By Jeanie Davis

New York City struggled, as did other hotspots. Patient care units sprung up in public spaces. Busloads of out-of-state nurses, medical residents, and retired doctors, nurses, and therapists pitched in.

To expedite patient care, insurance companies waived copays and deductibles. Discharge planning regulations were relaxed. Paperwork took a back seat, as all efforts were directed toward patient care.

All this was due to the declaration of a national emergency, which gave impetus to changes from the Centers for Medicare & Medicaid Services (CMS).

CMS initially enacted 28 pages of waivers of federal requirements to ensure that local hospitals and health systems had the capacity to absorb and effectively manage potential surges of COVID-19 patients. These waivers have been continually expanded, sometimes daily. (More information on the waivers is available at: https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient.)

“The waivers are appreciated by the healthcare community, and unprecedented,” says Sue Dill Calloway, RN, AD, BA, BSN, MSN, JD, CPHRM, CCMSCP, CCMSP, president of Patient Safety and Healthcare Consulting and Education. “However, the waivers are temporary and will end when the COVID-19 emergency is over.”

Also, these are not “blanket waivers” for every hospital, adds Beverly Cunningham, MS, RN, ACM, partner with Case Management Concepts, LLC. “These new rules can apply to every hospital. However, if your hospital doesn’t have a surge, be considerate on using the waivers. It’s an important thing to remember.”

There is potential for a paradigm shift, says Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL.

“Hopefully, the changes from CMS will result in some regulations staying relaxed, like telehealth and home-based therapies,” Owen explains. “These may present such good results that some regulations will stay relaxed, whether COVID-19 is still a threat or not.”

Highlights from CMS Waivers

Highlights from the CMS waivers include:

• Establish adjunct hospitals without walls. CMS is allowing healthcare systems and hospitals to provide services in locations beyond their existing walls to increase the capacity for COVID-19 treatment.

Also, ambulances are allowed to transfer patients to a wider range of locations when other transportation is unavailable, including urgent care facilities, mental health centers, physician’s offices and dialysis centers, and still be covered by Medicare.

• Rapidly expand the healthcare workforce. Local private practice clinicians and their trained staff may be available for hospital practice. Medical residents are allowed to provide services under a teaching physician’s direction. CMS also allowed wider use of verbal orders so hospital doctors can focus on treatment.

Additionally, CMS issued a blanket waiver to allow hospitals to provide support to their medical staffs, such as multiple daily meals, laundry service, or childcare services. Nurses’ requirements to conduct a home health onsite visit every two weeks also are waived.

• Give priority to patients over paperwork. CMS is temporarily nixing paperwork so clinicians can spend more time with patients in COVID-19 isolation. Hospitals also will have more time to provide patients a copy of their medical record.

Medicare patients will have broader access to ventilators, multifunction ventilators, respiratory assist devices, and continuous positive airway pressure devices. Medicare will allow these for any medical reason determined by a physician.

• Promote telehealth. Medicare patients can use telehealth services from home, or a nursing or assisted living facility. This allows COVID-19 patients to remain in isolation and prevents exposure risk. CMS will pay for more than 80 services furnished via telehealth, including emergency visits, discharge visits, and home visits. Clinicians also can evaluate Medicare patients via phone calls.

Home health and hospice agencies can provide services via telehealth, although this does not replace needed in-home visits. Clinicians can provide remote patient monitoring services for patients with any condition.

• Modify discharge planning for hospitals. CMS is waiving certain requirements related to hospital discharge planning for post-acute care services to expedite the safe discharge of patients. CMS is waiving certain requirements for those patients discharged home, and for patients transferred to a skilled nursing facility, inpatient rehabilitation facility, or long-term care facility. These requirements include removing the requirement for choice and for sharing quality metrics for post-acute care providers.

“The discharge planning waivers are helpful, especially in light of the fact that CMS rewrote the discharge planning standards in 2019,” says Dill Calloway. “There were still many hospitals struggling to come into compliance with these new regulations, so this one was especially important for hospitals.”

Case Managers Must Lead in Crisis

It is a confusing time, as rules and regulations have been changed on the city, state, and federal levels, says Cunningham.

Payers also have made changes. For example, some payers may not require authorization for hospitalization or providing clinical treatment during a patient’s hospitalization. There is consensus among many payers that if a patient is diagnosed with COVID-19, they will not have to pay the deductible.

However, states differ in protocols involving Medicaid and nursing home admissions. States also have set their own definitions of “essential worker” status.

“Case management leaders must understand each of these regulatory situations, and they need to know what the government, the state, and the payers are saying,” says Cunningham. “Each hospital will establish its own protocols for operation. Will any patient care units accept visitors? Which units can be converted into COVID units? Case management leaders must be aware of changes in their hospital operations. As we’re working through pandemic issues, we as case management staff are not so much changing what we do but changing how we do it.”

She adds: “Hospital leadership will determine whether this planning occurs, and how effective it is. If the case manager or the staff is not getting answers, keep asking. You need to know now, not after the fact. It’s extremely important that the case management leader shares information with their staff on what your hospital is doing.”

Coordinate New Protocols

Case management leaders must collaborate with physician advisors to decide how they will evaluate medical necessity of patients suspected of COVID-19 — whether to place an order for inpatient or observation service. Guidelines can be established to assist case managers and physicians in creating accurate documentation and an appropriate order for these patients.

“Our physicians should not have to guess,” Cunningham says. Physicians have changed their operations, and case managers should respect how challenging their new workflow is. “Both case managers and physician advisors should be helping with that. Discussions with physicians regarding medical necessity for COVID patients should be consistent among the case management staff. Case management leaders also must watch for new updates.”

Advanced practice staff may not need the physician to cosign an order, Cunningham explains. “Case managers need to know how hospitalists are organizing their day. They must figure out how to collaborate effectively with those physicians.”

During this crisis, it also is necessary to assume that any patient in the hospital could have COVID-19, says Cunningham. “Case managers need to know what the protocol is going to be for their interaction with nursing, ancillary staff, physicians, patients, and families. With rounds, for example, how are we conducting those, yet keeping six-foot social distancing? Simply walking the halls of a hospital or doing rounds is very, very difficult. It’s not easy to manage six-foot distancing at the grocery store, so it’s certainly not easy in hospital halls.”

Be Considerate of Patients, Families

In some hospitals, ventilators might be in the hallway, connected via long tubes to the patient in the room. This decreases the time of contact with the patient, but also must take an emotional toll on patients, says Cunningham.

“We need to put ourselves in the patient’s place, in the family’s place, and in the doctor’s place,” she explains. “The doctor will be talking to the patient. We need to think about that, and be helpful in any way possible.”

Neither a case manager nor social worker needs to enter a patient’s room, Cunningham adds. “When PPE is so scarce, we do not need to be using those resources. CMS has agreed in FAQs that conversations for requirements, such as the MOON [Medicare Outpatient Observation Notice], can be done by telephone or iPad.” A clinical person can provide the written notice to the patient the next time they enter the room.

Some hospitals are asking staff to conduct all business with families via phone. It is critical to keep families informed sooner rather than later, says Cunningham. Her sister-in-law’s husband was recently in the hospital. She had to wait for a doctor to call her late in the day, every day, to tell her what was going on.

“We have to remember that communication is changing,” she says. “With no family members around, we will realize how supportive they can be, and how we communicate with them is important.”

While some Conditions of Participation have been waived during the surge, “we still need to ensure appropriate discharge planning,” says Cunningham. “We can do that in a phone call (to a family member) or give the patient an iPad.” FaceTime with families can be very effective, she notes.

Stay Flexible

Some hospitals are asking case managers to help nurses on the floors, says Cunningham. “Case managers are being used to help transfer patients, set IVs, and support the staff in other ways.” Leaders should ensure their staff is available to provide the appropriate utilization management and discharge planning for their patients. She also notes that the Two-Midnight Rule has not been waived.

It is important to understand the challenges the staff is experiencing, she adds. “They have to live this every day, then pray they have done everything per protocol so they don’t expose their families. Some are not even sleeping in their houses so they won’t expose anyone at home. As leaders, case managers must help as much as they can, in any way they can.”

Encourage Emotional Support

Case managers and their colleagues will need emotional support, says Owen. “They are seeing so much, involved in so much, and it’s going to be very difficult for them to decompress over the next months.”

Hospitals should be pulling resources to help staff maintain their mental health, Owen adds. “This should be paramount to make sure everybody is healthy going forward.”

Many health systems employ programs and Behavioral Intervention Teams (BIT) that work with patients. “BITs certainly could be organized to help patient care staff,” Owen suggests. “Maintaining mental health should be paramount to make sure everybody is healthy going forward.”