In conjunction with the federal government’s Guidelines for Opening Up America, on April 19, 2020 the Centers for Medicare & Medicaid Services (CMS) issued voluntary recommendations for healthcare facilities in regions with low incidence of COVID-19 to resume essential in-person care. This guidance, the first in a series of recommendations expected from CMS, applies to healthcare facilities in regions of the county that are qualified to open under Phase 1 of the federal government’s three-phase plan. States are eligible to proceed to Phase 1 if they meet the following criteria:
- Downward trajectory of influenza-like illnesses and COVID-like syndromic cases reported within a 14-day period;
- Downward trajectory of documented cases or of positive tests as a percentage of total tests in a 14-day period; and
- Hospitals able to treat patients without crisis care and a robust testing program in place for at-risk healthcare workers (including emerging antibody testing).
CMS’s guidance includes general guidelines for healthcare facilities to consider before proceeding with elective surgeries or procedures. CMS recommends that healthcare facilities evaluate the incidence and trends for COVID-19 in the area being considered. CMS also requires that, in deciding what procedures to perform, the facility evaluate the necessity of the care based on clinical needs. Facilities should prioritize surgical/procedural care and highly complex chronic disease management. However, CMS notes that certain forms of select preventive services (e.g., mammograms) might also be necessary. Facilities resuming in-person care should also establish Non-COVID Care (NCC) zones in which patients and staff can be screened. If possible, these areas should be as separate from other facilities as possible (e.g., separate buildings or floors). These NCC facilities will be required to screen all potential patients for potential symptoms of COVID-19 prior to entering. Additionally, NCC facilities should have steps in place to reduce the risk of COVID-19 exposure or transmission.
Although these recommendations are aimed at healthcare facilities, CMS makes it clear that decisions about non-COVID-19 care remain in the hands of state and local officials and cannot be made in a vacuum by an individual facility. Rather, such decisions require consideration of, and coordination with, the local healthcare delivery system as to the needs and resources of the region. The guidelines state that “in analyzing the risk and benefit of any planned procedure, not only must the clinical situation be evaluated, but resource conservation must also be considered.” As a result, factors such as the number of current and projected COVID-19 cases in the region, availability of PPE, staffing and bed availability (especially in the ICU), and ventilator availability must be considered. CMS also specifies that facilities should continually evaluate and monitor their region and be prepared to cease non-essential procedures in the event there is a surge in incidence of COVID-19.
The American Hospital Association (AHA) issued a statement of support for the CMS guidelines, highlighting CMS’s emphasis on providers working in collaboration with local and state public health leaders. The AHA also praised CMS’s acknowledgement that hospitals and health systems need to maintain flexibility as they may have to respond to surges of COVID-19 in their community. Other healthcare organizations have also issued their own guidance on how to safely resume elective surgeries and in-person care. The American College of Surgeons, along with the American Society of Anesthesiologist, Association of periOperative Registered Nurses and the American Hospital Association, released joint guidance for healthcare workers and facilities resuming elective surgeries. In addition, certain states have already begun to prepare for resuming elective surgeries. For instance, New York will begin allowing elective surgeries to take place starting April 28th in regions of the state without high numbers of COVID-19 cases. As more states begin to allow elective surgeries to resume, healthcare facilities seeking to provide in-person care should review both state and federal guidance on how to safely proceed.
CSG will continue to track any guidance or directives from CMS and state and local governments that may be issued in connection with elective surgeries and procedures and provide updates.