 Hello, everyone. I'm Dr. Margaret Bordeaux, I'm Research Director at Harvard Medical School Program and Global Public Policy. And I'm here to welcome you to our second COVID Response Seminar, Organizing, Budgeting, and Implementing Wrap Around Services for People in Quarantine and Isolation. This series is co-run by Harvard Medical School's Program and Global Public Policy, as well as Harvard University's Berkman Klein Center for Internet and Society. And it's also co-sponsored by the National Governors Association. The purpose of this series is to tackle issues regarding implementation and COVID response policy. So we really seek to showcase the work of implementers so as to support those standing up or building upon COVID response programs in their own states and in their own communities. And the topic of today's seminar is supported quarantine and isolation programs. And some of the questions that we're hoping to tackle today, share my screen here, I really include the following. So what we want to talk about today is, of course, what is supported quarantine and isolation and why is it important? How are quarantine and isolation programs set up and managed? And what is their value and what do they cost? And how does one get started? Or how does one build upon the resources that have already been established in the state in terms of building these programs out? So today, I'm enormously excited to have a panel of incredible guests with us from around the country that are going to help us answer some of these questions. I do want to go through a brief run of show with everyone and give some brief introductions to the folks that are going to be with us. So I'm going to go ahead and lead off by giving a kind of overview of what we mean when we talk about supported quarantine and isolation, how it fits into a broader strategy of COVID response. And then I'm going to turn it over to Dr. Sarah Madad and Dr. Amanda Johnson, who are both leaders of New York City's Health and Hospitals, the largest network of public health facilities and hospitals in the country. And they are both deeply involved in setting up home-based as well as facility-based quarantine and isolation support services in New York City. Then we're going to pass the mic to another dynamic duo, Dr. Mia Lazada and Dr. Jenny Wei, both doctors at the Indian Health Service in Gallup, New Mexico in the Navajo area, and who have both also been deeply involved in standing up very impressive, expansive programs, both again facility-based and home-based quarantine isolation programs there. To bring us home, I will turn it over to Dr. Linda Bilmez, the Daniel Patrick Moynihan senior lecturer in public policy at Harvard Kennedy School, a former assistant secretary of commerce, and a leading expert on budgeting and public finance. And she is going to lead us on a discussion of how to think about supported quarantine isolation programs from a budgeter's point of view, what its value is, what it costs, and how to think about investing in these efforts. One final introduction is of student Jessica Cushall. She's a student both at Harvard Kennedy School and Stanford, who has led a paper with myself and Dr. Bilmez that just came out today on estimating the costs of quarantine and isolation services in Massachusetts versus the cost of not investing in those programs. And she'll be joining us for the question and answer period after this session. So with that stellar crew in mind, I'm going to go over some basics. So the first question I often get when I bring up quarantine isolation at this moment in the pandemic is, why are we talking about this? Aren't vaccines here? And isn't this going to be over soon? And I would say I've sort of been hearing that thought really for about 18 months, where folks have been saying, this isn't going to be bad. This is going to be over soon. And I think one of the things I would say is I am very, very optimistic about vaccines. And I do think they're going to make a significant dent in transmission and bringing it about the end of this crisis. But I would say that if you really take an honest look at what our public health strategy has been to date across the country, it still remains pretty crude. And that is coming from somebody who has worked nonstop on public health strategies in response to COVID for the entire year. And so while we're waiting for vaccines to roll out, we really have to get more sophisticated about the public health strategies that we're using. Right now, we really are relying on public health strategies that, at their core, are about lockdowns, shutdowns, closing schools, closing businesses, closing places. And those do work, but they're very, very onerous. So the reason we need to talk about quarantine and isolation in particular is so that we can get a more nuanced approach, less onerous approach to our non-vaccine public health strategy. The second issue, of course, is that we are hearing a lot about variants, viral variants that are emerging that may potentially diminish the effectiveness of our vaccines. And the third issue is even if our vaccine strategy is completely perfect, we're still going to have outbreaks of COVID very likely in the future over the next year or so. So now is the time to really power up our non-vaccine public health strategy. And what do I mean by our non-vaccine public health strategy? You've probably heard a lot of different analogies and sort of ideas about what a good public health strategy is in respect to COVID. I love the Swiss cheese model, where you layer defenses, where you try to make sure all your holes in your Swiss cheese are covered, or the lasagna strategy, where you're layering on, layers of protection. I think that's fantastic. I also really like the analogy of the three-legged stool. And I like it because it talks about different elements of the public health strategy as being interconnected and dependent upon one another. And just briefly to give you a sense, on one leg of the stool, we modify our environment. What are the things that we can do to change the environment to make transmission less likely? And here, with respect to COVID, we're looking at things like improving ventilation and air filtration and closed spaces as an example. And the other leg over here, we have modifying behavior. These are things that we ask everyone to do or a huge number of people to do in order to drive down transmission. Here, the most relevant example probably with respect to COVID is we ask people to wear masks. And that's for the general population. This yellow leg here that I've highlighted in yellow is the third leg of the stool. And that's contact tracing. And contact tracing is a process by which you identify who is infected. You identify the folks that they have exposed to the disease. And then you ask those folks to either quarantine or isolate so that they don't transmit the disease forward. And that's a very specific exercise where you're really chasing down and trying to break individual chains of transmission. It's a much more refined approach than these other approaches, which are a little bit broader and involve a lot of folks. And of course, the top of the stool is public health intelligence. That's when you take your data and you understand of what you're doing. And these three different legs are working and you refine them. And so when we talk about quarantine isolation, we're really talking about it predominantly as a strategy that is part of contact tracing. And I would just submit to you to think about it as the defining intervention of contact tracing. You can test and you can trace contacts. But unless you're really asking folks to stay away from others, it's not going to have that much of an impact. So what is quarantine versus isolation? I keep using both of those words. Just to review a little bit for folks, they're a little different. So the goal of quarantine is to keep people who have been exposed to the virus away from others until it can be determined that they are not in fact infected. For isolation refers to the practice of keeping people who you know to be infected away from others so that they cannot transmit. The duration for these is a little different. And just two days ago, the CDC came out with refined guidance on how long we should last. The duration for quarantine remains at around 14 days. But it can be shortened to seven days if you get a test, 48 hours. That's negative 48 hours before that seven days is up, or 10 days without a test. Isolation is recommended for 10 days after the onset of symptoms, or if you never have symptoms, 10 days after a positive test, and at least 24 hours after fever has resolved. And it can last longer than that for very sick or immunocompromised patients. The contexts in which you're asking people to quarantine or isolate also vary a little bit. So as I mentioned, quarantine is often, folks that you ask to quarantine are often identified through the contact tracing program. And there's also increased practice of asking folks who are crossing state lines or country lines to travelers to quarantine for a certain period of time as well. Isolation is really for anyone who's been diagnosed with infection. So what is this issue around supported mean? And here is, and I like to tell a story from back in April 2020 when Massachusetts was just starting to get its contact tracing program up and running. And I had a friend that lives down the street from me who told me this story. And she said she's a midwife. And she had just come from the office where she had encountered a young woman who was about 25 weeks pregnant. And the young woman just come in for a routine visit. She noticed that the young woman was coughing. And she said, oh, do you think you could have COVID? And the woman said, boy, I think I might because I actually live at home with two parents, my two parents and my young toddler. And everyone in the house is sick. And so the midwife sends off a test. And it comes back a day later at that point as positive. And so she calls the young woman and she says, talks to her for an hour. Talks to her and says, you really have to stay apart from others. You have to stay at home. You really have to isolate. And the young woman is quite very worried and absolutely taking it seriously. And they go through how they're going to organize the bathroom and the toothbrushes and how they're going to make the inside of the houses as safe as possible. Anyway, the midwife hangs up the phone after about an hour and goes to the grocery store. And in the grocery store, lo and behold, is the young woman that she's just talked to. She knows to be positive. And she says, oh my gosh, what are you doing here? And the young woman said, I'm sorry, but I'm the wellest person in my household. And I need to get groceries. And it was so obvious that that was, in fact, would be a very natural need. But it really was a surprise. Here was somebody who took the epidemic very seriously, was very worried about it, and yet was unable to under to have a successfully immediately quarantine. And so this issue of support is essentially what do folks need to quarantine and isolate successfully? What are the services that need to be in place so that they can actually succeed and that this can be an effective disease control strategy? So there has been some interesting work done on looking at adherence to quarantine isolation. It's not a vast literature, but it is an interesting one where they've done studies of why do people break isolation or quarantine in different contexts. And it's pretty interesting that in that literature, it's pretty obvious that there are a couple of basic things that jump out that are common through all studies of this. Folks need to get food and necessities. They need to keep a job and earn some money. So they will break if they can't sustain that. Some folks have no safe place to stay. Either they don't have a place at all. Maybe they have a problem with homelessness or they are living in a situation that is simply not safe for them to stay in for the entire duration. Or they have to fulfill social and family obligations that they can't figure a way out of, can't figure a way to do from their homes. So with those sort of things in mind, really designing a supported quarantine isolation program helps kind of set us up for thinking through some of these requirements. And just on the last note, so there's sort of two flavors, if you will, of quarantine isolation support programs. One is home-based and the other is facility-based. And so the home-based option is really by and large what is unfolded in Massachusetts. There have been some facility-based isolation and quarantine programs, but in general folks here have done, undertaken quarantine isolation from home. And how the state of Massachusetts has chosen to organize some of its program is through its contact tracing program. So when they reach out to somebody who is infected or who has been exposed, they'll go through a questionnaire and ask them, what do they need in order to undertake a successful quarantine? And they have found that when folks identify a major barrier to successfully completing it, they will then kick the case up to a cadre of case resource managers, folks who will take on the case and work with the person over time to address those challenges. And that's been nice. I think the issue has been that usually case resource managers have to cobble together local resources in order to make it work for the person in quarantine isolation. I think there's a lot of thought now about how can we make it more standard, the supports more generous and more routine to make it even better. And then the second flavor is the facility-based quarantine. And there's a bunch of different sort of sub-flavors of this, but one approach has really been to use hotels as safe spaces to quarantine or isolate. And on that note, I would love to turn it over to Dr. Madad and Dr. Johnson, who again are some of the leaders at New York City's Health and Hospitals, the large network of public health facilities and hospitals in the country. And they are here to talk about the New York City experience and how they have run their program there. Thank you so much, Dr. Bardot. Thank you so much to the Berkman Client Center for having us here today. We're just gonna do a brief slide transition and then we are really excited to talk to you a little bit about how we're approaching this work in New York City. Just to orient folks to the pandemic response in New York City, the public health effort that we entered into as of June of this year is encapsulating what we call our Test and Trace Core. Thank you so much, Dr. Madad. So yes, great. So our Test and Trace Core has three pillars. And this is reminiscent of the slide that Dr. Bardot shared earlier in which we have an extensive community trusting operation. We have a community-based contact tracing of it as well as one that is focused on facilities or congregate settings. And then the last portion, the pillar that I'm the director of is our take care pillar. And we're responsible for ensuring that people who are exposed to or diagnosed or developed symptoms consistent with COVID-19 have everything that they would need in order to effectively and safely separate from individuals in their households, individuals in their community, individuals in their workplace. I think one of the themes of this program is to talk a little bit about organizational structure and leadership. And so I want to call out that the New York City Test and Trace Core was commissioned by our city leadership and is a partnership between our Department of Public Health, that's the Department of Health and Mental Hygiene, DOHMH, as well as New York City Health and Hospitals, which is our public healthcare delivery system. And so really being able to leverage the expertise of both of these sections as well as many other city agencies have really stepped up to help us combat the pandemic in New York City, I'll highlight those as we go. And so in our take care pillar, we support people both in our hotel program, as well as those who choose to isolate or quarantine at home. Now even down to the scripts that we use and our contact tracing, there's a little bit of choice architecture here. We promote the hotel above home isolation or quarantine whenever possible. If you look at a map of New York City and you see the distribution of cases and contacts across our five boroughs, you'll notice a few things. You'll notice this overlap of multi-generational households, of households overcrowding, which places where we have the highest positivity rates. Probably not surprising to this audience that these are also parts of our city that have greater underrepresented minorities, people of color, as well as people who are in jobs that don't allow them the luxury of working from home, where people are on public transportation and coming into Manhattan in order to be able to earn a living. And places where we know that there is just greater indices of poverty. And so truly there's an equity focus to how we've organized the work that we're doing. We try to promote the hotel at all costs because of many of those environmental factors. Sorry, busy Manhattan street outside. We try to promote the hotel over home isolation, but we know that for a variety of reasons it's not gonna be the right choice for everyone. So to that end, we have put together our resource navigation program that allows people to safely separate at home. In this effort, we work with over 400 resource navigators who are directly employed by a handful of community-based organizations, some of which are represented here. And when someone completes their contact tracing interview they are referred over to a resource navigator if they screen positive or identify a need for a few high yield resources. Some of the things that Dr. Bardot brought up that are commonly needed for people to be able to isolate or quarantine if they choose to stay at home as well as someone who has identified any other unmet need. And it's true that it is a little bit of cobbling together both city-wide resources as well as local resources. That's something that I think has really worked to our advantage in terms of being able to provide curated and resonant resources to the very diverse population that we're trying to serve is the fact that we brought together community-based organizations that span the five boroughs and have different niches, have different local expertise that they bring to bear in their conversation with these individuals. Even aside from language affinity, just being able to actually know the neighborhood that they're serving has gone a long way toward building trust and maintaining trust through our program. One thing that I do wanna call out is that people who have been identified through contact tracing are eligible for both hotel and home services but we also sometimes seek to invert this test trace and then isolate and quarantine paradigm. If we're waiting for test results to come back, if we're waiting for individuals to be contact tracing, we're missing valuable days. And we know that transmission can happen very, it does happen very early on in somebody's course of illness. So to that end, we have also built up a COVID-19 hotline so that people can call in and proactively request resources such as hoteling, such as support for isolating at home. And to say a little bit more about how this at home program is structured, we do work with these CBOs but they're all governed by the Mayor's Office of Housing Recovery who kind of oversees and coordinates with them and it's kind of the day-to-day management. Some of our key services you'll find here and I'll want to call out a little bit around food delivery to the next slide. So as with, it's not surprising the reason that people leave isolation and leave quarantine is you put food on the table, either literally or figuratively. And so Get Food NYC is actually a program that was run by our Department of Sanitation. That was the city agency that was identified as having the assets and the talent to be able to get emergency food out to people, especially early on in the pandemic when people were in their homes and oftentimes not able to get out to an open grocery store to provide for themselves regardless of whether they had been exposed who are infected with COVID-19. The Get Food continues to be our most requested service from our resource navigators and provides emergency home food delivery to up to two members of the household. There are logistical reasons and financing reasons and I would say just kind of lack of data reasons that that was the parameter set in the beginning but it's definitely something that we're looking into as we try to drill down into the reasons that people still find it challenging to isolate or quarantine. Now that we do our best to meet the various dietary preferences and restrictions of people in our city and that doesn't just extend to vegetarian kosher and halal but also working with vendors who specialize before in producing Latinx and Pan-Asian options. Next slide. Another piece of our support services for people who are choosing to isolate at home is our take care package. So everyone who is identified through contact tracing is offered a take care package which includes PPE. So it includes a typical grade mask as well as some hand sanitizer and then certain monitoring equipment like a digital thermometer and a pulse oximeter. And I will drop a link into the chat box later on but the booklet itself is a really wonderful asset that we've developed, it's available online. And I think just the thoughts that went into producing the content and really trying to detail for someone how to achieve isolation and quarantine in their home was really beautifully done. And we have Dr. Madad's expertise and guidance to thank for that. Contact can also request as part of their take care package and at home testing kits. So people aren't faced with a decision to either leave quarantine and get tested or go without a more definitive resolution as to whether they've actually developed COVID-19. Next slide. So before we turn it over, really turn our attention to the hotel program. I wanna talk a little bit about our successes and challenges in running the resource navigation program for individuals separating at home. I think the number of agencies that we were able to bring together to get a program off the ground by June 1st was really impressive. We then later undertook the work of building the resource navigation custom relationship management platform back into the contact tracing system before they existed in two entirely separate platforms. And it actually has done a great job of improving visibility in these critical handoffs that we have between our contact tracers and our resource navigators. And then we have been able to expand the reach of our resources since the launch of the resource navigation program in June of 2020. And in particular, I alluded before to figuratively the need to put food on the table. Not surprisingly, one of the most common reasons that people were leaving their homes, especially during quarantine was the fact that they felt the need to continue to go to work. And we can't downplay how critical being able to make that much friends, being able to pay for medication is for so many of the individuals that we're serving. And so as we made that transition into the integrated platform, it allowed us to better index many of the cash assistance resources that are available to New Yorkers, regardless of documentation status. So we really increased our communication around paid sick leave, which has both city, state, and federal components. And then we're able to refer people into other sources of cash assistance if for whatever reason, they didn't admit the criteria for some of these government funded programs. There are certain challenges that remain for us, however, things like childcare and adult care are not resources that we have available to people. So really finding a substitute for hands on care when someone becomes ill but they're responsible for other members of the household. It's still something that we're looking for solutions for. Most often we tell people if they're in that situation, you should go to the hotel where there will be staff on hand who can help you. I think another thing that we realized is that we're so happy we made the transition into an integrated information system platform. However, there's no good time to roll it out. And there are certainly some bumps in the road, some challenges, some growing pains that we endured during a time when post Thanksgiving, we're also dealing with an influx of cases into our city. And then lastly, having an integrated information systems platform does allow you to monitor, even at the community-based organization level, the status of your work and process and really hold ourselves accountable for connecting people to services within 24 hours. Yet, and still, there is a layer of management that we have to learn how to do in a time where a lot of our interactions are virtual, that cannot be substituted merely by monitoring what's in the system. There still is the need to understand how people are prioritizing work, managing their workforce. And it is one of the costs one could say, one of the extra sources of energy you need to expend to be able to get the benefit of having different CBOs leveraged through local knowledge. So with that, I'll talk a little bit about the hotel program, just to set up Dr. Madad. Again, what we really stress for people, and we're really excited to celebrate our, now it's 11,000 guests and growing in our hotel program since June, is to take care of hotel. It is free to stay there. It is free to be transported there. We try to stress that there are amenities. You will get free Wi-Fi, you'll get cable TV, and really let people know that it's not a substitute for a hospital. I think there was the concern that this was a medical facility in the beginning, and it was actually off-putting when all that people saw in the news were EDs that were overrun with COVID patients filling out into the hallway. We have medical professionals on site because especially as we entered into a realm of community-based contact tracing where people were coming in early in their COVID infection, not being discharged from the hospital to the take-your-hotels. People can become sick quite quickly, and so it is important to have some staff on site doing light monitoring and clinical support. Dr. Badat, I'll turn it over to you to talk a little bit more about the design of the program. Thank you so much, Dr. Johnson. That was wonderful. So I'm just gonna very quickly in a high-level fashion talk a little bit about the Infected Prevention and Control considerations and obviously health and safety and IPCs of the former student, everything that's being done. And so just very briefly, when we're looking at the hotel setting, obviously you wanna adapt Infected Prevention and Control strategies to this creative environment to ensure that obviously we have the best process in place based on the latest public health guidance. So anything from looking at the floor plan and having designated clean and soiled utility rooms, having donning and dopping areas and the like, health-keeping, linen management, food services, all of those obviously are essential services and looking at it through an Infected Prevention lens and preventing that cross-contabination. PPE and transmission-based precautions is certainly obviously caring for confirmed clients that have COVID-19 and ensuring that the PPE matches obviously the type of care that's being provided. Supply and equipment really important. And as Dr. Johnson mentioned, looking at the type of clinical duty that you're going to be providing care for and making sure you have the adequate supply and equipment to go along with it. So all these are different types of considerations certainly to look at. And this requires a lot of planning, thought and ensuring you have a multidisciplinary team that's able to kind of walk through and see how to look at all of these different processes from an IPC lens. The next one. And then when we talk about health and safety, really important about the education and training that's being provided both to the staff that are manning these isolation quarantine hotels as well as those going out in the field. So the resource navigators, community engagement specialists and the like. So the image that you have, for example, on my left is you see an image of a training happening at one of the isolation quarantine hotels in New York City where we're talking about the different processes that we have in place. And certainly as you're retrofitting a hotel you're looking at what that donning and doting space looks like, where that PPE card is and the light. And so making sure that all staff are familiar both clinical and non-clinical where things are ensuring their safety and ensuring knowing that they understand the guidance that is being provided. And this obviously is an ongoing basis. So as guidance changes, we learn more about the disease and the virus and there are trainings in public health guidance, which is normal. You're certainly obviously making sure that you're providing that education and training on an ongoing basis. And then on the other image, you're seeing a training take place with community engagement specialists and resource navigators ensuring that as you're going out in the community making contacts with the general public that they obviously know not only the type of PPE they're wearing but how to put it on safely and effectively. As simple as putting a mask and glove on really important to obviously understand the nuances there and preventing that cross-contamination to themselves. And then also understanding the policy and the guidance that goes along with it. So health and safety is at the cornerstone of everything that we do. And then lastly, I'll just end with just mentioning a quick publication that we have available on our New York City Health and Hospitals website. And it talks about all the more the effective prevention and control considerations and the environmental health and safety in these isolation quarantine hotels. So it gives you a deep dive of all the different topics I talked about and giving you templates, visual cues and the like. And so certainly if you're interested to click on that particular link. So with that, I'm gonna hand it back and we're happy to take questions at the end. Okay, that was a whirlwind tour. Thank you guys so much. I'm an incredible amount of work and the sophistication of the programs that you guys have stood up. And also I think it's helpful to hear about where are the gaps still? Where are you guys still wanting to build out more? And I think we can get back to some of those during the question and answer period. And there are a couple of good questions in the chat box as well. We'll get right back to those. I do wanna go ahead and bring on Dr. Lozada and Dr. Wei to talk about their experience in the Indian Health Service in the Navajo area. Okay, thank you so much. So I'm Dr. Mia Lozada and today we'll be talking about a slightly different setting in terms of population as compared to New York City. We work here in the Navajo Nation in Gallup, New Mexico in rural Northwestern, New Mexico. And we'll talk about the supported isolation and quarantine hotel that we stood up here in March of last year. So for context for those of you who haven't been out here to the Navajo area, Navajo Nation itself sits in the Four Corners region of the Southwest, does not go into Colorado. It's about 27,000 square miles about the size of South Carolina or so. And here the circled in red is where Gallup itself sits. We're about 25 miles from the Arizona border and we have a population here of a little over 20,000 individuals who, and technically here in Gallup, we are off the reservation but there's a lot of area surrounding us even within our town that's reservation itself. This is Gallup Indian Medical Center, which is where we work. We are an Indian Health Service facility. It was opened in 1961 soon after IHS was formed in 1955 which took over from the Bureau of Indian Affairs. And this is only important for context in terms of when you have an infrastructure that looks like this and you're trying to significantly ramp up and change your system for COVID preparations. It makes it exceedingly challenging using such an old facility. So what happened here in Gallup in terms of COVID, in terms of how hard we were hit and what we had to do to try to mitigate community spread? This was from August from the New York Times, hardest hit places across the country, I should say, where Gallup for many, many weeks and months continued to top a list that nobody wants to be the top of in terms of per capita, both cases and confirmed deaths. And we continue to be toggling in the top three for both of these categories even to now. And you can see that many of these areas share some similarities in terms of the characteristics of these regions. That's where New York City and Gallup are right next to each other which is maybe why we're on this talk together. So looking at the social vulnerability index that the CDC has, I think has been helpful for us in terms of actually characterizing what are the characteristics of our town, of our community that have made us so hard hit. And you can see here that of the different categories that are listed and I should in the very, very tiny print on the right, the different counties across New Mexico with the highest at the top or the least socially vulnerable and down at the bottom is the county with the highest social vulnerability index and that would be our county McKinley County. And so this is to say that, when you're trying to stand up some sort of community mitigation tool in terms of COVID here specifically that the community and the county in the state really needs to be aware of who is being impacted the most by COVID to be able to shape a program that fits those individuals specifically. So for our county, we were finding it was individuals that had lower socioeconomic status, we're Native American, we're living in multi-generational homes. Many times we would call patients to let them know if their positive status inquire about their home isolation option. And they would say that they live in a house, a three bedroom house with two bathrooms and you'd think, okay, that's probably possible for them to isolate pretty safely at home only to come to find out that they're sharing that space with 10, 11 other individuals and quickly your plan for safe isolation changes and we needed to figure out what alternative options we had. We also found that there were many individuals who were living with substance use disorders who were really the population hardest hit. So we have about a third of the population here who live on the reservation, lack running water and electricity as well. And so when those factors were really important into isolating safely, that many times an alternate option needed to be created or found. And so as folks are trying to gear up plans, we need to make sure that we're really tailoring to the individuals themselves. And here we can see in terms of the burden in terms of race here in New Mexico, those who are indigenous are American Indian, Alaska native population has been at least four times with a higher rate than all other races, which has been a profound experience here among our community. Hi guys, it's Jennyway. So I think it's also really hard to talk about the COVID, how COVID has hit Gallup without really focusing on some of the challenges that we've had for decades, for generations, right? And these are of course, by definition, the vulnerabilities that have made these populations more vulnerable in times of disaster and pandemic. So one of the lists you also don't want to be at the top of is alcohol related deaths in the United States. So unfortunately, New Mexico for the last two decades has had the most number of deaths per 100,000 people. So you can see here on average, we have 28 per 100,000 people on average in the United States and in New Mexico, we're at 51 deaths per 100,000 people. And if you actually focus again on keeping in mind that we are in Gallup, New Mexico, which is in McKinley County, the county with the highest social vulnerability index per the CDC, that social vulnerability index doesn't quite exactly incorporate substance use, but of course, we know that a lot of these are inextricably linked with a lot of the criteria that we're seeing there in terms of socioeconomic status, et cetera. So keeping that number in mind, 28 deaths per 100,000 here in McKinley County, we're at 166 deaths per 100,000 in terms of alcohol related deaths. And not surprisingly, American Indians and Alaska Natives bore the highest burden of alcohol related death at 170 per 100,000. So again, as Dr. Lozada was saying, it's so important for you to know the population that is most vulnerable to be able to tailor your community mitigation strategies to that population. So we knew that this population was gonna be very, very hard hit and it wouldn't make sense for us to open up mitigation strategies, hotel programs, et cetera, without being able to incorporate people with substance use disorders, for example. Unfortunately, a lot of the other isolation centers, alternate care facilities in our region do not take people with substance use disorder, but we knew this was gonna be a huge challenge for us as we were starting to plan for the pandemic. So again, let's talk about what happened here in New Mexico. So we have a detox facility in town that holds people like a sobering center and upwards of a hundred people per night pre-pandemic. Back about a year ago, we was holding about a hundred people per night in a very, very congregate setting in an area where people were all kind of wandering around together all night until they were sober enough to be able to be released. We tried to cut that capacity down 50%, but because we're a small community, we're the only level three trauma center in the whole area, we knew that if we cut that in half, we were gonna have an overwhelming number of people overflowing our emergency departments. Already we were starting to feel it where people were not able to go to these congregate settings and we're 30, 40 people in the emergency department impairing the flow and not being able to really safely house them. Our very first case in McKinley County was on March 18th. And around this time, we continued to get phone calls. What are we gonna do with this population? And honestly, a lot of us started to put together some money. We were taking donations from various other people in town to try to put up some money for hotel rooms for people. And I still remember the first couple weeks we were able to put together about $3,000 and we were so excited about that. And we thought, well, I think we're gonna get through this pandemic with this amount of money. Unfortunately, not seeing that far ahead, but what was fantastic was we were able to start to partner with the New Mexico Department of Health who was able, as well as a lot of what New York City talked about in terms of putting together FEMA funds as well as CARES Act funds to start to fund some more of these hotel rooms. So our first isolation hotel is actually the first hotel isolation program established in the whole Four Corners region on March 24th. And around that time, we had about a dozen folks in the hotel program either quarantining or isolating, waiting for their, with symptomatic COVID. As I've been foreshadowing, unfortunately on April 6th, we had an outbreak at our detox facility where the first person was tested positive. And we found that he had spent three of the last seven days in the detox program, had exposed over 170 people. And ultimately when we were able to find all of these folks, 75% were positive with COVID. So you can imagine in our small community here, the cases of COVID shot up and the need for these isolation sites shot up. So in the course of the first week or the couple of weeks of April, we quickly expanded into needing four different motels throughout the city. We had upwards of 140 to 160 people in the program. And again, tailoring to our population. Can you guys take people who may be going into, may go into withdrawal when they're in the hotel program? Absolutely, where else are they gonna go? They have no place else to go safely. So we were really, really ramping up the medical oversight as well to make sure that they would be delivered medication to help with alcohol withdrawal, to make sure that it was as safe as possible for them. And I think it really was the partnership of our hospital along with the community, along with the state financial funding that was able to make it possible for us to safely house a lot of these folks that are pretty high risk medically, not just alcohol withdrawal, but having many other medical problems that would otherwise have no other place to go. So we tried our very best to not have a lot of restrictive criteria and just to make sure that they did not need to be in the hospital. Even now we actually have a lot of people on oxygen at the hotel because as Dr. Lozada mentioned, so many of our patients lack electricity and running water and simply cannot plug in a concentrator at home because they don't have the electricity to be able to do that. Or we hear stories of people putting in four, five different extension cords to extend into grandma's trailer 400 feet away. So as of now from March of last year to today we've housed over 1,600 people in our program with the help of an incredibly supportive volunteer staff that have come from all over the country from San Francisco to New York City. And it's been an incredible collaboration. This is a little bit of a graph of the positive cases we've had at our Indian Medical Center. You can see we had that little outbreak back in April. We thought it was a big outbreak, but in retrospect was a little outbreak. And so that was a lot of the reflection of the outbreak at our detox facility right after shortly after the first week of April. And then unfortunately we got hit very, very hard again in November and December. We thought April was bad, but at least in April we could transfer our patients over to ICUs in Albuquerque and in the rest of the state. Unfortunately by two months ago, every place was full, it was not uncommon for us to have to transfer, call 10, 12, 14 different hospitals across the Four Corners region to find an ICU bed for our patients and they would have to wait days in order to, in the emergency department. And so as you can see, it is absolutely critical for our rural site to have places to safely transfer or discharge our patients to. So the hotel program remained that ability to be able to make beds available in the hospital, in the ED so that we could continue to try to triage as safely as possible. And similar to what New York was discussing in terms of what the structure of their program is, we were really trying to incentivize folks to stay in their hotel rooms as much as possible and we would provide them with any other services. So we would provide lodging meals, we had a contact here in town, nobody was willing to provide transportation for individuals who were COVID positive in the beginning of the pandemic. So it was a friend of a friend who was willing to drive folks between the hospital and our hotel program. We had wonderful collaboration with the PIH program, COPE, that works out here, which has been phenomenal that they really fielded when we had 150 individuals in hotel rooms, they fielded the non-medical calls that were coming through to help get folks books and coloring books and radios and whatever they needed to be able to stay in place. And then we would provide the medical oversight and coordinate with that, people would get in-person evaluations, we would bring medications to them as well. And if they were stable enough to not need an in-person provider evaluation each day, then they would get a phone call by a medical provider instead. We have chaplains working with us, Navajo interpreters, Zuni interpreters, native medicine, blessed healing herbs that we could distribute those to the patients who could warm up water to make tea in their microwaves and could still maintain many of their cultural beliefs throughout the course of their isolation as well, which was hugely important as many of them were losing family members outside of isolation. And we had a wonderful iPad program, not only for group visits, meetings, telemedicine, but as well as connecting with family on the outside as well, which was hugely helpful for individuals to try to allow them to stay inside. We'll just conclude by saying that I think what this program has taught us is that people obviously were, those that were most vulnerable were hit hard by the pandemic. And we realized that we as a community really need to be focusing more on these. These have been existing issues for decades. And what we found out is that housing first works, that if you actually are able to provide folks with the basic necessities, they're able to start to work towards more positive goals and contribute positively to society. We were actually able to get over 45 people into inpatient rehab programs, alcohol rehab programs across the country through just having them be stable in a place for a moment where we can get them to fill out the application, the lab work, et cetera. And so these are just some pictures of our patients artwork and they were incredibly talented. This was one that was given to one of our volunteer staff. Ahe means thank you and Navajo. And then finally just wanting to say this is a letter that was sent to us by one of our patients who was being discharged to the rehab program. And essentially what he's saying, he's thanking us for helping him. He has an addiction problem and the first responders help by talking to him and connect him with a treatment program. A healing center is what he calls it. So this is just the list of all the collaborators. It looks like an intimidating list but realizing that it's really just one person behind each of these big organizations that needs that connection to be able to put together these important programs for our community. I'll stop there and I'm happy to take questions at the end as well. It's fantastic. I have to say I'm so moved every time you hear it tell the story. And I think it's actually a perfect transition to Dr. Bilmos because when we're thinking about investing in these types of programs, we're thinking about not just the short game but the long game. How do we bring the crisis to heal as quickly as possible? But also how does that translate into building out a public health sort of system approach that really does underpin the health of our communities going forward and our people going forward? And so Dr. Bilmos, I know that you often say you come in to do the money talk and that's so critical now. So I'll hand it over to you. So thank you. Thank you so much. And these are, this is really an amazing number of sessions and very moving and very sort of humbling to listen to. So usually I come on at the end of panels and I'm usually Dr. Gloom saying that the wonderful ideas being discussed are expensive and that there is no way to pay for them. In this case today, I'm in the kind of unusual position of delivering some good news, which is that this kind of program is at least partially self-amortizing that there is actually likely to be funding that can be used for it and that this is a pretty cost effective way of spending public funds. And this is based on some research that we did in Massachusetts. I'm going to share my screen here. And are we here now? Now, oops, I'm going to start from the beginning here. This is based on some research we did in Massachusetts where we have the kind of audacious idea that actually this program might even pay for itself. And so just to recap the key points, as we know and as we've heard and read, these isolation and quarantine programs are can be effective at reducing transmission. We've seen that historically and certainly in Korea and Germany and elsewhere this time around. And as Margaret pointed out, this is likely to become even more important now as new outbreaks kind of crop up and we are in a whack-a-mole world where we're trying to contain such outbreaks. But the key obstacle to compliance is really financial. And people can't afford it or they can't afford the wraparound services or they can't afford caring for others. And so when we think about this, we kind of have to think about it in terms of what are the costs and the benefits of providing a program like this. So based on the cost model that I will just very briefly outline to you in Massachusetts, we found that the total cost of a supported isolation quarantine program between February 1st and August or 211 days, just modeling that that would be the remaining days of the pandemic would be from 300 to 570 million, depending on the rate of transmission and the number of cases per day and the number of contacts that each individual had. However, that may seem like a large number but it's actually not such a large number because the reduced transmission offsets the cost to the state. In Massachusetts, we found that the cost to the state of providing medical care was around $2,500 per person and of which 43% to 50% is borne by the state and the actual cost of providing a supported quarantine program was lower than that. And finally, the good news, which I'll show you at the end is that there's actually a lot of money in the proposed federal stimulus bill, which is likely to pass, which is usable specifically for things that would include contact tracing and supported quarantine. And states will pretty soon be in the fairly unusual position themselves are trying to figure out how to allocate these funds and trying to understand what are the most cost-effective ways to treat and to prevent transmission, particularly in underserved communities. So just to take a quick kind of look at our model, we modeled in Massachusetts, found that a seven day quarantine cost that the weighted average was about $403 per person, which is not very high, that is assuming that 95% would quarantine at home and that 5% would be quarantining in facilities. So the facility cost would be higher, about $1,300 per person over the course of the seven days, about $385 for the at-home quarantine cost. And this is based on the idea that we would pay people $50 a day, which is the same amount that we pay for jury duty to do the public service of being able to quarantine at home. And this is interestingly, there is a 1938 law on the books in Massachusetts, which allows for payment for quarantine, which in today's money is quite close to the $50 a day. Now this assumes that there would be, we based this model on looking at the average transmission rates and average contacts per day and average daily cases over the last nine months. So this basically assumes that we would have between 500,000 which would be kind of the low end to 1.3 million people that would require a quarantine that includes the infected individuals plus 4.25 contacts per person. And as I showed the cost of this, the on average would be 2260, which is below the actual $2,500 medical cost. So given the fact that we are at the lower end and given that we have a reasonable vaccine rollout happening, I mean, that's a big assumption that assuming that that is the case, we're looking at probably in Massachusetts and something around the order of $300, $350 million in costs. Now, if we look at that, one of the first questions is, what is the return on investment on that or how cost effective is that use of money? So to try and answer that question, we took a look prospectively at a kind of counterfactual to try and ask if we didn't do this, what would be the cost? So we asked what would be the likely medical bill? I'm using the average number of cases per day over the last few months, which has been 1,200 on average. In fact, yesterday was very close to that in Massachusetts and spreading at the average transmission rate from 2020, we found that the total medical cost in the state alone would be 1.1 billion, of which of course 43% would be borne by the state. And we found that, I mean, if the program could reduce the transmission rate even for one day of this group, which would be 1,200 people plus the contacts, there would be significant savings to the $300 million program. And even at lower rates of transmission, even at significantly lower rates of transmission, there would still be savings because every additional case avoided is essentially money saved. And this was a very narrow way of considering that the counterfactual, because we didn't include a number of the costs that the speakers outlined today. For example, we were just hearing about the reduced cost potentially of treating alcoholism due to the benefits of having people in facilities during their transition. And there are a whole range of costs which are in economics kind of packaged under the cost of exhaustion, which include the cost of paying rent or not having money for rent, the cost of running out in medications and so forth, which are associated with not having these quarantine wraparound services. I finally want to point out that we actually are, you know, the really good news. Massachusetts has, and this is just one state, but we've obviously spent overall a huge amount of money so far in things like, this is the Massachusetts rate where we spent 1.1, almost 1.1 billion already on PPE and hospitals and supplement payments to hospitals and 66 to 100 million on contact tracing. But we haven't really leveraged the full value of this. We haven't gotten the full bang for the buck, particularly out of the contact tracing money because of the lack of clear spending on setting up the supported quarantine and wraparound services. And we are about to have a situation where the funding and the stimulus bill provides in addition to a significant amount of general state and local aid, there's $46 billion specifically targeted toward testing contact tracing and mitigation of which the things we're talking about today would fall particularly into this area and particularly in medically underserved areas. So states are pretty soon gonna find themselves in the really happy but sort of complicated position of trying to figure out where is the best allocation of the marginal dollar and how do we prioritize that? So I would suggest that probably the spending priorities are around helping underserved communities, preventing transmission and spending in such a way that has offsets to the states and has savings. And this falls, the supported quarantine that we've heard about today falls absolutely ticks all three boxes. And so it was probably one of the most cost effective ways to fight the remainder of the pandemic in a way that achieves goals and at what you could call financially a sort of very positive return on investment for every public dollar that's expended. So our paper which provides this is out today. This was paper written led certainly by Dr. Bordeaux and by my amazing student, Jessica Cashel and others and Marie Sazdie and Megan Mishra and Anne Hoyt. And we have a pretty robust financial model both for the cost and for the quarantine which is available by request which any state could adapt to their own costs. So thank you very much. Awesome. Thanks so much. It is good to get good news from somebody that knows something about money. I think we are, it will be whiplash. I will tell you, Dr. Boma's for those of us in public health and those of us who've been, you know really chomping at the health equity bid for a long time to kind of be in this moment of like, oh wait, we have, there is funding available and how should we spend it? So I think that's fabulous. I would love to have everybody who can turn on their video and we can do some of the question and answer. I think our audience has few, I see Mary Gray. It's awesome. Always you guys ask the most astute questions here and in the question and answer box. I think I'm gonna invoke a little bit of the host privilege and in modifying a bit of your questions, Mary around especially the first question because it does get to something that I struggle with a little bit. And I wonder how it can be worked out a bit better. So there seems to be sort of a tension, at least I noticed it in Massachusetts where you want to make use of community members who really know their communities well and the community-based organizations that they are often involved with that are really tailored to potentially meeting the needs of community members. I think that, but as you transition over to trying to build out and have a bit more standardized approach and make sure that everyone in every community has access to high quality services, there becomes an issue where I have felt concerned a bit in Massachusetts that, gosh, we are leaning in on the community resources of some of the most impoverished communities in order to support people in quarantine isolation. Okay, it's wonderful if they happen to have an amazing food bank. Okay, great, wonderful. But what about the community that is also poor that does not have such an awesome robust food bank? I mean, can we start to both make sure that we're leveraging community-based organizations and community members with the expertise and knowledge about their communities while also making sure that we are applying a high standard of support across the board? I don't know, let me, I'll ask Dr. Johnson, you first, and then Dr. Lazada and Wade, maybe you guys have some insight. Yeah, I can try taking this first and I'm sure there'll be so much that others want to chime in about. But I think one of the ways that we've approached this in New York City is by saying, for example, let's take the case of food. We are going to use one of our city agencies that is highly effective as an operator to set a standard for the delivery that people should be able to expect. We'll get you it within 48 hours if we need to do a triage order, we can rush it. But it's through those partnerships and the management of those partnerships that we're going to be able to meet the local needs. So the reason that we're able to provide this range of services is because of the vendor contract management capacity that DSNY or Department of Sanitation possesses. I think if you want to take the example of our resource navigator program, it's managed by a city office that then contracts with CBOs that span all five boroughs that have different language capacities. And they get to tap in, of course, to those city resources when they're available and with basically, of course, the state and federal resources. At the same time, if they sign shortfalls and what's available locally, the apparatus that we have around HRO allows us to provide them additional funding to kind of build them up in areas where they are small so that you aren't punished by where you live in the city, which is just going to perpetuate a lot of the disparities that led to the situation we're in to begin with. I think another thing that's really a point of pride for the resource navigation program in particular is the jobs that we are creating. And so the Housing Recovery Office has this particular mandate for developing careers for people, for employing people. And so to be able to say we created 400 plus jobs of people from the community, expanding the capacity of these CBOs to hire and employ people, is another way that we're trying to build up and invest in the places that have been hardest hit by the pandemic. And something that is on our mind, we are also really excited about the expansion into mitigation services and what that means for our ability to continue some of these. This is just part of the ongoing response to COVID. And we're thinking about what is the next iteration of this core that we've been able to build up, this workforce, because they provide so much value and it would be a shame to lose the knowledge and skills that they've developed in the past year. Oh, community health workers, here we come. Dr. Osada and Dr. Wei, do you want to chime in on that? Yeah, I think I echo a lot of what Dr. Johnson said. We really tried to keep a lot of the, tried to keep things local. I think on the one hand, it could be perceived as a strain, but on the other hand, we were able to provide a lot of employment for the restaurants in town that were helping to deliver breakfast, lunch and dinner along with the hotel and support staff. I think they were all extremely and continue to be extremely grateful that they're busy and they continue to get a paycheck. The one other thing I wanted to highlight is that we at Gallup Indian Medical Center, we are going out to do check-ins with folks and we do bill them as medical visits. So that's one of the other things to try to advocate for and in partnership with the local medical centers is if they can kind of bill as home visits, especially during around this time last year, we weren't doing any visits. And so that was actually really helpful to be able to do, I don't know, 10,000 plus. I just got the number, 34,000 home visits is what it's counted as. Fantastic. I mean, it really is heartening, right? To see after this very dark year, this, you know, I don't know, reenshoots, am I allowed to use that? You know, maybe we're gonna merge from this with a much more sophisticated and kinder and more built out health system and public health system. And one of the things that I have really been thinking about with the Berkman Klein Center folks, including Mary Gray, you know, is this issue around the, you know, what is the information and tech infrastructure that we want for our public health system going forward? How do we want it to interdigitate with our medical care system? And, you know, how do we want it to be structured so that, you know, that social determinants of health and, you know, things that are impacting the health of patients that are not sort of popping up routinely in medical records, you know, that we start to, you know, have that system in place so that we have some communication between public health and our medical care system. Right now, so much of our IT systems and, you know, our runoff of that's machines and, you know, very old systems, you know, which are very cumbersome and I just wondered either New York team, Navajo team, whether you had some thoughts about or even dared yourself to think about what are the systems you'd like to build. And I think Mary Gray's specific question was about the resource navigator system being used. And she had a specific question about, you know, what were the features that made the pain of implementing it worth it? So maybe, Amanda, we can start with you and then zoom back out on the bigger question of IT. Sure, I can start by talking a little bit about the resource navigator CRM platform. So in the sprint to come up with a contact tracing platform that was gonna be ready on June 1st, a lot of attention was paid to making sure that we had a script that worked for our case investigators that worked for the monitors, the folks who call people on subsequent days of their isolation and quarantine. And we wanted to be able to launch the resource navigation program at the same day, but just the reality of the work is we only have so many developers, we only have so many system architects to go around. So the priority was getting a really strong contact tracing platform in place and the resource navigation program was able to function in its own separate system. Once some bandwidth opened up and people also really just saw how popular the resource navigation program was. I mentioned before that we were really excited to celebrate 11,000 plus guests to our isolation and quarantine hotels. But to put that into perspective, we have shipped out 220,000 take care packages over the course of our program to take care packages only launched in August. And then the resource navigators have completed upwards of 190,000 referrals. So people are still doing this at home. That is their preference and that is often their reality. So we wanted to make sure that we got the same benefits that the contact tracing program was afforded by their use of the platform. So I'd say there's probably three areas we used to have and we still have this meeting every week between the tracing platform and the take care platform just to talk about handoffs. And now we can talk a little bit less about handoffs because by working in the same system and anyone who's been in a medical record at any point understands and feels his pain. We now can see what were the interactions leading up to this. We can see your case notes. So it just provides a more complete picture of the situation that you're trying to intervene on. Like why was this particular need? What is my best chance of getting back in touch with this person? Because unfortunately we have to use word navigation because things can be so thorny and hard to come by but we wanna do that work as well and it's completely as possible. It also afforded us a better view into how tools. So we could see if I can't contact this person, is there somebody else in the household that I can assist or is that another way to get in touch with this person? Really what is the how tool need as opposed to just what is this individual please? It is an operational benefit. The more concrete operational benefits is that we were spending a lot of time doing manual assignments. This person has this language preference. They live in this code. They should go to this community-based organization and this resource navigator. This is all stuff that can be automated. And again, we can invest more time into thinking about programming and then managing aging work and process. So what is not been touched within 24 hours? What has been open but hasn't been resolved in 48 hours? Just having a lens into where that stands and who is facing more challenges and then being able to unpack why those are is really important. I mentioned before that CBOs preferentially serve a particular neighborhood. So you don't wanna penalize poor performers without really understanding what could be driving that change in performance. If it takes more time and it takes more effort to close the case for a person, you don't wanna hold them to the same standard as the CBO which has particular resource that's just more readily available in their neighborhood. So that brings it kind of to my last point which I think was the benefit of this platform is being able to pull in some of that really good contact tracing data around demographics, around neighborhood, around is this a case for contact? What day in their isolation are they? What, being able to actually do stratifications by race and ethnicity and language to really hold ourselves accountable to achieving what it is we think that we are doing. That has been a really impressive benefit of being able to pair, not have to work so hard to match contact tracing data with resource navigation by just treating it as part of one workflow. That's fantastic. I, yeah, Dr. Lazada, maybe you want, okay. I don't have a significant amount to add. I think that was excellent from Dr. Johnson. I think the one thing that we've found in terms of rather than connecting systems is really leveraging our own electronic health record here and showing how many of these other kind of touches with healthcare or with a system can all be really added into our existing EHR. So a lot of these home visits, what our CHRs, our community health representatives are doing, all of that, if we're keeping it in a more centralized place, then we can see all of those touches even within our EHR were unique and lucky in that we are mainly one system to take care of a community as opposed to numerous different hospitals and clinics where the care is slightly more by nature more disjointed. So I think we found a value in keeping everything as centralized as possible. That's fantastic. And I know there's a lot more questions we are at time. I do, I would like to just thank our incredible guests. I think they're, I encourage anyone listening that wants to continue the conversation to certainly reach out to us, to me. I am super happy to set up sidebar conversations. I think there's probably a lot more to be said about the money, there's a lot more to be said about the eligibility criteria and accessing the facility-based services. But so just know that we are here to make that happen if folks wanna follow up. And thank you so, so, so much to all of our guests and our experts.