By John H. Fisher II
April 21, 2020
The Centers for Medicare & Medicaid Services (CMS) have issued new recommendations targeted at communities in Phase 1 of the Guidelines for President Trump’s “Opening Up America Again.” The Phase 1 category includes communities with low incidence or relatively low and stable incidence of COVID-19 cases. The new CMS guidelines outline recommendations for a gradual transition. Health care providers are encouraged to coordinate with local and state public health officials, and to review the availability of personal protective equipment (PPE) and other supplies, workforce availability, facility readiness, and testing capacity when making the decision to re-start or increase in-person care.
The new CMS recommendations (the Guidelines) can be found here.
The Guidelines acknowledge that facilities in some areas are stretched to their limits of capacity, and surge areas are needed to augment care for patients with COVID-19 in these areas. However, CMS recognizes that not all areas are experiencing the outbreak to the same extent as the areas that have been hard hit. CMS recognizes that many areas of the country have a low, or relatively low and stable incidence of COVID-19, and that it is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 healthcare.
CMS also highlights the importance of restarting care that is currently being postponed due to the COVID-19 virus and the need to conserve needed resources and to control the spread of the virus. In order to meet the goal of having a smooth transition back to providing care consistent with more ordinary operations, states and regions that have passed the Gating Criteria identified in the April 16, 2020 Guidelines for Opening Up America Again, are permitted to move to Phase 1. The Gating Criteria are in three categories: Symptoms, Cases, and Hospitals, include:
- Symptoms: downward trajectories in both “influenza-like illnesses” in the previous 14 days and of COVID-like symptoms in cases reported over the same period
- Cases: downward trajectory of total diagnosed cases or of positive tests, compared with total tests given over the previous 14 days.
- Hospitals: able to treat all patients without crisis care and have testing in place for at-risk healthcare workers, including antibody testing.
CMS cautions facilities to continually evaluate whether their region remains a low risk of incidence and should be prepared to cease non-essential procedures if there is a surge.
The Guidelines included some recommendations on how to accomplish the goals of transitioning back to normal operations. Recommendations include:
- Maximum use of all telehealth modalities is strongly encouraged. Recommendations include use of telehealth technologies in treating COVID-19 patients, but also by lowering the risks associated with retransmission by using telehealth in connection with patients who are not infected with the virus.
- Non COVID-19 care should be offered as clinically appropriate and within a state, locality, or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases. Decisions on treating non-COVID-19 patients are to be consistent with public health information and in collaboration with state public health authorities.
- Careful planning is required to resume in-person care of patients requiring non-COVID-19 care, and all aspects of care must be considered.
- Adequate facilities, workforce, testing, and supplies.
The following recommendations were provided regarding permitting facilities to provide essential non-COVID-19 care to patients without symptoms of COVID-19 in regions with low incidence of COVID-19. It must be stressed that these recommendations only apply to areas where the Gating Criteria are met. These are areas with a downward trend in COVID-19 cases. There must be a downward trajectory in total diagnosed cases or of positive tests over a 14-day period. Hospitals in the area must be able to treat all patients without crisis and have testing in place for at-risk workers, including antibody testing.
The Guidelines contain specific recommendations in seven areas including general issues, personal protective equipment, workforce availability, facility considerations, sanitation protocols, supplies and testing capacity. A few highlights of the items that are recommended in the Guidelines include:
- Evaluating the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.
- Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.
- Staff should be routinely screened for symptoms of COVID -19 and if symptomatic, they should be tested and quarantined. Staff who will be working in these zones should be limited to working in these areas and not rotate into “COVID-19 Care zones” (e.g., they should not complete rounds in the hospital and then come to a Non-emergent Non-COVID-19 facility).
- Staffing levels in the community must remain adequate to cover a potential surge in COVID-19 cases.
- Creating areas in which steps are in place to reduce risk of COVID-19 exposure and transmission. These areas should be separate from other facilities to the degree possible.
- Within the facility, administrative and engineering controls should be established to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs at least 6 feet apart, and maintaining low patient volumes.
- Visitors should be prohibited but if they are necessary for an aspect of patient care, they should be pre-screened in the same way as patients.
- All patients must be screened for potential symptoms of COVID-19 prior to entering the Non-emergent Non-COVID-19 facility, and staff must be routinely screened for potential symptoms as noted above.
- Adequate equipment, medication and supplies must be ensured, and not detract the community ability to respond to a potential surge.
- When adequate testing capability is established, patients should be screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory testing as well.
These Guidelines do not apply to reopening of general businesses. Rather, the Guidelines only provide recommendations for the analytical process to follow when determining whether to continue restrictions on providing non-COVID-19 elective care during the pandemic. Considerations that are relevant to reopening other types of businesses require different considerations and are outside of the jurisdictional parameters of CMS.
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