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Ambulatory Physician Practical COVID-19 Resources

March 20, 2020 COVID-19, Infectious Disease, Practice Management, Public Health, Risk Management, Treatment Protocols Public Health, Infectious Disease, Practice Management, Risk Management 0

AMBULATORY PHYSICIAN PRACTICAL COVID-19 RESOURCES

A crowd-sourced collaboration of SDCMS, Be There San Diego, multiple institutions, and volunteer physicians from San Diego county working in all modes of practice.

These resources were put together at the request of our members looking for support for private practices. We have done our best to include sample workflows, sample language, and links that are updating frequently from reliable sources like the CDC, CDPH, and San Diego County. These are NOT meant to be guidelines or standards of practice. Use all of this at your own risk and discretion. We hope that you use this as an open-source resource and tailor the documents to your particular practice.

Please let us know if there are things that we can improve, or something that you don’t see on here that you or other practices may need. (email) If you have something helpful that is new or different enough that it would change practice/outcome, please send it our way. If what we have is close enough, please refrain from minor tweaks so we can triage our busy inbox. We’ll do our best to try to incorporate your feedback after reviewing it with our volunteers. Our volunteer physicians are also seeing patients and are doing this in their spare time, so we may not be able to get to every request or suggestion during this challenging time.

Should we change how we are seeing patients? -- Short version, yes.

Considerations for Ambulatory Practices (pdf)

CDC: Resources for Clinics and Healthcare Facilities website

CDC: Get Your Clinic Ready for COVID-19 (PDF Format

Clinic Operations Decision Tree (PDF Format)

Prior to starting your day:

Consider having all staff do daily self-screening at home prior to coming to work:

Upper respiratory symptoms (cough, shortness of breath, sore throat, etc.)?
Temperature > 100 F?
If either or both are true, they should notify HR and quarantine at home.
Consider referral for testing if fever or lower respiratory symptoms, as health care workers are considered a high-risk population. Continue to check current guidelines and most current CAHAN from San Diego CountyCAHAN:https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/cahan/communications_documents/03-19-20.pdf (last accessed 3/21/20)

Patient triage

Physician should review their upcoming appointments for the next 4 weeks to see who should be rescheduled, who can be converted to a telephone or video visit, and who needs to be seen inperson.

Sample workflow to call patients who need a non-urgent visit (PDF Format)

During your clinical day:

Telehealth

AMA: https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice

HIPAA rules have been loosened for telemedicine: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html (HHS)

Telephone visits

Video visits

CMS: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

Prescribing controlled substances:

https://www.deadiversion.usdoj.gov/coronavirus.html

How do I billing for telehealth visits:

ACP: https://www.acponline.org/practice-resources/business-resources/covid-19-telehealth-coding-and-billing-practice-management-tips

AMA: https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice

Medically necessary clinical visits

There is no guideline for every specialty on who you should and should not see in-person. Use best medical judgement to give the patients the best care possible.

Patient screening on arrival

- Have a staff member at the appropriate distance (6 feet) screen the patient (and any accompanying person) outside the clinic when they arrive.

- Limit anyone besides the patient from coming into the clinic, unless they are necessary. Consider including the accompanying person by phone if needed and okay with the patient. Include them via phone, if needed.

Our clinic has the capability to test patients

Many things go into this decision. If you are not sure how, don’t do it. There are not enough tests in San Diego County currently, so office-based testing may not be the priority. This will change as more testing becomes available. Consider prioritizing symptomatic health care professionals and first responders to get them back to work ASAP. Keep up to date and follow all County recommendations for testing.

CDC guidance on Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings

California Department of Public Health guidance as of Feb. 28, 2020: Outpatient Healthcare Facility Infection Control Recommendations for Suspect COVID-19 Patients

Reporting Positive Results:

San Diego County: Coronavirus 2019 for Health Professionals

Our clinic does not plan to test for COVID

Where do I refer them if I think they may qualify for testing? (They MUST call first to be screened)

If the patient is affiliated with a medical system, please refer them to the appropriate nurse line found on the 211 website (click here), or their main healthcare system phone number.
If the patient does not receive care in any of the systems listed, refer them to the Scripps COVID nurse line (this information will be updated as more community sites become available).
- https://www.scripps.org/news_items/6916-scripps-health-launches-nurse-line-dedicated-to-covid-19

How do I follow up for patients with COVID symptoms, whether or not they are tested?

Follow-up for patients at home with suspicion of or confirmed COVID diagnosis (PDF)

My patient tested positive, now what?

Reporting Positive Results:

San Diego County: Coronavirus 2019 for Health Professionals

If mild to moderate symptoms: See above for Follow-up PDF.

My patient is requesting a letter to be excused from work .

People do NOT need a letter to be excused from work at this time.

Info letter for patients and businesses here.

After hours:

Sample after hours recordings (PDF Format) Updated 3-21-20

Patient handouts and websites

General Info:

Info for patients on prevention (English) (CDPH):

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/COVID-19/COVID19-ProtectYourselfandOthers.pdf

Info for patients on prevention (Spanish) (CDPH):

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Covid19-Poster-SPANISH.pdf

Fact Sheets for Patients/Community (County of San Diego)

Patient Education Handouts: (CDC) PDF format in 3 languages (English, Spanish, Chinese)

Share facts about COVID19
What you need to know
What to do if you are sick

Website for: Clean and Disinfect: Recommendations for US Households with Suspected/Confirmed COVID-19 (CDC)

Handout for COVID-19 Home Disinfection Guidance (County of San Diego)

Individuals at higher risk of severe illness

Website for: People at higher risk of serious illness (info specific to older people, HIV, asthma, and pregnant women) (CDC)

Handout for Self Isolation for Older Adults and Those Who Have Elevated Risk

Symptomatic patients:

Handout for Patient with Respiratory Symptoms (CDC) PDF Format

10 ways to manage respiratory symptoms at home

Website on COVID symptoms and testing including a Self Checker (CDC)

Persons under investigation or positive for COVID:

Handout for Patient Positive for COVID-19 (CDC) PDF Format

What to do if you are sick with coronavirus disease 2019

Website for: Recommended precautions for household members, intimate partners, and caregivers in the home of people who are positive or being monitored/tested for COVID-19 (CDC) in 3 languagues (English, Spanish, Chinese)

Printable PDF document (data accessed 3/19/20)

COVID19 Fact Sheet PDF in 9 languages (English, Spanish, Chinese, Arabic, Farsi, Korean, Tagalog, Vietnamese, Japanese)

Website for: Preventing the Spread of Coronavirus Disease 2019 in Homes and Residential Communities: Interim Guidance in languages (English, Spanish, Chinese) (CDC)

Signage for your office

CDC: Office signs: PDF format

Please read before entering (outdoor sign)

CDC: Patient Education Posters: (PDF format in multiple languages)

Stop the spread of germs (English, Spanish, Chinese, Vietnamese)
Symptoms of coronavirus disease 2019 (English, Spanish, Chinese)
Stay healthy wash your hands (English, Spanish)
Wash your hands (English, Spanish, French, Arabic, Bengali, Chinese, Portugese, Urdu)
Keep calm and wash your hands (English, Spanish, French, Arabic, Bengali, Chinese)

What about PPE?

First, we are going to have shortages. Please conserve PPE by having only essential staff work in person with patients, and only do medically necessary visits in-person.

While it is not recommended due to increased infection risk, reusing PPE or using less than optimal solutions may be a reality.

CDC: Strategies for optimizing the supply of PPE

If you are unable to access appropriate PPE or supplies related to COVID response, please email: MOC.LOGS.HHSA@sdcounty.ca.gov

Business Concerns:

Where do I refer my staff if they need help or I cannot keep them employed?

There is a helpful article that is more LA-focused but has good links to California state programs here.

Website on Employment Development Dept State of CA with info on State Disability Insurance,

Unemployment Insurance, Covered California, and more.

Chart of state programs to help workers from the California Labor Workforce and Development Agency

How do I keep my business afloat?

Website on loans from the U.S. Small Business Association here.

Fact sheet on California’s Rapid Response program to help keep your business open.