What does Governor Polis’ Safer-At-Home order mean for my practice and elective surgeries?
Governor Polis announced the next stage of Colorado’s response to the pandemic on 4/20/20, issuing a Safer-At-Home phase when the statewide Stay-At-Home order expired on April 26. Medical practices were already considered essential businesses under the Stay-At-Home order, however, elective surgeries and procedures were postponed. Beginning April 27th, elective surgeries will be allowed to continue with strict guidelines in place to preserve the health and safety of providers and patients. Practices are asked to consider factors such as PPE availability before rescheduling surgeries and procedures.
PERSONAL PROTECTIVE EQUIPMENT
Where can I get PPE? The Colorado Department of Public Health & Environment has acknowledged the current shortage of PPE across the state and alerted physicians to expect continued, perhaps more severe shortages in the future until supply chains come back online. With limited supplies, it is recommended that practices contact their local health department and emergency operations centers to obtain PPE.
How can I best use the PPE supply I have?
In efforts to spare PPE, the CDC recommends that physicians consider selectively cancelling elective and non-urgent procedures and appointments. Specific PPE optimization guidance from the CDC includes:
Eye Protection: Shift eye protection from disposable options to reusable options such as goggles and face shields. For both options, extend use by wearing the same eye protection with multiple patients, without touching or removing the protection in between.
Isolation Gowns: Use alternatives that offer equivalent or higher protections, such as fluid-resistant and impermeable protective clothing where possible. Non-sterile, disposable patient isolation gowns are appropriate for use by HCPs who are caring for patients with suspected or confirmed COVID-19. In critical shortages, gowns should be prioritized for activities where splashes and sprays are anticipated, and/or when performing high-contact patient care.
Face Masks: Remove face masks for visitors in public areas. Extend use of facemarks by wearing the same mask with several different patients, without touching or removing the mask in between. Have patients with respiratory infection use tissues or other barriers to cover their mouth and nose.
N95 Respirators: Isolate patients with respiratory infection and utilize physical barriers and properly maintained ventilation systems when possible. Use N95 respirators only for HCP who need protection from both airborne and fluid hazards. Use alternatives where feasible such as elastomeric respirators with filters, powered air purifying respirators, or other disposable, filtering respirators.
Who should I prioritize for testing?
The CDC has issued updated priority levels for COVID-19 testing, identifying those that need test results to return to work or inform their clinical treatment as the highest priority:
- Priority 1: hospitalized patients and health care facility workers with symptoms;
- Priority 2: symptomatic patients in long-term facilities, patients 65 years or older, patients with underlying medical conditions, and first responders;
- Priority 3: all others who are symptomatic.
Where should I send patients for testing?
Testing is available through the state and at some commercial laboratories. Health care providers who want to order COVID-19 testing at CDPHE lab should use LabOnline to submit specimens and access results. Specimens with incomplete information will be delayed. This LabCorp Fact Sheet illustrates proper collection and handling of specimens for COVID-19 Testing.
For patients who do not require hospitalization, what information should I provide regarding self-isolation?
For all other suspected COVID-19 infections, recommend self-isolation at home when possible and provide them with the CDC’s Interim Guidance For Preventing COVID-19 From Spreading to Others in Homes and Communities. Patients should isolate for at least 7 days and before ending isolation should be fever free for 3 days with symptoms rapidly improving.
What do I need to know about how to implement telehealth in my practice? Have telehealth rules been loosened during the COVID-19 pandemic?
Physicians looking to implement telehealth should check out the AMA quick guide to telemedicine in practice.
Federal government has stated that they will not enforce penalties for noncompliance with the regulatory requirements under the HIPAA in connection with the good faith provision of telehealth (eg. through use of video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype) during the COVID-19 nationwide public health emergency. Physicians are encouraged, but not required, to notify patients of the potential security risks of using these services and to seek additional privacy protections by entering into HIPAA business associate agreement.
For the duration of the COVID-19 Public Health Emergency, Medicare will now pay for telehealth services provided to beneficiaries "in any healthcare facility and in their home" and won't enforce the established-relationship rule. Please see this CMS fact sheet for more information.
Throughout the COVID-19 state of emergency, Health First Colorado (Colorado’s Medicaid Program) is temporarily expanding its telemedicine policy to expand definition to include telephone, video, and live chat modalities, authorizing telemedicine visits in FQHCs, RHCs and Indian Health Service clinics, and adding PT/OT, home health, hospice and pediatric behavioral therapy as eligible services.
Commercial plans regulated by the state
The Colorado Division of Insurance (DOI) is requiring insurance companies to expand education about telehealth availability, and take specific steps regarding prescription refills and cost-sharing. Colorado commercial health plans are already required to reimburse telehealth at the same level as equivalent in-person services. DOI has directed insurance companies to provide COVID-19-related telehealth services with no cost-sharing, including co-pays, deductibles, and coinsurance that would normally apply to the telehealth visit.
CMS’ fact sheet on the DOI’s Telehealth emergency regulation
It’s becoming hard to practice given workforce shortages. What should I do if I or one of my team is exposed or is suspected of being exposed to COVID-19?
For those HCPs that are exposed by a confirmed case, current guidance is to quarantine at home for 10 days. HCPs that treat an unconfirmed exposure, depending on risk, should seek confirmation by testing, monitor themselves for symptoms and if no results within 72 hrs follow work restrictions. Given the assumed level of community spread CDC guidance (from 3/7/20) recognizes potential workforce shortages and details risk exposure categories and related recommendations.
I/members of my team were in the mountains last weekend and now don’t know when to come back to work based on the quarantine guidance from Gov. Polis. When can we resume work?
The guidance stands. However, in situations where other options to address staffing shortages have been exhausted, CDPHE recommends risk assessment/mitigation discussion within practice leadership, specifically considering level of mountain community exposure (e.g. time in confined restaurant or gondola) execute a 7-day quarantine, with return to work using masks to mitigate, active monitoring and immediate isolation with symptom onset.
I’m a retired physician or healthcare worker and I’d like to help. How can I get involved?
Volunteers are invaluable as Colorado works to address this crisis. Consider Colorado Volunteer Mobilizer for Medical and Public Health Professionals (CVM). The Governor has established Help Colorado Now to coordinate efforts. You can learn more about areas of need and sign up there.
The Department of Regulatory Agencies is expediting licensing to increase the workforce capacity and waiving certain restrictions to allow for late renewals, reinstatements, and reactivations. Their complete list of emergency measures can be found here.
When considering whether to volunteer, please be aware of the CDC guidelines around high-risk populations and exposure to the virus.
Check out the state’s COVID-19 Colorado Case Summary
Please join the Coronavirus (COVID-19) CMS-member physician discussion board on Basecamp
***The practice of medicine is highly regulated. While the Colorado Medical Society does not provide legal advice to its members, we provide general resources on common legal and regulatory questions. If you need legal advice, please consult a private attorney.