COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines FEBRUARY 2021 AUTHOR Goodwin Simon Strategic Research Contents About the Authors ........................................................................................................................................ 2 About the Foundation ................................................................................................................................... 2 Introduction .................................................................................................................................................. 2 Section 1: COVID-19 Vaccine Experience and Readiness.............................................................................. 4 Personal Vaccination Experience .............................................................................................................. 4 Side Effects ................................................................................................................................................ 6 Recommendation of COVID-19 Vaccine to Patients ................................................................................. 7 Preparedness to Administer COVID-19 Vaccines ...................................................................................... 8 Section 2: COVID-19 Surge Readiness ......................................................................................................... 10 Overall Preparedness for Current COVID-19 Levels................................................................................ 10 Preparedness in Specific Areas ............................................................................................................... 12 Staffing Shortages ................................................................................................................................... 16 Availability of PPE.................................................................................................................................... 17 Section 3: COVID-19 Impacts on Health Care Providers ............................................................................. 20 Health Care Providers' Emotional and Mental Health ............................................................................ 20 Morale ......................................................................................................................................................... 20 Indicators of Burnout .............................................................................................................................. 22 Public Response to the COVID-19 Pandemic .......................................................................................... 26 Exposure to and Concern About Contracting COVID-19 at Work ........................................................... 28 Section 4: COVID-19 Impact on Patients..................................................................................................... 30 Provider Treatment of COVID-19 Patients .............................................................................................. 30 Patient Behavioral and Mental Health Impacts ...................................................................................... 31 Section 5: Perception of When the COVID-19 Pandemic Will End ............................................................. 35 Appendix: Methodology and Sample Profile .............................................................................................. 36 Methodology ........................................................................................................................................... 36 Sample Profile ......................................................................................................................................... 40 COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 1 About the Authors Goodwin Simon Strategic Research (GSSR) is an independent opinion research firm with decades of experience in polling, policy analysis, and communications strategy for clients in the public and private sectors. GSSR Partner Amy Simon, Senior Research Director John Whaley, Research Analyst Andrea Hackl, and independent researcher Sharon Pinkerton all contributed their thought leadership to this survey research in collaboration with the California Health Care Foundation. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. Introduction On behalf of the California Health Care Foundation, Goodwin Simon Strategic Research conducted a California statewide online survey among doctors, nurses, nurse practitioners, physician assistants, and behavioral health specialists to assess their experiences during the COVID-19 pandemic. This survey, conducted January 4 to 14, 2021, is the second in a three-part series of research assessing COVID-19-related impacts on health care providers. The results of this second wave study are compared to the first wave of the survey conducted in September 2020, to assess changing experiences among providers during the often-changing pandemic environment. The report also highlights differences among occupation types (doctors, behavioral health specialists, NP/PAs, and nurses), by the proportion of providers' patients of color population and by safety-net providers (those with 30% or more of their patient population receiving Medicaid/Medi-Cal or who are uninsured) compared to non-safety-net providers. When reviewing this report, it is important to note that some of the demographic predictors may be collinear (e.g., safety-net providers are more likely to serve patients of color), and thus survey findings between these groups may be similar. Meaningful regional differences are also noted. A breakdown of the regions is included in the Methodology and Sample Profile in the appendix. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 2 Key findings including the following:  Most providers have received or want a COVID-19 vaccine - and would recommend it to their patients. At the time of this survey, 85% of providers had either received a vaccine (61%) or said they would do so immediately when it was offered to them (24%). While 10% want to wait a month or longer before taking it, just 2% say they will never get a vaccine (and 2% are unsure). Furthermore, 9 in 10 would recommend either the Pfizer or Moderna vaccine to their patients.  Yet providers have limited confidence in their health care systems' readiness to administer vaccines to the general public. Nineteen percent are "very" confident that the health care system in their area is prepared to administer a COVID-19 vaccine to the public when available. Notably, this proportion of "very" confident providers is lower than the 33% of providers who said they were "very" confident in the September survey.  Providers report significant shortages in personal protective equipment (PPE), clinical staff, and other resources. Forty-five percent of providers are reusing PPE - down only slightly from 50% in the September study. Specifically, 4 in 10 say they do not have enough N95 masks to meet their needs. Additionally, approximately half of providers say their hospital or clinic does not have adequate beds (48%) or staff (44%) for current COVID-19 levels. Moreover, 6 in 10 agree that staffing shortages hamper their ability to respond to the pandemic.  Providers are emotionally drained at work and frustrated with public behavior around COVID-19. Half or more providers feel frustrated at their job (50%), overworked (57%), burned out (59%), and emotionally drained (68%). Nine out of 10 agree with the statement: I am frustrated by the public's behaviors and attitudes related to COVID-19.  Safety-net providers and providers with larger populations of patients of color are more likely than other providers to report experiencing workplace hardships during COVID-19. They are more likely to report that they do not have adequate staff, hospital beds, or PPE. They are also more likely to report feeling burned out and concerned about contracting COVID-19 at work. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 3 Section 1: COVID-19 Vaccine Experience and Readiness Personal Vaccination Experience At the time this survey was conducted, from early to mid-January, 49% of the providers surveyed said they had received the first dose of a COVID-19 vaccine, while another 12% had received both doses - for a total of 61% having received at least one dose (Figure 1).  Doctors are more likely to have gotten a vaccine, at 77%, than nurses (60%), NP/PAs (56%), or behavioral health specialists (23%). Twenty-one percent of doctors have gotten the second dose, compared to around 3% of other respondents.  Those with 26% or more patients of color are somewhat more likely to have received a vaccine (65%) than those with 25% or less patients of color (55%).  Across all California regions, between 56% and 65% of respondents have gotten a vaccine. Figure 1. A Majority of Providers Have Received at Least One Dose of the COVID-19 Vaccine Q: HAVE YOU ALREADY RECEIVED A COVID-19 VACCINE? 77% 61% 21% 62% 66% 64% 60% 56% 61% 2% 5% 13% 55% 15% 13% 12% 12% 9% 49% 56% 58% 51% 23% 49% 49% 51% 51% 3% 46% 20% First Dose Second Dose Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. NP/PAs is nurse practitioners / physician assistants. Another 24% of respondents (or 63% of those who had not yet been vaccinated) said they would want to get a vaccine "immediately" when it becomes available to them (Figure 2). COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 4 Therefore, a total of 85% of providers have either received a vaccine or would like to receive it immediately when it is available. Just 2% of providers surveyed say they will never get a COVID-19 vaccine, with another 10% saying they plan to wait one to two months (4%) or wait longer (6%) before getting a vaccine (2% are unsure). Figure 2. A Strong Majority of Providers Have Either Received the Vaccine or Will Get It Immediately When Offered Q: HAVE YOU RECEIVED A COVID-19 VACCINE? / WHEN A COVID-19 VACCINE BECOMES AVAILABLE TO YOU, WHEN WOULD YOU WANT TO GET IT? 92% 85% 85% 87% 87% 85% 86% 15% 82% 79% 78% 24% 23% 25% 20% 22% 77% 25% 19% 31% 62% 62% 65% 64% 61% 60% 57% 56% 56% 22% Received Vaccine Will Get Immediately Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. NP/PAs is nurse practitioners / physician assistants.  Seventy percent of those with 25% or less patients of color who have not yet gotten a COVID-19 vaccine say they would like to get one immediately when it is available to them. This compares with 60% of those with a larger patients of color population.  Nurses (47%) and NP/PAs (59%) who have not yet gotten a COVID-19 vaccine are less likely to say they would get one immediately when it is available to them than are MDs (65%) and behavioral health specialists (72%). Moreover, 10% of nurses who have not yet gotten a COVID-19 vaccine say they would "never" get one, compared to 4% of MDs and behavioral health specialists and 1% of NP/PAs.  While 75% of self-described liberal providers who have not yet gotten a COVID-19 vaccine say they will get it immediately when one is available to them, a lower 46% of conservatives COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 5 give this response. Conservatives are more likely than liberals to say they will never get a COVID-19 vaccine or are unsure when they will do so (12% compared to 6%). Side Effects Forty-seven percent of providers say they experienced side effects from the first dose, with 86% describing these side effects as mild, 13% as moderate, and 1% as severe (Figures 3 and 4). Among those who had side effects, 34% said they lasted 24 hours or less, while 48% experienced side effects for 25 to 48 hours, 12% for 49 to 72 hours, and 5% for a longer duration. More providers experienced side effects from the second dose, with 64% giving this response. While 51% experienced mild side effects, the proportion who had moderate (47%) or severe (2%) side effects is substantially higher than experienced after the first dose. Yet these side effects were not more long-lasting than after the first does, with 34% saying the side effects lasted 24 hours or less, 52% saying they lasted 25 to 48 hours, and 13% for 49 to 72 hours. Figure 3. More Than 6 in 10 Providers Had Side Effects After a Second Dose of the COVID-19 Vaccine Q: DID YOU EXPERIENCE ANY SIDE EFFECTS FROM THE FIRST/SECOND DOSE OF THE VACCINE? 47% First Dose 52% 1% 64% Second Dose 29% 7% Yes, Had Side Effects No, No Side Effects Unsure Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Asked only of those who had received the first or second dose of a COVID-19 vaccine. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 6 Figure 4. Providers Who Experienced Side Effects of a COVID-19 Vaccine Describe Them as "Mild" or "Moderate" Q: WOULD YOU DESCRIBE THE SIDE EFFECTS YOU EXPERIENCED FROM THE FIRST/SECOND DOSE OF THE VACCINE AS MILD, MODERATE, OR SEVERE? 86% First Dose 13% 1% 51% Second Dose 47% 2% Mild Moderate Severe Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Asked only of those who had received the first or second dose of a COVID-19 vaccine. Totals may not add to 100% due to rounding. For those receiving the first or second dose, approximately 8 in 10 feel the side effects they experienced were similar to what they expected (81% after first dose and 78% after second dose). Just 11% and 18%, respectively, say they were different, while 3% and 2% say the side effects were both similar and different. Recommendation of COVID-19 Vaccine to Patients Not only are the vast majority of unvaccinated providers open to getting a COVID-19 vaccine themselves, approximately 9 out of 10 providers overall (89%) say they would recommend either the Pfizer or Moderna vaccines to their patients when it becomes available to the general public. Moreover, 79% and 77%, respectively, will "definitely" recommend the Pfizer or Moderna vaccine. Just 2% and 1%, respectively, say they will not recommend each vaccine (9% and 10% are unsure) (Figure 5).  High proportions of all subgroups say they would recommend the Pfizer and Moderna vaccines. However, nurses (13% Pfizer and 17% Moderna) and behavioral health specialists (30% Pfizer and 26% Moderna) are more likely to say they are unsure. The small number of providers who say they will wait three to four months or longer once it becomes available to them or say they will never get the vaccine are more likely to be unsure if they will recommend either company's vaccine. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 7 Figure 5. Nine out of 10 Providers Would Recommend Vaccines to the General Public Q: WHEN THEY BECOME AVAILABLE TO THE GENERAL PUBLIC, WOULD YOU RECOMMEND OR NOT RECOMMEND EACH OF THE FOLLOWING COVID-19 VACCINES TO YOUR PATIENTS? Pfizer 10% 79% 89% Moderna 12% 77% 89% Probably recommend Definitely recommend Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. Preparedness to Administer COVID-19 Vaccines Providers are generally confident in their health systems' readiness to administer COVID-19 vaccines to health care providers but far less so when it comes to vaccinating the general public. Nearly 9 in 10 providers (89%) are "very" (58%) or "somewhat" (31%) confident that the health system in the area where they practice is prepared to administer a COVID-19 vaccine to health care workers - perhaps reflecting the experience they have seen during the Phase 1A rollout. A somewhat lower 7 in 10 (71%) are confident their health system is prepared to administer the vaccine to nursing home residents. A far lower 27% are "very" confident (Figure 6). Confidence is lowest when it comes to readiness to administer the vaccine to the general public, with 62% feeling "very" (19%) or "somewhat" (43%) confident that their health system is prepared. There are no notable differences in confidence to administer a COVID-19 by occupation type, proportion of patients of color, safety-net and non-safety-net providers, or region of the state. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 8 Figure 6. Providers' Confidence in Their Health System's Preparedness to Administer a Vaccine Varies by Setting Q: HOW CONFIDENT ARE YOU THAT THE HEALTH CARE SYSTEM IN THE AREA WHERE YOU PRACTICE IS PREPARED TO ADMINISTER A COVID-19 VACCINE TO EACH OF THE FOLLOWING? (RANKED BY VERY CONFIDENT) Health Care Workers 58% 31% 7% 3%2% Nursing Home Residents 27% 44% 14% 4% 11% The General Public (when available) 19% 43% 24% 8% 5% Very Confident Somewhat Confident Not Very Confident Not Confident At All Unsure Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. The current level of confidence in preparedness to administer a COVID-19 vaccine to the general public (62%) is lower than what was found in the September 2020 survey (75%), with the change reflecting a far lower proportion feeling "very" confident (19% currently compared to 33% in September 2020) (Figure 7). COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 9 Figure 7. A Lower Proportion of Providers Is "Very" Confident Their Health Care System Is Prepared to Administer a COVID-19 Vaccine Today Than in the September 2020 Survey Q: HOW CONFIDENT ARE YOU THAT THE HEALTH CARE SYSTEM IN THE AREA WHERE YOU PRACTICE IS PREPARED TO ADMINISTER A COVID-19 VACCINE [JANUARY 2021:] TO THE GENERAL PUBLIC (WHEN AVAILABLE) / [SEPTEMBER 2020:] WHEN IT IS READY? 19% Very Confident 33% 43% Somewhat Confident 42% 24% Not Very / A Little Confident* 14% 8% Not Confident at All 5% 5% Unsure 5% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. *Response option in September 2020 was "a little confident" and in January 2021 was "not very confident." Section 2: COVID-19 Surge Readiness Overall Preparedness for Current COVID-19 Levels More providers anticipated they would be ready for another surge when asked in September 2020 than feel prepared now that it is upon them. In the September 2020 survey, 78% of providers who work at a hospital or send patients to one were at least "somewhat" confident that their hospital was sufficiently prepared for another surge of COVID-19 cases. When asked in the current study - amid such a surge - a lower 63% of providers who work at a hospital or send patients to one feel at least "somewhat" confident that their hospital is prepared for the current level of cases they are experiencing - and just 24% are "very" confident. Moreover, 16% are "not confident at all" - nearly three times greater than the 6% who gave this response in September 2020 (Figure 8). COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 10 Figure 8. More Than One-Third of Providers Are Not Confident Their Hospital Is Prepared for the Current COVID-19 Case Level Q: NOW THINKING ABOUT THE HOSPITAL WHERE YOU WORK THE MOST HOURS, WHERE YOU HAVE PRIVILEGES, OR WHERE YOU SEND THE MOST PATIENTS, HOW CONFIDENT ARE YOU THAT THIS HOSPITAL IS SUFFICIENTLY PREPARED FOR [JANUARY 2021:] THE CURRENT LEVEL OF COVID-19 CASES? / [SEPTEMBER 2020:] ANOTHER SURGE OF COVID-19? Very Confident 24% 36% Somewhat Confident 39% 42% A Little Confident 20% 13% Not Confident at All 16% 6% Unsure 2% 3% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Results exclude those who said the question was not applicable to them. Totals may not add to 100% due to rounding.  Doctors (66%) and nurses (64%) are confident that their hospital is prepared for the level of COVID-19 cases they are experiencing in higher proportions than NP/PAs (54%) and behavioral health specialists (53%) - however, low proportions of all four occupational groups are "very" confident they are prepared for the current level of cases, with between 18% and 26% giving this response.  Providers with less than half of their patients being people of color are more confident than are those with a higher proportion of patients of color (67% compared to 56%).  Providers from Northern California are more confident that their hospital is sufficiently prepared for the current level of COVID-19 cases compared to providers from Southern California (68% compared to 58%). COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 11 Preparedness in Specific Areas Less than half of providers believe the hospital or clinic where they work or send patients has enough clinical staff or hospital beds for the current COVID-19 case levels; under 6 in 10 say they have adequate ventilators and medicines as well (Figure 9).  More than 4 in 10 (44%) of providers say they "probably" or "definitely" have an adequate number of clinical staff at the hospital or clinic where they work or send patients to treat the current level of COVID-19 patients (49% say they do not). In the September 2020 survey, far higher numbers anticipated having enough clinical staff in a surge scenario, with 70% giving this response, while 22% did not feel they had adequate staff for a surge.  Less than half (48%) also feel their hospital or clinic has adequate hospital beds for the current level of COVID-19 cases - compared to the 73% who anticipated having enough hospital beds in a surge scenario when asked in the September 2020 survey.  Just over half (57%) feel their hospital or clinic has an adequate number of ventilators for the current level of COVID-19 cases - with 32% saying they do not. However, in the September 2020 survey, far more (72%) anticipated being prepared in a surge scenario with sufficient ventilators.  Fifty-six percent feel their hospital or clinic has an adequate supply of medicines, such as remdesivir, for their current level of COVID-19 cases - comparable to the 55% who anticipated having an adequate supply for another surge in the September study. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 12 Figure 9. Less Than Half of Providers Say Their Hospital/Clinic Has Adequate Beds and Staff to Treat the Current Level of COVID-19 Patients Q: DO YOU BELIEVE (THE HOSPITAL WHERE YOU WORK OR SEND PATIENTS) HAS THE BEDS, VENTILATORS, MEDICATIONS, AND CLINICAL STAFF IT NEEDS TO TREAT [JANUARY 2021:] THE CURRENT LEVEL OF COVID-19 PATIENTS / [SEPTEMBER 2020:] COVID-19 PATIENTS IN A SURGE SCENARIO? PROPORTION ANSWERING YES 44% Clinical Staff 70% 48% Hospital Beds 73% 56% Medicines 55% 57% Ventilators 72% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Results exclude those who said the question was not applicable to them. Totals may not add to 100% due to rounding.  Doctors are generally more likely than NP/PAs and nurses to feel prepared in each area (with behavioral health specialists far more uncertain). Thirty-eight percent of nurses and 40% of NP/PAs say their hospital or clinic has adequate clinical staff, compared to a higher 51% of doctors. While 55% of doctors say they have an adequate number of beds, a lower 39% of NP/PAs and 48% of nurses give this response. Further, NP/PAs (48%) and nurses (58%) are less likely to say they have adequate medicines than doctors (63%).  The proportion of providers who feel their hospital or clinic has adequate beds and clinical staff for the current level of COVID-19 cases declines with rising proportion of patients of color in their patient population. While 55% of those with 25% or less patients of color say they have adequate beds, 49% of those with 26% to 50% patients of color and 44% of those with a greater proportion of patients of color give this response. Providers with more than half of their patient populations composed of people of color are less likely than those with a lower percentage of patients of color to report they have adequate clinical staff for the current levels of COVID-19 in the hospital or clinic where they work - 39% compared to COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 13 49%. Moreover, 27% of those with a majority or more patients of color report that they "definitely" do not have adequate staff compared to 18% of those with a lower proportion of patients of color.  Safety-net providers are less likely to say they have adequate hospital beds than non-safety- net providers (46% compared to 53%). They are also less likely to report they have adequate ventilators (54% compared to 62%) and staff (42% compared to 49%). Twenty-five percent of safety-net providers say they "definitely" do not have adequate clinical staff compared to 16% of non-safety-net providers.  In general, providers in Northern California are more likely to say their hospital or clinic has adequate resources for the current level of COVID-19 patients than do those in Central or Southern California (Figure 10). * • Sixty-two percent of providers in Northern California say they have adequate beds- far higher than the 49% in Central California and 41% in Southern California who give this response. This is driven most by the 65% of Bay Area providers who feel this way. • Similarly, while 55% of those in Northern California say they have adequate clinical staff, a lower 41% in Central California and 40% in Southern California do so. One in four (25%) of those in the Inland Empire/Desert region say they have adequate staff. • Northern California providers are also more likely to say they have adequate ventilators (65% compared to 57% in Central and 53% in Southern California) and medicines (64% compared to 53% in both Central and Southern California). Twenty- two percent in the Inland Empire/Desert specifically say they "definitely" do not have an adequate number of ventilators compared to 4% giving this response in Northern California, 11% in Central California, and 11% in the rest of the Southern California region. * Regional definitions are provided in the Methodology. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 14 Figure 10. Northern California Providers Are More Likely to Report Adequate Resources for the Current Level of COVID-19 Patients Than Those in Central or Southern California Q: DO YOU BELIEVE (THE HOSPITAL/CLINIC WHERE YOU WORK OR SEND PATIENTS) HAS THE BEDS, VENTILATORS, MEDICATIONS, AND CLINICAL STAFF IT NEEDS TO TREAT THE CURRENT LEVEL OF COVID- 19 PATIENTS? PROPORTION ANSWERING YES, BY AREA 55% Adequate Staff 41% 40% 62% Adequate Beds 49% 41% 64% Adequate Medicines 53% 53% 65% Adequate Ventilators 57% 53% Northern California Central California Southern California Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Results exclude those who said the question was not applicable to them. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 15 Staffing Shortages Nearly 6 in 10 providers (58%) agree with the statement staffing shortages have hampered my ability to respond to the COVID-19 pandemic (Figure 11). * This is up notably from September 2020, when 45% agreed with this statement. Figure 11. A Majority of Providers Believe Staffing Shortages Are Negatively Impacting Their COVID-19 Response Q: AGREE OR DISAGREE: STAFFING SHORTAGES HAVE HAMPERED MY ABILITY TO RESPOND TO THE COVID-19 PANDEMIC. PROPORTION AGREEING January 2021 58% September 2020 45% September 2020 January 2021 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Results exclude those who said the question was not applicable to them. Totals may not add to 100% due to rounding.  Providers with 51% or more patients of color are more likely to agree that staffing shortages have hampered their ability to respond to the COVID-19 pandemic, with 64% giving this response compared to 55% of other providers.  Seven in 10 nurses (69%) agree that staffing shortages have hampered their ability to respond to the pandemic, higher than 58% of doctors, 53% of NP/PAs, and 51% of behavioral health specialists. * Results exclude those who said the question was not applicable to them. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 16  Safety-net providers agree with this statement in significantly higher numbers than non- safety-net providers (61% compared to 54%).  Providers in the Southern California region are more likely than those in Northern California to agree that staffing shortages have hampered their ability to respond to the pandemic (62% compared to 52%). Availability of PPE Providers continue to express concern about a shortage of PPE - a situation that survey results suggest has not improved over the last four months. Nearly 6 in 10 (56%) consider a shortage of PPE at their workplace to be at least a "somewhat serious" problem - with 30% calling it "extremely" or "very" serious. Overall concern is little changed from the September 2020 survey, when 60% called a shortage of PPE at least a "somewhat serious" problem (35% "extremely" or "very" serious) (Figure 12). Figure 12. Six in 10 Providers Say PPE Shortage Is at Least a "Somewhat" Serious Problem - Little Changed from September 2020 Q: THINKING ABOUT THE CURRENT SITUATION AT YOUR PRACTICE OR WORKPLACE, DO YOU CONSIDER A SHORTAGE OF PERSONAL PROTECTIVE EQUIPMENT (PPE) TO BE: 30% An Extremely / Very Serious Problem 35% 26% A Somewhat Serious Problem 25% 25% Not Too Serious a Problem 24% 16% Not a Problem At All 14% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. PPE is personal protective equipment. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 17  Nurses (67%) call a shortage of PPE at least a "somewhat" serious problem in higher proportions than doctors (59%), NP/PAs (55%), and behavioral health specialists (43%).  Safety-net providers are significantly more likely to call a shortage of PPE at least a "somewhat" serious problem than non-safety-net providers (60% compared to 53%). Reflecting PPE shortages, 45% of providers are currently reusing some or all PPE. This differs only somewhat from the September 2020 survey, when 50% said they were reusing PPE. Moreover, in both the September 2020 and current survey, approximately three out of four providers were either currently reusing PPE or have done so at some point during the pandemic. Two in 10 (21% in both surveys) have not had to reuse PPE during the pandemic (Figure 13). Figure 13. Half of Providers Currently Have to Reuse PPE Q: WHEN THINKING ABOUT YOUR USE OF PPE DURING THE COVID-19 PANDEMIC, PLEASE INDICATE WHICH OF THE FOLLOWING BEST REFLECTS YOUR EXPERIENCE. Unsure 2% Never Reused PPE 21% Currently Reusing PPE 45% Reused PPE in Past 6 Months 32% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. PPE is personal protective equipment. Totals may not add to 100% due to rounding.  NP/PAs are the most likely to be reusing PPE currently, with 56% giving this response compared to 49% of doctors, 44% of nurses, and 21% of behavioral health specialists. Behavioral health specialists are the least likely to have had to reuse PPE, with 46% saying they have not (Figure 14).  While 50% of those with a majority of patients of color and 46% of those with 26% to 50% patients of color are currently reusing PPE, a lower 37% of those with 25% or less patients COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 18 of color are doing so. In fact, 29% of those with 25% or less patients of color have never had to reuse PPE compared to 18% of those with 26% or more patients of color.  Fifty-one percent of those currently providing direct in-person care to COVID-19 patients are reusing PPE. Figure 14. NP/PAs and Those with More Patients of Color Are More Likely to Be Reusing PPE PROPORTION CURRENTLY HAVING TO REUSE SOME OR ALL PPE SHOWN 56% 49% 50% 45% 44% 46% 43% 46% 37% 21% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. NP/PAs is nurse practitioners / physician assistants. PPE is personal protective equipment. The greatest shortage in PPE is N95 medical grade masks. Four in 10 providers (39%) say they do not have enough N95 masks. Half (50%) say they have enough, while 10% are unsure. Two- thirds of providers have enough gowns (65%) and face shields (66%). However, 2 in 10 say they do not (16% and 12%, respectively, are unsure). Just over 8 in 10 providers (82%) say they have enough gloves, while 10% say they do not (8% are unsure) (Figure 15).  There are few notable subgroup differences in responses to having adequate gloves, gowns, face shields, and N95 masks. NP/PAs are somewhat more likely than those in other occupations to say they do not have enough gowns (28%), face shields (29%), or N95 masks (47%). Safety-net providers are somewhat more likely than non-safety-net providers to say they do not have enough gowns (21% compared to 15%) and face shields (25% compared to 17%). COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 19 Figure 15. Nearly 4 in 10 Providers Say They Do Not Have Enough N95 Masks Q: GIVEN COVID-19, DO YOU CURRENTLY HAVE ENOUGH OF EACH OF THE FOLLOWING PPE TO MEET YOUR NEEDS? N95 masks 50% 39% 10% Gowns 65% 19% 16% Face shields 66% 22% 12% Gloves 82% 10% 8% Yes, Have Enough No, Do Not Have Enough Unsure Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. Section 3: COVID-19 Impacts on Health Care Providers Health Care Providers' Emotional and Mental Health Morale Providers give lukewarm to negative assessments of their workplace and personal morale - and positive reviews are down from the September 2020 survey. Far more providers rate their workplace morale as "fair" to poor ("poor" includes ratings of "poor" and "very poor") than rate it positively. Six in 10 providers report that morale in their office or workplace is "fair" (40%) or poor (20%), while 39% see it as "excellent" (5%) or "good" (34%). Workplace morale is down from the September 2020 survey when opinions were more divided: 47% reported "excellent" or "good" morale and 52% "fair" to poor morale (Figure 16). Providers are more positive in their assessment of their own morale than that of their workplace, with 46% saying their own morale is "excellent" (8%) or "good" (38%) and just over half (54%) saying their own morale is "fair" (38%) or poor (16%). These results are also down COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 20 somewhat from September 2020, when 52% reported "excellent" or "good" morale and 47% "fair" or poor morale. Figure 16. Less Than Half of Providers Report Positive Morale - Down from September 2020 PROPORTION RATING PERSONAL AND WORKPLACE MORALE AS "EXCELLENT" OR "GOOD" 46% Personal Morale 52% 39% Workplace Morale 47% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding.  Higher proportions of those with 25% or less patients of color express "excellent" or "good" workplace morale than do those with a higher proportion of people of color in their patient population. While 44% of those with 25% or less patients of color give this response, 38% of those with 26% to 50%, and 33% with more patients of color do so.  While evaluations of personal morale are stronger regardless of patients of color population, those with 25% or less (51%) or 26% to 50% patients of color (48%) are more positive than those with 51% or more patients of color (39%).  Doctors (41% "excellent" or "good") and behavioral health specialists (43%) express more positive workplace morale than do NP/PAs (35%) or nurses (30%). In fact, workplace morale is most negative among nurses, with 31% saying it is "poor" or "very poor." This compares to 21% among NP/PAs and 17% among doctors and behavioral health specialists. However, doctors and NP/PAs working in emergency departments show the highest levels of poor workplace morale at 39%. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 21  When it comes to personal morale, doctors (48% "excellent" or "good") and behavioral health specialists (55%) are more positive than NP/PAs (41%) and nurses (36%). However, rather than giving more negative reviews, higher numbers of NP/PAs and nurses say their personal morale is "fair."  Safety-net providers are less likely than non-safety-net providers to rate their workplace morale as "excellent" or "good" (33% compared to 45%). They are also less positive in their assessment of their own morale (42% "excellent" or "good" for safety-net providers and 51% for non-safety-net-providers). Indicators of Burnout Half to two-thirds of health care providers feel emotionally drained, burned out, overworked, and frustrated - sentiments largely unchanged from four months ago (Figure 17).  I feel emotionally drained from my work: 68% agree, compared to 66% in September 2020  I fell burned out from my work: 59% agree, compared to 59% in September 2020  I feel overworked: 57% agree: compared to 55% in September 2020  I feel frustrated by my job: 50% agree, compared to 48% in September 2020 Figure 17. Many Providers Are Experiencing Emotional Hardships at Work Q: PLEASE INDICATE HOW MUCH YOU AGREE OR DISAGREE WITH EACH OF THE FOLLOWING. PROPORTION AGREEING (RANKED BY TOTAL AGREE) I feel emotionally drained from my work 25% 43% 68% I feel burned out from my work 21% 38% 59% I feel overworked 21% 36% 57% I feel frustrated by my job 14% 36% 50% Strongly Agree Somewhat Agree Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 22  Providers with 51% or more patients of color are somewhat more likely to agree with the last four statements compared to those with 25% or less patients of color - by about 10 percentage points. Seventy-two percent of those with 51% or more patients of color feel emotionally drained from their work, 64% feel burned out, 62% feel overworked, and 55% are frustrated with their job.  Seventy-eight percent of nurses and 72% of NP/PAs feel emotionally drained from their work - with 34% and 31% "strongly," respectively, agreeing with this statement. By contrast, fewer doctors and behavioral health specialists agree (64% and 67%, respectively). Nurses (64%) and NP/PAs (63%) are also somewhat more likely to feel overworked than doctors (55%) and behavioral health specialists (54%). Between 51% and 56% of doctors, nurses, and NP/PAs agree that they feel frustrated by their job, while a much lower 35% of behavioral health specialists feel this way. Near equal proportions of doctors (60%), nurses (66%), and NP/PAs (63%) agree they are burned out, but a lower 47% of behavioral health specialists feel this way.  Safety-net providers are somewhat more likely than non-safety-net providers to feel emotionally drained (71% compared to 65%), overworked (63% compared to vs. 52%), and burned out (62% compared to 56%).  Those in Southern California are more likely to agree that they are burned out (63%) than those in Central (50%) or Northern California (56%). They are also more likely to say they feel overworked (61% compared to 53% in Central and 54% in Northern California). Providers who feel burned out from their work were asked what they believe is contributing most to feeling this way. Some examples of their verbatim, open-ended comments are provided below: "Patient load has increased. Jumping from the patient exam room to telemedicine is stressful. I feel inefficient, overworked. I'm quite frustrated that the community will not take this pandemic seriously." -NP/PA, Rural North, female "Having to work more, lack of safe, affordable, available childcare while I'm working. As a single mother, working 15 hours straight, then having to care for my daughter when I get home. Just exhausted with no days off. So many Zoom meetings all day long. Miss my family and friends." -Doctor, Bay Area, female COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 23 "Expectations are to continue seeing the same volume of patients as pre-COVID, and not taking into account the extra time and work for donning and doffing PPE. Plus, PPE is very limited and have to order frequently in small increments. Also, expected to do telehealth visits instead of just phone contacts, which is an additional burden and skill level." -Nurse, Bay Area, female "New patients wanting therapy and not having enough space to take more people." -Behavioral health specialist, Bay Area, female "We are not getting patients tested prior to seeing them in person and are not made aware of actual exposures until days or week later." -Behavioral health specialist, Greater Sacramento, female "Short staffed due to people out with COVID. I'm seeing three times as many patients with no time to chart or catch up. Little appreciation or contact from my bosses. I have never had an N95 [mask]. The emotional toll this pandemic is taking. Being sick myself and spreading it to my wife and young kids. Still not fully recovered but needing to be at work due to physician shortages. Lack of professional growth, and a sense of lack of appreciation at work and feeling overworked. The sadness of the COVID-related deaths and the stories that go along with the disease. That's a lot of stuff to unpack." -Doctor, Central Valley, male "Emotional and physical exhaustion for third round of COVID-19 and 10 months of caring for COVID patients." -Nurse, Central Coast, female "I am dealing with way more depression and anxiety problems in my patients than ever before. I am halfway to my psychiatrist degree at this point." -Doctor, Central Coast, female "Doing my best to stay safe and keep others safe while seeing swarms of people who refuse to practice and follow the guidelines." -Nurse, Central Coast, female "Patients are very anxious, frustrated, and angry. Makes it difficult to treat them. The patients have little understanding of how difficult it is to work while wearing masks all day." -NP/PA, LA County, female COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 24 "Short staffed, so having to work more days. Hospital doesn't give the staff encouragement and positive reinforcement. The growing number of COVID patients is overwhelming. . . . The hospital is making nurses take patients over their ratio, and not providing hazard pay." -Nurse, LA County, female "Worry about contracting COVID and hours on end suffocating in my N95 mask." -Doctor, San Diego / Orange, male "More tasks to keep the work environment clean, policing staff and their approaches to adhering to COVID-prevention protocol, securing cleaning and disinfecting products on a regular basis, dealing with patients with social isolation and not being able to see them in person. Teens demonstrating more depression and anxiety and alienation due to COVID and not being able to see them safely in person. Technical difficulties in telehealth. Needing to take care of my regular health and having to put it off during these times." -Behavioral health specialist, San Diego / Orange, female "People's ignorance and selfish response to the pandemic." -NP/PA, Inland Empire / Desert, female Not only are providers voicing emotional impacts of providing health care during the pandemic, but over 8 in 10 (83%) agree not enough is being done to address the problems facing health care workers right now - up from 76% in September 2020 (Figure 18). High proportions of providers - across all key subgroups - believe not enough is being done to address the problems facing health care workers right now. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 25 Figure 18. More Than 8 in 10 Providers Feel Not Enough Is Being Done to Address Problems They Are Facing - Up from September 2020 Q: AGREE OR DISAGREE: NOT ENOUGH IS BEING DONE TO ADDRESS THE PROBLEMS FACING HEALTH CARE WORKERS RIGHT NOW. January 2021 40% 43% 83% September 2020 32% 44% 76% Strongly Agree Somewhat Agree Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. Public Response to the COVID-19 Pandemic More than 9 in 10 providers are frustrated with the public's behavior regarding COVID-19 (Figures 19 and 20).  Nine out of 10 providers (91%) agree with the statement I feel frustrated by the public's behaviors and attitudes related to COVID-19. Moreover, nearly 2 out of 3 (64%) "strongly" agree with this statement.  Related, 86% disagree with the statement the public is doing their part to stop the spread of COVID-19, with 60% "strongly" disagreeing. High proportions of all provider subgroups share these sentiments. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 26 Figure 19. Nine in 10 Providers Are Frustrated with the Public's Response to COVID-19 and Disagree They Are Doing Their Part to Stop the Spread Q: PLEASE INDICATE IF YOU AGREE OR DISAGREE WITH EACH OF THE FOLLOWING. I am frustrated by the public's behaviors and attitudes 64% 27% 5% 4% related to COVID-19 The public is doing their part to stop the spread of 11% 26% 60% COVID-19 Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree Unsure Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. Figure 20. Across Subgroups, 9 in 10 Providers Are Frustrated with the Public's Behavior Regarding COVID-19 Q: AGREE OR DISAGREE: I AM FRUSTRATED BY THE PUBLIC'S BEHAVIORS AND ATTITUDES RELATED TO COVID-19. PROPORTION AGREEING 91% 94% 91% 90% 91% 90% 90% 90% 92% 87% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Results exclude those who said the question was not applicable to them. Totals may not add to 100% due to rounding. NP/PAs is nurse practitioners / physician assistants. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 27 Exposure to and Concern About Contracting COVID-19 at Work Three out of four providers (73%) are at least "somewhat" concerned about contracting COVID-19 at work - near equal to the 70% who gave this response in the September 2020 survey. However, there is an increase in intensity of concern, with 43% saying they are "extremely" (18%) or "very" (25%) concerned currently compared to 36% (13% "extremely" and 23% "very") four months ago (Figure 21). Figure 21. Nearly 3 in 4 Providers Are Concerned About Contracting COVID-19 at Work Q: HOW CONCERNED ARE YOU ABOUT CONTRACTING COVID-19 AT WORK? 18% Extremely Concerned 13% 25% Very Concerned 23% 30% Somewhat Concerned 34% 17% A Little Concerned 19% 9% Not at All Concerned 11% 0% 5% 10% 15% 20% 25% 30% 35% 40% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding.  NP/PAs are the most concerned overall (86% at least "somewhat" concerned) and also show more intensity of concern about contracting COVID-19 at work. While 53% of NP/PAs are "extremely" or "very" concerned, a lower 45% of doctors, 44% of nurses, and 25% of behavioral health specialists give this response. Half (49%) of behavioral health specialists - who are least likely to work directly with COVID-19 patients - say they are little concerned or not concerned at all (Figure 22).  Concern is higher with those with patient populations of over 26% than those with a lower proportion of patients of color (77% compared to 66% at least "somewhat" concerned), and intensity of concern rises with patients of color population, from 37% "extremely" or "very" concerned about those with 25% or less patients of color to 47% of those with a majority or more. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 28  Safety-net providers are more concerned overall than non-safety-net providers (77% compared to 67%). Figure 22. NP/PAs Are More Concerned About Contracting COVID-19 at Work Q: HOW CONCERNED ARE YOU ABOUT CONTRACTING COVID-19 AT WORK? PROPORTION EXTREMELY OR VERY CONCERNED 60% 53% 50% 45% 44% 43% 40% 32% 20% 30% 25% 27% 25% 20% 16% 10% 21% 24% 18% 18% 9% 0% Overall NP/PAs Doctors Nurses Behavioral Health Specialists Extremely Concerned Very Concerned Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. NP/PAs is nurse practitioners / physician assistants. Reflecting the sacrifices that health care providers are making to care for COVID-19 patients, 43% say they have had to quarantine or isolate themselves from family members or others in their households due to concerns about being exposed to COVID-19 at their workplace (Figure 23). Figure 23. More Than 4 in 10 Providers Have Quarantined Due to COVID-19 Exposure at Work Q: AT ANYTIME SINCE THE COVID-19 PANDEMIC BEGAN, HAVE YOU HAD TO QUARANTINE OR ISOLATE YOURSELF FROM FAMILY MEMBERS OR OTHERS IN YOUR HOUSEHOLD DUE TO CONCERNS ABOUT BEING EXPOSED TO COVID-19 AT YOUR WORKPLACE? 56% 43% No Yes Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 29 While there are few differences by relevant occupation types, the proportion of providers who have quarantined or isolated due to concerns about being exposed to COVID-19 at work is higher among those with a higher proportion of patients of color (47% of those with 51% or more compared to 38% of those with 25% or less) and safety-net providers than non-safety-net providers (46% compared to 37%). Section 4: COVID-19 Impact on Patients Provider Treatment of COVID-19 Patients Nearly three out of four providers surveyed (72%) have seen or treated COVID-19 patients during the pandemic, while just 13% have not and 16% are unsure (Figure 24). This is similar to the 70% in the September 2020 survey who reported having seen or treated COVID-19 patients. Reflecting both the pandemic's longer duration and surge in cases, providers report having seen more COVID-19 cases over the course of the pandemic in the current survey than they did in the September 2020 survey. Twenty-five percent have seen or treated 51 or more COVID-19 patients, compared to 16% who gave this response in the September 2020 survey. Moreover, the proportion who have seen or treated over 100 COVID-19 patients has nearly doubled from 8% in the September 2020 survey to 15% currently.  Nurses (61%) and behavioral health specialists (55%) are less likely to have seen COVID-19 patients than are doctors (80%) and NP/PAs (73%). NP/PAs are also more likely to have seen or treated 51 or more COVID-19 patients (36%) than doctors (28%), nurses (25%), or behavioral health specialists (5%). Moreover, 23% of NP/PAs have seen more than 100 COVID-19 patients, compared to the sample average of 15%.  Providers with larger proportions of patients of color are more likely to have seen or treated more COVID-19 patients, with 75% of those with 26% or more patients of color having done so compared to 67% of those with a lower proportion of patients of color in their population. Those with a larger proportion of patients of color have seen higher numbers of them as well. Three in 10 (30%) of those with patient populations composed of 26% or more patients of color have seen or treated 51 or more COVID-19 patients - far higher than the 15% of those with fewer patients of color who give this response.  Safety-net providers are significantly more likely to have seen COVID-19 patients than non- safety-net providers (77% compared to 68%). Thirty-three percent of safety-net providers have seen 51 or more COVID-19 patients - nearly twice the proportion of non-safety-net providers at 17%. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 30  Twenty-eight percent of providers from the Inland Empire/Desert and 23% from the Central Valley have seen over 100 COVID-19 patients, compared to 9% in Northern California generally, * 16% in Los Angeles County, and 17% in the San Diego / Orange County region. Figure 24. Just over 7 in 10 Providers Have Seen or Treated COVID-19 Patients PROPORTION ANSWERING YES 80% 77% 72% 73% 74% 75% 68% 67% 61% 55% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. NP/PAs is nurse practitioners / physician assistants. Patient Behavioral and Mental Health Impacts Nine in 10 providers (90%) have seen an increase in patients experiencing anxiety, depression, suicidal ideation, stress-related disorders, and other mental health impacts during the COVID-19 pandemic. Overall, the proportion saying they have seen an increase in mental health impacts is statistically unchanged from 91% in the September 2020 survey. However, more report seeing a "significant" increase currently - at 61% - than did so four months ago - at 54% (Figure 25).  High proportions of providers - regardless of occupation type, patients of color population, or being a safety-net provider - report seeing an increase in mental health impacts among their patients. Seventy-five percent of behavioral health specialists and 67% of NP/PAs say they have seen a significant impact - higher than 55% among doctors and 58% among nurses. * Northern California includes the Bay Area, Rural North, and Sacramento regions. Regional definitions are provided in the "Methodology" section. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 31 Figure 25. Nine in 10 Providers See Increased Patient Mental Health Impacts During the Pandemic Q: ARE YOU SEEING AN INCREASE IN PATIENTS EXPERIENCING ANXIETY, DEPRESSION, SUICIDAL IDEATION, STRESS-RELATED DISORDERS, OR OTHER MENTAL HEALTH IMPACTS DURING THE COVID-19 PANDEMIC? 61% Yes, Significant Increase 54% 29% Yes, Small Increase 37% 5% No 5% 5% Unsure 4% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. Large numbers of providers continue to see increased use of alcohol or other drugs among their patients since the COVID-19 pandemic began. Currently, 69% report seeing a significant (30%) or small (39%) increase (Figure 26). This is equivalent to the September 2020 results, when 66% gave this response. Figure 26. Nearly 7 in 10 Providers See Increased Alcohol and Drug Use Among Their Patients Q: SINCE THE COVID-19 PANDEMIC BEGAN, HAVE YOU SEEN AN INCREASED USE OF ALCOHOL OR OTHER DRUGS AMONG YOUR PATIENTS? Unsure 15% No… Yes, an Increase 69% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 32  Seventy-six percent of behavioral health specialists have seen increased use of alcohol or other drugs among their patients, while 65% of doctors, 73% of NP/PAs, and 62% of nurses also gave this response.  There is no difference in the proportion of safety-net or non-safety-net providers who have seen increased alcohol or other drug use among their patients overall. However, safety-net providers are more likely to report a "significant" increase (33% compared to 26% among non-safety-net providers). Nearly all providers surveyed believe mental health impacts during the pandemic are having at least a "slight" impact on their patients' ability to take care of their physical health, with 96% giving this response (Figure 27). Just 1% say they think there is no real negative impact, while 2% are unsure. These findings are similar to those from the September 2020 survey overall. However, the proportion believing mental health impacts are having an "extremely" or "very" negative impact on their patients' ability to take care of their physical health is up six percentage points, from 44% to 50%. Figure 27. Nearly All Providers Believe Mental Health Impacts Also Negatively Impact Patients' Physical Health Q: TO WHAT EXTENT DO YOU THINK ANXIETY, DEPRESSION, SUICIDAL IDEATION, STRESS-RELATED DISORDERS, OR OTHER MENTAL HEALTH IMPACTS DURING THE COVID-19 PANDEMIC ARE AFFECTING YOUR PATIENTS' ABILITY TO TAKE CARE OF THEIR PHYSICAL HEALTH? 50% Extremely/Very Negative Impact 44% 37% Somewhat Negative Impact 41% 9% Slight Negative Impact 10% 1% No Real Negative Impact 3% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 33  Fifty-seven percent of providers with 51% or more patients of color say mental health impacts are having an "extremely" or "very" negative impact on their patients' ability to take care of their physical health. This is higher than the 49% of those with 26% to 50% patients of color and the 45% of those with fewer patients of color who gave the same response.  Safety-net providers are more likely to say COVID-19 mental health impacts are having an "extremely" or "very" negative impact on their patients' ability to take care of their physical health than non-safety-net providers (57% compared to 44%). More than 9 in 10 providers (92%) are "very" (44%) or "somewhat" (48%) concerned about their patients forgoing or delaying health services necessary for their long-term health and well-being because of the COVID-19 pandemic. While overall concern is up somewhat from the September 2020 survey (from 86% to 92%), the proportion "very" concerned has increased more notably from 33% to 44% (Figure 28). Figure 28. Nearly All Providers Believe Patients Are Delaying Health Services Because of the Pandemic Q: HOW CONCERNED ARE YOU THAT YOUR PATIENTS ARE FORGOING OR DELAYING HEALTH SERVICES NECESSARY FOR THEIR LONG-TERM HEALTH AND WELL-BEING BECAUSE OF THE COVID-19 PANDEMIC? 44% Very Concerned 33% 48% Somewhat Concerned 53% 7% Not too Concerned / Not Concerned At All 12% January 2021 September 2020 Notes: CHCF/GSSR Survey of California Health Care Providers (September 16–28, 2020, and January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 34  Doctors, behavioral health specialists, NP/PAs, and nurses alike are concerned their patients are forgoing or delaying health services, with between 88% and 94% saying they are "somewhat" or "very" concerned.  While concern is high across all subgroups, the proportion "very" concerned rises with the proportion of patients of color that providers have in their patient populations. While 38% of those with 25% or less patients of color are "very" concerned, 44% of those with 26% to 50% patients of color and 48% with 51% or more patients of color are.  Similarly, 93% and 92%, respectively, of safety-net and non-safety-net providers are concerned about their patients delaying or forgoing needed care, but safety-net providers are more likely to be "very" concerned, at 50%, than non-safety-net providers, at 36%. Section 5: Perception of When the COVID-19 Pandemic Will End Fifty-five percent of providers feel the pandemic will come to an end within the next six months (12%) or seven months to a year (43%). However, 35% see the end as a year to two off, and 3% believe it will be three to five years (1% says never and 5% are unsure) (Figure 29).  Low numbers of doctors, behavioral health specialists, NP/PAs, and nurses see the pandemic ending within the next six months. However, 49% of doctors see it ending in seven months to a year, compared to a lower 42% of behavioral health specialists, 38% of NP/PAs, and 30% of nurses. Figure 29. Four in 10 Providers Believe the Pandemic Will Not End for At Least a Year Q: NOW THAT COVID-19 VACCINES ARE BEGINNING TO BE ADMINISTERED, WHEN DO YOU FEEL THAT THE PANDEMIC WILL COME TO AN END? 1% Never 5% Unsure 12% 3% 3 to 5 years Within 6 months 35% 1 to 2 years 43% 7 months to a year Within 6 months 7 months to a year 1 to 2 years 3 to 5 years Never Unsure Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Totals may not add to 100% due to rounding. COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 35 Appendix: Methodology and Sample Profile Methodology The survey was administered online and conducted January 4–14, 2021, among 1,202 health care providers in California. Throughout this report, the survey respondents are referred to as providers. While the survey sample was designed to ensure it captures a broad cross section of health care providers in California, it is not a technically representative sample across the entire health care worker population of California. Instead, the survey was intentionally designed to focus on doctors, behavioral health specialists, nurse practitioners, physician assistants, and nurses who have provided direct patient care during the COVID-19 pandemic. Potential respondents who reported that they have not provided direct patient care since the COVID-19 pandemic began were terminated from the survey. The margin of error for n = 1,202 respondents is ±2.8 percentage points and is higher for subgroups. The first wave of this study was conducted September 16–28, 2020, and also included 1,202 health care providers in California. It was conducted using the same methodology and has the same margin of error. The survey includes the following sample sizes in each of these subgroups (please note that some providers qualified in more than one category):  Doctors, which includes those with an MD or Doctor of Osteopathic Medicine (DO) (approximately half the survey sample; for the current survey, n = 601 and for September 2020, n = 603)  Nurse practitioners (10%) and physician assistants (7%), represented together in this report as NP/PAs (current survey and September 2020, n = 201)  Nurses (17% in January 2021; 21% in September 2020), which includes those with the following licenses or credentials (current survey, n = 200 and September 2020, n = 250): • Registered Nurse (RN) • Clinical Nurse Specialist (CNS) • Certified Nursing Assistant (CNA) • Licensed Practical Nurse (LPN) • Certified Nurse Midwife (CNM) • Licensed Vocational Nurse (LVN) • Certified Registered Nurse Anesthetist (CRNA) COVID-19 Tracking Poll, February 2021: Views from California Health Care Providers on the Front Lines 36  Behavioral health specialists (17%), which includes the following (current survey, n = 200 and September 2020, n = 205): • Doctor of Education (EdD) • Doctor of Psychology (PsyD) • Doctor of Philosophy (PhD) • Licensed Clinical Social Worker • Licensed Marriage and Family • Licensed Professional Clinical Therapist (LMFT) Counselor • Other licensed behavioral or mental health therapist Throughout this report, when referring to behavioral health specialists, this excludes MDs (such as psychiatrists) unless that MD also has a license or credential in a behavioral health field. Quotas for each of these four occupational areas were established, and participants were randomly selected to participate. The sample was randomly drawn from providers registered with Web MD / Medscape. Those selected received an invitation email with a link to complete the survey online. The participants were also provided with a financial incentive to complete the 20-minute survey. The table below shows the proportion of providers who completed the survey by the various licenses, credentials, and degrees used to determine occupational categories. The proportions for each category are within two percentage points of those from the September 2020 survey. COVID-19 Tracking Poll, Wave 2: Views from California Health Care Providers on the Front Lines 37 Table 1. Provider Licenses, Credentials, and Degrees Q: WHICH OF THE FOLLOWING LICENSES, CREDENTIALS, OR DEGREES DO YOU CURRENTLY HOLD? (MULTIPLE RESPONSE WAS ACCEPTED) Occupation % Doctors MD 46% Doctor of Osteopathic Medicine (DO) 4% Behavioral Health Specialists PhD, Doctor of Psychology (PsyD), Doctor of Education (EdD) 4% Licensed Marriage and Family Therapist (LMFT) 6% Licensed Professional Clinical Counselor 1% Licensed Clinical Social Worker 6% Other Licensed Behavioral or Mental Health Therapist 2% NP/PAs Nurse Practitioner (NP) 10% Physician Assistant (PA) 10% Nurses Registered Nurse (RN) 14% Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) 2% Certified Nursing Assistant (CNA) * Clinical Nurse Specialist (CNS) 1% Certified Nurse Midwife (CNM) * Certified Registered Nurse Anesthetist (CRNA) -- Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. *Less than one-half of 1% of providers gave this response. COVID-19 Tracking Poll, Wave 2: Views from California Health Care Providers on the Front Lines 38 The following table shows the proportion of respondents in each region of the state and the counties included in those regions. The Northern California region referenced in this report includes those from the Bay Area, Rural North, and Greater Sacramento areas. Central California includes those in the Central Coast and Central Valley areas. Southern California includes those in Los Angeles County, San Diego / Orange, and the Inland Empire / Desert. Table 2. Regional Breakdown Region: Counties % Bay Area: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa 23% Clara, Solano, Sonoma Rural North: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, 3% Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba Greater Sacramento: El Dorado, Placer, Sacramento, Yolo 6% Central Coast: Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa 7% Cruz, Ventura Central Valley: Fresno, Kern, Kings, Madera, Mariposa, Merced, San Joaquin, 5% Stanislaus, Tulare LA County: Los Angeles County 31% San Diego / Orange: Orange, San Diego 19% Inland Empire / Desert: Imperial, Inyo, Mono, Riverside, San Bernardino 6% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. The providers represent a diverse population of practitioners. The demographic profile of the sample is provided in the "Sample Profile" section that follows. COVID-19 Tracking Poll, Wave 2: Views from California Health Care Providers on the Front Lines 39 Sample Profile Below is a profile of the overall sample and within each occupation. Table 3. Demographic Profile of Sample Occupations Behavioral Size of Health Subgroup Total Doctors Specialists NP/PAs Nurses (n) (%) (%) (%) (%) (%) Gender Male 434 36% 55% 18% 20% 14% Female 757 63% 44% 81% 79% 86% Age 18–34 138 11% 9% 6% 25% 12% 35–49 497 41% 44% 29% 42% 44% 50–64 396 33% 34% 38% 25% 34% 65+ 168 14% 13% 27% 7% 10% Race/Ethnicity White 685 57% 49% 78% 56% 62% Latinx 114 9% 6% 11% 14% 14% Black 25 2% 1% 4% 3% 4% Asian/Pacific Islander 411 34% 46% 10% 32% 24% Patient Population of Color 25% or Less 342 28% 29% 48% 20% 16% 26%–50% 390 32% 37% 22% 28% 34% 51% or More 437 36% 31% 28% 49% 48% Safety-Net Provider Safety-Net Provider 652 54% 47% 49% 68% 66% Non-Safety-Net Provider 497 41% 50% 46% 26% 24% Region Northern California 388 32% 32% 40% 16% 40% Central California 148 12% 13% 11% 15% 10% Southern California 666 55% 55% 48% 69% 51% Notes: CHCF/GSSR Survey of California Health Care Providers (January 4–14, 2021). See topline for full question wording and response options. Poll used the term Hispanic. COVID-19 Tracking Poll, Wave 2: Views from California Health Care Providers on the Front Lines 40