The Veterans Health Administration runs 1,255 health care facilities serving more than 9 million veterans, including many older adults with chronic conditions and many who struggle with depression, substance abuse, and other behavioral health conditions. To inform and guide the broader medical community, the VHA recently published its response plan for protecting veterans and health care workers. The Commonwealth Fund asked Richard A. Stone, M.D., executive in charge, how the country’s largest integrated health care system has adapted its operations to help veterans suffering from COVID-19, those who may be at heightened risk for serious complications from the virus, and those with ongoing medical and behavioral health needs.
Commonwealth Fund: Maybe we can start with changes the VHA has made in response to the pandemic in terms of staffing, distribution of resources, and even use of telehealth.
Stone: We began working on this in early January, right after China announced the potential of a new animal-to-human virus. We activated our emergency operations center by mid-January. We also developed a COVID-19 response plan that we actually made public in late March. It calls for establishing two tracks of care: one for patients infected with COVID-19 and the other for those who aren’t.
At the same time, we began making sure we were full up on all of our materials. Usually we keep about 14 days worth of personal protective equipment at our facilities. We expanded that to 21 days and began moving materials in to increase our supply chain. We also serviced all ventilators that were due for servicing in the next 90 days. Finally, we began retraining staff for our shift from a primarily ambulatory system to one that was really inpatient-centric.
Commonwealth Fund: Do you have the ability to send VHA staff to different facilities in different states?
Stone: We’ve already been doing that. We have moved substantial numbers of personnel to other regions, including New Orleans, which has been under substantial pressure for about a week. And we’ve also moved materials, including ventilators, from Texas and Minneapolis where we have not seen much demand. We are seeing dramatically sicker patients than Chinese clinicians described — who appear to need to be on ventilators for up to 11 days rather than seven.
Commonwealth Fund: Is that because these patients may be older than the Chinese population or have other issues like chronic conditions?
Stone: I can’t tell yet. Of about 1,200 positive veterans, we are seeing numbers that correlate with China’s experience of 20 percent being really sick. We are seeing that around 10 percent need ICU [intensive care unit] care. We have a very sick, fairly frail population with large numbers of comorbidities, and that may be why we are seeing this.
Commonwealth Fund: I wondered about your fully integrated electronic medical record system. What has that integration enabled you to do?
Stone: When we sent non-COVID patients from the New Orleans facility to our Biloxi hospital, everybody could see all of their medical records. The other thing is, when you move employees even from great distances, there is no training required for the use of the EHR. It has been pretty extraordinary in facilitating our success.
We cannot supplant the American hospital system. But what we can do is create a bridge for a community struggling to get their endgame in full gear.
Commonwealth Fund: How are you using telehealth differently?
Stone: About six weeks ago now, we began investing $60 million to $100 million in expanding our tele-ICU to make sure that we have tele-ICU services across our entire delivery system. We have seen dramatic increases in telemedicine for ambulatory services. We are now doing about 10,000 video visits a day, up from 2,200 visits per day in late February. What has been absolutely unique in this challenge is that much of the ambulatory system in America has been affected, and therefore veterans who might ordinarily have been sent to the community are beginning to be captured here in our system using telemedicine visits. At the other end of this thing, we are going to find tremendous interest in telemedicine from Americans who have found it a very positive experience.
We also have care teams reaching out to veterans if they are not coming in to make sure prescriptions are refilled and to make sure their needs are met. We have a great concern from a behavioral health standpoint. More than 50 percent of our mental health visits have been canceled by patients, and so there is a very active effort to reach out to those veterans to make sure they are okay.
Commonwealth Fund: By phone and video, or any way possible?
Stone: Yes to all. Whatever the veteran is most comfortable with. In fact, we’ve put mobile units on the ground in New Orleans, New York, Los Angeles, and San Francisco — literally driving around the community looking for veterans. We are also really concerned about our homeless population, which is down to around 38,000 but is an incredibly at-risk population because of the incidence of either substance abuse or mental illness. One of the cell phone providers in one market has given us 60 cell phones with data plans that we are handing out to homeless veterans so that they can reach us. We also have about 8,000 veterans housed in temporary accommodations as part of a bridge program to get people off the street. They are struggling with quarantine. A small percentage of that population has chosen to leave because we have restricted their movement, and we worry about them.
What is extraordinary to me is that every one of our VHA employees doing bedside care is under substantial risk and — in an era where their children are out of school, where there are stressors on their family finances — they are all still coming to work. It tells you how honored we are to have these employees doing this great work every day.
Commonwealth Fund: Are you considering using the hospital-at-home model that was used after Hurricane Katrina in New Orleans?
Stone: I think we’re going to have to. If in fact we have 11 days of ventilator use, there is no way we’re going to have the capacity to hold patients for long periods of time who simply may need oxygen. Treating patients who require acute care under the hospital-at-home model would also open up additional bed capacity, should our hospitals face a surge of COVID-19 patients.
Commonwealth Fund: What advice can you offer to leaders of other health systems, many of which clearly do not have the resources and integration you have, about ways they can prepare?
Stone: The key is grow as much critical care capability as you can. We have heard of hospitals laying off CRNAs [certified registered nurse anesthetists] and OR [operating room] nurses because their ambulatory surgery is down. All of those employees should be brought back and retrained for ICU services. They need to leverage every bit of expertise they have. They should make sure nurses can be supported by technicians to provide bed changes, baths, or even sitting with a dying patient. The ability of a nurse to sustain this will be the key to really getting through what is a once-in-a-hundred-years event.
My advice to all hospital leaders is to really move your nursing force to the level of expertise that they need, which includes every attempt, as New York has done, to move to full practice authority for those midlevel practitioners who need the authorities to really work. I think the other area that we are gravely concerned about is rural access hospitals, which must ensure that they have adequate capabilities from remote providers to support their facilities.
Commonwealth Fund: We’ve been hearing some rural hospitals are feeling very underprepared. What about the tele-ICU you mentioned? Could that be expanded to a critical access hospital?
Stone: That is absolutely a capability we could extend to them. We can support bedside nurses with hospitalists out of our two major ICU telemedicine centers.
Commonwealth Fund: If the VHA were to be called upon to act on its fourth mission as an emergency medical backup, what do you think the greatest contributions might be?
Stone: I can tell you what we’re already executing. We have already placed our emergency operations people in every FEMA region. We have 10 nonveteran patients in our Manhattan and Brooklyn hospitals and ICUs. We have offered to open our East Orange, New Jersey, hospital. We have also offered our telemedicine capabilities for hospitalists, infectious disease experts, and mental health experts to the Javits Center in New York City. The key will be, can we create enough capability in markets that we can fulfill our first mission — caring for veterans — while also providing a backstop for the American people?