By Andrew L. Concoff, MD, FACR, CAQSM
I have just heard that a close friend has decided to stop all in-person visits for the safety and well-being of her patients and staff because of the rampant local spread of COVID-19 in her community. Many of our practices are now experiencing such challenges for the sake of prudence or associated with learning that patients who have visited our clinics, or staff members themselves, have tested positive for, or have been exposed to, COVID-19. But what do you do in the case you decide that in-person visits need to cease completely?
In my friend’s case, her front office staff hurriedly called patients to cancel in-person appointments, telling them that her clinic was “closed,” even though she intended to robustly embrace Telerheumtatology to continue caring for them. This resulted in an explosion of patient calls to determine what, exactly, it meant that her clinic was “closed.” So, what steps should you follow to better communicate this information to our patients?
First, we need to develop a coherent and consistent lexicon with which to describe the move-forward scenario that defines exactly what services we will continue to offer to our patients. Why, you might ask, in the midst of this human tragedy, are we worried about such “wordsmithing”? The answer is that it is imperative because there are several overlapping circumstances and administrative plans that may confuse our patients if we fail to define our terms carefully.
What might these patients have thought we meant by “closing” a practice because of COVID-19? That might mean to patients anything from “we are no longer available in any way to address your concerns or care for you in any way,” or that “we are available only via telemedicine,” or that “we are discontinuing certain services,” or even just that “we are no longer taking on new patients” (as in, “my panel or clinic is closed”). Even worse, it might have meant that they had been exposed to COVID-19.
Consider for a moment one of the patients you have cared for over the course of many years and how differently each of these circumstances might feel to him/her/them. There is a hazard on either side of inexact communication here. On the one hand, patients may assume that you are completely unavailable when you are just a video link or phone call away, causing them unnecessary distress as they may feel abandoned. In this case, you may inadvertently sacrifice potential revenue needed to keep your practice afloat through these challenging times. Contrarily, if you are truly incapacitated by illness, unclear communication may cause your clinic staff to be overrun by calls and inquiries in your absence or may waste patients’ valuable time waiting for return calls and advice that are not forthcoming.
Further, patients should be informed as to whether the rationale for the changes in the approach at the clinic relates to events that pose any individual risk of exposure to COVID-19. We have previously covered the CDC approach to evaluating the risks of COVID-19 exposures. Instead, in keeping with the theme of this effort, the following, is a suggested rubric for clearly communicating the status of your clinic to patients:
- “Open with full services, but with additional screening procedures”: Let’s define this condition as the new norm for those clinics thus far unaffected by the pandemic. It is important to communicate that you have adopted new procedures to patients in order to reassure them that the new procedures have been enacted out of an abundance of caution, rather than a specific exposure to prevent anxiety and extreme, incapacitating fear (e.g., coronaphobia).
- “Open with limited services”: This circumstance might be necessitated by certain staff members for who you do not have available replacements who are critical to one or another in-office service becoming unavailable. This may be by virtue of non-work-related exposures to staff (when such exposures have not impacted the remainder of your office staff) or simply prudent stewardship of the clinic to prevent unnecessary interpersonal exposures. Of note, certain ancillary services such as musculoskeletal ultrasound require prolonged, face-to-face contact between the sonographer and the patient. It may be prudent in the case of the high prevalence of COVID-19 infection to consider suspending such higher-risk services before the suspension of “lower touch” services. On the other hand, clinics may choose to limit certain services if a staff member assigned to such tasks bears a particularly high risk of severe COVID-19 infection by virtue of age or pre-existing cardiovascular disease. Under high disease prevalence conditions, consideration should be given to transferring high-risk staff to tasks that are non-patient facing whenever possible, including re-training such persons to supervise the administrative aspects of Telerheumatology efforts. Cross-training staff, whenever possible, is a critical approach to avoid unnecessary limitations in services given the present scenario.
- “Completely virtual”: I would strongly recommend this terminology rather than “closed” in indicating that no further in-person visits are being offered. This terminology may limit the avalanche of questions that might otherwise be required to define what “closed” really means.
- Telemedicine with videoconferencing: If you are forced to stop seeing patients in your clinic by virtue of exposure from one or more COVID-19-positive patients or staff members but plan to continue care for your patients through Telerheumatology visits, it is strongly preferable that you do NOT indicate that your clinic is “closed”. Rather, indicating that you are stopping all in-person visits and “Completely virtual.” This communicates that you will maintain the doctor-patient relationship and have not abandoned your patients.
- Telemedicine by telephone only: Some might prefer “Remote care by telephone” to describe this circumstance. However, as Telemedicine codes include phone only variations, calling your patients technically counts as a form of telemedicine. I would expect this category to be used very infrequently in that CMS has relaxed HIPAA regulations and billing guidelines to allow for the use of smartphones and web applications (e.g., Skype, etc.) for medical communication from doctor to patient, a circumstance that reimburses better than telephone calls without video. Furthermore, in transitioning a patient panel unaccustomed to remote visits, the video portion of the interaction I likely to be reassuring. Most providers and clinics, therefore, have no reason to transition to “Telemedicine by phone only” and would, instead, utilize “Telemedicine via Videoconferencing”.
- “Unavailable for any patient care”: This condition represents the far end of the spectrum, reserved for the circumstance alluded to above, wherein, no provider is available to field patient calls, refills, health concerns, etc. Needless to say, it is our ardent hope that few clinics need to make use of this scenario, predominantly out of concern for our physicians, providers, and administrative staff. Furthermore, by cutting of care for your patients in this manner, patients are left to search for answers to medical questions and issues from other, likely already-overburdened, fellow Rheumatologists or Primary Care, Urgent Care, or Emergency Departments staffed by doctors with less specialty-specific knowledge and with greater risk of COVID-19 contagiousness upon any required, in-person visits.
Depending upon the duration of practice service changes, the progressively limited modes of service described above may require more draconian staffing changes. Each clinic must assess whether staff can be maintained through disruptions to the revenue cycle. It is likely that short-term interruptions can be absorbed by most practices such that staff will continue to be paid. Regardless, clear communication of the uncertainty of the current circumstances is critical in communicating about any such interruptions with team members.
The advent of the COVID-19 pandemic has fundamentally changed the practice of Rheumatology. One way that we can face such uncertainty and confront these challenges is band together virtually, by sharing our thoughts and approaches. Please send your concerns, solutions, thoughts, and novel approaches to email@example.com.
Stay safe, stay healthy, stay United.