September 2018 | Issue Brief The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma Jessica Sharac, Sara Rosenbaum, Jennifer Tolbert, Anne Markus, Peter Shin, Maria Diaz Executive Summary One year after hurricanes Maria and Irma struck Puerto Rico and the U.S. Virgin Islands (USVI), recovery has progressed but remains slow. This issue brief presents findings from the Geiger Gibson/Kaiser Family Foundation survey of community health centers in Puerto Rico and USVI one year after the hurricanes. It describes the current state of health center recovery and examines shifts in need and capacity, which have potential longer-term implications. Key findings include: Health centers experienced an increase in the overall number of patients and an increase in patients with more complex mental and physical health needs in the year following the hurricanes. Nearly three-quarters of health centers reported an increase in the number of patients served, and some have experienced increases of 10% or more. Additionally, reflecting the lingering effects of the hurricanes, increasing numbers of health center patients are from suffering mental health problems, stress-related conditions, and poorly managed chronic health conditions. Health centers reported a substantial uptick in patients suffering from depression and anxiety, including post-traumatic stress disorder (PTSD), and said their patients are more likely to have suicidal thoughts and attempts than before the storms. Many health centers expanded staff to meet patient needs, but some have experienced staffing losses over the past year. Most health centers have been able to retain or add key staff, including physicians and nurses as well as mental health staff. At the same time, losses of other professionals, including nurses, substance use disorder staff, and dental staff present challenges to service delivery for some health centers. Health centers face increasing challenges referring patients with complex needs for more specialized care. While health centers have faced long-standing shortages when referring their patients for inpatient and specialty care, among health centers that refer patients, many said that these shortages have gotten worse since the hurricanes, likely due to outmigration of other community providers, and, in the USVI in particular, ongoing operational disruptions at hospitals. Provider shortages are particularly acute for mental health and other specialty care as well as substance use disorder treatment and dental care. While most health centers reported that operations are back to normal at all sites, many continue to face critical infrastructure challenges. Over half of health centers reported that some or all sites still need repairs to their buildings and nearly 30% reported ongoing power grid and internet problems at some or all of their sites. Meeting the increasing health needs of the community, and operating in a complex and insufficiently funded environment, emerged as top challenges. The most commonly cited challenges currently facing health centers were their patients’ growing health needs, broader health system changes, and infrastructure issues. Insurance revenue that is inadequate to cover the cost of care was reported as a top challenge by health centers in Puerto Rico, while health centers in USVI cited the loss of community providers and reduced capacity of the health system overall as a major concern. Introduction In September 2017, hurricanes Maria and Irma struck Puerto Rico and the U.S. Virgin Islands (USVI), causing immediate widespread destruction and precipitating lingering infrastructure and health problems. In the year since the hurricanes hit, recovery of the health care system has been slow. Community health centers are an important part of the health care system and while most are fully operational, significant challenges remain. In the wake of the hurricanes, researchers at the Geiger Gibson Program in Community Health Policy at George Washington University’s (GW’s) Milken Institute School of Public Health have been chronicling the recovery experiences of health centers in both Puerto Rico and the USVI. A report issued in early 2018 found that, a few months after the hurricanes, 65% of health centers required building repairs and nearly half (48%) needed repair or replacement of their internet and phone service. 1 Health centers cited difficulties in recruiting and retaining physicians, pharmacy staff, mental health staff, and substance use disorder staff. Health centers reported that the loss of employees’ homes, transportation problems, and increased demand for care in community settings were among the top three challenges facing their staff. This brief presents findings from the most recent Geiger Gibson/KFF survey of community health centers in Puerto Rico and USVI one year after the hurricanes. It describes the current state of health center recovery and examines shifts in need and capacity, which have potential longer-term implications. Background Community health centers play an especially important role in providing access to health care in both Puerto Rico and the USVI. In 2017, 20 federally-funded health centers2 and one look-alike health center3 in Puerto Rico served nearly 370,000 patients and the two health centers in the USVI served 16,010 patients.4 Together, federally-funded health centers on the islands, which operated in a total of 98 sites, registered over 1.5 million patient visits in 2017 (Table 1). Medicaid is the most important source of revenue for health centers in Puerto Rico and USVI, but they are also heavily reliant on federal Section 330 grant funding, and in the USVI, local grant funding. Health centers in Puerto Rico and USVI have The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 2 been recognized by the federal government Table 1. Federally-funded Health Centers in Puerto Rico 5 and US Virgin Islands for quality and efficiency. In September Puerto Rico US Virgin Islands 2018, the Department of Health and Human Number of sites 93 5 Services (HHS) awarded Capital Assistance Total Patients 358,528 16,010 for Hurricane Response and Recovery Total visits 1,465,692 47,122 Efforts (CARE) funding to community health Revenues centers in states and territories affected by $301,397,359 $17,783,678 Total revenues last year’s hurricanes.6 The two USVI health Medicaid 51% 30% centers were awarded $1.26 million,7 while Medicare 8% 4% 19 health centers in Puerto Rico were Private insurance 3% 4% 8 31% 30% awarded $12.8 million. Federal 330 grants State/local/private 1% 23% grants/contracts A recent analysis increased Puerto 6% 9% Self-pay/Other Rico’s death toll from hurricane Maria. A Source: GW analysis of 2017 Uniform Data System data, Health study commissioned by Puerto Rico’s Resources and Services Administration Governor reported that the disaster was associated with 2,975 excess deaths in the six months following the hurricane.9 This number far exceeds the official death toll of 64 reported in the immediate aftermath of the storm. The analysis, conducted by scientists at GW’s Milken Institute School of Public Health in collaboration with the University of Puerto Rico’s Graduate School of Public Health, also found that death rates were far more elevated in the poorest municipalities. While the study focuses on near-term mortality impact, its findings underscore systemic challenges and suggest that the 2017 hurricane events will carry major longer-term health consequences. Key Findings Greater demand and more complex needs Most health centers experienced Figure 1 an increase in the number of Changes in the Number of People Receiving Care at patients seeking care in the year Health Centers since the Hurricanes following the hurricanes. More Since the hurricanes, has the number of patients who receive care at your health center increased, decreased, or stayed about the same? than seven in ten (71%) health Decreased by more than 10 percent centers reported an increase in the 5% number of patients they served Decreased by 10 percent or less (Figure 1). Both USVI health centers 14% reported an increase in patients of 5- Stayed about the same 10%, while 68% of Puerto Rico 10% Increased by 10 percent or less health centers reported an increase Increased by more than 10 percent 62% 10% in patients (Appendix Table 1). Still, one in five health centers said the number of patients they served had Note: Percentages may not sum to 100% due to rounding Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year after Hurricanes Maria and Irma The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 3 decreased, possibly due to ongoing infrastructure issues, staffing constraints, or population shifts. Reflecting the lingering effects of Figure 2 Share of Health Centers Reporting Patients Are More Likely the hurricanes, increasing to Present with Conditions in the Year since the Hurricanes numbers of health center patients are suffering mental health Depression 86% Anxiety, including PTSD and panic attacks problems, stress-related 86% Stress-related conditions 75% conditions, and poorly managed Poorly-managed chronic conditions 71% chronic health conditions. The Respiratory conditions, including asthma 70% trauma of living through the Alcohol or other substance use disorders 70% hurricanes and the stress of the Suicidal thoughts or attempts 70% recovery have taken a toll on the Conditions requiring specialty care 50% residents of Puerto Rico and USVI. Dental problems 50% Over eight in ten (86%) health Infectious diseases 48% centers reported an uptick in patients with depression and anxiety Note: Don’t know responses were excluded from this analysis. Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year after Hurricanes Maria and Irma compared to the time period before the hurricanes, and seven in ten reported that patients were more likely to have suicidal thoughts or attempts and alcohol or other substance use disorders (Figure 2). Large shares of health centers also reported their patients were more likely to present with stress-related conditions such as insomnia and heart palpitations (75%), chronic conditions, such as diabetes and hypertension, that were not well- managed (71%), and respiratory conditions including asthma (70%). Meeting patient demand for services Many health centers have maintained or added staff to meet patient needs, but some have experienced staffing losses since the hurricanes. While many private providers left the islands in the aftermath of the hurricanes, most Figure 3 health centers were able to retain or Changes in Health Center Staffing since the Hurricanes expand key staff (Figure 3). As Increased Stayed about the same Decreased patient needs have increased, health Substance use disorder staff 38% 46% 15% centers have responded by Mental health staff 33% 57% 10% expanding key staff. About a third of Nurses 25% 60% 15% health centers reported an increase Physicians 24% 67% 10% in mental health and substance use Outreach workers 15% 75% 10% disorder staff, and one-quarter reported increased physicians and Pharmacy staff 15% 80% 5% nurses. However, a small but sizable Dental staff 11% 74% 16% share of health centers reported Other enabling services staff 10% 80% 10% decreased staffing, including dental Administrative staff 10% 86% 5% staff (16%), nurses (15%), and Note: Not applicable responses were excluded from this analysis. Percentages may not sum to 100% due to rounding. Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year substance use disorder staff (15%). after Hurricanes Maria and Irma The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 4 Despite increases in demand, most health centers were able to meet the need for services with available staffing. Health centers in Puerto Rico and USVI increased their capacity in response to the rising demand for services. All Figure 4 responding health centers reported Health Centers’ Ability to Meet Patient Demand for that they were able to provide Services needed pediatric and pharmacy Able to meet patient demand Not able to meet patient demand services, and nearly all were able to Dental services 78% 22% meet patient demand for obstetric Off-site services such as mobile vans 80% 20% care, family planning services, and Mental health services 86% 14% Substance use disorder services general primary care services 86% 14% Transportation services 88% 12% (Figure 4). At the same time, health Family planning services 89% 11% centers were most likely to report not General primary care services 90% 10% being able to meet patient demand Obstetric services 95% 5% for dental services (22%), off-site Pharmacy services 100% services (20%), mental health Pediatric services 100% services (14%), and substance use Note: Not applicable responses were excluded from this analysis disorder services (14%). Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year after Hurricanes Maria and Irma Health centers are experiencing growing constraints on their ability to secure specialty referrals for patients with complex needs. While health centers have increased capacity to meet the demand for a wide range of services at their facilities, some patients require more specialized services from other health care providers. Health centers in both Puerto Rico and USVI have faced longstanding provider shortages (defined as either no available providers or long wait times for appointments) when referring patients, but in some cases, these shortages have worsened since the hurricanes hit. Health centers that refer for services were most likely to report facing provider shortages when referring patients for inpatient hospital care, specialty care, and mental health care (Figure 5). While problems with access to hospital- based care predated the hurricanes, Figure 5 this remains a particular challenge in Reported Shortages for Referral Services since USVI where the hospital on St. Croix Hurricanes is operating at significantly reduced All Reported Shortages, by Service Type, among Worsened Shortages by Service Type Health Centers That Refer since Hurricanes 10 capacity. Although most health Other specialty care services 75% 67% centers said they were able to Mental health treatment services 67% 63% provide needed pediatric and Substance use disorder treatment services 64% 44% obstetric care on-site, when they did Dental services 63% 40% Outpatient surgeries 63% need to refer for these services, 33% Pediatric services 78% 29% likely for pediatric specialty care and Diagnostic services, such as X- 62% 25% rays, MRIs high-risk obstetric care, they faced Family planning services 71% 20% significant challenges. Laboratory services 60% 17% Obstetric services 67% 17% Even as more patients have Inpatient services 71% 17% Note: Not applicable responses were excluded from this analysis. presented with behavioral health and Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year after Hurricanes Maria and Irma stress-related conditions and are in The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 5 need of specialty care, shortages have worsened for mental health and other specialty care referrals. Among health centers that face shortages when referring patients, two-thirds said shortages for specialty and mental health care have gotten worse over the past year, and four in ten said access to substance use disorder treatment and dental care have worsened (Figure 5). Current status of operations, services, and supplies While most health centers are Figure 6 fully operational, many continue Current Status of Health Center Infrastructure and to face disruption and critical Supplies Fully restored at all sites Recovery or repair needed at some sites Recovery or repair needed at all sites infrastructure challenges. Four in Building 48% 38% 14% five (81%) health centers reported Grid power 71% 24% 5% that operations are back to normal Internet 71% 24% 5% nearly a year after the hurricanes; IT infrastructure/hardware 76% 19% 5% however, this masks serious Phone 81% 10% 10% challenges facing some health Electronic health records (EHRs) 81% 10% 10% centers (Appendix Table 2). Both Air conditioning system 81% 14% 5% health centers in the USVI are back On-site diagnostic equipment 83% 11% 6% to normal operations, while in Puerto Vaccine supplies 86% 14% Rico, three health centers continue Dental supplies 89% 11% to face minor disruptions at some or Note: Percentages may not sum to 100% due to rounding. Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year all sites and one reported critical after Hurricanes Maria and Irma disruptions at some sites. Over half (52%) of health centers still need repairs to buildings at some or all of their sites (Figure 6). Nearly three in ten health centers reported that grid power and internet have not been fully restored, and nearly a quarter reported that their IT infrastructure and hardware are in need of repair or replacement. While most said vaccine supplies are available at pre-hurricane levels, 14 percent noted that supplies have not been fully restocked at all sites. Hurricane Figure 7 Actions Taken by Health Centers to Prepare for the preparation and Current Hurricane Season community-wide Developed emergency staffing plans 100% recovery actions Developed strategies to reach people in the community (e.g., mobile vans, outreach workers) 90% Targeted community outreach efforts to particular All responding health centers populations (e.g., elderly or chronically ill) 76% reported taking action to prepare Stocked up on other essential supplies 71% for the current hurricane season, Purchased new generators 67% and developing emergency Shored up communication networks (phone system, internet, satellite phones, etc.) 62% staffing plans was a top priority. Installed solar panels to support health center 62% operations during power outages Having withstood an unexpectedly Increased supplies of needed medications 57% catastrophic hurricane season, Increased diesel capacity 52% health centers have taken numerous Purchased batteries to support health center 48% operations during power outages steps to ensure they are prepared Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year after Hurricanes Maria and Irma The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 6 for the next storm. All said they had developed staffing plans for future emergencies and nine in ten reported developing strategies for community outreach, such as through mobile vans or community outreach workers (Figure 7). Over 70% said they planned to target community outreach to vulnerable populations like the elderly or people with chronic conditions and had stocked up on essential supplies. With ongoing electrical power problems for many health centers, over six in ten reported preparing for future power outages by purchasing new generators or installing solar panels. To assist in the broader hurricane Figure 8 recovery effort, most health Health Centers’ Participation in Community-wide centers participated in activities Hurricane Recovery Efforts in the Past Year to improve access to critical Improving access to safe, drinkable water 75% health, social, and infrastructure Education services 70% services in their communities. Food and nutrition services 70% Nearly all respondents indicated that Other environmental health projects 60% their health centers had been Transportation services 55% involved in activities, either alone or Child care services 30% with other community agencies and Recovery of basic utilities (e.g., electricity, phones) 30% organizations, to address Domestic violence services 20% community-wide needs for recovery Employment services 15% from the hurricanes in the past year. Housing repairs or placements 15% Three in four respondents reported Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year participating in efforts to improve after Hurricanes Maria and Irma access to safe drinking water, seven in ten worked on education and food and nutrition initiatives, and six in ten reported participation in other environmental health projects (Figure 8). Greatest challenges currently facing health centers Meeting patients’ increasingly Figure 9 serious health care needs and Top Three Challenges Reported by Health Centers operating in an insufficiently funded, complex, and rapidly Impact of broader health system changes 48% evolving system emerged as top Increasing health needs of patients/community challenges. Health centers in members 48% Puerto Rico and USVI face many Infrastructure issues 43% ongoing challenges as they work to Insufficient insurance reimbursement 38% recover fully from the hurricanes. Loss of patients 29% The impact of broader health system Ability to retain staff 24% change occurring in both territories, Ability to recruit staff 19% managing the increasingly complex Loss of community providers/reduced capacity of health system overall 14% health needs of patients, and Increase in patients exceeding health center capacity 14% ongoing infrastructure issues were Insufficient grant funding 5% among the top three challenges Source: GW/KFF Survey of Community Health Centers in Puerto Rico and the US Virgins Islands One Year after Hurricanes Maria and Irma The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 7 facing health centers in both Puerto Rico and USVI (Figure 9). More than four in five (83%) reported that the hurricanes worsened the impact of these challenges. Insufficient insurance reimbursement was reported as a top-three challenge by 42% of health centers in Puerto Rico, while health centers in USVI cited the loss of community providers and reduced capacity of the health system overall as a major concern (Appendix Table 3). Discussion One year after the hurricanes, health centers are grappling with a far sicker patient population, a fact that is not surprising given the devastating impact of the catastrophe on the health and well-being of the general population. Health centers continue to show recovery but still require repair, particularly of buildings, grid power, and internet. Staffing growth is underway, but health centers are also reporting the loss of key staff. Specialized referrals, never easy, present a growing challenge for some services. Nearly all health centers have been involved in community-wide recovery efforts as well as their own. Consistent with the findings, health centers report that their top challenges are caring for a sicker patient population, meeting demand with limited revenue, and operating within the constraints of the broader changes in the health system, intensified in Puerto Rico by efforts to control health care costs in the face of the island’s ongoing financial crisis. The recovery grants awarded to health centers in both Puerto Rico and the USVI are an important step, but they are modest in size and do not obviate the need to maintain the strength of Medicaid funding, the most important source of health care financing for health centers operating on both islands. The greater reliance on federal health center funding in Puerto Rico and the USVI also underscores the importance of sustained federal grant funding to ensure that these community health centers are able to fully and effectively serve their patients. The authors express their appreciation to Feygele Jacobs at the RCHN Community Health Foundation (RCHN CHF) for her assistance with the survey and invaluable insights on the brief. Additional funding support for this brief was provided to the George Washington University by RCHN CHF. The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 8 Methods The Survey of Community Health Centers in Puerto Rico and US Virgin Islands One Year after Hurricanes Maria and Irma was conducted by the Geiger Gibson Program in Community Health Policy at the George Washington University (GW) and the Kaiser Family Foundation with support from the RCHN CHF. The online survey was distributed in August-September 2018 by email to upper-level management of the 23 community health centers in Puerto Rico and the USVI (21 health centers in Puerto Rico and two in USVI). Nineteen community health centers in Puerto Rico and both health centers in the USVI responded to the survey, for a 91% response rate. Survey findings are presented for all surveyed health centers and, for some questions, separately for Puerto Rico and USVI health centers. The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 9 Appendix Appendix Table 1: Change in the number of patients who receive care at health centers since the hurricanes US Virgin Percent of health centers where the number of All Puerto Rico Islands patients since the hurricanes… (N=21) (N=19) (N=2) Stayed about the same 10% 11% 0% Increased by less than 5% 19% 21% 0% Increased by 5-10% 43% 37% 100% Increased by more than 10% 10% 11% 0% Decreased by 5-10% 14% 16% 0% Decreased by more than 10% 5% 5% 0% Appendix Table 2: Status of health center operations a year after the hurricanes US Virgin All Puerto Rico Percent of health centers where… Islands (N=21) (N=19) (N=2) Operations are mostly back to normal at all sites 81% 79% 100% Operations remain disrupted in minor ways at some or 14% 16% 0% all sites Operations remain disrupted in critical ways at some 5% 5% 0% sites Appendix Table 3: The three biggest challenges currently facing health centers US Virgin Percentages reported for responses selected as a All Puerto Rico Islands top three challenge (N=21) (N=19) (N=2) Infrastructure issues 43% 42% 50% Ability to recruit staff 19% 21% 0% Ability to retain staff 24% 26% 0% Loss of patients 29% 26% 50% Increase in patients exceeding health center capacity 14% 16% 0% Loss of community providers/reduced capacity of 14% 5% 100% health system overall Increasing health needs of patients/community 48% 47% 50% members Insufficient insurance reimbursement 38% 42% 0% Insufficient grant funding 5% 5% 0% Impact of broader health system changes 48% 47% 50% Other challenge 19% 21% 0% The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 10 Endnotes 1 Sharac, J. & Rosenbaum, S. (2018). The state of recovery: an update on community health centers in Puerto Rico and the Virgin Islands. Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University. Policy Research Brief No. 52. https://www.rchnfoundation.org/?p=6694 2 Bureau of Primary Health Care. (2018). 2017 Health Center Data: Puerto Rico Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2017&state=PR 3 Bureau of Primary Health Care. (2018). 2017 Puerto Rico Health Center Data: Community Health Foundation of Puerto Rico Inc. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/lookalikes.aspx?q=&bid=02E01268&state=PR&year=2017 Look-alike health centers must abide by health center program requirements but do not receive Bureau of Primary Health Care (BPHC) health center program funding. 4Bureau of Primary Health Care. (2018). 2017 Health Center Data: Virgin Islands Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2017&state=VI 5 HRSA (2018). Health Center Quality Improvement FY2018 Grant Awards. https://bphc.hrsa.gov/programopportunities/qualityimprovement/awards.aspx?state=PR; https://bphc.hrsa.gov/programopportunities/qualityimprovement/awards.aspx?state=VI 6 HHS.gov. (September 6, 2018). HHS awards nearly $60 million to support community health centers impacted by Hurricanes Harvey, Irma, and Maria. https://www.hhs.gov/about/news/2018/09/06/hhs-awards-60-million-support- community-health-centers-impacted-by-hurricanes.html 7 HRSA. (2018). FY 2018 Capital Assistance for Hurricane Response and Recovery Efforts (CARE) awards - Virgin Islands. https://bphc.hrsa.gov/programopportunities/fundingopportunities/care/fy2018awards/vi.html 8 HRSA. (2018). FY 2018 Capital Assistance for Hurricane Response and Recovery Efforts (CARE) awards - Puerto Rico. https://bphc.hrsa.gov/programopportunities/fundingopportunities/care/fy2018awards/pr.html 9 The George Washington University in Collaboration with the University of Puerto Rico Graduate School of Public Health (2018). Ascertainment of the estimated excess mortality from Hurricane María in Puerto Rico. https://publichealth.gwu.edu/sites/default/files/downloads/projects/PRstudy/Acertainment%20of%20the%20Estimated %20Excess%20Mortality%20from%20Hurricane%20Maria%20in%20Puerto%20Rico.pdf 10 Hall, C., Rudowitz, R., Artiga, S., and Lyons, B. (2018) One Year after the Storms: Recovery and Health Care in Puerto Rico and the U.S. Virgin Islands. Kaiser Family Foundation. The Recovery of Community Health Centers in Puerto Rico and the U.S. Virgin Islands One Year after Hurricanes Maria and Irma 11