COVID-19 & Clinical Practice Changes?

[erg923]

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

No...no, sorry. I was saying what your documentation needs to show to authorize payment (medical necessity) by most insurance companies who require pre-authorization for psychological testing. So, no. I was just saying what needs to be met (shown) in order to be paid.

I would not expect many people will actually be doing in-person testing assessments for the next few weeks, at least? WADA, organ transplant, DBS, tumor, will need to continue. Bariatric and Dorsal Column Stim is probably considered "elective" at this time? General psych stuff? No. So, only very medically involved and necessary neuropsych, in other words.

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[cara susanna]

Thanks, @erg923 and @WisNeuro. I'm getting some administrative pushback about a psychodiagnostic eval.

 

[PsyDr]

Whelp...Florida shuts down all non-emergency "procedures".

Bout to get interesting.

 

[erg923]

Thanks, @erg923 and @WisNeuro. I'm getting some administrative pushback about a psychodiagnostic eval.

Why? (serious question to ask your admin)

As much as we don't like to say it out-loud (for a variety of reasons), we treat symptoms...not diagnoses. That's just the way it is.

Your MMPI, or whatever, is not going to save anyone's life and is not worth any risk it may reap upon you or other populations at this time. Your patient's symptoms can be treated without any of our precious psychological testing at this time...I assure you. Kinda like most of the rest of the...world!

I can understand where you are. I was there once too. But I again assure you, the VA will not fire you for just saying "no'. You just have to try it. I said no to something, then something else. Then it was like: No... I don't want to see the transgendered, schizophrenic, bipolar veteran with PTSD who wants to have hormone replacement surgery for an eval...because I don't know anything about all that. And magically, Dr. erg was off the rotation list.

 

[beginner2011]

Whelp...Florida shuts down all non-emergency "procedures".

Bout to get interesting.

Per Section 1A, does this order stop in person psychotherapy, for example? Does this apply to VA sites in Florida?

I'm on internship at a site with a lot of cases in the local area, and the hospital is still allowing Veterans to come in-person. It's really bizarre, and I'd like to see an order like this put a stop to it.

 

[IWillSurvive]

Per Section 1A, does this order stop in person psychotherapy, for example? Does this apply to VA sites in Florida?

I'm on internship at a site with a lot of cases in the local area, and the hospital is still allowing Veterans to come in-person. It's really bizarre, and I'd like to see an order like this put a stop to it.

This makes me angry that this is still happening, esp. in a place like Florida with so many cases. I hope the same...seems like it should come down the line from national VA considering VA does have this power to enact this when local leadership is unwilling. For the moment, I think national is in the dark how various VA's are handling a lot of these things unfortunately.

 

[PsyDr]

Per Section 1A, does this order stop in person psychotherapy, for example? Does this apply to VA sites in Florida?

I'm on internship at a site with a lot of cases in the local area, and the hospital is still allowing Veterans to come in-person. It's really bizarre, and I'd like to see an order like this put a stop to it.

Hell if I know. Doesn’t look good.

 

[AcronymAllergy]

Per Section 1A, does this order stop in person psychotherapy, for example? Does this apply to VA sites in Florida?

I'm on internship at a site with a lot of cases in the local area, and the hospital is still allowing Veterans to come in-person. It's really bizarre, and I'd like to see an order like this put a stop to it.

Chatter amongst listservs is that basically, people don't know. Some practitioners are interpreting it as only applying to procedures that involve use of PPE, so psychotherapy is exempt; some are reading it as all healthcare practitioners and providers (including psychotherapy); some are viewing themselves and their services as urgently necessary and exempt; and some are interpreting it as putting a stop to in-person psychotherapy, but telehealth is still ok.

Also, remember that VAs generally try to adhere to state legislation, but at the end of the day, only "answer" to federal law and guidelines. I don't know that VA can (or would) stop in-person visits altogether (e.g., such as for urgent appointments), but most seem to be strongly discouraging them. I'd be surprised if your site isn't doing the same next week.

 

[cara susanna]

Our VA had stopped all non-emergency procedures, but mental health was still considered essential (or something like that) so those appts were kept. I think procedures are different from appts.

 

[PsyDr]

Our VA had stopped all non-emergency procedures, but mental health was still considered essential (or something like that) so those appts were kept. I think procedures are different from appts.

The discussion is about if the term refers to all CPTs (i.e., "Current Procedural Terminology") or if the term refers to procedures/surgical interventions.

 

[cara susanna]

The discussion is about if the term refers to all CPTs (i.e., "Current Procedural Terminology") or if the term refers to procedures/surgical interventions.

Ohh, I see. That could definitely have interesting implications.

 

[AcronymAllergy]

The discussion is about if the term refers to all CPTs (i.e., "Current Procedural Terminology") or if the term refers to procedures/surgical interventions.

There have been a few listserv posts referencing interpretation from attorneys suggesting they read it as relating to preserving PPE, and thus limiting procedures/surgical interventions. But at this point, who knows.

 

[LadyHalcyon]

Our governor announced that healthcare providers will be required to stop elective procedures; this had previously been a recommendation, but now non-compliance on the part of some healthcare providers required this to become an order

Is outpatient therapy a non-essential healthcare procedure? I guess I depends on the patient...

Sent from my SM-G973U using Tapatalk

 

[IWillSurvive]

Our governor announced that healthcare providers will be required to stop elective procedures; this had previously been a recommendation, but now non-compliance on the part of some healthcare providers required this to become an order

Is outpatient therapy a non-essential healthcare procedure? I guess I depends on the patient...

Sent from my SM-G973U using Tapatalk

This is something that has been discussed a few posts up in the thread. It seems there is no current consensus but report that a few attorneys have interpreted this as being a measure to preserve PPE...meaning this would not extend to psychotherapy.

 

[AcronymAllergy]

This is something that has been discussed a few posts up in the thread. It seems there is no current consensus but report that a few attorneys have interpreted this as being a measure to preserve PPE...meaning this would not extend to psychotherapy.

Still waiting on official/formal follow-up, as it's mostly just been continued educated guesses. But it's still probably a good idea even without formal orders to limit in-person appointments to only urgent/emergent appointments.

 

[IWillSurvive]

So what I have learned is that national sent out a memo on providers moving to telework, which occurs in 'tiers.' Apparently, psychologists are not in 'tier one,' which is why other disciplines are going before us in terms of telework. This makes no sense to me but that's how it goes.

 

[cara susanna]

So what I have learned is that national sent out a memo on providers moving to telework, which occurs in 'tiers.' Apparently, psychologists are not in 'tier one,' which is why other disciplines are going before us in terms of telework. This makes no sense to me but that's how it goes.

Central office you mean?

 

[IWillSurvive]

Central office you mean?

The Executive in Charge of the VA.

 

[PsyDr]

But seriously: estimating 90 days of non-clinical contact.

 

[AbnormalPsych]

So what I have learned is that national sent out a memo on providers moving to telework, which occurs in 'tiers.' Apparently, psychologists are not in 'tier one,' which is why other disciplines are going before us in terms of telework. This makes no sense to me but that's how it goes.

We are never in the good tiers of anything. Sometimes I think this is because we as individuals and a profession let ourselves get walked over way too easily because we are supposed to be nice, warm, empathic, understanding, whatever, in all situations.

 

[WisNeuro]

We just got told that if you had symptoms, but are asymptomatic now, return to work. But, with the lack of testing supplies, almost no one has actually been tested, so no one knows if they had it or something else. This should be fun.

 

[cara susanna]

We just got told that if you had symptoms, but are asymptomatic now, return to work. But, with the lack of testing supplies, almost no one has actually been tested, so no one knows if they had it or something else. This should be fun.

Given that asymptomatic transmission has been demonstrated, that's a terrible idea.

Also, now I'm wondering who the top tier telework VA providers are. Lol.

 

[WisNeuro]

Given that asymptomatic transmission has been demonstrated, that's a terrible idea.

Also, now I'm wondering who the top tier telework VA providers are. Lol.

Should be interesting, I was sick last week, mostly GI, but did have fever of 102, mild respiratory. But, I am currently awaiting a decision from Occupational Health on if I should show up on Thursday for work as usual. But, on the bright side, I will be provided a mask

 

[PsyDr]

I was curious about that “flatten the curve” graph. Read a bit more. You know what the scale on X axis is? 40 weeks.

“But if that can be spread out over 40 weeks, it’s more like 50,000 critical cases a week and more within our range to handle.”

...40 weeks...

 

[WisNeuro]

Just confirmed with Occupational Health "You haven't had a fever since Friday? Yeah, you need to report back to work tomorrow."

 

[WisNeuro]

I was curious about that “flatten the curve” graph. Read a bit more. You know what the scale on X axis is? 40 weeks.

“But if that can be spread out over 40 weeks, it’s more like 50,000 critical cases a week and more within our range to handle.”

...40 weeks...

Pssh, what's 9ish months?

 

[PsyDr]

Pssh, what's 9ish months?

We only have about 37 weeks to go!

 

[cara susanna]

Should be interesting, I was sick last week, mostly GI, but did have fever of 102, mild respiratory. But, I am currently awaiting a decision from Occupational Health on if I should show up on Thursday for work as usual. But, on the bright side, I will be provided a mask

People are increasingly talking about GI symptoms as part of the profile. In fact, our employee health sent out an email with symptoms to watch for and that was included.

 

[WisNeuro]

We only have about 37 weeks to go!

I'm gonna need a few more videogames and puzzles. My building projects will really only last a weekend at this point.

 

[WisNeuro]

People are increasingly talking about GI symptoms as part of the profile. In fact, our employee health sent out an email with symptoms to watch for and that was included.

We saw that too, my wife is a PCP, so she's been looking for things to screen for in her patients.

 

[AcronymAllergy]

We just got told that if you had symptoms, but are asymptomatic now, return to work. But, with the lack of testing supplies, almost no one has actually been tested, so no one knows if they had it or something else. This should be fun.

I want to say our guidance has been to not return to work until asymptomatic for 3 days. Pretty sure I saved the email. Somewhere.

 

[cara susanna]

Ours is also 3 days

 

[WisNeuro]

As far as I knew, there is no evidence base for the "asymptomatic for 3 days" return policy. I thought people were essentially shedding virus for weeks after initial symptom presentation.

 

[deleted106747]

Should be interesting, I was sick last week, mostly GI, but did have fever of 102, mild respiratory. But, I am currently awaiting a decision from Occupational Health on if I should show up on Thursday for work as usual. But, on the bright side, I will be provided a mask

What kind of GI? Just curious. Not totally dreading the idea of a fever plus vomiting, or anything like that.
Congratulations on the mask.

 

[Ollie123]

I realize they don't want to scare the public, but the wildly mixed messages coming out about this even from the reliable sources really need to freaking stop. I feel like providers are getting oversimplified politicized messages distilled for the public and it leaves everyone even more confused.

"Asymptomatic folks can spread it, which is why social distancing is important. Except if you aren't symptomatic you should still go to work. If you are sick its probably just the flu, but you should get tested for COVID. This is a highly contagious disease and there are now clearly documented cases of community spread but unless you have traveled recently you do not need to be tested"

Seriously. Just tell us you need healthcare providers to work sick even if it risks spreading it because that is just where we are now. Its not OK, but I get it. There aren't enough tests so we're conserving it for those most likely to yield a positive? Welp, that was a catastrophic and embarrassing ****-up for a supposedly 1st-world nation, but too late to go back now. At this stage I am honestly not sure testing accomplishes much anyways - would have been great early on for containment, but that ship has long sailed. Most asymptomatic people are not going to show up at the hospital for a test right now "just to check" (for good reason) and unless I am missing something we would need regular testing of everyone still maintaining public contact regardless of symptoms for it to do a lick of good beyond helping us track and quantify our current level of ****-ed-ness. Might change as we learn more about prognostic indicators and early intervention options improve, but right now I'd be fine with forgoing testing completely for the next few weeks if it gave us the bandwidth to crank out an extra couple ventilators.

Also, trying to stimulate a closed-down economy is sheer idiocy. You can prop up stock prices all you want, ain't no one hopping on a flight to Venice right now. Implement draconian public health measures for 1-2 months while we watch the stock market plummet and laugh, bolster unemployment for the worker bees to make sure we don't end up with mass COVID encampments running around, throw the doors back open and THEN set the economic defibrillator to max.

The staggering incompetence with which this whole thing has been managed from top to bottom is just baffling to me. And I say that as someone who went into this with amazingly little respect for how things are managed.

 

[Sanman]

I realize they don't want to scare the public, but the wildly mixed messages coming out about this even from the reliable sources really need to freaking stop. I feel like providers are getting oversimplified politicized messages distilled for the public and it leaves everyone even more confused.

"Asymptomatic folks can spread it, which is why social distancing is important. Except if you aren't symptomatic you should still go to work. If you are sick its probably just the flu, but you should get tested for COVID. This is a highly contagious disease and there are now clearly documented cases of community spread but unless you have traveled recently you do not need to be tested"

Seriously. Just tell us you need healthcare providers to work sick even if it risks spreading it because that is just where we are now. Its not OK, but I get it. There aren't enough tests so we're conserving it for those most likely to yield a positive? Welp, that was a catastrophic and embarrassing ****-up for a supposedly 1st-world nation, but too late to go back now. At this stage I am honestly not sure testing accomplishes much anyways - would have been great early on for containment, but that ship has long sailed. Most asymptomatic people are not going to show up at the hospital for a test right now "just to check" (for good reason) and unless I am missing something we would need regular testing of everyone still maintaining public contact regardless of symptoms for it to do a lick of good beyond helping us track and quantify our current level of ****-ed-ness. Might change as we learn more about prognostic indicators and early intervention options improve, but right now I'd be fine with forgoing testing completely for the next few weeks if it gave us the bandwidth to crank out an extra couple ventilators.

Also, trying to stimulate a closed-down economy is sheer idiocy. You can prop up stock prices all you want, ain't no one hopping on a flight to Venice right now. Implement draconian public health measures for 1-2 months while we watch the stock market plummet and laugh, bolster unemployment for the worker bees to make sure we don't end up with mass COVID encampments running around, throw the doors back open and THEN set the economic defibrillator to max.

The staggering incompetence with which this whole thing has been managed from top to bottom is just baffling to me. And I say that as someone who went into this with amazingly little respect for how things are managed.

Now imagine where we would be if we didn't have a "very stable genius" running the country. Voting matters folks...Now back to your regularly scheduled pandemic nightmares.

 

[WisNeuro]

What kind of GI? Just curious. Not totally dreading the idea of a fever plus vomiting, or anything like that.
Congratulations on the mask.

Nausea and diarrhea for the GI stuff. I rarely vomit. Usually if I'm vomiting, I am very sick. But, my wife was sick several days prior, and did have vomiting. So, who knows. Maybe we just had the flu or mild norovirus. With the complete lack of testing available, we wouldn't know.

 

[deleted106747]

Nausea and diarrhea for the GI stuff. I rarely vomit. Usually if I'm vomiting, I am very sick. But, my wife was sick several days prior, and did have vomiting. So, who knows. Maybe we just had the flu or mild norovirus. With the complete lack of testing available, we wouldn't know.

The absurdity of this situation is overwhelming.

 

[Ollie123]

As much as I dislike Trump (and the buck does stop with him - especially after eliminating the pandemic team?) a lot of these screw-ups are happening across all levels. Even at the institutional level - sure seems like every hospital is having their legal team vet emails right now. So you have to read between the lines to know what they are trying to say, because no one wants to come out and admit they are OK with their providers potentially spreading it.

 

[futureapppsy2]

I'm legitimately shocked that my colleague who's a general internist/hospitalist hasn't been called back to actually do clinical work at this point.

 

[futureapppsy2]

Nausea and diarrhea for the GI stuff. I rarely vomit. Usually if I'm vomiting, I am very sick. But, my wife was sick several days prior, and did have vomiting. So, who knows. Maybe we just had the flu or mild norovirus. With the complete lack of testing available, we wouldn't know.

Mild norovirus doesn't really exist--you either get a pretty extreme clinical presentation or nothing. Could have been some other GI bug, though.

 

[cara susanna]

We're told that they're starting to consider moving people to telework at our VA CBOC. Those of us who applied for remote access got asked to sign the agreement form just in case.

 

[Sanman]

As much as I dislike Trump (and the buck does stop with him - especially after eliminating the pandemic team?) a lot of these screw-ups are happening across all levels. Even at the institutional level - sure seems like every hospital is having their legal team vet emails right now. So you have to read between the lines to know what they are trying to say, because no one wants to come out and admit they are OK with their providers potentially spreading it.

Agreed, but part of that is due to everyone doing what they want when there is a lack of appropriate national leadership and instruction. Just look at how differently all the VAs are reacting nationally. These are precisely the moments when a clear unified message goes a long way to getting people to work together. A scattershot policy of social distancing and partial isolation with no goals are not that useful. A national period of mandated isolation with a plan to identify and prep testing, isolation, and treatment centers, stock centers with needed supplies, and identify treatment protocols would have been much more useful. We are well on our way to being the epicenter of the pandemic. India just shut down a nation of 1.3 billion to quickly manage less than 500 cases of COVID.

 

[iliketohelppeople]

Paid trainees (interns and postdocs) at our site (VA) are moving to telework soon. The trainees are not allowed to be doing telehealth from home through official means, though [but this may change in the near future].

 

[IWillSurvive]

Given that asymptomatic transmission has been demonstrated, that's a terrible idea.

Also, now I'm wondering who the top tier telework VA providers are. Lol.

private message me and I can send the info I have.

 

[futureapppsy2]

private message me and I can send the info I have.

I'd be curious about that as well.

 

[IWillSurvive]

Ok, for us federal employees...the stimulus bill has passed and agencies have encouraged maximum telework (I know VA at least should be receiving a chunk of cash, some of which to boost tele/IT capabilities). Let's do an updated survey....

What general type of agency are you working for?

Who is teleworking and who is still working from the office?

If you are in the office, are you at least only doing tele visits?

I work for a VA, continuing to go in the office, and am doing VVC and telephone only therapy appointments.

 

[cara susanna]

I'm working for a VA. I am doing phone and VVC only in the office, but they are getting things ready for telework. Not sure if it's going to happen or if it's just a contingency plan though.

 

[Therapist4Chnge]

Pssh, what's 9ish months?

Only 18 years and change until college tuition is due for many soon to be future parents.

 

[ClinicalABA]

Ok, for us federal employees...the stimulus bill has passed and agencies have encouraged maximum telework (I know VA at least should be receiving a chunk of cash, some of which to boost tele/IT capabilities). Let's do an updated survey....

What general type of agency are you working for?

Who is teleworking and who is still working from the office?

If you are in the office, are you at least only doing tele visits?

I work for a VA, continuing to go in the office, and am doing VVC and telephone only therapy appointments.

Multi-site private group practice. Almost exclusively assessment. Everything is telehealth, done from home.