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    November 02, 2020

    Leading the Way in Response to COVID-19: How the Department of Veterans Affairs Long Beach Healthcare System is Navigating a Global Pandemic

    By Antoinette Balta, Esq., LLM, Veterans Legal Institute, Santa Ana, CA, Samantha Taubman, J.D. Candidate, Chapman University Dale E. Fowler School of Law, Orange, CA and Brendan Ford, Esq., Ford & Diulio PC, Costa Mesa, CA

    In response to the growing pandemic that has overwhelmed the United States, the Department of Veterans Affairs (VA) quickly adapted its facilities to protect veterans and staff from COVID-19. Nationally, the VA has tested over 780,000 veterans and employees, and has diagnosed 58,240 veterans with COVID-19. Of the 58,240 veterans who have tested positive for COVID-19, 10,697 of them have been admitted to a VA facility.1 While these numbers remain volatile and continue to increase, the VA is prioritizing the implementation of safety precautions throughout its facilities, as well as adjusting its online platforms to provide alternative methods of care. 

    The VA’s Response to COVID-19 on a National Level

    Throughout the country, the VA, which operates the largest healthcare system in the country and treats a significant number of at-risk patients, has administered several policies and procedures to ensure that veterans and staff are protected. These policies and procedures are specifically addressed in the Veterans Health Administration-Office of Emergency Management’s COVID-19 Response Plan.2 These procedures include clinical screenings at all VA healthcare facilities, as well as enhanced protective policies, such as no visitors, and no new admissions for geriatric and spinal cord injury patients. Additionally, the VA requires physical distancing of all persons in the facilities, mandates every person to wear a face covering, and abides by the Centers for Disease Control and Prevention’s (CDC) sanitation guidelines.

    In addition to enforcing these protocols, the VA is using remote technologies to provide care to veterans. Prior to the onset of COVID-19, the VA had a working telehealth system in place. In fact, nearly two-thirds of the primary care and mental health providers saw their patients through video appointments.3 Therefore, when COVID-19 began and the need to see patients through online platforms heavily increased, the VA was able to ramp up its telehealth systems to meet these demands. Through the use of online platforms and video teleconferencing, veterans can receive care from the safety and comfort of their own homes. They can also check for regularly updated information without coming in physical contact with any person. To find updated information on COVID-19, veterans can go onto the VA’s website and check out the Frequently Asked Questions page, engage in conversations with a Chatbox, or find links to the CDC’s website.4

    Case Study: VA Long Beach Healthcare System’s Response to COVID-19

                Safety Precautions Implemented to Protect Patients and Staff

    The VA Long Beach Healthcare System’s (VA Long Beach) response to COVID-19 is representative of the VA’s response on the national level.  Generally, directors of local VA facilities are given wide latitude to support emergency responses if the operations fall under a declared local or national federal emergency. VA Long Beach’s response to COVID-19 was coordinated in conjunction with a “federal incident command team” and in conjunction with local authorities. Therefore, VA Long Beach made local decisions based on what was happening in the local community but continued to follow federal authorities. For the most part, VA Long Beach’s response was similar to many other VA facilities that supported its communities in accordance with local, statewide, and federal incident command systems.

    At the known onset of COVID-19, VA Long Beach quickly implemented safety precautions pursuant to the Veterans Health Administration’s COVID-19 Response Plan. Before entering any VA Long Beach building, every person is screened for COVID-19. Furthermore, every person is required to wear a face mask, and some parts of the hospital require a face shield. Along with wearing protective gear, all VA Long Beach employees must repeatedly wash their hands and use hand sanitizer.5 From the start, VA Long Beach was aggressive in fielding supplies and creating processes that enabled it to be stocked with the proper equipment and staffed with skilled employees. Up until this point, VA Long Beach has not encountered any issues such as lack of beds or personal protective equipment.

    To limit the flow of people who come in and out of the facility, VA Long Beach, like many other local VA facilities, made the painful decision to enforce a strict no visitor policy after VA Long Beach confirmed its first case of a positive COVID-19 veteran.6 A no visitor policy means that no one can visit a patient in the hospital or accompany a veteran who has an appointment at the facility. While this decision was difficult to make, VA Long Beach recognized that it was necessary to impose this policy to protect the patients and staff from exposure to COVID-19. There are two populations VA Long Beach specifically had in mind when it created this rule: geriatric patients and spinal cord injury patients. The patients in these populations stay at the hospital for an extended period of time and are considered extremely high risk. If they contract COVID-19, they are at increased risk to lose their life.7

    There are two exceptions to the no visitor policy. The first exception is if a veteran is actively dying. When a veteran has less than 24 hours to live, his or her family members are allowed to visit. The second exception is if a veteran comes to a VA Long Beach facility for an appointment and needs a caregiver. However, this is a strict rule. VA Long Beach will only allow a caregiver to accompany the veteran if the veteran would not be able to go to the appointment without one.8

    VA Long Beach has also been extra careful in tracking its employees who test positive for COVID-19. If an employee tests positive, VA Long Beach will trace where the employee has been within VA Long Beach, as well as the people the infected employee may have contacted.9 Once VA Long Beach determines the potential spread risk, every employee or veteran is monitored and tested as needed to reduce COVID-19 exposure. This requires a lot of COVID-19 testing, but VA Long Beach has continued to stay on top of this.10  However, the situation remains tenuous: one significant outbreak, a delayed shipment of critical testing supplies, or one errant testing machine can undermine the entire testing systems at a VA Long Beach facility.11 For this reason, the VA Long Beach leadership actively monitors all aspects of COVID-19 operations on a daily basis, given the high risk of the population served.

                Modifications to Hospital Infrastructure

    When the VA Long Beach Medical Center was built, the facility was not designed for single-patient rooms, which are now essential in treating COVID-19 patients. Due to the increased need to modify the hospital infrastructure, VA Long Beach asked the Hospital Incident Command System to address any identified deficiencies or risks.12 Every physical space was reviewed to determine what it would take to turn each area into a hospital room. In two weeks, VA Long Beach added 30 new beds. It also created isolation rooms using fake walls, transformed particular floors of the hospital to COVID-19 positive patients only, and changed “the air systems across the medical facility to transition from negative pressure rooms to negative pressure floors.”13

    Additionally, in an effort to decrease the risk of having potentially positive testing patients mixed with other non-COVID-19 veterans, VA Long Beach adapted the spaces to separate patients who were suspected of having COVID-19 from the rest of the hospital population. The emergency room lobby was altered to accommodate five to six beds, and if a patient waiting to be admitted was suspected of having COVID-19, he or she would be moved to one of these beds until testing could confirm his or her COVID-19 status.14 Also, because VA Long Beach was concerned about running out of space inside the hospital, it created a Mobile Medical Unit (MMU) in the parking lot of the facility. The MMU is a tent with six different wings, stocked with equipment, supplies, portable Wi-Fi, sinks, and staff ready to treat patients. The MMU took three to four weeks for VA Long Beach to set up.15 To this day, VA Long Beach has not had to utilize the MMU; nevertheless, it is still open and ready to be used should the need arise.

                Increased Use of Technology to Communicate with Staff and Veterans and to Ensure Accessible Care

    Throughout the pandemic, VA Long Beach has received information regarding COVID-19 from the CDC.16 Early on, VA Long Beach communicated what the VA understood about COVID-19 and made sure that all pertinent information was accessible to both staff and veterans. VA Long Beach posts information on its website and Facebook page, and sends out emails to those who have signed up for updates.17

    COVID-19 has also created opportunities for the VA to take advantage of its online platforms to provide care to its veterans. To put the increased use of online platforms into perspective, “in the first half of 2020, Veterans attended about 25,000 telehealth video appointments each day, a 1,000% increase from the previous year. As of July, [the VA collectively has] already surpassed the number of telehealth encounters in 2019 by 7 million.”18 While VA Long Beach Medical Center remains open during the pandemic, it has severely limited its in-person services, and instead is using its online services to provide care. VA Long Beach’s goal during this pandemic is to see 70 percent of its patients virtually and 30 percent in-person.19

    To safely provide care, VA Long Beach quickly ramped up its online platforms, like telehealth via Veterans Video Connect (VVC) and “MyhealtheVet.” Telehealth via VVC enables veterans to video chat with their healthcare providers from their own homes. Through VVC, veterans can utilize “primary care, mental health care, and many specialty clinics where an in-person interaction isn’t necessary.”20 Video appointments through telehealth are straightforward. First, the veteran must talk to his or her physician to see whether VVC is appropriate for the care plan. If so, the veteran schedules an appointment and receives an e-mail link for the VVC session. At the time of the appointment, the veteran clicks on the link, enters a name and location, and then is connected with a healthcare professional.21

    MyhealtheVet is another online platform that provides veterans access to medical records, appointments, and pharmacy refills. This web page launched in 2003 and “has grown from a simple website to a robust suite of tools and resources that further enables Veterans to take charge of their health care.”22 Due to the restrictions on in-person services, MyHealtheVet has become extremely useful during this pandemic and has allowed medical service providers to continue to assist veterans.

    While the internet has become an effective and efficient tool to communicate information regarding COVID-19 and provide medical services to veterans, many homeless veterans are unable to access the internet and obtain this critical information and care. In January 2019, approximately 37,085 veterans experienced homelessness.23 VA Long Beach usually relies on face-to-face interactions to keep in contact with its homeless veteran constituency, which is impossible during COVID-19. While VA Long Beach acknowledges that 96 percent of Americans have access to a cellphone and 81 percent own a smartphone, VA Long Beach is mindful that there is still a large population of homeless veterans who do not have access to the internet.24 Providing access to care and information to homeless veterans is a critical challenge moving forward.

                The “Fourth Mission”

    The VA rarely provides care to non-veterans because typically, by law, the VA is only permitted to treat veterans. However, in 1980 Congress passed legislation enacting the VA’s “Fourth Mission.”25 During national emergencies, the VA can authorize the Fourth Mission, which allows VA staff to extend its services to non-veterans.26 The goal of the Fourth Mission is “to improve the Nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters by developing plans and taking actions to ensure continued service to Veterans, as well as to support national, state, and local emergency management, public health, safety and homeland security efforts.”27 Through the Fourth Mission, the VA provides services based on requests from the states. For example, if a state realizes it needs more beds or nurses,  the state makes a request to the Federal Emergency Management Agency (FEMA) and the request gets sent to the VA. If the VA can support the request, the VA takes on the mission.28

    Even though the Fourth Mission is rarely executed, it has been activated in those communities hardest hit by COVID-19.29 Across the nation, 345 United States non-veteran citizens have been admitted to VA Medical Centers and greater than 832,000 pieces of Personal Protective Equipment have been provided by the VA in support of the Fourth Mission. Additionally, the VA has provided support to each state, but the services vary depending on the state’s individual needs.30 For example, over 23 VA Long Beach staff were deployed on 11 deployments to nursing homes in the community and to Indian Nations in Arizona. VA Long Beach also collaborated with local county and city health departments to provide over 3,500 COVID-19 tests to non-veterans. Most recently, VA Long Beach committed three beds in the VA Long Beach facility to non-veterans so that if local hospitals are overwhelmed, the VA Long Beach Medical Center can care for the patients.31

    Taking Medical-Legal Partnerships Virtual in Response to COVID-19

    COVID-19 has also affected the legal opportunities offered to veterans. Before COVID-19, some VA facilities offered free legal clinics in partnership with local legal aid organizations that operated onsite.32 The goal of these clinics is to offer veteran patients — many of whom are extremely low income — access to justice. However, with the onset of the pandemic, most medical-legal partnerships shifted online for safety reasons.33

    Luckily, VA Long Beach did not have to suspend its virtual legal services and plans to resume in-person legal clinics in January 2021, assuming it is safe. Veterans Legal Institute® (VLI) is the legal service provider for the VA Long Beach Medical Center. VLI is a legal aid organization that provides legal services to homeless, at-risk, and disabled veterans in Orange, San Bernardino, and Riverside County. VLI’s legal services range from discharge upgrades, veterans’ benefits, landlord-tenant, bankruptcy, expungements, consumer law, family law, estate planning, and nonprofit assistance.34 VA Long Beach has worked hand in hand with VLI to ensure that its veterans do not lose access to legal services, particularly given the unprecedented challenges presented by COVID-19.

    As a result, VA Long Beach has been able to virtually forward veterans who need pro bono legal assistance to VLI by providing them with a website application and phone number. Although some veterans do not own telephones or computers, social workers at VA Long Beach have been key contributors in removing barriers to legal services by assisting veterans in need. Notwithstanding the usual challenges of a virtual environment, veterans at the VA Long Beach have continued to receive legal care virtually and have been kept apprised of the opportunity via  VA Long Beach’s social media and flyers throughout its facility.

    Conclusion

    While the pandemic has created immense fear and anxiety around the country, veterans should seek comfort in knowing that the VA is taking active measures to ensure that its facilities, staff, and patients are kept as safe as possible. From examples like VA Long Beach, veteran patients continue to benefit from medical and legal services, even during these unprecedented times. This holistic approach, helping veterans not only medically but legally, leads to a happier and healthier veteran population. 

    1. U.S. Department of Veterans Affairs COVID-19 Pandemic Response Weekly Report, U.S. Dep’t of Veterans Affairs (September 8–14, 2020), https://www.va.gov/health/docs/VA_COVID_Response.pdf.
    2. Veterans Health Administration - Office of Emergency Management’s COVID-19 Response Plan, COVID-19 Response Plan (Mar. 23, 2020), https://www.va.gov/opa/docs/VHA_COVID_19_03232020_vF_1.pdf.
    3. U.S. Dep’t of Veterans Affairs, 4 Ways VA is Improving Access to Care in 2020 (Oct. 6, 2020), https://www.blogs.va.gov/VAntage/79473/.
    4. See https://www.va.gov/coronavirus-veteran-frequently-asked-questions/; https://www.va.gov/coronavirus-chatbot/; https://www.cdc.gov/coronavirus/2019-nCoV/index.html.
    5. Veterans Health Administration - Office of Emergency Management’s COVID-19 Response Plan, COVID-19 Response Plan (Mar. 23, 2020), https://www.va.gov/opa/docs/VHA_COVID_19_03232020_vF_1.pdf.
    6. VA Long Beach Healthcare System First Case of COVID-19 (Mar. 17, 2020), https://www.longbeach.va.gov/features/2020_03_17_First_Case_of_COVID_19.asp?fbclid=IwAR3_DLvqJBmD4y4znJTsePdusEwo1o5onxi9csdEAxCEZP51o2e8ru_d_Vc.  The VA Long Beach Healthcare System is comprised of a medical center and several community-based facilities.
    7. Press Release, VA Office of Public and Intergovernmental Affairs, VA announces safeguards to protect nursing home and spinal cord injury patients (Mar. 10, 2020).
    8. Interview with Richard Beam, Spokesperson for VA Long Beach Healthcare System, Orange County, CA (July 30, 2020).
    9. Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration Standard Operating Procedure, Interim Guidance for Medical Management of Hospitalized COVID-19 Patients (Mar. 21, 2020), https://www.va.gov/oig/pubs/VAOIG-20-03076-217.pdf.
    10. Interview with Richard Beam, supra n. 8 (indicating that VA Long Beach is equipped with enough swabs and chemical reagents to run the tests).
    11. Id.
    12. Id. (explaining that the Hospital Incident Command System is the management system in charge of improving emergency responses).
    13. Id. (stating that negative pressure rooms isolate patients with infectious diseases and protect people outside of the room from exposure. Negative pressure floors use lower air pressure to allow outside air inside the room, but traps inside potentially harmful air from leaving the space.).
    14. Id.
    15. Id.
    16. Id.
    17. See https://www.longbeach.va.gov/; https://www.facebook.com/VALongBeach.
    18. U.S. Dep’t of Veterans Affairs, 4 Ways VA is Improving Access to Care in 2020 (Oct. 6, 2020), https://www.blogs.va.gov/VAntage/79473/.
    19. Interview with Richard Beam, supra n. 8.
    20. Press Release, VA Long Beach Healthcare System, COVID-19 Restrictions Should Not Restrict Access to VA Care (July 23, 2020) (on file with authors).
    21. U.S. Dep’t of Veterans Affairs, VA Telehealth, https://telehealth.va.gov/type/home (last visited Aug. 5, 2020).
    22. U.S. Dep’t of Veterans Affairs, VA Marks 15th Anniversary of My HealtheVet (Nov. 27, 2018), https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5150#:~:text=Launched%20on%20Veterans%20Day%202003,care%20team%2C%20access%20their%20VA.
    23. U.S. Dep’t of Veterans Affairs, Veterans Experiencing Homelessness, https://www.va.gov/HOMELESS/pit_count.asp (last visited Aug. 11, 2020) (reporting the latest data available).
    24. Pew Research Center, Mobile Fact Sheet, https://www.pewresearch.org/internet/fact-sheet/mobile/ (last visited Oct. 14, 2020).
    25. 38 U.S. Code § 8111A.
    26. Id.; See also Press Release, U.S. Dep’t of Veterans Affairs, VA Announces ‘Fourth Mission,’ Actions to Help America Respond to COVID-19 (Apr. 14, 2020), https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5420.
    27. U.S. Dep’t of Veterans Affairs, VA Fourth Mission Summary, https://www.va.gov/health/coronavirus/statesupport.asp (last visited Aug. 5, 2020).
    28. Id.
    29. Press Release, U.S. Dep’t of Veterans Affairs, VA Announces ‘Fourth Mission,’ Actions to Help America Respond to COVID-19 (Apr. 14, 2020), https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5420.
    30. Veterans Health Administration, VA Fourth Mission Summary, https://www.va.gov/health/coronavirus/statesupport.asp (last visited Oct. 15, 2020).
    31. Interview with Richard Beam, supra n. 8.
    32. Free Legal Clinics in VA Facilities, U.S. Department of Veterans Affairs (August 2020), https://www.va.gov/ogc/docs/LegalServices.pdf.
    33. Id.
    34. Id.
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    About the Authors

    Antoinette N. Balta, Esq., LLM is the Executive Director and Co-Founder of Veterans Legal Institute, a military specific legal aid. She spent six years in the California State Guard first as a JAG Officer and then as a Marketing Officer. She is accredited by the Department of Veterans Affairs and was a 2018 Presidential Leadership Scholar. She can be reached at [email protected].

    Samantha Taubman     is in her second year at Chapman University Dale E. Fowler School of Law. She has been a law clerk at Veterans Legal Institute since May 2020.

    Brendan Ford    , Esq. is a mediator and Partner at Ford & Diulio PC and can be reached at [email protected].