As more than half of states in the U.S. have loosened COVID-19 restrictions on shelter-in-place and social distancing. Healthcare providers are, to a greater degree, reopening clinical practices and beginning to reaccept patients in person for non-emergent or urgent care.
Managing the decision of whether or not to schedule an on-site visit with a patient is a difficult balance: clinic managers and physicians are weighing health risks and benefits, and considering the very real business impact of telehealth.
The Clinical Dilemma of Reopening
Even a day with under-reimbursement, however, has a measurable impact on any practice’s bottom line.
Unfortunately, CMS and private payors have not provided clear, comprehensive and early guidance for the range of practice environments, leaving those of us providing direct clinical care/service for our patients struggling with excess financial and logistical burdens.
At my own clinic, being hospital-based has represented a major barrier to scaling up telehealth services despite the increasing need for e-visits via telemedicine platforms. This is primarily due to the absence of facility fees from remitted reimbursements, which may change.
Deciding on which visits absolutely require an in-person office is difficult, to say the least. The overall guidance (offered as a recommendation in most states) is primarily to maximize telehealth for care. However, many formerly delayed services (medication management, for example) are accumulating a backlog, until they can be completed in person.
Attempting to decide which care is “essential” seems futile, since we are trained to esteem all care as essential. Overall, patients have tended to defer care — or reschedule, “until COVID is over.” Based on available data, this is not a feasible or sustainable option. We need to find ways to resume full care now.
Recommendations for Practices
The CDC lists six recommendations for resuming in-person care:
- Triage care based on clinical needs
- Establish screening before entering clinic, with temperature and symptom checks
- Staff should wear masks at all times when interacting with others; patients should wear cloth masks
- Staff should be screened with temperature and symptom checks daily
- Visitors should not accompany patients unless clinically indicated, and they should follow the same screening and mask requirements
- Disinfect all surfaces routinely
Other recommendations include erring on the side of caution for deferring or delaying a visit based on observed symptoms, or referral for testing or treatment for Coronavirus.
Make a Written Plan
As you begin reopening your practice, share a written plan for all staff that addresses the CDC’s recommendations. Indicate extended use measures, such how you will preserve PPE (e.g., one mask per day per staff member, etc.). Provide a clear staffing plan should individual members become ill. Take steps to open incrementally. Plan which patients to refer for testing, and which to assessed via telehealth, due to presentation of symptoms.
COVID Impact on Cognitive Status
For many of our patients, cognitive care during COVID has been especially neglected. Patients and their families concern about leaving home disrupted many care planning strategies.
Successful cognitive care relies on a large, resilient support network of varied caregivers and social resources. Many of my patients are exhibiting decline in cognition, mood, and anxiety due to the unique (and perhaps unprecedented) circumstances caused by the pandemic and the lockdowns imposed by states.
We as healthcare providers can point them towards online resources from an array of dementia-support organizations such as the Alzheimer’s Association’s COVID resources.
We also must help them find new ways to be outside, and maintain a consistent exercise regimen. Be creative and think of how your patients can fit in some safe socialization or outside activity. Perhaps some driveway or yard visits. Gardening or yard work has become a frequent recommendation in my practice.
Planning for the Future
Most clinicians did not expect to see a widespread, multi-week lockdown preventing patients with important medical needs from pursuing basic care and followup. And unfortunately, practices cannot rule out these types of events happening again in the future.
Fortunately, telemedicine solutions, such as remote cognitive testing with BrainCheck, allowed some continuity of care during the crisis. In order to ensure the best outcomes both for patients and your clinic, adapting to a continuation of telehealth and limited in-person visits is a contingency for which you must prepare.