Practice Management Perspectives: May 2020

COVID-19: A Physician Practice Guide to Reopening

American Medical Association

May 1, 2020 (www.ama-assn.org) – As public health experts determine that it is safe to see patients and stay-at-home restrictions are relaxed, physician practices should strategically plan when and how best to reopen.

The AMA believes that four signposts must exist before state and local governments relax stay-at-home orders:

  • Minimal risk of community transmission based on sustained evidence of a downward trend in new cases and fatalities
  • A robust, coordinated and well supplied testing network
  • A public health system for surveillance and contact tracing
  • Fully resourced hospitals and health care workforce

The Centers for Medicare & Medicaid Services (CMS) has published a Phase 1 guide  for reopening facilities to provide non-emergent, non-COVID care. To build upon those recommendations, the AMA has compiled a guide with a checklist and other resources to ensure that your medical practice is ready for reopening.

A checklist of criteria for reopening your practice

Comply with governmental guidance

States and the federal government have outlined guardrails that should be in place before reopening. On the federal level, the White House has published guidelines for Opening Up America Again. At the state level, governors have begun to detail what reopening will look like; for example, California’s Governor Gavin Newsom recently released a roadmap to modify the state stay-at-home order.

Some states and cities have recently enacted, extended or modified previously issued stay-at-home orders which detail essential services permitted while the order is in place including medical care. These state and city guidelines should be closely reviewed and followed. The AMA has also developed a chart and fact sheet detailing state-specific delays, and where applicable, resumption of elective or non-urgent procedures.

Make a plan

Pre-opening planning will be vitally important to the success of your practice reopening. Sit down with a calendar and chart out your expected reopening day and, ideally, a period of “soft reopening” where you can reopen incrementally. Assess your personal protective equipment (PPE) needs and alternatives such as cloth masks, what stockpile you have currently and will need in the future and place the necessary orders. As much as possible, have supplies delivered in advance before you reopen so that sporadic deliveries and other visitors do not disrupt the order of your daily plan.

Plan in advance how you will handle staffing and cleaning if an employee or patient or visitor is diagnosed with COVID-19 after being in the clinic. Develop guidelines for determining when and how long employees who interacted with a diagnosed patient will be out of the clinic.

Open incrementally

Consider a step-wise approach to reopening so that the practice may quickly identify and address any practical challenges presented. Identify what visits can be done via telehealth or other modalities, and continue to perform those visits remotely. Begin with a few in-person visits a day, working on a modified schedule. Direct administrative staff who do not need to be physically present in the office to stay at home and work remotely. Consider bringing employees back in phases, or working on alternating days or different parts of the day, as this will reduce contact. Communicate your weekly schedule clearly to the practice’s patients, clinicians and staff.

Institute safety measures for patients

To ensure that patients are not coming into close contact with one another, utilize a modified schedule to avoid high volume or density. Designate separate waiting areas for “well” and “sick” patients in practices where sick patients need to continue to be seen (much like many pediatric practices have longtime used). Consider a flexible schedule, with perhaps a longer span of the day with more time in between visits to avoid backups. Limit patient companions to individuals whose participation in the appointment is necessary based on the patient’s situation (e.g., parents of children, offspring, spouse or other companion of a vulnerable adult).

Consistent with U.S. Centers for Disease Control and Prevention (CDC) guidance, practices should require all individuals who visit the office to wear a cloth face covering. This expectation should be clearly explained to patients and other visitors before they arrive at the practice. To facilitate compliance, direct patients to resources regarding how to make a cloth face covering or mask from a household item if needed, such as the CDC webpage. Visitors and patients who arrive to the practice without a cloth face covering or mask should be provided with one by the practice if supplies are available.

Ensure workplace safety for clinicians and staff

Communicate personal health requirements clearly to clinicians and staff. For example, the employee should know that they should not present to work if they have a fever, have lost their sense of taste or smell, have other symptoms of COVID-19 or have recently been in direct contact with a person who has tested positive for COVID-19. Screen employees for high temperatures and other symptoms of COVID-19. Records of employee screening results should be kept in a confidential employment file (separate from the personnel file).

Minimize contact as much as possible. This includes during the employee screening process, as employees conducting temperature checks have been the potential sources of spread in some workplaces. Consider rearranging open work areas to increase the distance between people who are working. Also, consider having dedicated workstations and patient rooms to minimize the number of people touching the same equipment. Establish open communication with facilities management regarding cleaning schedules and protocols regarding shared spaces (e.g. kitchens, bathrooms), as well as reporting of COVID-19 positive employees in the office building.

Learn more about health care institutions’ ethical obligations to protect health care professionals from AMA ethics.

Implement a tele-triage program

Depending on a patient’s medical needs and health status, a patient contacting the office to make an in-person appointment may need to be re-directed to the practice’s HIPAA-compliant telemedicine platform, a COVID-19 testing site or to a hospital. Utilize a tele-triage program to ensure that patients seeking appointments are put on the right path by discussing the patient’s condition and symptoms. If the practice had already engaged a tele-triage service to handle after-hours calls pre-COVID, contact this service to see if the service can be expanded to tele-triage daytime calls or consider redeploying the practice’s own clinicians or staff to manage this service.

Screen patients before in-person visits

Before a patient presents in the office, the practice should verify as best it can that the patient does not have symptoms of COVID-19. Visits which may be conducted via telemedicine should be. For visits which must take place in person, administrative staff should contact the patient via phone within twenty four hours prior to the office visit to 1) review the logistics of the reopening practice protocol and 2) screen the patient for COVID-19 symptoms.

Utilize a script for your administrative staff to follow when conducting these calls. The AMA has developed a sample script included in this guide. Once the patient presents at the office, the patient should be screened prior to entering. Some practices may utilize text messaging or another modality to do such screening, subject to patient consent and relevant federal and state regulations. Others may deploy staff in a designated part of the parking lot or an ante room of the practice to screen patients before they enter the practice itself.

The practice should strictly limit individuals accompanying patients, but in instances where an accompanying individual is necessary (e.g. a parent of a child), those individuals should be screened in the same manner as a patient.

Coordinate testing with local hospitals and clinics

There will be instances where your patients require COVID-19 testing. Contact your public health authority for information on available testing sites. Identify several testing sites in your catchment area. Contact them to ensure that tests are available and to understand the turnaround time on testing results. Provide clear and up to date information to patients regarding where they can be tested and how the process works.

Some health systems have instituted the practice of testing all patients who are being scheduled for elective or high-intensity procedures (such as outpatient surgeries or services requiring close contact). Depending on the nature of your practice, you may consider doing the same.

Limit non-patient visitors

Clearly post your policy for individuals who are not patients or employees to enter the practice (including vendors, educators, service providers, etc.) outside the practice door and on your website. Reroute these visitors to virtual communications such as phone calls or videoconferences (for example, a physician may want to hold “office hours” to speak with suppliers, vendors or salespeople). For visitors who must physically enter the practice (to do repair work, for example), designate a window of time outside of the practice’s normal office hours to minimize to the extent possible interactions with patients, clinicians or staff.

Contact your medical malpractice insurance carrier

To ensure that clinicians on the front line of treating COVID-19 patients are protected from medical malpractice litigation, Congress has shielded clinicians from liability in certain instances. As the practice reopens, however, there may be heightened risks caused by the pandemic which do not fall under these protections. Contact your medical malpractice liability insurance carrier to discuss your current coverage and whether any additional coverage may be warranted. As much as is practicable, you should protect your practice and your clinicians from liability and lawsuits resulting from current and future unknowns related to the COVID-19 pandemic. The AMA is also advocating to governors that physicians be shielded from liability for both COVID treatment and delayed medical services due to the pandemic.

Establish confidentiality/privacy

Institute or update confidentiality, privacy and data security protocols. Results of any screenings of employees should be kept in employment records only (but separate from the personnel file). Remember that HIPAA authorizations are necessary for sharing information about patients for employment purposes. Similarly, coworkers and patients can be informed that they came into contact with an employee who tested positive for COVID-19, but the identity of the employee and details about an employee’s symptoms cannot be shared with patients or co-workers without consent.

While certain HIPAA requirements related to telemedicine are not being enforced during the COVID-19 public health emergency, generally, HIPAA privacy, security, and breach notification requirements must continue to be followed. Review answers to frequently asked questions in the Privacy and confidentiality FAQs section of this guide.

Consider legal implications

New legal issues and obligations may arise as the practice reopens. For example, some practices may not have had to make decisions about paid sick leave(per the Families First Coronavirus Response Act) because they were on furlough; as the practice reopens, these sorts of employment obligations should be considered and decisions about opting out or procedures for requesting these leaves communicated to employees. The AMA has additional resources for physician practices related to employees and COVID-19. Lastly, coordinate with your local health department as provided for by law; provide them with the minimum necessary information regarding COVID-19 cases reported in your practice, and stay informed of local developments.

Disclaimer: The information and guidance provided in this document is believed to be current and accurate at the time of posting. This information is not intended to be, and should not be construed to be or relied upon as, legal, financial, medical or consulting advice. Consider consulting with an attorney and/or other advisor to obtain guidance relating to your specific situation. References and links to third parties do not constitute an endorsement, sponsorship or warranty by the AMA, and the AMA hereby disclaims all express and implied warranties of any kind.

Copyright © 2020 American Medical Association. All rights reserved.

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