COVID-19 & Clinical Practice Changes?

[member978]

As of now, my VA is strongly urging VVC or phone-based appointments, but is not denying in -person appointments if requested. They have been doing a basic screener of symptoms/risk on entry for about a week and a half. I think all groups have been transitioned to VVC or VANTS phone line only. I'm in a AMC/VA consortium setting which leads to some confusion when policies between the two sites differ. I could easily telework for my AMC research tasks, but because I am also with the VA, I am being required to come in.

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[summerbabe]

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.

We desperately need leadership to make these decisions, ideally nationwide.

I read that Goldman Sachs on their most recent investor conference call is projecting that 50% of the country will be infected with a 2% mortality rate (~3 million Americans). They can make money whether 10 people die or 10 million, as long as they are making the right bets.

The elephant in the room is that there are service connection seeking/maintaining Veterans who will insist on coming to appointments unless explicitly ordered not to, which is going to put them and staff at increased risk.

 

[AcronymAllergy]

I agree that unless VA comes out and explicitly says we're requiring (or at least strongly encouraging) all non-emergent appointments to be rescheduled or handled via telehealth, based on clinical judgment of the provider, there will be push back.

 

[cara susanna]

We desperately need leadership to make these decisions, ideally nationwide.

I read that Goldman Sachs on their most recent investor conference call is projecting that 50% of the country will be infected with a 2% mortality rate (~3 million Americans). They can make money whether 10 people die or 10 million, as long as they are making the right bets.

The elephant in the room is that there are service connection seeking/maintaining Veterans who will insist on coming to appointments unless explicitly ordered not to, which is going to put them and staff at increased risk.

Travel pay also factors in, probably. And given our population (especially in my CBOC's location), a lot of our patients think that this whole reaction is overblown.

We need to make this decision for patients. Of course, I make this same frustrated speech every time we have inclement weather and don't close or cancel appts, too.

 

[cara susanna]

C&P evals have been cancelled. They are going to work to see if we can do MH ones via video, but that wouldn't happen immediately it sounds like.

 

[Fan_of_Meehl]

We desperately need leadership to make these decisions, ideally nationwide.

I read that Goldman Sachs on their most recent investor conference call is projecting that 50% of the country will be infected with a 2% mortality rate (~3 million Americans). They can make money whether 10 people die or 10 million, as long as they are making the right bets.

The elephant in the room is that there are service connection seeking/maintaining Veterans who will insist on coming to appointments unless explicitly ordered not to, which is going to put them and staff at increased risk.

I've come to realize that the most grotesquely mangled space in the universe lies at the point of collision between an inept bureaucracy (the VA) and an actual crisis (this COVID19 situation).

Of course, the only real driving force behind any apparent 'decisionmaking' at VA is, "How can I try to make myself or my boss *look* good or---more importantly--not *look* bad.

 

[Whedonverse]

A quick poll: Is your AMC postponing outpatient, non-urgent neuropsychological evaluations? Not sure if what I am seeing at my institution is normal or not.

 

[summerbabe]

A quick poll: Is your AMC postponing outpatient, non-urgent neuropsychological evaluations? Not sure if what I am seeing at my institution is normal or not.

My VA is still testing. Spoke with one of our interns as he was on his way to NP for an apt earlier today.

Overall, our service is highly recommending telehealth appointments but are not officially cancelling appointments. Informally, seems like some providers are/have shifted to full telehealth, some are doing a split, and some are still seeing a good number of in-person apts.

Overall, our response is pretty terrible and overly focused on putting out short-term fires.

 

[lg1527]

A quick poll: Is your AMC postponing outpatient, non-urgent neuropsychological evaluations? Not sure if what I am seeing at my institution is normal or not.

Nope. Tested a patient on Monday and have another scheduled next week. No plan to reschedule or postpone that I know of despite likely community spread. My spouse is a physician. Who knows what he has been exposed to and what I have at this point. We are really pushing the boundaries of "do no harm."

 

[erg923]

In light of things, despite my earlier sarcasm:

It is laughably admirable how the VA Healthcare System: 1. Reacts vs setting an example. 2. Accommodates vs adapting and setting boundaries (per CDC). 3. Appeases despite medical advice and empirical evidence to the contrary. It's like the VA even pays for acupuncture...oh, wait?

It's weird to contrast America vs the VA Health Care System at this point. It's...get 10 feet away from me d-bag, vs...Yea, its cool, ya know, whatever you want man. Come on in if you want. Because you once had a job with the feds as a soldier/marine/airman....I'm cool if you disregard all current CDC/NIH/state/city/county guidelines about how to behave in our our society at this point in time.

I would again highlight this as a problem that is uniquely due to segregating healthcare/health systems by occupation (or former occupation) in this country.

 

[CatsFan]

A quick poll: Is your AMC postponing outpatient, non-urgent neuropsychological evaluations? Not sure if what I am seeing at my institution is normal or not.

Yes, for the rest of this week and the next two at least.

 

[cara susanna]

My VA is still not allowed to cancel MH appts, non urgent psych testing included

 

[Fan_of_Meehl]

My VA is still not allowed to cancel MH appts, non urgent psych testing included

Personally, I think there's zero chance that the VA will cancel operations (until the last possible moment--i.e., unless essentially there is a Federal order). Going by Secretary Wilkie's comments today at that press conference--essentially that our fourth mission is to 'stand ready' to support / heal the nation and other Federal operations, etc., blah, etc., blah, pompom, blah, #BeThere, blah, etc., whole health, blah {insert slogan of the week}, blah. If they have to--rather than shutting down operations and sending us home--VA admin will have 1/3 of our staff on one end of the facility filling sandbags to be transported to the other end of the facility by another 1/3 of our staff where the remaining 1/3 of our staff will empty said sandbags into a giant 'victory' pile. The following morning, they will have everyone swap out positions and begin the critical 'operations' of saving the country yet again by moving the pile of sand to the opposite end of the facility, renaming it the 'freedom' pile and planting a flag on top of it along with a silver statue of a service dog.

That, or they'll have us doing stuff equally as useless (or even iatrogenic) such as 'critical incident debriefing,' trauma 'first aid,' or teaching (via telemedicine and iPhone therapy) random American citizens how to do a body scan mindfulness meditation exercise. Actually, the mindfulness stuff is kinda cool and effective.

 

[summerbabe]

That, or they'll have us doing stuff equally as useless (or even iatrogenic) such as 'critical incident debriefing,' trauma 'first aid,' or teaching (via telemedicine and iPhone therapy) random American citizens how to do a body scan mindfulness meditation exercise. Actually, the mindfulness stuff is kinda cool and effective.

In the span of a few hours this morning, I was identified as somebody who does not have telehealth equipment at my work station, pegged as a candidate for remote access, did a TMS for telework, submitted an administrative request to receive remote access, was approved for remote access, and picked up a PIV card reader for home remote access.

Only oddity is that my clinical role is 100% inpatient and nobody in our actual outpatient mental health clinics (that I know of) received this approval or the PIV card reader...

 

[AbnormalPsych]

In the span of a few hours this morning, I was identified as somebody who does not have telehealth equipment at my work station, pegged as a candidate for remote access, did a TMS for telework, submitted an administrative request to receive remote access, was approved for remote access, and picked up a PIV card reader for home remote access.

Only oddity is that my clinical role is 100% inpatient and nobody in our actual outpatient mental health clinics (that I know of) received this approval or the PIV card reader...

....... this was a roller coaster

 

[AbnormalPsych]

So, bad news. My hospital has informed me we are quite low on hand sanitizer, and our order for more was not approved due to short supplies out in the world. So our clinic is about to be even higher risk. Sweet.

 

[cara susanna]

I don't really know how I could telework, unless they want me to see patients via VVC from home. That seems to have a number of potential confidentiality problems, though.

We were given the TMS for telework and told to sign up to request it, but they're having us hold off on signing the actual paperwork right now.

 

[summerbabe]

Asking for a colleague in our outpatient MH clinic:

Has anybody received guidance on how to bill for telephone sessions for veterans who don't have home internet or a compatible device since the RVUs for a telephone encounter and telehealth encounter are very different?

Also, has anybody heard from their supervisor/leadership about whether RVU or clinic utilization goals may change?

 

[Fan_of_Meehl]

So, bad news. My hospital has informed me we are quite low on hand sanitizer, and our order for more was not approved due to short supplies out in the world. So our clinic is about to be even higher risk. Sweet.

The VA element of this experience is incomplete without an 'infection control champion,' a 'safety seneschel,' or a 'patient advocate paladin,' chasing you around and constantly upbraiding you for failing to use the hand sanitizer after each exhalation (the lack of hand sanitizer availability notwithstanding).

 

[summerbabe]

I don't really know how I could telework, unless they want me to see patients via VVC from home. That seems to have a number of potential confidentiality problems, though.

I heard from a friend at another VA that all their outpatient MH folks no longer have the option of coming into the hospital to work (they had already pretty much transitioned to tele) and will be plugging PIV card readers into their personal laptops/computers and using Citrix remote access.

Hope everybody has Malware Bytes

 

[Fan_of_Meehl]

I heard from a friend at another VA that all their outpatient MH folks no longer have the option of coming into the hospital to work (they had already pretty much transitioned to tele) and will be plugging PIV card readers into their personal laptops/computers and using Citrix remote access.

Hope everybody has Malware Bytes

I wonder if any of their VA clinicians don't have the high speed internet that would be required for telehealth.

Due to exorbitant costs our local cable company cabal charges, I recently considered just using my cell phone plan (and tethering) to cover my online needs. It's possible that a busy professional who doesn't watch a lot of online movies or do online gaming could've cut the cable chord.

Moreover, I suppose it's even possible that some people's ISPs have them on a plan that isn't unlimited upload/download and therefore have an upper limit/ cap on data. It's usually in the hundreds of gigabytes but, still, if there's a cap on data, VA can't exactly require people use their personal accounts for official business.

 

[cara susanna]

Asking for a colleague in our outpatient MH clinic:

Has anybody received guidance on how to bill for telephone sessions for veterans who don't have home internet or a compatible device since the RVUs for a telephone encounter and telehealth encounter are very different?

Also, has anybody heard from their supervisor/leadership about whether RVU or clinic utilization goals may change?

We're being told to schedule and bill it as a phone call. I did ask yesterday if I can code for two counts of a 30 min if it's a 60 min appt (did a PE session over the phone).

 

[AcronymAllergy]

We're being told to schedule and bill it as a phone call. I did ask yesterday if I can code for two counts of a 30 min if it's a 60 min appt (did a PE session over the phone).

This has been the guidance as best I can tell; "bill" with the non-physician telephone codes and put in a telephone clinic. The telephone codes are single-count, unfortunately.

CMS has relaxed telehealth restrictions such that providers can now count telephone services as telehealth, I believe, but I don't think that's impacted VA.

Edit: Looks like I was wrong, at least partially. Telephone sessions can count as telehealth only if they use audio AND video; audio-only phone sessions are allowed, but are not reimbursable as telehealth.

 

[summerbabe]

So, bad news. My hospital has informed me we are quite low on hand sanitizer, and our order for more was not approved due to short supplies out in the world. So our clinic is about to be even higher risk. Sweet.

We are out of the small bottles of Purrell from our inpt stock. Somebody in our outpt MH clinic said their clinic was out as well.

So far, I haven't run into any empty wall dispensers yet but I'm afraid it'll only be a matter of time.

 

[cara susanna]

I have an expired bottle in my office and can't get it replaced.

 

[AcronymAllergy]

I have an expired bottle in my office and can't get it replaced.

We've been able to replace the wall dispensers for now, but have been told to keep the expired stand-alone dispensers, since they're out.

 

[cara susanna]

Just got news that we're cancelling all in person appts for the next 30 days. It's phone/VVC or nothing.

FINALLY.

 

[AcronymAllergy]

Just got news that we're cancelling all in person appts for the next 30 days. It's phone/VVC or nothing.

FINALLY.

We seem to be a few days behind you. So that'll probably hit us on Monday.

 

[foreverbull]

My spouse is getting almost daily emails from upper management that show touching stories of how “essential” psychologists are to skilled care facilities in a hard-hit area (“essential” even if the appointments are 20-30 minutes once/week and only a tiny percentage of residents are seen by psychologists for therapy). Telehealth is not a viable option because none of these facilities are set up to have computer/laptop access for residents and staff are wayyyy to overworked to take the time to drag around a laptop and set it up for everyone.

Subtext: you better keep working or else.

 

[PsychPhDone]

I don't really know how I could telework, unless they want me to see patients via VVC from home. That seems to have a number of potential confidentiality problems, though.

We were given the TMS for telework and told to sign up to request it, but they're having us hold off on signing the actual paperwork right now.

We do this.

 

[cara susanna]

We do this.

Normally or just temporarily during this situation? Do you have VA cell phones?

 

[mypointlesspov]

Intern at an AMC/community MH setting here. We live in a county that was basically just ordered to shelter in place. This morning, we got an email saying that we could still hold in person sessions if we felt comfortable, but they are encouraging telehealth. Not sure if the new county announcement means we're finally going to close our doors or what. I'm concerned because my setup at home isn't ideal for holding therapy sessions (aka loud cats and spotty wifi). I tried with two clients yesterday and it was not good, so I ended up coming into the office today anyway.

 

[Sanman]

Normally or just temporarily during this situation? Do you have VA cell phones?

Our VA is doing this. Most of our dept was VVC certified last year if you log in via remote access and follow guidelines (private space, neutral background, proper lighting, etc) it should be doable. I already have proper equipment, but my population is not the most tech savvy to it is slow going.

 

[cara susanna]

Our VA is doing this. Most of our dept was VVC certified last year if you log in via remote access and follow guidelines (private space, neutral background, proper lighting, etc) it should be doable. I already have proper equipment, but my population is not the most tech savvy to it is slow going.

Good to know! I could probably make that work if I needed to. I used to work remotely a few days per week so I have the equipment, but I didn't see patients on those days.

 

[summerbabe]

Did anybody just get the "Use of Video Communication Technology Under COVID-19" memo?

That while VVC is preferred, we can use FaceTime, Facebook Messenger video chat, Google Hangouts, and Skype to provide telehealth if we inform about possible 3rd party privacy issues? But don't worry, apps like Facebook Live, Twitch, and TikTok are off the table!

Does this mean that the telehealth stress test yesterday showed the current system is woefully ill-equipped to handle a full transition to away from face-to-face contact? How many people will actually give out their personal contact info to freaking FaceTime a patient because they don't know how to make burner Gmail or FB accounts?

 

[PsychPhDone]

Normally or just temporarily during this situation? Do you have VA cell phones?

Normally for a few of us.
Everyone else now, temporarily.

 

[AcronymAllergy]

Did anybody just get the "Use of Video Communication Technology Under COVID-19" memo?

That while VVC is preferred, we can use FaceTime, Facebook Messenger video chat, Google Hangouts, and Skype to provide telehealth if we inform about possible 3rd party privacy issues? But don't worry, apps like Facebook Live, Twitch, and TikTok are off the table!

Does this mean that the telehealth stress test yesterday showed the current system is woefully ill-equipped to handle a full transition to away from face-to-face contact? How many people will actually give out their personal contact info to freaking FaceTime a patient because they don't know how to make burner Gmail or FB accounts?

The initial relaxation of HIPAA requirements for secure communication was put out by CMS a couple days ago I believe, so VA may just be saying they're going along with those guidelines.

 

[SportsNeuroPsych]

A quick poll: Is your AMC postponing outpatient, non-urgent neuropsychological evaluations? Not sure if what I am seeing at my institution is normal or not.

Yeah - they cancelled all my appointments for the remainder of the month as of this Monday. They are going to reassess afterwards but I am not hopeful since I am located in a hot spot.

 

[IWillSurvive]

The initial relaxation of HIPAA requirements for secure communication was put out by CMS a couple days ago I believe, so VA may just be saying they're going along with those guidelines.

This memo blew my mind a bit, but i guess that's how we are going to work-around the issues with not having the technological capacity for everyone to use VVC from home. This to me said: get ready to telework ASAP, even though our facility has told us over and over again this will NOT be happening whilst having certain staff completing telework paperwork under the radar.

It also blows my mind that they are still running the cafeteria and store in our facility. When you walk down the hallway, you can see people congregating and socializing. We've still been holding meetings in person. Some providers continue to see in-person appts w/o clinical necessity/urgent need or crisis. We are so not CDC compliant right now. Sigh.

 

[Spydra]

So, bad news. My hospital has informed me we are quite low on hand sanitizer, and our order for more was not approved due to short supplies out in the world. So our clinic is about to be even higher risk. Sweet.

Looks like breweries and distilleries are coming to the rescue by starting to make hand sanitizer. From what I can see on Google so far this is happening in Europe, Michigan, Mississippi, Colorado, and Canada but perhaps others. I had no idea they could do that, my inner nerd finds this very interesting.

 

[AcronymAllergy]

This memo blew my mind a bit, but i guess that's how we are going to work-around the issues with not having the technological capacity for everyone to use VVC from home. This to me said: get ready to telework ASAP, even though our facility has told us over and over again this will NOT be happening whilst having certain staff completing telework paperwork under the radar.

It also blows my mind that they are still running the cafeteria and store in our facility. When you walk down the hallway, you can see people congregating and socializing. We've still been holding meetings in person. Some providers continue to see in-person appts w/o clinical necessity/urgent need or crisis. We are so not CDC compliant right now. Sigh.

Our meetings have all switched to V-Tel or VANTS, and the patient areas were pretty sparse yesterday, but we're still seeing people in-person and the canteen is still open (the latter probably more for the staff than anything).

Personally, I'd prefer to avoid telework and just hole up in my office doing telehealth and catching up on admin tasks. But that's me.

 

[cara susanna]

Is anyone else amused by how much they've been pushing VVC and like "YEAH anyone who wants VVC can do it" and now it turns out we don't have the capability?

 

[Fan_of_Meehl]

Looks like breweries and distilleries are coming to the rescue by starting to make hand sanitizer. From what I can see on Google so far this is happening in Europe, Michigan, Mississippi, Colorado, and Canada but perhaps others. I had no idea they could do that, my inner nerd finds this very interesting.

Jim Beam hand sanitizer will be a hit at the bars .

In all seriousness, glad they're doing this. Good karma.

 

[cara susanna]

For those of you whose institutions are using the medically necessary criteria, how are you determining if that is met for psych testing?

 

[erg923]

For those of you whose institutions are using the medically necessary criteria, how are you determining if that is met for psych testing?

Clinical question cannot be answered by a thorough psychiatric evaluation and collateral info and brief rating scales. The tests (and their results) are needed to treat the patient, and are not just for "curiosity"...so to speak. Interqual and MGC also have additional criteria too, but these are the main points.

 

[Spydra]

Jim Beam hand sanitizer will be a hit at the bars .

In all seriousness, glad they're doing this. Good karma.

Me too! The last thing we need is a bunch of drunk people trapped at home. There's already concern about domestic violence victims and where they are supposed to go if being trapped in the house is no longer safe. While drinking is not always involved, it often is and we don't need that mess right now.

 

[erg923]

Is anyone else amused by how much they've been pushing VVC and like "YEAH anyone who wants VVC can do it" and now it turns out we don't have the capability?

The Charleston study stuff came out in what, 2010? 2009? Its been "the wave of the future" for over a decade. Problem is, it was seen as an alternative vs primary modality (the whole patient-centered care thing...which in VA land translates to patient-dictated care). I'm not arguing for one or the other, but when you have to sit in a office until 4:30 despite no work... so as to be a "good steward of the taxpaxer", what did we really think was gonna happen? The VA is into the tech and PR, but not why/how telemedicine can be beneficial for both sides of the healthcare system.

 

[Fan_of_Meehl]

The Charleston study stuff came out in what, 2010? 2009? Its been "the wave of the future" a over decade. Problem is, it was seen as an alternative vs primary modality (the whole patient-centered care thing...which in VA land translates to patient-dictated care). I'm not arguing for one or the other, but when you have to sit in a office until 4:30 despite no work... so as to be a "good steward of the taxpaxer", what did we really think was gonna happen? The VA is into the tech and PR, but not why/how telemedicine can be beneficial for both sides of the healthcare system.

To add to this...my anecdotal experience with the shiny new Video on Demand option (basically, the provider calls the veteran's cell phone for a 'video chat') has been less than stellar, and I hear similar anecdotes from colleagues. You call the veteran and typically (a) awaken them from a deep slumber; (b) get their voicemail; (c) they tell you that they are driving cross country (and want to have a video session while doing it); (d) have screaming kids and spouses in the background (or in frame); (e) want to have the session whilst on duty at work and hiding behind a stack of boxes in a warehouse (and whispering).

Some things aren't supposed to be maximally convenient. No investment in the therapy process means ineffective therapy.

 

[cara susanna]

Clinical question cannot be answered by a thorough psychiatric evaluation and collateral info and brief rating scales. The tests (and their results) are needed to treat the patient, and are not just for "curiosity"...so to speak. Interqual and MGC also have additional criteria too, but these are the main points.

So if it met that criteria, you would automatically keep the testing appt instead of r/sing?

 

[WisNeuro]

So if it met that criteria, you would automatically keep the testing appt instead of r/sing?

It would appear that erg is presenting you with what insurance companies consider "medically necessary." I assume that you are talking about "medically necessary during Covid." In that case, we were only keeping testing appointments needed for surgery. E.g., tumor resection. They are considering bariatric elective at the moment, so those fell off the schedule. So, my answer, very little is necessary in my system. My schedule has 2 appointments on it for the next 3 weeks.