The Weitzman COVID ECHO presentation from December 2, 2020

1. CARING FOR AGRICULTURAL WORKERS
DURING THE COVID-19 PANDEMIC
December 2, 2020

2. CME Credit
• Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State
Medical Society to sponsor continuing medical education for physicians. The
Bridgeport Hospital Yale New Haven Health designates this live activity for a
maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only
credits commensurate with the extent of their participation in the various
activities.
• This activity has been planned and implemented in accordance with the Essential
Areas and policies of the Accreditation Council for Continuing Medical Education
through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and
the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited
by the Connecticut State Medical Society to provide continuing medical education
for physicians.
• The content of this activity is not related to products or services of an ACCME-
defined commercial interest; therefore, no one in control of content has a relevant
financial relationship to disclose and there is no potential for conflicts of interest.

3. CARING FOR AGRICULTURAL WORKERS DURING
THE COVID-19 PANDEMIC
2 Dec 2020
www.americanprogress.org/

4. COVID-19 in the United States
13,714,024 cases on 12/1/20 up from 10,392,702 cases on 11/11/20 270,532 deaths
https://coronavirus.jhu.edu/map.html

5. COVID-19 in the United States
https://coronavirus.jhu.edu/covid-19-daily-video

6. COVID-19 in the United States
https://coronavirus.jhu.edu/covid-19-daily-video

7. COVID-19 around the World
https://coronavirus.jhu.edu/map.html

8. COVID-19 around the World
https://coronavirus.jhu.edu/map.html

9. News headlines
Pfizer-BioNTech and Moderna Vaccine Candidates under FDA review
DECEMBER 10th
-Could potentially start distributing coronavirus vaccines Dec 11th
-both highly ~95% effective in preventing COVID-19
-Both have good safety profiles: no serious safety concerns observed

10. Resources
• Nuvance health ~1700 articles reviewed:
https://spark.adobe.com/page/WJjPryEErhIS4/
• CDC:
https://www.cdc.gov/coronavirus/2019-ncov/index.html
https://emergency.cdc.gov/coca/calls/2020/
• WHO:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• Johns Hopkins:
https://coronavirus.jhu.edu/map.html
• Others
https://www.thelancet.com/coronavirus
https://covidactnow.org/

11. CARING FOR AGRICULTURAL
WORKERS DURING THE COVID-19
PANDEMIC
Jeannie McIntosh, MSN, APRN, FNP-C
CHC Center for Key Populations
2 December 2020

12. BACKGROUND
• How the COVID-19 pandemic has impacted farms and migrant
and seasonal agricultural workers (MSAWs)
• About the CT River Valley Farmworker Health Program (CRVFHP)
• Unique challenges in providing primary care and COVID-19
outreach to this patient population
• Role of the community health worker (CHW)
CRVFHP

13. IMPACT OF COVID-19 ON FARMS AND MSAWs
• There have been more than 250,000 covid cases among farmworkers in US, but this
number may significantly underestimate cases among migrant and seasonal agricultural
workers (MSAWs). [1]
• Large-scale covid outbreaks have occurred at farms across the country. The largest to
date was at Foster Farms, a poultry farm in CA, where 392 workers tested positive and 8
died. [2]
• H2-A visa holders are required to get tested and quarantine for 14 days upon arrival to
US. However, a large percentage of MSAWs (up to 49% of horticulture workers, for
example) are here without visas so may not have quarantined upon arrival.
• As of September, only eight states had issued mandatory regulations for protecting
agricultural workers from exposure to COVID-19. Twenty states currently have non-
enforceable recommendations.
• Covid has had a massive impact on our agriculture industry – US farmers and ranchers
are estimated to lose approx. $20 billion in revenue in 2020.

14. Covid outbreaks on farms Cumulative covid cases on farms
FOOD AND ENVIRONMENT REPORTING NETWORK (FERN)
https://thefern.org/2020/04/mapping-covid-19-in-meat-and-food-processing-plants/

15. ABOUT CRVFHP
• Founded in 1997 and directed by the Mass League of Community Health Centers
• A voucher program funded by HRSA and the Bureau of Primary Health Care (BPHC)
• Covers primary health care for qualified MSAWs and their families along the Connecticut River Valley
in MA and CT
• Services included: medical and dental care, medications, outreach and transportation, some
specialty care through MOUs with local hospitals and clinics
• Care is offered to seasonal farmworkers during peak growing season and to greenhouse workers
year-round
• MSAW countries of origin: Jamaica and Caribbean, Mexico and Central America, West Africa,
Southeast Asia, South America
• Crops: shade tobacco (used to wrap cigars), apples, other fruits and vegetables, flowers, x-mas trees
• CHC, Inc. is one of the 9 clinics contracted to provide care through this voucher program
• Our program is embedded within CHC’s Center For Key Populations
• CHC’s CRVFHP core team:
- Director of CKP -
Family nurse practitioner
- Community based services manager - Registered nurse
- Outreach worker / clinical champion
- Health advocate

16. UNIQUE CHALLENGES IN PROVIDING CARE TO
MSAWS• Primary medical care
- Seasonal ag workers have very long work shifts, often 7 days per week
- Reluctance to report symptoms of illness for fear of missing out on work
- Language and cultural differences
- Limitations on what is covered under voucher program
- Lack of transportation and reliable phone access
- Need to establish trust and rapport in a short time
• Covid-specific medical care and counseling
- Communal living spaces
- Working in close proximity
- Limited access to sinks and bathrooms when working in field
- Difficulty wearing a mask when doing farm or greenhouse work
- MSAWs may fear getting tested, feel pressured by employer not to get
tested, or have limited access to testing in spare time
- Tech access or tech literacy barriers
- Rural health systems less equipped to handle large outbreaks
- Coordinating with local consulate officials from different countries where
rules around
testing, quarantine and travel vary

17. ROLE OF THE COMMUNITY HEALTH WORKER
Joelle Isidor, MD, CRVFHP Outreach Worker
• Advertise our services to farm owners and ag workers
• Schedule appointments
• Deliver supplies and medications
• Transport patients for appointments, labs, imaging
• Have language skills and cultural knowledge of MSAW countries of origin
• Provide health education and convey personal medical information in an accessible
and culturally appropriate way
• Facilitate communication between farm owners, ag workers and medical team
• Help connect the different contracted FQHCs to share resources
• Build trust with the ag workers
• They are essentially the glue that holds the program together!

18. MEDICAL CARE FOR MSAWs: OUR
EXPERIENCE THIS GROWING SEASON
• Covid-19 prevention efforts
• Maintaining access to primary care services
• Agency response to outbreaks

19. COVID-19 PREVENTION EFFORTS
Joelle Isidor, CRVFHP Outreach Worker
• DELIVERY OF SUPPLIES
- Masks
- Hand sanitizer
- Protective eyewear
- Food and other goods for workers in quarantine or isolation
• PREVENTATIVE EDUCATION
- Hand hygiene
- Physical distancing
- Health risks associated with covid
• FLU VACCINE CLINICS – to reduce risk of influenza co-infection

20. MAINTAINING ACCESS TO PRIMARY CARE
SERVICES• TELEHEALTH
- Cell phones and iPads distributed by CRVFHP
- Phone or video visits available 6 days per week during regular
clinic
office hours (any provider)
- 24-hour nursing triage line
• FARM-BASED OUTREACH CLINICS
- Sunday afternoon/evening 1-2 x per month
- Care provided in tents for privacy
- Outreach worker, 1 provider + 2 providers in
training (NP resident and fellow), nurse, MA
• SITE-BASED VISITS AS NEEDED
- Nurse visits for EKG, STI treatment, BP check
- Provider visits if face-to-face exam needed based on tele health
assessment
• VITALS MONITORING SUPPLIES – delivered to farms (BP monitors, pulse oximeters)
to allow for V/S assessment during tele health visits

21. AGENCY RESPONSE TO OUTBREAKS
Kasey Harding, MPH
Director of the Center for Key Populations
• MASS TESTING AT FARMS
- Rapid response at onset of outbreak
- Leveraging mobile testing supply units, workflow and team members already
experienced in large-
scale testing events sponsored by state
- Returning to retest those who initially tested negative
- Results conveyed via texts, phone calls, outreach worker visiting farms
• COUNSELING AND EDUCATION
- Consulting with local DPH, CRVFHP staff, and CHC clinical leadership to come up with
plan
- Advising farm owners on how to quarantine and isolate workers in close communal living
situations,
ex. moving those who test negative to separate barracks or nearby off-site location
- Nurse triage and tele health provider visits utilized for counseling symptomatic patients
on
supportive care measures and ED precautions
- Return-to-work guidance
- Measures to prevent repeat outbreaks (or additional spread of existing outbreak)
LESSONS LEARNED FROM MULNITE FARM OUTBREAK:
- Coordinating with DPH
- Handling media attention

22. NEXT STEPS?...
VACCINATION CLINICS
• Currently doing flu vaccine clinics at the greenhouses and farms
• Setting the stage for future covid-19 vaccine outreach clinics?
MIGRANT CLINICIAN NETWORK’S HEALTH NETWORK
• A program that provides bridge case management, medical
records transfer, and follow-up services for mobile patients.
• Founded in 1995. Thousands of patients served.
• Used to track LTBI treatment completion and chronic disease
continuity of care.
• Potential utility in tracking covid cases and connecting MSAWs to
testing resources + medical care?

23. LEARN MORE
• Brown Institute for Media Innovation. “Documenting Covid-19: The Migrant Farm Project.”
https://www.documentingcovid19.io/migrant
• Centers for Disease Control and Prevention (CDC). “Covid-19 Guidelines for Agriculture
Workers and Employers.” https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-
agricultural-workers.html
• CT River Valley Farmworker Health Program (CRVFHP). http://www.crvfhp.org/
• Migrant Clinicians Network (MCN). https://www.migrantclinician.org/
• National Center for Farmworker Health, Inc. (NCFH). “COVID-19 in Rural America: Impact on
Farms & Agricultural Workers.” http://www.ncfh.org/msaws-and-covid-19.html
• Pennsylvania Action Coalition. “Examining the Impact of Covid on Community Health Centers,
Part 2.” https://www.paactioncoalition.org/about/podcast/item/601-examining-the-impact-of-
covid-on-community-health-centers-part-2.html

24. THANK YOU!
Kasey Harding, MPH
Joelle Isidor, MD
Jeannie McIntosh, APRN
mcintosj@chc1.com

25. Thank You!
To learn more about The Path Forward series
WeitzmanLearning.org/the-path-forward
To view previous COVID-19 sessions:
WeitzmanLearning.org/coronavirus