Presented by

Vidal Seegobin, Global Forum for Health Care Innovators

What you need to know in 30 minutes

Weekly Global COVID-19 Update: Part 3

27 April 2020

© 2020 Advisory Board • All rights reserved • advisory.com

Today’s Research Expert

Vidal Seegobin

Practice Manager, International Research

Vidal is a practice manager on the Global Forum for Health Care

Innovators—Advisory Board International's health care strategy

programme.

Prior to joining the Advisory Board, he worked as a researcher on

disease surveillance and pandemic response. He holds a master's

degree in international economics from American University and a

bachelor's degree in international business from Carleton University

in Ottawa, Canada.

SeegobiV@advisory.com @SeegobiV

Vidal photo

© 2020 Advisory Board • All rights reserved • advisory.com

6

1

10

100

1000

0 5 10 15 20 25 30 35 40 45 50 55 60

Number of days since 3 daily deaths first recorded

Spain

Italy

U.S.

South Korea

U.K.

France

Germany

4000

1. Current as of 04/25/2020.

Source: Bernard S et al., “Coronavirus Tracked: The Latest Figures as the

Pandemic Spreads,” Financial Times, 2020; Roser M et al., “Coronavirus

Disease (COVID-19) – Statistics and Research,” Our World in Data, 2020.

‘Peak’ of curve proving to be a long plateau

Advisory Board interviews and analysis.

Daily coronavirus deaths (rolling 3-day average), by number of days since 3 daily deaths first recorded1

Country Total deaths

per million

Spain 482

Italy 430

France 341

U.K. 287

U.S. 154

Germany 66

South Korea 5

© 2020 Advisory Board • All rights reserved • advisory.com

7

Singapore tightens social distancing measures after recent COVID resurgence

A second surge undermining some initial successes

Advisory Board interviews and analysis.

Missed population leads to resurgence in cases Early action intended to capture entire population

Immediate border closures

Rapid testing in over 1,000

newly-established private clinics

Extensive contact tracing through

TraceTogether phone application

Heavily-enforced social

distancing measures

Source: J Guy and J Griffiths, “Singapore threatens 6 months in jail for breaking social distancing laws”, CNN, 27 March, 2020; M Sullivan, “Singapore Sees Surge in COVID-19 Cases, Now has Highest Number in

Southeast Asia”, NPR, April 20, 2020; R Pung et al., “Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures”, The Lancet, 28 March, 2020; “COVID-19: Cases

in Singapore”, Singaporean Government Agency Website, 23 April, 2020; “Circuit Breaker extension and tighter measures: What you need to know”, Singaporean Government Agency Website, 21 April, 2020.

New COVID-19

cases between

20-24 April

5,487Of new cases are

migrant workers

residing in dormitories

95%

‘Circuit Breaker’ extended and tightened

• Stay-at-home order

extended until 1 June

• Less critical services and

business suspended

• Schools to be

temporarily closed

DATA SPOTLIGHT

• Opticians operate by

appointment only

• Employees expected

to telecommute, if

possible

© 2020 Advisory Board • All rights reserved • advisory.com

8

Source: P Chan-kyong, “South Korean patients who test positive for reactivated coronavirus have ‘little or no infectivity’, officials say”, South

China Morning Post, 23 April, 2020; J Power, “Poor immunity or mutations? South Korea investigates ‘shrewd’ coronavirus as reinfections creep

up”, South China Morning Post, 16 April, 2020; H Shin, “South Korea finds patients testing positive post-recovery from coronavirus barely

infectious”, Reuters, 22 April, 2020; “South Korean firm starts production for rapid antibody testing kits in India”, Times of India, 22 April, 2020.

South Korea highlights knowledge-gap in disease immunity

Advisory Board interviews and analysis.

Questions still to be answered

If patients can be reinfected, how

effective will an antibody vaccine be?

How long will antibodies provide

immunity, if at all?

Can the virus be reactivated after a

period of time?

What we know

207 South Korean patients have tested

positive for COVID-19 after

previously recovering

South Korean experts have found

patients who are ‘reinfected’ to have

little to no infectivity to others

On 19 April, South Korean firm

launches its test kit production, with

a production capacity of 500,000

tests per week

What is the likelihood of being infected

by a different strain of SARS-Cov-2?

© 2020 Advisory Board • All rights reserved • advisory.com

9

Source: “Malaysia turns to coronavirus antibody tests to supplement laboratory checks”, WHBL, April 14, 2020; T You, “Chinese police wear smart helmets equipped with AI-powered infrared cameras to detect

pedestrians with fevers as they patrol the streets amid coronavirus crisis”, Daily Mail, March 4, 2020; “Help speed up contact tracing with TraceTogether”, Singapore Government Website, March 21, 2020.

Focus and solutions needed for three unanswered questions

At minimum, what we need from public health to reopen

Who is immune? How is it spreading?Who has it and doesn’t know?

Antibody tests

To understand community

spread and immunity

levels in the population

What is needed

to reopen,

state-by-state

What’s in the

way of doing

more?

Disease surveillance

To scan populations broadly

for early symptoms and

collect data

Scaled contact tracing

To isolate those who

may have been exposed

to symptomatic people

Singapore

TraceTogether app tracks

contact between people

using Bluetooth

Where it’s

already

happening

China

Chinese police wear smart

helmets equipped to check

pedestrians for fevers

Few commercially available,

government-approved tests

Malaysia

Antibody tests used in

conjunction with PCR1 tests

during quarantine periods

Training and deploying newly

idled government workers

Potential infringement on

personal privacy laws

Advisory Board interviews and analysis.

1. Polymerise chain reaction.

© 2020 Advisory Board • All rights reserved • advisory.com

10

Source: N Evershed et al., “Coronavirus numbers in Australia: how many new cases are there? Covid-19 map, statistics

and graph”, The Guardian, 23 April, 2020; ”Government eases elective surgery restrictions”, Australian Government

Department of Health, 21 April, 2020; “National Cabinet update, media release,” Prime Minister of Australia, 26 March 2020.

Elective surgeries start to reopen as daily new case count dwindles

Australia’s reality soon expected to become the norm

Advisory Board interviews and analysis.

0

50

100

150

200

250

300

350

400

450 Excerpt

Government eases elective

surgery restrictions

The Australian Government will gradually ease restrictions

on elective surgery from Tuesday 28 April 2020.

The easing will cover:

• IVF

• Screening programs (cancer and other diseases)

• Post cancer reconstruction procedures (such as breast

reconstruction)

• Procedures for children under 18 years of age

• Joint replacements (including knees, hips, shoulders)

• Cataracts and eye procedures

• Endoscopy and colonoscopy procedures

Timeline of COVID surgery limits against daily new cases

21 April 2020Excerpt

Temporary suspension of all

semi-urgent elective surgery

26 March 2020

© 2020 Advisory Board • All rights reserved • advisory.com

11

Three patient demand waves moving forward

Advisory Board interviews and analysis.

Assessing potential cases after COVID surge passes

Challenge: Surge in delayed procedures

while productivity dips due to sanitation

requirements and scarce PPE; must treat

all patients as COVID-positive upon

entering

Patient types:

Immediate: COVID demand

Challenge: Sudden influx of COVID

patients requiring isolation and new

pathways; some systems experiencing

consequences without elective revenue

Patient types:

Imminent: Postponed demand

Looming: Complex demand

Challenge: Latent demand growth from

delayed diagnostics, planned, and

unplanned care; chronic patients return;

must treat all patients as COVID-positive

Patient types:

Newly infected COVID patients

ICU-requiring COVID patients

Readmitted COVID patients

Rescheduled non-urgent

cases, e.g. hip replacement

Discontinued care of chronic

condition, e.g. diabetes, COPD

Delayed emergency clinical and

behavioural needs, e.g. PCI

Rescheduled but deteriorated

elective patients, e.g. GI surgery

Delayed diagnosis of long-term

conditions, e.g. breast cancerPlanned semi-urgent cases,

e.g. diagnostic imaging

Wait listed elective cases, e.g.

non-invasive vascular care\

© 2020 Advisory Board • All rights reserved • advisory.com

12

Three shifts in approach to sustain the system

Advisory Board interviews and analysis.

Challenge: Surge in delayed procedures

while productivity dips due to sanitation

requirements and scarce PPE; must treat

all patients as COVID-positive upon

entering

Immediate: COVID demand

Challenge: Sudden influx of COVID

patients requiring isolation and new

pathways; some systems experiencing

consequences without elective revenue

Imminent: Postponed demand

Looming: Complex demand

Challenge: Latent demand growth from

delayed diagnostics, planned, and

unplanned care; chronic patients return;

must treat all patients as COVID-positive

From PPE acquisition to PPE reuse

From hospital reinforcement to continuum reinforcement

From staff expansion to staff resilience

© 2020 Advisory Board • All rights reserved • advisory.com

13

Lack of redundancy across the supply chain prevents flexibility in times of crisis

Why not just make more PPE?

Advisory Board interviews and analysis.

Factors that limit flexibility across the supply chain

ManufacturingProvider

contracting

Providers often

contract with a

limited number of

vendors to secure

preferential pricing

Distribution

Providers favour

just-in-time inventory

management as

opposed to

stockpiling or

holding reserves

Regulators limit

provider use of

certain items by

classifying certain

versions as “medical

grade”; can limit

manufacturers’ ability

to flex production

Regulatory

Suppliers often rely

on the same limited

set of vendors to

source component

parts

Component

parts

Manufacturers

may rely on very

few sources

(often abroad)

for complex or

harvested raw

materials

Raw

materials

Manufacturers

centralise

production (often

in far-away, lower-

cost markets) to

gain economies

of scale

UpstreamDownstream

Shift #1: PPE Reuse

© 2020 Advisory Board • All rights reserved • advisory.com

14

Health systems must balance tradeoffs in ensuring sufficient PPE to reopen

Imperfect solutions to a critical PPE problem

Advisory Board interviews and analysis.

Sustainable

at scale

Major safety and cost considerations

Timeliness

Procure steady stream

of new disposables

Do I have stable,

reliable vendors?

What is the price premium

for guaranteed delivery?

Sanitise and

reuse disposables

Does sanitisation break

down protective materials?

How many times can we

safely reuse?

Spectrum of options for obtaining PPE needed to reopen non-essential services

Use DIY products

from local businesses

and volunteers

Are we compromising on

individual safety?

Can we scale and sustain?

Shift to medical-grade

reusable products

How can we encourage design

and manufacturing of medical-

grade, reusable masks?

What are added costs for

procurement and cleaning?

© 2020 Advisory Board • All rights reserved • advisory.com

15

Source: S Braithwaite, “Almost half of coronavirus deaths in Europe were in care homes, World Health Organization says,” CNN, 23 April, 2020; R Booth and P Duncan, “Coronavirus: England and Wales care home

deaths quadruple in a week,” Guardian, 21 April, 2020; “Fifth death confirmed at Newmarch House aged care home,” Guardian, 24 April, 2020; Stockman F et al., “‘They’re Death Pits’: Virus Claims at Least 7,000

Lives in U.S. Nursing Homes,” New York Times, 17 April, 2020; “Canada: 50% of COVID-19 deaths are aged care residents – Government flags tighter regulation on ownership,” The Weekly Source, 21 April, 2020.

Hotspots emerge across the globe in post-acute, care home facilities

Long-term care now the vulnerable point in the system

Advisory Board interviews and analysis.

DATA SPOTLIGHT

50% Covid-19 deaths in

Europe that occurred in

long-term care facility

residents, according to

estimates from the World

Health Organisation

“Canada: 50% of COVID-

19 deaths are aged care

residents”

The Weekly Source

“Australia coronavirus news: fifth

Covid-19 death at Sydney's

Newmarch House aged care home”

The Guardian

“Coronavirus: England and

Wales care home deaths

quadruple in a week”

The Guardian

“‘They’re Death Pits’: Virus

Claims at Least 7,000 Lives

in US Nursing Homes”

The New York Times

Shift #2: Continuum reinforcement

© 2020 Advisory Board • All rights reserved • advisory.com

16

Sample ways to support long-term care partners

Support post-acute providers to mitigate hotspots

UW Medicine

Collaborating with post-acute partners to:

Advisory Board interviews and analysis.

Set expectations about discharge

strategy and testing capabilities 1

Educate staff on infection

prevention skills and protocols2

Prepare an on-demand team to be

deployed in case of escalation3

We can’t afford the post-acute care providers

to not be ready, that will only create another

surge for us down the line.”

Mary Shepler, CNO

EvergreenHealth

Source: “'Do your planning now': EvergreenHealth CNO's stark warning to American

hospitals,” Advisory Board Daily Briefing, 1 April, 2020; UW Medicine, Washington, US.

© 2020 Advisory Board • All rights reserved • advisory.com

17

1. As of 7 April 2020.

2. The company is called eConsults.

Sources: S Fanel, “Ontario doctors warn of primary care 'crisis' as care shifts to virtual visits,” CTV News, 17 April, 2020; N Bostock, “Millions of patients 'avoiding calls to GP' during COVID-19 pandemic,” GPonline,

25 April, 2020; L Haynes, “Nearly 2,000 GPs self-isolating as BMA demands 'drastic improvement' in testing,” GPonline, 16 April, 2020; L Xing, “As callers wait days to hear from Telehealth Ontario, province says to

call your family doctor,” CBC News, 7 April, 2020; R Browne, “Demand for telemedicine has exploded in the UK as doctors adapt to the coronavirus crisis,” CNBC, 9 April, 2020; Knaus C and McGowan M,

“Australia's small medical practices on brink of collapse amid coronavirus,” Guardian, 8 April, 2020; L Haynes, “Allow GP practices time to regroup after COVID-19, BMA warns NHS chiefs,” GPonline, 22 April 2020.

Influx of complex patients soon to be managed by primary care

As virtual care becomes default, GPs struggling to keep up

Advisory Board interviews and analysis.

Rush to telehealth leaving

demand outpacing supply

Telehealth incentives threatening

primary care economics

‘Cannonball’ of complex GP

visits to hit as wave one eases

Of UK citizens are avoiding

routine GP care because they

are afraid to burden the NHS

during the COVID pandemic

NHSE may need to relax or suspend

primary care network targets to help

general practice cope with a backlog

of work after the coronavirus

pandemic.

40%Estimated UK GPs

self-isolating due to

COVID-19

2,000

Average days1 to respond

to a non-COVID telehealth

inquiry in Ontario

2.5

Increase in monthly

telehealth visits at one2

UK virtual care company

1,200x

Surveyed GPs in Australia

who have lost over 30% of

their expected YTD

revenue amidst national

telehealth boom

How can we keep being

heroes if we’re going to go

bankrupt in our practices?

50%

Family doctor

Ottawa, Canada British Medical Association

© 2020 Advisory Board • All rights reserved • advisory.com

18

Source: “RACE Program provides rapid specialist consults,” Canadian Medical Association Journal ,185, No. 18 (2010).

Formal connection to hospitals gives GPs rapid access to specialist expertise

Specialist knowledge is your most valuable resource

Advisory Board interviews and analysis.

Providence Health Care

8-site health network • Affiliate of Vancouver

Coastal Health • BC, Canada

• Established the RACE telephone

hotline to allow GPs easy access to

needed hospital specialist expertise

• Expanded to 23 specialty areas, each

call to the line saves approximately

$200 in avoided acute care costs

CASE EXAMPLE

Integration Benefits

Better informed GPs provide better care,

often avoiding unnecessary specialist

follow-ups or ED presentations

Quick decision support

Specialists available to speak to GPs and

give treatment advice immediately; majority

of consults happen within 10 minutes

Low-cost infrastructure

Low-tech way for primary care providers to

connect with specialists in over 23 clinical

areas when a difficult patient presents 1/3Of patients avoided

hospital and ED visits

60%Of patients avoided

subsequent

specialist referrals

Tangible benefits

across continuum

hotline’s key pillars:

© 2020 Advisory Board • All rights reserved • advisory.com

19

As surge subsides, staffing challenges will take centre stage

Advisory Board interviews and analysis.

Frontline staffing

shortages

Senior leader

burnout

Negative publicity

as staff speak out

More aggressive

collective bargaining

Anger, distrust

over leadership

surge decisions

Extreme stress,

trauma, and burn out

among frontline staff

Current challenges

Looming

challenges

COVID has eroded staff resilience thus far, but challenges poised to grow

“You know, in combat situations,

soldiers come home and get at

least a few months of R&R. After

COVID, our clinicians are going

to be asked to be even more

productive, with their backlogs

and delayed improvement projects,

and any subsequent COVID

waves. What conclusion is there

other than burnout?"

Director of Workforce,

UK Hospital

Shift #3: Staff resilience

© 2020 Advisory Board • All rights reserved • advisory.com

20

Source: T Hurst and V Reid, “Starter list: How you can support frontline staff during the

Covid-19 crisis,” Advisory Board, 2 April, 2020; A Polyak and M Simmons, “3 ways to meet

the essential needs of your frontline staff during Covid-19,” Advisory Board, 2 April, 2020.

Health systems investing in expanding access to emotional support services

For long-term resilience, focus on staff well-being now

Advisory Board interviews and analysis.

Set up confidential phone line to

navigate staff to behavioural

health support services

Run virtual peer support sessions

once a week to discuss personal

and professional concerns

Leverage local mental health

professionals willing to offer free

virtual therapy to frontline staff

Take care of essential needs,

like meals, transportation,

and childcare

Provide virtual drop-in sessions with

staff who have expertise in providing

mental and emotional support

Create ‘bounce back kits’ with

items like a reflection exercise and

store them in a central location

Partner with local facilities like

YMCAs to provide staff a place to

shower and change after shifts

Widely share open online

resources on coping with

anxiety and stress

Provide onsite or virtual

meditation at various times

across shifts

© 2020 Advisory Board • All rights reserved • advisory.com

21

Source: L Rewers, “The 4 key imperatives for your Covid-19 staffing strategy,” Advisory Board,

17 April, 2020; R Pilling, “Where’s your #WobbleRoom?,” 15 Seconds 30 Minutes, 1 April, 2020.

Embed opportunities in frontline workflow to process grief and moral distress

Opt-in support important, but not sufficient

Advisory Board interviews and analysis.

Establish a peer

accountability system

• Use team meetings to encourage

clinicians to reflect on and plan self-

care habits

• Then, assign each clinician a peer

to periodically check in on their

well-being and ensure they’re

following through on self-care plans

Convert existing meetings

to well-being checks

• Use previously scheduled

meetings, like unit huddles, as

opportunities to facilitate discussion

• Create a safe space with the goal

of helping staff process emotions,

not eliminating emotional distress

Integrate physical space

for staff to decompress

• Establish ‘wobble rooms’ and

encourage staff to take a few

minutes per shift to use the

dedicated space to process difficult

emotions or decompress

• Make sure the spaces are easily

accessible from priority units, and

encourage leaders to model use

© 2020 Advisory Board • All rights reserved • advisory.com

22

Source: M Cornner and V Reid, “How to talk with staff about PPE shortages,” Advisory Board, 20 April, 2020;

R Richmond, “Preventing and responding to staff burnout during the pandemic,” Advisory Board, 9 April, 2020.

Four communication tips for executives

Effective communication vital to staff well-being and trust

Advisory Board interviews and analysis.

Emphasise

transparency

• Communicate the

‘why’ behind difficult

decisions, such as PPE

policies, staff

redeployment, and

postponing non-Covid-

19 care

• Be upfront about what

you don’t know and

share the steps you’re

taking to learn more

1

Give staff a consistent

source of COVID-19 truth

• Send messages from

the same person/email

address

• Regularly publish

answers to FAQs to field

and respond to

rumours

2

Make yourself

virtually accessible

• Establish regular virtual

office hours and use

open-ended questions

to prompt conversation

• Hold virtual town halls

and repeat sessions

across shifts

3

Share your gratitude

personally and often

• Acknowledge the

challenges and

uncertainty staff are

navigating

• Recognise the

sacrifices team

members are making

• Emphasise staff health

and safety as much as

patient/family health

and safety

4

© 2020 Advisory Board • All rights reserved • advisory.com

24

Speed of recovery will vary based on multiple factors

When will hospital utilisation get back to ‘normal’?

High impact Low impactMedium impact

Near-term

Long-term

Medium-term

Centralised decision-making over

health care reopening continues to

delay return of elective procedures

Manufacturers increase availability of

PPE and tests, increasing comfort and

readiness among patients and staff

Backfilled cases lead to bed and

operating room capacity constraints,

shifts to “higher capacity” peers

Lingering consumer anxiety/fear of

exposure to infection results in site of

care shifts or absolute reductions in use

Delays in care lead to exacerbation of

health issues

Referrals from GPs are delayed due to

primary care focus on COVID-19 needs

Positive experiences with telehealth

encourage first-time users to use virtual

care for future needs, possibly with

competing organisations

Lasting negative stigma of long term

care homes leads to longer LOS, less

bed turnover

Loss of clinical workers who are burnt

out or COVID-19 positive

Organisations proactively reach out to

patients to reschedule appointments;

effectively communicate re: safety

The availability of therapeutics and

vaccines reduces the probability of a

second Covid-19 wave—and need for

additional postponements

Reduced travel leads to less accident-

induced trauma

Mortalities in highly affected regions

reduces demand

Increased interest, funding and

focus on population health

management decreases acute care

utilisation

Decreased utilisation Increased utilisation

Advisory Board interviews and analysis.

Greater home health uptake for post-

acute and rehabilitative care

Telehealth becomes the default for

specialty care, reducing reliance on

in-person appointments

© 2020 Advisory Board • All rights reserved • advisory.com

26

Your top resources for COVID-19 readiness

Advisory Board interviews and analysis.

To access the top COVID-19 resources,

visit advisory.com/covid-19

WHO Guidelines

Compiles evidence-based information on

hospital and personnel preparedness, COVID-

19 infection control recommendations, clinical

guidelines, and case trackers

Coronavirus scenario planning

Explores ten situations hospital leaders

should prepare for and helps hospital

leadership teams pressure test the

comprehensiveness of their preparedness

planning efforts and check for blind spots

Managing clinical capacity

Examines best practices for creating flexible

nursing capacity, maximising hospital

throughput in times of high demand, increasing

access channels, deploying telehealth

capabilities, and engaging clinicians as they

deal with intense workloads

How COVID-19 is transforming

telehealth—now and in the future

Explores how telehealth is being deployed

against COVID-19 and essential next steps for

telehealth implementation

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