Public health impacts of COVID-19

But what’s covered and what’s not? Is laboratory testing an allowable expense? What about clinical care? Staff overtime and extra hospital beds? This podcast breaks down the three main sources of federal funding for health and medical costs related to COVID-19—CDC, ASPR, and FEMA—and offers a deep dive into what each one covers to meet the medical needs of the community.

In addition, now that over 35 states have received a major disaster declaration, more categories of federal assistance are open to both governments and individuals. As the crisis unfolds and stress levels rise, government officials also need to understand the programs and services available to individuals under the Individual Assistance (IA) program—and how to support their mental and emotional needs.

In this podcast, two ICF experts—Meghan Treber, senior director for emergency preparedness and public health preparedness, and Dr. April Naturale, traumatic stress specialist—discuss the public health impacts of COVID-19. Moderated by Marko Bourne, former director of policy at FEMA, the conversation covers:

• Current status of HHS programs and support.
• An overview of the three main sources of funding for COVID-19 health and medical costs—and a breakdown of allowable versus unallowable expenses for each.
• How to prepare healthcare workers on the front lines for what they might face—both physically and emotionally.
• What the research says about managing stress during traumatic times.

Full transcript below:

Today, we're going to be discussing more about the public health impacts, both from a public health community and hospitals, the HHS programs that are being put in place now and will continue over the next several months, and also some of the behavioral challenges and mental health issues that are being addressed as well. We have a tremendous group of experts with us again today and wanted to introduce them briefly here and then ask them to talk a little bit about the challenges that they're seeing, the solutions that are being developed, and some of the questions that we need to be looking at. And finally, we will do a Q&A session with both to try to tease out more information about how things are being managed and where we need to go.

Just a reminder, this is a series of podcasts that'll range on a number of different subjects beyond federal assistance, state/local assistance, as well as what's happening with the public health community in general. ICF is proud to present this podcast series and we welcome you and thank you for listening, and look for your ideas moving forward. You'll be able to see this [on our] website at www.icf.com under Insights where all of the podcasts will be listed, and there will also be a number of links for information that you can look into in more detail.

Today, we once again have Meghan Treber. Meghan is one of our senior emergency management and public health officials, has worked at state public health, has worked at the federal level, and supports our clients at the Department of Health and Human Services as well as a number of other emergency clients across the country. Meghan, welcome and thank you for joining us today. I think one of the questions that we have most importantly on all of our minds at this point is the current status of where we are with HHS programs and support. And what are the most recent actions that HHS is doing that we should all be aware of.

Meghan: Sure. Thanks, Marko. So as of April 6th, which is the time of this recording, we still have widespread disease transmission in cases in every state. Most models predict that we will not see peak disease spread until the end of April or early May, depending on your state. So, we are still very early in this process as a nation. Some states are further ahead in the epidemiological curve than others, but as a whole, we still have a ways to go. Some of you are actively responding and our thoughts are with all of you, and some of you are bracing for what is yet to come. So our goal, as Marko said today, is to get a bit more granularity on funding and to talk about some of the behavioral health implications of a prolonged response--and one with such fear and uncertainty. Many of you are not ready to start talking about those things.

Federal funding sources for COVID-19 preparedness and response

So to update you on [Inaudible 00:03:47] which is something that many of you are concerned about and focused on, there are three main sources of funding for health and medical costs related to COVID-19 preparedness and response operations, and these are from the Centers for Disease Control and Prevention, the CDC; from ASPR, the Assistant Secretary for Preparedness and Response; and from FEMA, the Federal Emergency Management Agency. So CDC has released a response supplemental to the Public Health Emergency Preparedness and Response Cooperative Agreement. It's approximately $570 million divided among all of the 62 recipients and it is to cover six domains: incident management for early crisis response, jurisdictional recovery, information management, countermeasures and mitigation, surge management, and biosurveillance. And there are several required activities which specifically include ensuring surveillance, laboratory testing, and reporting, and a community intervention implementation plan.

There are some unallowable costs which most notably include research and clinical care. CDC did release this week a FAQ on allowable and unallowable expenses. A link to these FAQs will be posted with this podcast. To pull out a couple of the notables specifically the CDC funds, they can cover beds and other furniture purchases to support patients under quarantine, and can support alteration or renovation of facilities to support any activity listed in the guidance. Hospitals and health care facilities can receive funds from this cooperative agreement so long as it is for allowable activities specifically enumerated within the funding opportunity announcement, and clinical care costs for individuals while subject to -- and this is important -- while subject to state or federal quarantine and isolation orders that aren't eligible for payment by other sources are allowable but they had to have been subject to state or federal quarantine and isolation orders. This isn't a blanket clinical care coverage. And then laboratory testing related to COVID-19 is an allowable clinical care cost. Again, all of these things should be coordinated with your state health department and with the CDC project officer as we are not trying to interpret guidance and tell you what to do.

Next is the ASPR funding. It is in the process of being awarded. It's $100 million that is being divided among existing recipients, which are the state, local, tribal, and territorial health departments along with a couple of city health departments, the National Emerging Special Pathogens Training and Education Center, the 10 regional Ebola and other special pathogen treatment centers, and there is an additional cooperative agreement that's being added for 53 state, territorial, and city hospital associations. The health department recipients will provide this funding to or can provide this funding to health care coalitions which are the 300 to 400 regionally, geographically-coordinated partnerships and to the special pathogen treatment centers that are in their states and jurisdictions. And hospital associations can distribute the funds directly to hospitals and other related health care entities. So you need to coordinate at the local level for these applications and for this process. These funds, these ASPR funds, may not be used for clinical care or staffing to provide clinical care. They could be used to support the setup and overhead operation of an alternate care site though, just not the direct costs of patient care.

And then finally, as we discussed in our last podcast, there is funding available through FEMA and the disaster relief fund for Category B Emergency Protective Measures. We have linked to the relevant fact sheets on this podcast page. The key here really is to track all costs--every single one--related to preparation for, response to, and recovery from this event, and then to coordinate with your insurers and your state and local emergency management agencies and your health departments to determine what costs are eligible and through which programs.

Any state representatives that are listening, please coordinate with your respective ASPR and CDC project officers, the ASPR regional emergency coordinators, and FEMA's regional administrators for clarification on allowable and unallowable expenses and to submit requests for assistance generally.

So now, in terms of resources for health care facilities to prepare for COVID-19 or to look for best and promising practices, there is a lot of focus right now on preparing...supporting the cities that currently have medical surge and preparing the cities where we are anticipating surge will occur. And that includes getting needed medical equipment and augmenting staff and setting up, in some cases, alternate care sites. So to do that, we would be remiss not to mention the three main resources that are available: CDC bonds page, which has up-to-date clinical guidance and recommendations for health departments, clinical labs, and clinicians; the FEMA COVID-19 webpage, which includes some best practices; and finally, the ASPR TRACIE website. ASPR TRACIE has housing resource collections specifically focused on health care facility response operations with a special emphasis on plans, tools, and templates, including resources with actions that are immediately implementable. ASPR TRACIE also staffs the Technical Assistance Center, so if you have a question while planning or working through this response, you can reach out for a tailored answer. There are links to both CDC and FEMA pages from the ASPR TRACIE COVID-19 landing page, which is linked to this podcast page. Marko?

Marko: Thank you. I appreciate it. I think one of the challenges that a lot of the states are going to have and the resources they're gonna have available now that over 35 states have gotten a major disaster declaration, it's opening up a couple of other avenues within the Public Assistance Program. It opens up the other categories which may support some infrastructure work, if necessary, whether that be for temporary hospital sites, other kinds of utility work or things that need to be done that can support the overall effort. But it also opens up individual assistance, which we'll talk about just in a few minutes because there is...that is, support to people directly as opposed to governments in covering their costs. We'll come to that more in one moment, but I did wanna go back to some of the planning that's being done and, really, around the notion of what kind of additional contingency planning should state and locals be thinking about in terms of their work with HHS and others on how this is going to play out over the next couple of months--or there's some critical things they need to be thinking about that are in the longer-term here as we hopefully get past the peak in the next few weeks.

Coordination and collaboration at the community level

Meghan: Sure. So, the first thing I would say is really to emphasize the collaborative relationship between local, state, and federal health officials. So coordinate and work with your ASPR regional emergency coordinators, with your state health departments, with your state hospital associations, with others. They are working across many states and are working with their partners so they can bring the lessons learned and the experience of cities that are currently experiencing major outbreaks to your planning in your state. So the focus, of course, as I mentioned, is on the immediate needs of the community, which are generally testing and clinical care and meeting the medical needs of the community. And, of course, I'm speaking specifically to the public health and medical response. There are other issues that every community is facing with regards to social distancing and schooling children and the, you know, downstream effects of a pandemic. And that, I think, Marko, it's probably a great topic for another podcast, is to talk through those downstream effects of pandemics and recovery. Well, we'll definitely get into that.

But in terms of contingency planning, you know, for right now, it's equipment, supplies, and people. So, you need to think through how are you going to resupply and restock. Are you connected with everybody that you can be? How are you going to access additional personnel to support not just your existing health care structures, but any alternate care sites that you may be thinking about? There are a number of states that have relaxed certification standards, that are allowing medical practitioners from other state licenses to come in and practice in their state with a very reduced process to transfer the license. There are also efforts underway to bring back folks who have let their licenses lapse, either--you know, there's a wide range of how people are doing this, you know--either within the last five or 10 years or as long as the license lapsed in good terms. So, there's lots of strategies at all of those links that I mentioned earlier and that'll be on this page. There are links to some, you know, promising practices and some documented efforts.

Marko: That's great to hear and certainly, yes, I agree we're going to definitely delve into that subject downstream as well in a future podcast as well as the additional assistance that's out there in order to address those larger and longer-term needs. We're also talking a lot, of course, about the fact that the unprecedented nature of this has actually now extended a natural...what used to be a natural disaster declaration is what most people think about it, but it was the emergency declaration, which is all 50 states and territories has been extended to more than 35 states now where a major disaster declaration, which actually opens up many more of the categories of federal assistance, both to governments as well as to individuals. And given that an event like this is both taxing on government and can be very traumatic and certainly of deep concern to individuals at home who are coping not only with protecting themselves and their families, but also potentially dealing with loved ones who are ill. Social distancing has created a number of both stressors on individuals and mental health and certainly creating a different dynamic as we look at some of the behavioral issues that are out there. Under the Individual Assistance Program, there's certainly the opportunity for crisis counseling and how to deal with traumatic events like this, which have a very different impact, I think, on people than most realize.

The personal impact of those on the frontlines of COVID-19

We're blessed today, and thank you for joining us, Dr. April Naturale, Pardon me, our P.h.D. in traumatic stress specialist with 30 years of experience in mental health and health care administration. She's a clinician, specializing in response to traumatic events. She led the New York State response to the World Trade Center disaster and was also the architect of the Boston Marathon bombing behavioral health response efforts as well and for the past five years, has been training humanitarian aid workers and psychologists in the military service of our European Union friends and crisis workers, and launched the first Ukraine, I'm sorry, first suicide prevention hotline, an expert not only in mental health, but also in the impacts of both natural disasters and manmade disasters on people and the public.

April, welcome, and thank you for joining us today and would love to get your views on how this particular disaster and this particular event has affected you and affected the work of the public health community that you work with every day.

April: Thanks, Marko. Appreciate the opportunity to talk with you this morning and thank you, Meghan, for all that fantastic information. From what we can see at this point where we're deep in a number of months in this response, it really is very obvious to me that our health care workers, while they've always been on the frontline and providing ongoing medical care, but in the aftermath of disasters and emergencies like we're seeing here with COVID-19, they continue to be the folks that are the go-to and they continue to be the responders without question, not only here, but throughout...not only throughout the U.S. but internationally, they have this long history as well. And even though this is one of the largest events that we've seen in several decades, again, our health care workers continue to respond to the need. They show up, even when it's frightening. They cover overtime, cover other people shifts, and they take on more whenever it's needed. We haven't seen that people aren't wanting to work, we instead see that they wanna be more involved and they wanna continue to do whatever they can. I think this event certainly showed us that we can always rely our health care staff.

I think what it's also showed us too is that we can't be lax about preparedness and planning efforts because we've got to ensure that because the staff are showing up, we've got to be able to provide them the supports that they need both physically and emotionally, so that they can continue to do the work that we need. And so, we've got to go beyond, you know, stocking the equipment that we need, which is certainly important, but it's got to be more than just managing. We've got to be able to do the extensive longer-term planning and help prepare the health care workers for what they might be facing and how to become stronger and more resilient than we've prepared them for at this point, especially with our concerns around the numbers, which is so frightening, and around the personal protective equipment.

Marko: April, one of the things that I think is foremost in a lot of folks' minds, especially those that are in the public health community or in the emergency management community or some of the folks that are really on the frontlines of dealing with this is, is it...how to deal with this from their own perspective? Is it better to keep a normal routine or is it...should they use their time differently and explore different ways to interact and to handle the challenges that are in front of them right now, given the fact that they are so immersed in this issue?

April: Yeah. It's a key question, Marko. Thank you. What we know from people who go through traumatic events like this is that it's really important to keep as much a normal routine as possible, especially for those of you who are caring for children, elderly, or other sick folks because even though we feel like we should be doing things, you know, differently and maybe start something new, it really does help keep our stress levels down if we have routine. We're creatures of habit. We love our routines. And so, we do suggest, as much as possible, especially for those of you who have children, to keep as much of a family routine as possible and also to watch boundaries around the professional work because, again, health care workers tend to be, "I'm there. I'm gonna do this," to the point where they really overwork themselves. And so, normal routine is very good.

It is an opportunity to learn new things. And so, if there is a time when we can decide we're gonna do something a little different, I think that's fine, but just not to overdo it, not to do too much that's new and different because your body and your mind are already under such stress, looking at the risks of this event and how it's impacting so many people is, even though we might not be thinking about it and doing our job, it's there in the back of our head. We know this is a life-threatening event and so, we want to be able to get some sense of comfort by our daily routines. So, they are important.

Coping mechanisms to minimize information overload and its impact on health and stress management

Marko: Certainly, one of the things that is ubiquitous about this as the information that's available because most of us are either home or we're in an area where televisions are on all the time, radios are on all the time, the news cycle regarding this is 24/7, unrelenting. Is it good to be avoiding the news right now, not talking about this? Some of us avoid the news, anyway, in general. But the simple fact is, is how should we be addressing the amount we're paying attention to what's being thrown at us by all of these sources, especially as we go through our day?

April: Yeah, That's a really important question too. I mean, the answer right off, what we know from today is we're all on overload with news and, unfortunately, there's a lot of inaccuracy in the social media. Of course, we're concerned about that. So, we generally follow the rule of checking in at key points in the day when you have a need to know any change in recommendations or status of your community or work. So, checking in a couple of times during the day--especially for health care workers--is important. But please, please, we should really be stressing to people to avoid this overload of television media, radio media stories, and especially social media.

Exposure is really the change agent that makes us more or less stressed, or more or less comfortable. And so, if we continue to overexpose ourselves to news, we're gonna have this underlying anxiety. We've got it anyway. We don't need it to be worse because of news. We tend to get really involved in listening to the news. Some people keep it running all day. And we know from the research that this overexposure just adds to stress and anxiety. So only check in when you need to with the news, but give yourselves a break other than that. It really can be something that increases stress levels terribly.

Marko: And when you talk about the anxiety, I mean, not all of us are fighter pilots or astronauts who don't talk about these things. What about the fear or the anxiousness? Does it make it worse to talk about it or is it better to talk about it and talk it through?

April: It's always good to be able to share your story, your concerns, your fears with somebody that you trust, somebody who understands and accepts how you feel. Not somebody who's gonna say, "Oh, I'm not talking about this anymore. Get over it." You know, people can have a habit of dismissing emotional concerns. And so, we do encourage people to find that buddy, somebody that you can talk to or with other people in your community, your networking community, maybe your family, so that you don't feel alone. Isolation is difficult. We're doing physical isolation, but this emotional isolation and disconnect from our social supports is problematic. Isolation is one of these high-risk issues that we're concerned about along with the exposure. But there are 40% of the population are introverts and they don't wanna be talking about what's happening to a larger group or to a number of people.

So, we do suggest that people who would prefer not to speak to others or to speak to groups, maybe to do some journaling. There's very, very good research that tells us that writing about or writing down your story or telling someone or creating a journal or some kind of an expression of your feeling is extremely helpful. Narrative is a wonderful way for us to say, "Gee, this is what happened to me." It helps us to be able to observe what's going on, but also, again, most importantly to feel like we're not alone.

Marko: Well, that's certainly important, and I think stress management is really critical in this time. Are there good stress management exercises or things we should be thinking about and practicing that will help us, especially when, you know, if we're a health care worker and we're dealing with patients every day and they have, you know, dozens, if not hundreds to work with, what are the stress management exercises? What are the things we should be encouraging?

April: That's a great question too, Marko, because as health care workers, what we usually hear is this theme song that says, "I'm fine." And, "I don't need to do this." Or, "I don't have time to do this." So we've introduced all different ways of doing simple stress management while you're still on the job, but ways that might help you to stay strong and feel less stressed doing the work, whether it's simple breathing exercises, there's a lot on when you have one minute, here's what you can do, when you have two minutes, here's a good exercise, or five minutes, here's a good breathing exercise. And we know that taking in oxygen, taking in a breath several times and just focusing on that absolutely decreases our blood pressure, our heart rate, and therefore, our stress level. So, it is one of the most common and important things, especially for people who are so anxious that they may even be feeling a rapid heartbeat or a panic attack coming on. You can't deep-breathe and have a panic attack at the same time. So, while some people might roll their eyes when we say do breathing exercises, they really are one of the most simple and effective ways to help ourselves to de-stress.

Stretching is also something our health care workers can do, no matter whether in the emergency room or in an office, simple stretches to get adrenaline and cortisol and the negative toxic stress hormones out of your body can be very helpful in addition to walking. So, when you've got 10 minutes, it's worth going outside, being in nature and taking a walk. We highly, highly recommend that our health care [staff] do this. Problem is getting them to do it. Again, they're usually so committed that they say, "I can't do this." But we know that if they don't stop and take some time to do some self-care, that they're gonna be worse off in the other end, especially if they're working long or extra shifts where we start to see judgment problems or decision-making becomes poor when people are too stressed out. So, we need to be mandating that they take the breaks as assigned to them and practice some way to help de-stress themselves and feel the strength that their need that they need to go back to work again.

The future of public health practices—and health care workers

Marko: Thank you. And I think that advice and counsel is true for any of our workers, whether they're in public health or emergency management or quite frankly, stocking and restocking our grocery stores who are also under a tremendous amount of stress as well. Let's bring you both back into the conversation because I'd really like you both to kind of put your crystal balls on for a minute and think about what do you see as the potential long-term impacts of COVID-19 on how we're planning out the nation's behavior and health practices may change over time.

April: You wanna take a shot at it, Meghan?

Meghan: Sure. Well, that's... Yeah. That is the question a lot of us are talking about right now, what does the future look like? You know, how does the public health system reshape itself in light of the way that it responded and reacted and saw this coming and things like that? How does the health care system recover? It's a just-in-time system. It's very similar to any other hospitality...I hate to throw it as a hospitality system, but it is, you have as many restaurant tables, hotel rooms as you have potential clients on a day-to-day basis. You don't [Inaudible 00:28:46] the big events. You don't have lots of hotel rooms and lots of restaurants open for the one or two times a year that there's a convention in town or there's something big. Health care is no different.

Health care is built to support the general day-to-day demand of a health care community and it does that by funding itself generally through elective procedures and other non-emergent, non-infectious disease activities. When those are curtailed, which is what's happening right now, people are not getting their elective surgeries, even they're important, necessary. There is no revenue being generated from them. And all of those providers are out of work and all of the staff are out of work. Now, some are being pulled into the response, but not all, not every specialty easily translates to being able to care for COVID-19 patients. So, it's a restructuring and it's a look at the future that is going to necessarily need to happen. It may not be a comfortable conversation to have, it may not be something that people want to talk about. I guess I'm already hearing discussions of it. So I think trying to figure out what the health care system looks like and what the public health system looks like after this and what the role of each governmental level in a disaster is in the future is going to have to happen. April?

April: Yeah. That's certainly the key, right? From the behavioral health standpoint, I think there's a couple of things that we'll be taking away. One of the things that I hope we take away is the recognition that our health care staff and facilities really are the frontlines in these events and they need to be, you know, given the strength and the supports that allow them to be continuing to do what they're doing because the staff are ready and able. But an important point to make is that often in emergencies like these, everybody starts talking about post-traumatic stress disorder. And yes, there are gonna be some people who may develop some serious anxiety or have had that problem before and it will get exacerbated, some depression and small amounts of PTSD, but what we know is that the majority of people will not. And, in fact, what we're already seeing everywhere is that people are showing their strengths, their ability to help each other, to reach out to each other in so many ways, even when they can't be physically close, being helpful and supportive to others, what we call post-traumatic growth as well, this ability to examine what's happening around you and make this thinking, this cognitive shifts, starting to think more about how important our connections are to our loved ones. We think about appreciation for what we do have, and looking for more ways to have more of a sense of meaning in their lives, both professionally and personally, which I think is important for health care workers because so many are so embedded in their work that it really is part of their personal as well as their professional lives.

So I think it's great that people are...we're starting to see that shown on social media news everywhere, from Italy who's suffering so much as well as here in the U.S., that people really are rising to the occasion, checking in on their neighbors, figuring out how to be in touch with their elderly family members, and how to be in touch with each other on a regular basis. So I think we'll continue to see post-traumatic growth and really positive ways of accommodating the difficulties that we're going through. But, of course, we have to be aware of and be looking for that smaller percentage who may, in fact, go on to develop a mental health problem and make sure that we can help identify that and then connect them with the right resources.

Marko: Thank you, April. Appreciate that. And certainly, both you and Meghan have allowed us an opportunity to get a window into the health care community that we might not otherwise have had. Thank you very much for joining us. I think today, one of the things that we wanted to accomplish was a better understanding of, for our listeners, of where we are as a nation right now at this stage, at this point in time with regards to how HHS is addressing and CDC and ASPR are looking at COVID-19 and the response, but really also to spend a little bit more time on the public health community and the larger frontline community that's dealing with this every day from a behavioral health and a mental health perspective.

I wanna thank you both again for joining us. This particular podcast will be available on ICF's website under the Insights section and COVID-19, where our prior podcast is and our future ones will be. Topics that are under development for the next series of podcasts include FEMA's individual assistance, where we'll go through a little bit about what the public can expect and the types of services that are available through that program; duplication of benefits challenges between all of the funding sources that are out there and how state and local governments can manage to avoid duplication of benefits and maximize the ability to use the federal dollars that are coming their way. We'll talk a little bit about critical facility needs. We'll talk about continuity of government, continuity of operations for the private sector, and several other topics that are under development. We wanna thank you all for listening. We look forward to your feedback and additional questions and ideas for future topics. Please know that ICF is ready to support all of our federal, state, local, and private sector clients. And search for us, and look us up, and look for all this information and much more on www.icf.com. Thank you again to both of you and thank you for joining us today.