COVID-19 Prep Document

March 4, 2020

Now is a good time to prepare for the COVID-19 virus, both personally and professionally. COVID-19 is a novel virus that spreads via aerosol droplets, meaning exposure to the coughs or sneezes of infected individuals. Those droplets can also land on surfaces and exposure can occur if you touch an infected surface and then touch your nose, eyes or mouth. If you want to know more about the COVID-19 virus from the CDC’s website, click here. Here are some guidelines as well as important information concerning work-related matters such as keeping the clinic a safe working environment and how to deal with clients who become sick or request teletherapy options. This document may be updated as new information becomes available.

General preventive behavior:

It is important to try to minimize your exposure to infection, not only to protect yourself, family members, and those you come into contact with, but also because as healthcare workers, we see a multitude of people every day in a healthcare setting (sitting face to face for a good amount of time, sometimes fairly close, people may cry, which can lead to coughing, etc). We have a duty to the people we see to minimize their exposure and offer a safe healthcare setting in which for them to receive care, and, because we see multiple people per day and per week, to minimize our own exposure so we do not become hubs of transmission to several or many others.

To minimize exposure, we recommend practicing several modifications to your usual personal, social and clinical habits. Keep in mind that some individuals can carry the virus asymptomatically and transmit it to others without or prior to experiencing any symptoms. While we are typically warm, kind, nurturing and available individuals as helping professionals, it is important to keep in mind that protecting yourself and others from exposure may be more important for a period of time than shaking hands, hugging, sitting close to others, etc. It is recommended that individuals, including healthcare workers, practice what is called ‘social distancing.’ It sounds awful, but social distancing involves eliminating or reducing any unnecessary handshakes, hugs and kisses in order to minimize exposure to viral transmission. You may notice your clients wishing to practice the same, and they may avoid handshakes as well unless you initiate. This practice may also mean sitting a little further away from your clients if you tend to sit close.

Social distancing is an appropriate measure in the workplace for the time being and you can explain to clients who are accustomed to hugs and handshakes that as a healthcare worker, for the time being, you have a responsibility to eliminate unnecessary touch in order to protect all the clients and people you work with. It is also reasonable to implement more social distancing in your personal settings, minimizing unnecessary handshakes or hugs at social events like kids sports games and cocktail parties, and being careful with who you kiss.

Some people are practicing the ‘elbow bump’ as a greeting instead of handshakes, hugs and kisses. This form of greeting has been embraced by healthcare leaders and political leaders and will become more common. You can also just wave when you say hi to others and to clients and most people understand now that handshakes may be a little off limits just to protect everyone as much as possible.

In addition to social distancing, there are several other important preventive behaviors that may alter your usual habits. Those are mentioned below.

Approach to work:

We’re lucky enough to work in a field where we can do our work completely remotely if needed. Clients may request remote sessions or you may need to conduct remote sessions if you or a family member develops cold or flu symptoms.

We recommend letting your clients know that phone or video sessions are available if they ever don’t feel well or are wanting to stay home for whatever reason. We have also updated our cancellation policy for 2020 and you should advise your clients of it: They are welcome to cancel sessions on short notice without penalty if their cancellation is related to feeling sick, having cold or flu symptoms, or due to similar illness or virus-related logistical issues in their families. Tools we have available for remote sessions are you setting up a doxy.me account, or using our clinic’s Zoom for Healthcare account. Some clients may “put you on notice” that they may want to just do phone sessions for the next couple of months because they are going to try to stay home as much as possible. Some clients may be anxious or scared of public exposure with the virus and may want to stay home and do remote sessions proactively. We have listed some guidelines for conducting remote sessions below. If you need any help with doxy.me or preparing for online sessions beyond the guidelines below, let us know.

If your clients are self-pay, the charge for remote sessions is the same as for in-person sessions.

For those who accept insurance for sessions, treatment reimbursement can continue as usual unless the session is marked as remote in the notes and billed with the use of a different treatment code for remote sessions. Seton reimburses seamlessly for remote sessions. With BCBS, if you mark the session location as remote, BCBS will usually just put the session towards a separate deductible so clients are then responsible for their full allowable ($115 or so per session) until their deductible has been met. Similarly, if you mark the session as remote with Whole Foods clients they will not reimburse. We recommend you discuss these options and any changes to their fee schedule proactively so that both and you client understand what it would look like both clinically and from a payment side to shift to remote sessions and so have time to discuss that shift in person prior to needing to enact the change.

If BCBS and Whole Foods clients cannot afford their out of pocket allowable for remote sessions, you are free to negotiate a temporary sliding scale to preserve the treatment schedule. You are welcome to make special arrangements for a sliding scale with these clients if they can’t afford to pay out of pocket and you or they need to do remote sessions for a period of time or handle that however you want.  If you have any questions or need help trouble-shooting any part of what would be needed to move your practice temporarily completely remote, please let us know. We will also be discussing these options at an upcoming staff meeting.

If your clients decide to wear a surgical mask (blue) because they believe they may be contagious and want to protect others, it is best to advise the client to move to remote sessions. Those blue surgical masks do not prevent the person wearing it from contracting a virus. If a client begins wearing a N95 or similar mask to keep themselves from contracting the virus, is the recommended that you move to remote sessions. If those masks are properly fitted, they are difficult to talk through, limit breathing, and can be uncomfortable to wear properly. The same is true for us as providers: If we feel the need to wear either type of mask, it is probably best to move to remote sessions at that point.

We also recommend keeping sanitizing wipes and spray in your office from the approved list of disinfectant products (those made with bleach such as Clorox or Lysol products). If someone comes in looking sick or coughing, please let them know that you cannot see them in person right now if they are sick or have cold or flu symptoms such as runny nose or coughing, so send them home, but encourage them to schedule a make-up session to be done via remote tools, or to check with you on getting set up for remote sessions for their next appointment. Then use your sanitizing supplies to quickly clean surfaces the client may have touched, such as doorknobs or handles on the front door, bathroom, and counter surfaces.

Obviously, we expect that you will let your clients know via a bulletin proactively that they cannot come in to the clinic now if they feel sick or have cold or flu symptoms, or have recently traveled to any hotspots for the virus, and to work with you to setup a video or teletherapy option if that is the case. If someone does come in sick, however, after you ask them to leave, use the sanitizing wipes and spray in your office to wipe down door knobs (front office door, bathroom door, and office surfaces, etc) quickly after they leave. This is standard practice in some therapy and healthcare clinics anyways and helps prevent you from getting ordinary colds and flus as well. Use hand sanitizer liberally and after meeting with patients. If our waiting rooms do not have hand sanitizer out for clients to easily use, please place one there from your office and replace your own. In some cases, visitors may ‘borrow’ our sanitizer that is in the waiting rooms, so we all need to be vigilant that there is some there and available for use.

Personally:

• If you feel sick, stay home
• Try to avoid large gatherings, especially those where there may be people who have recently traveled
• Wipe down surfaces, doorknobs, and handles with Clorox wipes or other wipes containing bleach. See this cleaning guide if you need to do a deeper cleaning.
• Wash hands with soap often and thoroughly
• Avoid touching your face, nose, eyes and mouth
• Do your best to avoid exposure to any sick individuals
• Cover your coughs and sneezes with a tissue, then throw away the tissue
• Engage in habits that promote maintaining a healthy immune system, such as getting good rest and sleep, taking supplements, not wearing yourself down, etc.
• If a family member becomes sick with cold or flu symptoms, consider testing for coronavirus, monitor the situation, and stay in touch with your doctor
• We recommend stocking a minimum of a 6-week supply of basic supplies in case supply chains are disrupted or water systems/utilities experience failure. See below for supply recommendations
• If you are planning any personal travel this year, please let the office know. It is not recommended to travel to virus hotspots, and you may be quarantined upon your return if you do. Traveling to large gatherings and festivals, especially those that attract overseas visitors, is also discouraged. Keep in mind that even domestic travel to non-hot spots multiplies your risk of exposure due to the shared ventilation and close quarters of airplanes and the exposure to crowds of travelers at airports. If you can reduce or eliminate non-essential travel, that helps reduce your exposure and keep you, your family, and workplace safer.

Professionally:

• As staff, we request that if you feel sick, or have cold or flu symptoms, that you stay home and let the office know
• If you feel sick, cancel your clients or ask the office to help you cancel clients for that day and until you feel better
• Try to avoid large gatherings, especially those where there may be people who have recently traveled
• Wash hands with soap often and thoroughly
• Avoid touching your face, nose, eyes and mouth
• Cover your coughs and sneezes with a tissue, then throw away the tissue
• We have already begun wiping down surfaces, doorknobs, and handles with Clorox wipes at the office
• Do your best to avoid exposure to any sick individuals. If clients come in visibly sick or with cold or flu symptoms despite our request that they do not do so, it is important that you ask the client go home to rest rather than conduct the session, in order to avoid possible contagious exposure to yourself or others
• Should you begin to experience cold or flu symptoms, we recommend that you quarantine in place–do not come in to work–check in with your doctor so symptoms can be monitored, and check with your doctor to determine the appropriate time to return to work
• Should a family member become ill with cold or flu symptoms, we recommend that you discuss your risk of exposure with your doctor in order to determine whether to stay home or go to work. When in doubt, err on the side of caution and stay home
• If you feel well enough to work but are not yet cleared to return to the workplace, or if your clients request telehealth options to do remote sessions via phone or video, you may use your own Doxy.me account or the clinic’s Zoom for Healthcare account. Christina can get you set up on our Zoom account. We recommend that you familiarize yourself with these telehealth options and how to use them now so you feel confident agreeing to meet remotely if clients request it. When possible, we recommend keeping the same clinical schedule, just conducting the session remotely if needed
• Advise clients of our new cancelation policy (they may cancel on short notice with no penalty if they are feeling ill or have cold or flu symptoms) verbally and by email
• Advise clients verbally and by email to not come in for a session if they are experiencing cold or flu symptoms or if they feel sick and to request telehealth options so that their therapy/medical care may continue
• If clients ask about the nature of our medical services, or notice medical supplies beginning to arrive for our primary care department, you can put them at ease by assuring them that we are not a walk-in clinic and we do not treat colds or flus on site
• If you need to stay home due to quarantine, to take care of a sick family member, or due to school closures, please make every effort to maintain a normal work schedule and keep session times by utilizing telehealth tools such as Doxy.me or our clinic’s Zoom for Healthcare account

Telehealth Protocols and Guidelines:

We are still refining our approach to teletherapy and telehealth options, and will update this document as additional information is gathered and decisions are made. For the time being, it is easy and HIPAA-compliant to open a Doxy.me account and use that with clients. You can text or email them the link to your platform once it’s set up, and it’s easy for them to use. We may also have a Zoom for Healthcare account for the clinic that may be available for you to use.

In most of our offices, you can hardwire into the clinic’s internet with an ethernet cable to improve the stability and speed of the internet connection, which can be helpful when conducting video-based sessions. This may not be necessary, but if you notice glitches or lags doing sessions over wifi, it would be recommended to set up a wired connection.

You should have a device available to conduct teletherapy sessions from home. Once you identify the best device for that purpose, whether it be a laptop, desktop computer, or your phone, set up your telehealth platform and test it so that you know how it works. Feel free to ask us about videoconferencing tips like establishing privacy, quiet, proper lighting and options for improved audio. You should identify a place at home where you can conduct telehealth sessions privately, with an appropriate and professional backdrop, and test your internet connectivity for video conferencing at home. You will also want to coach your clients on establishing privacy and on all of the above guidelines to improve the quality of telehealth sessions.

Stocking supplies at your home:

It is advised to stock up on non-perishable food and supplies at home. These supplies may come in handy if you or family members need to quarantine in place, if there is a local run on certain staples, or in case supply chains for products, such as those made overseas, are disrupted. We recommend amassing a 6-week or more supply of non-perishable food, water, medicine, toiletries, and household items. Having extra supplies will minimize work disruptions due to seeking supplies that may be in low stock, and help you stay healthy if you or a family member decides to stay home for a week or two to recover from illness or to prevent exposure. Since stocking up on supplies is an added and significant expense, it is generally recommended that you stock items you would generally use anyways, so they don’t go to waste. You can rotate your stocks by using some items and replacing them as you go. It is also recommended that you do not rely on frozen stocks, as frozen items may only last 24-48 hrs if electricity goes out. Such items may include:

Water

• Bottles or jugs of drinking water
• Water filters in case electricity or municipal water systems become disrupted (see below)

Apple juice

Non-perishable food, such as:

• Sardines
• Tuna
• Peanut butter
• Almond butter
• Nuts
• Beef jerky
• Broth
• Dried vegetables, chicken, rice and beans
• Canned soups including chicken soup
• Rice
• Beans
• Canned veggies
• Pasta
• Protein bars
• Canned fruit

Medicines and prescriptions, or other medical supplies, especially if you need them to survive (heart medicine, inhalers, syringes, etc).

• Aspirin or Advil
• Tylenol
• Vitamin D3
• EmergenC
• Pedialyte
• Imodium AD
• Vitamin C
• Multivitamin

Toiletries:

• Soap
• Detergents
• Hand sanitizers
• Toilet paper
• Kleenex
• Clorox wipes and bleach-based disinfectant spray

Emergency supplies:

• Batteries
• Radios, such as a battery-powered or weather band radio
• Outdoor survival supplies, such as a camp stove
• Cash
• Water filters, such as the Sayer 0.1 micron squeeze water filter system: https://www.amazon.com/gp/product/B00B1OSU4W/ref=ppx_yo_dt_b_asin_title_o00_s00?ie=UTF8&psc=1

Planning resource: https://www.dartmouth.edu/hrs/pdfs/pfp_checklist.pdf

If you are considering travel this year:

Check the CDC’s Traveler’s Health Notices for the latest guidance and recommendations for each country to which you will travel. Non-essential travel, especially by plane, is discouraged at this time.

For updates on the COVID-19 virus, we recommend that you monitor the CDC’s website, which also contains information from the CDC’s telebriefings, such as their recent March 3, 2020 briefing:

“While information so far suggests that most COVID-19 illness is mild, a report out of China suggest serious illness occurs in 16% of cases.  Older people and people with underlying health conditions, like heart disease, lung disease and diabetes, for example, were about twice as likely to develop serious outcomes versus otherwise younger, healthier people.”