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Volunteers, Homelessness, Supply Shortages: Nonprofit Health Providers Confront the Coronavirus Pandemic

In a new Direct Relief survey, hundreds of health care organizations serving lower-income and at-risk patients weigh on what concerns them most.



A shipment bound for International Community Health Services in Seattle, Washington, leaves Direct Relief’s warehouse on March 10, 2020. The shipment contained more than 400 pounds of protective gear, including surgical masks, N95 masks, gowns and gloves, for the health center’s staff, who are continuing to provide primary care as the city works to contain the coronavirus outbreak. (Lara Cooper/Direct Relief)

As the coronavirus gains ground in pockets all over the United States, attention has been laser-focused on closing schools and offices, dwindling supplies of masks and gloves, and overwhelmed hospitals.

But the health care organizations providing primary care to low-income patients – even as the outbreak gains ground – haven’t claimed a fair share of the public attention. Like hospitals, these organizations are fighting on the ground level – screening patients, dispensing advice, and working hard to keep patients out of the emergency room.

They’re also treating a high percentage of uninsured patients on scant operating budgets. In some cases, staff are partly or mostly composed of volunteers. Some focus on particularly high-risk patient populations, including people experiencing homelessness or with HIV.

And right now, they’re facing worrying shortages of personal protective equipment like masks and gloves, while confronting the real possibility that their patient numbers will surge, their volunteers will stop coming, or that they may even need to temporarily shut their doors.

Direct Relief surveyed 612 safety net providers in 47 states, Puerto Rico, and the U.S. Virgin Islands to learn more about their concerns, plans, and needs. Here’s what they said.

The Data

Asked about the possibility of COVID-19 to significantly impact patients, disrupt daily operations, or create a difficult-to-manage surge of patients, a significant majority of the organizations surveyed said that they were “very concerned” or “moderately concerned.”

Only 42.5% of responders had an emergency response plan that was specifically tailored to epidemics. (37.3% said their plans were still in development.) And only 24.3% had completed a response plan specific to the COVID-19 outbreak.

Widely-reported shortages of masks, gloves, and other personal protective equipment (often called PPE within the health care industry), are affecting primary health facilities as well. Only 28.4% of respondents said they had a reliable vendor to supply them with protective gear over the next 1-2 months.

Health centers from across the United States responded to Direct Relief's survey about preparedness and coronavirus. Click to see more of the results.
Safety net health providers from across the United States responded to Direct Relief’s survey about preparedness and coronavirus. Click to see more of the results.

“Right now, the primary urgent and all-consuming need is PPE – the N95 mask shortage is acute community wide and without them, we are worried about our overall operations,” a representative from one facility wrote.

“We are literally running out of protective gear,” another organization reported.

Perhaps most crucially, only 35.9% of respondents were certain that their doors would stay open. The rest either said that a closure of operations was a possibility or that they were “uncertain.”

Why It Matters

A shortage of protective gear is dangerous – and not just for patients. It’s actually health care workers – who rely on those layers of masks, gloves, and gowns every time they encounter a high-risk patient – who are most at risk.

And staff members who can’t rely on a steady supply of protective gear may be (understandably) less willing to continue to aid in coronavirus efforts.

“Since everyone is coming on a volunteer basis, people could choose not to come anymore if we lack adequate supplies to protect our staff,” wrote a representative from one facility.

In addition, many volunteers are older adults, who are significantly more likely to become dangerously sick from COVID-19. Some health care facilities expressed concern about exposing older volunteers to potentially sick patients.

Even beyond the risk to staff, it’s conceivable that health care organizations could become part of the problem, not the solution.

“If we are unable to protect those in the building (patients, staff, volunteers) from contamination when they enter, we would become a way to spread disease,” another provider reported. “At that point, it may be in the best interest of the community to close our doors temporarily.”

If Doors Close

Safety net providers shutting their doors isn’t just a shame. It’s a potential contribution to a growing public health crisis.

Typically, these organizations have close ties to the community and have worked over long periods to gain the trust of vulnerable populations. That includes providing care that’s sensitive to patients’ preferred languages and customs, along with maintaining a strong community presence.

Losing those resources in the midst of the coronavirus pandemic would place more pressure on overcrowded emergency rooms and public health officials. Some patients might even be more hesitant to seek care.

But another, more hidden crisis threatens.

Should their doors close, one facility reported, “this would leave our diabetic and hypertensive patients without access to vital care and medications.”

Chronic health conditions such as diabetes, hypertension, asthma, and cardiovascular disease are frequently manageable with high-quality care – medication management, supervised lifestyle changes, and even addressing underlying mental health concerns are all often part of the process.

Unmanaged, however, “chronic conditions become crises. Crises put more pressure on overburdened emergency rooms,” said Direct Relief President and CEO Thomas Tighe.

The coronavirus pandemic threatens to create a “concurrent situation where demand for health services go up at the same time as the capacity of the health system contracts.”

What the Data Can’t Capture

Significant numbers of safety net patients have circumstances that put them at particular risk. People with HIV live with compromised immune systems. So do people experiencing homelessness, who frequently sleep in rough conditions and have less access to good nutrition.

Health care organizations are well aware of the risk. “We serve a large homeless population and have concerns if the outbreak were to spread through the encampments,” wrote one facility. “We serve patients in the encampments and want to ensure appropriate [protective gear] especially for those staff.”

For low-income patients, the costs of a pandemic – from losing work to stockpiling supplies to increased medical needs – are a serious concern. “We have a large number of patients with multiple serious health issues as well as food insecurity and lack of work,” another organization reported.

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