Slowly but surely, the country is starting to open up again following weeks of state-issued orders to stay home or shelter in place. For many, one of the first changes is allowing elective surgeries and other “non-essential” medical procedures to resume—something that, as of this blog post’s publish date, 28 states have authorized. For outpatient rehabilitation practices, more surgeries means more patients. Pediatric practices may also see a boost in the demand for therapy as parents seek ways to continue critical services for their children through the summer months. And, on April 30, CMS announced that OTs, PTs, SLPs are authorized telehealth providers—which means providers may see an influx of Medicare patients who are eager to start (or resume) therapy care from the safety and comfort of their homes.
All of these developments support many clinic leaders’ desire to get up and running again—or, for those clinics that never actually shut down, to get back to operating at normal capacity. But, it’s important to recognize that the threat of the pandemic has not completely subsided. You cannot simply throw your doors open and resume business as usual. Instead, it’s important to focus on re-opening your practice in a way that meets patient demand while also ensuring the safety of patients and staff alike. To that end, this blog post covers strategies for welcoming patients and employees back to your clinic in a manner that will allow your practice to not only rebound, but also thrive.
Before we dive in, I want to emphasize that while I am a lawyer, I am not your lawyer. Nothing in this blog post should be construed—or relied upon—as legal advice. Please consult legal counsel if you are considering any of the following strategies. Retaining legal counsel ensures you will obtain guidance specific to your practice and your state.
1. Establish a reopening committee and create a work plan.
Create a committee to brainstorm your reopening work plan. Your committee should meet often (preferably daily at first) to spearhead a coordinated effort for reopening your clinic in a way that instills confidence in patients and employees. If you have a human resources team, get them involved. If you have access to an attorney, include him or her in your plans to make sure you are thinking about discrimination, disability, Occupational Safety and Health Administration (OSHA) requirements, and other employment considerations. Furthermore, loop in any third-party vendors that play a key role in your work plan, and designate a point person to answer employee and patient questions as well as proactively respond to complaints.
Here are some more tips for developing your work plan:
- Create a communication plan for informing employees on new clinic protocols (e.g., schedule spacing, use of personal protective equipment [PPE], and equipment cleaning frequency).
- Create a communication plan for distributing pertinent information to new and existing patients. This includes information about scheduling in-clinic or telehealth visits as well as safety procedures and requirements (e.g., medical screens, visitor restrictions, and clinic measures to enforce Centers for Disease Control [CDC] guidelines).
- Review existing workplace safety policies and make a plan for updating them with your new procedures.
- Develop a plan to let your referral sources know you’re open for business. Be sure to inform them of your hours of operation (especially if they differ from your pre-pandemic hours), the protective measures you’ve implemented to prevent infection, and any innovative service delivery options you are offering (e.g., telehealth).
- Consider signage for vendor reps who need access to your clinic so they know when and where they can enter (e.g., whether they can enter through the front door and the hours during which they can enter).
- Assess your cleaning and PPE supplies to make sure you are well equipped to ramp up in-person services.
- Develop checklists to make sure you are considering everything before you move forward. Save this blog post and its resource links, and use them as a guide for brainstorming areas to consider.
- Develop a cleaning protocol in accordance with CDC guidelines that covers everything from computer hardware to linens and surfaces.
2. Reconfigure your clinic to meet all CDC guidelines.
CDC guidelines for healthcare settings recommend certain measures for reducing the spread of infection, including
- limiting face-to-face contact whenever possible;
- frequently washing hands;
- using face coverings;
- creating at least six feet of space between individuals;
- installing physical barriers or partitions in waiting room areas;
- placing curtains or partitions between shared patient areas;
- routinely cleaning and disinfecting all surfaces and equipment.
Shared Work and Break Areas
Use these guidelines to develop a strategy for reconfiguring shared work spaces for social distancing. Limit the number of employees allowed in any shared areas at the same time. Implement cleaning and infection control protocols (e.g., no-touch trash receptacles and requirements for cleaning common items like refrigerators and microwaves). Do not allow employees to share food for the time being. In high-traffic work areas, either create individual workstations or implement cleaning protocols to reduce the spread of infection via computer hardware and office equipment.
Entry Spaces and Waiting Areas
Rethink your clinic’s entry space by restricting the area to patients only. Better yet, consider restricting the number of patients allowed in the area and/or requiring patients to wait in their vehicles. Create a barrier or use a visual guide (e.g., a tape line) at the front desk to encourage social distancing. When checking patients in, encourage them to use a secure online portal to process their payment, if possible (rather than having your staff run patient credit cards).
Speaking of online portals: Consider having patients use a patient portal to complete questionnaires and electronically sign documents. Finally, try to arrange for delivery people to use an alternate entrance so they can avoid entering the waiting area.
The entry space isn’t the only clinic area prone to crowding. To reduce density throughout your office, consider the following measures:
- Stagger your patient schedules. Consider expanding clinic hours or increasing the number days per week your clinic is open to reduce the number of patients in the clinic at any given time while continuing to meet patient needs.
- Offer virtual visits whenever possible—or offer a combination of in-person and telehealth visits.
- Remove extraneous furniture and equipment to open up your space.
- Post signs explaining your clinic’s social distancing guidelines for employees and patients.
For your mobile therapists, implement cleaning protocols for equipment that will come back into the clinic after home visits. Provide your therapists with PPE, hand sanitizer, and cleaning supplies for the road. Consider scheduling telehealth visits in lieu of home visits whenever possible to reduce the spread of infection.
Thanks to expansion in coverage for telehealth services during the pandemic, therapy providers have a rare opportunity to start integrating telehealth into their practice models. Doing so as soon as possible allows your employees and patients to become accustomed to new workflows. It also supports business continuity in the event of any future disasters or emergencies. Lastly, it provides patients with more options for receiving services. Be creative and think about how you can incorporate virtual care into your intervention plans. Develop a process for reviewing your schedule and thinking about which patients may benefit from virtual visits—and when during their course of care they would benefit most. Educate your employees about the appropriate use of telehealth services. For more information and ideas, be sure to check out our telehealth webinar and read this blog post on getting up and running with telehealth and this one on incorporating techs and therapy assistants in your telehealth practice.
3. Reconfigure your employee schedules.
As you reconfigure your clinic, also consider reducing the number of employees allowed in the clinic at any given time. To do so:
- Identify those employees (e.g., your front office staff) who can continue to telecommute.
- Review your patient schedule and create a rotating dedicated telehealth day for your employees to work at home.
- Allow therapists who are delivering virtual visits to do so at home to avoid overcrowding in the clinic.
- For those clinicians who need to be onsite, stagger their schedules to ensure observance of social distancing guidelines.
4. Prepare for potential employment issues.
The pandemic and subsequent lockdown put a new spin on employment legal issues. Employers must now consider the following when reopening their clinics:
- how and when to bring back furloughed employees;
- the best approach to for hiring new employees in the midst of a pandemic;
- employee testing and monitoring protocols to keep everyone in the clinic safe;
- reasonable accommodations for employees in accordance with the Americans with Disabilities Act; and
- employee concerns about returning to the workspace out of fear about becoming infected with the virus.
Your first step should be to consult an employment attorney. Employment law is multi-faceted and complicated; the pandemic only makes it more challenging. You may be collecting confidential health information about your employees that will require special protections. Furthermore, decisions about who can return to work can easily implicate discrimination laws. So, seek counsel if at all possible. If that isn’t feasible at this time, I have provided several resources below to use as a guide.
Bringing Back Furloughed Employees
If you furloughed any employees, determine who will return to work and how they will return to work. Communicate early with employees if you are changing their compensation, work hours, and job duties. If you advanced payment on health insurance premiums, develop a plan for repayment. Consider whether you should redistribute the employee handbook and execute new confidentiality and non-compete contracts—or any other agreements. Some state laws consider longer periods of furlough a legal separation from the company, which means you may be required to complete new-hire paperwork and have employees fill out new I-9s.
Your decision regarding who to invite back to the workplace must adhere to discrimination laws, such as the Age Discrimination and Employment Act (ADEA) and the Americans with Disabilities Act (ADA). It is appropriate to base your decisions on your operational needs as well as seniority. Make sure your decisions are not based on factors such as age or disability. Additionally, you should carefully consider employee requests for reasonable accommodations. For example, now that most states allow rehab therapists to provide telehealth, allowing an employee to work from home could be a reasonable accommodation for a disability—one that may not pose an undue hardship on your practice. For more information about reasonable accommodations in the workplace, refer to this ADA resource. Additionally this blog post provides more information about various employment considerations when reactivating furloughed employees.
Reducing Risk in the Workplace
OSHA imposes a general duty on employers to furnish employees with a workplace free from recognized hazards that cause—or are likely to cause—death or serious physical harm. Rely on the OSHA Guidance on Preparing Workplaces for COVID-19 when developing your protocols for infection control, testing and monitoring, and PPE use. These guidelines follow CDC standards and recommend workplace controls based on exposure risk levels. Healthcare roles are classified as high-risk exposure jobs because of the high potential for COVID-19 exposure. The guidelines recommend the following for employees who fall into the high-risk category:
- Implement policies for reducing exposure, including educating patients on COVID-19 symptoms and instructing them to cancel in-person sessions if they are sick. Here is a sign on germ prevention you can post in your clinic area and email to patients.
- Post signs in your clinic describing COVID-19 symptoms and inviting patients to bring their own mask if they have safety concerns. Here is a sign listing symptoms of the COVID-19 virus. Email this sign to your patients before they come into your clinic.
- Consider implementing an employee testing and monitoring plan to prevent outbreaks.
- Provide employee training about infection control, COVID-19 symptoms, and your new post-pandemic policies. If you don’t have a robust human resources department or time to develop training materials, the CDC website has loads of free resources you can use.
- Make sure you have plenty of cleaning and sanitation supplies on hand (and do not require your employees to bring their own). Have hand sanitizer, soap, and cleaning supplies readily available to coincide with your new protocols for cleaning treatment areas.
- Remove equipment and supplies that are not easy to disinfect, such as therapy putty, play dough, bean bags, and cloth chairs.
- Provide your employees with PPE masks and gloves. Your employees should be equipped with the N95 filtering facepiece respirators. Make sure you have enough PPE for all employees. Implement protocols for how and when to use PPE.
- Implement procedures for PPE disposal and have dedicated biohazards bins for disposal.
The Department of Labor (DOL) has a whole website dedicated to OSHA standards during the COVID-19 pandemic, including an overview of the risk classifications and a short fact sheet on different workplace protections. If you don’t have access to legal counsel, the DOL website or your state’s OSHA-approved workplace safety plan is your next best bet. Don’t forget to review state, county, and municipality guidelines; check your state health department website for additional guidelines.
Infection Testing and Monitoring
As previously mentioned, you may want to implement a COVID-19 testing and monitoring plan when your clinic reopens to reduce the risk of infection. In a previous blog post, we explained that job-related employee testing that is consistent with business necessity is permissible during the pandemic. However, testing and monitoring is a tricky balancing act of considering employee protections and preventing the spread of infection.
Your testing plan can include any combination of the following:
- screening protocols, such as temperature and symptom checks;
- virus testing; and
- contact-tracing and survey questionnaires.
To be frank, testing employees for COVID-19 implicates many complex employment laws. Your testing protocols must consider:
- confidentiality safeguards for test results (e.g., creating a separate, secure space for test results and health information);
- testing privacy;
- the logistics and feasibility of performing daily temperature tests while simultaneously running the clinic;
- the accuracy of virus testing; and
- whether the measures are sufficient to prevent the spread of infection.
Consider partnering with an occupational health provider to assist with testing and monitoring. Alternatively, ramp up your environmental controls, cleaning protocols, and strict policies on prohibiting sick employees and patients from entering your clinic in order to reduce the risk of infection.
For more information on this topic, review the FAQ on the Equal Employment Opportunity Commission (EEOC) website. Or, check out this short EEOC FAQ about ADA protections or this legal blog post covering guidelines for protecting employee privacy, which also includes a handy checklist for temperature checks.
Require employees to stay home if they or their family members are sick. Review this blog post and this one for information on the Families First Coronavirus Response Act (FFCRA), Emergency Paid Sick Leave, and Emergency Family Medical Leave Expansion Act. In the wake of the pandemic, these pieces of legislation have introduced measures intended to protect employees who may be recovering from COVID-19, self-quarantining, or caring for sick children.
Don’t forget to talk with your employees about their return-to-work concerns. The pandemic posed many unique challenges for workers, including childcare issues, fear of infection due to comorbidities and other risk factors, and transportation risks (e.g., concerns over using mass transit to get to and from work). Keep the lines of communication open and brainstorm ways to accommodate employees who are hesitant to return. For example: Can the employee provide virtual visits from home, assist with policy and procedure development and other administrative tasks, or come in earlier or later when there are fewer people in the clinic?
For more tips on protecting employee health, see this CDC page on guidance for small businesses.
5. Implement an exposure plan.
The pandemic is not over, and experts are predicting a second wave. So, implementing an exposure plan is a critical component of your reopening strategy. As a healthcare provider, your plan will cover both employees and patients. Your exposure plan can include the following key points, based on CDC guidance:
- Requiring return-to-work certifications for employees who fail a screening or who have tested positive for the virus. The certification can either be a physician note or clearance from an occupational health clinic.
- Getting a list of the people who were within six feet of the infected employee or patient.
- Requiring employees who were exposed to an infected person to remain home for 14 days.
- Prohibiting infected patients from returning to the clinic for 14 days.
- Closing off the area where the infected employee or the patient was located for 24 hours and heavily disinfecting the area (require gowns and gloves as part of a decontamination process and refer to the CDC cleaning guidelines for specific decontamination steps).
- Informing employees of the exposure while maintaining the confidentiality of the individual.
- Training employees on the exposure plan.
See what I mean—a carefully planned reopening can set your practice up to innovate, thrive, and become resilient in the face of any disaster or pandemic. It will take plenty of forethought, team work, and additional time outside of clinical care, but the end result will be worth it. Have questions about reopening your clinic to employees and patients? Leave them in the comment section below, and we’ll do our best to get you an answer.