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Health
Routine medical care can wait, Nebraska doctors say, but not too long

While most eyes these days are trained on the battle against the novel coronavirus, regular health care continues almost in the background.

There’s not as much of it. A state health directive issued last month shut down most elective surgeries and other procedures, from routine dental care to knee replacements.

Even before that took effect, Omaha-area hospitals agreed in mid-March to reschedule most nonessential surgeries and medical procedures for 90 days.

That has left some to wonder whether some important care — cancer screenings for adults, routine care for people with diabetes and hypertension — will be missed along the way.

Health officials say they’re working hard to make sure such care continues, even if some of it looks different from how it used to look. But they’re also trying to balance providing care with the need to maintain social distancing and protect both patients and their staff members from infection with the virus.

To help fill the gap, doctors and health systems over the last several weeks have quickly expanded what’s known as telehealth, or telemedicine, with visits conducted over the phone or by video link.

BOYS TOWN NATIONAL RESEARCH HOSPITAL 

Dr. Kevin Murphy, an allergist and pediatric pulmonologist with Boys Town National Research Hospital, conducts a telehealth visit with patients. Use of telehealth is ramping up as health care systems seek to ensure that patients get needed care while protecting patients and staff from the novel coronavirus.

For those who must be seen in person, many providers have designated separate locations for sick people and healthy ones or separated the two by designating different hours or building entrances. That’s in addition to screening patients ahead of time for symptoms of COVID-19, the disease caused by the virus.

“What we want to do is take care of our patients … at the right time, in the right place and in the right way,” said Dr. Michael Schooff, director of primary care for CHI Health.

CHI Health started ramping up telehealth by offering telephone visits, logging more than 400 in one day last week. Now it’s rolling out video visits. As of Tuesday, more than 600 providers in primary care and a variety of specialties had signed up to conduct telehealth visits via Zoom for Healthcare.

Telehealth, in both forms, has been on the uptick for some time. CHI Health, for instance, has offered virtual care as a convenience for patients with minor illnesses for several years. The large health systems in Omaha and Lincoln also have used the technology to stretch specialties such as behavioral health care and emergency stroke treatment across a sprawling, rural state.

While providers and insurers still are working through billing issues, the shift has been aided by recent decisions by most commercial insurers as well as Medicare and Medicaid to pay health care providers the same amount for telehealth consultations as they do for in-office visits. Many insurers also have waived cost-sharing for patients for in-network telehealth visits.

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Still, the health care sector faces some of the same financial challenges the pandemic has posed for other businesses. Visits, and revenue, are down. CHI Health’s Schooff noted that primary care clinic volumes are down 40% or more. He said he’s hearing the same from other health systems.

Across the country, thousands of health care workers have been laid off, furloughed or had their hours reduced in response to the downturn. In Nebraska, health care workers have been among those contributing to the state’s record unemployment claim filings. During the week ending March 28, health care and social assistance workers posted the biggest numerical gain in claims filed, up 106% from the preceding week.

Dr. Donald Darst, president of Midwest Regional Health Services, said the primary care clinic in Omaha recently laid off a third of its workforce.

“I never thought 15 years ago when I started this business that I would be in this position,” he said.

But Darst said the clinic has been working to check in with patients, particularly those with chronic conditions. He said he’s worried that patients will ignore their health issues because they’re afraid to come in to the clinics. Some diabetics already have seen blood sugar levels increase.

While Midwest Regional has offered video visits for three years, Darst said such interactions now make up 50% or more of all visits. Staff members also have been calling patients to check in and sending them notes. The clinic also started doing sidewalk visits for diabetics to check their sugar levels, following up with video visits.

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Dr. Sian Jones-Jobst made an even quicker pivot. The president of Complete Children’s Health in Lincoln, Jones-Jobst tried telehealth for the first time March 20 and then saw about 80% of her patients for initial visits while on duty the following weekend, with about half coming in for in-person parking lot exams. By March 23, all of the group’s providers were seeing patients first via telehealth and then bringing in those who require an in-person visit.

With multiple locations, the group also has designated one for sick visits and others for well checks. “We’re trying as best we can to still get patients in for their preventive care,” she said. “But there’s a reluctance for patients to come in.”

Boys Town National Research Hospital also has begun offering virtual visits for a number of services, including mild illness, chronic care follow-up and medication checks. Monday, the health system began dividing those who must be seen in person between well and sick locations, sorting them first by telephone if possible, said Dr. Jason Bruce, associate medical director for primary care.

But the health system is trying to keep children up to 18 months on a normal schedule with in-person visits for well care and vaccinations, as requested by the American Academy of Pediatrics and the federal Centers for Disease Control and Prevention.

After 18 months, kids aren’t due for more shots until they’re between ages 4 and 6, he said, so physicians have some leeway.

But if patients have questions about whether they must come in, they should simply call. “We don’t want them worried at home, do they come in, do they not come in,” he said. “If they don’t know, give us a call.”

Schooff, the CHI Health physician, said doctors there, too, will assess the situations of patients who have appointments and consider the options. They may, for instance, recommend delaying a well visit and sports physical for a teen who has no pressing questions or concerns.

Many annual wellness visits for patients on Medicare, on the other hand, can be done virtually. A significant portion of such visits is devoted to screening for fall risk and mental health issues, things that can be done remotely.

Some patients, however, still will need to be seen in person so a provider can listen to their hearts and lungs. Diabetics still need foot and eye exams.

Methodist Health System has been asking patients 65 and older who are stable and doing well to stay home. “These patients can easily wait three or four months to see their physician,” Todd Grages, president and CEO of Methodist Physicians Clinic, said in a statement.

Meanwhile, Grages said, patients who must be seen are getting the care they need. In addition to ramping up its telehealth services, the system’s health coaches and care navigators continue to contact those with chronic conditions.

And then there are cancer screenings such as colonoscopies for colorectal cancer, mammograms for breast cancer and prostate exams for prostate cancer.

Dr. Michael Schafer, a gastroenterologist with Midwest Gastrointestinal Associates, said it’s not a big deal to delay screenings for a couple of months.

Dr. Margaret Block, a medical oncologist with Nebraska Cancer Specialists, agreed, noting that all three types typically grow relatively slowly.

But the concern, Schafer said, is that some people who have to reschedule may not get back in, especially if they lack resources or had to summon a lot of courage to schedule in the first place.

And Block stressed that people with symptoms — a lump in a breast, blood in the stool — should not delay.

Even now, people are being diagnosed with and treated for cancer, she said. The oncology group is screening patients for the virus before they come in the office. Last week, she joined some other partners in the practice and did her first telehealth visit. They work well for going over scans and reports with patients.

Schafer said people who miss an appointment must be diligent about getting back on schedule. Providers already send reminders, he said, but they probably will be more aggressive in future.

The gastroenterologists already are planning to accommodate a surge of patients later this year, he said.

Bruce said Boys Town doctors, too, are looking ahead and adding clinics in order to catch up with delayed appointments, including kindergarten checkups and sports physicals.

If the timeline gets too tight, he said, the state may want to look at pushing back the deadline for kindergarten physicals, which normally are required by the first day of school.

“I think people will be happily busy, happy to see their patients,” he said. “We’ll do everything in our power to meet the need.”

Schooff said patients, whether they’re treated in person or virtually, are pleased they can still get the care they need.

“Our providers are loving it, too, the fact that they can be safe and help you be safe,” he said. “Because we’re still here for you. And that’s one of the most important messages we can give right now.”

April photos: Nebraska faces coronavirus

Education
Nebraska education chief: School may not be normal in the fall

Will school get back to normal for Nebraska kids in the fall?

You know, the kind of school where hallways bustle with students, band members march shoulder to shoulder and football players get in each others’ faces.

Don’t count on it, officials say.

Nebraska Education Commissioner Matt Blomstedt is advising local district leaders to draw up contingency plans in case the coronavirus crisis lingers on.

“I don’t believe it will be normal in the fall,” Blomstedt said.

It’s hard to say yet what the situation might look like this fall, but possibilities include delaying the start of the school year, separating students into groups and rotating them into school buildings at different times or using partial or complete distance learning.

Of course, there’s still time between now and then for a medical breakthrough, a presidential reopening order or other event that could turn the tide against COVID-19 and clear the way for normal operations.

Most districts are slated to start in mid-August. The first day for students in the Omaha Public Schools is currently Aug. 18.

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But even the start dates on the calendar are in question, as some officials have floated the idea of starting later in the fall or having only staff return in August to organize and prepare for whatever plan is put into effect to meet the health requirements.

Already, summer school is looking iffy, with some districts rescheduling later in the summer and reimagining how summer school might be delivered remotely.

“I think it’s going to be very difficult to have summer school in June with students,” Blomstedt said.

He said it’s prudent for local officials to plan on disruptions in the fall. He wants them to be prepared and not wait until the last minute to draw up plans.

So, what might those plans look like?

Nothing’s for certain yet — not by a long shot — but it’s instructive to recall why schools closed in the first place.

The governor has said that schools are the most concentrated gatherings of people in the state. Closing them was to blunt the disease’s spread.

Blomstedt said that unless there’s a vaccine or antibody test by then, or assurances that medical facilities won’t be overwhelmed, schools should prepare for the possibility that gatherings will still be limited.

JOE DEJKA/THE WORLD-HERALD 

Ninth grade physical science teachers Trina Nelson, left, and Shauna Stauffer maintain a safe distance while planning lessons in an empty classroom Friday at Gretna High School. The school’s teachers reported to work, but no students were on the premises.

The most drastic scenario would be for districts to continue distance learning with students staying at home.

Because schools already rolled out distance learning this spring, by fall they should have the wrinkles ironed out and know where it’s working and where it’s not, and what more they need as far as training, technology and resources if it’s to continue on a grander scale.

A less drastic scenario, if health officials deemed it safe, would be allowing smaller groups of students to enter schools, he said.

Schools might have to separate students into smaller groups who would be kept isolated from one another, he said. Student groups could report to the school building on different days — for instance, one group attends classes on Monday and Tuesday, the other on Thursday and Friday, he said.

Blomstedt said it’s possible that delivering lessons via television could play a bigger role. Already the state teachers union, Nebraska State Education Association, is providing televised lessons through its Teacher TV.

Perhaps, he said, those TV lessons could be scaled up, and classroom teachers could take on more of a tutoring role, he said.

Students could even attend three weeks in class followed by three weeks of remote learning, all aimed at avoiding spread, he said.

Blomstedt’s outlook tends toward the cautious side — as it has been since the start of the crisis. But he points to the Spanish flu pandemic of 1918 for a history lesson. The flu subsided but rebounded with a second deadly wave.

At the time, he said, there were waves of shutdowns.

Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, has spoken optimistically about the possibility of schools reopening in the fall.

But he has also suggested that things wouldn’t be completely normal.

During a White House briefing on April 7, Fauci said he couldn’t predict accurately what the situation would look like but said he expected that by fall “we will have this under control enough that it certainly will not be the way it is now, where people are shutting schools.”

Medical officials, however, would still have to identify, isolate and contact-trace people with the disease, he said.

With an antibody test, officials would know more about the actual penetration of the infection in society, he said. Knowing how many people have been infected, who’s protected and who’s vulnerable would help inform decisions on how close to normal things can return, Fauci said.

“The bottom line is: No absolute prediction, but I think we’re going to be in good shape,” he said.

Blomstedt said it’s important that schools complete this school year and provide kids with learning opportunities in the summer.

Millard Public Schools Superintendent Jim Sutfin told his board this week that district leaders are discussing ideas for fall, including the possibility of full remote learning and smaller groups in school.

“Without immunizations, we’re going to be in a tough spot for a long time,” Sutfin said.

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OPS has a team working on plans, according to Jeremy Maskel, communication director.

Fall is too far out to talk specifics right now, Maskel said.

“Much of that will be determined in coordination with health officials and the Nebraska Department of Education,” he said. “We have already gathered feedback to evolve and grow our distance engagement efforts this spring and will continue to do so heading into fall.”

He said the district should decide soon on how to handle summer school.

Lincoln Public Schools Communication Director Mindy Burbach said district leaders have begun initial discussions.

“Without further guidance on timing and social gathering limits, it is difficult to make firm plans in regards to next school year,” Burbach said.

For now, the district’s focus remains on providing meaningful learning for students and finishing the current school year as strong as possible, she said.

Officials will examine the effectiveness of current remote learning and look for ways to improve it, she said.

Lincoln is considering potential changes for summer school, she said.


Omaha-area high schools ranked by 2019 ACT scores

Omaha-area high schools ranked by 2019 ACT scores

Articles
TRUE, OR AT LEAST ASPIRATIONAL

Amessage along Martha Street. We're all in the same boat, mostly rowing in the same direction. As Executive Editor Randy Essex writes: "It seems, stay-at-home order or not, pretty much all of America is living the same way. Almost everyone is compliant with restrictions and recommendations, but everywhere I checked has seen an arrest here or there and cops breaking up crowds."


Health
Grand Island area now has highest number of coronavirus cases in Nebraska

The Grand Island area reached an unwanted milestone Wednesday: It had more confirmed coronavirus cases than anywhere else in Nebraska.

The Central District Health Department reported 278 known cases in Hall County, where Grand Island is, on Wednesday afternoon.

That exceeds the 263 cases reported the same day in the far more populous Douglas County.

Douglas County reported its first case on March 6. Hall County didn’t report its first cases until nearly three weeks later, on March 26, showing how quickly the virus has taken hold and spread in the central Nebraska region.

The local health agency also oversees neighboring Merrick and Hamilton Counties, which have four and 15 total cases, respectively, for a total of 297 cases in the three counties.

An estimated 571,300 people live in Douglas County, roughly nine times Hall County’s population of 61,000. On a per capita basis, Hall County actually has 10 times more cases than Douglas County.

In fact, though Douglas County has the second-highest number of cases in the state, its per capita rate is actually below the statewide average. And it’s far below that of the state’s biggest hot spots: Hall, Kimball, Adams and Custer Counties.

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Hall County also reported its fifth death Wednesday, a man in his 80s who was hospitalized.

Clusters of the disease have cropped up at the massive JBS USA plant, where 3,600 workers clock in for shifts cutting and packaging beef, the McCain Foods frozen appetizer factory, nursing homes and a health clinic.

Forty workers or residents at nine long-term-care centers or home health agencies have tested positive for the coronavirus, including Tabitha, Wedgewood, Lakeview, Tiffany Square, Heritage, Edgewood, Country House and Good Samaritan in Hall County and Westfield in Hamilton County, the health department said Wednesday.

The actual number of people infected is hard to tell and could be even higher.

Central District Health Department Director Teresa Anderson said the availability of testing in the Grand Island area remains very limited. The Nebraska National Guard assisted with swabbing people for testing last week, and Gov. Pete Ricketts said Guard members will return again this weekend.

A little more than 600 people have been tested in Hall County, according to figures from the Nebraska Department of Health and Human Services, compared to more than 3,800 people in Douglas.

“We are hopeful that the number of much-needed COVID-19 tests will increase in the near future,” Anderson said.

Earlier this week, data showed that 35% of those being tested in Hall County had the virus — much higher than the statewide average of 7.65%.

Health officials have said the number of confirmed cases will increase as a larger pool of people are tested.

2ND LT. NATASHA HILSGEN/U.S. AIR FORCE 

Nebraska National Guard airmen with the 155th Medical Group practice health and safety protocols by carefully donning their protective personal equipment in Grand Island.

Adams County and Hastings are just south of Grand Island, and many travel between the two cities to work or shop. Coronavirus cases there are also climbing, with 66 people testing positive as of Tuesday, including 12 workers at a Western Reserve beef processing facility in Hastings.

State and local officials said it’s hard to pinpoint exactly why the Grand Island area has emerged as such a coronavirus hot spot.

But some of the largest employers in the area are food processing and manufacturing facilities, including plants for JBS, Hornady ammunition and Case New Holland farm machinery. Case New Holland temporarily shut down production last week to prevent the virus from spreading.

It’s harder to follow social distancing guidelines on a production line.

“Grand Island stands on the front line in the fight against COVID-19 because we have many people employed in necessary jobs — manufacturing, food processing, agricultural equipment,” Mayor Roger Steele said last week at a press conference. “While other cities can ask office workers to work from home, that is not an option for our workers.”

Local doctors and Anderson have been warning for weeks that the number of cases would continue to rise and that there are most likely many more undetected cases in the community, given the testing shortage.

Anderson and Steele said they would have liked to institute a two-week shelter-at-home order to get a better handle on the virus, but Ricketts didn’t support that approach.

The governor has said Nebraska’s directed health measures, which have closed schools and dine-in areas at restaurants, and prohibited gatherings larger than 10 people, are similar to, and in some cases even stricter than, the stay-at-home orders enacted in other states.

Anderson has said she fears that the local health care system is just weeks away from being swamped, but administrators at St. Francis, the Grand Island hospital, say they are not there yet.

The hospital has erected a negative-pressure respiratory care unit in a tent outside the emergency room and could add 28 beds, expanding to a capacity of 157 beds, to care for additional patients.

At a press briefing Wednesday, Ricketts said three people at St. Francis were on ventilators for breathing support one week ago. That number has now risen to 17, he said. At least seven COVID-19 patients this week have been transferred to other hospitals, including ones in Omaha.

But St. Francis is not at capacity and staff members are staying calm and collected, said Ricketts and Dr. Gary Anthone, Nebraska’s chief medical officer.

“We are deploying resources to be able to address it,” Ricketts said. “People are working very, very hard, in Grand Island, but the plan is working. We have not overwhelmed the health care system.”

World-Herald staff writers Henry J. Cordes and Nancy Gaarder contributed to this report.

April photos: Nebraska faces coronavirus

Articles
Relief money starts arriving; drop in U.S. output is biggest since WWII
BUSINESS SLOW OVERSEAS

WASHINGTON (AP) — Government relief money began arriving in Americans' bank accounts as the economic damage to the U.S. from the coronavirus piled up Wednesday.

In Europe and China, sluggish sales at reopened stores made it clear that business won't necessarily bounce right back when the crisis eases.

With many factories shut down, American industrial output shriveled in March, registering its biggest decline since the U.S. demobilized in 1946 at the end of World War II. Retail sales fell by an unprecedented 8.7%, with April expected to be far worse.

The world's biggest economy began issuing one-time payments this week to tens ofmillions of people as part of its $2.2 trillion coronavirus relief package, with adults receiving up to $1,200 each and $500 per child to help them pay the rent or cover other bills. The money will be directly deposited into accounts or mailed as checks to households in the coming weeks, depending on how people filed their tax returns.

In an unprecedented move, President Donald Trump's name will be printed on the paper checks. When asked why he wanted his name on the checks, Trump said he didn't know too much about it.

"I do understand it's not delaying anything, and I'm satisfied with that," he said, adding that he didn't think it was a big deal.

"I'm sure people will be very happy to get a big, fat, beautiful check and my name is on it."

Trump said Wednesday that he's prepared to announce new guidelines allowing some states to quickly ease up on social distancing even as business leaders told him they need more coronavirus testing and personal protective equipment before people can safely go back to work.

The industry executives cautioned Trump that a return to normalcy will be anything but swift.

The new guidelines, expected to be announced Thursday, are aimed at clearing the way for an easing of restrictions in areas with low transmission of the coronavirus, while keeping them in place in harder-hit places.

But in a round of calls with business leaders Wednesday, Trump was warned that a dramatic increase in testing and wider availability of protective equipment will be necessary for the safe restoration of their operations.

Trump said at his daily briefing that data indicates the U.S. is "past the peak" of the COVID-19 epidemic, clearing theway for his plans to roll out guidelines to begin to reopen the country.

He called the latest data "encouraging," saying the numbers have "put us in a very strong position to finalize guidelines for states on reopening the country."

In some places under stay-athome orders, frustrations began to boil over among those worried that the economic toll is more crushing than the virus itself.

Around the world, the first steps in lifting economically crippling restrictions are running into resistance, with customers staying away from reopened businesses and workers afraid of risking their health.

In China, millions are still wary of spending much or even going out. Some cities have resorted to handing out vouchers and trying to reassure consumers by showing officials in state media eating in restaurants.

"I put off plans to change cars and spend almost nothing on eating out or entertainment," said Zhang Hu, a truck salesman in Zhengzhou who has gone back to work but has seen his income plummet because few people are buying 20-ton rigs. "I have no idea when the situation will turn better."

In Austria, Marie Froehlich, who owns a clothing store in Vienna, said her staff was happy to be back after weeks cooped up at home. But dependent largely on tourism, which has dried up amid the travel restrictions, she expects that the business will take months to return to normal.

"Until then, we are in crisis mode," she said.

Rome's streets were also largely deserted despite the reopening of some stores.

Worldwide, deaths have topped 130,000 and confirmed infections 2 million, according to the tally kept by Johns Hopkins University. The figures understate the true size of the crisis, in part because of limited testing, different ways of counting the dead, and secrecy by some governments.