Greetings From North Carolina!

This is part of a series looking at different practices of all sizes and locations, and how they are all dealing with issues during this pandemic. 

By Suneya G. Hogarty, DO, FACOI

We are a multi-specialty practice with one rheumatologist and one NP, who primarily sees rheumatology patients. We practice in rural eastern North Carolina, where COVID-19 has not had widespread impact, partly because of our rural nature. However, we also have not hit our peak of infection either, as social distancing has successfully flattened and prolonged our curve. We have a staff of 12 and offer lab, infusion, DXA, and X-ray services. We converted to telerheumatology follow-up visits on March 19, doing a few a day initially, but within a week, transitioning to all telerheumatology visits using platform. I stopped seeing new patients at the beginning of April because I do not feel that I can adequately assess a new patient via telemedicine. I just recently decided to extend that policy until May 15. On April 3, we furloughed our X-ray tech and an MA with some comorbidities who was increasingly anxious about her risk of exposure. Our phlebotomist was moved to part-time, afternoons only, to assist with her childcare needs. Though we cost-share health insurance premiums, we have assumed these three employees total premium payments during their furlough. In addition, we have kept in weekly contact with them and unfortunately discovered that, despite filing timely unemployment claims, they had not received any money from state unemployment. We have sent these employees an advance to help them over the next few weeks until we can bring them back full time. We have also reduced office hours to four days a week to help with payroll burden and to ensure all remaining employees can stay off furlough. Because of a reduced patient volume load, four full days of work accommodates our current patient volume.

We have continued to offer infusion services throughout this time period, although I meet with my infusion staff weekly to review the patients who are scheduled for the upcoming week. Based on comorbidities and degree of disease control, I have recommended some patients postpone or skip their infusion altogether. However, the majority have continued to take their infusions on schedule. We are using unoccupied exam rooms and the x-ray suite to deliver infusion medicines so that we can isolate older infusion patients and maintain appropriate social distancing in the infusion suite. Since early to mid-March, we have been keeping a very small infusion medicine inventory, ordering drugs every few days since our schedule is changing more frequently. We feel that this keeps us financially in a safer position with our GPO bill.

At this point, I exclusively see only telerheumatology visits. I have in-person visits only for emergent procedures; all viscosupplement injections have been rescheduled for later in the summer. Our MA staff is spending much more time on the phone, explaining telerheumatology to patients and helping them successfully navigate their own smartphones or rescheduling their appointment to a time when a younger family member can be present to help with the call. We have one employee posted at the door, taking temperatures and rescheduling any patient with a temperature for an appointment the following week. We are short on PPE, but a family member of one staff has graciously sewn us cloth masks, with which we cover our PPE and then wash daily. We have ordered a UVC germicidal light (still not delivered), which we plan to use for sterilization of our remaining N95s. The employee at the door and the infusion suite staff wear N95 all day.

One of the most important new measures we have implemented, which I think has helped staff and patients, is to have more frequent conversations about COVID-19. I have posted several write-ups on our Facebook page, website, and text service, Luma, for patients regarding COVID; some topics have included the benefits of social distancing, proper hand-washing, HCQ shortage and some of the measures that we have taken as an office to protect patients (many of which I have outlined above.) For staff, I have had almost weekly meetings with them to share medical learning about the virus, symptoms, local hospital criteria for testing (since we continue to have inadequate testing capabilities), and emerging data about HCQ/Actemra for treatment. I have reviewed the burgeoning literature with them and answered questions. We have one pregnant MA, and I have shared as much information as I have with her about COVID and pregnancy. I think this has helped us stay calm and combat overwhelming fear as a team and has allowed us to message consistently to our patients about appropriate safety measures and risk/benefit decisions.

In all of this, United Rheumatology has been an invaluable partner, helping guide me so that I can guide them and giving me the support I need to make best practice decisions.

Suneya G. Hogarty, DO, FACOI
Member – Medical Policy Committee
Integrative Arthritis and Pain Consultants
Goldsboro, North Carolina

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