AMGA Quality Council: COVID-19: Response at the Epicenter
March 27, 2020
This summary is based on a presentation and discussion of AMGA’s Quality Council on March 23, 2020. For more information about the Quality Council, please click here.
Speakers: Ashish Parikh, M.D., Senior Vice President of Medical Affairs and Quality, Summit Medical Group - CityMD, Berkeley Heights, NJ; and Scott Hines, M.D., Chief Quality Officer, Crystal Run Healthcare, Middletown, NY
Ashish Parikh: Summit Medical Group – City MD is a large multispecialty group in New Jersey just outside Manhattan with more than 800 physicians. Last fall, we joined forces with CityMD, which has about 120 urgent care centers in North New Jersey and New York. Both Scott Hines’ group, Crystal Run Healthcare, and our group are in the epicenter of COVID-19. We evolved over the last three weeks from being in a sporadic case zone to going to full-on outbreak.
Essentially, about three weeks ago, we started by thinking of what could happen. So we started canceling all elective visits and procedures for those highest risk patients who are 60 + with chronic conditions, over 80, and/or have immunocompromised conditions. We started increasing our urgent care staffing because we thought there may be an increase there.
By the following week, we had more and more cases in the community, so we tried to switch everything we could to televisits. On March 17, the rule changes allowed for expansion of telemedicine and helped us out. We pretty much started moving everything that we could, not just those at higher risk, to televisits to keep our office safe for those who do need to come in for procedures or urgent issues that were not COVID related.
On the COVID side, we started screening everyone coming into our buildings, and anyone who had symptoms of COVID we transferred over to our urgent care so that we could keep our offices infection free for routine care and non-COVID visits.
By the third week, there was significant community spread and our hospital systems were getting overwhelmed. We are pretty close to max capacity in northern New Jersey, and in Queens, I think, many of them are beyond capacity. We have had hospitals set up multiple ICUs, CCUs, etc. into COVID units and many regular floors are turning into isolation units. Our clinic has turned into a multispecialty outpatient group to try and support health care by keeping as many patients out of hospitals and EDs as possible.
On the office side, we are essentially trying to see anyone who is calling us for routine care, urgent visits, or any other questions through virtual care. Not just Summit Medical Group patients, but patients from the community whose providers may not be able to see them. On the urgent care side, we are seeing surges and are trying to put out signs for anyone who is willing to move to a telemedicine visit. The prevalence is so high at this point that we are making presumptive diagnoses and we are not testing anyone at this point unless they are very high risk or they are frontline healthcare workers who need to get back to giving care.
We are trying to manage asymptomatic and mildly symptomatic patients at home as much as possible without sending them to ED. We are trying to make sure we manage all chronic condition patients virtually so they don’t end up with exacerbations, answer questions about any chronic medicine, and make sure we address all these issues so we can keep them healthy.
We try to come up with a silver lining every day in our emergency management calls and our messages to our staff and providers. A couple things we have noticed, as I’m sure you all have, are teamwork and some heroes in all of our staff and providers, as well as people in the community who are donating money or are willing to come in and bring food in for our staff, etc.
We have been testing telehealth for two years, and this really gave us the push we needed to get this off the ground. So when this outbreak is over, hopefully it will help us with a full robust telemedicine strategy.
Scott Hines: I’m an endocrinologist and the chief quality officer at Crystal Run Healthcare. We are located in Sullivan County about one hour and 15 minutes outside of New York City. In February, our Chief Medical Officer asked to use one of our executive team meetings to talk about this coronavirus thing that was going on in China. He had concerns that it may spread and if it did, it could have devastating effects on not only our patients but on the financial health of healthcare organizations. That was hugely beneficial because we got over the “holy crap” stage pretty early.
We got to thinking about what the worst case scenario could be, and as things developed over the last month or so, we on the executive team have been a bit ahead of the curve compared to the other managers in the organization. That allowed us to focus more on executing plans in advance as opposed to being reactive. We looked at this in three phases: Phase one was the initial outpatient phase; phase two, where we are now, is the smoldering inpatient phase that is getting ready to surge; and phase three is the chronic phase.
In the initial phase, there are two things worth mentioning. One was we quickly converted one of our smaller sites into a COVID testing site. Initially the plan was to do that indoors, but then as we started to do the math and the terminal cleaning involved in having to clean the rooms and let them sit for two hours after a suspected case, we quickly realized we had to move this outside. So we bought a lot of tents, bought a lot of hotspots so the computers could be outside, and had providers and nurses outside doing testing in many cases in patients’ cars.
This was not drive-by testing, this was symptomatic triage. If you had symptoms, you would come and be evaluated, and as you all know, every day the recommendations changed. On the first day, we were doing flu and then only testing COVID if the flu was negative. But as time went on, we stopped testing for flu and tested for COVID. This allowed for us to see patients, not just test them. It allowed providers to see patients a lot of times in their cars. We’re still doing this and we have expanded to every one of our buildings that have urgent care. We have a pop-up area for COVID evaluations outside, with the urgent cares inside the buildings designated as well locations. We triage all symptomatic patients over to testing sites and all well patients in the buildings. We have screeners at the door who are asking the usual questions, and if the patient answers yes to any questions, they are being shunted over to a different part of the building.
The second thing in phase one was getting telehealth up and running. As Ashish mentioned, we looked at telehealth about five-to-six years ago and the market just wasn’t ready for it, so it has been kind of collecting dust. Last week, we really launched this practice-wide. There has been a lot of attention paid to getting the providers comfortable with it and developing workflows, as well as getting the patients comfortable with it. I think it helps that New York State passed an executive order saying that copays for all state insurance would be waived for all telehealth visits. We started the middle of last week with about 150 visits per day, and yesterday we saw about 1,000 visits per day. The goal is to get to 2,000 visits per day by next week.
Phase two is the inpatient surge. We thought we were a little ahead of the curve on this, and I think we are just about there. We have been planning for this since the middle of last week, meeting first with our intensivists to have them available for hospitals if and when they need them. We got our first call from a hospital today about needing intensivists to come in and start pitching in there. On the non-pulmonary side, our CEO a couple days ago did a practice-wide video appeal to all our providers as a sort of call to arms for folks to raise their hand and be available to help out in the hospital.
We have to realize that the way medicine has evolved over the last couple of years, there are inpatient people and outpatient people, and most of our docs are outpatient people. So it is going to be a heavy lift to get them involved in a hospital, but anything they can do would be much appreciated. It would probably be along the lines of a fellow intern kind of relationship, with a hospitalist heading up the team and folks like me, who have not been in the hospital in a long time, as sort of their intern to help out in any way we can. I think our CEO or CMO said they are pulling medical examiners from insurance companies and asking them to go to the hospitals and taking docs out of retirement and asking them to go to the hospitals, so we at least have as much to offer as they do.
Phase three remains to be seen. There has been a lot written about the inpatient impact on both the healthcare system and the financial stability of organizations after this is over. I think there are a lot of questions to be answered, the biggest of which is will these waivers for telehealth be maintained after this is over? I think patients are getting used to it and starting to like it and see the advantage of it. If the waivers are removed and old rules applied, it will be really disappointing for people who have put a lot of time and effort into getting telehealth up and running.
That then begs the question of how do you right-size your staff? Your space and size needs may be very different. What will be the long-term impact of social distancing on patients? Will patients be afraid to come to the office in the future because even if COVID calms down, what is next? Should I be out or should I do as much stuff from home as possible? What about home visits, drive-through lab draws, etc.?
Question: If an employee at your organization tests positive for COVID-19? Are you tracing back their close contacts at all? If you are, are you tracing back five days or fewer or more?
Hines: We are tracing back for five days. We are tracing back to see, but the current recommendation is if you are a healthcare provider and you are exposed but you are asymptomatic, you can work wearing a mask. Whereas in New York State now, anybody who is patient facing has to wear a mask. You monitor twice a day for fever, and if you have a fever, then you go on home to quarantine and are presumed positive.
Parikh: In areas where you are not as hard hit, it’s great to start early. We started early to ask all providers to wear masks in all areas, and that has really helped us in terms of not getting a lot of exposure and people out on self-quarantine. In areas where you maybe aren’t as hard hit, I would strongly recommend you start wearing masks wherever there is patient care involved. If you’re handling patients’ stuff, such as insurance cards, you should be wearing gloves. That will really help you retrospectively. We added a note in our chart of whether or not the patient and provider were wearing masks and gloves. This helps when you go back and try to find exposures. As of right now, we are at the point where we aren’t even doing trace backs the last day or two because there is so much exposure.
Question: How are you managing inventory and PPE?
Parikh: About three to four weeks ago, we ramped up our procurement so we have been a bit ahead of the game. We quickly started moving patients out of the office and to virtual visits. So, we are actually down 90% in terms of visits. We usually average about 11,000 to 12,000 visits a day and we are down to about 1,200 visits a day, so that has helped conserve PPE for our urgent cares, where they are seeing the high-risk patients. We are in a lucky position where we are actually able to support some of our hospitals with some additional PPE. We did do a lot of conservation of PPE in terms of educating people on maximizing the life of their masks, particularly the N95 masks, so they can use them as long as possible.
Hines: We are very similar here. That was the main reason why we decided to significantly limit and eventually stop doing elective visits.
Question: How many virtual visits are you doing per day and per week?
Hines: We are up to almost 1,000 per day, and our goal is 2,000 a day by end of next week.
Parikh: We were at about 3,200 last week, and it is going up significantly every day. I think we will probably hit 4,000 visits today.
Question: Has your group enacted any specific protection to your doctors who are at or above 60 or 65 years old to reduce the risk to COVID-19?
Parikh: We did give an option to not just only physicians but to every staff member who is over 60, has chronic conditions, or is pregnant to have the option to work from home wherever we could possibly allow for that in their job position. Not just clinical but non-clinical too.
Hines: As of right now, if providers or staff have a note from their physician saying they need to be not physically on site, we are honoring that. We are trying to move as many visits over to telehealth, so many of our docs are still coming to the office, but they may only be seeing a handful of patients in person and the rest via telehealth. We have been spacing people out much more than usual; using exam rooms as offices. In New York in the process of being passed is Matilda’s Law, which allows folks who are older to work from home. We have been moving more and more toward that as there is some more clarity around that executive action.
Question: Are you actively reaching out to patients who have chronic conditions to use a virtual visit?
Hines: Yes, we are trying to flip as many patients as we can from actual visits to virtual visits. Our staff who is doing that is non-clinical, so what we have been telling them is to flip as many of the visits as they can. Then the clinical teams at the beginning of the day are looking through what are the telehealth visits for the day, and if somebody whom a provider feels they need to actually see because there is something in the exam that would affect their care, then they call that patient and try to arrange for them to come in at a time that is mutually convenient.
Parikh: We are doing something very similar. Basically everyone’s schedule is being converted to telehealth right now and then the clinical staff can pick and choose ones who absolutely do need to come in. For the clinical staff in the office, we have had to combine sites due to the decrease in volume, so there is only about one out of four clinical teams that are in during the day and the rest are doing virtual.
Question: How are you addressing compensation from the COVID-19 perspective?
Hines: It is a little premature to give details. Our board has reached a decision, but it has not been publically shared yet. We plan on doing that over the weekend, but it is safe to say that our goal is to protect our non-provider employees as much as possible and really try hard not to have their compensation impacted at all and have the brunt of the impact be on the member physicians. We are an independent group that is physician owned, so the 40 or so owning physicians would take the brunt of the impact and our employed physicians would take a modest cut in their pay. The executive team and board felt it was important to try and protect our non-provider staff during this difficult time.
Parikh: We are taking a similar stance, and any of the cuts have not been finalized. As Scott says, you get into this chronic phase and how can you increase revenue by expanding hours or working seven days a week and try to look past the crisis to see how later in the year we can make up for some of these loses.
Question: What are you doing for staff wellness and to protect against burnout?
Parikh: The one thing that staff really values is feeling like they are protected. Early on, we put screeners at the front door and messages out on our webpages to try and limit the amount of people we have coming into the offices. We tried to distribute PPE to the offices so they had it and could use it if needed. So that really helps them feel like the risk is minimized. Once the virtual visits were up and running, we tried to reduce staff hours, and that helps protect against burnout. Here in northern New Jersey, where it is widespread, we have a lot of anxiety from staff members who find out three days later a fellow staff member did turn out to be positive, so we’re working very hard to manage that. For areas that aren’t as widespread as this, try to early on protect the staff and get them the PPE. It will make a big difference down the road.
Hines: I would say the most important thing for folks not in the thick of it is there is no such thing as over communicating. Let your staff know what you are doing, what steps are being taking, what is going on in the community, and what wellness programs you have in the organization. One of the things we have been getting ready to launch is having LCSW and our behavioral health department virtually do some meditation and some wellness sessions for our staff. Think now about what support systems you need to put into place. It’s never too early to start communicating to staff.