Let me begin this second post by noting that anyone over the age of 65 who lives in California has been told to shelter in place. On Wednesday (three weeks ago), I went down to do some legal stuff for my 92-year old stepmother, who just moved into assisted living. Between 10:00, when I arrived, and 1:30, shortly before I left, the facility locked down and now will not allow any visitors except family and only if the patient is dying.
The two feet of snow we got Tuesday made things even more difficult for the patients of our clinic – not only locked down but snowed in. At our clinic, we just got approval to start seeing patients in what we are calling televisits. We will get our usual fee from MediCal for a telephone visit as long as there is supporting documentation of the same sort we use for a face-to-face visit. So far Medicare hasn’t agreed to televisit payment, but we’re operating on the premise they will follow suit. That means a lot of fleet-footed revising of our usual visit process. For example, we complete various assessment forms, weigh and measure patients, take blood pressure, pulse etc. Can’t do that with televisits. We use medical assistants as scribes to document all the findings from a visit and any orders for things like medications, X-rays and so forth. I’m thinking we’ll put the providers in their offices with the scribe, close the door to minimize distractions and have them turn on the phone microphone so both scribe and provider can hear what the patient says. Certain visits won’t lend themselves to televisits – hard to do a pelvic and pap, or perform vision and hearing tests for a well-child. We’re still figuring those out – may wind up doing a lot more home visits.
RNs in California can perform certain tasks under what is called a standardized procedure – a document that has been formally approved by the medical director and administrative staff. The SP expands the scope of practice for an RN and allows us to order in-house lab tests or refill prescriptions as long as the patient meets certain criteria. The way our procedure is currently written, if the patient has not had a visit within a certain interval, or hasn’t gotten lab or screening (like a mammogram) done, we can only refill for 30 days. We rammed through an overnight change in the policy (the process usually takes a couple of months) to allow us to renew for 90 days even if the criteria aren’t met. This will be in effect for the duration of the pandemic. The effect is to decrease patients coming through the doors in a potentially infectious situation and cut down on trips to the pharmacy.
From the televisit standpoint, the timing couldn’t have been better. The two feet of snow we got Tuesday shut us down and snowed in a lot of our patients. So today in huddle (first day open since the snowstorm) we developed plans to call, beginning with the older people and the ones of any age we know are most vulnerable. We want to see who needs medication refills and/or food, find out whether they have adequate heat and check on those who are dependent on oxygen. The planning was interrupted by the news that the county backhoe clearing the road into the clinic had broken our water main (which was admittedly invisible under the great berm of snow that had already been piled up). To add insult to injury, the backhoe then drove over the water line from the water main to the clinic.
So the minute huddle was over, we sent staff to the Dollar General across the street to buy enough water for staff to drink and so we could flush toilets, while we started calling off the scheduled patients. And since we were closed, we had to notify various agencies, like state licensing. We can’t reopen until we have water – probably (we hope) Monday. Even then, we’ll have to shut off water valves in the exam rooms because we can’t use the water for anything except flushing toilets until we finish testing for coliform bacteria – think E. coli – which means staff can only use hand sanitizer rather than washing their hands between patients. My second RN made it in to work today (she had been snowed in since last Friday). I was delighted to see her, as it meant I could deal with multiple snow/water/coronavirus/procedure issues instead of taking triage calls and doing prescription refills.
My back office supervisor and right hand woman came in walking very oddly because the previous day she, her husband, sons and two of her cousins had been shoveling snow off the walks and away from the walls to prevent melting snow from causing a flood inside the clinic (as happened to us in February 2019). Our HR/compliance person (who is also our resident disaster prep expert) is out with pneumonia, and I’m her disaster back-up. Then the RN who usually relieves me sent an email from her IPhone that she was in the emergency room of a local hospital with chest pain and dizziness.
I finally managed to eat breakfast about 1100. I ate my lunch after I got home around 6. Our staff pulled off a tremendous amount of work despite our trials and tribulations. As I told them in huddle; “I said we’d let you know when it was time to panic. Well, here’s the deal – we aren’t going to panic. Our patients need us.” I was so proud of them.