Article In Brief
Neurology staff have developed new protocols to keep their patients and staff safe as their clinics—in academic and community settings—slowly reopen amid COVID-19.
While serving scores of patients via telemedicine in socially distant times, neurologists foresee the challenges of reopening their offices before the COVID-19 pandemic ends.
Many patients are requesting traditional face-to-face visits, said Brad C. Klein, MD, MBA, FAAN, chief operating officer at Abington Neurological Associates, Ltd. in Willow Grove, PA. “They feel there's more value in that in-person evaluation.”
The reasons vary. With certain neurological disorders, physician contact is critical. Even when it isn't, patients may lack a viable internet connection, computer with a camera, or smartphone. Troubleshooting the technology could be too cumbersome. Others “may not be ready to transition to this approach, do not trust it, or just feel more comfortable with an in-person visit regardless,” Dr. Klein said.
On the flip side are patients who worry about setting foot in a doctor's office during a pandemic. “The more reasonable course for most is to not come in due to the risk of exposure,” he said.
About 20 percent of patients in his group's practice declined to try telehealth visits. Despite reassurances of their reliability in follow-up assessments, mere thoughts of a video-based appointment stirred up anxiety.
That said, he added: “There's an impressive push within my community to convert to in-person visits,” he said. How to accomplish that safely is “the interesting dilemma that we're now in.”
Checklists for Reopening
Both private and university-based neurology practices are taking more infection-conscious measures as they reopen their doors, at least partially, in regions across the country. Protecting staff and patients from viral transmission will continue to be a major undertaking during the transition of some telemedicine care back to the clinic.
The AAN has developed a series of checklists as guidance for reopening—including general operations strategies, as well as considerations to account for the safety of patients and staff, scheduling, and other practice needs.
Among the recommendations, the checklist advises practices to consult with federal, state, and local guidelines regularly regarding reopening and continue to use telemedicine as appropriate.
(For the complete guidance, see the sidebar, “AAN Considerations for Reopening: A Neurology Practice Checklist.”)
The AAN acknowledged the likelihood that “subsequent waves of COVID-19 may suspend in-person visits again” and urged practices to exercise flexibility, which would entail being “prepared to close again or scale back quickly in event of a recurrence.”
Among the safety considerations for opening, for example, the AAN recommends that practices “assess and secure appropriate personal protective equipment (PPE) and other supplies.”
PPE for Staff and Patients
Procuring enough masks during the height of the pandemic presented a formidable challenge for some private and academic practices across the country. Replenishment of precious reserves became a top priority, said David A. Evans, MBA, chief executive officer of Texas Neurology in Dallas, a private practice with two physician offices and a third location housing a sleep center.
A supply of 10,000 three-layer medical masks has assuaged concerns over a potential shortage, which would affect the 16 neurology providers, who offer imaging, infusion, and electrodiagnostic services and employ a pharmacist and a social worker on staff. The practice collaborated with several sizeable neurology groups to purchase a large quantity from China, Evans said.
“There have been issues with getting long-term supplies, and initially, it was really hard to get any mask,” he said. “But now, we've got a pretty robust amount, and we're trying to maintain that inventory, not knowing if there's going to be a second or third wave” of the virus outbreak.
To ensure that every patient would have a mask upon entry, the practice's operations manager identified a few staff members who were interested in assembling cloth face coverings on site.
“Patients and providers also receive face shields before procedures, which often require close contact. Clinicians are keenly aware that a sneeze, even when largely confined to the inside of a mask, could release contagious droplets into the air, Evans said.
Guidance for Social Distancing
The practice also emphasizes the importance of maintaining ample physical space between patients. Employees screen patients before entry into the building, inquire about potential virus exposure, take temperatures, and check to ensure their masks fit properly. At higher-volume times and when patients have specific needs, Evans noted, they're instructed to wait in their cars until a text message signals it's their turn to come inside for an appointment.
There are 15 providers seeing a total of about 20 to 25 patients in the office at a time, and one clinician is working via telehealth from home while taking care of her children. The sleep center, which closed in early March to prevent the spread of COVID-19, is scheduled to re-open on August 1, Evans said.
“Our second office only has one provider, so the volumes are different,” he explained. The main office, spanning 40,000 square feet, has multiple exam rooms for separating patients from each other.
Restrictions on bringing visitors, implemented with safety in mind, have upset some patients. To avoid confrontations, the staff will no longer restrict access to anyone accompanying a patient but will continue pre-appointment notifications, requesting that each individual only bring a caregiver or a translator, if needed, Evans said.
Medical Specialists of the Palm Beaches in Atlantis, FL, which was slated to reopen June 1, intended to schedule only a few face-to-face appointments. The independent practice plans to manage the majority of new cases and follow-up visits via telemedicine “to minimize office traffic and exposure,” and walk-ins will not be accepted, said Casandra I. Mateo, MD, a neurologist and epilepsy specialist at the practice.
“We are aware of the risk for a second peak in Florida,” Dr. Mateo said, citing fears of more aggressive virus resurgence. “Therefore, we will continue to enforce strict precautions,” including the requirement that everyone wear masks.
In addition to limiting the number of procedures, the practice will continue to disallow vendors, pharmaceutical sales representatives, resident physicians, and medical students. Only companions who are deemed necessary to a patient's care will be permitted, she said.
No more than two or three physicians, nurse practitioners, and other staff can be in the office simultaneously. They will abide by alternating schedules, with the rest of the group continuing to work remotely via telemedicine, Dr. Mateo said.
“The checklist provided by AAN is very helpful and simple to follow,” she said. “We are adhering to each of the recommendations provided, with special attention to the safety considerations.”
“Certain restrictions are going to have to apply in a time of a pandemic,” said Mary L. Zupanc, MD, FAAN, FAAP, professor and division chief of pediatric neurology at the University of California, Irvine. “We all have to make collective sacrifices.”
Now more than ever, it's important for health care professionals to set an example for others to emulate. At Children's Hospital in Orange County (CHOC), CA, Dr. Zupanc, who is director of the neurology fellowship program, said there have been strict limitations on how many people can accompany or visit a sick child.
Before the pandemic, the hospital often allowed both parents, siblings, aunts, and uncles. Not anymore, said Dr. Zupanc, who is also co-medical director of the CHOC Children's Neuroscience Institute.
Only one parent can be with a child at any given time. The protocol aims to protect them and others in a setting of immunocompromised pediatric patients with serious illnesses. “Parents get it,” she said. “They understand.”
With the AAN guidelines and life in general, “we're trying to balance safety with preventing the economy from collapsing,” Dr. Zupanc said. “I weigh in on the side of public health. This can be a very dangerous virus.”
A Phased Reopening
By tracking the spread of the virus on the websites of local county and state health departments, Lori Noorollah, MD, and her colleagues at two HCA Healthcare hospital-based neurology clinics in the suburbs of Kansas City, MO, are developing plans to resume in-person care.
“Our strategy for transitioning patients back to the clinic involves phases based on the level of risk to the patients and the level of transmission within the community,” said Dr. Noorollah, a neurologist and director of sleep medicine at Centerpoint Medical Center in Independence, MO, and Menorah Medical Center in Overland Park, KS.
“We are starting to bring back patients who cannot be managed realistically via telehealth,” she added, referring to those who require a hands-on physical exam, emergent EMG, or botulinum toxin injections.
Because the clinics are located in an area that “currently falls into the mild to moderate community transmission category,” Dr. Noorollah said neurologists initially will see younger patients without high-risk medical conditions or comorbidities.
The practice will advise most patients older than age 60, or those with significant heart disease, lung disease, or immunocompromised states to wait until local transmission drops to a minimal or nonexistent level, she said. In addition, “as we bring people back to the clinic, we are working on ways to adjust the flow of traffic in order to avoid having multiple people in the waiting room at once.”
At Kaiser Permanente medical centers and offices in Washington, DC, Maryland, and Virginia, physicians and patients are using separate entrances, and, once inside, everyone must don a mask, said Ejaz A. Shamim, MD, MS, MBA, FAAN, chief of neurology for the region.
“We have taken steps to preserve our protective equipment during the pandemic,” Dr. Shamim said. Temperature screenings, hand washing, and hand sanitizer have become staples in the prevention of infections. Only one physician works in the office at a time; the rest see patients via telemedicine.
“A lot of our patients are very happy with the virtual visits,” he said, explaining that due to virus concerns, “some patients are afraid to come into the clinic if they don't have to.”
Slowly Ramping Up to Full Volume
In some cases, patients who felt they were stable in their disease states opted out of telehealth services and preferred to wait for the clinic to resume routine operations, said Jamie L. Friede, MBA, administrator for the department of neurology at Stony Brook University's Renaissance School of Medicine in Stony Brook, NY.
Before the pandemic, the department was averaging more than 800 patients in the clinic per week. It has maintained about 60 percent of that volume, with the majority of visits shifting to telemedicine, Friede said.
“We are not at full in-office volume yet,” she said in early June. With expectations of ramping up to full in-person capacity by the middle of the month, the department planned to accommodate the influx of patients while continuing to assess if providers need to work additional hours.
Numerous precautions have been implemented with social distancing in mind. A multi-pronged approach includes the installation of plexiglass at the front desk, ongoing cleaning throughout the day, and removal of shared water coolers and coffee machines, Friede said.
Minimizing Time In the Clinic
Minimizing the amount of time patients spend inside the clinic also helps prevent infections, said David Greer, MD, FAAN, FANA, chief of neurology at Boston Medical Center and professor and chair of neurology at Boston University School of Medicine
As part of what Dr. Greer called a “hybrid visit,” a patient's history can be obtained in advance of the clinic appointment. “All they're coming in for right now is a brief physical examination,” he said. “Then we can do a wrap-up phone call later on.”
Dr. Greer said a combination of telemedicine and in-person care will continue into the foreseeable future. Under the circumstances, it's the safest way to treat patients with neurological disorders at an academic medical center grappling with an unpredictable caseload of COVID-19.
Masks and face shields for providers have become the new normal. Everyone else, including patients and visitors, must wear masks, too. Some restrooms have been designated for patients, others for staff only. Five minutes prior to an appointment time, patients are allowed in the waiting room, where social distancing is being enforced by placing red tape on chairs that are off limits, Dr. Greer said.
“Our hospital was really hit very hard, given that we take care of an underserved population,” he explained. “At one point, 70 percent of hospital was COVID-positive patients, so we were really hammered, but neurology had to go on.”
Seeking Parity for Telehealth
The decision to fully reopen will hinge partly on how long the Centers for Medicare and Medicaid Services (CMS) and commercial insurers allow pay parity for telehealth visits.
“We can't stay in business offering services without receiving fair compensation,” said Bruce H. Cohen, MD, FAAN, professor of pediatrics and integrative medical sciences at Northeast Ohio Medical University and director of the Neurodevelopmental Science Center at Akron Children's Hospital in Akron, OH.
Furthermore, CMS is waiving state licensure requirements for telehealth services, which enables clinicians to provide care for patients in states other than where their offices are based. With Akron Children's Hospital's proximity to the borders of Michigan, Kentucky, and Pennsylvania, patients often venture outside of their state to receive care, Dr. Cohen said.
For telemedicine in the current environment, “the payment is the same as face to face,” he said. “A lot of the regulatory burdens have been pushed by the wayside as well.”
Continued pay parity for telehealth visits is also an important consideration for Dr. Klein. In early May, when he and his colleagues reopened their office in Pennsylvania, “we dipped our toes in the water” with botulinum toxin injections and a few other nonurgent cases, he said. Later in the month, he noted, the practice of 10 neurologists and two advanced practice providers was operating at “full throttle.”
Meanwhile, their contract to provide inpatient neurology care at Abington Hospital in Abington, PA, has remained in force throughout the COVID-19 pandemic—and they are holding steadfast to that commitment.
“When asked to answer that call, I'm there to help because the community needs neurological care,” Dr. Klein said. “That's what we signed up for in medicine—to take care of people. Regardless of the diseases they deal with, it's our job to figure out a way to help them through it. It's just the oath we took, and to the best of our abilities, we're going to do it.”
AAN Considerations for Reopening: A Neurology Practice Checklist
The AAN developed this guidance for neurology providers and their practices as they navigate the reopening of neurology practices and plan to expand in-person visits and services amid COVID-19. The checklist is offered as a general resource and may vary depending on different practice settings and locations. Practices should consult and continue to monitor guidelines and recommendations issued by federal agencies and state and local municipalities to ensure your practice is complying with regulations for reopening. Practices should seek the advice of local counsel and not construe the following to be legal advice. Visit the AAN COVID-19 Resource Center, https://bit.ly/AAN-COVID19, for up-to-date information and email [email protected] with questions.
GENERAL OPERATIONS STRATEGIES
- Remain flexible and strategic
- Consult with federal, state, and local guidance regularly
- Evaluate your local situation and data before reopening
- Open your neurology practice gradually
- Continue practicing telemedicine as appropriate
- Update your professional liability carrier of your reopening o Develop a plan to prepare for and manage future closings
- Assess and secure appropriate personal protective equipment (PPE) and other supplies
- Develop practice protocol for sanitizing patient rooms and common areas
- Minimize contact and maintain physical distance to the extent possible
- Require face masks for all staff, patients, and visitors
- Limit visitors except for patients requiring a parent or caretaker to be present
- Request that patients check in via phone or text and wait until exam room is ready before entering the facility
- Offer hand sanitizer and/or hand washing station for patients and visitors upon entering the facility
- Remove shared items such as magazines, toys, coffee machine, etc. and space chairs to allow social distancing in waiting room
- Establish patient flow so that patients enter and leave through different doors, avoiding passing through common areas more than necessary
- Laminate paper signage for regular cleaning
- Install plexiglass barriers between staff and patients
- Ensure practice supplies including medications are available and safe for use
- Consult with building management on safety guidelines for tenants if leasing practice space
- Develop staff policies for returning to work
- Implement quarantine and sick leave protocols for clinical and support staff
- Maintain HIPAA compliance if instituting a regular staff health or temperature screening
- Consider using a daily survey to track staff symptoms
- Comply with federal guidance if a staff member contracts COVID-19
- Discuss changes to provider and support staff ability to return to work
- Establish frequent and open communication with staff
- Develop a system to determine which patients should be seen in person versus via telemedicine, based on community and patient risk factors
- Implement pre-visit screening for in-person patient appointments
- Assess how scheduling of procedures will affect practice PPE, sanitization, and maximal scheduling capacity
- Extend practice hours to include early morning, evening, and weekend hours to accommodate safety and cleaning protocols and maintain overall patient volumes
- Notify patients that the practice is open for in-person visits
- Develop a plan for patients who are uninsured or previously insured o Discuss safety and care plans with patients
- Maintain detailed documentation for all patients