{"subscriber":false,"subscribedOffers":{}} The COVID-19 Shadow Pandemic: Meeting Social Needs For A City In Lockdown | Health Affairs

Commentary

COVID-19
Commentary

The COVID-19 Shadow Pandemic: Meeting Social Needs For A City In Lockdown

Affiliations
  1. Jenifer Clapp ([email protected]) is assistant vice president, Social Determinants of Health, Office of Population Health, New York City Health + Hospitals, in New York, New York.
  2. Alessandra Calvo-Friedman is medical director, Social Determinants of Health, Office of Population Health, NYC Health + Hospitals.
  3. Susan Cameron is director of social work at NYC Health + Hospitals/Kings County Medical Center.
  4. Natalie Kramer is director of social work at NYC Health + Hospitals/Bellevue.
  5. Samantha Lily Kumar is director, Social Determinants of Health, Office of Population Health, NYC Health + Hospitals.
  6. Emily Foote is senior director, Social Determinants of Health, Office of Population Health, NYC Health + Hospitals.
  7. Jenna Lupi is assistant director, Office of Population Health, NYC Health + Hospitals.
  8. Opeyemi Osuntuyi is assistant director, Social Determinants of Health, Office of Population Health, NYC Health + Hospitals.
  9. Dave A. Chokshi is the health commissioner in New York, New York. He is also a physician at NYC Health + Hospitals, and a clinical associate professor in the Department of Population Health, NYU Grossman School of Medicine, in New York, New York.
PUBLISHED:July 16, 2020Free Accesshttps://doi.org/10.1377/hlthaff.2020.00928

Abstract

Addressing patients’ social needs is key to helping them heal from coronavirus disease 2019 (COVID-19), preventing the spread of the virus, and reducing its disproportionate burden on low-income communities and communities of color. New York City Health + Hospitals is the city’s single largest health care provider to Medicaid and uninsured patients. In response to the COVID-19 pandemic, NYC Health + Hospitals staff developed and executed a strategy to meet patients’ intensified social needs during the COVID-19 pandemic. NYC Health + Hospitals identified food, housing, and income support as patients’ most pressing needs and built programming to quickly connect patients to these resources. Although NYC Health + Hospitals was able to build on its existing foundation of strong social work support of patients, all health systems must prioritize the social needs of patients and their families to mitigate the damage of COVID-19. National and local leaders should accelerate change by developing robust policy approaches to redesign the social and economic system that reinforces structural inequity and exacerbates crises such as COVID-19.

TOPICS

The fast-moving, far-reaching novel coronavirus is unlike any public health crisis that New Yorkers have experienced in their lifetimes, and yet it follows a well-trodden pathway that connects social conditions to health. New York City Health + Hospitals is the city’s single largest health care provider to Medicaid and uninsured patients. During the spring of 2020, NYC Health + Hospitals served close to 20 percent of patients hospitalized for coronavirus disease 2019 (COVID-19) in New York City. The demographics of patients with COVID-19 largely reflect the system’s typical patient population. The majority are low income and identify as Black or Latino, and many are immigrants. Citywide, Black and Latino New Yorkers passed away from COVID-19 at double the age-adjusted rate of White and Asian New Yorkers,1 exposing the effects of structural inequity on the health of historically marginalized communities.

Beyond the tragic direct effects of COVID-19 is a “shadow” pandemic related to the social determinants of health. “Upstream” social factors, such as food, housing, and financial security, sometimes follow long and complex pathways to influence health outcomes. In the era of COVID-19, many of those pathways have become short and direct.

There are numerous interrelated reasons for this. Four in five minimum wage earners in New York City are people of color employed in sectors such as grocery stores, restaurants, and health services, where maintaining social distance is impossible.2 In addition, stay-at-home orders create economic dislocation, which has cascading effects on health outcomes by diminishing food security, housing stability, and financial security. For immigrants, problems can be amplified. Nearly 70 percent of New Yorkers living in crowded dwellings, where it is harder to isolate, are immigrants.3 Many immigrants will not qualify for government benefits because of their immigration status or may forgo government benefits out of fear of how the public charge rule may affect them, as that rule can be used to deny immigrants visas because of a lack of economic resources.

NYC Health + Hospitals continued building on an existing foundation that incorporates social needs into patient care.

For health systems, addressing patients’ social needs during the pandemic requires developing strategies to counteract the reverberating effects of COVID-19.4 To meet the intensified social needs of our patients, NYC Health + Hospitals continued building on an existing foundation that incorporates social needs into patient care. This effort began at the turn of the nineteenth century, when Bellevue Hospital launched its Social Work department. In more recent years, NYC Health + Hospitals developed a systematic approach to addressing patients’ social needs through large-scale interventions in four key areas: food insecurity, housing, legal resources, and income support. For example, NYC Health + Hospitals regularly screens primary care patients for social needs, provides medical-legal services through an on-site partnership with the New York Legal Assistance Group, and provides tax assistance preparation at a handful of clinical sites. When the COVID-19 crisis hit, the NYC Health + Hospitals staff reassessed patient need and shifted its efforts and resources toward the most critical needs, expanding its approach within the operating frameworks of its foundational programs.

A key step was determining the nature of patients’ social needs in the context of the COVID-19 crisis and developing a plan to meet those needs that allowed for flexibility and rapid dispersion given anticipated changes in NYC Health + Hospitals’ approach to care delivery. One such anticipated change was a decrease in in-person visits, which limited access to social services provided on site. Social workers and other clinicians advised on the greatest needs; guided the operationalization of plans; and along with care coordinators, case managers, and community health workers, executed plans to get services to patients and their families.

Addressing Patients’ Nonmedical Needs

The influx of patients with COVID-19 began to escalate quickly in March 2020, rising from 38 NYC Health + Hospitals patients having tested positive for COVID-19 on March 15 to 6,746 patients by March 31. This made it clear that a concentrated proportion of the NYC Health + Hospitals inpatient population would soon need care for this disease. NYC Health + Hospitals’ investment in addressing social determinants of health before the COVID-19 pandemic had laid the groundwork to quickly address the needs of its patient population during an emergency. The Social Determinants of Health team based in the system’s central office was already in place to build interventions and bidirectionally communicate with front-line staff working to address patients’ unmet social needs across the system’s hospitals and community-based clinics. The team solicited insight from social work directors about the needs of patients both hospitalized and isolating at home as a result of COVID-19. Food, housing, and income support were identified as immediate priorities.

Because New York City shut down almost overnight, it was difficult and time consuming for staff to access resources from their usual social service partners, many of which had suspended services, shifted hours of operation, or were transitioning from in-person to telephonic services. In addition, new resources were emerging. The Social Determinants of Health team created a short list of curated, high-yield social resources. For example, the team shared guidance about New York State’s new paid family leave policy and tips on how to apply for it. The list was designed to be relevant to social workers, who are expert at navigating social services, while being easy to follow for doctors and nurses, who might not typically promote social services in their day-to-day practice. The team worked with NowPow, a community referral platform, to update its comprehensive inventory of local organizations to reflect current operational status. NowPow used web research, social media research, email, and telephone calls to more than 5,500 local nonprofit and public organizations asking about operational status. NowPow then tagged listings with updated operational information so NYC Health + Hospitals users would know which organizations were still operating and whether the organizations were offering phone, virtual, delivery, or pick-up services.

Food

A prime concern for many NYC Health + Hospitals patients is access to food. Unequal access to healthy food is a byproduct of the structural inequities that exist, particularly in communities of color.5 Before COVID, food insecurity was consistently identified by patients in structured social needs screening programs as a key need. The COVID-19 crisis exacerbated this need because of the loss of income, social isolation, and closures of public schools and senior centers where people had reliably accessed meals.

To address the food crisis, NYC Health + Hospitals built a team to reach out to patients to connect them to food resources. The team consisted of workers who were underused when normal operations ceased and included NYC Health + Hospitals community health and social workers as well as employees of community-based organizations that are contracted by NYC Health + Hospitals through funding from New York State’s Delivery System Reform Incentive Payment Program. Community health workers typically serve patients with high-risk medical conditions to help them address complex social and medical needs and connect patients to primary care. Community-based organization partners typically provide on-site Supplemental Nutrition Assistance Program benefit enrollment and connection to other food resources.

To identify patients in need of food, NYC Health + Hospitals staff used the electronic medical record system to create lists of adult patients who tested positive for COVID-19 and were discharged after inpatient treatment at NYC Health + Hospitals. Staff also developed a toolkit of workflows and scripts to be used by the food outreach team. To ensure that patients received clear, cohesive postdischarge care, the food outreach team coordinated their efforts with other NYC Health + Hospitals teams, such as the certified health home agency and primary care physicians whose patients were hospitalized.

After 1.5 to 3 hours of training, team members began making outreach calls. Team members helped patients enroll in the Supplemental Nutrition Assistance Program, navigate food pantries, and enroll in a new temporary meal delivery program put in place by a mayor-appointed “food czar” to address food insecurity during the COVID-19 crisis. Team members also asked about emotional well-being and addressed other needs that patients raised (for example, they provided details about the moratorium on evictions). Low supervisor-to-staff ratios were implemented, and ongoing supervision was provided to support team members navigating challenging logistical and emotional conversations with patients.

Of the approximately 1,000 outreach calls made in the first week, more than half of all targeted patients were reached, and one-quarter were provided with assistance to secure food. Moreover, the development of the program generated tools, such as telephone scripts, trainings, and resource lists, that can be replicated to meet the food needs of other targeted groups of NYC Health + Hospitals patients in a holistic and thoughtful way after the pandemic. These tools were already adapted by a social needs resource team operating under the Test and Trace Corps launched by the New York City government in early June.

Housing

Homelessness and housing instability pose significant challenges to addressing the COVID-19 crisis in New York City. Residing in shelters, streets, or overcrowded dwellings makes social distancing measures difficult to implement and exposes homeless people to infection with COVID-19.6 In addition, because homeless people suffer from a high burden of chronic diseases, they are particularly vulnerable to complications from COVID-19.7

In New York City, more than 55,000 people sleep in the shelter system nightly, many in congregate settings with dormlike sleeping, bathing, and eating spaces.8 NYC Health + Hospitals serves approximately 45,000 homeless patients in a year. With the onset of the pandemic, NYC Health + Hospitals collaborated closely with the New York City Department of Homeless Services to develop protocols for moving infected patients from the shelter system to the hospital or to sites where patients could be isolated and receive telemedicine. NYC Health + Hospitals also created a number of hotel beds with varying levels of on-site medical care for homeless patients requiring care but not hospitalization for COVID-19 infection.

In addition, NYC Health + Hospitals has a long-standing partnership with the New York Legal Assistance Group’s (NYLAG) LegalHealth division to provide free, confidential services to patients, which can be used to help patients with housing-related legal issues, particularly eviction.9 Traditionally, NYLAG attorneys are on site, and referrals are coordinated locally by hospital staff. Because of limits on the presence of nonessential staff at hospitals during the COVID-19 crisis, NYLAG attorneys transitioned to telecommuting, and one centralized system for scheduling was established to ensure that demand for legal counsel was available on a first-come, first-served basis for all NYC Health + Hospitals patients through telephone-based appointments.

Financial Assistance

NYC Health + Hospitals provides every patient with health care regardless of their ability to pay, which means that money is not a barrier to care. However, clinicians reported hearing from patients struggling to protect their health because of loss of income. One doctor recounted the story of a patient who called describing symptoms of COVID-19. The patient herself was not hospitalized, although her husband was in intensive care on a respirator. At the time, testing was available only for those seeking hospital care. Still, the patient was considering returning to work cleaning houses the next day because she needed the income to support her husband and son. Many patients hospitalized for COVID-19 expressed similar concerns about their inability to cover rent, phone, food, and energy bills. Many patients had limited eligibility for federal benefits because of their immigration status.

To address some of their financial needs, Robin Hood, an antipoverty foundation, supported a novel cash assistance fund, the Emergency Financial Hardship Grant, for up to 500 low-income patients with COVID-19 hospitalized at NYC Health + Hospitals. The program, run by New York Disaster Interfaith Services, provides grants of $1,000 per patient without restrictions on how funds are spent. Screening of patients is conducted by social workers and care coordinators providing support for patients hospitalized for COVID-19. Patients who are undocumented or are ineligible for alternative financial benefits, including federal stimulus checks, are prioritized for a referral into the program. The goal is to provide a quick burst of funds to support patients’ basic health, financial, and social needs in their recovery from COVID-19.

Challenges

One of our most difficult challenges has been securing financial assistance for families to defray the expenses associated with burials. The number of New Yorkers who have died because of COVID-19 is tragic, and many families have informed NYC Health + Hospitals clinicians that they cannot cover burial costs. Existing programs that cover burial costs are limited. Many programs require that families cover the costs up front and seek reimbursement later, that both the decedent and the applicant have Social Security numbers, and that the decedent have no assets.

Another challenge lies in the complexity of accessing cash benefits such as stimulus funding and unemployment benefits. Some benefits require filing a bank account with the Internal Revenue Service, having filed taxes last year, and successfully navigating onerous paperwork. Moreover, these financial benefits are not available to undocumented immigrants, despite the fact that many pay taxes, leaving a large swath of our patient population without a safety net and with limited paths toward legal permanent residency and citizenship status.

The COVID-19 crisis stalled many standard operations at NYC Health + Hospitals, including a plan to integrate NowPow into its electronic medical record system and to streamline access to medical-legal services. However, NYC Health + Hospitals was able to quickly implement new programs to address social needs because of its investments in systems and social work departments before the COVID-19 crisis. The partnership with NowPow was leveraged to provide up-to-date information about social services that are relevant and matched to patients’ needs, for example. Recalibrating these existing resources allowed NYC Health + Hospitals to address the needs of patients with COVID-19 during a significant public health crisis. This crisis also opened up unique opportunities to build new unconventional models, such as the Emergency Financial Hardship Grant.

Lessons Learned

Outreach was well received in part because it included human-to-human connection at a time when it was scarce.

There are a number of relevant lessons from NYC Health + Hospitals’ experience addressing the first wave of the COVID-19 pandemic that can be applied to other health systems. NYC Health + Hospitals strived to offer targeted, convenient resources to meet the social needs of its most vulnerable patients. For instance, food outreach calls were successful because patients had minimal burden other than fielding a call and accepting assistance. Outreach was well received in part because it included human-to-human connection at a time when it was scarce. Further, NYC Health + Hospitals was able to rely on its well-trained and empathetic staff of social and community health workers, a critical resource during a time of crisis.

The social and economic crisis ignited by the COVID-19 pandemic will continue to evolve. Mitigating the damage of COVID-19 to patients may require further adjustments to existing approaches to address social needs, such as strengthening eviction prevention resources, addressing trauma through mental health support, and securing philanthropic support to fill gaps in financial assistance programs such as burial assistance. Although we continue to prioritize the social needs of patients with COVID-19 and their families, we must also develop robust policy approaches to address the “shadow” pandemic affecting millions more.

For many New Yorkers, the solution to the COVID-19 crisis is not simply a vaccine or treatment, but an end to structural inequities that have put an unfair proportion of the burden of COVID-19 on communities of color. Strategies such as universal health care; increases to the federal minimum wage and poverty threshold; and investments in universal child care, pre-K programs, and public schools are needed, and they require broad-based political coalitions. As health systems strive to meet the medical and social needs of their patients, policy makers, public health leaders, and community leaders should demand and execute strategies to remove the inequity underlying US social and economic systems, which exacerbates crises such as COVID-19.

ACKNOWLEDGMENTS

The authors thank the following team members for their leadership and persistence in meeting patient needs: Evelyn Perdomo and Janine Knudsen from NYC Health + Hospitals; Marjorie Momplaisir-Ellis and Savitha Mani from OneCity Health; Veyom Bahl and Jon Goldman from the Robin Hood Foundation; Randye Retkin, Julie Brandfield, and Beth Breslin from the New York Legal Assistance Group; Rachel Kohler, Stacy Lindau, Catherine Ma, and Caroline Sudduth from NowPow; Arielle Burlett, Mireille Mclean, Julieta Velasco, and Ralitsa-Kona Kalfas from Public Health Solutions; and Chris Leto and Colin Edgar from Riseboro. An unedited version of this article was published online July 16, 2020, as a Fast Track Ahead Of Print article. That version is available in the online appendix. To access the appendix, click on the Details tab of the article online.

NOTES

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