Founder Letter: Emergency Preparedness and Business Continuity for Rehab Therapists During the COVID-19 Pandemic

Please note that developments related to the COVID-19 pandemic and associated legislative guidelines are changing rapidly. While we are doing our best to keep this content as current as possible, for all government guidelines, we recommend referencing the actual legislation.

First of all, I want you all to know that you, your families, your teams, and your patients are in my thoughts as the situation with COVID-19 continues to evolve. In no uncertain terms, we are in this—and whatever is to come—together. While I can only hope that this article finds you and your loved ones safe and healthy, I know that we are all being impacted by this global crisis to varying degrees. To be clear, we are in uncharted territory here. We’re all learning together, and things are changing at an unprecedented pace. 

That said, the coronavirus outbreak has put a massive spotlight on crisis response—not only at the government level, but also within communities, healthcare organizations, businesses, and individual citizens. With that in mind, I thought it would be beneficial to share with you some best practices for crisis response. You may have already put some of this into practice. Some you may be able to implement immediately, and some is more preventive in nature, meaning it may be more helpful the next time around. After all, even if we never experience another global health pandemic in our lifetime—and I hope we don’t—natural disasters (e.g., hurricanes and tornadoes) and system failures (electrical/Internet outages) are much more common. Plus, clinics are prone to a variety of non-emergency events—like the sudden departure of a critical employee or the loss of a major referral source—that require similar forethought. 

Regardless, though, my goal right now is to help ensure that you and your team have everything you need to feel prepared during this crisis and beyond. With that, here are four critical elements in any disaster recovery and business continuity plan:

1. Health and Safety

Staff and patient safety is of the utmost importance always—but especially during a contagious disease outbreak. Thus, priority number-one is taking every precaution to keep your staff and patients healthy. As rehab therapists, you’re in an interesting position, because your work is hands-on. This means planning ahead to ensure you are always fully stocked with things like hand soap and sanitizers—and that you’ve properly educated your team on how to use these effectively. Depending on where you are currently located, these items may be difficult to come by, which is another reason to (when possible) build up your reserves ahead of time.

For the most up to date advice regarding prevention and containment (read: sanitization) best practices, check out the CDC guidelines. As for putting these practices into, well, practice, your patients and your teams will be looking to you to set the standard for the new normal right now. Be the example. While there’s no reason to panic, there’s every reason to adhere to these guidelines, which means washing your hands—well and often—and minimizing the chance of exposure for everyone involved by taking appropriate precautions. In this case, that includes asking patients who have been feeling at all unwell in the last two weeks to cancel their appointments—or perhaps attend their sessions via telehealth (more on that later). It may also call for you to actively monitor patients entering the clinic for fever and respiratory symptoms—and sending away anyone who exhibits either.

Social Distancing

Some practices are already being asked to implement social distancing in the clinic; and even if you haven’t been officially asked yet, it’s an excellent preventive measure to enforce anyway. That essentially means minimizing the staff and patient density in your facility by:

• Reducing the number of concurrent appointments; 
• Encouraging non-clinical personnel to work from home;
• Keeping your patients at least six feet away from one another at all times;
• Filtering your schedule to exclude the most vulnerable patients and therefore, help shield them from exposure (e.g., anyone who is frail and elderly; is immuno- or respiratory-compromised; or has severe comorbidities such as diabetes and obesity);
• Preventing visitors from entering the clinic; and/or
• Asking patient family members to wait outside or in their cars as opposed to the waiting area.

Furthermore, bear in mind that the only way to completely eliminate the risk of transmission in your clinic is to cease all operations entirely. In some states, you may not have a choice, as there have been mandates for all “non-essential” businesses to close. (Stay tuned for more content pieces on advocating for PTs to be included on the list of “essential” providers.) For many others, clinic closure is currently a choice, and I know that may not seem like the most realistic option for your organization at this time. That being said, but it will most likely become a reality soon, which is precisely why we have created this resource.  

Sick Leave

Staff members should also be strongly encouraged to stay home at the first sign of illness—or if they have any reason to believe that they’ve come into contact with the virus. To that end, it’s important for you as a business leader to—as much as possible—establish supportive (i.e., “non-punitive, flexible, and consistent with public health guidance”) sick leave policies. That way, employees are able to rest and recover without having to weigh their decision to stay home against their ability to pay the bills. 

Per the Families First Coronavirus Response Act, companies with fewer than 500 employees are required to provide two weeks of paid leave, either:

• with full pay at the employee’s regular rate to quarantine, seek a diagnosis, or obtain care for the virus, or
• at two-thirds of the employee’s regular rate to care for a family member for the same reasons or care for a child whose school has closed or when a child care provider is unavailable due to the coronavirus. 

Furthermore, “Full-time employees are entitled to 2 weeks (80 hours) and part-time employees are entitled to the typical number of hours that they work in a typical two-week period.” 

Additionally, under the Emergency Family and Medical Leave Expansion Act, companies with fewer than 500 employees must also grant employees who have worked for the company for at least 30 days with additional job-protected leave to care for a child during school or child care closure.

According to this Time article, employers with fewer than 50 employees that can demonstrate that these stipulations would “jeopardize the viability of the business” may be able to apply to the Department of Labor for an exemption. Additionally, the Secretary of Labor has the authority to exclude certain healthcare providers and emergency responders from these provisions, although it’s not yet clear to whom that statement applies. To offset these upfront costs, businesses will receive reimbursement in the form of comprehensive government tax credits. 

Trust me when I say that on every single count, having an unwell employee stay home is better for you and your business in the long term than having that person come in and risk contaminating others—even if it means rescheduling patients or losing revenue. According to this workplace law resource, you are also allowed to request that an employee go home and/or seek medical attention if you suspect he or she may be exhibiting symptoms.

Having clear policies and procedure manuals that are available, accessible, and understood by your employees is so important—especially during times when stability is paramount. That way, you’ll also have a starting place from which to make temporary changes as needed to support the business. Engaging in clear communication with employees as changes are made will be important to maintaining positive morale.

Testing Positive

Now, what should you do if a staff member either:

• tests positive for COVID-19, or
• exhibits symptoms that go beyond the common cold?

According to the above-cited resource, you should first review that employee’s schedule with him or her to determine with whom he or she was in close proximity (i.e., within 6 feet) over the last two weeks. Then, assist the employee with obtaining the medical support that he or she needs as quickly as possible. Finally, send home every other employee that person came into contact with—and get in touch with all patients who may have been exposed to inform them on the situation. 

Just be sure not to share any identifiable information about your ill employee, as that would be a breach of workplace privacy laws. Instead, simply tell the person you have reason to believe he or she has been in contact with someone who has either tested positive for COVID-19 or is exhibiting symptoms. Emphasize that, while there is no cause for immediate alarm, the person may wish to self-quarantine while monitoring for symptoms. According to the same resource, you may also want to hire a professional cleaning crew to disinfect the office before allowing staff or patients back in. And for reference, “The most common symptoms of COVID-19 are fever and a dry cough.”

2. Staffing and Financials

We’re already seeing staffing issues crop up across all industries—not only as the virus spreads and staff members either fall ill or decide to self-quarantine out of precaution, but also as schools close and parents must stay home with their children. If you’re feeling the crunch, you’re not alone. However, that also means you’re seeing enough patients to make the crunch a problem, and some may argue that’s a good problem to have. 

That said, you may need to make some tough decisions during this time in order to save your business and ensure you can continue serving your community on the other side. I’ll get into more of the specifics in a moment, but no matter what comes, make it a point to remain open and transparent about your decisions—whatever they may be. This will be critical for maintaining positive relationships with your employees. Now, more than ever, we must function as a true community, which is a good segue to our next topic.

Gaps in Staff Availability

If you find that you don’t have enough working therapists to assist your patients, consider reaching out to the greater rehab therapy community—especially if you’re serving a population for whom continued rehab therapy support is crucial. After all, as therapists, our first priority is always our patients. In the aftermath of the Joplin, MO, tornado, for example, providers from all disciplines came together to set up a makeshift clinic to treat those who were hurt. On that note, this is a good exercise for rehab therapists to think like primary care providers and step into that role. Are you ready and able to organize disaster efforts at scale? Are you prepared to evaluate any type of patient and direct the patient to the proper practitioner?

As more states go into lockdown and close down all non-essential businesses, you probably won’t see many new patients for issues like low back pain over the next month or so. But, you may be called on to support post-surgical rehabilitation and provide maintenance care to patients who would otherwise experience severe functional decline. Additionally, considering that patients with the most severe cases of COVID-19 tend to be elderly, a very large number of patients may require acute rehabilitative care to get back on their feet following lengthy bed rests.

It’s also important to keep current on all news and announcements from your payers, as many are making day-by-day changes to help their beneficiaries get the care that they need. As this health and financial crisis continues, care access will remain an issue, which is why it is critical that we receive the designation of “essential providers.”

Drops in Patient Volume

On the other side of the staffing equation, what should you do if a steep decline in patients halts staff productivity and thus, your clinic’s cash flow? There is no easy answer to this question. If you have behind-the-scenes operational work for your team to do, consider focusing staff resources there. After all, while we have no idea how long this pandemic will last, it likely isn’t permanent—so, you could use this time to get a jump start on big improvement projects.

Additionally, in Los Angeles, hospital workers are undergoing disaster training and setting up overflow tents to prepare for a potential influx of patients who may push the hospital beyond capacity. If you or your staff happen to hold EMT or other emergency training, there may be opportunities for you to support on the front lines as well.

Either way—and also on the topic of support—now is the time to check in on elderly patients and those in your community who may need extra help during this time. If you can, offer to provide supplies and food to those who are too high risk to shop for themselves. Alternative services—like the ones outlined in section three below—could also be extremely beneficial for this population as well as your clinic’s cash flow.

Layoffs and Pay Cuts

That said, there may come a time during this crisis when you need to cut staff pay or lay off employees. This is never an easy decision to make nor conversation to have, but it can be especially challenging in the midst of a global pandemic. If you can provide even a small amount of pay in the interim—or maintain employee health benefits during a layoff—do so. It will encourage staff members to return once you’re back up and running at full capacity. If that’s not feasible, be as supportive and empathetic as possible as you explain the reality of the situation, and provide resources to help your staff access unemployment benefits. Under most state laws, you’ll still need to compensate employees for any paid time off they’ve accrued. In fact, you’ll likely also want to run these decisions by a healthcare attorney to ensure that you’re handling all layoff and furlough decisions legally. 

Most of the world is scared right now, so take that into consideration as you have these difficult conversations. If you’ve bucketed three to six months of cash for emergency situations (as we suggested during the ICD-10 transition), then you’ll likely be able to ride out the storm with your employees. If you haven’t, please make it a priority to do so as soon as things stabilize again. While we couldn’t possibly have predicted these exact circumstances, I can say without a doubt that there will come a time when having those funds will help you through a rainy day.  

Ultimately, these are mission-critical decisions for your business, which means you must do what’s best for you—as an owner—and the business to make it through this downturn. That’s the only way that you will be able to continue providing employment and care in the long-term. These decisions are never easy—and usually gut-wrenching—but remind yourself why you became a therapist in the first place and how many patients you have helped, and will continue to help, once this situation stabilizes.

Loans and Support

While we’re still waiting on official news from the federal government about the COVID-19 relief package for individuals and businesses, we do know that disaster relief loans are available through the US Small Business Administration. If your practice is struggling to make ends meet during this pandemic, then you can apply for a low-interest, long-term loan with the SBA. Small businesses may borrow up to $2 million for economic injury. The SBA is also committed to assisting small businesses in “accessing federal resources and navigating their preparedness plans.” To learn more, visit this page.

3. Alternative Services

If patients are unable to come to you for their care, consider going to them, either via home visits or telehealth services.

Telehealth

Compliance expert John Wallace put together an entire blog post on how to implement telehealth services in the midst of this crisis, so I won’t go too deep into that subject except to say that now is absolutely the time to equip yourself with the tools you need to reach your patients via secure video conference. In addition to being an excellent means for serving patients during quarantines, it could mean the difference between your practice keeping its lights on or shutting down. Of course, current regulations don’t exactly make it easy for rehab therapists to implement telehealth at scale—which is why I’m calling on all of you to seize the opportunity to advocate for swift changes to those regulations (learn how in this post I recently wrote). And even after this crisis is behind us, telehealth is something we as an industry should continue paying attention to and trying to incorporate in our clinics permanently. After all, more and more patients are going to demand it.

Home Visits

Home visits are another alternative service option to consider, especially in situations where it is essential to care continuity. Outpatient physical therapy practices can conduct and bill for at-home physical therapy visits under Medicare Part B and many commercial payers. If in doubt, check your payer contracts for billing specifics—and be sure to reach out to your liability insurance company to ensure your coverage extends outside of the clinic. Just like in the clinic, though, you’ll want to verify that Medicare patients are not concurrently receiving Medicare Part A services; otherwise, you won’t be paid for any Part B services.

While you’ll still want to take every necessary precaution to keep yourself and your patients safe and healthy during this pandemic, home-based care may be a better option than having multiple patients and staff members in the clinic together. If you go this route, be sure your clinic’s technology supports remote work. That means having an EMR and scheduling software you can access via a mobile device like a phone or tablet. You can also forward your office line to a mobile phone, so patients can reach you to schedule their appointments while you’re out of the office. 

4. Communication

There’s enough fear-mongering in the world right now; most people—staff and patients alike—are craving a calm, level-headed discussion about next steps. As business leaders, we walk a fine line between ensuring that our staff members are well informed and proper precautions are in place—and avoiding creating panic, especially when that panic could extend to patients. One approach I’ve found particularly helpful is to share detailed, granular information with my leadership team and then distribute a more high-level message to the rest of my staff. For example, right now, it might be best to keep the staff-facing message focused on frequent hand-washing, staying home when unwell, and social distancing as much as possible outside of the clinic to ensure the safety of not only your clinic’s patients, but also the community. (That is, until you’ve made other decisions that they need to know about.) 

Patients

When it comes to patient communication, take a similar tact. They don’t need to know what’s keeping you up at night right now; they need to know what precautions you, as a trusted healthcare provider, are taking to ensure their safety and continued ability to access needed care. With that in mind, be proactive about sharing that you’re adhering to all CDC guidelines and implementing alternative treatment options to better serve them. 

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In most situations, now would be the time I would encourage you to put your plan for handling a crisis in formal writing, but putting it into action takes immediate precedence right now. Just make it a point to perform a thorough review of what worked well and what didn’t when this is all behind us. Then, make adjustments and turn it into a comprehensive disaster relief and business continuity plan for the future (ideally, one that also addresses critical data storage and other potential emergency-mode operations). After all, that’s a requirement under HIPAA, and this is not a one-and-done kind of thing. No pun intended, but an ounce of prevention is worth a pound of cure. 

For now, though, we’re all doing the best we can to roll with the punches in a rapidly evolving situation. As changes occur, be sure to communicate them to your staff in a way that they can understand and implement. In other words, don’t allow your own fears to wear off on your staff or patients. 

As clinic owners, directors, and leaders, we are all in unprecedented, uncharted territory. If it’s possible to see a silver lining during these very dark times, know that opportunity arises during times of crisis. With that in mind, please use this time to really examine your business practices, processes, and tools for efficiency. Take the time to really work on your business—as opposed to just in your business.  But most of all, be well, stay healthy, and trust that we will get through this—together.