TO: Long-term Care Physicians and Nurse Practitioners
FROM: Dr. Margaret Manville, Medical Director Long-term Care
RE: LTC update
DATE: April 3, 2020
- Many questions have been asked about essential physician/NP visits. LTC homes, in collaboration with our medical leads in our four geographies, have come up with different solutions to this issue. Most LTC homes have limited the number of physicians who provide in-person visits, some to just the medical coordinator. Some have altered their on-call structure to reduce the number of physicians available to the facility. To protect our LTC residents from contracting COVID-19, we must:
- Reduce the number of physicians attending at LTC homes
- The physician who attends the LTC home should attend the fewest sites
- The attending physician should be of ‘ lowest risk’ to patients for COVID-19
- Any in-person essential visits are restricted to visits that are critical to a medical decision
- No proactive in-person visits at this time – please use telephone or telehealth options for proactive visiting. The LTC billing code 0114
- Your medical leads and medical coordinators in the geographies are working with LTC homes to come up with the safest and most resource-efficient plans for your communities.
- Most LTC homes are still contacting the MRPS for faxes, phone calls and telehealth visits.
- On-call physicians – there are also questions about whether on-call physicians can or should visit a LTC facility. If a visit is deemed essential to the medical or comfort care of the patient, especially if a visit can help with a decision to transfer or keep the resident in the LTC facility for care, that visit would be deemed essential. A good assessment from nursing and excellent communication are paramount for all to feel that they have enough information to make a good decision. The medical coordinator should only get involved if there are issues that cannot be resolved between the on-call physician and the nursing staff.
- Please see the New England Journal of Medicine article and CDC Morbidity and Mortality Weekly Report on COVID-19 in Nursing Homes in Washington State published last weekend. These reports support recommendations that reduce the ability of health care workers and others to bring COVID-19 into the nursing home (enhanced screening, reducing to essential visits only, restricting HCW working at different sites, self-monitoring for symptoms, use of PPEs). They also discuss asymptomatic and pre-symptomatic spread of COVID-19.
- MOST/ Goals of Care conversations. It is challenging to have these conversations in the context of COVID-19, with so many unknowns. However, it places an unnecessary burden on our on–call colleagues to have to do this when deciding about disposition if the MOST has not been recently reviewed. These conversations are better had with families before a decision must be made about transfer. If not already done in the last 6 months, please review your M3-C2 patients for their appropriateness for ER transfers and acute care admissions.
- E-MOST: here are some instructions about how to put the MOST into Powerchart.
- Medication reviews: it is very important that medication reviews are also done at this time. Please try to safely reduce the number of medications and the number of times a medication needs to be given to your patients. This reduces the exposure of patients to HCW interactions if the medication not absolutely necessary. Please target vitamins and supplements, and medications with uncertain benefit. If you think families will not agree, please state that the medications can be ‘held’ (eg. 4 weeks) and can be reviewed once the pandemic threat is reduced.
- Charting progress notes for telehealth visits (0114 or 14077). Many LTC facilities use an EHR (eg. Point Click Care, Powerchart) and many physicians are now charting progress notes in the facility’s EHR. The local site administration can help you with access if you are interested in charting electronically. Using your own office EHR is acceptable as long as your progress note is sent to the facility where your patient resides, and it should have 3 patient identifiers (Name, PHN, DOB). Dr. Bekker can help if you are interested in charting remotely in Powerchart. If you are not using an EHR, please use a template for recording your encounter (see the attached as an example) and send it to the facility. Templates also need 3 patient identifiers as stated. All progress notes should be sent into the facility as soon as possible after the telehealth encounter is completed so that documentation can be reviewed by staff and filed. Please type your notes if at all possible so they are legible for the staff. For this time, Island Health facilities will accept dictated progress notes, instructions in the memo below:
Dr. Margaret Manville, Medical Director Long Term Care
Geography 1: Dr. Kathleen McFadden, Medical Lead, LTC
Geography 2 Dr. Erfan Javaheri, Medical Lead, LTC
Geography 3 Dr. Stacey McDonald, Medical Lead LTC
Geography 3 Dr. Eric George, Medical Lead LTC
Geography 4: Dr. Ian Bekker, Medical Lead LTC