of folks from the hospital goes and sits with them, debriefs and coaches them, and provides support,” Loucks explained. The team includes a member of senior leadership, an employee assistance program (EAP) representative, as well as members of the human resources, security and employee health teams.

Unlike many hospitals, St. Joseph has its own on-site EAP representative – who is a licensed marriage and family therapist. “She is available to our staff and their immediate families if they need counseling,” Loucks said. The hospital pays for up to five counseling sessions for each staff member.

To help alleviate staff concerns about getting infected, the hospital also provides COVID-19 tests on request. More than 300 employees have been tested over the last six months. “We will swab any employee who feels they are either symptomatic or have been exposed to COVID-19, because we know they’re fearful of contracting the coronavirus and giving it to their families,” Loucks said. “We can get them the test results within one hour and help them isolate, if needed.”

To further reduce employee burnout, St. Joseph allows staff seeking more hours to work extra six-hour – rather than standard 12-hour – shifts. “A lot of our staff are working extra hours,” Loucks explained. “We offer partial shifts because we don’t want them to burn themselves out.”

MEMORIAL CARE ORANGE COAST MEDICAL CENTER

“One of our biggest commitments to our staff is communication, communication, communication,” said Shela Kaneshiro, MBA, RN, BSN, NEABC, CPHQ, vice president of patient care services and CNO at MemorialCare Orange Coast Medical Center in Fountain Valley.

Kaneshiro and the hospital’s chief operating officer both round constantly. Employees receive regular email messages from senior management. MemorialCare’s chief medical officer provides regular clinical updates. “Communication has been crucial, particularly early in the pandemic when everyone was quite scared and still learning about COVID-19,” Kaneshiro said.

To address staff and physician burnout, Orange Coast offers a wide range of support services and programs. Most were already in place prior to the pandemic. Some had to be adjusted due to the new COVID-19 restrictions. Others were specifically designed with pandemic stress in mind.

Together, they provide a wealth of resources to promote mental and physical wellness and to boost morale through positive affirmation and staff recognition.

One program is called RISE (Resilience in Stressful Events) that provides confidential peer-to-peer counseling for staff and
physicians during the workday. Staff can also access via their computer or phone The Good Life wellness program, which, in addition to offering services to enhance their physical well-being, provides social and community support, and a host of free online classes, including assistance with managing personal finances. The hospital also set up a SELF (Sleep, Exercise, Love and Food) Care room where employees could take time away from the pressure of work, when needed.

Prior to the pandemic, the hospital’s popular Tea for the Soul program allowed day- and night-shift staff once a month to get away from their unit and be served tea in a quiet environment, with chocolate, hand massages and aromatherapy included. “We didn’t want to stop it altogether but, due to COVID, we couldn’t have people congregating so we took a cart to our staff and had our leaders serve them tea,” Kaneshiro said. “Our staff mean everything to us. We can’t take care of our patients if we don’t have staff here who are thriving and healthy and want to come to work.”

DIGNITY HEALTH CALIFORNIA HOSPITAL MEDICAL CENTER

Located in downtown Los Angeles, Dignity Health California Hospital Medical Center has cared for a disproportionate share of COVID-19 patients.

“At first, our staff had to deal with two kinds of stress – one due to their own anxiety about this unknown viral syndrome that so many people were dying from, and the other due to the heavy workload because we were so incredibly busy,” said Trudy Johnson, MA, RN, NEA-BC, FNAP, the hospital’s chief nursing executive officer.

The hospital emphasized increased leadership communication with staff, especially face-to-face communication. “During the peak of the pandemic, we had a frontline clinical director present 24/7,” Johnson explained. “They were out there talking to staff and solving problems in real time, not just sitting in a command center.”

The hospital’s president sent out regular email messages, first daily then weekly. Rounding by the leadership team throughout the entire hospital was also increased. “Staff really appreciated seeing our non- clinical executives showing their support,” Johnson said.

To address workplace stress, the hospital offered employees mental health counseling and helped arrange same-day appointments, if needed. In addition, the hospital distributed information from its EAP provider designed to help staff deal with stress and offered a webinar on resiliency and coping with uncertainty.

Because many employees were working overtime during the pandemic peak, the hospital was able to secure hotel rooms donated by the business community for employees concerned about bringing the virus home to their families – or if they just needed some time to recharge. “The risk for burnout can start with physical fatigue, which then leads to emotional fatigue,” Johnson said. “Sometimes, it’s nice to just get a little break.”

And when elective procedures were halted, the hospital allowed staff from those areas to voluntarily assist in COVID-19-impacted units such as the ICU. “We were creative in our use of staff who had the right skills and were willing to participate,” she said. “Our ICU staff felt a sense of teamwork and support, which also helps avoid burnout.”

For additional information about Communities Lifting Communities, contact Karen Ochoa, CLC Project Manager, at (213) 538-0765 or kochoa@hasc.org.

A heightened sense of urgency influenced flu season planning for 2020-21 across California. This was certainly the case in Los Angeles County – center of the state’s coronavirus surges since spring 2020. The specter of an influenza epidemic appearing on top of a COVID-19 pandemic meant that failure to plan was not an option. Over a span of months, existing connections between Los Angeles area hospital managers and County public health personnel matured into a coordinated approach.

Participants in the L.A. Hospitals Coordinated Flu Effort are unanimous that a bigger accomplishment should be recognized. The coordinated flu effort is a model not only for future flu season responses in L.A. County – but for hospital-public agency collaboration in a range of areas. These include future influenza response campaigns in L.A. County and neighboring counties, the critical COVID-19 immunization campaign now unfolding and many more public health campaigns and population health strategies.

The California Hospital Association (CHA), the Hospital Association of Southern California (HASC) and Communities Lifting Communities (CLC)  have also played important roles in developing communication tools as well as the statewide, “FightFluTogether” public awareness campaign and supporting communications to ensure consistent messaging across participating organizations.

Components of the Collaborative

Several elements came together in the first part of 2020 to make the Los Angeles-area flu immunization campaign a true collaborative effort. These included the following.

• Los Angeles Department of Public Health received one-time funding for developing communications tools that can be used this year and beyond.
• HASC brought the statewide FightFluTogether.org campaign to
  the collaborative, joined regular teleconferences, made key connections and involved its strategic communications team and CLC community health initiative with the effort.
• Sharing lessons learned and strategies proven to boost participation by groups with traditionally lower immunization rates.
• A community health partnership of West Los Angeles organizations including Cedars-Sinai, Kaiser Permanente, Providence St. Joseph, and UCLA Health reached out to Martin Luther King, Jr. Community Hospital, Adventist Health White Memorial, and L.A. County Department of Public Health to launch a wider, regional collaborative.

Carolyn Buenaflor of Cedars-Sinai recalled some thoughts that accompanied the effort’s launch in April 2020.

“The public health-hospital collaborative was dipping its toes, somewhat hesitantly, into the flu effort,” Buenaflor, associate director, community health improvement at Cedars, recalled. “We needed to focus on specific goals unique to the group and we narrowed it down to three: unified and consistent messaging regarding importance of getting the flu shot, coordinating flu outreach to provide flu vaccines to vulnerable populations, and sharing of best practices and lessons learned as we navigate flu outreach in a pandemic.”

Another important milestone was the integration of L.A. Dept. of Public Health immunization outreach with hospital efforts. The two had long worked separate paths, several participants agreed.

“I think DPH had some assumptions about the way hospitals work,” said Mary Anne Chern, president of Adventist Health White Memorial’s Charitable Foundation. “It’s good for them to participate in problem-solving with the staff who have boots on the ground.”

White Memorial nurses conduct flu shot clinics for people experiencing homelessness and have identified practical steps that earn trust, Chern said.

The seven-plus months the collaborative has met and exchanged ideas has broken down barriers that existed previously, said Aizita Magaña, director of planning and public partnerships for L.A. County Department of Public Health’s Vaccine Preventable Disease Control group.

“Hospitals and County public health are now working together to leverage relationships and not competing,” she said.

Magaña emphasized the effort’s precedent-setting work, calling it “critical and historic.”

“The collaborative has given us a new foundation to engage partners on their current capacity, needs and resources – and this will significantly inform the coming COVID-19 immunization effort,” Magaña said. “Having relationships and communication through the collaborative with key representatives makes immunization implementation strategies more effective. We hope to learn and share more in the months ahead.”

Lessons Learned

Most gains noted by project collaborators derive from better communication. These best practices fall into two categories – more effective communication between project partners, and more strategic, informed messaging for the public.

Examples of important communications lessons learned include the following.

• Hospitals previously reported COVID-19 results to L.A. County Dept. of Public Health via fax or phone. A new electronic reporting platform has streamlined the process.
• HASC identified area flu clinic locations in a single location on the FightFluTogether.org website and created an immunization outreach social media and messaging toolkit. The association’s strategic communications team offers guidance on specific communications issues and challenges.
• L.A. County Dept. of Public Health held “brainstorming and listening outreach sessions” to learn more about the needs of specific communities, Magaña related. Specific sessions targeted older adults, Native Americans, Latinos, African-Americans, Asian Pacific Islanders and pregnant women.
• Practical trust-building techniques learned during flu immunization clinics and other events are now routinely shared between partners.

One insight gained by clinic teams is that nurses in the field are trusted more if they stand out as health workers by wearing scrubs, Chern of White Memorial explained.

“Success in the field is about so much more than lining people up and giving them a shot,” Chern said. “You have to build trust over years working with the homeless communities. That experience
is what we really have offer to DPH. I hope that in coming years the County will think about funds to really get these shots – including COVID vaccines – out into the communities through the hospitals.”

Other collaborative partners agreed that trust is a key element for any outreach campaign. What’s more, trust works in two directions. Providers need to build it with constituents. They also need trusted partners with strong ties to communities.

One campaign by the Providence Wellness and Activity Center in Wilmington (near San Pedro in Los Angeles County) partnered with the local YMCA and Boys and Girl Clubs, said Jim Tehan, Providence’s regional director of community partnerships.

“One of the keys to success is working with a partner who is trusted by neighbors – as well as someone we know and trust,” he said. “The model that works best is linking up with places that people know and are familiar with.”

The model helps combat the kind of misinformation that can dissuade residents from attending flu shot clinics – or from attending COVID-19 immunization clinics over the coming months, Tehan said.

“There may need to be multiple attempts to convince people to take the vaccine,” he said. “People may need to be encouraged to actually take it – for their own health, and for the health of their neighbors and their children.”

Links forged by the collaborative will almost certainly pay dividends as state and local COVID-19 campaigns press toward distributing the new vaccines and overcoming the virus, Adventist’s Chern underlined.

“We didn’t know each other before, and now I can pick up the phone with counterparts working at the County and other hospitals,” Chern said. “Together we are learning and sharing best practices. I think tasks we have ahead will be easier given that we’re coordinated, connected and communicating.”

Collaborators included the LA Partnership, a collaborative of non-profit hospitals, the three local health departments, HASC and the California Community Foundation, working to maximize community health impact and promote best practices in L.A. County.