LIFE IN A PRIMARY CARE PRACTICE DURING THE COVID-19 PANDEMIC - 7 WEEKS

The last 7 weeks we have been following a small, independent primary care clinic, located in Colorado Springs, Colorado. They have shared with us the struggles and celebrations during these weeks.

Week 7 - Status on May 29. 2020

Generally, feels like we’re almost “back to normal”. 

We are seeing 80% of usual schedule; 20% of those visits are virtual, we continue to make slow progress. We will continue our telephone outreach to high risk patients and those with gaps in care.

Throughout this intense period, we communicated how to access care using a number of methods; text messages, emails, our website, Facebook and Instagram. Despite these efforts, during our outreach, we were surprised by the number of patients that thought we were closed.  Analyses of the data identified the sub-population; Medicare patients over age 65. In the future, mass patient communication methods will include US Postal Service for the Medicare over age 65 subpopulation. 

In April, we canceled our quarterly Patient Family Advisory Group Meeting. We plan to reschedule soon using a virtual platform. 

As I reflect on the last two and a half months, I realized the following.

Accomplishments

• Provided comprehensive care to our patients.
• Successfully implemented Telemedicine services.
• Maintained our current team; no resignations or permanent layoffs.

Grateful

• That we have a strong, dedicated team, committed to our mission
• That we received the PPP funds and things look promising for the forgiveness program
• That we are members of a strong ACO that helped us obtain PPE when we couldn’t find any on our own
• That we have a major payer that is providing an additional $100 incentive for annual wellness visits.
• That we have prepared for another “wave” of the pandemic; higher levels of PPE, Telemedicine sustained, protocols and policies in place. 
• That we are active members of various professional/industry organizations that can advocate for what we need.

What we need
Permanent changes to policies regulating telemedicine; eliminating the requirement that the patient location (originating site) must be a physician’s office, allowing patients to be located in any setting during the visit, including home and not just rural areas.  We also need for reimbursement to remain at or similar to current levels. Continued recognition and support of the important role that Primary Care plays in our health!
 

Week 6 - Status on May 19, 2020
Good News (Accomplishments) 
It’s been a good week, it’s nice to reflect on the week and see a number of positives.  We are thankful that we offer inhouse labs. I’ve heard colleagues mention the challenge of convincing patients (and their families) that it is safe to go to the lab for necessary draws. Since we offer inhouse phlebotomy patients feel safe. Our outreach is working, we scheduled 37 annual wellness visits in the last week! We are starting to see a decrease in care gaps. We plan to continue with our current level of telemedicine services. We completed our detailed cost/benefit analysis for telemedicine we now offer those alternative appointments as part of our regular service line. Things have settled down enough that I feel comfortable enough to go on vacation for a few days. I am modeling a little self-care for my teammates.

Team Care (Self-Care/Support)
Daily, I individually round with each team member. This allows me to check-in with each individual team member to provide additional support and encouragement as needed.

Top Priority
PPE supplies are getting a little low. We are searching suppliers to get levels back to par. This was a lesson learned earlier in the pandemic, so we monitor this very closely. We still continue to work on patient outreach to close gaps in care, improve our eCQMs and get our schedule back to normal.

What we need
Permanent changes to policies regulating telemedicine; eliminating the requirement that the patient location (originating site) must be a physician’s office, allowing patients to be located in any setting during the visit, including home and not just rural areas. We also need for reimbursement to remain at or similar to current levels. 

Week 5 - Status on May 14, 2020
Good News (Accomplishments) 
Between in person visits and telemedicine we are at 75% of our usual visits. Three fourths of the visits are in person, the balance is telemedicine. No significant change in the number of audio only visits, but it’s great to have that flexibility for those patients who need that option. After lively discussion about the future of telehealth services at our clinic, we achieved consensus on a vision for telemedicine. This depends on some permanent policy changes, but we are hopeful they will be a reality soon. Had our kickoff meeting for the Innovation Support Project (ISP).  It’s nice to be getting back to normal and working on a new project.

Team Care (Self-Care/Support)
Yesterday, we closed the office a little early and hosted a Team Appreciation “Happy Hour”. We provided snacks and sweets for everyone to enjoy. It was our way showing our appreciation of their flexibility, dedication and commitment, especially during these difficult times. Everyone had a good time and enjoyed spending a little special time together. 

Top Priority
Continue patient outreach to close gaps in care and get our schedule back to normal. Complete a detailed cost/benefit analysis for telemedicine. Currently, we are using a complimentary platform available from our ACO. This benefit ends soon. We need to investigate our options and select what makes the best sense for us.  

What we need
Permanent changes to policies regulating telemedicine; eliminating the requirement that the patient location (originating site) must be a physician’s office, allowing patients to be located in any setting during the visit, including home and not just rural areas. We also need for reimbursement to remain at or similar to current levels. 

Week 4 - Status on May 6, 2020
Another busy week, but it feels much better. We’re seeing results of our hard work!

Good News (Accomplishments) 
Received our Paycheck Protection Program (PPP) Loan! Starting today all staff are back to regular schedules!! Thanks to additional changes in Telemedicine regulations; we started offering audio only visits for our patients with no video option. Although this is not a large number of patients, they are some of our highest risk patients and need very close monitoring. This is a great option for care until we can safely see them in the office again. We completed our portion of the process to receive Medicare Accelerated and Advanced Payments (part of CARES 3.5).

Team Care (Self-Care/Support)
This past weekend we held an emergency virtual all staff meeting. We shared the news about the PPP  loan and our plans to return to regular schedules. Although this happened during their weekend, the team appreciated hearing this news asap. I think it also built more trust and credibility with them. We continue to show commitment to good communication and transparency. 

Top Priority
Although we never stopped seeing patients and have quickly implemented Telemedicine, our volume is at 60%. Our top priority is to scrub our panels; identify patients with care gaps and close them.

What we need to do  
First, develop the workflows to support and provide the necessary accounting documentation to improve the likelihood that our PPP Loan will actually be a grant. Second, determine the role of telemedicine in our practice. We need to evaluate our current process and strategize our next steps; what do we keep, expand and how do we sustain theses services.

Week 2 and 3 - Status on April 28, 2020
My challenge writing this blog parallels my everyday challenge. By the time I get something done, things have changed so much, I need to re-do it, or it no longer seems relevant. Since my first post we needed to furlough all staff to a 3-day work week. We delayed this change as long as possible and hope it will not last for long.

Good News (Accomplishments) 
We avoided a permanent re-organization and staff layoff. Our team understands the necessary actions and are committed to working through this rough spot and “getting back to normal”! No one has resigned.

Team Care (Self-Care/Support)
At this point, we cannot over communicate with our team. Frequent, transparent, direct communication is our best practice of self-care. We continue to have daily huddles to help the day run smoothly and provide focus and accountability for our short-term goals. Additionally, I round with each employee individually on days they are scheduled to work. This check in provides private time to ensure team members feel individually supported, have another opportunity to ask any questions or make suggestions. These individual meetings also provide transparent progress updates on returning to the regular schedule. I feel it’s important that I initiate this outreach, it  demonstrates caring, shared problem solving and accountability. 

Top Priority
We continue to pursue different opportunities for financial support. Unfortunately, the PPP loan, ran out of funds prior to us receiving the loan. The best we can do is be prepared in case the Small Business Administration (SBA) releases more funds.

Last week we initiated the process to receive the Medicare Accelerated and Advanced payments. Again, things change rapidly, with the passage of the “CARES Act 3.5” as April 26, they are no longer accepting applications for this option. Here is the latest link:
https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf

What we need to do  
First, is to outline our plan to re-engage with our patients as we slowly move to implement our “Safer at Home Colorado” plan. Second, determine the role of telemedicine in our practice. We need to evaluate our current process and strategize our next steps; what do we keep, expand and how do we sustain theses services.

Week 1 - Status on April 15, 2020
Good News (Accomplishments) 
At this point telemedicine is running like a well-oiled machine. We are using Updox as our telemedicine platform. Telemedicine visits are designated with a color that really stands out in the schedule. Heidi (our admin. assistant) goes through the schedule and sends consents to the patients.  She makes sure we receive all consents back prior to the visit time. This is documented in the schedule so that all staff and providers can easily see that the visits are ready. Everything is in place for when the provider calls the patient. Currently about 40% of our visits are telemedicine visits. 

Team Care (Self-Care/Support)
Right now, one of our biggest self-care priorities is to support staff members, who are also parents and trying to help their children with distance learning. Each provider has a designated admin day, where they normally go over labs, radiology reports and get paperwork done. Since we are only seeing about 55% of our regular patients, the admin day is not needed currently. Providers are taking these days off. Support staff has the option to take the time off as well to help their kids with distance learning. Our staff has found that this really helps with the stress level. The staff members without kids have been offered a day off as well just for their mental health. This is optional and only if people want this time off. We are trying our best to keep everyone working the hours they need in order to be able continue their lifestyle. 

Top Priority
Our top Priority this week is the Paycheck Protection Program (PPP)loan. We started the process on April 4th and have completed the first 4 steps. We are hoping we get the final documents for signing this week. This has definitely been a process! 

What we need  
We are using telemedicine and that has helped increase our patient visits, but we are only about 55% of our usual volume. Our goal is to make sure we are reaching out to our highest risk population and chronic care patients to get telemedicine visits set up. These are patients, who we want to keep out of the hospital and Emergency Departments (EDs) during this time. By staying in touch and making sure they have all their medications and good care plans in place, we can help keep them safe and healthy. This week we need to create a good process to meet this goal.