Is It Time to Increase Office-Based Patient Visits?

A Netrin Q&A With Primary Care Practices

Beginning May 7, 2020, Maryland health care providers were finally allowed to schedule in-person elective and non-urgent care appointments. Nearly one month later, are practices scheduling more in-person visits? And what is the role of telemedicine as practices increase patient visits?

Netrin Health spoke with Aruna Nathan, MD, a Kensington-based independent primary care physician with a specialty in lifestyle medicine, and Janet Gerber-Salins, the practice administrator for Laurel-based MedPeds LLC, to learn what their practices are planning to safely increase office-based patient visits as the COVID-19 pandemic continues.

Here’s a summary of our discussion.

Aruna S Nathan MD PA

  • Internal medicine and lifestyle medicine
  • 1 provider
  • 1 practice manager
  • Patients: Adults only

MedPeds LLC

  • Family medicine practice
  • 9 providers
  • 27 staff
  • Patients: Children through elderly

Netrin: What are some of the COVID-19 issues to consider as you reopen your office?

Dr. Nathan: Our office has been open through this pandemic on an as-needed basis. We schedule and see patients with no COVID-19 symptoms, and those who we have to see in the office. If patients describe symptoms not indicative of a coronavirus infection, such as abdominal pain or heart palpitations or insect bite reactions, and they have no COVID-19 symptoms, I schedule them to come into the office for a physical exam and testing. Most of the patient consultations have ben via telemedicine.

Safety is our No. 1 concern—safety for our staff and our patients. We are following protocols and doing everything possible not to spread infection.

To ready our office for more in-person patient visits, we had to review our inventory of PPE [personal protective equipment], as well as the PPE supply chain and delivery times to ensure we are well stocked.  In addition, we had to consider cleaning supplies and wipe-down procedures; and we also create a revised workflow to limit the number of patients in the office at any given time.

“We are considering how to beat the virus by exploiting what we know about it.”

– janet gerber-salins –

Gerber-Salins: We never really stopped seeing patients in the office; we just saw a smaller number.

We are starting the process of thinking about how we can safely offer more office visits to more people, and there are so many factors that we have to consider. It’s daunting.

First, we want to make sure that our patients are entering a safe place and that our staff are entering a safe place.

We are trying to figure out which patients need to come into the office.

And we are considering how to beat the virus by exploiting what we know about it. One way is to use a 3-on, 11-off schedule:

  • Team A would come into the office Monday, Tuesday, Wednesday; and then the rest of that week and the following week, they would work from home [a self-quarantine].
  • Team B we would Thursday, Friday, Saturday, and then work from home the next 11 days.
  • Team C does the following Monday, Tuesday, Wednesday, and so on

So, by the time that we know they have the virus, they’re already self-quarantined; and if they don’t have symptoms, they come back into the office.

But not all providers can commit to this 3-on, 11-off schedule.

Netrin: What is your patient-intake process for office visits?

Dr. Nathan: We have a well-defined process to intake patients ensuring the safety of everyone involved.

We sent out regular email communications to all our patients about our office protocols throughout the last three months. Currently, we call our patients a day before their appointment to ask COVID-19 screening questions. Any patient with symptoms suggestive of COVID-19, such as shortness of breath, muscle pain, unexplained cough, fever, chills, and loss of smell or taste, we evaluate via telemedicine and refer them for testing as appropriate.

“One of the bright spots during this pandemic is the adoption of telemedicine.”

– Aruna Nathan, MD –

We have taken steps to limit the number of patients in the office at all times. When patients arrive for their appointments, we have asked them to remain in their cars and text/call the front desk. And only once they have received a reply from us, they can come into the building wearing a mask at all times. This is to ensure we have followed our cleaning/wiping protocol of all high-touch surfaces that the patient may come into contact with.

Gerber-Salins: We pre-screen all patients by phone before their appointment. We adapted the CDC screening tool for our practice. If anyone scores a “yes,” then we change their in-office appointment to a telemedicine visit. We emphasize to patients that they have to be pre-screened.

Patients come alone unless they have a required caregiver. We allow only one caregiver, and we also pre-screen them. When they arrive, they stay in the car and call a special extension that goes directly to the front desk. The front desk confirms the pre-screening was done. If not, they complete the pre-screening on the spot.

Netrin: What is Netrin doing or can Netrin do to help support practices and patients during the COVID-19 pandemic?

Dr. Nathan: Netrin has really helped us with our home-bound patients. The data that Netrin provide [about our patients] are also helpful; they are helping us track patient immunizations and general preventive health.

I would like Netrin to help more with care coordination during these times to ensure continuity of care, especially for patients transitioning from hospitals to homes.

Gerber-Salins: We look forward to remote patient monitoring because that would increase telemedicine capabilities. Also, lobbying Medicare to continue to pay for telemedicine because if they don’t, that will increase the pressure to open the office and unintended consequences.

Netrin: What do you think post-pandemic, office-based patient care will look like?

Dr. Nathan: It’s too premature to answer that question. I should say, one of the bright spots during this pandemic is the adoption of telemedicine by our patients. Elderly patients with chronic conditions feel comfortable with tele-visits in the comfortable surroundings of their home. Telemedicine also eliminates the commute, time off from work, and does not compromise care.

In a few years, we may be close to where we were pre-pandemic. I believe most patients will return to office-based visits after the pandemic ends, but a sizeable number will probably opt for telemedicine.

Gerber-Salins: I don’t think it will ever be exactly like it used to be. It will get closer, but not for at least another year. Patients will demand more telemedicine now that they have had access to it. But I do not think patients can rely on telemedicine 100% of the time. Physicals on telemedicine are not the same, and some things you cannot do with telemedicine, like EKGs, vaccinations, and PAP smears.

I value seeing my doctor face-to-face, but at what cost? I can’t see why we would push it.

Netrin: What advice would you give other primary care practices who want to increase office visits?

Dr. Nathan: Stay alert and proceed with caution. This is not the time to become complacent, as changes are happening on a daily basis. Try not to get overwhelmed. Focus on the facts and look at all the available options. Take it slowly. If we act too quickly, we may end up in trouble. Communicate with peers, and stay connected to exchange notes on a consistent basis.

Gerber-Salins: We will slowly reopen. Really limit the patients who come in because if one of our providers gets infected, they could infect more patients and their families and the staff. The priority are those patients who really need the doctor to see them.

My point of view, if you can handle the patient visit on telemedicine, why risk it for the patient or for anyone bringing the patient into the office?

Netrin Health provides a variety of services to support primary care practices, including an easy-to-use telemedicine platform. Contact us to learn more.