We are living in an unprecedented time in health care. To effectively respond to the COVID-19 pandemic, we need all hands on deck to ensure that providers are mobilized and available to treat patients appropriate to their level of training. This is why during this public health emergency, the Centers for Medicare and Medicaid Services (CMS) has enacted an unprecedented number of waivers and flexibilities to expand the capacity of facilities and providers; CMS has acted under Medicare rules that allow the provider workforce to adapt to meet the dynamic needs of patient care.
What do these rapidly implemented policy changes mean for health care professionals on the front lines?
Staffing New Health Care Spaces
With the hospital without walls flexibilities, physicians affiliated with hospitals and health care systems will now be able to provide essential care for patients not only within the hospital, but also in extended hospital-associated facilities that are able to provide inpatient-level care. This may include locations such as skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), or ambulatory surgical centers (ASCs). To support this expansion, however, hospitals and health systems will need to redeploy providers, which could include utilizing physicians who have greater availability as a result of lower service volume or postponed elective procedures. Redeployment should be done in a way that ensures providers practice at the top of their license, which could include non-physician providers (such as physician assistants and nurse practitioners) leveraged to assist with triage, telehealth, or supporting patient care to expand capacity of intensivists or other physicians.
Inpatient And Post-Acute Care Through Expansion Sites
To adapt to changes in patient volume, hospitals and health systems will need an efficient and coordinated approach to discharge planning. This may involve transferring stabilized patients to lower intensity locations or discharging patients home to convalescence, preserving intensive care beds for patients who can only be cared for by intensive care teams. With the new workforce flexibilities, we have an opportunity to make care in the home a viable alternative to care in a hospital. Patients can be discharged and assessed under the watchful eye of home health services, using remote monitoring, and cared for by clinicians using telemedicine or performing house calls. To ensure continuity, care should be closely coordinated with the patient’s primary care provider, who may be part a larger medical group or accountable care organization.
Ingenuity At The Bedside
We have listened to and heard from front-line clinicians who have developed new team-based approaches to care to meet the demand. Many health systems have begun innovating. To expand intensive care capacity, some hospitals have identified “critical care capable” specialty physicians to assist those with formal critical care training. These could include Anesthesiologists or Cardiologists who are also trained in Internal Medicine, and have intensive care unit (ICU) experience managing ventilators and critically ill patients. These physicians can provide care to patients in the ICU care during a capacity surge with minimal training.
Many hospitals have expanded all available space for ICU care and have expanded capabilities, which includes needed supplies, ventilators and PPE. Hospitals can plan to potentially use operating rooms, post-anesthesia care units, endoscopy suites, cardiac catheterization suites, ambulatory surgery centers, or other available facilities. Some have developed specialized teams such as “intubation teams”, “procedure teams” or “proning teams” for specific care which can be done efficiently and safely. In some centers where there is a shortage of respiratory therapists (RT), respiratory therapy has been expanded to include other available providers such as certified registered nurse anesthetists, anesthesia residents, or others who can be trained to do respiratory therapy with RT oversight.
In support of finding effective treatment for COVID-19, CMS is encouraging clinicians who participate in the Quality Payment Program (QPP) to contribute to scientific research and evidence through clinical trials to help fight the COVID-19 pandemic. CMS recently finalized a policy to award Merit-based Incentive Payment System (MIPS) credit for the 2020 Performance Year to clinicians who attest to the new COVID-19 Clinical Trials improvement activity and report their findings to a clinical registry. This improvement activity provides flexibility in the type of clinical trial, which could include designs ranging from the traditional double-blinded placebo-controlled trial to an adaptive design, or a pragmatic design that flexes to workflow and clinical practice context.
Leadership And Collaboration
The COVID-19 pandemic is fostering collaboration across the healthcare system. This includes sharing of resources across hospital systems within a region, across a state, or across state lines. Ohio State University in Columbus, Ohio, in conjunction with two other systems, developed a large COVID care facility staffed by providers from all three hospitals. Northwell Health in New York is standing up 1500 new beds, and has partnered with hospitals in Rochester, New York, for staff and supplies in return for exchange of staff and supplies to Rochester should the need arise.
In addition to these examples of collaboration, development and utilization of a national physician resource is needed. This may include Veterans Administration Hospitals, utilization of Department of Defense/Public Health physicians, or development of a “national physician corps” that could be deployed in the event of future pandemics.
Frontline clinicians, we applaud you and express our deepest gratitude. Clinicians are more essential now than ever in enabling our healthcare system to adapt to the volume and intensity of the care needed to treat patients with COVID disease. We also appreciate our clinicians’ continued attention to those patients with chronic conditions but without COVID-19 who are remaining at home and deferring healthcare visits during this crisis. Finally, as we look towards the weeks ahead, our dedicated health professionals will stand ready to serve where they are needed most, helping our country to recover and heal.