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COVID-19 Practice Management Issues
Managing supplies, testing, personnel, medico-legal concerns, and looking toward re-opening.
- Effective July 30, 2021, the Small Business Administration (SBA) is revising the forgiveness process for the Paycheck Protection Program (PPP) to make it easier for borrowers with loans <$150,000 to submit loan forgiveness applications. Because the SBA has been overwhelmed with loan forgiveness applications, lenders have limited when applications are accepted, which creates uncertainty among borrowers that need to begin making principal and interest payments while waiting for a decision from their lender. For more information about how this helps PPP loan recipients, go here.
- This collection of policies and procedures from the University of Washington offer some practical guidance that practices can use, especially related to triaging patients and conservation of PPEs.
- ACP’s vaccine resources page includes comprehensive information regarding vaccines, including clinical and ethical guidance as well as advocacy.
- Information for Employers: Can practices require employees be vaccinated? The EEOC says yes, but with conditions and as long as the employer is in compliance with the Americans with Disabilities Act (ADA) and Title VII of the Civil Rights Act. The following articles provide more information about the implications of COVID19 vaccine requirements (Updated 7/28/2021):
- CMS also released an emergency regulation requiring all healthcare workers at Medicare and Medicaid certified facilities to be vaccinated against COVID-19. This regulation does not apply to private physician practices unless they are part of one of the applicable entities.
- Vaccine Mandate for All Health Workers – ACP and more than 50 other organizations called for all healthcare employers to require COVID-19 vaccination for all employees.
- What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws (from the EEOC) – Section K addresses vaccination requirements
- When Employers Can Require COVID-19 Vaccinations (from the Society of Human Resources Management)
- OSHA has provided guidance for employers who require or recommend employee vaccination, particularly related to the handling of adverse reactions.
- DOJ determined that federal law does not prohibit COVID-19 vaccine requirements – The DOJ July 6 opinion says that even vaccines with EUAs can be required.
- The Office of Civil Rights (OCR) has issued guidance for employers, including covered entities, regarding whether HIPAA Privacy Rules prohibit asking employees about the status of COVID-19 or other vaccinations.
- Information for Patients:
ACP’s clinical guidance includes up-to-date information and resources on testing and treatment protocols, resources specific to PPEs, and much more. Like this toolkit, it is being updated regularly as new information is available.
- Access to testing is changing rapidly and varies by locality. Check with your local health department, hospital, reference labs, or state health authorities regarding access to testing.
- The CDC is the best resource for information regarding testing criteria and resources. As new testing becomes available, keep coming back for more information.
Practice Re-opening Resources
- COVID-19 Recovery: Team Based Care Toolkit – This toolkit helps practices use their entire team to recover from the pandemic, as well as to optimize team-based care in general.
- ACP’s Clinician’s Guide includes some resources to help guide practices in plans for re-opening. Resources include guides, checklists, staffing and workflow modifications, and materials for communicating with patients.
- The CDC offers a framework for providing non-COVID-19 care during the pandemic.
- ACP offers clinical and public policy guidance on how to resume some economic, social and medical care activities to mitigate COVID-19 and allow expansion of healthcare capacity.
Staffing and Personnel
Due to illness, quarantine, or self-isolation, medical practices may be experiencing personnel shortages. Below are some tips and considerations to mitigate these issues.
- The Families First Coronavirus Relief Act included some requirements regarding paid leave for employees during the PHE. The Department of Labor has guidance on these temporary changes:
- The stimulus legislation signed on December 27, 2020, extends the refundable payroll tax credit until March 31, 2021, but only if employers choose to offer such leave. This means that employers may elect to provide the leave, and still receive the tax credit for it, until March 31, 2021. However, employers are not required to extend FFCRA paid sick and family leave past Dec. 31, 2020.
- For employers: guidance regarding sick leave and extended family leave
- This employee rights poster can be provided to employees electronically and/or posted in employee common areas.
- The Department of Labor has an ongoing Q&A with updated information, such as who is eligible, who may be excluded, and more.
- Have your staff call high-risk patients and check on them. If they need to be seen, bring them into the office. If they have COVID symptoms, consider “parking lot” visits.
- To minimize the number of patients in your waiting room or office, consider “parking lot check-in” or “car visits”:
- Have the patients call the office when they have arrived. If the office is ready for them, they can come in and go directly to a designated exam room – or wait until the the staff member calls them back. This allows staff to clean the exam rooms between patients and eliminate the need to use (and constantly disinfect) the waiting room.
- For sick, high-risk, or non-ambulatory patients, there are some HIPAA-compliant texting apps that can be used when patients arrive for all types of appointments. ACP does not endorse products, but some examples of solutions that other practices have found to be helpful include Doctible, Jellyfish, Rhinogram, Luma Health, and UpDox.
- For patients who are new to telehealth, have your staff call them prior to the appointment to do the history, confirm medication lists, and gather other information prior to the clinician appointment. This gives a chance for the patient to “practice” using the technology (whatever that may be) before the physician conducts the actual visit.
- For check-in and check-out staff, you may need to get creative on solutions that create barriers or distancing between the patients and staff, using supplies such as plexiglass or sheets of plastic stretched across the opening, or set up a table in front of the desk to create more physical distance.
- The CDC offers guidance regarding personnel with exposure to patients with COVID-19. Practices should establish contact with state or local health departments about responsibilities of the practice vs the public health departments.
- On June 10, 2021, OSHA released new emergency temporary standards related to COVID-19 that apply to most physician offices. Here's a fact sheet, a summary, a flow sheet to determine who is covered, and FAQs.
Supplies and Infection Control
We know that access to Personal Protective Equipment (PPE) has been a huge challenge. Until supplies are able to catch up, below are some tips on where to find and how to conserve and/or maximize PPEs in your practice.
- Project N95 - ACP’s partnership with Project N95 now extends to an online marketplace with ongoing availability of vetted PPE, test kits (as available), and cleaning products. Products and pricing will vary. Project N95 can only ship to US addresses.
- The CDC has more information on optimization of PPE and guidance regarding infection control, including patient placement, staff protection, and disinfection/cleaning.
- Amazon has a COVID-19 Business Group available to access supplies reserved for front line workers. Once you have set up a business account subscription and certified that you are a medical practice with your TIN and other information, supplies will become available. It takes 3-5 days to process applications.
- It is important to contact your medical liability carrier regarding the current conditions in YOUR state because there is a good deal of variation regarding what immunity means during the COVID-19 public health emergency. Some states are more “plaintiff friendly” than others so the flexibilities offered at the federal level may or may not apply to your state.
- This 32-minute podcast by 2 medical malpractice attorneys discusses considerations about medical malpractice during the COVID 19 pandemic. Some states are adopting emergency measures that provide practitioners with additional protection, changing the standard for civil cases to 'gross negligence or willful misconduct'. But this does not mean the provider has blanket immunity from being sued at all. Lawsuits might still be filed that will need to be defended, even with this new standard (though likely fewer cases will be brought forth, because they will be much harder for plaintiffs to prevail). Because of the large costs associated with defending lawsuits, it is imperative that you are properly insured for however your practice changes in this pandemic. They also discuss considerations for retirees and volunteers, physicians who are changing the manner in which they see patients, and the importance of documenting circumstances in general.
- Consent is still important. Because cost sharing still applies in many cases, and because using telehealth is still new, it is important to seek and document verbal consent from the patient at the beginning of each remote visit. The Texas Medical Association includes many resources, but specifically has sample consent forms.