COVID-19

Anticipating and preparing for challenges during the COVID-19 pandemic will improve clinical operations during times of stress. Due to the fluidity of the COVID-19 crisis, effective solutions require creative thinking and planning. The earlier healthcare systems can do this, the further ahead and prepared they will be to provide effective care that protects the lives of their patients, staff, and community. 

Review the HHS COVID-19 Hospital Preparedness Checklist to audit your Coronavirus preparations and remember to adapt the checklist to meet the needs of your organization. This checklist covers several crucial steps to consider, including:

1. Structure for Planning for Decision Making
2. Development of a Written COVID-19 Plan
3. Elements of a Written COVID-19 Plan
4. Facility Communications
5. Consumables and Durable Medical Equipment and Supplies
6. Identification and Management of Ill Patients
7. Visitor Access and Movement within the Facility
8. Occupational Health
9. Education and Training
10. Healthcare Services/Surge Capacity

For the initiation or expansion for telemedicine services during times of surge census we also use an Inpatient Telemedicine Surge Checklist to be filled out jointly by telemedicine providers and their partner healthcare facilities.  This can also be adapted to outpatient settings. It includes the following:

1. Contractual Agreement Process
2. Facility Mapping
3. Facility Numbers (by department)
4. Point Person Information (by the individual leader)
5. Process Statuses
6. Telemedicine Equipment Statuses
7. Clinical Notes By Client
8. Clinical Notes by Telemedicine provider
9. Respiratory Therapy Capacity Checklist
10. Critical Care Capacity Checklist
11. Mock Drill dates and outcomes

Overall goal:

Telemedicine can improve and/or augment clinical services at your facility, strengthen infection control measures, provide backup and support to onsite clinicians, and keep employees and patients connected

Telemedicine Operations:

• Hardware: You can go live with telemedicine services with an existing medium-range hospital laptop and a webcam. This is possible with anywhere from a zero dollar investment in hardware to $2,500 for a simple telemedicine cart with a tablet. Peripheral hardware such as digital stethoscopes and other cameras are available in a wide range of budgets.
• Software: Telemedicine software is web-based, affordable, and scalable. Remember, Telemedicine is simply a more secure version of video chat platforms such as FaceTime. Over technical software is not required.
• Telehospitalist Services: Access high-quality inpatient care. Remote physicians and advanced practice providers (NP/PAs) can provide direct patient care, daily rounding, admission and cross cover services. 
• Tele-ICU and Ventilator management: Manage a higher level of acuity. A telemedicine pulmonary/RT team can help manage critically ill, pulmonary and ventilator-dependent patients.
• Specialty Consultation: Access specialists through the same telemedicine hardware. Cardiology, Pulmonology, Gastrointestinal, Infectious Disease, and other specialists can directly consult on your patients. 
• Backup Hospitalists: Create support systems for onsite staff. Telemedicine Hospitalists can provide stop-gap measures for surge censuses, admission, and nighttime back up. This also serves as an option for quarantined providers who are otherwise able to work.
• Continued Quality of Care: Telemedicine services can engage traditional quality measures. Quality monitoring, dashboard development, and process improvement projects remain an important part of telemedicine-based hospital work.
• Human Resources: By providing consistent staffing, telemedicine optimizes personnel through consistent coverage lending itself to continuity of care, professional practice evaluations, and continuing medical education.

Connect with Employees:

• Please see Supporting and Organizing Staff section below for ideas on technology and mobile applications to bolster employee engagement.

Connect with Patients:

• Overall, telemedicine portals are widely accepted by patients and families. They provide high-quality patient interactions without compromising communication or medical assessment.
• Telemedicine equipment also has the potential to provide access to patients by family and community members who may be restricted from entering the hospital.
• Telemedicine can also augment transitions of care. Phone calls and outpatient PCP follow-up may be limited by the pandemic.
• Consider using HIPAA-compliant applications with text messaging capabilities to stay connected with recently discharged patients, provide follow up visits, avoid complications, and reduce readmissions.

CMS Reimbursement & Process Waivers

Reimbursement for telemedicine service had been evolving in positive ways prior to the COVID-19 Pandemic. In response to the pandemic, government and private insurers have created sweeping changes to facilitate the use and billing of telemedicine encounters. For now,  these changes are both temporary and developing. Engage but remain mindful of these changes.

• Waivers allow healthcare providers to overcome previous barriers to providing care, meaning they can reach more patients and do so in new ways. A list of these waivers are available through the Centers for Medicare & Medicaid Services (CMS), see the CMS COVID-19 waivers webpage. 
• Blanket Waivers are a way for healthcare providers to quickly effect change. These waivers DO NOT require requests to CMS. CMS has listed blanket waivers in this List of Blanket Waivers (PDF).

Tip: Important billing and licensing rules have been suspended. For example:

• Location restrictions were removed— telemedicine in rural and non-rural areas can be reimbursed.
• Advanced practice providers — physician supervision requirements have been relaxed.

Tip: Be mindful that while the federal emergency proclamation has passed, state law can still uphold prior requirements.

Tip: Remember to review state health department guidance to learn more about Medicaid reimbursement.

Further Regulatory Resources: 

• Watch this simple CMS video to learn more about telehealth basics. 
• The Center for Connected Health Policy is a reliable source for telehealth related reimbursement and policy changes, on the state and federal level. Center for Connected Health Policy 

CMS Physician and Practitioner Guidance is a helpful resource that outlines:

• Medicare Telehealth, including added services with CPT codes
• Virtual Check Ins and E-visits
• Remote Patient Monitoring
• Removal of frequency limitations in Medicare
• Workforce considerations
• Patients Over Paperwork Initiative

Many federal and state grants are available to help start telemedicine programs. Equipment, wiring, software, technical assistance, education, installation and maintenance are commonly reimbursable. Some allow for salaries and payor of last resort billing. HRSA, SAMHSA, FCC, USDA, and state health departments are good places to look for grants and can be accessed through Grants.gov.

Effective inpatient care provision during the COVID-19 pandemic prioritizes infection control, evolving and dynamic clinical care guidelines, critical care resource management, and informed discharge planning. Updates to these patient care domains from both front-line experiences and expert guidelines will be ongoing. The below is meant to provide a platform with which to start strategizing the requirements of COVID-19 care. We believe telemedicine equipment, care provision, and consultation can be fundamental to meeting these care needs.

Infection Control

Protecting staff and minimizing exposures are of utmost importance. Further complicating matters are PPE and test shortages that make it difficult to keep staff safe and identify infected patients quickly. Based on available guidance, Beam recommends the following:

• Designating COVID and non-COVID care areas
• Place trained observers in care areas to supervise donning doffing of PPE
• Minimize movement of COVID-positive patients throughout the hospital
• Determine, based on available PPE supplies, strategy of reuse or extended use to conserve supplies while minimizing risk to staff
• Develop a plan for intubation and ACLS of COVID-positive patients
• See Beam’s Patient Care Continuum for a door to door map on infection control interventions.

Inpatient Care Management

To develop treatment plans and prepare for the care of COVID-19 patients, clinicians must assess a combination of factors including risk/benefit ratio, accessibility, and procurement, local specialty input/guidance, rolling updates for data from therapeutic trials and expert guidance. Our COVID-19 Inpatient Response and Door-to-Door Instructions documents are a starting point for developing and planning models of care delivery. Mechanical Ventilation during a Pandemic by William Owens, MD is a great resource to have for any ICU/IMC patient. However, as the evidence base surrounding COVID-19 care evolves, management plans will need to adapt and frequent updates will be required.  Additional resources to check frequently include some of the ones listed below and more.

Overall goal

Maintaining the mental and physical well-being of your existing employees is paramount.

Optimized scope of practice

Priorities should be patient care and efficiency over extensive notes. Empower your RNs, CRNAs, RTs, and APPs through progressive policies and protocols.  

Support from other clinicians

Depending on individual comfort level, consider using PCPs and specialists as hospitalists. Hospitalists with sufficient ICU experience should stay focused on open ICU patients if there is no Intensivist available.

Create a floor plan

Not just for surge capacity, floor plans should be dedicated to Med Surg, IMC, and ICU COVID patients.

Designate COVID teams and spaces:

Create one team for COVID patients and one for non-COVID patients if possible. Minimize the risk of transmission to other employees and patients by keeping your designated COVID staff/wing isolated.

Flex Scheduling

The standard 7 days on/7 days off model may not be sustainable due to high risk for burnout. Consider limiting the provider shift block to 5 days if possible.

Develop your team

Facilities should make every effort to develop a full clinician roster to draw from in times of crisis.

Quarantined staff

Staff that is COVID+ but asymptomatic can still be involved in administrative or telemedicine clinical work.  Keep in mind that there may come a point where COVID+ staff are required to work onsite due to a shortage of healthcare staff.

Return To Work Policy

These policies are ever-changing, so please refer to your HR and CDC guidelines.

Mental wellness

It is prudent to stay connected with your employees. Utilize apps such as Slack, Google Chat, or Microsoft Teams where people can chat and connect. We strongly suggest providing your team with access to online therapy/medication apps such as Headspace, Downdog, Talkspace, BetterHelp, etc.

Physical wellness

Consider providing access to online workout programs for your staff to decompress.

Proper fuel & rest

Mental and physical wellness can only occur if employees are eating well and have had sufficient sleep. We recommend hospitals invest in healthy snacks and avoid offering empty calorie options. Providing dedicated nap/sleep rooms for staff is also recommended.