Resuming routines: Lessons from ‘Phase 1’ reopenings

Jacquie Bowen, O.D., is growing accustomed to the occasional chime in her foyer—a cue that her next patient needs a mask before entering the office. She's aware of over-annunciating patient orders—a tradeoff for separating not only her medical scribe in a separate room but also her patients behind a slit-lamp screen. She knows she's over-expressing her eyes when talking to patients and staff—a consequence of the necessary personal protective equipment (PPE).

"It's cumbersome and clumsy, and it's hot," Dr. Bowen says. "We had a few new patients today—patients who I realize now don't even know what we look like—and I had to explain this was the new routine. It's awkward but it's the new normal."

Chairside mannerisms are among the less obvious consequences of the "new normal" brought on by the novel coronavirus pandemic, now gripping America for nearly three months, but even these changes are indicative of something positive: optometry practices are once again resuming delivery of complete, comprehensive eye health and vision care. Slowly but surely, doctors of optometry are reopening to a new normal when and where it's safe to do so.

"As our nation's and our profession's response to the crisis enters a new phase, it is critical that doctors of optometry are able to provide the care patients are seeking in a safe and healthy environment," says Barbara L. Horn, O.D., AOA president. AOA and affiliates are working consistently to ensure you have the resources to deliver that care, and together we are all making a positive difference in communities across the country as we begin the process to return to providing routine, along with urgent and emergency, care."

New guidance directs resumption of routine care

But safety is relative in a world of asymptomatic transmission of SARS-CoV-2, the viral strain causing the COVID-19 respiratory syndrome, and it's predicated on a community-by-community response. Dr. Bowen's Greeley, Colorado, office reopened for routine visits April 26 only after a statewide stay-at-home order expired. Now, Colorado's "Level Two" guidance notes some counties may choose to extend or enact stay-home orders depending on the situation in that community. It's a phased approach to reopening businesses that new federal guidance supports, especially as it applies to health care.

"Ultimately, it's up to each individual state to determine how they're going to reopen," says Chris Wroten, O.D., AOA Federal Relations Committee member, who leads an #AskAOA webinar on optometry practice reactivation. "That's where any specifics are going to come from—stay in touch with state and local health authorities and your state associations and regulatory boards."

As doctors of optometry prepare to resume routine, comprehensive eye health and vision care under a guided transition as part of America's COVID-19 pandemic response, the AOA recommends that clinical judgement and practice operations should be informed by new guidance from the Centers for Medicare & Medicaid Services (CMS).

Issued April 19, the CMS guidance on reopening for nonemergent, non-COVID-19 patient care adheres to a phased approach outlined by the Trump Administration's "Guidelines for Opening Up America Again." Specifically, the guidance outlines how states or localities with low or relatively stable incidence of the virus may proceed into a "Phase 1" reopening of businesses and services, where providers may resume in-person care of non-COVID-19 patients.

Under CMS' new framework, states will guide when and how doctors and practices can resume delivery of complete, comprehensive care. To be certain, the AOA confirmed with CMS that its April 19 guidance doesin fact supplant March 17 guidance from the Centers for Disease Control and Prevention (CDC) that recommended postponing routine eye care. Nonetheless, many doctors of optometry have remained available in their communities for urgent and emergent care, as well as expanding their services to provide telehealth consultations under current CMS guidance.

In response, the CMS noted in an April 28 message to the AOA: "We also appreciate your willingness to help ensure care for patients during the COVID-19 pandemic."

The AOA recommends—and Dr. Wroten reiterates—that doctors remain in close contact with their state association and stay informed of state and local government measures concerning public health and safety.

"Eye health and vision care is essential care without question, but we have to do everything reasonable to ensure the safety of our patients, staff and even ourselves as we begin to resume providing that level of care once again," Dr. Wroten says.

Word to the wise on reopening

In Kentucky, the state board of optometric examiners posted guidance on April 25 that optometry practices could resume routine care in accordance with a gradual reopening of "Phase 1" health care services as early as April 27. AOA President-elect William T. Reynolds, O.D., acknowledged the swift and sudden reversal of the "urgent care-only" order did leave many scrambling to get ready; however, Dr. Reynolds expected to begin seeing patients as soon as April 30 after several days of training.

"It's a lot of work to get everything ready to go and, of course, the No. 1 thing is the safety of our staff and patients and making sure this is done in the correct manner," Dr. Reynolds says.

Like other practices, Dr. Reynolds' drafted new practice protocols that include taking patient temperatures, disinfecting trial frames, proper PPE usage, social distancing of patients and closing the waiting room. Additionally, Dr. Reynolds' practice will initially give priority to patients with the greatest need, but scheduling will be done in a way that doesn't overcrowd the optical or pathology.

First and foremost, Dr. Reynolds recommends that optometry practices begin securing the proper PPE to resume care whenever their state permits. AOA-member doctors should know that AOAExcel^®'s exclusive group purchasing organization (GPO) partner, Intalere, is positioned to gain assured, long-term access to steady supplies of hospital-grade, quality-controlled PPE at competitive pricing. What's more, the AOAExcel GPO is a member benefit that only requires basic registration.

"Plan for these things now so that you're ready to go when you're called back—don't sit around and wait," Dr. Reynolds advises. "Once you get into planning, there's a lot more to it than what you think there's going to be."

Echoing those sentiments, Dr. Bowen suggests getting a jump on reopening preparations knowing that staff education of new office protocols and expectations is a major piece of the puzzle. So, too, practices should continue patient communications as to not only when routine services resume but also what's expected of them at an appointment.

"It's on every patient form that they need to bring a mask, that we're taking patient temperatures and if it's above 100 then we won't see them," Dr. Bowen says. "Once you've established your rules, stick to them."

Adds Dr. Reynolds: "Walk before you run. It's going to be a long time before you're seeing patients at the speed you were before, but we need to do this right."

Access AOA's COVID-19 guidance, resources

To facilitate these preparations, the AOA offers new recommendations for the reactivation of optometry services in the form of AOA's Optometry Practice Reactivation Preparedness Guide. This guidance provides doctors of optometry a step-by-step reference as doctors and practices prepare to resume nonemergent care. Such recommendations include:

1. Anticipate when you will return to a normal (or a new normal) schedule.
2. Develop an action plan for your staff before you open your doors for both routine and emergency care.
3. Develop a new system for sterilization of the office, based on all available guidelines.
4. Continue messaging to your patients.
5. Prepare for your staff needs as they assimilate into the new working environment.
6. Contact other medical practices in the area to see when they will reopen or if they have new protocols in place.
7. Post signage in the office of new steps or protocols to ensure maximum safety.
8. Make use of AOA resources available at aoa.org.

The AOA remains committed to providing the most up-to-date information, relevant care guidance and resources, and timely updates on federal actions through AOA's COVID-19 Crisis Response page. Doctors may also send COVID-19-related questions to AskAOA@aoa.org.