Inpatient hospital and COVID?

[Forensic234]

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Hello,

I'm a psychology intern at a forensic state hospital. Both staff and residents have tested positive for covid. However, we are still expected to work, go on dorms, and carry on "business as usual." Telehealth has been denied as an option. My fellow interns and I are scared and dont feel like we are being heard. We are told "this may not be the right field for you," when we push for alternative ways to see clients.

Is this how other state hospitals are operating? Are other interns at such placements in a similar boat?

 

[PhDenial]

No, this isn't how other state hospitals are operating. I personally know of a state hospital in my area that asked trainees (practicum students and interns) not to come into work due to the outbreak. We're not even in a state with a high number of cases, and nobody at the hospital tested positive for COVID-19, but they're taking action to prioritize the safety of patients and staff.

 

[PsyDr]

Prisons in many states are not allowing experts to come in. Criminal courts in several states are delaying proceedings.

 

[irishgoodbye]

Have you ha da chance to review the document from CCTC? It might be worth sharing with your direct supervisors as a lot of it indicates trainees should be removed from face to face situations at this time and work should be completed by staff instead. Here’s the link:

https://www.appic.org/Portals/0/downloads/COVID-19/CCTC_Stmt-Education_and_Training_Considerations_during_COVID-19_Pandemic_3-23-20.pdf?ver=2020-03-24-073249-060&timestamp=1585053447039

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[MiniLop]

Hello,

I'm a psychology intern at a forensic state hospital. Both staff and residents have tested positive for covid. However, we are still expected to work, go on dorms, and carry on "business as usual." Telehealth has been denied as an option. My fellow interns and I are scared and dont feel like we are being heard. We are told "this may not be the right field for you," when we push for alternative ways to see clients.

Is this how other state hospitals are operating? Are other interns at such placements in a similar boat?

I am in more or less the same situation as you (also inpatient). Only, after lots of complaining, getting APPIC involved, etc., we were told to go home and our internship is "on pause" and will resume whenever the higher-ups decide we can come back. Meaning our internship will likely be going on for months after its original end date. We proposed many suggestions for how we could continue to work/train from home but, like telehealth, they were dismissed offhand.

Sigh.

 

[CatLover&PsychEnthusiast]

I feel for you, that is awful and negligent.


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[R. Matey]

I am in more or less the same situation as you (also inpatient). Only, after lots of complaining, getting APPIC involved, etc., we were told to go home and our internship is "on pause" and will resume whenever the higher-ups decide we can come back. Meaning our internship will likely be going on for months after its original end date. We proposed many suggestions for how we could continue to work/train from home but, like telehealth, they were dismissed offhand.

Sigh.

That’s absolutely horrible.


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[WisNeuro]

That’s absolutely horrible.


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Well, until waiving the video requirement across the board, something of a reality for institutions not set up for video visits. No reason to set up telephone visit infrastructure if you won't get reimbursed for much of it. Furlough makes more sense from a long-term financial viability standpoint.

 

[DynamicDidactic]

We are told "this may not be the right field for you,"

Invalidation and threats are always a good a good strategy for supervisors. I hope you understand that these folks represent poor mentorship. I understand that everyone is in a difficult bind in this situation but there are better ways to handle the problem.

 

[BuckeyeLove]

We have "upped" mitigation efforts at my state facility; however, that being said, my unit just had a confirmed case from a nurse, and I am almost positive I myself had it. I had the weirdest nausea of my life about 12 days ago, tired, malaise, no fever, no cough. Then it went away. Then it came back intermittently. It's that intermittent course of symptoms that makes me think I did have it. Finally went away after about a week and a half. I say all this to make the point that the screening that is being done at my facility doesn't have the greatest sensitivity.

 

[MiniLop]

Well, until waiving the video requirement across the board, something of a reality for institutions not set up for video visits. No reason to set up telephone visit infrastructure if you won't get reimbursed for much of it. Furlough makes more sense from a long-term financial viability standpoint.

In our case, the site is payed by insurance for "treatment" that consists of the patient's stay + whatever comes with that. It could include telephone or video sessions, but administration has dismissed this offhandedly, and apparently prefers there just be essentially no treatment at all (since essentially all treatment was provided by the interns and externs, who are now home).

 

[WisNeuro]

In our case, the site is payed by insurance for "treatment" that consists of the patient's stay + whatever comes with that. It could include telephone or video sessions, but administration has dismissed this offhandedly, and apparently prefers there just be essentially no treatment at all (since essentially all treatment was provided by the interns and externs, who are now home).

Most insurances will not cover telephone based MH services, and Medicare has been wishy washy on this thus far in its COVID guidelines.

 

[WisNeuro]

Per latest APA guidelines

"As of this time, CMS HAS NOT agreed to cover psychotherapy or E/M services by telephone only., but have indicated that they are considering using the enforcement discretion granted to them by the CARES Act that was passed by Congress to possibly allow this in the future. APA is continuing our advocacy efforts to expand access to necessary services for those lacking video technology. APA recommends you contact your malpractice carrier before engaging with a patient over the phone without video (e.g., not true telemedicine) to gauge their official, legal position."

 

[MiniLop]

Right, but my understanding of how payment works at our specific (inpatient) institution is that insurance does not pay for individual parts of patient's stay, but rather the overall stay. Hence the fact that, currently, patients are not receiving any type of group or individual sessions, yet insurance is still paying the same that it was before. When discussing the situation with management, they made no mention of insurance issues, just logistic issues.

 

[WisNeuro]

Right, but my understanding of how payment works at our specific (inpatient) institution is that insurance does not pay for individual parts of patient's stay, but rather the overall stay. Hence the fact that, currently, patients are not receiving any type of group or individual sessions, yet insurance is still paying the same that it was before. When discussing the situation with management, they made no mention of insurance issues, just logistic issues.

That billing situation makes no sense. Insurance reimburses billing codes, not overall stays. And, for most MH inpatient stays, the institutions are losing money. Not saying that how teh situation has been handled with you interns has been good, just that the monetary situation is not great, and I can see the sense of straight furlough for pragmatic reasons.

 

[MiniLop]

That's not my understanding, but I will double-check with my supervisor to clarify.

 

[MiniLop]

Hello,

I'm a psychology intern at a forensic state hospital. Both staff and residents have tested positive for covid. However, we are still expected to work, go on dorms, and carry on "business as usual." Telehealth has been denied as an option. My fellow interns and I are scared and dont feel like we are being heard. We are told "this may not be the right field for you," when we push for alternative ways to see clients.

Is this how other state hospitals are operating? Are other interns at such placements in a similar boat?

Also, to un-hijack your thread, have you been in contact with APPIC? You can request a consultation (without your internship knowing) with them: APPIC Informal Problem Consultation
They were helpful when I spoke with them.

 

[PsyDWannabe]

That billing situation makes no sense. Insurance reimburses billing codes, not overall stays. And, for most MH inpatient stays, the institutions are losing money. Not saying that how teh situation has been handled with you interns has been good, just that the monetary situation is not great, and I can see the sense of straight furlough for pragmatic reasons.

That's not my understanding, but I will double-check with my supervisor to clarify.

I have it on good authority that what @MiniLop is saying is, in fact, factual. My workplace as well as other state and federal institutions reimburse by way of 'daily lump sums' per RESIDENTIAL patient. So no matter what you do or don't do with them, you get reimbursed simply because you are housing them. Basically one day = one "encounter". But as i said, I have only heard of this in instances where taxpayers are funding the institution in some way-shape-form, never heard of it with private insurance.

 

[R. Matey]

I have it on good authority that what @MiniLop is saying is, in fact, factual. My workplace as well as other state and federal institutions reimburse by way of 'daily lump sums' per RESIDENTIAL patient. So no matter what you do or don't do with them, you get reimbursed simply because you are housing them. Basically one day = one "encounter". But as i said, I have only heard of this in instances where taxpayers are funding the institution in some way-shape-form, never heard of it with private insurance.

I was wondering something similar. In places where I worked in the past that had inpatient facilities that billed Medicaid the documentation was different because we weren't billing per service. I didn't know nuts and bolts of the billing though. Us lowly peons weren't privy to such information.

 

[AcronymAllergy]

The consultation link with APPIC is certainly a resource, and APPIC as a whole has a h/o being a very responsive organization. Has the push back to your push back been from training faculty, the internship director, facility leadership, all of the above...?

I certainly can't speak for every site out there. I can say our site stopped in-person contact by trainees 3 or 4 weeks ago, and a nearby site did the same (including inpatient, although the facility is not only inpatient).

My personal (non-institution-endorsed) view is that if they're pulling medical students out of direct patient-contact rotations, it's hard to justify keeping psychology interns in those same situations. Although our situation is admittedly different. I imagine it may be the case that if a medical school pulls its students but decides they've done enough to graduate and grants them a degree, states and residencies may not care how many hours they've completed. In psychology, even though your internship may be able to adjust their requirements to support your successful completion and your doctoral institution may grant you a degree, individual states have their own specific internship-related training requirements. This makes it a bit of a tricky situation for internship directors, especially if inpatient services are the only services being provided and the facility isn't supporting telehealth for such.

All that being said, I unfortunately wouldn't be altogether shocked to hear that some sites are just trying their best not to deal with it.

 

[forensic13]

I'm also an intern at a state hospital. We are going in for our direct patient contact only and telecommuting from home for all of our report writing, documentation, didactics, etc. It seems like a fair trade off because I'm reducing exposure (both to me and from me) while also still earning direct hours in order to finish internship (hopefully) on time. All staff have to wear masks at work, and we try to practice social distancing as much as possible while still providing necessary treatment and assessment to our patients.

 

[PsyDr]

Kiddos:

I would HIGHLY recommend:

1) Combing through APPIC definitions of "direct hours"
2) State definitions of "direct hours"
3) Printing any and all state memos that say something like "telemedicine will count as direct hours", "we are allowing exceptions because of covid...".
4) SAVE ALL OF THOSE THINGS. PRINT TO PDF, EMAIL TO YOURSELF. KEEP THOSE IN A HARDCOPY FILE FOREVER.

There is a possibility that those memos are no longer hosted on servers, or policy changes, or whatever. If you move states ,you will have some differences in your application that bureaucrats will have to deal with. If you apply for boards, same. You would benefit from having state and professional association documents that substantiate such differences are okay.

It seems stupid, but it is MUCH easier to have these things saved forever than to try to find them 2, 5, 10, 20, 30 years after the fact. At some point, you'll be dealing with a bureaucrats that wasn't even born when Covid19 happened.

 

[AcronymAllergy]

Kiddos:

I would HIGHLY recommend:

1) Combing through APPIC definitions of "direct hours"
2) State definitions of "direct hours"
3) Printing any and all state memos that say something like "telemedicine will count as direct hours", "we are allowing exceptions because of covid...".
4) SAVE ALL OF THOSE THINGS. PRINT TO PDF, EMAIL TO YOURSELF. KEEP THOSE IN A HARDCOPY FILE FOREVER.

There is a possibility that those memos are no longer hosted on servers, or policy changes, or whatever. If you move states ,you will have some differences in your application that bureaucrats will have to deal with. If you apply for boards, same. You would benefit from having state and professional association documents that substantiate such differences are okay.

It seems stupid, but it is MUCH easier to have these things saved forever than to try to find them 2, 5, 10, 20, 30 years after the fact. At some point, you'll be dealing with a bureaucrats that wasn't even born when Covid19 happened.

Seconded. If you email state boards and receive guidance on any temporary accommodations/changes they're making, save those emails. Forever.

 

[StellaB]

This is absolutely reprehensible behavior on the part of your internship site. At my facility, which is also forensic inpatient, and which also has an internship program, there has been a significant amount of planning around intern and patient safety. We don't have any [known] positive cases of COVID in the institution yet, but staff are already being moved to partial work-from-home, and interns are going to be working over 50% from home effective immediately. Even though we aren't set up to do telehealth, the interns will still be able to do all of their writing/research/grand rounds prep/etc remotely. It's not just a question of protecting them, but also protecting the patients, as staff are likely going to be the ones eventually introducing the disease to our vulnerable population. Considering how many inpatients are on drugs that cause diabetes and/or weaken their immune systems, I am horrified to hear about how cavalier sites are being about this crisis. People are dying, this isn't a time for lazy complacency.

 

[WisNeuro]

I have it on good authority that what @MiniLop is saying is, in fact, factual. My workplace as well as other state and federal institutions reimburse by way of 'daily lump sums' per RESIDENTIAL patient. So no matter what you do or don't do with them, you get reimbursed simply because you are housing them. Basically one day = one "encounter". But as i said, I have only heard of this in instances where taxpayers are funding the institution in some way-shape-form, never heard of it with private insurance.

Much more complicated than that. There is the Medicare IPF PPS policy, which pays x number of days a year, up to x number lifetime, but for many services, many providers such as psychologists are not covered the same as physicians

"The IPF PPS does not include payment on a fee schedule basis for physicians under 42 CFR § 415.102(a) such as physician assistants, nurse practitioners and clinical nurse specialists, certified nurse-midwives, qualified psychologist services, and certified registered nurse anesthetists."

Additionally, this rate is usually much lower than how much it costs the hospital to house the patient along with the services that they need on a daily basis. Huge money loser the vast majority of the time. What's a common link for hospital systems that are hemorrhaging money? Large inpatient units that take medicare/aid patients.

 

[AbnormalPsych]

PA recommends you contact your malpractice carrier before engaging with a patient over the phone without video (e.g., not true telemedicine) to gauge their official, legal position."

I'm curious how many of us are doing this?

 

[WisNeuro]

I'm curious how many of us are doing this?

I'm not, but I'm also not doing any telephone visits that I am billing.

 

[clausewitz2]

Much more complicated than that. There is the Medicare IPF PPS policy, which pays x number of days a year, up to x number lifetime, but for many services, many providers such as psychologists are not covered the same as physicians

"The IPF PPS does not include payment on a fee schedule basis for physicians under 42 CFR § 415.102(a) such as physician assistants, nurse practitioners and clinical nurse specialists, certified nurse-midwives, qualified psychologist services, and certified registered nurse anesthetists."

Additionally, this rate is usually much lower than how much it costs the hospital to house the patient along with the services that they need on a daily basis. Huge money loser the vast majority of the time. What's a common link for hospital systems that are hemorrhaging money? Large inpatient units that take medicare/aid patients.

So I will say this is not how it works for inpatient reimbursement in our system, provided that a) the patient has Medicaid or medicare advantage and b) is a resident of specific counties in our area, including the most populous ones. We are most definitely reimbursed on a per diem per patient basis irrespective of what services are provided (above a certain very bare minimum). So say we get an MRI on someone while they're inpatient - we have to eat the cost, it comes out of the per diem. Our inpatient units actually subsidize the outpatient side of things.

Part of this is because our system owns the outfit that administers Medicaid in our neck of the woods and the private market is dominated by our self-insurance products but most private insurers in our area have fallen into line.

Medicaid from more remote outlying counties, however, is a totally different story.

The per diem is also why when we want to give someone a long-acting injectable antipsychotic we try to time it so at least one dose is on the day of discharge. That way, the patient is "discharged" and does not receive the injection while inpatient, but instead receives it at our "Day of Discharge Clinic". This means in practice they receive it from the charge nurse, who is the sole clinical staff of the day of discharge Clinic on each unit. This way inpatient does not eat the cost of the med but it is billed as an outpatient service.

 

[WisNeuro]

So I will say this is not how it works for inpatient reimbursement in our system, provided that a) the patient has Medicaid or medicare advantage and b) is a resident of specific counties in our area, including the most populous ones. We are most definitely reimbursed on a per diem per patient basis irrespective of what services are provided (above a certain very bare minimum). So say we get an MRI on someone while they're inpatient - we have to eat the cost, it comes out of the per diem. Our inpatient units actually subsidize the outpatient side of things.

This is the opposite of us. Our hospital has the most inpatient MH beds in the state, proportionally, and see a largely Medicare/aid population. These units are the largest factor in our system's nearly 100 million shortfall last year. So much so that they have proposed closing down this one hospital and its MH units to get us back to solvency.

 

[singasongofjoy]

Most insurances will not cover telephone based MH services, and Medicare has been wishy washy on this thus far in its COVID guidelines.

medicaid in our state and most other insurance companies are (supposedly) reimbursing telehealth at the same rate as the usual 90834 and etc codes. Telephone only though is peanuts but at least almost all insurance companies have OK'd it.

 

[WisNeuro]

medicaid in our state and most other insurance companies are (supposedly) reimbursing telehealth at the same rate as the usual 90834 and etc codes. Telephone only though is peanuts but at least almost all insurance companies have OK'd it.

I haven't seen any clear issuance of CMS on this yet (phone only). Our state is a patchwork of this when it comes to private insurers. Some will cover therapy, at the moment. As far as neuro assessment, anything beyond very basic screening still requires video capability.

 

[Ollie123]

How much success are folks having with video so far?

We are very rapidly rolling it out, but right now the big barriers seem to be server-side rather than issues relating to patients or providers. There just isn't the bandwidth to reliably do video and this leads to most telehealth visits being a frustrating series of dropped video attempts before the clinician finally says screw it and moves to phone. Admin continues to push video visits yet is unable to tell us what is going on with the technical problems.

Unsure to what extent this is due to our specific telehealth system versus the global bandwidth issues we are dealing with across all areas right now due to so many things being moved online.

 

[WisNeuro]

How much success are folks having with video so far?

We are very rapidly rolling it out, but right now the big barriers seem to be server-side rather than issues relating to patients or providers. There just isn't the bandwidth to reliably do video and this leads to most telehealth visits being a frustrating series of dropped video attempts before the clinician finally says screw it and moves to phone. Admin continues to push video visits yet is unable to tell us what is going on with the technical problems.

Unsure to what extent this is due to our specific telehealth system versus the global bandwidth issues we are dealing with across all areas right now due to so many things being moved online.

I have some colleagues doing some pretty brief testing/screening. So far, report is that many patients (especially elderly) either do not have the capacity for video visits, or cannot/do not want to figure out how to do it. One colleague in a similar circumstance and setting I am in has reported that about half of people he asks, just want to wait until they can come in for F2F. When the video visits do happen, technical issues are fairly common. These are either due to server/connection issues, or patient connection issues/poor reception.

I am actually testing out my computers to ready for some clinical interviews and possibly some brief testing/screening as well. So far, encountering a lot of technical issues with our process. I've tested it out at home a couple times and had some dropped calls sessions, not ideal in a testing context. Going to go into the office tomorrow and test it out there and see if I get the same issues.

 

[R. Matey]

How much success are folks having with video so far?

We are very rapidly rolling it out, but right now the big barriers seem to be server-side rather than issues relating to patients or providers. There just isn't the bandwidth to reliably do video and this leads to most telehealth visits being a frustrating series of dropped video attempts before the clinician finally says screw it and moves to phone. Admin continues to push video visits yet is unable to tell us what is going on with the technical problems.

Unsure to what extent this is due to our specific telehealth system versus the global bandwidth issues we are dealing with across all areas right now due to so many things being moved online.

I’m doing roughly 20-25 hours of tele-therapy right now and it’s going well. No dropped calls yet but some slowing that was abated by switching off video and doing an audio only call. We’re not billing so these distinctions between telephone therapy and “tele-therapy” don’t really apply to us.


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[AcronymAllergy]

How much success are folks having with video so far?

We are very rapidly rolling it out, but right now the big barriers seem to be server-side rather than issues relating to patients or providers. There just isn't the bandwidth to reliably do video and this leads to most telehealth visits being a frustrating series of dropped video attempts before the clinician finally says screw it and moves to phone. Admin continues to push video visits yet is unable to tell us what is going on with the technical problems.

Unsure to what extent this is due to our specific telehealth system versus the global bandwidth issues we are dealing with across all areas right now due to so many things being moved online.

My own experiences with telehealth have been similar to yours, and I've switched to doing most/all appts via telephone. Which is consistent with guidance from upper leadership anyway.

Our interns have had better luck with telehealth, as have (reportedly) some providers elsewhere in the state. Although the video does seem to freeze/stutter a not-infrequent amount, so for any testing/screening, I could see that being a problem. We also serve a good number of rural patients, so it's possible some of the connectivity and network issues are patient-side.

 

[iliketohelppeople]

This is the opposite of us. Our hospital has the most inpatient MH beds in the state, proportionally, and see a largely Medicare/aid population. These units are the largest factor in our system's nearly 100 million shortfall last year. So much so that they have proposed closing down this one hospital and its MH units to get us back to solvency.

When I did work at a big hospital system in a major metro, I heard quite a bit of talk about how the inpatient mental health unit was bleeding money. I don't know if they were talking about closing it down, but it would not surprise me if that were the case.

How much success are folks having with video so far?

We are very rapidly rolling it out, but right now the big barriers seem to be server-side rather than issues relating to patients or providers. There just isn't the bandwidth to reliably do video and this leads to most telehealth visits being a frustrating series of dropped video attempts before the clinician finally says screw it and moves to phone. Admin continues to push video visits yet is unable to tell us what is going on with the technical problems.

Unsure to what extent this is due to our specific telehealth system versus the global bandwidth issues we are dealing with across all areas right now due to so many things being moved online.

We have had a few kinks with telehealth. I think it has been a couple of things: service specific bandwith issues and patient issues. Suposedly they are working on the bandwith issues and some of that may have been resolved. However, I am savoring the last few months of not being beholden to productivity requirements and not pushing folks to telehealth. Many of my phone sessions are going well for the most part, but a few dropped calls here and there. However, I have noticed that our patients have been quite patient with the process for the most part.

 

[singasongofjoy]

How much success are folks having with video so far?

We are very rapidly rolling it out, but right now the big barriers seem to be server-side rather than issues relating to patients or providers. There just isn't the bandwidth to reliably do video and this leads to most telehealth visits being a frustrating series of dropped video attempts before the clinician finally says screw it and moves to phone. Admin continues to push video visits yet is unable to tell us what is going on with the technical problems.

Unsure to what extent this is due to our specific telehealth system versus the global bandwidth issues we are dealing with across all areas right now due to so many things being moved online.

In our department i've heard that many clients have had much better luck using their phone - idk if they are using phone data instead of wifi or what. My understanding of how technology works and what might address which problems is... slim.

 

[WisNeuro]

In our department i've heard that many clients have had much better luck using their phone - idk if they are using phone data instead of wifi or what.

I'd be fine with phone for therapy, but it seems like it would add further validity issues in an assessment context.

 

[smalltownpsych]

Our residential facilities continue to function and we have made alterations to how we de;liver our services and the structure of our program. We do not have any positive cases yet, but have plans in place for isolation, containment, and video sessions if and when that happens.

One challenge we have is that most of our program is transitional with the goal of integrating young adults with severe mental health concerns into the community. We can't do much integrating these days and so all of our levels of care look about the same now. 🙁

Another issue is that our residents are not able to have family visits and this morning I am kicking off our second virtual family weekend. It is definitely lowering the bar of what we normally deliver.