COVID-19 & Clinical Practice Changes?

[summerbabe]

I'm a VA staff psychologist and a ton of veterans are older and have underlying medical conditions that may decrease their recovery prognosis should they contract COVID-19. Since social distancing and staying away from higher-risk public spaces are good common sense measures, I'm curious to hear about any hospital/mental health-specific changes that are being discussed or implemented at your sites, especially you work at a VA.

Are groups still running? Are patients with complicated medical pictures being cancelled or rescheduled further into the future? Are there significant shifts to telehealth? Is this even being talked about among staff at your site?

Our VA medical center has been holding regular town hall meetings to discuss updates in hospital policy but so far, mental health leadership has been quiet (there's been a single 'business as usual' Friday afternoon email blast). There was a physician-only meeting yesterday to review primary care responsibilities and possible policy changes but no changes have been announced yet.

I'm also currently in a state with minimal confirmed COVID-19 cases (but also barely any testing) and a population that can be rather dismissive of this pandemic.

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[CatLover&PsychEnthusiast]

Wow I’m surprised things have been so quiet! I feel like I’m getting so many emails everyday about preparation and procedure changes that I can barely keep up with them. However, I’m in a state with many known cases. Psychotherapy is being offered via phone or VVC as an alternative to vets who want that instead of in person. Most groups cancelled. Other types of psychology clinics appear to have changes coming as well. Everyone is getting set up with remote access as well.


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[Seven_Costanza]

Wow I’m surprised things have been so quiet! I feel like I’m getting so many emails everyday about preparation and procedure changes that I can barely keep up with them. However, I’m in a state with many known cases. Psychotherapy is being offered via phone or VVC as an alternative to vets who want that instead of in person. Most groups cancelled. Other types of psychology clinics appear to have changes coming as well. Everyone is getting set up with remote access as well.


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My VA has been similar. Tons of emails every day with new changes. There’s an urgency to get us all trained and setup for telehealth right now. Most groups are canceled. The plan for the SUD IOP is still uncertain because those vets are so at risk for relapse and overdose. We reduced the number of groups planned for next week but are still planning to hold them daily to keep the vets connected. That all may change over the next couple days, though.

 

[summerbabe]

Thanks for the info, and I hope to see these changes soon at my VA.

Our state has tested less than 100 people total but I'm sure our confirmed cases will explode in the not so distant future so it sure would be nice to see more proactive planning.

 

[AcronymAllergy]

All of our behavioral health providers are setup to perform video on demand/telehealth, but last I heard, there hasn't been an official push to have all or most patients use that modality. I've not heard anything about groups being cancelled, either, although large gathering-type events are getting shut down.

 

[Seven_Costanza]

I'm curious what is meant by 'remote' access? Do you mean VVC from the VA? or providers having remote access as well?

Also, is your site doing any screening of staff or just patients? I think our VA is really poorly prepared to have telehealth sessions with vets. I am one of few providers set up for that, which is because I wanted to be (many seem to have resisted this shift). I am feeling like we should be looking at our caseloads and identifying vets with risk factors that make them more vulnerable and strongly recommending telehealth for them, but we have had zero discussions about this, or even basic common sense measures like hand hygiene, wiping down surfaces, lysol, etc. I am pretty unhappy with all of this.

Both! It’s a very real possibility that we may have to switch to working from home so we’ll need remote access.

Yikes. NYT just indicated that 49 states have active cases now so you should absolutely be having conversations about it especially given how quickly it transmits.

 

[deleted106747]

My workplace has taken a lot of antiviral steps, but nothing concrete in terms of remote work or alternate scheduling. They stated that a plan would be forthcoming but nothing so far. It's stressful to not hear, even if they'd just say they're working on something still. The schools are closed and many people are in a tough spot with childcare.

 

[CatLover&PsychEnthusiast]

Yes there’s screening at the entrance for both staff and pts. Also both VVC offered and remote access from home is being prepared in case we need it. Lots of protocols/guidelines for health safety and risk assessment safety coming in by email. I would think collaboration among the VAs would be a good idea so places don’t have to start from scratch for coming up with an action plan.

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[cara susanna]

We're calling pts scheduled in the next 30 days and recommending that they push their appt out 90 days or do phone/VVC. This has resulted in me having a lot of ten min conversations in which people complain about how this reaction is over the top. We are not allowed to say that they can't come in even if they're high risk.

We're also doing a two step screening process. If they have cold/flu sx we ask them to go home. If they refuse we make them wear a mask. If they have the sx plus travel history they get quarantined in an office and see a PCP via VVC (I am not a fan of requiring the travel history at this point, but whatever). Right now only patients and visitors are being screened.

Right now we are still telework exempt and they haven't talked about changing that.

I think if things get worse in the next two weeks--which they will--things may become more drastic.

 

[cara susanna]

I'm wondering how essential outpatient mental health is at this moment. Do we need staffing? I feel like we need to make this decision for patients. Some hospitals are cancelling all elective surgeries.

I should add that I'm at a CBOC, not a main hospital.

 

[AbnormalPsych]

I think a good chunk of decision makers are heading that direction. Our (non-VA) hospital outpatient programs cancelled all groups aside from IOP. Individual apts are being strongly recommended to be shifted to phone or video, but we won't turn anyone away who wants to come in person.

 

[AcronymAllergy]

I always say that there aren't really ever any neuropsychological emergencies. We'll see if that actually pans out in terms of being asked to cancel patients. I'm in an area with few confirmed cases, but I also work with a vulnerable population.

 

[deleted343839]

I've been thinking along the same lines. I was surprised that a couple of scheduled new patients on my schedule actually showed up for their appointments with me on Friday. Both over 50, neither in crisis. And mind you, I work in a medical (not psych) practice. I'm still surprised they showed up.

 

[PsyDr]

I always say that there aren't really ever any neuropsychological emergencies. We'll see if that actually pans out in terms of being asked to cancel patients. I'm in an area with few confirmed cases, but I also work with a vulnerable population.

Disagree.

If you drop from sudden onset seizures on a Friday(it’s always a Friday), the ED/ER finds an aggressive tumor pushing on territory adjacent to brocas, they want to do surgical resection by Wednesday, and the prognosis is likely 13-18 months... some might have an emergency neuropsych.

If one reads Ruff, one might note that neuropsych used to have a call schedule.

On a funnier note: the med exec committee did not appreciate input like, “So we shouldn’t lick patients anymore??”.

 

[AcronymAllergy]

Disagree.

If you drop from sudden onset seizures on a Friday(it’s always a Friday), the ED/ER finds an aggressive tumor pushing on territory adjacent to brocas, they want to do surgical resection by Wednesday, and the prognosis is likely 13-18 months... some might have an emergency neuropsych.

If one reads Ruff, one might note that neuropsych used to have a call schedule.

On a funnier note: the med exec committee did not appreciate input like, “So we shouldn’t lick patients anymore??”.

Agree with your disagreement. It's more a semi tongue-in-cheek saying given the relative rarity of neuropsych emergencies in many settings, coupled with logistics about where I specifically work.

I'm interested to see what this week looks like. I imagine I'll walk in to a slew of emails in a couple hours.

 

[WisNeuro]

I always say that there aren't really ever any neuropsychological emergencies. We'll see if that actually pans out in terms of being asked to cancel patients. I'm in an area with few confirmed cases, but I also work with a vulnerable population.

You mean our primarily 65+ population, usually with comorbid cardiopulmonary issues? Yeah, we've received no guidance on those issues. I e-mailed my next three superiors in the chain of command and told them my secretary will be starting to call all scheduled appointments for the next 8 weeks today to ask about suspending/rescheduling to a later date.

 

[cara susanna]

Yeah, I feel like we should be able to cancel assessment appointments (provided that they aren't, like, a liver transplant eval or something).

 

[WisNeuro]

Yeah, I feel like we should be able to cancel assessment appointments (provided that they aren't, like, a liver transplant eval or something).

Exactly, as far as I know, I do not have any pre-surgical evals coming up, just finished up a few pre-resection evals, but nothing else in at least the next 6 weeks.

 

[PsyDr]

Agree with your disagreement. It's more a semi tongue-in-cheek saying given the relative rarity of neuropsych emergencies in many settings, coupled with logistics about where I specifically work.

I'm interested to see what this week looks like. I imagine I'll walk in to a slew of emails in a couple hours.

I know. My rationale for saying something:

1) I believe that psychology staying in medicine is extremely important for the field (i.e., financially, esteem, etc).
2) I would guess that many students are unaware that historically neuropsych was so ingrained in medicine as to have a call schedule.

 

[SmithPsy24]

In our VA they are working on getting everyone set up with telework agreements, and encouraging anyone who is able to telework. Clinicians are working on converting appointments to VVC or telephone appointments, or encouraging them to reschedule for 30 days out - though I suspect if someone insists on coming in they'll have to see them in-person, where they will be screened at the door. All groups are suspended (unless they can be run via phone or VVC). Inpatient unit and CLC are trying to put social distancing in place as much as possible (eating in rooms, etc).

 

[AcronymAllergy]

Setting up telework agreements and pushing to have us try to get all follow-up appts scheduled for telephone or VVC (same as post above). Not sure what this means for my neuropsych appts and new intakes as of yet.

 

[cara susanna]

We've been notified that all VA non-urgent, non-elective procedures are being cancelled. Nooo idea what that means for OPMH yet. Stay tuned.

 

[WisNeuro]

Afternoon eval called to cancel. Which I am glad about given their age and medical history. My secretary is now calling future appointments. I may have a good amount of time on my hands in the coming weeks.

 

[deleted343839]

I'm waiting to get the green light on a telehealth arrangement through my AMC. My template is emptying out, so it's that or else I'll catch up on a lot of non-clinic work.

 

[BuckeyeLove]

jails aren't letting evaluators in for assessments. which makes sense. My primary employment is taking our temp prior to entering and making us all come through one entrance, and also sign a waiver saying we're not coughing and haven't traveled anywhere, and that's about it as of now. one of our max security wings has an extra unit that talks are in to make the "corona unit" should we get admits later found to be carrying. the whole thing is a hot mess. I feel for people I know who have contracts with Courts in my area or for evaluators at forensic centers. their work is essentially completely halted.

 

[cara susanna]

VA announced that mental health is still considered essential and we can't cancel appts, although we can recommend the same options as before. We are cancelling all groups though and recommending postponing non-urgent MH appts (for instance, we can use our clinical judgment about starting new EBP cases)

 

[cara susanna]

Update: We were informed that no new appts are to be scheduled during the next 30 days. If a patient cancels, that appt slot will be closed.

 

[thebalmofhurtminds]

Update: We were informed that no new appts are to be scheduled during the next 30 days. If a patient cancels, that appt slot will be closed.

What does that mean for staff coming in?

 

[WisNeuro]

What does that mean for staff coming in?

It's the VA, it's the same if you get a no show. You get to sit there and do nothing til your shift is done.

 

[Ollie123]

AMC Plan:
Very rapid ramp-up of telehealth. Several major insurers have formally agreed to allow us us to conduct phone sessions and bill as in-person visits during this period. Some oddities to it (30 minute limit on sessions, except for one, etc.). No new appts. We are maintaining limited on-site coverage for emergency situations (high-risk folks, etc.). We don't yet know what that will look like, but I imagine rotations of staff - I have very limited clinical effort so am hoping they won't tap me for that.

My lab is basically shut down as of today. I'm working from home. I'm continuing to pay a staff member who pretty much won't be able to do anything. We'll see how long that lasts.

 

[siliso]

Groups are canceled now, here, until beginning of May at least. Everything that can be done by phone visit or VVC will be done that way. We still need you though to care for (remotely or in person) our mentally ill veterans. We’ll all get through it together.

 

[singasongofjoy]

I work in a specialty OPC as part of an AMC. Similar quick ramp-up in the psychiatry dept for telehealth, but in my clinic all non-urgent appointments have been cancelled for the next 2 weeks with high likelihood of it extending the next 1-2 weeks after that. All trainings and travel have been suspended through May 11. All staff who can work from home are very highly encouraged to work from home though we can't mandate it at this point. We have work-from-home forms to go through with our staff to help outline what their work hours will be (realizing they may have to be flexible and include weekends since schools are closed) though the current plan is to have one admin and one clinical person (probably rotating director and associate director) in the office each day. Trying to be very creative with how our hourly front office staff can still get in all their hours. Clinicians are instructed to check in via phone with their regular clients each week (10 minutes or less and if more is needed then schedule them as "urgent" for a session in-clinic since most aren't up on telehealth quite yet). The majority of my clinic's income comes from diagnostic evaluations (all cancelled with plans to reschedule starting mid-May) and trainings, so this is going to be a pretty hard hit financially, but we'll cross that bridge when we get there. Right now trying to get some resources to our families. Staff who are not in high risk category may be pulled to work at residential facility or elsewhere in the hospital. For essential operations (urgent appointments and also currently includes supported employment clients whose places of employment are still allowing them to work) staff have to go through whole screening protocol each time before working with them. Visitors are not currently allowed at residential and community outings are very limited so staff will be getting pretty creative in the upcoming weeks I'm sure.

 

[AcronymAllergy]

Groups still running here; I imagine we'll get the cancellation notice later this week, judging by what you folks have said. Same here as above RE: everything that can be done by VVC or phone should be. Which is only a portion of my appts. As above, we are not to cancel appts; only patients can do that. And thus far, I have no cancellations.

We've been asked to submit telework paperwork, but no mention if that's the eventual plan (I'd actually probably prefer to be in the office most days; I imagine I could be ridiculously unproductive at home if it were a daily thing).

 

[deleted106747]

Working from home now via telehealth; all groups, meetings, program development suspended. I have discovered I hate working from home. I always knew I hated telehealth. Trading off with the spouse on homeschooling. I still can't get my head around this. It all changed in less than a week.

 

[PsychPhDone]

We're all being encouraged to use vvc/phone and telework when possible. Moved all my patients to video, including a group, and my clinical trial is ready to be run remotely now.

 

[pearlsmom]

I know that APA CoA, APPIC, and ASPPB are having calls tomorrow to discuss guidelines. My VA cancelled all groups and VVC/phone sessions are being encouraged. Staff is working on getting set up to work from home but no one has been approved for that yet. No changes from Central Office on trainees. My intern cohort made a group decision to not report to work, per recommendations from our DCTs. Unfortunately, this means using leave. Hopefully, after tomorrow there will be more guidance.

 

[AbnormalPsych]

More movement. We are not seeing any in person apts unless they walk into the clinic uninvited in crisis.
All groups cancelled. All indiv apts moved to phone or video. Guess who gets to call all the group and indiv patients to inform each and every person of this policy change and work on rescheduling and talking through phone/video protocal? Hint, it is not the cheap labor.

I had a high safety risk phone intake apt today (yes, we are expected to now see all intakes by phone). it was not a good time for either of us.

 

[IWillSurvive]

Are you being told to offer VVC/phone or require it? I have already had some veterans declining this...some approaching older adult age range and with chronic medical conditions.

Also, does anyone have experience with VVC group in the VA? How nightmare-ish is it? I am considering pushing to move my group back that was supposed to begin in April. I have never done group via VVC.

 

[AbnormalPsych]

Well, we won't "require it" (that would be a PR mess and denial of medical services issue that would cause lots of drama) if someone demands to come in, but we are basically being instructed to not give patients the in person option, so there really isn't a choice... I imagine if anyone showed up all hell would break loose in the management offices.

 

[cara susanna]

We

Are you being told to offer VVC/phone or require it? I have already had some veterans declining this...some approaching older adult age range and with chronic medical conditions.

Also, does anyone have experience with VVC group in the VA? How nightmare-ish is it? I am considering pushing to move my group back that was supposed to begin in April. I have never done group via VVC.

I've also had some veterans decline as well. We are being told to use stronger language to push VVC/phone/delaying appt when discussing options but we still can't tell someone they can't come in even if they're in a high risk group. I don't know why we can't move everyone to phone or VVC. It's not declining services - they're the ones who insist that VVC is everyone's right and we shouldn't be concerned about potentially less clinical effectiveness. At some point we need to make this decision for patients. As we've seen in other countries that are further into the outbreak, people don't always make the best decisions on an individual level. We also can't turn someone away from the clinic if they have flu symptoms.

How are my fellow VA people handling EBP referrals? I just received one and am not sure what to do. I told the referring clinician that it doesn't really seem clinically urgent (PTSD tx) and they said "well, it might be to the patient." My supervisor told me it's clinical judgment.

 

[WisNeuro]

How are my fellow VA people handling EBP referrals? I just received one and am not sure what to do. I told the referring clinician that it doesn't really seem clinically urgent (PTSD tx) and they said "well, it might be to the patient." My supervisor told me it's clinical judgment.

I say you tell that referring provider where to shove it. Patient can wait, for their own and others' safety.

 

[cara susanna]

We were just notified that we aren't cancelling C&P.

 

[WisNeuro]

We were just notified that we aren't cancelling C&P.

This is the most VA thing ever!

 

[cara susanna]

This is the most VA thing ever!

Words cannot describe how frustrated I am by this particular decision (I mean I'm frustrated by a lot of the other decisions, too, but especially this).

 

[CatLover&PsychEnthusiast]

Our VA now ONLY phone or VVC for general mental health for over a month unless there’s a high risk situation that warrants otherwise.


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[IWillSurvive]

Our VA now ONLY phone or VVC for general mental health for over a month unless there’s a high risk situation that warrants otherwise.


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This is what our VA should be doing too but they won't take a stance and instead leave it on the providers to convince veterans.

 

[erg923]

So we are being told we don't have the technology capabilities to do telework/remote from home. Meanwhile, I am hearing about other VA's that are doing this. They aren't even screening staff for symptoms at the door. Veterans are giving me a hard time about telehealth which could be greatly eased if the system would provide more support with this. Someone asked about staff that are at high-risk given medical conditions and they were basically told the whole hand-washing deal. I am very frustrated after today to say the least.

When i was still at the VA, i broke my leg and was out for 8 weeks. I asked about doing telework so that I could keep one of my groups going and at least offer some degree of continuity, as no one really covered by clinics/patients at all. The simply scoffed and said, "oh, no we dont do that." When I asked why, i was told i was being difficult, lol.

I have been full remote in my current position for over 2 years now. Fantastic!

 

[cara susanna]

Our VA now ONLY phone or VVC for general mental health for over a month unless there’s a high risk situation that warrants otherwise.


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Can I ask what region you're in? Is it one with a high amount of cases?

Just wondering what will finally make our VA take this step.

 

[CatLover&PsychEnthusiast]

Can I ask what region you're in? Is it one with a high amount of cases?

Just wondering what will finally make our VA take this step.

.

 

[AcronymAllergy]

Our VA screens all patients, but not staff; they currently leave it up to us to self-report.

They've also, as others here, encouraged changing all appointments to telehealth or phone, but haven't required it. Nor have they authorized cancelling in-person appointments.