New Delhi: These are unprecedented times incredibly trying for rheumatology and patient care. Social distancing has made delivering patient care more difficult and challenging. Patients are now relying on us for accurate information and easing their minds, in addition to continuing to manage their autoimmune diseases.
Unlike other specialties that can deliver point-of-care or elective services, rheumatologists are involved in the management of chronic medical issues and we are unable to put patient care “on hold” despite what feels like insurmountable disruptions and distractions. Much of the time, this care involves the use of immunosuppressant medications, which, by nature, increase the patient’s risk for complications and potential infection from COVID-19 and other causes. We are learning to operate in new ways while exercising an abundance of caution to continue meeting the needs of our patients.
Here are just a few of the learnings that have been part of my experience and may help others approach care.
Patients are scared and longing for information. We received hundreds of phone calls the first 2 weeks of the pandemic, when social distancing and travel restrictions were being placed. Patients were concerned for themselves, their loved ones, and their providers. Some patients on essential medications that must be continued regardless of the pandemic were unsure what preparatory steps to take. In the last few weeks, many health plans have agreed to waive their traditional refill policies, making it easier for patients obtain a 90-day prescription or switch to a home delivery option.
However, not all patients are able to take their medications at home. For those receiving infusion therapy, which is meant to be administered on a set schedule, there are a few important considerations to keep in mind. According to the American College of Rheumatology’s guidance, “Healthcare professionals must consider several factors…the potential [effect] of immune modulating therapies on outcomes for infected patients; the effect on a patient’s rheumatic disease-related outcome when changing or interrupting their treatment; and patient access to treatment.” We take all of these into account as we tailor our approach to each patient, making the best choices for their health and controlling their disease severity.
In some instances, a patient’s hospital infusion center may not be available. Finding alternative centers or options like in-office infusions will be an important part of helping them continue to receive therapy. We have been working with local hospitals to provide infusion services in our office, which would not require the patient to go to the hospital where there is significantly more exposure to other potentially high risk patients. With the recent guidance from the Centers for Medicare and Medicaid Services, prescribing physicians now have the option to provide infusions at home if alternative sites of care and/or leaving the home are not an option for patients. This can be done using current staff or a contracted service while monitoring the process via tele-health. Since many of our medications require active nurse monitoring during the infusion, we should carefully consider which of our patients are best suited to receive infusions at home.
Leaning on Digital and Virtual Platforms
In our practice, we have continued to run with full staff, but we know that this is not possible everywhere or for everyone, so patients are given the option to participate virtually through tele-health modalities. By connecting virtually, we can continue to deliver care and provide another way of ensuring that patient concerns are heard and their needs are met.
Although many of us enjoy the opportunity to talk with patients in person and conduct physical exams, we are learning the value of telemedicine and appreciating how it could allow us to provide the quality of care that our patients deserve. Moreover, as isolation procedures create challenges for not only patients’ physical health but their mental health, portals and email communication can be very helpful and enable us to be available at any time to answer questions, discuss concerns and provide care.
Our practice has also implemented twice-daily virtual forums where information can be readily exchanged between the staff to keep everyone up to date on the current happenings within the practice, the community and the state. This has been helping in allowing staff to ask questions and be on the same page as we care for patients.
Finding New Approaches
Any patient that wishes to come into our office is still able to, as long as they are screened for infection prior to coming in. For us, this seems to be working well and lets us provide the care needed while protecting both our providers and patients. In our practice, we have also maintained infusions to the fullest extent, implementing additional sterilization procedures and screening processes for patients and staff. This has included taking temperatures at the door before entering the building and wearing a mask if someone has traveled within the prior 14 days. While maintaining a safe and clean office environment is always a priority, we have been more aggressive in frequently disinfecting all surfaces, including door handles, chairs, hallway rails, and other surfaces that patients may come into contact with beyond the examination room.
Practices can also accommodate patients in a few other ways. First and foremost, it’s essential to communicate increased hygiene processes and changes in procedures to patients. Practices can also limit the time each patient spends in the office by reducing or removing the waiting room experience altogether. Instead of asking patients to check in and take a seat in the waiting room, practices can have patients wait in the car, escorting them in or summoning them by phone or text when the examination room is ready. Other simple adjustments shift check-in procedures ahead of the visit by phone, email, or internet check-in.
With social distancing approaches in place and a decrease in patients coming to the office, practices can revisit how to use patient rooms to deliver essential services, such as creating as private room for infused treatments.
For patients receiving infusions, routine laboratory work may be a vital part of their treatment. We know not everyone will be able to visit a patient service center or hospital and feel comfortable doing so. We therefore implement laboratory testing at the time of the infusion. For some patients located in larger cities, mobile laboratory services may be available, enabling services like blood draws to take place in the patient’s home. As physicians, we will continue to receive their laboratory results as we normally would to continue ensuring our patients are responding to therapy appropriately.