COVID-19: How to safely reopen your medical practice

As stay-at-home restrictions are relaxed, heath care systems in some regions are reopening for non-emergent care. This reopening has come with a flurry guidelines for physician practices. Let’s summarize the most important recommendations, so you can safely reopen your medical practice.

Before we look at specific guidelines for reopening, here’s a quick 2020 COVID-19 timeline:

• Feb 28: US confirms first COVID-19 death
• Mar 13: President Trump declares a national emergency
• Mar 15: CDC recommends no gatherings of 50 or more people
• Mar 18: CMS recommends limiting non-essential care and expanding surge capacity into ambulatory surgical centers and other areas
• Mar 19: California issues first statewide stay-at-home order, and many other states follow
• April 16: White house releases federal guidelines for “Opening up America Again”
• April 19: CMS issues recommendations to reopen healthcare systems in areas with low incidence of COVID-19

Since April 19, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

The AMA created a physical practice guide to reopening (updated May 1), and many other organizations have done the same. This article will summarize federal reopening criteria, CMS phase 1 guidelines, recommendations from the AMA, and MGMA’s Medical Practice Reopening Checklist.

Federal guidelines for reopening America

On April 16, 2020 the White House released federal guidelines for reopening America.

The guidelines have three sections. The first is “Criteria,” which outlines conditions each region or state should satisfy before proceeding to a phased reopening. The second is “Preparedness,” listing how states should prepare for reopening. The third section is “Phase Guidelines,” which details responsibilities of individuals and employers during distinct reopening phases.

Physician practices should pay the most attention to “Criteria.” The key question to ask as you plan for reopening is, “Has my state or region satisfied the gating criteria for Phase 1 reopening?”

According to the White House, states and regions should satisfy the following three criteria before proceeding to a phased reopening:

1. Symptoms reported within a 14-day period should be on a downward trajectory. This includes both influenza-like illnesses and COVID-like cases.
2. Cases documented within a 14-day period should also be on a downward trajectory. Alternatively, there should be a downward trend in positive tests as percent of total tests.
3. Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk healthcare workers, including emerging antibody testing.

Refer to public health resources to make sure your state and locality meet gating criteria before proceeding to Phase 1 reopening.

CMS Guidelines for phase 1 reopening

If your area meets the gating criteria above, then it’s time to plan for Phase 1 reopening. On April 19, 2020, CMS released their recommendations for Reopening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase 1.

The CMS guide gives you the big picture. It covers general advice related to PPE, workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway is this: if your area has the resources to quickly respond to a surge of COVID-19 cases, start offering care to non-COVID patients as clinically appropriate. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management (before moving on to preventive services).

Work with your state public health authorities and plan carefully.

AMA’s physician practice guide to reopening

Now that you’re familiar with the federal and CMS recommendations, the AMA’s guide is a great next stop.

The AMA believes state and local governments should have four things in place before relaxing stay-at-home orders. In addition to federal guidelines, make sure the following signposts are in place as you reopen your medical practice:

1. Minimal risk of community transmission based on sustained evidence of downward trend in new cases and fatalities
2. A robust, coordinated and well supplied testing network
3. A public health system for surveillance and contact tracing
4. Fully resources hospitals and health care workforce

If you're ready for phase 1 reopening, review the following 11 steps. These steps are a simplified version of the AMA’s checklist of criteria for reopening your practice. Make sure to visit the original checklist for official guidance.

11 steps to reopen your medical practice

1. Make a plan

As emphasized above, coordinate with state and local public health officials to evaluate trends for COVID-19 in your area. Make sure your area meets gating criteria before beginning to reopen your medical practice.

Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after being in your clinic.

2. Reopen incrementally

Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.

3. Institute safety measures for patients

As you reopen your medical practice, patient safety is your top concern. Designate separate “well” and “sick” waiting areas, and encourage patients to visit without companions whenever possible. Make sure to follow CDC guidance, which requires all individuals who visit the office to wear a cloth face covering.

4. Ensure workplace safety for clinicians and staff

Screen employees for high temperatures and other symptoms of COVID-19, and keep records in a confidential file. Minimize contact between employees as much as possible.

AMA ethics has more about healthcare institutions’ ethical obligations to protect health care professionals.

5. Implement a tele-triage program

Use a tele-triage system to direct patients toward care that best fits their health status and medical needs. For example, many patients may be better served via a telemedicine visit, hospital admission, or testing for COVID-19.

6. Screen patients before in-person visits

Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. It can help to create a script that office staff can use to contact patients 24 hours before they com come in. Use this as a chance to ask about symptoms and explain any reopening logistics they should know about.

7. Coordinate testing with local hospitals and clinics

Contact your public health authority to identify available testing sites in your catchment area. Some patients will require COVID-19 testing, and it’s important to provide them with clear and up to date information.

8. Limit non-patient visitors

Minimize contact with non-patient visitors such as vendors, educators, and service providers. Communicate with these visitors virtually as much as possible, and establish clear protocols for those who must enter your practice.

9. Contact your medical malpractice insurance carrier

Congress has shielded clinicians treating COVID-19 patients from liability in certain instances. However, there may be heightened risks caused by the pandemic which do not fall under these protections. Contact your malpractice liability insurance to discuss whether you need additional coverage as you reopen your medical practice.

10. Establish confidentiality/privacy

As you phase into reopening your practice, it’s a great time to update your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy, for example if you had to inform coworkers or patients that they had come into contact with an employee who tested positive. Make a plan that follows HIPPA guidelines during COVID-19.

11. Consider legal implications

New legal issues and obligations may come up as you reopen your medical practice. Make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

MGMA’s medical practice reopening checklist

After you’ve worked through the AMA guidelines, a final useful resource is MGMA’s COIVD-19 Medical Practice Reopening Checklist.

Use the checklist to confirm you’re addressing key items as you reopen your medical practice. The checklist covers the following general areas, with specific considerations under each heading:

Employee expectations

Patient communication

Financial management

Human resource management

Operational management

How to safely reopen your medical practice

As you consider reopening for non-emergent patient visits, use the following steps to review relevant guidelines:

1. Understand the federal guidelines for reopening America, including the gating criteria (symptoms, cases, and hospitals) for phase 1 reopening.
2. Make sure your area meets the criteria for phase 1 reopening.
3. Review the 3-page CMS guidelines for phase 1 reopening.
4. Think through the AMA’s 11 steps to reopen your medical practice.
5. Review MGMGA’s reopening checklist to make sure you haven’t missed anything.

Disclaimer: The information and guidance provided in this document is believed to be current and accurate at the time of posting. This information is not intended to be, and should not be construed to be or relied upon as, legal, financial, medical or consulting advice. Consider consulting with an attorney and/or other advisor to obtain guidance relating to your specific situation. Please refer to referenced resources for official guidance for organizations cited in this synthesis.