COVID Chronicle

COV ID- 19 CHRONI CLE

MAINE MADE US RESILIENT

Northern Light Health’s response to a global pandemic

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INTRODUCT ION

CRISIS DOES NOT BUILD CHARACTER, IT REVEALS IT. - DENIS LEARY

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COVID-19 and the Resiliency of Maine People In his novel The Stand , Stephen King wrote, “There are no maps of change. You just come out the other side. Or you don’t.” That statement fairly sums up the path we have been blazing since February, and we are firmly committed to coming out the other side of COVID-19 stronger and better than ever. Sometimes, the most significant events in our lives happen without us even noticing them. This is not one of those times. During this worldwide pandemic, we know the tough decisions we are making will have significant impact on the lives of people throughout Maine and beyond. We know our lives and habits will change — perhaps in permanent ways. I’ve been fortunate to have the support of the team that is Northern Light Health to work through these events. Our promise to make healthcare work for you has guided our thinking, kept us grounded and focused on what’s important to our patients and to the communities we serve. Within these pages you’ll read about how the COVID-19 pandemic first touched us through a supply chain shortage. About how, from there, we set up a systemwide incident command, called all hands on-deck, and met challenges in patient care, community knowledge, and preparedness for any situation. I’m beyond proud of what our team has quickly built, advanced, and organized for what has happened and may still come, while keeping open the lines of communication with our patients, communities, and each other. The final chapter of this story is not written. There is much more to come, but we face the future knowing we can rise to the challenge while maintaining our compassion and care for all who need us. We have already started After Action Reviews of our work during the last few months so we are better informed of what went well and where we might need some improvement. I remain confident that Northern Light Health will emerge from this pandemic even stronger. Remember the adage, “Crisis does not build character, it reveals it.”

Tim Dentry President & CEO

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BACKGROUND & T IMEL INES

Wuhan Municipal Health Commission, China,

Officials confirm a case of COVID-19 in Thailand, the first recorded case outside of China. •

The COVID-19 pandemic spreads to the United States. •

reported a cluster of cases of pneumonia in Wuhan, Hubei Province. A novel coronavirus was eventually identified. •

DECEMBER, 2019

JANUARY 3, 2020

JANUARY 19, 2020

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MAY 2020

JUN 2020

JUL 2020

AUG 2020

SEP 2020 AND BEYOND

Something’s Happening Here In mid-January Northern Light Health Supply Chain noted information about COVID-19 overseas and the effect it was having on supplies. On January 24, our primary supplier Owens and Minor began hearing that allocations would begin on Personal Protective Equipment (PPE) to protect against inventory hoarding. This news came while we were managing a product shortage due to a recall by Cardinal Health. We continued our sourcing efforts to include PPE manufactured in China but were either locked in China or en route, but in limited supply. The early warning served us well as the conversation turned to an escalated national concern around COVID-19.

Coming to America There is much debate about exactly when COVID-19 reached the United States. Respiratory illnesses on the West Coast in December and January may be early cases but COVID-19’s presence was not officially recorded here until January. It is widely believed the virus first emerged in Wuhan in December when a series of people developed symptoms of a viral pneumonia. An examination found they had been infected with a new coronavirus.

Maine announces the state’s first confirmed case of the coronavirus. •

The World Health Organization (WHO) characterizes the COVID-19 outbreak as a pandemic known to be caused by a new coronavirus.

Northern Light Health member organization incident commands are requested to activate. •

Northern Light Health stands up its system incident command. •

•

FEBRUARY 28, 2020

MARCH 4, 2020

MARCH 11, 2020

MARCH 12, 2020

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STAND-UP OF INC IDENT COMMANDS

While Maine has experienced a low incidence of community transmission so far, Northern Light Health acted early to prevent spread, and track real-time data to facilitate planning.

Incident Command We knew we needed to think differently to meet the challenges that were about to sweep the nation. It became very clear a systemwide incident command structure was our answer to provide effective communication, management of resources, and ensure that all Northern Light Health facilities were in as near lockstep as possible. Jeff Doran, VP System Clinical Services was selected to serve as incident commander. Jeff immediately established standing 7am Zoom meetings with leaders representing the entire organization. We also stood up incident commands at each member organization. While they worked within their regions to manage operations (including staff and care of patients) system level incident command facilitated information sharing, resource gathering and allotment, and advanced communications to ensure people had the information they needed to stay safe, continue to provide care, and prepare for what might happen next.

The Incident Command System (ICS) is a fundamental form of management, with the purpose of enabling incident managers to identify key concerns—often under urgent conditions— without sacrificing attention to any component of the command system.

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Attendance included but was not limited to clinical areas; infection prevention; business operations; supply chain; lab and pharmacy; marketing and communications; finance and planning; human resources; and other critical systems. This marked the first time an incident command structure had been activated from the system to lead our member organizations through a crisis while providing an equal voice for all members.

Incident Command Members

“Early in the response we realized that we were all working towards the same goal but at different paces, and the fact that we could be more efficient and consistent across the system was apparent to all. The infection prevention council quickly adapted our meeting structure to allow both collaborative discussions and in-depth workgroups. We identified the various strengths of the members to leverage the strengths of an individual to meet the needs of the system. Within a few weeks we were working as an efficient team, and collectively we have been able to provide guidance and policies to the system. COVID-19 has been a challenge but it’s been rewarding to watch the team grow and evolve from individuals working separately, to a team that works and supports each as a unified voice.”

Medical Specialists

Laboratory

Medical Equipment

Communications

Pharmacy

Environmental Services (EVS)

Government Affairs

Work Health

Nutrition Services

Information Systems (IS)

Emergency Medical Services (EMS)

Security

Facilities

Finance

– Suzanne Moreshead, RN, BSN Infection Control Specialist Co-Chair NLH System Infection Prevention and Control Council Sebasticook Valley Hospital

• External Testing/Assessment • Supply Chain • System Surge Strategy Planning Stand up of Targeted Work Groups: • Behavioral Health • Zoom/Telehealth • Alternate Site Planning

• LTC/SNF Surge Planning • Ethical D/M Guidelines • Rapid Assessment Requests

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WORK ING TOGETHER FOR A COMMON GOAL

Teamwork At a time when many hospital systems and businesses began mandatory furloughs and to lay people off, Northern Light Health made the decision to make any furloughs voluntary and to pool staff for assignment to other areas wherever possible. Senior vice president of Human Resources, Paul Bolin said because we had postponed elective services (to ensure enough capacity to handle a possible surge of coronavirus patients), some of our medical assistants and administrative workers could be reassigned to areas that need help.

IT’S AMAZING WHAT YOU CAN ACCOMPLISH IF YOU DO NOT CARE WHO GETS THE CREDIT. - HARRY S. TRUMAN

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Effective leadership means more than just being a boss. It means coaching, supporting, directing, and taking decisive action to do what’s right, especially in times of crisis. Very early on we knew bold and swift decisions were needed to ensure the safety and resiliency of our workforce.

Moving Staff Home

Step one in the earliest stages involved making the difficult decisions surrounding cancellation of elective procedures to make room for the expected surge in patients, restricting visitation policies and sending staff home to work where possible. Having staff work from home would not only help slow community spread to the benefit of our employees, but to the benefit of our communities, freeing up much needed resources for patients who needed care, directly reducing the risk of a patient surge related to COVID-19. This was also a help to employees with school-age children since schools and day cares were closed until further notice and many had young children at home during the workday.

There was plenty of work to be done, after all:

All other ‚including member organizations and clinical Tracked in API

HOURS DEVOTED TO COVID

Information Systems Tracked in Service Now

Home Office Tracked in ACE

Tracked in Project Management Tool Communications

HOURS

HOURS

HOURS

HOURS

TOTAL HOURS SINCE MARCH PAY PERIOD

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COV ID- 19 INNOVAT ION

With supplies drying up from our usual vendors, we began looking for unusual sources – and we found some right in our own backyard!

Northern Light Supply Chain and Clinical Engineering also began talks with University of Maine to test masking materials and Maine Manufacturing Association to identify local manufacturers that could produce face shields and procedure masks, supplementing our diminishing supplies. Also, Ford Motor Company, in partnership with 3M began designing and producing urgently needed medical equipment. They sent us 5,000 face shields! As consumers throughout America struggled to find hand sanitizer to help slow and prevent the spread of viruses, hospitals too found their supplies drying. Northern Light Pharmacy immediately began making hand sanitizer, but the raw materials they needed were back ordered. A new relationship developed with Maine distillers, University of Maine’s chemistry lab, and Poland Spring to make and bottle sanitizer. After establishing a solid process, we made sure other hospitals also had a steady supply.

We partnered with Ntension Corp, based in Hermon, to manufacture face masks and face shields, and Poly-Tech Solutions and Flowfold, both based in Gorham, to make face shields.

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Across the nation there was concern there could be a shortage of ventilators. Innovators were testing methods that would allow a single ventilator to be shared between multiple patients in extreme emergencies. The Jackson Laboratory came up with a ventilator manifold that would allow five patients to be (theoretically) connected to one machine. We tested several versions with different vendors and worked closely with University of Maine’s Advanced Manufacturing and Biomedical Engineering departments, and Bowdoin College. We also consulted with Duke University, University of Massachusetts, and Nebraska Health. Thankfully, we never progressed to the stage of needing to utilize any of the prototypes that were being developed. Overall, community support during this global pandemic has been unprecedented.

Clinical masks come in one size. They don’t fit everyone the same and over the course of a long shift they can become uncomfortable and cause chafing. In April, 25-year-old Dennis Allen of Dover-Foxcroft began making 3D printed plastic facemask holders to donate to Northern Light Mayo Hospital. At about the same time, Matt Jones was firing up his 3D printer for the same reason. 3D printers use spools of plastic string to build different items layer by layer. In this case it’s a reusable plastic band that goes at the back of the head and holds the elastic bands of a facemask away from the ears, allowing users to adjust for a better fit. Together, Dennis and Matt donated hundreds of these to Mayo and Northern Light C. A. Dean Hospital.

There have been countless handy folks who’ve sewn cloth headbands with buttons (that serve the same purpose as the plastic 3D printer version)– to keep the elastic from chafing and creating a better fitting face mask. Hundreds more people have made and donated cloth face masks. Home Depot in Bangor donated 10 carts for use as medication and supply carts to be used in the event we needed to establish off-site COVID-19 care sites. To date, those sites have not been needed.

ANYTHING IS POSSIBLE IF YOU’VE GOT ENOUGH NERVE. – J.K. ROWLING

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INFORMAT ION SYSTEMS

IS Support for Patient Communications

Internal customers weren’t the only clients for IS. Not only did IS make changes to the portal landing pages to help communicate important information to patients, they helped pull together a mailing list and pushed approval through for an email communication tool to ensure that patients could get weekly updates about the most important, newest information available. And, for the first time, they facilitated a public facing helpdesk to support telehealth patients.

AN INVISIBLE HEALTHCARE HERO

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The thing about technology is that when it’s working well, you don’t think about it at all. The biggest challenge to moving 16% of our workforce to home offices was ensuring we had the right technology and bandwidth to ensure their productivity.

Information Systems managed the following:

G

Increase in bandwidth from G to G

Number of COVID support tickets

Number of staff assisted to move off site

Number of Zoom accounts set up Since March we have added  users are business and the remainder are set up for Telehealth Licensed vs Basic is … Paid and  Basic

%

An unprecedented % increase in spam emails were blocked in the month of April ……

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SPACE BETWEEN US

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Adapting to Safe Distancing

Fewer People in Spaces One difficult but necessary decision was limiting visitation. Unless absolutely necessary, we determined that the possible exposure of patients, staff, and yes, even the visitors themselves was a risk too great to take. While not everyone was happy about this decision most understood the need for it.

Safe, or social, distancing quickly became the COVID-19 mantra, following hot on the heels of asking people to do “The Five.”

For the safety of all

STOP AND CALL If you have any of the following symptoms, stop and call ahead before entering the building:

While staying home was best practice, as essential workers we know that is not always possible. In a culture of handshakes, high-fives, and face-to-face meetings we had to find ways to adapt and to help our patients adapt.

� Sneezing � Sore or scratchy throat � Stuffy nose

� Fever � Cough � Runny nose

Please call: 844.489.1822

Rendering

Patient Care Providing safe, reliable patient care in the time of COVID-19 was the most important challenge we faced. While some elective procedures and visits could be delayed not all care can wait. To protect patients and staff we started changing the way we do U R C O M M U N I T Y S A F E T T H R O U G H PLEASE STAY SIX FEET APART A

Project: Northern Light Health

Patient Cohorts and Alternative Care Sites One of the biggest steps we took, and continue to take, is trying to keep COVID-19 patients in separate care areas from other patients to help limit exposure. Early on we developed tent sites, which have transitioned to dedicated Date: 04.30.20 Revisions: Design Review By: CP/JF Type S

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business. For business side staff who still needed to come into the office this could be as simple as moving into spaces recently vacated by those who could work from home, giving us room to spread out. For patient care areas, we needed to look at changing processes. E W I L L S E E Type RFD.b Floor Decal 14.0"d

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space and processes in permanent locations for our facilities. We established a system wide central triage phone service to support the implementation of external testing tent sites in all our member hospital communities to help patients determine next steps when they have symptoms.

Scale: 3" = 1'

COLOR KEY

First Light: PMS 7549C Moss: PMS 390C Pine: PMS 2301C Wintergreen: PMS 7723C Tourmaline: PMS 2236C

Notes: • Sign copy shown is for sample purposes only

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Product Approval

MA INE MADE US CONNECTED

While it can’t replace in-person visits, telehealth may be the silver lining in this pandemic, according to Michael Ross, MD, regional medical information officer at Northern Light Eastern Maine Medical Center, “This is a technology whose time has come, especially for a rural state like Maine.” Telehealth is already being used for some pre-procedural and follow-up visits in cardiology, rheumatology, gastroenterology, neurology, orthopedics, and even some primary care.

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In April alone Northern Light Health hosted more than 36,000 telehealth visits!

Topping our list of concerns was how to continue providing care to Maine people who were under a stay-at-home order. Adding to the confusion, hospitals had postponed elective procedures, leaving many people reticent to come to hospitals due to fear of COVID-19. Hospital leaders became increasingly worried people might put off care they need. Fortunately, Northern Light Health had a strong telehealth foundation that could rapidly expand services. The first thing we did was move telehealth services to a HIPAA secure Zoom platform. Then, we informed patients about our increased telehealth offerings, letting them know that we are here for you, no matter where you are. A robust marketing campaign was quickly put together and we shared our messages far and wide on social media, web, TV & radio, and in print. Mainers Love Telehealth In April alone Northern Light Health hosted more than 36,000 telehealth visits! The feedback we are getting is highly positive. For example, a mother in Presque Isle worried her young son wouldn’t receive his speech therapy from Northern Light AR Gould Hospital. Imagine her relief when he easily transitioned to a ‘warm and welcoming’ telehealth environment with his therapist. In Portland, Northern Light Home Care & Hospice and Northern Light Mercy Hospital leveraged the power of telehealth in the city’s homeless shelter. A patient there was being monitored for COVID-19 exposure when a nurse noticed the individual was having trouble walking and discovered ulcers and swelling in the patient’s feet. She was able to get the patient registered for services and seen by a primary care doctor using her own iPhone ¬- from the homeless shelter. With a diagnosis stemming from having constantly wet feet, the patient was given a medication, dry socks and shoes and was on the road to recovery.

MAINE MADE US Connected

NORTHERN LIGHT TELEHEALTH, ACCESS TO CARE IN UNUSUAL TIMES. We're still here for you, even while times have changed. Through Northern Light Telehealth, patients can securely connect with a healthcare provider from home. With a variety of services offered, we're able to meet the individual needs of Mainers. Talk to a Northern Light Health provider about experiencing quality care from home with Telehealth.

NorthernLightHealth.org/Telehealth

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DATA- INFORMED DEC I S IONS

Behind the scenes of any dashboard is the effort to identify, gather, and validate data before it is displayed in a meaningful way as information. Whenever possible, data is drawn from trusted, automated sources. As COVID-19 had never been seen before, some of the information had to be gathered manually by reaching out to frontline staff at our locations. In most cases the external requests were for developing, mandatory reporting for State and Federal agencies, about the same data. Decision Support stepped up to be the single source of truth for this data, therefore clearing up confusion and allowing frontline staff to focus on patients. Streamlined Reporting

DATA POWERS EVERYTHING WE DO. – JEFF WEINER

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Real-Time Data for Real-Time Solutions

Board Summary and Trend Views

In an effort to offer a concise relevant look at system information, two views were created specifically for our Board members.

As soon as we stood up incident command the need for consistent reliable data became apparent. The Business Intelligence department, which produces most of our dashboards in Tableau, stepped up and created views that allowed us to understand where we were and where we needed to go. Initially we tracked testing, COVID-19 cases, PPE supplies, inpatient capacity and initial financial influences. As the system’s data needs changed, the dashboard kept up. From just a few views, the dashboard soon grew to have 12. But information wasn’t just added, information that was no longer useful was “retired” to keep the dashboard focused. An example of this is ventilator demand. Early guidance suggested this would be an area of concern, but as it became evident to us and the State that Maine would likely not experience a shortage, we removed that information. Any information that was removed is still tracked and can be brought back if necessary.

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PROJECT ING THE FUTURE

Filtering Data for Quality and Accuracy

As a brand-new virus, predicting things like fatality rate, how many people who are affected are symptomatic vs. non, and rate of transmission, we rely on emerging information. Experts were building models based on incomplete data, leading to wildly different predictions. Because of this, Northern Light Health focused our efforts on working with the Maine CDC on its “Hospital Demand Planning” team. This group met weekly and focused on three curves: a low demand curve (from IHME), and a middle and high demand curve that the state was developing, based on a model developed by Johns Hopkins.

Each week, the Northern Light Strategic Planning Department would package the new projections from the state, broken down by Northern Light region, and send this out to the local NLH hospital leadership teams. The good news is that our actual experience in the state (demonstrated by the black line in the adjacent graphic, that shows the state peaking on April 17 with 28 ICU admissions) was well lower than even the most conservative of the original estimates (i.e. 28 vs. 164), and dramatically less than the higher projections (28 vs. 13,203).

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Picking a Predictive Model When we started looking at demand at the end of March, different models were emerging, with vastly different projections for the state of Maine.

PREDICTIONS OF PEAK ICU DEMAND FOR MAINE

Updated April

ICU HOSPITALIZATIONS

Maine Actual ICU Hospitalizations

John Hopkins University Maine % Reduction R Mean

John Hopkins University Maine ‚ % Reduction R Mean

IHME Mean

The Institute of Health Metrics and Evaluation (IHME) projections are adjusted to reflect differences in aggregate population mobility and community mitigation policies.

One of the most discussed issues about COVID-19 is its basic reproduction number (R0). This epidemiological value refers to the spreading potential of this novel infection, defining R0 as a “fatal number”: the more it increases, the greater is the risk for the population, including higher mortality potential.

The Johns Hopkins University model assumes that the effectiveness of interventions is reduced after shelter-in-place orders are lifted.

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SURGE PL ANNING

“Although we have surge plans for mass casualties and pandemics in place, it is anticipated we will need to conduct additional “just in time” planning that is specific to the emergency being mitigated. Surge Capacity development is a complex, multifaceted planning initiative which requires the participation and collaboration of many healthcare organizations, government agencies, and businesses. It is non-competitive, highly collaborative, and overall very fulfilling. These are good people working together and sharing resources, so we can care for our communities. I am proud of Northern Light Health and the incredibly hard working, innovative, and selfless employees who go above and beyond everyday – and especially during this pandemic.” – KATHY KNIGHT, RN NORTHERN LIGHT HEALTH

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Often called the cornerstone of preparedness, patient surge planning isn’t something that a hospital, or even a healthcare system, can effectively do alone. The Patient Surge Planning System Strategy Task Force relied on the predictive models put out by the IHME and others and regional partners to develop an effective strategy for a possible patient surge.

Phased Approach We decided on a phased approach, opening more care and adding beds as patient volumes increased. Because our case numbers were growing slowly, we had time to evaluate locations and determine solutions that would put less stress on our facilities, providers, and patients. A phased approach also meant less strain on our physical and financial resources as a state.

Staffing Along with cross training staff pooled from other areas in the hospital, the greater Bangor Region and Aroostook County looked at regional solutions for alternate care sites that could be staffed by clinical providers from multiple facilities and systems.

Phase 1: Full use of all beds

Phase 2: Full use of all beds, stretchers, and treatment areas

Phase 3: Full use of all possible bed locations on campuses

Phase 4: Addition of alternate care sites

BED COUNTS

Phase

Phase

Phase

Phase

COVID

NON COVID

TOTAL

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BEHAV IORAL HEALTH

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While safe distancing is an important part of slowing community spread, it also takes a toll on our communities – inside and outside of our organization. Along with social isolation, staff and community members were facing a news cycle of trauma and loss, and for many of our staff members the loss was palpable in their day-to-day work. We knew that behavioral health and our resources at Northern Light Acadia Hospital would be integral to the long-term health of our patients and staff.

Healthy Life Resources For Northern Light Health staff, Acadia developed Healthy Life Resources, a full-service mental health resource available online and by phone including:

ospital

Support. Resiliency. Connection.

Leadership Support Training Web-based trainings focused on learning the signs and symptoms of stress in yourself and staff using a simple, three-step model to use during staff meetings and/or team huddles. This service also provides practical ways to prevent compassion fatigue and burnout, and ongoing, live “Ask a Mental Health Expert” Q&A sessions. Northern Light Health employees is critically important. Northern Light Acadia exposed to prolonged stress, anxiety, and trauma, and that is why it is offering a able set of supports for all 12,000+ employees to promote their well-being and ce. Healthy Life Resources is highly integrated with existing employee supports ordinated to respect the needs and culture of each organization. d mental wellness resources on aterials, pre-recorded training a self-guided, digital, evidence- rt

Crisis Management Briefings Designed for Northern Light Health staff working in areas under persistent, intensive daily stress, these 15-minute meetings at the beginning and end of each shift are delivered by local facilitators with a focus on maintaining employee wellness, minimizing anxiety, and retaining high productivity of staff.

Critical Incident Stress Debriefings The Critical Incident and Stress Management service is an on-demand virtual or in-person, one-time debriefing lasting 90-120 minutes provided by Acadia clinical experts. This is used when a department or organization experiences a localized, acutely stressful event, like the death of a colleague or multiple deaths in the department, for example.

How to access: Visit https://mystrength.com/ and use access code HLRWellness , to create an account. Use your @northernlight.org or @mayohospital. com email address.

ources and interactive activities to d negative feelings. Those who use to a personal and confidential mental

t

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learning the signs and symptoms of a simple, three-step model to use

How to access:

STATE AND FEDERAL GOVERNMENT

WHATEVER WE ACCOMPLISH BELONGS TO OUR ENTIRE GROUP, A TRIBUTE TO OUR COMBINED EFFORT. – WALT DISNEY

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Declaration of Public Health Emergency On March 13, 2020 President Trump declared a National Emergency under the Stafford Act and DHHS Secretary Azar issued a public health emergency declaration. These steps allowed the federal government to waive regulatory requirements, known as “1135 waivers.” The President’s declaration was followed by Governor Mills proclaiming a State of Emergency on March 15, 2020. The state and federal declarations created the opportunity for an unprecedented number of state and federal regulatory waivers providing healthcare organizations and healthcare professionals significant flexibility to care for individuals during the COVID-19 pandemic emergency period. Waivers that allowed hospitals to establish off-campus COVID-19 testing sites, expand licensed bed capacity, employ licensed providers from out of state, and significant expansion of telehealth services are examples that highlight how Northern Light Health operationalized waiver opportunities.

Tracking Federal Waivers Working collaboratively with the Maine Hospital Association (MHA) and MaineHealth to understand state and federal authority to implement waivers, we learned that the Maine Department of Health & Human Services needed to review and approve each federal waiver in addition to approving waivers initiated at the state level. Working as a team, MHA, MaineHealth and Northern Light Health created a tracking inventory of federal waivers for the state to review and approve. Weekly meetings with DHHS leaders and staff from the Governor’s office provided the communication structure to ensure that all the state and federal waivers received proper approval for implementation. Northern Light Health also worked closely with staff of Maine’s congressional delegation to ensure that Maine’s Senators and Representatives were informed of the financial and clinical impact the pandemic is having on our hospitals, home care services, and nursing homes. Staff for Senators Collins and King also assisted Northern Light Health supply chain leaders to obtain necessary personal protective equipment and access to Remdesivir, a medication for patients severely affected by the COVID-19 virus.

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Maine’s Healthcare Systems Soon after the emergency declarations, Northern Light Health began working with MaineHealth and the Maine Hospital Association to develop clinical protocols for patients who were discharged from hospitals to skilled nursing facilities. Many nursing homes were closed to hospital admissions and other nursing facilities had significant variation in admission standards for COVID-19 patients. The hospital transfer protocols approved by MaineHealth and Northern Light Health were then accepted by the Maine Hospital Association and distributed to hospitals throughout the state. Consistency in hospital transfer protocols for patients discharged to skilled nursing facilities has improved the ability of nursing homes to accept new patients during the pandemic. Northern Light Health also worked with the Maine Long Term Care Ombudsman to facilitate weekly conference calls with leaders from the Maine Health Care Association, the Home Care & Hospice Alliance of Maine, and MHA. All worked collaboratively to address the many challenges experienced during the pandemic. WE ’ RE IN THI S TOGETHER

“I am proud of the collaborative work we were able to do with our

friends at MaineHealth. While seen as competitors, we came together for the greater good to care for Maine people. We have collaborated on the initial response to COVID-19 in our state, worked together assisting nursing facilities with outbreaks, and with the help of other health systems in the state, developed statewide strategies for the management and treatment of Mainers infected with this virus. These efforts continue.” – James Jarvis, MD

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Bangor Community Health Leadership Board The Community Health Leadership Board (CHLB) is a community partnership between Bangor region hospitals, healthcare providers, human service organizations, educational institutions, and the City of Bangor. For the last six years, the CHLB has worked together regularly to assure the health and wellbeing of our community is cared for. From the very beginning, during the unprecedented challenge of COVID-19, Bangor area institutions have been responding to this crisis together. This partnership has forged stronger relationships, initiated unprecedented levels of collaboration, and a shared sense of community. Trust in one another’s expertise and commitment has been proven week after week during planning sessions and implementation of shared objectives:

• Community COVID-19 test site at Bass Park (led by Northern Light Health). This tent site continues to be staffed by caregivers from the three Bangor health agencies with security provided by the Bangor Police Department. • Plan for a surge site, and PPE use and distribution. • Response to the needs of vulnerable populations including the elderly and transient/ homeless populations. • Plan for provision of food, housing, and transportation for those impacted by COVID-19; as well as childcare for essential workers. • Website and social media campaign to ensure community members don’t ignore or delay essential health care: https://chlb.me/ and https://www.facebook.com/CHLBMaine/

• Approach to slowly and thoughtfully returning to normal health care operations, including elective procedures, diagnostic testing and check-ups. • Resource for primary care providers to address increased youth mental health concerns during times of isolation and stress. • Set of measures to ensure the safety of staff, visitors and community members by encouraging them to wear face coverings (masks), practice hand hygiene, and follow social distancing protocols. The CHLB’s Mask Up for ME campaign will launch in late May. • Site selection, planning and operational design for a 100-bed field hospital at the Cross Insurance Center (which to date has not been needed). Maine National Guard, Maine Emergency Management Agency, and the Army Corp of Engineers assisted with planning and offered staffing assistance should become necessary.

The Community Health Leadership Board (CHLB) is grateful to all healthcare workers for their tireless commitment to serve patients, and for all of Maine’s workforce who are serving on the front lines every day. The trials we are facing have brought us closer together and forged even stronger bonds that will continue as we move forward. We also want to thank you, the residents of central and eastern Maine, for showing your commitment to one another by following suggested protocols and watching out for one another.

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THE CHALLENGE OF CONSTANTLY CHANGING GU IDANCE

New Englanders are known for being hardy folks and weathering all kinds of storms, and we faced COVID-19 just like we do our rapidly changing weather (just wait five minutes, it will change). We learned to modify plans as we learned more about the virus, as resources grew (and waned), and as we learned from the experiences of other healthcare systems across the country.

THE WIND OF CHANGE... BLOWS FREELY THROUGH AN OPEN MIND. – HOWARD MACMILLAN

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When the Rules Change, We Change the Rules One of the hardest changes we faced was limiting visitation for patients. The support of family and friends is vital to healthcare, but for the first time it was unsafe for patients, staff, and the visitors themselves to allow them in most care settings. It took some time for CMS to catch up with the CDC recommendations around limiting visitation, but when they did we adjusted out policies looking to technology and services like Facetime, Zoom, and Skype to help our patients maintain their connections with their support teams. We also made specific, compassionate exemptions for patients who require care advocates, birthing mothers, and end of life visitation. The comfort and care of our patients remained our guiding star, while keeping safety top of mind.

Testing, Testing, 1, 2, 3 Limited access to testing became (and remains) a hot button issue across the country, not just in Maine. Northern Light Health worked hard to not only establish testing capacity in-house to be able to expand the state’s ability to offer testing but to establish a rapid assessment process to screen patients who met the testing criteria set by the state. A statewide triage line, staffed by care managers from Northern Light Beacon Health, still leads patients with COVID-19 symptoms through a series of screening questions to help determine the next steps for care and direct them to the assessment site closest to them for additional care. The good news is that more and more testing is becoming available, in May the state announced its ability to process 7,000 tests per week. The challenging news is that the materials to take the samples needed to run the tests are still in short supply but working together as a system and with our healthcare partners across the state we’re sure that we’ll meet this challenge, too. A challenge of another sort arose amid this latest testing twist. When the state announced it was expanding testing, the phone calls sharply increased to our providers and hospitals from Mainers seeking to be tested. When we could not accommodate all requests due to a limited supply of test kits, some people became very angry with our staff on the other end of the line. Kudos to those who managed the collective outrage with a calm and professional voice.

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THE CHALLENGE OF CONSTANTLY CHANGING GU IDANCE “Policies are integral to the consistent delivery of high quality care across a healthcare system. They establish evidence-based guidance or ‘guard rails’ within which providers apply their training, knowledge, and care. At the same time we were responding to the COVID pandemic, the scientific clinical evidence was being developed. Best-practices evolved daily. As a result, guidance from accepted sources of truth (e.g. WHO, US CDC, ME CDC) was often ambiguous and remains so in many aspects of caring for COVID positive patients. As result, the organizational policies on which Northern Light Health relies to ensure consistent care to patients across the state changed frequently requiring those changes to be communicated to all levels of the system and care team. Timely and effective communication of the constant changes were not only essential to safe patient care, but equally important to the safety and sense of security/control to our employees during a very uncertain time.” – JEFF PARSONS

VP RISK & PATIENT SAFETY NORTHERN LIGHT HEALTH

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There’s just something about Policies From the use of personal protective equipment, to working from home, to meetings in our facilities, and visitation, everything in a hospital and a healthcare system is managed and maintained by having clear, concise, and well vetted policies.

New Policies

Ten new policies have been created since the beginning of the COVID-19 pandemic to help leaders manage staff and resources, and to help staff understand the steps they need to take to stay safe at work. A group effort frequently lead by Northern Light Health’s Infection Prevention Council, these systemwide policies were written, rewritten, and reviewed by key decision makers across the system to ensure they meet our needs from Portland to Presque Isle.

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LONG-TERM CARE AND CONGREGATE L I V ING

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The earliest COVID-19 outbreaks in the US were in congregant living situations, so we entered the preparation phase of this pandemic with special care and attention towards our long-term care facilities and partners. Early communication with patients and families about the steps we were taking and why they were being taken were a key consideration. For patients living away from their families, we wanted to ensure that they felt supported and that their families would continue to feel connected to their care.

Early on Holly Macrae, LMCSW Palliative Care, knew that the patients of Northern Light Home Care & Hospice would be especially vulnerable to isolation. She posted the need for old iPads on her social media, hoping to round up enough to give to the clients without access. It turned out she wasn’t the only one worried about this because the next day an opportunity for grant funding appeared to meet the need. While standing up the use of the iPads for both socialization and Zoom visits with providers has taken some work, Home Care & Hospice staff, along with our IS team, have gone the extra mile to ensure patient safety and privacy and help some of our most vulnerable patients feel connected. Facilitating Technology Use

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LONG-TERM CARE AND CONGREGATE L I V ING

Supporting Our Friends and Neighbors

Northern Light Eastern Maine Medical Center, St. Joseph’s Hospital, Penobscot Community Health, and Northern Light Home Care & Hospice worked together to support a long-term care facility facing resource shortages and uncertain times. As a community, these healthcare providers joined together to deliver: • staffing support • assistance with fit testing • development of plans for patient services at local facilities, and • shared policies, procedures, and training tools, as well as many other activities to ensure the staff and patients know they are not alone. Northern Light Health’s facilities department assisted Brewer Rehab to develop a negative pressure unit through the art of creative engineering so they may more safely care for potential COVID positive patients.

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Changing Our Process Northern Light Acadia Hospital has had to look at offering services in new ways to the people who need them most. COVID-19 thrives in congregate living. With an inpatient design similar to long-term care facilities, Acadia is taking thoughtful steps to protect residential clients. A negative COVID-19 test is required prior to all admissions, and staff are screened each time they enter the building. Inpatient activities were limited due to the risk of spreading germs. This was especially evident for children as play therapy games like dodgeball, climbing the rock wall, or playing basketball were canceled. Staff have found creative ways to continue routines while adhering to safety guidelines. All outpatients who visit Acadia are required to wear a face covering. Enforcing face coverings on inpatient clients is more challenging, although residents are provided with masks and strongly encouraged to wear them. A strict no-visitor policy remains in effect, including in the pediatric unit. We do everything possible to help patients connect with their families or guardians via phone or video conferencing. Telehealth continues to be well-received at Acadia. Within two weeks, nearly all outpatient services were moved to our HIPAA compliant Zoom platform. Pediatric Day Treatment services were also uninterrupted via Zoom, providing much-needed structure for families as schools remain closed The world quickly realized the effect COVID has (and will continue to have) on mental and emotional health. Northern Light Acadia Hospital has been proactive in sharing timely information in the media, and with our community and state.

We also:

• Continued to safely serve those in the Narcotics Treatment Program with extended take-home dosing and close monitoring

• Launched Healthy Life Resources program to serve all of Northern Light Health

• Provided uninterrupted tele-psych services in emergency departments throughout the system and across the state

• Offered care via Integrated Behavioral Health and the Behavioral Health Home programs throughout the system

• Offered education and resources to healthcare providers

• Delivered niche services such as Mood and Memory Clinic, Eating Disorders Program, and Pediatric Day Treatment. All are positioned to expand into new markets through video conferencing

• We continued to recruit and onboard new providers

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THE HEALTH OF OPERAT IONS AMID COV ID- 19

Pausing Services On March 17, 2020 we paused elective surgeries and procedures under the guidance of the American College of Surgeons. Patient volumes declined immediately and significantly with admissions, emergency department, diagnostic testing, and provider office visits all down approximately 50%. Net patient service revenue for March was below budget by $26m (17%) and $66m (45%) in April resulting in large operating losses.

Financial Assistance from CMS The Centers for Medicare and Medicaid Services

stepped up to help rural hospitals with multiple components: • Funding Advance: six months of historical claims payment to be repaid over the course of a year after 120 days, for Northern Light Health this was $175M • CARES Act Grants for Northern Light Health, this was $65M • HRSA Grant for Northern Light Health, this was $422k The state of Maine funding also distributed funding of $2.5M.

Additional Steps Northern Light Health took additional steps to shore up our financial foundation by expanding our line of credit with three banks by $120M, with total lines of credit of $150M; reprioritizing and restricting capital spending; and advocacy through continuous contact with AHA, MHA, and DHHS.

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The finances of rural healthcare systems are always challenging. With COVID-19 one of the greater tasks Northern Light Health faced was not only ramping up services to meet the needs of patients needing care, but also adapting care to ensure that non-COVID patients would not be at risk.

Dialogue with State and Federal legislators After the Maine Legislature adjourned on March 17, Northern Light Health initiated a weekly COVID-19 email update for legislators and staff of Maine’s congressional delegation. Updates included information on CDC COVID-19 guidance, screening and drive-through testing, personal protective equipment (PPE), expansion of telehealth, COVID-19 outbreaks in long term care facilities, the significant role of our home care team, and Congressional COVID-19 legislation. We also discussed the financial impact of COVID-19 on Northern Light Health member organizations and resuming non-COVID-19 elective procedures and outpatient care. Response to the weekly communication has been very positive. Northern Light Health has also worked closely with staff of Maine’s Congressional delegation. Regular communication highlighted the significant financial impact that COVID-19 has on our members as our delegation worked with Congressional leaders to pass the CARES Act and subsequent additional funding. Staff for Senators Collins and King provided substantial support to resolve challenges with vendors not fulfilling our orders for masks and other personal protective equipment. The same staff, along with Governor Mills’ office were critical in communicating to federal DHHS and the White House the need to ship Remdesivir to Maine as a clinical resource for critically ill COVID-19 patients.

Participation in national forums to strategize on funding opportunities Lisa Harvey-McPherson, VP of Government Relations is an active member of the American Hospital Association Government Relations Officer’s Network. During weekly conference calls with AHA and hospital government relations leaders across the country, Northern Light Health advocated for the need to transition Medicare Accelerated/Advanced Payments to a forgivable loan or significantly change the terms of the advance payment recoupment. While much of national focus was on COVID-19 hot spots and effect on hospitals, Northern Light Health consistently advocated for the need to include rural hospitals in COVID-19 financial support. Both priorities have been advanced in Congress and in COVID-19 public health emergency funding provided by federal DHHS. Work continues with AHA and Maine’s Congressional delegation to transition the COVID-19 telehealth flexibility waivers into permanent Medicare policy.

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