Despite the ongoing need to care for patients presenting with symptoms consistent with COVID-19, we’ve started the early steps to ramp up care again for the rest of our patients, looking to get them to come back to our practice.
We are continuing to run our cough/cold/fever clinic for the evaluation of patients with any symptoms potentially due to COVID-19, isolating them physically as much as possible from the rest of the practice.
We are also doing swabs on asymptomatic high-risk healthcare workers who’ve had workplace exposure to COVID-19 patients, as well as offering serology testing for all of the employees of our institution who’ve worked with this patient population and for whom sufficient time has passed that they may have developed antibodies.
But the rest of our patients, those with all of the things we’ve always cared for, the hypertension, diabetes, asthma, low back pain, anxiety, depression, emphysema, hypothyroidism, and all the rest, need to get back into care, and for many they’ve had pressing needs that they’ve put off out of fear of this virus, and the near complete shutdown of our city.
When a Video Visit Won’t Do
When the pandemic began, and everything started to shut down with mandatory sheltering in place, we committed to providing our patients with the best remote care we could, through telephone calls, video visits, and communication through the electronic patient portal. Like most providers operating under these conditions, we began offering patients a 3-month supply of all their medications, without the usual office visits and lab testing, in an effort to minimize trips to the pharmacy, as well as keeping them safely at home so they didn’t have to come in for a check of their HbA1c or their blood pressure.
As I described before, we are hoping to innovate new ways to manage our patients, with fewer requirements for them to come into the office, while still being able to safely manage their health conditions. I think video visits and telephone care work best with patients with whom we have a strong pre-existing relationship, when they know that we’re their doctor, when they already know that we’ve always been there for them, and we always will be. But there are lots of times where, no matter what, we’ve just got to see them in the office, when a telephone call won’t do, when a video visit won’t suffice, when we really just need to lay our eyes and hands on them.
We are offering to our providers a list of their own patients, grouped by comorbidities and acuity of need, and then letting each provider choose, based on those groupings, the patients that he or she feels are most needed to get back into on-site care after being away for so long. We are also working on new models to refine how we identify our high-risk high-need vulnerable patients, as well as a system to better anticipate the needs of all of our patients when we again, inevitably, encounter another event like the one we are even now overwhelmed by. For now, we do want to try and minimize people having to come back in, offering video visits as a first best option for almost everybody who calls up.
Changes to the Patient Workflow
As patients have called over the past week or two, or those we have actively reached out to, there has understandably been extreme anxiety over physically coming back in. I expect the no-show rate this coming week to be high. People are worried about leaving home isolation, worried about getting on the subway or buses, worried about coming anywhere near the hospital or a medical office, worried they might catch it, or worried we might tell them they have to be admitted. But for those who we decide are high risk enough that we need to get them in, or for those who insist on an in-person office visit, we are developing the processes to safely bring them into the office, have them move through our practice in a way that’s safe for them as well as for all the staff, and then quickly get them back out and home.
Before COVID-19, patients made multiple stops. Check-in. Waiting room. Vitals. Exam room. Lab. Vaccine station. Nutritionist. Referrals. Follow-up appointments. Now we want it to become In and Treat and Out — one-stop healthcare.
We’ve changed the flow in the office, with lots of stickers on the floor spaced out in 6-foot increments, and we are testing no-touch registration and ways to have screening and questionnaires administered before the visit on the phone or online. We’ve effectively cordoned off most of our waiting room, stretching tape across the chairs so that no matter what, even if someone really has to sit down, they can’t violate social distancing. Patients will be taken directly from registration into the exam room, and we’re going to perform all the functions that used to be spread out over the practice right there in that one space — moving the members of our team, not the patients.
Screening questions and medication reconciliation and initial history will take place by phone from a provider outside the room, to minimize face-to-face contact. Vital signs will be taken by the medical technician, and then the provider will come in the room for the physical exam. Personal protective equipment will be worn as appropriate to protect all parties involved. Once the provider is done, he or she will flip the room back to the technician, for an EKG and phlebotomy if needed, and then the patient will be handed off again to the nurse for vaccinations and other tasks, such as instruction in how to inject insulin or use an inhaler, or counseling on medication use.
Cutting Out the Extra Stops
Many additional stops that we used to do in person, such as with our nutritionist, our social workers, our smoking cessation team, our certified diabetes educators, or our pharmacist, will all mostly be defaulted to video visits rather than being done on the premises. And we also are trying to innovate and streamline our system for referrals. Patients used to spend an enormous amount of time waiting around our office, getting a referral for their mammogram, their colonoscopy, their dermatology consultation, as well as scheduling a follow-up appointment for their next visit. We are working to build this into the electronic medical record so that we can process the electronic part of this referral without seeing the patient, and they can do the scheduling (for the most part) on their own.
For those in need of extra assistance, such as those requiring interpreter services or those with cognitive deficits or a host of other reasons, we have a team that will focus on helping them obtain these appointments before leaving the practice. And for those urgent same-day things we need to get done, such as an x-ray or ultrasound, there’s a special place where we’re going to make sure that patients can safely wait and the staff can take care of them, and then quickly get them over to where they need to be to continue their care.
As with any sort of process like this, we’re trying to keep it simple, trying to avoid over-complicating things, trying not to create too many rules, too many exceptions, too many pathways, too many ways for things to go wrong, but we’re sure there are going to be problems. Just the other day, for example, as we tried one of these systems out, a patient described to the front reception staff what they were there for in a way that we didn’t expect or anticipate, which sent them down the wrong pathway.
As with any new system, we are going to need feedback and data from all of those involved, from our patients and our staff, to make sure we build the best new way to take care of people as we slowly rise up from under this pandemic.
And even while this is going on, and as we’re continuing to see patients coming in for care of suspected or confirmed COVID-19, we are already thinking about how to anticipate and better prepare for the next wave. Because the new normal is fast approaching, and we need to ride that wave as best we can.