DHEC makes vaccine available to anyone that wants it

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Getting a COVID-19 vaccine appointment requires going online. But plenty of South Carolinians are not connected.

At the end of March, 2021, COVID-19 has killed more than 9,000 people in South Carolina, and almost 8,000 of them are people above the age of 60.

Reconcile that with the Pew Research Center’s findings that once above the age of 60, access to and ownership of smartphones or any device connected to the internet drops sharply as age increases.

Where this overlaps dangerously is in the middle of the COVID vaccine rollout, which requires residents to register through their phones, tablets, or computers. In a state where broadband access is being addressed more urgently by federal and state officials, huge parcels of South Carolina between Newberry and Jasper counties still have zero access to the internet, according to coverage maps by Palmetto Care Connections (PCC), a nonprofit advocate for equitable and wide-reaching broadband access in the state.

Kathy Schwarting, CEO of PCC, says that this puts residents – particularly rural seniors – in a bad spot.

“There’s the access issue,” Schwarting says. “Whether or not your area even has the ability to have internet. If you live out in the country, outside of the city limits, you may not even have fiber; and it’s very expensive to run it.”

But there’s also an age issue, remember. The Pew study shows that in 2017, the last year data is available, 67 percent of seniors were on the internet but 51 percent had access to broadband. Those numbers are likely a combination of choice and circumstance and may have changed in the intervening years, but there are, nevertheless, seniors who are simply not connected, at a time when the way to get registered for a COVID vaccination is online.

Schwarting has an aunt in her 70s who wanted to get vaccinated and had to call the South Carolina Department of Health and Environmental Control (DHEC) on the phone. The department initially told her she needed to sign up online, but Schwarting’s aunt has no computer and no internet-capable phone.

Schwarting says DHEC brought her aunt into an office and registered her in person. And while she’s happy it worked out for her aunt, Schwarting knows not everyone who’s offline will be able to do that. For rural seniors in particular, physically getting to a DHEC office could be a near impossibility.

Schwarting says several seniors without email addresses or even a connection have enlisted help from their children and grandchildren to register. For those who can get that kind of help, great, but again, she says, not everyone has someone connected whom they can call upon for help.

Cost, of course, is another issue. Even with access to some kind of reliable internet, it can be expensive. High-speed internet, which is often needed to navigate websites these days, is considered anything above 25 megabytes per second. Some plans in South Carolina run at 300mbs. The more mbs, the more money.

Monthly plans for low-income residents can start at $10 (or in some cases be essentially free). Some providers temporarily expanded eligibility to broadband because of the pandemic.

AT&T, one of the major providers in the state, did this. Lead Public Relations Manager Megan Daly said in a statement to South Carolina Public Radio that the company’s Access from AT&T program was offered to households participating in the National School Lunch Program and Head Start, “for $10 a month or less. Also, for a limited time, customers at locations with available AT&T Internet speeds above 10 Mbps may be eligible for a speed upgrade up to 25 Mbps.”

But if you don’t qualify for a low-income plan, broadband service can be pricy. It’s not unusual for South Carolinians to have plans costing around $75 a month in some well-connected areas. And, of course, plans expanded because of the pandemic will not be permanent, which, Schwarting says, could become problematic for unconnected lower-income residents looking to access medical records or find work after life moves past COVID’s disruption.

“If you are living paycheck-to-paycheck,” she says, “and you are trying to balance getting your medications, paying your light bill, paying your mortgage, making sure you have groceries, $75 is an awful lot of money. And [a $15] increase is a lot of money in a house where they don’t have extra money.”

According to BroadbandNow, South Carolina ranks 31^st among U.S. states in high-speed connectivity, and about 53 percent of residents have access to a wired, low-price plan.

 

Connecting with the Unconnected: ‘Word of Mouth is Powerful’

An unexpected side-effect of the pandemic is that for as much as it put a spotlight on the need for technology access, it also reminded us that we still need analog options for getting in touch with people in a crisis.

Social media is the favored distribution method of health agencies, social services workers, news companies, and whoever else wants to get the word out about something. The reach is immense and immediate, but it does zero good for anyone who isn’t connected.

“Boots on the ground,” says Davia Smith, PCC’s director of education. “Social media works for some but it doesn’t work for all.”

Smith says that meeting people where they live – the grocery stores, churches, pharmacies – is the key to getting through to communities that might be cut off. That includes poor communities, communities of color, and rural neighborhoods, which all share something important to remember – a tendency to trust most in people they already know personally.

Getting to people in these communities is a clearly hefty task. But Smith says it’s necessary, especially in light of the continuing disappearance of one particular source of information.

“You have some communities that no longer have a local newspaper,” she says.

And even in places where local papers still exist, they are usually weeklies, which Smith says can create troublesome lags when people need to receive urgent information. So social and health workers, she says, need to ramp up their alternatives for how to get information to residents, and need to stop thinking that a website or an app solves every problem.

“We can’t stay behind the computer screen and expect everything to get done,” she says. “Word of mouth is powerful.”

DHEC, for its part, appears to have learned this lesson some.

In a statement, DHEC said:

We work to get current messaging to people who don’t rely on the internet for their news and information by way of:

• signage at gas stations (targeted rural areas)
• billboards (target rural areas)
• advertisements in every weekly newspaper in the state
• radio PSAs
• TV PSAs
• direct mailers
• ongoing partnerships with local organizations that promote our messaging within their communities
• continued partnerships with our state’s faith-based organizations to help share important information and resources
  • We partner with the nonprofit Hold Out The Lifeline (HOTL) to support grassroots statewide efforts directed toward African American churches and community groups. Among the many services offered, HOTL is conducting virtual briefings, distributing some of DHEC’s hardcopy resources and materials, and distributing PPE (face masks, hand sanitizer, gloves etc.) HOTL also provides church leaders with a toolkit to help them plan educational sessions that help inform their members about COVID-19 and COVID-19 vaccine. In January alone, it’s estimated that HOTL reached nearly 30,000 congregants with current DHEC messaging.
• information at public transit hubs
• shared information with the S.C. Department of Commerce and DHEC’s regulated business community to share with employees (breakroom signage and take-home literature)
• sharing information and resources with the S.C. Commission for Minority Affairs, S.C. Department of Aging, Office of Rural Health, S.C. Department of Employment and Workforce, AARP, PASOS, housing authorities, public transportation systems, etc., to share current key messaging and phone numbers for accessing additional information.

Smith sympathizes with anyone trying to get real information out to communities that aren’t as well-connected. She says that between misinformation, constant updates of real information about what’s safe or where and when a vaccination event will happen, and the sheer volume of information hitting people (especially, ironically, the connected), getting good information through to residents is a tall task, but one that demands getting done right.

She says that as tech access becomes more ubiquitous, it will be important to remember that tech is not a Messiah, but a tool.

“I remember when stores … put in the U-Scan™ registers, and it was like, ‘Technology is going to take everyone’s job,” she says.

That didn’t happen, of course, and that’s her point.

“COVID has shown us that technology is a useful tool, but it’s not going to replace everything,” she says.

Efforts to Expand Access

One positive thing about the pandemic is that its main lesson about internet access – that it’s not a luxury anymore, but a necessity – appears to have gotten through to lawmakers who could do something about it.

Both of South Carolina’s U.S. Senators, Lindsey Graham and Tim Scott, Republicans, co-sponsored the Governors’ Broadband Development Fund, along with Sen. Mark Warner, Democrat, of Virginia. In December, the Federal Communications Commission granted the measure $121 million to expand rural broadband in South Carolina. The bill aims to get access to almost 109,000 homes that otherwise, according a statement Graham made, “might as well be on the moon when it comes to getting high-speed internet service.”

In mid-January, the outgoing Trump administration announced a $1.6 million grant to the Lancaster Telephone Company to deploy a fiber-to-the-premises network to connect 5,574 people, 20 businesses, 17 farms, and three educational facilities to broadband in Lancaster and Chester counties.

While measures like these certainly can help, South Carolina still has quite a way to go. The State newspaper reported last June that connecting all of South Carolina could be an $800 million endeavor. An ambitious plan introduced by U.S. Rep. and House Majority Whip Jim Clyburn (D, SC-6th), the Accessible, Affordable Internet for All Act, looks to invest $100 billion to build high-speed broadband infrastructure in unserved and underserved communities all over the country.

That bill was introduced last June and is making the rounds among the Biden administration’s American Rescue Plan.

And South Carolina’s state leaders have looked to tackle the issue of broadband access as well. In September, Gov. Henry McMaster signed the GREAT (Growing Rural Economies with Access to Technology) program into law. It looks to set the stage for a codified broadband access law in the state.

And the state’s 2021 budget features a $30 million safeguard to expand rural broadband to schools and businesses.

All of this is good news to guys like Graham Adams, CEO of the South Carolina Office of Rural Health (SCORH), who says that one of the pandemic’s few positives is the attention broadband access to rural America has gotten.

“[It’s] a much more recognized problem,” Adams says. “There’s a lot more attention on the lack of broadband in rural communities. The whole world was thrown into telecommuting and tele-learning; we all gained a greater appreciation for the importance of connectivity in the home.”

Something Adams hopes people in general come to understand better as access accelerates is that rural communities do want broadband. He says it’s not a matter of not wanting so much as a matter of simply not having access nor the ability to pay for it.

For now, he is glad to see progress being made, including in efforts like the joint SCORH, PCC, South Carolina Rural Innovation Network effort to map access points in Barnwell and Williamsburg counties. Those are two areas plagued by lesser tech access and lesser tech literacy, which Adams also says needs to be a major component of broadband expansion – because tech access won’t do anyone any good if no one can afford it and if no one knows how to use it.

 

A Small Data Snapshot

The caveat with this section and its accompanying graph is, don’t try to apply it too broadly. But as a way of illustrating a piece of the intersection of age, access, and vaccination, the data points do show a couple interesting things, as of March 26, 2021.

 

Allendale, Aiken, and Bamberg counties, all mostly rural, have some of South Carolina’s largest areas without internet coverage; they each also have, according to data from the South Carolina Fiscal Affairs Office, senior populations above 20 percent – and, according to data from DHEC, have higher rates of death from COVID compared to three of the most connected counties in the state, Charleston, Greenville, and York. All three of these counties have senior populations below 20 percent.

While the dataset is too small to extrapolate any sweeping trends, there are also some correlations between how wired a county is and the percentage of that county’s residents who have been vaccinated at least once. Only York County, which is highly connected but has a relatively low vaccination rate, stands apart.

Addendum, March 26, 2021: On the day this story published, U.S. Senators Lindsey Graham and Tim Scott of South Carolina announced the $20 billion State Fix Act to build 5G fiber infrastructure in underserved rural communities.

If signed into law, the APTA-backed bill would achieve a major association goal. Contact Congress now to voice your support.

Informed by lessons learned during the COVID-19 pandemic, a bipartisan group of lawmakers in the U.S. House of Representatives has introduced APTA-backed legislation that would make payment for services delivered via telehealth a permanent option for PTs and PTAs participating in Medicare. If passed into law, the legislation would represent a major shift in payment policy long advocated by APTA.

Known as the Expanded Telehealth Access Act (H.R. 2168), the bill was initially sponsored by Reps. Mikie Sherrill, D-N.J., and David McKinley, R-W.Va. The proposed legislation rapidly gained additional support from both parties, and by the time of its introduction it included 14 additional original cosponsors. The association is urging all PTs, PTAs, students, patients, and other supporters to contact members of Congress by way of the APTA Patient Action Center to voice their support for the new bill.

Essentially, the bill would instruct the U.S Centers for Medicare & Medicaid Services to permanently adopt what is a temporary waiver of restrictions on payment for telehealth delivered by PTs and PTAs, occupational therapists, occupational therapy assistants, speech-language pathologists, and audiologists. The Secretary of Health and Human Services also would be allowed to further expand the list of authorized telehealth providers.

The inclusion of PTs and PTAs as authorized to provide services via telehealth to Medicare beneficiaries has been a longtime advocacy focus for APTA, dating back years before the pandemic triggered the CMS decision to invoke so-called 1135 waivers to allow for payment.

In a press release announcing the introduction of the bill, the primary cosponsors point to the effectiveness of telehealth during the pandemic as an indication that the approach can work for PTs, OTs, and other providers.”During the COVID pandemic, healthcare providers adapted and provided telehealth services to serve the needs of millions of vulnerable Americans,” said Rep. McKinley in the release. “Telehealth services have been beneficial to the health and well-being of America’s seniors and after the public health emergency ends, it’s crucial that critical access to telehealth does not abruptly end.”

“The use of telehealth services during this crisis has demonstrated the critical role technology can play in improving health equity,” said Rep. Sherrill. “No one should have to go without care when a video or phone conversation with a health care provider could mean quicker, safer medical attention.”

APTA President Sharon L. Dunn, PT, PhD, applauded the bill on behalf of the association, saying that “the use of telehealth during the pandemic has helped ensure patient access to physical therapist services, minimize potential exposure to the virus, and provided an option for therapy clinics and their patients during quarantine restrictions — and it’s made it all the more clear just how valuable telehealth is to patients who may need alternative access to therapy.”

“Passage of this bill would represent a major win for physical therapy and the patients they serve,” said David Scala, APTA senior specialist of congressional affairs. “We need to seize the momentum on telehealth and make it clear to lawmakers that maintaining it as an option for Medicare beneficiaries is the right thing to do.”

Get Involved

It’s time to make telehealth a permanent option for PTs and PTAs. APTA makes it easy to add your voice to the effort: PTs, PTAs, students, patients and others can send messages to lawmakers by way of the APTA Patient Action Center. Just follow the instructions for contacting members of Congress.

After a year of moving IT heaven and earth to enable a huge jump in telehealth services for veterans during the coronavirus pandemic, officials from the Department of Veterans Affairs (VA) said March 23 that one of the biggest remaining obstacles to delivering telehealth is a lack of sufficient and/or affordable broadband service in areas where some veterans live.

VA’s success in ramping up telehealth services during the pandemic has been well documented, with daily service capacity rising ten-fold by mid-2020, to 35,000 appointments per day and the ability to hold 17,000 concurrent sessions. By February of this year, VA was averaging 45,000 telehealth visits per day, up from just 2,500 per day in March 2020.

With firm plans to keep moving forward with telehealth into the post-pandemic era, VA officials said at an event organized by AFCEA Bethesda that a lack of robust broadband infrastructure – along with affordability and service uptake issues among some veterans – represents a big hurdle to further progress.

“One of the biggest telehealth challenges is covering the digital divide in rural areas,” said Jack Galvin, Associate Deputy Assistant Secretary, OI&T Information Technology Operations and Services at VA.

Dr. Kevin Galpin, Executive Director, Telehealth Services, Office of Connected Care, at the Veterans Health Administration (VHA), agreed. “The digital divide is by far the number one issue that we are encountering and dealing with,” he said.

“We have a lot of veterans for whom it’s hard to get affordable internet … or they don’t subscribe” to the service, said Galpin, who cited a 2019 Federal Communications Commission (FCC) finding that 15 percent of veterans don’t have broadband service.

Galpin explained that veterans can be directed to the FCC’s Lifeline program to get subsidized broadband service, or that VA can provide veterans with 4G connected tablet devices in order to receive telehealth services. The agency, he said, has purchased more than 100,000 of the devices to distribute to veterans.

“It’s probably the biggest barrier – just making sure that everyone in this country is connected,” Galpin said. “It’s a crisis … for those that don’t have [broadband service], it’s a real big problem.” He added that VA is excited to work with the government and private sector firms “to get people to the right side of the divide.”

Locking in Pandemic Gains

Elsewhere during the March 23 event, VA officials explained they are looking to make permanent the agency’s pandemic-era gains in telehealth and other veterans services, and then press on with additional IT-driven service improvements going forward.

Galpin said that VA’s various telehealth programs logged 5.6 million “episodes of care” for veterans in 2020, and have “become an integral part of how we deliver services.”

“The vision of our office is to enhance the accessibility of healthcare to patients and caregivers … and bring care closer to the veteran,” he said. During the pandemic, he said, VA showed “how flexible the organization was in the complete pivot of the care delivery model …  Everything had to be scaled and pivoted … to see an organization do that in such a nimble fashion needs a spotlight shined on it.”

Galvin said the quick pivot in care models benefited from brushing past “the bureaucratic things that used to hold us back.” The conditions brought on by the pandemic, he said, “really brought to the forefront of what the art of the possible was … and shows what we can do with the right impetus.”

“The new functionality was delivered very rapidly … I think it’s here to stay,” Galvin said.

Dr. Ryan Vega, Chief Officer, Healthcare Innovation and Learning at VHA’s Office of Discovery, Education, and Affiliate Networks, credited the sharp ramp-up in VA telehealth programs during the pandemic as “the only way we were able to reach veterans for chronic care.”

In addition, he pointed to the agency’s work in improving customer-facing websites to deliver healthcare information to veterans. Those efforts, he said, “sometimes are below the surface, but they played out to be incredibly vital” to overall service delivery during the pandemic. “It was all of those pieces that came together,” he said.

Galpin said the quick move to telehealth services was greatly helped by planning that VA started in 2018 with the goal of delivering more care to veterans in their homes by 2021. When the pandemic hit, much of the service pivot “was accelerating what we were doing.”

“It was part scale, and part pivot,” he said, adding, “we had a lot of the platforms in place that we could move from.”

“You can’t wait for an emergency and then think you are going to do it well,” he said.

Shaun Robinson
Boston University Statehouse Program
Published 4:40 a.m. ET Mar. 18, 2021″

BOSTON – Outer Cape Health Services runs three clinics in one of the state’s most rural coastal areas, but for much of the past year, many of their patients have sought care from home. Some are measuring their blood sugar levels on a clinic-provided monitor; others are phoning in for behavioral medicine.

The organization, which has locations in Provincetown, Wellfleet and Harwich Port, took a financial hit and furloughed staff last spring as the number of in-person visits fell, said Pat Nadle, Outer Cape Health Services CEO. Still, Nadle said, remote care is going to stick around as patients come back in. The technology may even help doctors serve them better.

Remote care may help doctors serve patients better

In rural Massachusetts communities from Nantucket to Berkshire County, local health care providers are playing a critical role in the state’s fight against COVID-19. Yet, many of these facilities, which already were operating on thin profit margins and with small staffs, have faced outsized challenges as patients canceled elective procedures and doctors took on additional responsibilities.

Now, as vaccines are rolling out statewide and a new, post-pandemic normal is in sight, advocates say rural health care centers need strong support from local residents and lawmakers. In addition, advocates say, expanding access to telehealth, which lets doctors reach patients safely in underserved areas, is critical.

“They’re not just providing quality health care, but they’re also an economic driver in the community,” Ann Marie Day, executive director of the New England Rural Health Association, said of programs such as Outer Cape Health Services. “They provide a lot of jobs and bring a lot of folks to the community to work, so it’s really important to be able to invest in those rural safety-net providers.”

Statewide, hospital profit margins fell about 4.5% by the end of June 2020, compared with the same time a year earlier, according to the most recent data from the Center for Health Information and Analysis. Less than half of hospitals were in the black, the center found, and the median total margin was -0.7%.

Community hospitals, which serve many of the state’s most vulnerable communities, were among the hardest hit, the data shows. They reported a roughly 7.5% drop in profit margins, and a median total margin of -4.8%. Without government support, the report states, facilities would have gone deeper into the red.

Hospitals in Massachusetts received about $1 billion in federal funding and about $160 million in state funding through the end of last June, according to the report.

President Joe Biden’s approved COVID-19 relief plan includes $8.5 billion of funding for rural hospitals and health care centers to cover expenses and lost revenue as a result of the pandemic. The plan also will provide $500 million for Department of Agriculture grants to rural providers.

“Support from the state and federal government has helped our community hospitals survive this crisis,” Steve Walsh, president and CEO of the Massachusetts Health & Hospital Association, said in a statement. “We remain in close contact with our elected officials to ensure these providers have the resources they need moving forward.”

Providers also have benefited from a state law signed in January requiring insurance companies to provide equal coverage for telehealth and in-person visits, or what is known as coverage parity.

Telehealth lets doctors safely reach patients in underserved areas

Andrew Solomon, senior program manager for Northeast Telehealth Resource Center, said while remote care has helped rural hospitals reach patients for decades, the need for social distancing, as well as legislation like the commonwealth’s parity law, have made the technology more ubiquitous and accessible.

For patients who have a disability or live in areas with limited transportation options, Solomon said, telehealth is a vital tool that enables access to care. Patients who live in small communities may not want to be seen receiving treatment and so prefer the privacy of telehealth, he said, and in some cases, a virtual emergency room visit can provide more timely care than an in-person visit would.

“Providers who hadn’t adopted telehealth before are seeing benefits like reduced no-shows, and those kinds of things are big drivers for providers,” Solomon said. As demand increases and “consumers get more familiar with the potential benefits,” he added, “there will continue to be big drivers there.”

Day, of the New England Rural Health Association, said one challenge for rural telehealth care continues to be limited broadband internet and cellphone connectivity. This is why it’s important that insurance covers telephonic visits, she said, since all that some households may have is a landline.

In 2016, the state identified more than 40 towns in western and north central Massachusetts lacking residential access to broadband. Towns can apply for state grants to build municipally owned networks.

What is telehealth?

“Telehealth is a very broad term,” Solomon said. “There’s a lot of applications and use cases within that, that range from the on-demand live video to remote patient monitoring to provider education opportunities.”

Solomon said telemedicine also allows for joint consultations between primary care providers and specialists, which can help save patients’ time. For instance, he said, a primary care doctor could take a picture on an iPad and send it through a secure platform to a dermatologist; the latter could then decide whether the patient could be treated where they were or whether they required more advanced care.

“Specialists don’t drive out to the Outer Cape much,” said Nadle, of Outer Cape Health Services. “To be able to ‘Zoom’ into a specialist in the treatment room, while you’re in there with your primary care provider, is certainly an option right now to help coordinate care in a much different way.”

Day said rural medical providers also are important vehicles for getting COVID-19 vaccines out to isolated and vulnerable people in their communities. Outer Cape Health Services is distributing about 600 to 800 shots per week across each of its clinics, Nadle said.

In addition to the vaccine rollout, Nadle said, the organization is expanding support for victims of substance abuse who may have been especially struggling with the stressors of the pandemic. Behavioral health care has worked well as a remote service, she said.

At Athol Hospital in northern Worcester County, one takeaway from the pandemic has been the importance of staff collaboration, said Dawn Casavant, vice president of external affairs for the hospital’s parent organization, Heywood Healthcare. Senior leadership and managers have started holding daily meetings to share updates from across the hospital’s departments, she said.

Athol Hospital is a critical-access hospital, a federal designation given to some rural hospitals in remote areas.

“The intersection of all of the primary areas that allow a hospital to function was exaggerated by 1,000% when you’re in a pandemic,” Casavant said. “It’s proven to be really worthy and beneficial for the system to have that opportunity every single morning to start the day on the same page.”