Pandemic Forces Changes in Health Systems, Including Case Management
Case manager face barriers to seeing patients
By Melinda Young
EXECUTIVE SUMMARY
Health systems employed social distancing measures and changed their day-to-day operations due to COVID-19, affecting case management as well.
• Often, case managers could only interact with hospitalized patients and their families via a phone call or video conference.
• The Centers for Medicare & Medicaid Services issued new rules and waivers of federal regulations, including easing telemedicine restrictions.
• The Centers for Disease Control and Prevention data from March 27 revealed that 57% of asymptomatic, elderly patients tested positive for COVID-19.
Hospital case management changed dramatically in the spring. Health systems began implementing far-reaching infection prevention measures and changed some operations to accommodate expected surges in patients with COVID-19.
Social distancing is one of the most important ways to protect hospitals and public health, according to the Infectious Diseases Society of America (IDSA). In March, IDSA sent a petition to President Trump, asking that social distancing measures remain while COVID-19 transmissions continue to climb. (The petition can be found at: https://docs.google.com/document/d/1qnUb5VEd0pTN3liZeAYoHtylbfeJG5RuaR78_7zxJY8/edit.)
“We know social distancing works, based on the 1918 [influenza] pandemic. Those who did social distancing had lower mortality, and it took longer for it to happen,” said Thomas File, Jr., MD, MSc, FIDSA, president of IDSA and chair of the infectious disease division and co-director of the antimicrobial stewardship program at Summa Health in Akron, OH. File spoke about COVID-19 at an April 3 web conference sponsored by IDSA.
As part of social distancing, hospitals have stopped allowing visitors. COVID-19 patients can connect with families via text messages and phone calls, when possible. This also includes their meetings with case managers and other hospital professionals who do not work in the intensive care unit (ICU) or critical care unit (CCU). Case managers have described talking with their patients via phone calls. (See story of case managers’ experiences in the pandemic in this issue.)
“One of the fortunate things about the timing of this pandemic is that we live in an age where we have a lot of technology to leverage,” said Alexander Wolf, DNP, RN, APRN, palliative care nurse practitioner with TriHealth in Cincinnati. “Our health institution just bought hundreds of iPads to help with some of these communication issues, since families cannot visit.”
Conference apps have allowed healthcare providers to hold face-to-face conversations with families. These also allow patients to see their loved ones, he added.
“I’ve been able to bring our office’s iPad into the room and have a family meeting right there in the room,” Wolf explained. “Or, if the patient can’t participate, this affords the family the opportunity to see, physically, how their loved one is doing.”
Even these virtual visits are difficult with COVID-19 patients because every person who enters their rooms must wear personal protective equipment (PPE). These must be conserved because of shortages in various cities and hospitals, he noted.
“There’s a huge burden on nurses to do a lot of this because they have just enough staff to maintain safety on their unit, and they’re trying to reduce PPE use and avoid exposing too many staff,” Wolf explained. “But the expectations to keep families informed is enormous, so bedside nurses work tirelessly to call families and use iPads to FaceTime their families and allow them to see their loved ones.”
Case managers are in similar situations. “In some cases, case managers cannot even call patients,” Wolf said. “They have to call the patient’s room and make decisions that way.”
In some health systems, case managers are not allowed in ICUs and CCUs because facilities must preserve their PPE and infection prevention equipment and keep exposure to COVID-19 as low as possible, said Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director, care management nursing at Cleveland Clinic.
“Patients are sick, and even getting them on the phone is sometimes challenging,” she said. “We reach out to their families or call patients on their room phone and ask if we can call them on their cellphone.”
Case managers are mindful that patients might have limited minutes on their cellphone plan and that communication might be challenging if patients have hearing deficits, Davis added.
Case managers are seeing an increase in demands as the pandemic continues. “They have to call patients, call families, set up conference calls, and we’re seeing an evolution in telehealth, very quickly,” Wolf said.
CMS Rule Changes Ease Telehealth
The Centers for Medicare & Medicaid Services (CMS) issued new rules and waivers of federal regulations — including those governing telemedicine — on March 30. (Information on the rule changes is available at: https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient.)
The changes include:
- Hospitals and communities can set up testing and screening sites for COVID-19.
- Hospitals can provide benefits and supportive services, including meals, laundry, and childcare services for physicians and other medical staff.
- CMS gave Medicare patients simpler access to respiratory devices and ventilators.
- Clinicians can provide remote patient monitoring services, including pulse oximetry, for both COVID-19 patients and those with chronic conditions.
Case managers may have fewer options of where to transition patients during a city’s COVID-19 crisis and surge. The American Health Care Association and the National Center for Assisted Living issued guidance on how long-term care facilities should determine when to accept hospital discharges to their facilities. (The guidance is available at: https://www.ahcancal.org/facility_operations/disaster_planning/Documents/SNF-Admit-Transfer-COVID19.pdf.)
The guidance reports Centers for Disease Control and Prevention data revealing that 57% of elderly patients without symptoms tested positive for COVID-19. Within seven days, they developed symptoms. This highlighted the challenge for long-term care (LTC) facilities in handling these patients. The guidance urged facilities to create separate wings and units for COVID-19 patients and to have all hospital patients waiting to be admitted or returned to an LTC tested for COVID-19 before a hospital discharge.
COVID-19 patients who recover without a ventilator might need rehabilitation to help them return to their normal daily activities. But if a city’s LTCs are not admitting these patients, their options are limited, Davis said.
“A lot of case management conversations are about what our options are,” Davis said. “Even getting home care is much harder.”
Hospital case management changed dramatically in the spring. Health systems began implementing far-reaching infection prevention measures and changed some operations to accommodate expected surges in patients with COVID-19. Social distancing is one of the most important ways to protect hospitals and public health, according to the Infectious Diseases Society of America.
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