COVID-19 Crisis Action Plan for Gastroenterology Practices: 10 Actions Your Practice Should Be Taking

By Louis J. Wilson, MD, FACG
Wichita Falls, Texas
Chair, ACG Practice Management Committee

Crisis is Opportunity

During my recent special edition ACG podcast entitled “ACG Leadership in a Time of Disruption” with ACG President Dr. Mark Pochapin and President-Elect Dr. David Greenwald, Dr. Pochapin pointed out that the Chinese characters for “crisis” are a combination of the characters for “danger” and “opportunity.” Although it’s uncomfortable to call a terrible infectious pandemic an opportunity, I realize that it’s critical for practicing physicians to view it that way.

While hospitalists, intensivists, and critical care nurses are certainly on the frontlines taking care of COVID-19 infected patients, gastroenterologists must avoid being pushed to the sidelines and must take meaningful action. This is the time for gastroenterologists to respond with leadership and foresight, contribute to emergency efforts and improve the way we do things. Today I’m sharing some of the actions I consider important for practicing gastroenterologists at this time.

1. Emergency PSA with your Hospital

Now is the time to approach your hospitals for emergency expansion of your current professional service agreements, or for new ones. While it’s probably not the time to negotiate or re-negotiate a long-term PSA, the timing is perfect for new emergency provisions. This COVID-19 pandemic is not going to resolve with a few weeks of social distancing and shelter-in-place rules. It is very likely to continue for months. Hospitals are under severe stress as they hurriedly prepare to handle the expected surge of patients. Hospitalists and intensivists will require significant support from specialists in every part of the hospital. Hospital-based endoscopy units will also be challenged as PPE requirements dramatically increase and anesthesiologists work to support the intensive care units. We immediately petitioned the hospital for financial support for a second gastroenterologist on-call for at least the next two months. This additional GI specialty support that we provide will help reduce admissions, hospital stays, and improve the quality of care.

2. Maintaining Outpatient Endoscopy Access for Urgent Indications

Ambulatory surgery centers (ASCs) are in a unique position to provide safe and efficient outpatient services, including necessary or emergency endoscopy procedures. This is not the time to push such procedures to the hospital setting. My practice has moved to set up comprehensive and effective pre-screening at our endoscopy center, as well as expanded use of PPE for physicians and staff. The hospital system should be fully supportive of these efforts. Currently, we have reduced our staffing profile to keep one endoscopy room open. As the pandemic stretches from weeks to months, the pressure of patients with urgent or urgent-elective will most likely increase. The basic infrastructure of the endoscopy center also needs to be protected for future use. There is likely going to be a tremendous increase in demand for routine endoscopy, possibly as soon as June.

On March 30th, CMS announced that ASCs, which have been restricted by states from performing elective surgeries, can contract with hospital systems to provide hospital space and/or services. ASCs also can even enroll and bill as hospitals, subject to certain caveats. In March, CMS released guidelines to cancel or postpone all elective and non-emergency procedures, specifically citing endoscopy. CMS provided further guidelines in early April, providing some examples on what services should not be postponed. My practice is currently focusing on providing endoscopy services. Risk stratification is key. Our gastroenterology call-team will work closely with referring hospitals, the emergency department, and other units to provide endoscopy services for urgent indications in low risk patients (COVID-19 test-negative, lack of contact or exposure to COVID-19 and/or absence of COVID-19 symptoms).

3. Support your Staff

The staff at our offices and ASCs represent critical infrastructure that must be protected during these difficult times. We have made protecting their jobs and wages a top priority in our practice. The physicians in our practice are willing to work for little or no compensation to meet payroll despite substantial revenue reductions. The Payroll Protection Program administered through the Small Business Administration included in the CARES Act should be of considerable help. Businesses with less than 500 employees who do not reduce their payroll by more than 25% are eligible for substantial loan forgiveness. You should contact your SBA office or accountant for details. Click here for ACG’s guidance on the Payroll Protection Program.

Employee Retention Credits are also available to companies with receipts that decline by more than 50% compared to the same quarter the previous year. These provide a refundable payroll tax credit. Finally, WorkShare Unemployment Benefits have been substantially increased. We will be assessing all these opportunities as ways to retain and support our staff wherever possible. Congress is expected to provide more financial assistance for small businesses in the coming weeks.

4. Participate in Transitional Care

Hospitals will be aggressively seeking ways to reduce hospital stays over the next several months. Hospital patients without insurance or adequate financial resources are challenged as they transition to the outpatient setting. Our hospital system has a Transitional Care Clinic to facilitate hospital discharges, coordinate outpatient care, and provide immediate access for patients recently discharged from the hospital. Gastroenterologists can support these efforts by scheduling once per week office hours at the Transitional Care Clinic for recently discharged patients with digestive issues. We’re using our newly funded second gastroenterologist on-call (see above).

5. Improve Transfer Center Access

The Hospital Transfer Center receives many calls from referring hospitals and providers for patients that may require transfer or specialty consultations. These calls are an excellent opportunity for our on-call gastroenterologists to advise these referring providers, reduce hospitalizations and improve care coordination of patients. Again, risk-stratification is critical. Many low risk patients can be sent to the ASC instead of the hospital, and even transferred back after appropriate procedures have been performed. Other patients can be scheduled for telemedicine consultation or outpatient follow-up. Now is the time to communicate these goals with the staff of the transfer center.

6. Emergency Department and Clinical Decision Unit

Communicate clearly with the emergency departments and clinical decision units about new opportunities to prevent hospitalizations, coordinate care, and provide gastrointestinal services. This communication may need to be repeated several times. If physicians and advanced practice providers in the emergency department are aware of what resources are available for patients with gastrointestinal issues, the increased access to care will support all our priorities.

7. Telemedicine and Videoconferencing

If your practice has been on the fence about starting telemedicine, now is the time for rapid adoption. The recently published Practice Management Toolbox entitled, “Essential Guide to Telemedicine in Clinical Practice: Easy Steps to Rapid Deployment” by Eric D. Shah, MD, MBA, Stephen T. Amann, MD, FACG, and Jordan J. Karlitz, MD, FACG is an excellent place to start. The article also provides a website that provides the latest telehealth developments in each state, including information on commercial payers. The Telehealth Services during Certain Emergency Periods Act of 2020 has eased previous Medicare restrictions that made it less practical to deploy. CMS also announced in March that Medicare patients can receive telehealth for all services (even if unrelated to COVID-19) and providers can reduce or waive cost-sharing for telehealth visits. Medicare continues to announce new waivers related to telehealth.

Videoconferencing technology is making it easier to see patients in the hospital or intensive care unit when they are in respiratory isolation. Telemedicine and videoconferencing technology will extend our reach beyond our office and hospital to other facilities and communities in a way that was previously impossible.

8. Efficient, Structured Meetings

Times of crisis often become crowded with conversation and communication. Structuring efficient meetings becomes very important. I strongly recommend you schedule regular meetings, at least twice weekly, for updates on the situation for your entire team. We include our physicians, advanced practice providers, practice administrators, hospital administrators and ASC leadership. Social distancing is practiced carefully, and teleconferencing should be used when feasible. Efficiency is key. Structured content should be anticipated and provided. These meetings are not a time for open argument between physicians. Some of the things we are including are listed:

a. Community COVID-19 statistics and projections
b. Hospital and inpatient GI service census
c. GI service COVID-19 impact (number of GI consultations and patients listed as COVID-19 positive or under investigation)
d. Scheduling updates and adjustments
e. Staffing update (manpower update, staff illness, staff challenges)
f. New issues

Having the hard conversations in a structured way dramatically reduces tension and improves efficiency of our communication. These meetings are a critical way of reducing risk to our practice in these uncertain times.

9. Infection Control Plan

A structured infection control plan is essential. If your practice has not already adopted such a plan, it should do so immediately. The ACG Practice Management Toolbox on “Developing an Infection Control Plan” is an excellent place to start. It even provides a template that can be applied to most practices with very little modification. The plan should be reviewed with staff and frequent coaching and encouragement by the physicians is very important. I walk through all patient care areas frequently to monitor and encourage appropriate infection control practices. Signage concerning COVID-19 should be placed very clearly at every entrance point of every facility. Pre-screening for COVID-19 risk factors by telephone for all patients at the office or ASC should occur at least 24 hours before any face-to-face appointment.

10. Social Distancing and Personal Care

These are very stressful times. This is the wrong time for physicians to forgo self-care. Social distancing, hand washing, and PPE doesn’t end when we leave the office. We must all communicate clearly with the people we live with at home as well. This especially applies to children and young adults. Shelter-in-place makes exercise much more difficult, so is the perfect time for calisthenics, yoga and meditation. This crisis will be a marathon, not a sprint. It is critical that we take care of ourselves along the way.

STAY IN THE FIGHT

Gastroenterologists are critical members of the healthcare team during this time of crisis. With crisis comes opportunity. Now is the time for action and leadership. These steps are helping our gastroenterology practice contribute to the broad effort to overcome the COVID-19 pandemic. Stay healthy and stay in the fight.