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Even before coronavirus, almost half of adults in rural areas went without dental care

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Even before coronavirus, almost half of adults in rural areas went without dental care - North Carolina Health News

Rural adults are less likely than their urban peers to see a dentist for preventative treatments, according to the CDC.

By Liora Engel-Smith

Millions of rural residents have not seen a dentist in over a year, a recent CDC report reveals. 

In 2019, before the coronavirus pandemic forced dentists to shut down, 42 percent of adults in rural areas did not receive dental care, according to the survey. In urban areas, roughly a third of adults did not see a dentist that year.

In both groups, people of color and low-income residents were less likely to have seen a dentist in 2019. These disparities were wider in rural areas, where issues such as transportation barriers, dentist and dental hygienist shortages and lack of health insurance are more common. The coronavirus pandemic has likely exacerbated the need, especially for low-income patients, the report says.

“The things that really went by the wayside [with the pandemic] are the maintenance, the routine exams and the cleanings — things that keep people healthy,” said Katherine Jowers, who oversees oral health programs at the Asheville-based Mountain Area Health Education Center.  “ … We’re still dealing with very old treatment plans for patients we haven’t seen in two years. Nothing was on fire so they didn’t come, and now all of their plans are completely disrupted and we have to start from scratch.”

Since cavities and other dental problems don’t resolve on their own, what might have been small areas of decay that could have been addressed with a filling have likely advanced to more extensive decay that requires a root canal or even extraction. 

Lower-income patients are already predisposed to forgoing preventative dental treatment because of cost, especially if they aren’t in pain, said Anahita Shaya, a dentist at the Brunswick County Health Department. 

“People are having to choose between the necessities of life,” she added. “If they’re having to pay for fillings and a cleaning out of their pocket and that’s against having to pay their electric bill or mortgage or rent, [preventative dental care] is not always at the top of the list.” 

A dentist in a mask and gown cares for a patient
Dr. Anahita Shaya is a dentist at the Pender County Health Department. Photo credit: Pender County Health Department

Oral health is an important part of overall wellness and if left untreated, tooth decay can lead to a whole host of other complications. Cavities have been linked to heart disease, pneumonia and sepsis, for example. Pregnant women with poor oral health have been found to have a higher risk of premature births and other complications. 

Shaya sees some of these complications in her own practice, with patients turning to the emergency department for dental abscesses. 

The same is true for communities nationwide. Dental abscesses accounted for 3.5 million visits between 2008 and 2014 and cost a collective $3.4 billion, research shows. Uninsured people and Medicaid beneficiaries accounted for the bulk of these emergency visits.

Though receiving antibiotics at the ER can cost $1,000 or more out of pocket, Blake Gutierrez, a dentist at MAHEC, said patients go there because they don’t think there are other options. In most cases, however, emergency departments can’t fully address a dental issue. At most, emergency providers can administer antibiotics and painkillers, but without dental treatment, the source of infection remains and can flare up again. 

Even after an ER visit, patients may still be hesitant to seek dental care because of cost. Care Credit, a company that provides financing for dental and other health procedures, estimates that an extraction, the cheapest option for advanced tooth decay, can cost anywhere from $130 to $500, depending on the complexity of the extraction. Root canals, another common treatment, can cost $1,000 or more. 

Scarce North Carolina providers

Rural North Carolinians have another significant challenge to deal with when seeking care: lack of dentists. Most dental providers congregate in urban areas, according to data from the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Some rural counties, including Hyde, Tyrrell and Gates, did not have an active dentist in 2019, the data shows.

Greg Chadwick, dean of the East Carolina University School of Dental Medicine, keeps close tabs on that data. By his calculation, the state has roughly 5,600 active dentists, and most of them — over 4,500 — work in cities. The remaining 1,400 serve North Carolina’s 80 or so rural counties.

A study published this year by the American Dental Association notes North Carolina has about 54 dentists per 100,000 residents, behind the national average of about 61 dentists per 100,000. Based on a 2015 analysis generated by the federal Health Resources and Services Administration, North Carolina is likely to remain a state with not enough dentists to meet the demand into the future. 

That math alone makes it so patients in rural areas have to travel farther for care, he added, something that many residents struggle with. The only way to address these disparities is to make dental care more accessible, perhaps by coupling it with primary care as many community health centers do across the state.

These health centers aren’t always enough. MAHEC’s dental clinic, for instance, has a two-month wait for a cleaning and general exam. Another provider, CommWell Health – a community health center with locations in Sampson and surrounding counties – has seen a similar trend.

Time, said MAHEC’s Jowers, isn’t on rural patients’ side, especially since the pandemic delayed care for so many of them.

graphics show rate of dentists in North Carolina, map on the graphic shows county distribution
Data, graphic courtesy: Sheps Center for Health Services Research, UNC-Chapel Hill

“You’re not addressing needs that were minor needs two years ago,” she said. “[Dentistry] is the type of health care where if you don’t address the problem, it doesn’t get better by itself.”

shows a reel of fiberoptic cable being pulled behind a tractor as the cable is being laid in the country side

In North Carolina’s mountains, broadband isn’t a given

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In North Carolina’s mountains, broadband isn’t a given - North Carolina Health News

The state’s Appalachian region lags behind the rest of the state in internet connection recent data from the Appalachian Regional Commission shows.

By Liora Engel-Smith

Internet dead zones are as much a staple of Appalachia as the mountains, lakes and rivers that have made the region so popular among tourists.

The pandemic — and the lack of broadband infrastructure in some of these areas — has pushed North Carolina’s mountain people to embrace short-term solutions, including Wi-Fi hotspots at library parking lots and grocery stores. At the height of the pandemic, Gov. Roy Cooper even initiated a program that dispatched just under 300 Wi-Fi-enabled school buses to rural communities in need, alongside limited investments in rural infrastructure. 

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As life returns to some semblance of normalcy with the vaccine rollout, North Carolina’s mountain region continues to lag behind other rural areas in the state in internet access, recent data from the Appalachian Regional Commission shows. Roughly 22 percent of North Carolina’s mountain households lack an internet connection at home, compared with 18 percent of the state’s rural areas outside of Appalachia, according to the study.

Within the mountain region, the disparities grow even more stark, where sparser counties such as Graham and Swain have 30 to 40 percent of households without broadband access. 

Rural broadband in these areas is an issue of volume and feasibility, according to the report.  Much of the mountain region is far too sparse for internet service providers to want to expand there. And ISPs who do want to expand may find it difficult because of the exorbitant cost of laying fiber in the mountains.

Telehealth unavailable

When it comes to health care, the lack of broadband can mean anything from not being able to offer telemedicine appointments to doctor’s offices using fax instead of email for prescription requests, referrals and other routine tasks. Several physician offices even asked NC Health News to fax questions, rather than email them.

In other instances, physicians such as Steve Crane in Hendersonville said that the lack of reliable internet meant they could not pivot to telehealth during the pandemic because some payers would only reimburse if a telehealth visit included both audio and video, something that was impossible in places with no broadband.

Such challenges affect people’s access to care, Steve Heatherly, who heads Harris Regional Hospital and Swain Community Hospital, wrote.

There are workarounds, he noted, but these solutions are far from perfect. For example, hospital staff has worked with community partners to offer Wi-Fi hubs through which patients can access telehealth services. Paramedics in Swain and Jackson Counties may also bring Wi-Fi hotspots to patients who can’t otherwise travel to facilitate online consultations with hospital staff. 

Bryan Hodge, director of rural initiatives at the Asheville-based Mountain Area Health Education Center, has seen these issues again and again in health care. During the pandemic, for instance, MAHEC helped create a virtual coronavirus vaccine outreach campaign, but it became clear early on that this information wouldn’t reach rural residents. MAHEC opted for the costlier, slower method of reaching residents with information, including billboards, radio and television ads, and printed materials. 

For a short time, it seemed as though the renewed focus on telemedicine would bring the funds and public attention that would eventually connect more rural residents to the internet. Late last year, Gov. Cooper announced a $30 million investment in roughly 70 rural broadband projects, at least seven of which would benefit rural households in the mountain region of the state. 

Pricier work

Drilling through the granite of the Appalachians is far more expensive than burying internet lines in the sandy coastal plains, or even the rocky soil of the Piedmont. Data from the state shows that the cost of hooking up 300 homes and businesses at Haywood County, just west of Asheville, is estimated to cost $2 million.

map of broadband internet access from the Appalachian regional commission
Map credit: Appalachian Regional Commission

A project of roughly the same size in Lenoir County to the east got just over $135,000 in last year’s grant cycle. The project cost roughly $200,000 with matching funds, data from the state shows.

Despite these long-standing issues and the urgency of the pandemic, the spotlight on rural broadband needs is perhaps fading somewhat, said Sarah Thompson, executive director of the Southwestern Commission Council of Governments, a Sylva-based organization that helps internet service providers find the funds for rural broadband. 

Nonetheless, the need remains urgent.

“We’ve been beating this drum for years before the pandemic,” Thompson added. “For the people who live in rural communities, the pandemic was an example for everyone else, but we (rural residents) always knew it. I don’t think it’s going away.”

There’s at least some signs that federal and state lawmakers have taken that to heart. President Joe Biden’s American Rescue Plan — of which North Carolina received $5.7 billion — earmarks significant funds for rural broadband improvements. The state’s exact allocation to the rural broadband infrastructure remains to be determined, but Gov. Cooper said last March that more than $1 billion could be allocated. 

The final tally, of course, is up to the lawmakers in Raleigh to work out, Thompson said. That decision will likely come after the state budget negotiations between the North Carolina House of Representatives and the state Senate. While the Senate unveiled its proposal, lawmakers in Raleigh said the House’s proposal likely won’t be released until next month and a consensus budget may be even farther off, if previous budget talks are any indication. 

Some county governments received additional support from the Biden administration, but they likely won’t use it for broadband improvements, at least not until the state clarifies its spending priorities for the rural broadband money.

“The silver lining of the crisis of the pandemic,” Thompson added. “Is that we’re going to have a lot more money to throw at the problem than we did before.”

A wrapped strip of suboxone is on a counter.

Expanding medication-assisted therapy training for health care professionals

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Expanding medication-assisted therapy training for health care professionals - North Carolina Health News

The opioid overdose crisis has highlighted the need for more medication-assisted therapy.

By Melba Newsome

About a decade ago, Blake Fagan vowed he would never write a prescription for Suboxone, a combination of buprenorphine and naloxone used to curb the opioid craving. The Asheville family physician had seen the ravages of the opioid crisis up close and couldn’t imagine aiding and abetting it which he believed medication-assisted therapy would do. 

“I said, you’re just substituting one addiction for another,” said Fagan, chief education officer at UNC Health Sciences at the Mountain Area Health Education Center in Asheville. 

These days, Fagan not only prescribes Suboxone (the generic name is buprenorphine), he sees that primary care doctors in residency programs in North Carolina are qualified to prescribe the drug, too. He views this as another spoke in the wheel of addiction treatment.

Fagan’s thinking changed after a patient was brought into the emergency room after an overdose and later died. Years earlier, he had delivered the young woman’s two children. 

“It just broke my heart,” he says. “I realized that this medicine could have saved her life. That’s what’s been driving me.”

Preliminary 2020 data shows the coronavirus pandemic exacerbated North Carolina’s opioid crisis, increasing overdose-related ER visits by 23 percent. But Suboxone, a drug that can help, is still too hard to get. 

Overdose crisis forces a change in prescribing

Fortunately, the one upside to the epidemic of overdose deaths is a slew of new initiatives and additional funding to improve the way physicians, physician assistants, nurse practitioners and other health care providers prevent, identify, treat and support the recovery of their patients who have, or are at risk of developing, an opioid use dependency.

Much of the focus has been on educational outreach to health care providers about safer opioid-prescribing practices. But many addiction medicine specialists believe the greatest opportunity to curb opioid overdoses lies in expanding access to medication assisted treatment. 

Most training efforts have focused on practicing primary care providers, but these efforts have fallen short in North Carolina and elsewhere. North Carolina is one of 11 states where buprenorphine prescribers per opioid death rates are well below the national average. Nationally, fewer than 4 percent of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and roughly half of all counties lack a buprenorphine-waivered physician.

According to a report created by the U.S. Department of Health and Human Services Office of Inspector General in 2018, 64 North Carolina counties (colored in red) reflect a high, or highest, need for treatment services for opioid misuse and abuse. Map courtesy: US DHHS

Prioritizing medication assisted therapy

When Mandy Cohen first came in as secretary of the North Carolina Department of Health and Human Services, Fagan says she made the opioid crisis a big priority. 

“Dr Cohen said ‘I want our state to be progressive. What are some of the progressive things around opiates we need to do?’” he recalls.

To prescribe Suboxone, doctors must complete an eight-hour training program and get a waiver from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to prescribe buprenorphine for addiction but not for pain. Physician assistants and nurse practitioners require 24 hours to get the waiver that enables them to provide opioid treatment with buprenorphine in an office-based setting.

One of the things Fagan and others suggested was the need to train more providers in the state to write prescriptions for buprenorphine. A few days later, Fagan got a call from DHHS asking how MAHEC could help more doctors get waivered to prescribe the drug. 

“We said, we need to train the residents that are actually in training, the majority who will practice across the state,” he said. 

Learn more about practitioner buprenorphine training requirements.

Training residents

North Carolina first released its Opioid Action Plan in June 2017 and has updated it twice since — in June 2019 and May 2021. The Opioid Action Plan addresses the provider shortage through coordinated residency training in family medicine, internal medicine, ob gyn, psychiatry, emergency medicine and pediatrics, the six first line residencies. 

So far, over 1,000 residents in over 50 residencies in the state have been trained. Since there are new residents each year, Fagan and MAHEC devised a training plan for the faculty at each of these programs so that this education is ensconced into their training. 

According to DHHS, since the Opioid Action Plan was launched, dispensing opioids as a pain reliever has decreased by 34 percent while at the same time prescriptions for drugs used to treat opioid use disorders increased by 33 percent. In addition, opioid use disorder treatment specifically for uninsured and Medicaid beneficiaries has gone up by 48 percent.

Looking for a health care provider who prescribes Suboxone/ buprenorphine? Click here.

Training medical school students

The Governor’s Institute, a Raleigh nonprofit focused on improving how the health care professions prevent, identify and treat substance use disorders, was awarded the three-year SAMHSA grant to expand medication-assisted therapy by training medical school students, physician assistants and nurse practitioners. 

According to executive director and program director Sara McEwen, the schools of medicine at UNC Chapel Hill, East Carolina University, Wake Forest University and Campbell University have all integrated eight hours of opioid use disorder training into their standard medical school curriculum. Collectively, they churn out approximately 545 physicians each year who have the option to apply for their waiver once they receive their prescribing authorization number from the federal Drug Enforcement Administration.

Participants in seven of the state’s nurse practitioner programs and one of the physician assistant programs have integrated a mandatory 24-hour training course into their curricula. In North Carolina, waivered Advanced Practice Providers, or APPs, cannot prescribe buprenorphine unless their physician supervisors are also waivered. The Governor’s Institute is offering professional mentoring to encourage physicians who are on the fence to take the training. 

The Institute’s SAMHSA training grant runs out in September but, given the program’s success, fingers are crossed that the funding will be renewed. 

“We are hoping to get a no-cost extension so that we can further build out the clinical exposure/faculty development components which were affected by COVID,” says McEwen.  “We have also applied for funding to work with several of the APP schools next year.”

According to a report created by the U.S. Department of Health and Human Services Office of Inspector General in 2018, the U.S. counties colored in green reflect a high need for treatment services for opioid misuse and abuse. Those include 20 North Carolina counties listed as being at “highest need” and 44 listed as “high need.”
A resident listening to a baby's heart

Tackling NC’s rural provider shortage, one residency slot at a time

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Tackling NC’s rural provider shortage, one residency slot at a time - North Carolina Health News

Medical residents who train in cities tend to stay in cities. Some rural providers say that closing the rural-urban physician gap is a matter of training some residents away from these population centers.

By Liora Engel-Smith

Later on this month, more than 550 newly graduated physicians will hang their stethoscopes around their necks, don their scrubs and begin residency training at medical centers across North Carolina. 

Despite a crushing need for primary care practitioners, few of those residents — roughly 1 in 4 — will train in family medicine.

Fewer still will train in rural areas, despite a decades-long legacy of physician shortages in some of the state’s most remote areas. As Bryan Hodge, director of rural initiatives at the Asheville-based Mountain Area Health Education Center sees it, rural communities often lack the staff and financial resources to establish and sustain residency programs.

“It’s harder to train in those environments and there’s less workforce in those environments,” he said.

A modest but growing number of primary care physicians, however, will train in smaller facilities at least part of the time. Residents in these “rural track” programs typically spend a year in a large medical center, followed by two years in a rural hospital, clinic or community center.

This year, Duke University has created two such slots in collaboration with Duke Primary Care Oxford and Henderson-based Maria Parham Health. Watauga Medical Center has a partnership between MAHEC and the medical center at UNC Health in Chapel Hill, yielding four additional rural health slots in Boone.

Molly Benedum, a MAHEC physician who oversees the residency in Boone, knows the need for primary care in rural areas is bigger than her program alone can fill. Four primary care residents, however, are enough to make a huge difference in her town, she said.

“While the residents are here, they’re also helping to meet the primary care needs of the community,” she said. “ … We have a clinic here, and since they got here, they’ve been taking care of patients in the clinic and in the hospital. It immediately creates access where there wasn’t access.”

Recruiting physicians, for a price

The price of that access can be quite steep, often more than cash-strapped rural facilities can afford. 

Residencies are a partnership between medical schools and hospitals. Medical schools offer a pipeline of recent graduates as well as access to research opportunities for newly minted MDs. Hospitals cover resident salaries, staff training time and the cost of materials. The cost per resident can average roughly $150,000 annually, said Matthew Huff, director of postgraduate affairs at Campbell University’s Jerry M. Wallace School of Osteopathic Medicine, a Harnett County institution that has placed 134 graduates in family practice residencies from 2017 to 2020.

While some funding for residencies can come from Medicare, in most cases, hospitals seek grants to absorb at least a portion of the costs. Other hospitals elect to absorb the losses on their own, a prospect that may be beyond some of the more financially unstable programs.

Campbell’s collaboration with UNC Health Southeastern in Robeson County has eight family medicine slots of which five have been filled for 2021, data from Residency Match shows. Hospital officials told NC Health News in 2018 that these 8 slots, along with several specialty slots cost them roughly $11 million. The hospital recoups roughly a third of that cost from Medicare, said Campbell medical school’s associate dean for postgraduate affairs, Robin King-Thiele.

Hospitals that can afford this kind of hefty price tag will often set up residencies as a way to eventually recruit at least some of these physicians-in-training to stick around.

“Having the chance of recruiting one to two, maybe three primary care physicians a year once the program matures, that’s a wonderful opportunity,” Huff said. 

Many hurdles

Patient volume is another issue. 

For instance, primary care physicians in training are required to care for children and deliver babies. In most rural communities, pediatrics and obstetrics are difficult to practice not only because maternity units have shut down but because there aren’t nearly enough pediatric patients for residents to see. The hospital in Boone, for example, only admits roughly four to six children a month, Benedum said.

Doctors stand in front of a machine
MAHEC rural family medicine residents John Cunningham, left, and Jeb Fox, right, see patients along with Appalachian Regional Healthcare System hospitalist Bryant Ward (center) at Watauga Medical Center in Boone, NC. Photo credit: MAHEC

The Accreditation Council for Graduate Medical Education, the body that accredits residencies in the United States, requires at least two months and 250 pediatric encounters with children in the hospital, a benchmark the hospital in Boone cannot fulfill on its own. By comparison, Watauga Medical Center’s more than 600 births per year on average are more than enough to satisfy the ACGME’s gynecology and obstetrics training.

Benedum, the MAHEC physician overseeing the Boone residency, helps residents in her program get the training they need by sending them to a larger hospital to fulfill their pediatrics training. 

That arrangement or “rural track” appears to be gaining momentum, in part thanks to a Health Resources & Services Administration program that recently awarded a collective $20 million over three years to 27 organizations nationwide focused on rural health. MAHEC and Duke’s rural primary care residencies were among the recipients. HRSA signaled that it is planning to allocate roughly $23 million to the expansion of the rural track grant program in FY 23 and 24. 

Funding alone likely won’t address all of the hurdles for rural residency programs, Hodge said, especially because of the long lead time it takes to set up new programs. 

“There has to be some balance here,” he added. “Because if you try to set up a residency in a place that really doesn’t have enough capacity to train them there, then there’s a risk of having poorly trained physicians and that’s not going to solve our problem.”

An older woman in graying hair is wearing a mask as a nurse prepares to give her a coronavirus vaccine at a temporary clinic in Asheville.

The next ‘new normal’: Navigating the pandemic with full immunity

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The next ‘new normal’: Navigating the pandemic with full immunity - North Carolina Health News

North Carolina’s residents have gotten a collective 8 million vaccine doses in recent months. But the rules of this post-vaccination existence, however, aren’t so simple.

By Liora Engel-Smith

Coronavirus changed much of daily life in the last year and a half, but as more North Carolinians get vaccinated, activities that just recently seemed inconceivable are returning to our lives. 

Fully vaccinated people can now travel and be in public without a mask. With weddings, concerts and family reunions on the horizon once more, the next new normal, one that resembles the life we had before, is emerging. 

That transition has proven to be anything but simple, especially as more than half of the state’s population have yet to receive even one shot, data from the state shows. 

These rates are a far cry from the 70-85 percent vaccination rate that experts have long said would give us “herd immunity” and stop the spread of the pandemic altogether. Nonetheless, coronavirus cases have declined from an average of 8,000 new infections a day at the peak last December to fewer than 2,000 new infections per day this month. 

The next “new normal” is shaping up to be similar, but not identical to pre-COVID life. We’ve asked health experts to help us make sense of it. Here are some of their suggestions.

Hold on to your masks

Fully vaccinated people can safely attend small or large gatherings both indoors and out without wearing a mask, but some are not ready to embrace that yet. Many businesses, including Walgreens and Kroger, are continuing to require masking for customers and staff, vaccinated or not. 

Scientists are still collecting data, so they don’t yet know if and when the protection from the vaccine expires. That means vaccinated people should hang onto their masks – for now. 

Vaccinated parents of young children who cannot yet get vaccinated may also wish to wear masks when they’re out and about with their unvaccinated children to model the behavior and prevent confusion surrounding mask-wearing.

“We still do need to be encouraging our kids to continue to wear masks,” said Ashley Perrott, physician executive at Novant Health’s Community Health and Wellness Institute. “I went to the grocery store with my daughter just yesterday and she put on her mask and in solidarity, I put on my mask with her.” 

Navigating the vaccine “honor system”

State health officials lifted many of the mass gathering bans and masking requirements in North Carolina in accordance with the new guidelines from the Centers for Disease Control and Prevention. And while the risk of a vaccinated person catching coronavirus from an unvaccinated person is miniscule, Perrott said, transmission is still possible as long as the virus is circulating. 

Some unvaccinated people may choose to forgo masks now that masking requirements have been lifted. As a result it can be impossible to tell who is vaccinated in larger gatherings and public places. Perrott encouraged vaccinated people to continue to wear their masks in mass gatherings and some public settings as a precaution. 

“I think in places where you are in a large group of people, not knowing whether they are fully vaccinated or not, we still have to have some caution, the way we would with any infectious disease,” she said.

Zoom happy hours are (almost) a thing of the past 

Fully vaccinated people can safely return to an in-person social calendar. Weddings, birthdays and family reunions are safe to attend, Perrott said, with some caveats. 

“We can get back to some of our normal events and celebrations in life,” she said. “Though they may look a little bit different than they did in the past with more access to get the sanitizer and hand-washing and masks available for people who still need them, or for people who want them.” 

At least one pre-pandemic ritual may be a thing of the past, however: blowing candles on a birthday cake. 

“I personally hope that we lose the blowing [candles] tradition,” said April Baur, school health program manager at the Asheville-based Mountain Area Health Education Center. “Another thing that we see with all of our COVID safety measures is that the rates of seasonal flu were extremely low. So I think there may be things we can take forward with us.”

Sibling rivalries 

Teenagers can now get the Pfizer vaccines, effectively ending quarantine for young people in that group who get a shot. Their younger, unvaccinated siblings, however, still have to practice caution for now. Vaccine approval for children under 12 likely won’t happen until the fall, Baur said. 

The vaccinated teenagers may return to normal activities including outings and summer camps on their own. Families, however, may need to find activities that both vaccinated and unvaccinated kids can safely enjoy. 

That scenario will likely play out in Baur’s own family activities this summer, since two of her three children are too young to get the vaccine. 

“Our plan is to do the things we can that are easy to stay safe,” she said. 

“We’re just going to keep using our same safety protocols indoors for them and then focus on as many things that we can do that are outdoors and have social distancing.”

Traveling in the U.S.? Check out what COVID and vaccination rates are where you’re going. Search by state, even by county, using this tool from the Centers for Disease Control and Prevention.

shows the back of a wheelchair, with an old and wizened hand on the arm of the chair

Project ECHO resounds throughout WNC

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Project ECHO resounds throughout WNC - North Carolina Health News

Long-term care facilities use a “guided practice” model to mitigate the coronavirus.

By Melba Newsome

Each Monday at noon, Janice Somers closes her office door at Westwood Hills Nursing and Rehabilitation and puts her phone on Do Not Disturb. For the next 90 minutes, the nurse administrator and four team members join hundreds of employees from over a hundred North and South Carolina facilities for the Nursing Home COVID-19 Action Network, a four-month online course designed to establish common guidelines for infection control in nursing homes.

The training is a way to share best practices and other practical information. But Somers says the camaraderie is important, too.

“I want to know what other people are doing,” says Somers. “We’ve all been so isolated. Ever since March, everything is a Zoom meeting.”

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Long-term care facilities have been ground zero for the COVID-19 pandemic but many proved ill-equipped for the challenge. Though facilities are required to have someone focusing on infection control, only 3 percent of those staff have taken a basic infection control course. The North Carolina Health Care Facilities Association, the statewide industry group for skilled nursing facilities, sent out a memo about an upcoming course being offered by the Mountain Area Health Education Center and Somers signed right up.

Nursing Home COVID-19 Action Network’s training series is just one of eight pandemic-related continuing education series operated by MAHEC using this model. They include screening/treating COVID-19 in primary care; acute care for hospital inpatient; and developing resilience in the healthcare workforce.

A way to expand learning

After seeing patients wait a long time to be treated for hepatitis C, Sanjeev Arora, a liver specialist at the University of New Mexico Health Sciences Center in Albuquerque, got the idea of teaching rural physicians how to screen, diagnose and treat patients.

Arora believed that if patients didn’t have to drive six hours to see him, many more of these hepatitis cases could be treated effectively.

That’s where Project ECHO comes in. Instead of moving people, the ECHO (Extension for Community Healthcare Outcomes) model, using remote learning technology to involve people who are actually delivering the care in the teaching process. The technique moves knowledge out to more people, allowing for expanded treatment capacity and making better health care available, particularly in remote and rural areas.

The model was so successful it has been replicated all across the country, particularly in areas when geographic and socioeconomic barriers make access to specialty care difficult, if not impossible. Topics include advanced disease management techniques for conditions ranging from Type II diabetes, epilepsy and chronic obstructive pulmonary disease to substance use disorders and other complex behavioral health problems.

Bringing Project ECHO to MAHEC

When Lourdes Lorenz-Miller, MSN, trained to bring Project ECHO to MAHEC in September 2017, she was told that it takes six months to get similar programs up and running.

A month later, UNC Health Sciences at MAHEC became one of the first academic health centers in the state to offer a continuing education ECHO for rural physicians. In January 2018, they unveiled the school nurse ECHO, followed by one for treating chronic pain in patients with opioid use disorder.

“Project ECHO allows us to share what we have learned with providers and their patients across the region,” says Lorenz-Miller. “ECHO learning isn’t from up top but from each other who are on the front lines. It has the potential to address health challenges in a big way by reaching more people. That is what makes this model so exciting.”

To date, MAHEC has developed 10 different ECHO series: chronic pain management, behavioral health, rural medicine, high-risk prenatal care, geriatric care, oral health, adverse childhood experiences and school health. These workshops have trained more than 8,000 participants from all 16 WNC counties and 96 counties statewide.

The training model

The training sessions follow a standard pattern. Actual case studies are submitted by participants or experts in advance for feedback and recommendations for next steps. In each training session, MAHEC’s experts share specialized knowledge in real-time with providers who, in turn, share their first-hand experiences. The other participants on the call get a chance to weigh in with suggestions and tips about what’s worked for them in similar situations.

Nurses, physicians and pharmacists receive continuing education credits for participating.

Programs are paid for in a variety of different ways. For example, the ulcerative colitis ECHO is free to participants because it attracts sponsors. In contrast, an eight-week school nurse training costs $115.

The nursing home ECHO is supported by the federal Agency for Healthcare Research and Quality (AHRQ) in collaboration with the non-profit Institute for Healthcare Improvement (IHI).

Participating nursing homes receive a $6,000 stipend.

The training program is designed to meet five key benchmarks:

  • keep the virus from entering nursing homes;
  • identify infected residents and staff;
  • prevent spread between staff, residents and visitors;
  • provide safe and appropriate care to residents with mild and asymptomatic cases of the virus;
  • ensure staff is adequately trained to implement best-practice safety measures.

Somers and her staff welcomed the detailed plan.

“The information stream has been very confusing, not only for physicians but for people that work in clinics and nursing homes because there wasn’t any kind of national strategy,” says Somers. “The CDC was saying something, the state was saying something else and there was a lot of confusion. This way everybody gets the same training and information.”

Most of the participants work for standalone facilities and struggle to keep abreast of ever-changing directives. However, Westwood is one of many nursing homes owned and operated by Principle Long Term Care. Somers and her team have relied on the corporate office to sort through and keep them informed on the latest coronavirus-related news and policies.

Nonetheless, she still believed there were reasons to participate in the ECHO, like hearing from someone going through the same thing.

“It’s an unbelievable experience when you find out that COVID is in your building and that the staff has got COVID,” says Somers. “It takes long hours and everybody has to do many different jobs.

“One night, my job was to collect trash in all the rooms because the housekeepers were out. Thank goodness my dietary staff never went down because I would have had to be in there cooking and that might have been a problem.”

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