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MARCH 23, 2020 -- At one large practice in Bergen County, New Jersey, the waiting room is empty — but its patients are still receiving care. As of mid-March, the practice is still operating, thanks to the group's willingness to adapt its work flow, sometimes radically, to mitigate the threat of the COVID-19 pandemic.
For example, patients now call the receptionist from their vehicles when they arrive, and wait there until receiving a call back telling them the clinician is ready. The practice has also started using telemedicine for the first time, to the extent it can be adopted in a hurry, and some clinicians are working from home on tasks such as medication refills.
Still, the rapidly increasing numbers of COVID-19 cases in the United States raises the possibility that some physician offices will decide or be forced to close temporarily, as occurred in London last month.
Many practices across the country are having to adjust the way they operate, amid daily changes in the pandemic. What should you do to adapt to this new way of operating your practice?
1. Create a Task Force to Manage Change
The readiness of medical practices to address the myriad challenges posed by this crisis has so far been a mixed bag, said Owen Dahl, MBA, a Texas-based medical practice management consultant. "Leadership is going to have to assess what's happening in the community, what's happening with staff members who may or may not have the disease and may or may not have to self-quarantine," Dahl said.
The physicians, the administrator, CEO, or managing partner should be involved in decision making as the global crisis unfolds, added Laurie Morgan, MBA, a California-based practice management consultant. And depending on the size of the practice, it may be useful to delegate specific components of this work to various department managers or other individuals in the group.
The team should assess:
- Recommendations and/or mandates from local, state, and federal governments
- Guidance from specialty and state medical societies
- How to triage patients over the phone, virtualvisits, or referral to an alternate site of care
- Where to send patients for testing
- The practice's inventory of personal protective equipment (PPE)
- Review of and possible revision of current infection control policies
- Possible collaborations within the community
- Reimbursement policies for suspected COVID-19 triage, testing, and follow-up treatment — in office or virtually
- Whether some employees' work (eg, billing, coding) can be done remotely
- Options for paying personnel in the case of a temporary shutdown
- What's covered and excluded by the group's business interruption insuranc
2. Consider Postponing Nonessential Appointments
What's more, it's crucial for practices to form a strategy that does not involve bringing patients into the office, said Javeed Siddiqui, MD, MPH, an infectious disease physician, epidemiologist, and chief medical officer of TeleMed2U. "One thing we really have to recognize in this pandemic is that we don't want people going and sitting in our waiting room. We don't want people coming, and not only exposing other patients, but also further exposing staff. Forward triaging is going to be essential in this type of pandemic."
Reliant Medical Group, with multiple locations in Massachusetts, for example, announced to patients recently that it will postpone appointments for some routine and elective procedures, as determined by the group's physicians and clinical staff.
"Taking this step will help limit the number of people passing through our facilities, which will help slow the spread of illness [as recommended by the CDC]," noted an email blast to patients.
3. Overcommunicate to Patients
With a situation as dynamic and unprecedented as this, constant and clear communication with patients is crucial. "In general, in my experience, practices don't realize how much communication is necessary," said Morgan. "In order to be effective and get the word out, you have to be overcommunicating."
Today's practices have multiple ways to communicate to keep people informed, including email, text messaging, social media, patient portals, and even local television and radio.
One email or text message to the patient population can help direct them to the appropriate streams of information. Helping direct patients to updated information is critical.
In contrast, having the front desk field multitudes of calls from concerned patients ties up precious resources, according Siddiqui. "Right now, practices are absolutely inundated, patients are waiting on hold, and that creates a great deal of frustration," he said.
"We really need to take a page from every other industry in the United States, and that is using secure SMS, email communication, and telehealth," Siddiqui said. "Healthcare generally tends to be a laggard in this because so many people think, ‘Well, you can't do that in healthcare,' as opposed to thinking, ‘How can we do that in healthcare?'"
4. Take Advantage of Telemedicine
Fortunately, technology to interact with patients remotely is almost ubiquitous. Even for practices with little experience in this arena, various vendors exist that can get secure, HIPAA-compliant technologies up and running quickly.
Various payers have issued guidance regarding reimbursement for telemedicine specific to COVID-19, and on March 6, Congress passed a law regarding Medicare coverage and payment for virtual services during a government-declared state of emergency. Some of the rules about HIPAA compliance in telemedicine have been eased for this emergency.
But even with well-established telemedicine modalities in place, it's crunch time for applying it to COVID-19. "You need to find a way to have telemedicine available and use it, because depending on how this goes, that's going to be clearly the safest, best way to care for a huge number of people," said Darryl Elmouchi, MD, MBA, chief medical officer of Spectrum Health System and president of Spectrum Health Medical Group in Michigan.
"What we recognize now, both with our past experience with telehealth for many years and specifically with this coronavirus testing we've done, is that it's incredibly useful both for the clinicians and the patients," Elmouchi said.
One possibility to consider is the tactic used by Spectrum, a large integrated healthcare system. The company mobilized its existing telemedicine program to offer free virtual screenings for anyone in Michigan showing possible symptoms of COVID-19. "We wanted to keep people out of our clinics, emergency rooms, and urgent care centers if they didn't need to be there, and help allay fears," he said.
Elmouchi said his company faced the problems that other physicians would also have to deal with. "It was a ton of work with a dedicated team that was focused on this. The hardest part was probably trying to determine how we can staff it," he said.
With their dedicated virtual team still seeing regularly scheduled virtual patients, the system had to reassign its traditional teams, such as urgent care and primary care clinicians, to the virtual screening effort. "Then we had to figure out how we could operationalize it. It was a lot of work," Elmouchi said.
Telemedicine capabilities are not limited to screening patients, but can also be used to stay in touch with patients who may be quarantined and provide follow-up care, he noted.
5. Identify COVID-19 Testing Sites
Access to tests remains a problem in the US, but is improving by the week. For practices that can attain the tests themselves, it will still require some creativity to administer them with as little risk as possible. In South Korea, for example, and increasingly in the United States, healthcare organizations are instructing patients waiting to be tested to stay in their cars and have a practitioner wearing the proper PPE go out to patients to test them there.
Alternatively, some practices may opt to have PPE-wearing staff members bring PPE to patients in their cars and then escort them to a designated testing area in the building —through the back door if noninfected patients are still being seen.
"Once in the office, you still need to isolate virus patients in any way you can," Dahl said. "In fact, you want a negative-pressure environment if possible, with the air being sucked out rather than circulating," he said, adding that a large restroom with a ventilation system could be repurposed as a makeshift exam room.
Community testing sites are another possibility, given proper coordination with other healthcare organizations and community officials. Siddiqui has been working with several communities in which individual clinics and hospitals are unable to handle testing on their own, and have instead collaborated to create community testing sites in tents on local athletic fields.
"One of our communities is looking at using the local college parking lot to do drive-through testing there," he said. "We really need to embrace collaboration much more than we've ever done."
Collaboration also requires sharing supplies and PPE, noted Dahl. "Don't hoard them because of the shortage. Look at your inventory and make sure you can help out whomever you may be sending patients to." And if your office is falling short, Dahl advises checking with offices in your community that may be closing — such as dentists or plastic surgeons — for supplies you can purchase or simply have.
The US Food and Drug Administration has issued some guidance to healthcare providers about shortages of surgical masks and gowns, including advice about reusable cloth alternatives to gowns.
In addition, some hospitals have asked clinicians to keep their masks and provided guidance on how to conserve supplies.
6. Preparing to Potentially Shut Down
A temporary closure may be inevitable for some practices. "Maybe the physician owners will not feel like they have a choice," said Morgan. "They might feel like they want to stay open for as long as they can; but if it's not safe for patients or not safe for employees, maybe they'll feel it's better if they check out for a bit."
Should practices make the decision to close or reduce hours, multimodal communication with patients and the public is paramount. Patients will want to know whom to call if they are feeling ill for any reason, where to seek care, and when the practice expects to reopen. Again, proactive outreach will be more efficient and comforting to patients.
Handling financial ramifications of closure is a top priority as well, and will require a full understanding of what is and isn't covered by the practice's business interruption insurance. Practices that don't have a line of credit should reach out to banks and the Small Business Administration immediately, according to Dahl. Practices that have lines of credit already may want to ask for an increase, added Morgan.
Protecting employees' income is challenging as well. For employees who are furloughed, consider allowing them to use their sick and vacation time during the shutdown — and possibly let staff 'borrow' not-yet accrued paid time off.
"However, there's a risk with certain jobs in a medical practice that tend to have extremely high turnover, so physicians and administrators may be reluctant to pay people too much because they don't know for sure those employees will come back to those jobs," Morgan said. "On the other hand, if you have had a stable team for a very long time and feel confident that those employees are going to stay, then you may make a different decision."
7. Seize Work-From-Home Opportunities
Even if the practice isn't seeing patients, there may be opportunities for some employees, such as billers and schedulers, to continue to work from home," Morgan noted. Particularly if a practice is behind on its billing, a closure or slowdown is an ideal time to catch up. This measure will keep at least some people working — perhaps including some individuals who can be cross-trained to do other tasks — and maintain some cashflow when the practice needs it most.
Other remote-friendly jobs that often fall by the wayside when practices are busy include marketing tasks such as setting up or updating Google business pages, Healthgrades profiles, and so on, noted Morgan.
"Another thing that can be even more important, and is often overlooked, is making sure health plan directories have correct information about your practice," she added. "These are pesky, often tedious tasks that may require repeated contact with health plans to fix things — perfect things to do when the office is not busy or closed."
For administrators and billers, if the practice is able to keep paying these employees while partially or fully closed, it can also be an excellent time to do the sort of analysis that takes a lot of focused attention and is hard to do when busy. Some examples: a detailed comparison of payer performance, analysis of referral patterns, or a review of coding accuracy, Morgan suggested.
Although practices have varying levels of comfort in letting employees work from home, it's not much different from working with external billing or scheduling services that have grown more popular in recent years, Morgan said.
As with many technologies, HIPAA is a leading concern, though it needn't be, according to Morgan. "If you are on a cloud-based electronic medical record and practice management system, there's a good chance that it's very straightforward to set someone up to work from elsewhere and have that data be secure," she said.
Finally, as the crisis begins to abate, practices must keep working in teams to evaluate and structure an orderly return to business as usual, gleaning best practices from colleagues whenever possible.
"I would tell practices this is not a time when anyone is competing with anyone," said Elmouchi. "The more collaboration between practices and health systems that have larger resources, the better."