Reopening and maintaining services for patients during the COVID-19 pandemic have presented unexplored and unforeseen challenges for medical practices.
The pandemic has forced owners and practice administrators to make on-the-fly decisions that directly affect care and the economic health of their clinics.
Staying open, continuing to serve high-risk patients and slowly reestablishing patient volume as state and federal guidelines take shape are ever-changing challenges. Practices need to be fluid and receptive to new strategies to ensure safety for staff, providers and patients, according to Patti Barkey, COE, CEO of Bowden Eye & Associates in Jacksonville, Florida.
Patti Barkey, COE, suggests practice administrators look to the American Society of Ophthalmic Administrators for updated information and best practice strategies during the pandemic.
Source: Patti Barkey, COE
“Prior to the pandemic, we wouldn’t take an employee’s temperature when they walked in the front door. We wouldn’t ask about their signs and symptoms because it’s an invasion of personal information. But all of that has changed. We had to adapt. We didn’t want to be a contributor to the transmission of the disease,” Barkey said. “Our method has worked, we weren’t able to ever close completely, and — knock on wood — we have been very fortunate to not have one single positive COVID test on any of our team. Who would have ever thought that I would have to add ultraviolet light technology to sterilize areas of the office daily?”
Restrictions on services
In April, CMS published guidelines on nonemergent, elective medical services and treatment recommendations for medical practices. The guidelines divided patients into three categories and suggested doctors only treat those on site when “lack of in-person treatment or service would result in patient harm.” All other patients could delay treatment or be evaluated via telehealth to determine the necessity of an on-site examination.
Additionally, the American Academy of Ophthalmology published recommendations in March that urged ophthalmologists to cease providing treatment other than necessary urgent or emergent care as a means to flatten the COVID-19 curve.
Medical practices suddenly had to navigate a slew of mandates, changing orders and safety recommendations from medical organizations and state governments to keep services open and their employees safe.
“We never missed a day, but it was hard. Routine contact lens and glasses services were pushed out, obviously. Anything that wasn’t urgent in our minds was delayed. But that was one of the things around the country that caused confusion: People had different perspectives as to what was urgent, as to what was absolutely necessary and what could be put off,” Barkey said.
Preparing for patients
Bowden Eye & Associates decided to limit its services to only at-risk and emergent patients. The practice serves a large at-risk glaucoma population, and denying those patients medical care would put them at high risk for blindness or disease progression, Barkey said.
“We couldn’t just shut our doors. We had to continue taking care of these patients,” she said.
When it became clear that state restrictions would begin to lift across the country in late April and early May to allow more access to health care, clinics began to plan for the increase in volume in an uncertain landscape. Karen Spencer, CEO of Virginia Eye Consultants and senior vice president of operations for CVP Mid-Atlantic region, said the practice began planning out a course of operation weeks before the limitations were lifted.
Virginia Eye Consultants reopened to elective cases and visits May 4 but remained open for urgent, emergent and pathology cases throughout the pandemic. Currently, clinic volume ranges from 90% to 115% of pre-pandemic numbers, she said.
To prepare for the full reopen, Spencer established a task force to provide daily communication with practice employees regarding guidance on CDC mandates, state and federal recommendations, and updated human resources information.
“During April, we deployed a group of our staff to make masks for all of our returning staff and focused on ensuring our [personal protective equipment] was sufficient for a return to normal operations. This required a lot of creativity and working with what we would consider more nontraditional vendors to achieve,” she said.
Physician videos were created to inform patients about the steps Virginia Eye Consultants was taking to increase protection and safety in its clinics. The videos were published on the practice’s website and social media venues and attached to preregistration links.
“We implemented technology to send preregistration links to all patients coming in for appointments to ‘check in’ in advance and to begin their chart setup from their own smart device. We limited the amount of time the patient had to be in the office and limited contact for them and our staff,” Spencer said.
Finding new strategies
Discontinuing care for emergency patients was never an option, according to Sydney L. Tyson, MD, MPH, president of Eye Associates and SurgiCenter of Vineland, New Jersey.
By the first week of July, Tyson’s practice was seeing about 80% of its volume compared with before the pandemic.
The implementation of new and inventive safety policies has been a crucial strategy to ramping up capacity in the past several months. The protocols begin before a patient steps foot in the clinic, he said.
“Prior to scheduling, we ask the patients a series of questions set by the CDC, such as if they have any symptoms, have they been out of the country, etc. If they answer yes to any of the questions, they are handled as a telemedicine patient. If not, they are scheduled,” Tyson said.
When individuals arrive for an appointment, they must stay in their cars and check in by phone. Masks are mandatory, Tyson said, and are provided for those who do not have one.
Temperature checks are done before the patient enters the office, and individuals whose temperature is 100°F or more are sent home and told to contact their primary physician.
Patients who pass the screening are brought directly to an exam room. Each room has been thoroughly cleaned and disinfected, including all chairs, counters and examination equipment, he said.
“After the doctor finishes their exam, the patient is escorted to check out and then out the door. We took every opportunity to cut back the amount of time the patient is in the office, so as to limit exposure for the patients and staff,” Tyson said.
Ensuring safety for all
Ensuring safety for all employees has been a top priority, according to Carrie Jacobs, COE, CPSS, OCS, executive vice president of operations for Chu Vision Institute.
Chu Vision Institute in Bloomington, Minnesota, officially reopened May 4 but had been taking appointments with urgent and emergent patients. The institute’s ASC reopened May 26 and is operating at 100% pre-COVID numbers, with the clinic at about 80%, she said.
In addition to mandatory face coverings for anyone inside the clinic, face shields or goggles are required for doctors, nurses and technicians during examinations. Face shields are made available to any clinic member who requests them.
“We’ve added plexiglass protective shields at the front desk and in our waiting room, in addition to removing 75% of our seating for social distancing. We’ve added medical-grade dividers in our testing rooms, which can be wiped down between patients,” she said.
A new nonclinical role has also been added at Chu Vision Institute, Jacobs said: a “clinic cleaner.” The employee wipes down and disinfects exam rooms and testing equipment between visits, allowing technicians, scribes and doctors to focus on medical issues and not on cleaning.
Daily fogging of the clinic break room, reception area and hallways has also been instituted.
“And communication to the patients is key. They know what to expect and all the measures we’ve put into place for their safety. The patients love that,” Jacobs said.
Unique solutions for unique challenges
The unique challenges posed by the pandemic have required unique solutions, according to Kim Bartels, vice president of operations for Vance Thompson Vision.
Doctors and leadership from all six locations of Vance Thompson Vision, in North and South Dakota, Nebraska, Minnesota and Montana, met daily via Zoom before increasing clinic flow. Six teams were formed from the pool of doctors and leaders, and each team was in charge of separate responsibilities: financial decisions, clinic communications, referring optometrists communications and patient communications. A separate physician team was formed to gather information on COVID-19 to stay abreast of breaking news and evaluate the impact on the practice and its patients, Bartels said.
The teams met each day before lifting patient restrictions and continue to meet on a regular basis to address any new concerns.
“I think the transition has been fairly smooth because of the preparation we have done with our patients and team. Some patients are frustrated by the repeated questions, but they do understand we are trying to keep them as safe as possible,” Bartels said.
Vance Thompson Vision continued to accept appointments for its most urgent and at-risk patients throughout the early days of the pandemic. Clinic volume has returned to about 90% to 95% of pre-COVID-19 numbers.
Staffing changes necessary
“Our team has been amazing during this transition, balancing home and work,” Bartels said. The practice used the Paycheck Protection Program and the Family and Medical Leave Act to keep the team and practice as whole as possible.
At Bowden Eye & Associates, staff cuts were determined by seniority and need. Keeping the doors open throughout the pandemic has been difficult, Barkey said, with the budget stretched thin and early on not knowing whether stimulus money or government assistance would be available.
Managers from all three locations met and determined how many employees were necessary to care for urgent patients. Fifteen employees were laid off.
“You try so hard to be fair and to save your practice,” Barkey said, but the furloughs took a toll on staff morale, even though the majority of employees have been rehired.
Furloughing employees can bring about personnel conflicts and make clinics vulnerable to Equal Employment Opportunity complaints from staff members who may feel they were terminated unfairly.
“It’s an unfortunate fallout administrators are dealing with right now,” Barkey said.
Rebuilding a team
Human resources issues posed the biggest challenge for Chu Vision Institute after reopening. Due to personal safety concerns, not every staff member wanted to return when the clinic reopened. Among those who did return, there were frequent callouts from work, which affected the morale of employees who showed up each day, Jacobs said.
Chu Vision Institute furloughed 90% of its staff at the outset of the pandemic but has since brought back 75% of those employees. Several employees returned to work but changed their minds for various reasons, leaving the practice to rebuild a team on the fly, which has been challenging, Jacobs said.
It has been difficult to manage the backlog of patients that developed during the semi-closure, process new patients and manage the needs of current patients with a smaller staff.
“There is so much demand right now and not enough hours in the day to meet the needs,” Jacobs said.
Managing staff morale
Managing the emotional well-being of employees was an unexpected challenge, according to Jacobs.
“It was harder than I imagined it would be for furloughed employees to return,” she said. “The employees who were not furloughed worked hard during the shutdown and haven’t had the opportunity to catch their breath. Creating the space to talk, listen and be compassionate has been critical in nurturing the team throughout all of this change.”
Constant reassurance about the clinic’s commitment to safety and comprehensive training have helped mitigate the pandemic’s effects, Tyson said. Doctors set the example through their commitment to proper safety techniques and by practicing social distancing. Employees are provided with information for 24-hour assistance for managing stress and anxiety.
“Also, we have a staff member who provides support for COVID education and ‘tips of the day’ to help employees feel more comfortable at work. Keeping our employees safe and stress-free is very important to us, so we try hard daily to make things a little bit better,” Tyson said. “Free lunches also help.”
Opportunities for new technology
The pandemic has allowed practices to experiment with new technology and innovations that may become commonplace after the pandemic. Using technology to assist in registration and basic medical questions has been a big success at Virginia Eye Consultants, Spencer said.
Remote workforces for the call center, revenue cycle operations and remote scribes have also helped improve clinic workflow during the pandemic, she said.
“Of course, the potential use of telemedicine where and when appropriate — provided it is a service CMS and private payers will continue to allow — for care that doesn’t necessarily require the patient to come into the office should continue,” Spencer said.
Barkey said she took the opportunity to purchase ultraviolet light disinfecting systems for each practice location to help sanitize exam rooms. The standup system is wheeled into an exam room and bathes it in disinfecting UV light, adding another layer of safety for all in the practice, she said.
Look for resources
As the pandemic continues to evolve, Barkey strongly suggested practice administrators look to the American Society of Ophthalmic Administrators (ASOA) for updated information and best practice strategies. Barkey is the current vice president of the society.
The ASOA has been an advocate for practices since the beginning of the pandemic and has focused on eliminating confusion and misinformation about the virus, she said.
“The ASOA did a great job of staying calm and proactively providing administrators with information about the pandemic. There were suddenly too many experts in the field, and people were making mistakes listening to some of the wrong ones. We wanted to be the trusted source for practice administrators to get their information,” Barkey said.
Nobody has all the answers, so administrators and medical practices need to rely on the relationships they have cultivated to help navigate through this difficult business climate.
“Nobody is perfect. We are all collectively in this together, and if we bring out the strengths of each other, lean on one another, we can get through this,” she said.
- AAO recommends ophthalmologists treat only urgent cases during COVID-19 pandemic. www.healio.com/news/ophthalmology/20200319/aao-recommends-ophthalmologists-treat-only-urgent-cases-during-covid19-pandemic. Published March 19, 2020. Accessed June 22, 2020.
- Non-emergent, elective medical services, and treatment recommendations. www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf. Published April 7, 2020. Accessed June 25, 2020.
- Recommendations for urgent and nonurgent patient care. www.aao.org/headline/new-recommendations-urgent-nonurgent-patient-care. Published March 18, 2020. Accessed June 22, 2020.
- RePlan: Financial survival and growth opportunities post-pandemic. Presented at: Eyecelerator LiveStream; April 22, 2020 (virtual meeting).
- State guidance on elective surgeries. www.ascassociation.org/asca/resourcecenter/latestnewsresourcecenter/covid-19/covid-19-state. Published April 20, 2020. Accessed June 23, 2020.
- For more information:
- Patti Barkey, COE, can be reached at Bowden Eye & Associates, 7205 Bonneval Road, Jacksonville, FL 32256; email: [email protected].
- Kim Bartels can be reached at Vance Thompson Vision, 3101 W. 57th St., Sioux Falls, SD 57108; email: [email protected].
- Carrie Jacobs, COE, CPSS, OCS, can be reached at Chu Vision Institute, 9117 Lyndale Ave. S, Bloomington, MN 55420; email: [email protected].
- Karen Spencer can be reached at Virginia Eye Consultants, 241 Corporate Blvd., Norfolk, VA 23502; email: [email protected].
- Sydney L. Tyson, MD, MPH, can be reached at Eye Associates and SurgiCenter of Vineland, 251 S. Lincoln Ave., Vineland, NJ 08361; email: [email protected].
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