Rutherford County

photo shows 7 syringes full of a COVID vaccine in sealed packages laying on a black tablecloth.

Parts of Western NC see vaccine demand drop to a ‘trickle’

May 16, 2021 by Carolina Public Press Leave a Comment

Parts of Western NC see vaccine demand drop to a ‘trickle’ - North Carolina Health News

Several Western NC counties seeing recent surge in COVID-19 cases even as willing pool of vaccine recipients dries up.

by Christian Green, Carolina Public Press May 7, 2021

In late April, Gov. Roy Cooper set the end goal for North Carolina’s COVID-19 vaccination rollout at two-thirds of adults. When that number is reached, Cooper said, then he would end the statewide indoor mask mandate, effectively ending pandemic restrictions.

But it may prove difficult to reach that number soon, as there has been a slowdown in vaccinations in some parts of Western North Carolina, driven by a lack of demand.

“In Rutherford last week, we had a clinic and, in a place where we were previously doing 1,100 (doses) a day, we did 190, and we were open all day,” said Karen Powell, health director of Foothills Health District, which covers Rutherford and McDowell counties.

“Right now, we’re like at this … it’s not a screeching halt, but it’s a trickle,” she said.

Health directors across the region voiced the same story.

“We’ve hit a wall, basically,” said Kathy McGaha, director of the Macon County Public Health Administration.

The least vaccinated counties in the west are Rutherford, Cherokee and Graham counties, with an estimated 34%, 36% and 37% of adults vaccinated, respectively.

“At this point, we’ve pretty much vaccinated everybody who wanted to be,” said Beth Booth, health director of the Graham County Health Department. “Even those who were on the fence.”

Booth was pleasantly surprised that her county reached those numbers.

“When we passed (having vaccinated) a quarter of our population, that was a higher uptake than I thought we would have,” Booth said.

“If you’ve spent any time out here, you would quickly figure out that it’s a very suspicious, closed group out here. … So, I got to say I’m pretty proud of how many folks have taken it.”

Though some individual western counties are lagging, the total percentage of vaccinated adults in the 18 westernmost counties is around 47%, according to an analysis conducted by Carolina Public Press, not far behind the 50% of adults vaccinated statewide.

While vaccine hesitancy in Western North Carolina is not dissimilar from the state and the country, some of the reasons for hesitance or resistance differ by region.

Local differences for hesitancy

As has been previously reported, no single factor drives vaccine hesitancy, and no single group is uniquely hesitant.

Booth said Graham County is uniquely distrustful of influence from outside the county. She thinks that mindset contributes the most to low rates of vaccination in the county.

“They’re very private, and so if they have a belief system, if outside government is trying to step in or if the government is trying to overreach, they aren’t having it,” Booth said.

“It’s really hard to change their mind because … it’s not necessarily the science or any medical reason. It’s a belief system.”

This aligns with previous survey studies that have reported that conservatives appear to be more hesitant to receive a COVID-19 vaccination than liberals, but that does not tell the full story.

For instance, Avery County voted for former President Donald Trump at a similarly high percentage as Graham County in the 2020 election; however, Avery County has vaccinated roughly 45% of adults, compared with Graham’s 37%.

In general, a county’s 2020 election results had a weak correlation with the level of vaccination, based on CPP’s analysis.

Instead, education levels, measured in this case by how many people over the age of 25 held a bachelor’s degree or higher, were the strongest predictor of vaccination levels. The percentage of residents living below the poverty line was the second-strongest predictor.

This disparity can be seen in the margin of vaccinations in the neighboring counties of Swain and Jackson. Swain has vaccinated roughly 37% of its adults while Jackson has vaccinated around 42%.

The two share similar demographics, poverty levels and cultures, but Jackson is home to Western Carolina University and has nearly double the number of residents with bachelor’s degrees as Swain.

It is possible that higher levels of education are not directly responsible for increased vaccine uptake, but that educational achievement is correlated with other socioeconomic factors like income, living conditions and access to health care, which may also affect vaccine enthusiasm.

Breaking trends

When looking at county trend-line data, one in particular stands out: Macon County.

Macon County voted heavily Republican in 2020, it has a below-average number of bachelor’s degrees and an above-average number of people living in poverty. By all metrics, it should be lagging in vaccinations.

But Macon apparently has vaccinated over 51% of its adults, putting it just ahead of the statewide average.

McGaha, director of Macon’s Public Health Administration, said she wasn’t entirely sure why the county’s vaccination rate was so high. If she had to guess, she said, it was because of her department’s approach to contact tracing and communication throughout the pandemic.

“Anyone who tested positive for COVID-19 was called by our staff every day to check in on them,” she said.

“We did very intensive contact tracing with them, and we spent a lot of time on education. … The community developed relationships and trust for this agency over the past year. I think that probably is part of what we see now.”

In other counties, people have said personal relationships with individuals and agencies matter.

Powell said she would have expected McDowell County to have a lower rate than Rutherford, but McDowell is almost 10% more vaccinated. Powell said she thinks the strong relationship between McDowell residents and their local Emergency Management Services Department is key.

“Their residents trust them. So, if emergency management says, ‘Hey, you need to do this,’ they say, ‘OK, because you never, ever led me astray.’”

Rutherford County, on the other hand, had less trust in institutions on average, which makes it tougher to overcome people’s doubts about vaccination, Powell said.

‘This pandemic is not over’

The slowdown in vaccinations means that it may take months to reach the 66% goal set by Gov. Cooper, and even that number would likely not produce a level of “herd immunity” that would completely squash the disease.

While cases and deaths are way down from their January peaks, the state is still reporting over 1,000 new COVID-19 cases per day and local health departments remain worried about outbreaks.

“We have right now, we have a cluster in McDowell,” Powell said. “An outbreak with 11 positives in a business, and none of them are vaccinated, and they probably won’t be. They probably will not do it.”

Booth also said that after nearly two weeks of zero new cases, Graham County had recently begun to see cases rise again. Graham has found seven new positive cases in the past week.

To try to quash the possibility of more outbreaks, health departments are shifting tactics to try to reach and convince more people to get vaccinated. Powell said her department is using mobile clinics to reach into neighborhoods with low vaccination rates.

She hopes that even if people don’t immediately choose to get vaccinated, it will be an opportunity to educate them and make a contact that might eventually change their minds.

Booth said she thinks that hearing from neighbors will prove to be even more important than education from health officials.

“I think the only way at this point to really see an increase in vaccinations in Graham County is just time,” Booth said.

“They’re not going to believe the science behind it. They want to see that their neighbors are OK. And I don’t mean two weeks or a month. … They want to see that over a long period of time that it really is OK.”

Powell has less patience.

“This pandemic is not over,” she said. “The outbreak we have right now in McDowell is a clear indication of that. And it scares me. You know, with the low vaccine rate that we have in the county, these outbreaks will just continue to happen.”

photo shows a series of white pipes, plumbing that is not regulated by housing codes in most NC counties

Thousands without adequate plumbing could be helped by minimum codes

February 27, 2021 by Carolina Public Press

Thousands without adequate plumbing could be helped by minimum codes - North Carolina Health News

73 NC counties lack any minimum housing code, which the state doesn't require. Tenants may have little recourse, and conditions can be unsafe during a pandemic.

by Korie Dean and Taylor Buck, Carolina Public Press

When Shane Dotson receives a complaint that a home in Rutherford County doesn’t have properly functioning plumbing, there’s not much he can do.

He can follow up on the complaint and make a visit to the property. He can carefully document every leaky toilet and broken water heater on his inspection report sheet. He can take photos of the home for the county’s records and offer his sympathies to the tenant.

But Dotson, who is the director of building inspections for the county, can’t require the landlord or homeowner to fix any of those plumbing problems. Unless the home has electrical hazards or otherwise poses a danger to human life, his hands are tied.

That’s because Rutherford is one of 73 counties in North Carolina that doesn’t have a minimum housing code at the county level.

“We’ve been called out on complaints for sewer running out into the field, for sewers not connected, people having homes where they’re using the restroom out in the woods,” Dotson said.

“We go as far as we can with that. We bring in environmental health to help deal with that process. We do our best, but we do not have an ordinance in place.”

The homes Dotson sees on those calls aren’t anomalies or isolated incidents.

An analysis of U.S. Census Bureau data from 2018 shows that an estimated 12,544 North Carolina homes lack some form of plumbing, such as hot or cold piped water, a functioning bathtub or shower, or a functioning toilet. Statewide, that number is down approximately 24.5% since the Census Bureau’s previous data collection in 2013.

But as cases of the coronavirus continue to rise around the state, a lack of proper plumbing in any amount of North Carolina homes is perhaps a more pressing issue than ever before: Without running water or a working sink, hand-washing is impossible.

And unless a county has a minimum housing code in place, people living in homes without proper plumbing have few places to turn as the pandemic rages on.

Under state law, North Carolina counties and municipalities have the option to establish minimum housing codes, but it isn’t a requirement.

When a county, like Rutherford, doesn’t have a minimum housing code, there’s nothing county employees can legally do to stop a home from falling into disrepair. They can only step in when the home is in such bad shape that it is “unfit for human habitation.” That’s the first and only time that they can require that the landlord or homeowner make necessary repairs or condemn the house.

“It is optional in North Carolina for a local government to enact a minimum housing code,” said Tyler Mulligan, professor at the UNC Chapel Hill School of Government.

“If you don’t have a minimum housing code, then all you have is a set of statutes to condemn unsafe buildings. A minimum housing code is designed to get at the problem a little sooner and address factors that make a building unfit for human habitation.”

Generally, urban and suburban counties are more likely to enact a code because of the links between substandard housing and higher crime rates as wells as poorer public health outcomes, Mulligan said.

“There is a desire in these urban counties and urban cities to avoid the negative externalities of deteriorated housing,” he said. “When someone lives in substandard housing, it doesn’t just affect them in an urban area; it also affects their neighbors, thus justifying a public response.”

In those counties, minimum housing codes seem to be doing the trick.

Since 1970, North Carolina counties with minimum housing codes have generally reduced the number of homes with inadequate plumbing at a faster rate than counties without minimum housing codes.

Charlotte, the county seat of Mecklenburg County, has its own minimum housing code, which has been in place since 1962. The code specifically outlines the plumbing standards that homes in the city must meet, including “no leaks shall be in a shower stall floor and/or wall” and “facilities for furnishing adequate hot water to each tub or shower, lavatory and kitchen sink,” among other requirements.

Mike Jenkins, Charlotte’s code enforcement coordinator, has seen firsthand the positive impact that the code has had in addressing inadequate plumbing in the city.

Jenkins started working for the city in 1985, when there were homes in parts of Charlotte and its 2-mile extraterritorial jurisdiction that didn’t have indoor plumbing and relied solely on outhouses.

Now, Jenkins said he and his team rarely run into homes like that, though they still see homes with plumbing issues.

“Every once in a while, we’ll run across a house — very rarely, actually — that doesn’t have indoor plumbing, that has an outhouse,” Jenkins said.

“We do see a good number of plumbing cases, leaky pipes. We do see septic systems that are failed. There’s still a few of those around.”

Because Charlotte has a minimum housing code, Jenkins and his team have the authority to step in and require that those leaky pipes and failing septic systems, as well as any other violations to the code, be fixed by the homeowner or landlord.

While the standards for minimum housing codes can vary from county to county or city to city, the enforcement procedures are set forth by state law and are the same for every local government.

“The standards can change, other than the ones that are read to you (in the state statute),” Mulligan said. “Then there’s enforcement. And enforcement is the same across the entire state; it has to use the procedures that are put into the statute.”

After inspecting the home, the county or city employee determines whether repairs can be made or if the home is fit to be condemned.

If the homeowner or landlord can afford to make the necessary repairs or demolish the home, the public official orders them to do so in a set amount of time. If the homeowner or landlord cannot afford to make repairs or demolish the home, the local government can make the repairs and set the cost of the work done as a lien on the property.

A 2017 report published by the UNC Chapel Hill Center for Urban and Regional Studies suggests that local government actions, such as implementing minimum housing codes, are some of the most needed solutions to substandard housing conditions around the state.

But the possible cost of repairs and demolition associated with minimum housing codes is one reason that local governments, especially those in smaller and rural areas, might opt out of implementing a code.

“It can be a pretty expensive process for a government, and time consuming,” Mulligan said. “And that makes governments cautious about using this power, but they will use it when a situation is bad enough.”

Danny Searcy, Rutherford County’s planning director, said via email that county budget constraints are a leading reason that Rutherford County hasn’t implemented a minimum housing code.

“After some research of potential budget impacts of an ordinance that included condemnation and removal of structures at a cost of several thousand dollars per incident across a 565-plus-square-mile county, it could become a rather daunting task in an already tight budget,” Searcy said.

Searcy also said citizens of Rutherford County have historically been opposed to planning ordinances, and previous attempts at implementing countywide land use and zoning regulations have failed, though a municipal minimum housing code does exist in Forest City, the county’s largest incorporated town.

“The local citizenry input has been abundantly clear, and while considering minimum housing code, one may speculate that the lack of zoning and comprehensive land use bears a factor,” Searcy said.

In counties without a minimum housing code, where county officials can’t require that repairs be made, homeowners, landlords and tenants are left to rely mostly on local nonprofit organizations to address plumbing concerns in their homes.

In Rutherford County, one of the nonprofits addressing the need is the Rutherford Housing Partnership, which provides urgent home repairs to low-income, elderly and disabled homeowners.

Mel Ailiff, the organization’s executive director, said the organization currently has 111 applications for repairs on file. Of those applications, 32 request some sort of plumbing repairs, which could range from installing a handicapped-accessible shower to connecting the home to running water.

Ailiff said a minimum housing code would help address some of the issues that RHP can’t, since it would legally require homes to have proper plumbing, and the county could step in to shoulder some of the burden.

“Right now, the situation is that some homes are in such bad condition that people really shouldn’t be living in them because it’s not that they’re dangerous, but they’re not safe for the families, just due to the health hazards of living in those conditions,” Ailiff said. “But there’s really nothing the county can do to fix it.”

While the organization tries to assist as many applicants as possible, the reality is that nonprofit organizations don’t have enough funding or resources to fix every issue in every home — though the state does offer some resources for those organizations, mostly through the N.C. Housing Finance Agency.

The agency was established in 1973 by the N.C. General Assembly to provide additional support to North Carolinians whose housing needs are not met by the traditional market.

The agency receives funding from a variety of federal and state sources and administers the N.C. Housing Trust Fund, which is financed annually by the General Assembly and is considered by some as the state’s most flexible funding resource for housing.

The agency offers various grant and loan programs to bolster the abilities of counties and nonprofits to repair homes in their locales, including the Urgent Repair Program, which is available to elderly and disabled homeowners around the state whose annual income is below 50% of their county’s annual median income.

The program is funded through the Housing Trust Fund and received $4.5 million in the 2020 fiscal year. Individual counties and local organizations can apply for up to $100,000 annually through the program, or $200,000 if the county is part of a council of government or if the organization serves more than one county. Counties that receive funding then allocate the money to perform repairs at individual homes.

Individuals served through the program can receive a lifetime maximum of $10,000 in repairs for their homes, which is typically enough to either make one big repair, such as installing a new roof or an entirely new bathroom, or a few small repairs, such as fixing leaky pipes or installing a new water heater.

The program typically serves between 600 and 700 homeowners each year. Last year, the program funded repairs in 52 counties, performed by 37 local governments or community partners.

Rutherford County has a strong track record of applying for and receiving funding through the Housing Finance Agency. Searcy said the county has annually received Urgent Repair Funding for at least a decade and typically partners with the Rutherford Housing Partnership to screen applications and perform the repairs.

But even with resources like the Urgent Repair Program in place and nonprofits doing the groundwork, thousands of North Carolinians each year are unable to receive the help they need — and without minimum housing codes in place to prevent homes from falling into disrepair, some county employees, like Dotson in Rutherford County, are worried that things won’t get much better.

Dotson knows implementing a minimum housing code would be an uphill battle. It would take years to find and repair all the homes in the county that lack some form of plumbing, and it would likely be met with backlash from some landlords and homeowners.

But to him, it would be a worthwhile battle to fight.

“I think if they took it in baby steps, even if it’s a five-year or a 10-year plan, anything’s better than not having it,” Dotson said.

shows a woman in medical gloves giving an injection to an older man, while an older woman looks on. They're all wearing masks to prevent transmission of COVID-19.

Shifting allocations cause confusion for vaccine seekers, frustration for local health departments

January 26, 2021 by Rose Hoban

Shifting allocations cause confusion for vaccine seekers, frustration for local health departments - North Carolina Health News

Changes in the allotment of vaccines force health providers to delay and reschedule appointments as the state grapples with the low supply.

By Rose Hoban and Anne Blythe

Across the state, phones at local health departments are ringing off the hooks, with people on the other end all asking the same question: “When can I get my vaccine?”

“Now we receive more than 15,000 calls per day,” wrote Granville-Vance Health Director Lisa Harrison in an email.

At NC Health News, we’ve received hundreds of emails asking the same thing.

The answer to that question has been upended across the state as health care systems and local health departments realized appointments they had made would have to be postponed and rescheduled because of shifting state allocations.

For example, Cone Health postponed vaccine appointments for 10,400 people because the state did not deliver enough doses for a mass vaccination clinic to be held in the Greensboro Coliseum Special Events Center.

“We are deeply disappointed that we are forced to delay these essential vaccinations,” said Cone Health CEO Terry Akin in a Friday press release. “In order to maintain an aggressive vaccination strategy, we need predictability and regular vaccine shipments from the state as originally promised.

“I am very unhappy that the state appears to keep changing the rules for vaccination allocation.”

Meanwhile, a mass vaccination event went forward at Charlotte Motor Speedway over the weekend, where close to 16,000 people received doses of the COVID vaccine between Friday and Sunday.

People up and down the supply chain are frustrated and confused.

“Due to a change in the number of COVID-19 vaccines Cape Fear Valley Health has been allotted by the State of North Carolina, the health system has had to reconfigure the way in which we run our COVID-19 vaccination clinics,” a spokesperson for the system told the public Monday in a press release.

On Monday afternoon, the state Department of Health and Human Services put out their own press release to address some of the controversy swirling around vaccine supply.

The statement noted that the federal distribution network told North Carolina that only 120,000 first doses will come to the state.

The release noted that as of Sunday evening, 88 percent of the state’s first doses had reportedly been administered. The state also has second doses for all of those people who received their first doses. But state officials are holding those in reserve so that they can complete the vaccine series for all those people who got their first doses.

In some ways, the way the federal government has distributed vaccines to states has created a Catch-22: States like North Carolina that worked to get vaccines to small health departments and into remote counties with few people have been criticized for moving too slowly. But ramping up mass vaccination clinics in population centers and focusing on speed has meant that supply gets shut down to those smaller counties and municipalities.

And there aren’t enough supplies anywhere.

“I know that’s really frustrating and I know that is not something that we are used to,” Betsy Tilson, North Carolina’s State Health Director, said during a telephone town hall meeting with AARP members Monday afternoon. “That is going to be the reality for the next couple of months, is that the demand and the people eligible for the vaccine is going to be far greater than the amount of vaccine that we have.”

Supply and demand

There are about 400,000 health care workers in North Carolina, about half of whom are seeing patients regularly and could be exposed to COVID. That group was the very first cohort of people to receive vaccines based on federal guidance created last fall from both the Centers for Disease Control and Prevention and the National Academies of Science, Engineering and Medicine.

shows four phases for COVID vaccine priorities in a chart — Vaccine priority phases designated by the National Academies of Science, Engineering and Medicine in the fall of 2020.

The CDC and NASEM agreed that the second priority group would be older people living in nursing homes and assisted living facilities where the virus has taken a tragic toll. North Carolina had designated “Phase 1b” to also include everyone over the age of 75, who has been at the greatest risk of dying from COVID. According to statistics from the U.S. Census, there are more than half a million North Carolinians in that age group.

Initially, North Carolina planned to focus vaccine distribution on just those two big groups of people, but targeting just those people was proving to be slow.

“The way we did our allocation prioritization was to make sure that we were getting an equal number of doses per county population,” Health and Human Services Secretary Mandy Cohen told lawmakers during an oversight committee meeting on Jan. 12. “And you know, we have a very geographically diverse state, a very rural state, but we felt it was a priority to get vaccine out everywhere.”

But Cohen came under intense criticism from lawmakers for the pace of the rollout.

“Most of us don’t feel that this process has moved as quickly as it could or should have to this point, and we’re wanting to deal with it,” said Sen. Ralph Hise (R-Spruce Pine). “We merely handed it over to basically 100 county health departments and hospitals and said, ‘Have fun.’”

Around the same time Cohen was getting grilled by lawmakers, former federal HHS Sec. Alex Azar changed the federal vaccine distribution strategy.

“Only four weeks into our launch, we have gained confidence in the integrity of our system,” Azar said during a press briefing on the same day. “It’s time to move onto the next phase of our vaccination campaign.”

Laying the blame squarely on states for the slow vaccine rollout, Azar expanded the scope of the people recommended to receive the vaccine to people who were 65 years old and older, even as the other groups were not completely vaccinated yet. Azar also told states to speed things up and threatened to penalize states that were moving more slowly by releasing less vaccine to them.

“Some states’ heavy-handed micromanagement of this process has stood in the way of vaccines reaching a broader swath of the vulnerable population more quickly,” he said.

At the same time, he opened up eligibility to people 65 years old and older, and those people under the age of 65 with a preexisting condition with some form of medical documentation of their condition.

Azar’s move meant expanding the number of eligible people in North Carolina by more than a million people and unleashing a wave of demand. Now, between health care workers and people over 65, North Carolina has as many as 2 million people who are eligible for receiving the vaccine, with each person requiring two doses of either the Pfizer or Moderna vaccines.

But, to date, North Carolina has received 960,000 doses, according to CDC data. And what’s been hard for many people to absorb is that eligibility does not mean availability.

“What we get in the state is about 125,000 doses a week,” Tilson told the AARP town hall. “So less than 10 percent of the doses for the population.

“It is going to be in short supply for the foreseeable future and it’s gonna be hard for people to find appointments,” she said. “The demand is greatly gonna outstrip the supply.”

No win situation

“I think we … could have done a better job at setting expectations, managing those expectations, communicating to the public, and how we are measuring state performance,” said Julie Swann, a faculty member at NC State University who studies pandemics and supply chains.

She said that the federal government told states to do one thing and then evaluated states by a different metric.

“The advisory bodies told states ‘prioritize these populations in these orders,’ and then we’re measuring them, how fast are you administering doses,” she said.

Swann pointed out that the advice from the CDC and NASEM were geared toward reducing deaths, not getting lots of people vaccinated at once.

“The goal of the vaccination was never ‘stop the pandemic immediately.’ There’s no way but it can’t do that, you’ve got to have 400 million doses before you get to that level,” she explained. “You’re not going to stop the pandemic in a short number of weeks with a limited supply, what you can really do is prevent some deaths and prevent some hospitalizations.

“The real question we need to ask is, what is the best way to prevent deaths, prevent hospitalizations, and ensure that our society continues to function,” she said.

And the current focus on speed and getting all those older adults vaccinated now doesn’t accomplish some societal goals of getting people back to work.

“What about the teachers and the firefighters and the food workers and the grocery store workers who are exposed potentially every day and need protection against that risk?” she said. “We’ve now set aside what states were told for months to focus on.”

Swann also said that the numbers people are dealing with here are so big, they’re hard for people to wrap their heads around. Right now, the federal government has distributed about 40 million doses to states, enough to vaccinate about 20 million people, which sounds like a tremendous number.

But that’s only enough to vaccinate about six percent of the total population.

She also said that the folks in local health departments who are tasked with doing vaccinations now are the same people who have been working overtime since last March to manage the pandemic.

“Let’s start with the fact that state and local health departments had been asking for funding and resources for last-mile distribution for months, and finally got allocated something December 27, December 27!” she said. “We did not have a national focus on last-mile distribution until somebody was unhappy.”

Speaking of equity and diversity

At issue is whether the state can effectively get its weekly vaccine allotments into arms quickly while also equitably getting doses to communities of color and historically marginalized populations.

DHHS has committed to equitable distribution to the historically underserved and under-represented communities, while also struggling to meet the demands of lawmakers and vaccine enthusiasts in the 65 and older groups.

The Association of Mexicans in North Carolina, or AMEXCAN, an advocacy organization for Latinx residents, held an NC Latino COVID-19 Task Force meeting on Zoom meeting Monday morning in which part of the discussion was about vaccines.

The DHHS dashboard showed on Monday afternoon that Hispanics had received only 3 percent of the first doses given over that past month and only 4 percent of the second doses.

“Our numbers don’t look good in our Latino community,” Juvencio Rocha-Peralta, executive director of the community resource organization, told meeting participants.

Public health officials have been rolling out campaigns to overcome the expected vaccine hesitancy in communities of color. Latinx residents have voiced concerns about having personal information they provide to health care workers being turned over to immigration officials. State health officials have tried to counter those fears, saying there are no plans to do that.

In McDowell and Rutherford counties in the western part of the state, Centro Unido Latino-Americano, a non-profit organization working to promote social justice, health equity and inclusive education services for the Latinx community, has been working with the county health departments to educate residents about the vaccine.

Margarita Ramirez, executive director of CULA, told participants on the Zoom call that her organization has been contacting people who tested positive for COVID-19 or were tested for the virus and giving them information and answering questions for those who are hesitant.

Over the weekend, they gave out flyers to families who came to the food pantry. Afterward, CULA received calls from two families asking to be put on the vaccine waiting list.

“They said, ‘We trust you,’” Ramirez said. “We’ll do this.”

Steve North and Amanda Martin of the Center for Rural Health Innovation, which administers the Spruce Pine-based MY Health-e-Schools program.

School-based health centers fill rural provider vacuum

November 17, 2020 by Melba Newsome

School-based health centers fill rural provider vacuum - North Carolina Health News

Making healthcare available to students, faculty and staff on campus is vital to well-being in rural areas.

By Melba Newsome

Growing up in a small town in central Wisconsin, many of Steve North’s relatives and friends assumed he would follow his father into medicine but North had other ideas. He earned a liberal arts degree at the University of Wisconsin-Madison in 1993 but, instead of applying for medical school, he applied for Teach for America.

For the next two years, North taught 5th- through 8th-grade exceptional education in Edgecombe County where he saw how unaddressed medical problems kept his students from reaching their academic potential.

“The kids were frequently coming to school sick or missing lots of school,” recalls North. “I started doing some reading and got turned on to the idea of school-based health centers (SBHC), which were relatively new on the national scene at the time.”

What he learned persuaded North to finally follow in his father’s footsteps and he was accepted to medical school at UNC Chapel Hill.

While practicing family and adolescent care medicine in Bakersville, a remote mountain town with fewer than 500 residents, North continued to look for ways to provide better care to the children he served. A Jim Bernstein Community Health Leadership Fellowship gave him the support and resources to start the Center for Rural Health Innovation, a non-profit dedicated to improving rural access to health care. That led to the formation of Health-e-Schools, remote clinics that provide primary care and behavioral health services for school kids.

A doctor’s office on campus

North Carolina has been trying to solve the state’s provider scarcity problem for decades with varying degrees of success. In the western part of the state, the doctor-to-patient ratio can be as high as one to 2,000 in some of the most remote areas. School-based health clinics (SBHCs) bring together educators and health practitioners to bridge the health care and education gap and help reduce the disparities that impact school children in rural burgs.

SBHCs are essentially doctors’ offices conveniently located on campus to provide a range of health care services for students, as well as for teachers and staff. For many rural, low-income residents in health care deserts, these clinics are their only access to care.

With permission from a parent or guardian, students are enrolled at the beginning of the school year and can take advantage of available resources. In addition to seeking medical attention for acute issues such as ear and stomach aches, enrollees can also receive chronic disease management, immunizations, well-child checkups, sports physicals, adolescent medicine consultants, and hearing and vision screenings.

North Carolina law also allows minors to seek medical health services for the prevention, diagnosis and treatment of sexually transmitted diseases, pregnancy, substance misuse or emotional disturbances without parental consent.

Additionally, these clinics also help reduce the number of days of classes missed by students.

“This is a good thing because when they come back after being out for a couple of days, they’re behind and it takes a while for them to get back up to speed,” said North. “If that happens more frequently with chronic absenteeism, it can be really tough to bring students back on track.”

SBHCs continue to expand

SBHCs continue to grow across the country and the state, particularly in areas with a shortage of health care providers. Some are funded through private grants but many others are supported by state and federal appropriations. Most partner with the local school district and a community health organization, such as a community health center, hospital or local health department. All are committed to serving every student, regardless of insurance or ability to pay.

When North and the Center for Rural Health Innovation launched Health-e Schools in 2011, the program served just three schools. Now, it reaches more than 25,000 students in 80 schools across three western counties, McDowell, Mitchell and Yancey.

“Parents might work 30 miles in one direction and children go to school 20 miles in the other,” said North. “Before this, when that inevitable call comes in that said ‘Johnny is sick,’ parents had to drive to school, pick up the child and go to the doctor’s office. A lot of those people would end up in the ER who probably didn’t need to be there.”

Shows a man smiling behind a mask worn to prevent transmission of COVID-19. He's standing next to a sign for the Health-e Schools sign for a clinic site at Greenlee School. — Jason Hall, principal of Greenlee Primary School in the Mitchell County town of Spruce Pine shows off his school’s affiliation with Health-e Schools. Photo credit: Lacey Jones, RHI

Similar alliances operate all across the state. Blue Ridge Health operates 13 SBHCs in Henderson, Buncombe, Swaine, Jackson, Rutherford and Polk counties. Many of their students have an hour-long bus ride to and from school so the convenience of on-site clinics means a child doesn’t have to miss a day of school just to see a doctor.

On the other end of the state, the Pender Alliance for Teen Health (PATH) operates three SBHCs in southeastern Pender County, filling a big gap in a place where families routinely drive 50 miles one-way to see a health care provider.

“We have certainly improved their access,” said Kimberly Collins, lead nurse for Pender County Schools. “More kids are getting their annual physicals and getting vaccinated on time. Our staff is able to see them for whatever needs they might have without having to leave work or take a whole day off, or even a half a day off.”

Using high-definition video conferencing with specially equipped stethoscopes and cameras, a centrally located health care provider can examine students at multiple schools without traveling.

As these programs continue to grow, equipping them with these tools becomes more economical, said North.

“It used to cost $30,000 to put telemedicine technology in a school,” he said. “We can now equip a school nurse for about $2,000, with a better piece of equipment that they can take from school to school.”

Behavioral care a gaping need

A study in JAMA Pediatrics found that 72 percent of North Carolina children diagnosed with a behavioral health condition waited more than a year to meet with a licensed mental health provider. According to a brief from the North Carolina Institute of Medicine, this is due in large part to the shortage of specialized instructional support personnel such as nurses, counselors, psychologists and social workers. For example, the recommended ratio is one social worker for every 250 students. North Carolina has one for every 1,427 students, according to the NC IOM report.

Lack of high-speed internet can complicate telehealth delivery in rural communities but SBHCs have made great strides in using technology to connect students to counselors, psychologists and social workers.

In September 2018, Hurricane Florence dropped more than 40 inches of rain in one day on Pender County. Up to 70 percent of the county was under water, 3,000 homes were damaged, and tens of thousands of residents were displaced. Schools remained closed for 29 days while families tried to rebuild or relocate.

By the time the coronavirus pandemic hit 18 months later, hundreds of families still lacked permanent housing.

“The pandemic is like a second wave gut punch for Pender County,” said Sandy Rowe, PATH executive director. “We were still reeling from Florence. With the poverty, remote areas and the domestic violence against our kids, they are feeling like they can’t count on anything.

“We’ve focused on doing what we can to reach them and offer services early enough in the process so that we don’t have a bigger problem later on.”

When a post-Hurricane Florence mental health risk assessment found that 30 percent of the children were at risk for depression, PATH stepped in to add two full-time teletherapy counselors and a health coach to its team of providers. It also boosted preventive measures by developing a mindfulness curriculum for teachers.

Blue Ridge has on-staff counselors for district students and Health-e-Schools partners with Mission Health to address the needs of students with complex mental health issues. Instead of missing school and possibly driving an hour to see a therapist, they can see a mental health provider and still get back to class before the school day ends.

There is a growing recognition of the value SBHCs have to their communities. In 2016, the Federal Office of Rural Health Policy and the Health Resources and Services Administration encouraged expanding access to SBHCs and provided more than $6 million in grants for rural telehealth programs. Last year, HRSA awarded $11 million to SBHCs for technological upgrades.

This is a win-win that bodes well for the growth of SBHCs, particularly in rural areas.

Melba Newsome is a 2020 EWA Reporting Fellow. This story is produced as part of EWA’s drive to support enterprising journalism that informs the public about consequential issues in education.

shows a video conferencing call with six people who were talking about Cardinal Innovations

Union, Cabarrus, other counties look to cut ties with Cardinal

October 20, 2020 by Rose Hoban

Union, Cabarrus, other counties look to cut ties with Cardinal - North Carolina Health News

Union and Cabarrus counties are exploring changing mental health management organizations ahead of a critical deadline. Others may follow suit.

By Rose Hoban

With little debate, members of the Union County board of commissioners voted unanimously Monday afternoon to disengage the county from their relationship with Cardinal Innovations, which has managed mental health services there for years.

Several hours later, Cabarrus County commissioners followed suit, initiating the process of severing ties with the organization, which once built a multimillion dollar corporate headquarters there.

In front of PBH's Kannapolis office. — In front of Cardinal Innovation’s Kannapolis office, which was the corporate headquarters until they were moved to Charlotte. Photo credit: Lydia Wilson for NCHN

The moves come after commissioners in both counties received repeated complaints, particularly about children in need of services who were difficult to place because of the complexity of their care.

According to Union County deputy manager Michelle Lancaster, who also manages county human services, people have been frustrated that Cardinal has dragged its feet on getting the appropriate level of care for kids in foster care, some kids with Medicaid, and other children with extensive needs.

“And we have providers of services in the community who have expressed frustration, about the difficulty of working with Cardinal around approvals and feeling like the array of services was appropriate for the clientele,” she said.

Cabarrus County commissioner Blake Kiger said that he’s been hearing complaints about Cardinal almost since taking his seat in 2017.

“I’m sure it predates me. That, at least, is the reference point that I have for how long … we’ve tried to work through some of the issues,” Kiger said. “This is not something that we just have decided to do on a lark or a whim, to a lot of people, this is long overdue.”

The changes come even as state Department of Health and Human Services deadlines are looming for behavioral health providers to apply for contracts to serve people with the most complex needs. Once those “tailored plans” are put into place, it will be a more complicated process for counties to change their behavioral health managers.

Rocky past, present

Cardinal, and its predecessor organization Piedmont Behavioral Health, has managed mental health services in both Union and Cabarrus counties for at least 20 years. The two were part of the five involved in the original PBH pilot program that got counties out of the business of providing mental health services directly to patients. Instead, the state allowed these organizations to pivot and act as mini-insurance companies, contracting with counselors, psychologists, psychiatrists and other providers to deliver care to people with behavioral health issues.

That pilot program eventually spurred North Carolina to completely transform the state’s mental health system to have all care managed by similar “local management entities/ managed care organizations,” a change that went into effect in 2013. Under this managed care system, the agencies, known as LME/MCOs, get a pot of money for every Medicaid mental health consumer in their area to pay for all mental health services a person might need. In addition, the LME/MCOs receive state dollars to cover costs for some people who have no insurance.

The organizations have the power to approve or deny the claims providers submit on consumers’ behalf.

Check out our 2012 series on how Piedmont Behavioral Health spurred changes to North Carolina’s mental health system

The changes were controversial and turned the lives of some patients upside down as the whole way of receiving care changed. The changes also were rough on providers who saw their revenues shift and had to reorganize themselves as well.

As the changes took effect, some LME/MCOs went out of business, at least one ran its finances millions in debt. All the while, Cardinal grew and grew, taking over the management for patients in more counties, growing from the original five-county system in the southern Piedmont to covering more than 20 counties in far-flung parts of the state.

Throughout its history, Cardinal had often gone its own way. Leaders at the organization seemed impervious to criticism about agency spending and about the way they presented themselves and their agency. They long insisted that Cardinal did not need to adhere to state rules, but that as a “quasi-governmental agency” it was free from legislative oversight.

That facade began to crumble in 2016 when then-secretary of DHHS Rick Brajer publicly took former Cardinal CEO Richard Topping to task for his million-dollar-plus compensation package.

Cardinal CEO Richard Topping was finally pushed out of his position by state officials after a headline-grabbing audit revealed a million-dollar-plus salary, lavish parties and travel on chartered jets at state expense. Image courtesy Cardinal Innovations

Then came a headline-generating report from the state auditor in 2017 that found senior management at the agency were paying themselves handsomely, throwing lavish parties on the public dime and flying board members to resorts for meetings in private jets. Topping’s compensation package was well north of a million dollars a year.

Later that year, a new DHHS secretary, Mandy Cohen, took over the agency, expelling the CEO and the board of directors and installing new upper-level managers. Cohen said Cardinal’s consistent flouting of state rules, Topping’s and the board’s defiance of her agency’s attempts to rein them in, and the added tussle over Topping’s salaries finally pushed her to act.

With a new CEO hand-picked by DHHS leaders and a new board, Cardinal seemed to enter a quieter period, during which it expanded but stayed out of the limelight.

But troubles persisted.

“For years and years and years, these same issues just keep coming up,” said Cabarrus County commissioner Lynn Shue. “Even after all the changes that the Department of Health and Human Services made with the appointment of a new board and all of that, it seems as though we’re not getting things that we’re looking for.

“We’re looking for collaborative effort.”

Cardinal losing its grip

On Monday evening, Cardinal’s management expressed their disappointment.

“We have been committed partners in Union and Cabarrus counties for decades,” wrote Cardinal CEO Trey Sutton in an email to NC Health News. “We have been working hard at these relationships and feel that our joint efforts have been headed in the right direction, so today’s activities were especially disappointing.”

Sutton argued Cardinal has been working to “do the right thing for our most vulnerable citizens.”

He pointed out that under state law, the final decision over whether to allow counties to disengage from Cardinal as their mental health manager will have to come from DHHS leadership. He also noted that the multi-month process is “lengthy and certainly not guaranteed.”

Both Union and Cabarrus counties have resolved to move their county contracts to Partners Health Management, an LME/MCO based in Gaston County which covers nearly a million people in Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Rutherford, Surry and Yadkin counties.

shows people sitting at long meeting tables, with hands raised — In 2017, commissioners from 19 counties met to choose new board members for Charlotte-based Cardinal Innovations. Photo credit: Rose Hoban

An official in Forsyth County said she’s putting finishing touches on a letter outlining her commissioners’ issues with the organization. She said her commissioners weren’t quite ready to jump ship, but they were open to exploration.

“Local citizens wish for more locally based leadership that is responsive to community stakeholders, especially consumers and families, but instead sense internal chaos and frequent staff changes,” said Winston-Salem-based mental health advocate Laurie Coker.

Rutherford County actually switched to Partners last year. In a presentation to that county’s board of commissioners earlier this month, a representative of the organization outlined the increased level of service.

“The Partners presentation of their first year serving the citizens of Rutherford County was impressive,” county commission chair Bryan King told the Daily Courier. “The news of an increase in providers, and an increase in citizens served was welcomed news.”

Changes coming for complex patients

One of the long-held complaints about the LME/MCO system has been that it disincentivizes spending big dollars on people who have some of the most complex needs. For Union County’s Michelle Lancaster, the big issue was treatment and placement for children with exceptional needs.

“They’re typically hard-to-place kids. They may have,” Lancaster paused and sighed, “It is what it is – over-sexualized behaviors, they may have a history of violence, things that wouldn’t make a traditional foster home appropriate for their care.”

She said her county has ended up spending local dollars to provide the appropriate level of care for these children, sometimes for months or years because the county couldn’t get satisfaction from Cardinal.

“They really see their job as providing treatment and the role of DSS is to provide placement,” Lancaster said. “However, these are complicated kids, you cannot separate the two of those things. You can’t say, ‘Hey DSS, go place that kid somewhere, and we’ll come and catch up with you on the treatment side.’ It just doesn’t work that way.”

These children are among the complex patients whose care will be addressed in upcoming changes to the state’s Medicaid program. In the coming month, DHHS will ask provider agencies to put in their proposals for how to create tailored plans for the most complicated patients.

It’s expected that LME/MCOs will put in applications for contracts that will last for four years. Once counties start down the road with whoever gets chosen to administer these tailored plans, it will be difficult to disentangle themselves, said Corye Dunn, an attorney with Disability Rights North Carolina.

“It’s the rollout of tailored plans that really put the decision point right in front of counties right now,” she said.

The request for applications will open up in November, with contracts awarded sometime early next year.

“And at that point, managed care entities are going to get a multi-year contract to serve a fixed catchment area,” she said. “I can imagine that if I were a county official, and I were unhappy, I’d be pushing for change now.”

Correction: All local management entities/ managed care organizations, transferred to the new system in 2013, not 2015.

We see a hand holding a cardboard sign that says, "#Free Them All" sticking out the passenger window of a compact white car passing the Durham County Detention Facility. The car is part of a caravan of protestors calling for the release of inmates who are unable to pay bail during the pandemic. It's Father's Day, 2020.

Even as NC’s COVID numbers stabilize, jail outbreaks spike

August 11, 2020 by Hannah Critchfield

Even as NC’s COVID numbers stabilize, jail outbreaks spike - North Carolina Health News

Cases have risen at nine local jails; at least one outbreak is connected to a transfer from the state prison system.

By Hannah Critchfield

Nine jails in North Carolina have reported new COVID-19 outbreaks since August 1.

The infections have occurred just as the state has begun to see a hint of stabilization in its overall COVID-19 cases.

The vast majority of these jails — in Avery, Carteret, Catawba, Gaston, Orange, Rutherford, Stokes and Wilkes counties — had no previous outbreaks, making this their first correctional outbreak since the pandemic began. Rutherford County Jail in particular has been particularly hard hit, with 21 inmates and five staff infected.

Durham County Detention Facility, where an outbreak in April killed one staffer, reported eight new cases among inmates on Sunday.

“Our worst fear has come true inside the facility and we are taking immediate and corrective steps to get in front of it,” Sheriff Clarence F. Birkhead said in a press release announcing the outbreak.

What caused the outbreaks?

It’s difficult to completely prevent outbreaks in congregate settings such as jails, as staff must enter and exit facilities each day.

However, one jail’s outbreak, Avery County Detention Center, resulted from the transfer of an inmate from a state prison under the Misdemeanant Confinement Program, a partnership in which county facilities hold low-level, convicted prisoners on behalf of the state. Like other types of transfers, the program has not ceased during the pandemic.

Because the Department of Public Safety, the agency that oversees the state prison system, is currently the subject of a lawsuit over COVID-19 conditions, people who are transferred must now either undergo quarantine upon arrival or receive a COVID-19 test prior to entry, according to Citlaly Mora, communications strategist at the the American Civil Liberties Union, one of the plaintiffs in the case.

This inmate was asymptomatic, according to Avery County Sheriff Kevin Frye.

A detention staffer at Orange County Detention Center, who contracted the virus from a significant other, similarly did not show symptoms in their initial days with COVID-19. Two more staff tested positive in late July (these cases did not appear on the Department of Health and Human Services website until August), and after mass testing was conducted, one incarcerated person had the virus.

Arrangements were made “immediately to remove him from the facility,” according to Alicia Stemper, director of public information at Orange County Sheriff’s Office.

“As a congregate living facility, we feel very fortunate to have only had one inmate with COVID 19 and we are pleased to report our staff members are recovering,” Stemper said in an emailed statement.

It’s possible this inmate already had the virus — he too had been transferred from another facility days earlier.

“That inmate had been in a different facility since April and arrived at the Orange County facility on July 20,” said Stemper, noting this was the same day the officer’s COVID-19 test result came back positive. “As is protocol, the new inmate was in isolation the first three days at our facility. He or she showed no symptoms and was transferred into a regular cell.”

When the local health department engaged in mass testing of all inmates on July 23, this person was the only one who tested positive, according to Stemper.

We see Andréa “Muffin” Hudson, director of the North Carolina Community Bail Fund of Durham, wearing sunglasses and a mask as she waits to bail out black fathers outside the Durham County Detention Facility. Her organization raised $100,000 for bail funds on Father's Day 2020. — Andréa “Muffin” Hudson, director of the North Carolina Community Bail Fund of Durham. Photo credit: Hannah Critchfield

Carteret County Jail, where two employees have the virus, also said a detention staffer likely infected other staffers. One inmate has since tested positive and is in isolation; they’re awaiting results from mass testing of all staff, according to Carteret County Sheriff Asa Buck.

The Durham County Detention Facility has engaged in contact tracing with the local health department, according to AnnMarie Breen, public information officer for the Durham County Sheriff’s Office. She declined to comment on any suspected origin of the outbreak at this time.

Other sheriff’s offices whose jails are experiencing new outbreaks have not yet responded to requests for comment.

‘If they had money, they’d be free’

Not everyone who is eligible for release has been let go within the 99 county jails across the state, as criminal justice reform groups have pointed out since the novel coronavirus virus hit the United States in full force in March. Some individuals remain incarcerated because they’re unable to pay bail fees — advocates claim these fines serve as a “poll tax” that denies the person’s right to a healthy, safe living environment amid the pandemic.

“It’s a lot of folks who are here only because they’re poor,” Andréa “Muffin” Hudson, director of the NC Community Bail Fund of Durham, previously told NC Health News in a June interview. “It’s not a public safety issue — because if they had money, they’d be free.”

Jails and prisons have been called incubators for COVID-19. As in other congregate settings such as nursing homes, these environments place large numbers of people in relatively small spaces where it can be difficult to socially distance.

In North Carolina, the burden of pretrial detention disproportionately falls on black and brown people and those living with disabilities, according to Luke Woollard, staff attorney at Disability Rights NC.

“Folks with disabilities of all types are overrepresented in North Carolina jails,” he said. “And people with specific disabilities are at heightened risk for serious complications or even death if they contract COVID. Medical services provided in jails varies county to county, and is often inadequate to meet the growing need, especially during a pandemic.”

On nearly every Friday since April, Decarcerate Mecklenburg, a local coalition of attorneys, advocates and community members, has led demonstrations outside the Mecklenburg County Detention Center to call for the release of people incarcerated inside. During an August 7 protest, the group accused the jail of “disregard for human life,” according to the News & Observer. The facility currently has 59 jailed people who are infected with the virus.

“There’s a difference between a COVID outbreak in a jail and a COVID outbreak in a prison,” said Kristie Puckett-Williams, a statewide campaign manager at the ACLU of North Carolina who helps organize the Friday protests. “It’s actually more dangerous in a jail because people are coming in and going out. If they go in without COVID and come out with it, now they’re back in the community with the disease. Not just inside a facility with it. It’s a public health issue, like we’ve been saying all along: Correctional health is public health.”

The coalition is asking for jails in the state to release all people who are awaiting trial for a misdemeanor crime, according to Puckett-Williams.

“Our research team, along with others across the country, is seeing a push to lessen the populations within jails,” said Felicia Arriaga, an anthropologist and professor at Appalachian State University who has studied North Carolina sheriff’s offices’ responses to COVID-19. “For organizers, I think it’s also an opportunity to push decarceration, and to maintain populations at a low level, because of the issues of social distancing within jails.“

To date, there have been no confirmed deaths of jailed people due to COVID-19-related causes in North Carolina.

UPDATE: This story has been updated with an additional quote from the ACLU of NC.

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