April 30, 2020

Telehealth Initiatives for the Advanced Practitioner Amid COVID-19

By Sara Toth, FNP-C, AOCNP®, AGN-BC, Texas Oncology

These are unprecedented times, and we continue to see rapid changes during the COVID-19 pandemic. During a health-care crisis, we have no option but to meet this storm head-on. Nearly every clinic process and workflow has been changed, sometimes by the hour. Daily tasks have been completely transformed, from the way we greet people, navigate the grocery store, interact with our friends and family, and of course how we care for our patients who are at higher risk. The last thing any patient with this ugly and often ruthless disease needs is a pandemic that isolates them, disrupts their treatment, and causes more anxiety.

Changes in Telehealth Regulations

Telehealth services provided by advanced practitioners (APs) have traditionally been tricky and generally full of restrictions, at least in my state of Texas. Therefore, telehealth services carried out by APs, particularly in oncology, have been minimal. One silver lining of COVID-19 is the temporary lifting of restrictions on telehealth services both on the state and federal level.

In March 2020, we saw a significant shift surrounding telehealth services. The White House Task Force and the Trump administration put into place the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Because of this, CMS has temporarily expanded access to health care so that patients can now receive the same quality of care from the comfort of their own home. Many, but not all, commercial carriers have followed suit. Telehealth options will continue as long as we are under COVID-19 constraints, and we need to use this opportunity wisely.

Telehealth Initiatives

During this time of telemedicine initiatives, I encourage APs to be engaged with their practice and ensure telehealth options are fully operational, as much as they can and as quickly as possible, using all available resources. As oncology APs, we have a unique opportunity to seize this chance and embrace telehealth. This is a way to continue to see patients, stay engaged, be productive, and continue to provide good patient care. Advanced practitioners who may have the opportunity to work from home should remain available during working hours to assist with clinic needs, urgent and add-on telehealth patients, triage questions, etc. Normal expectations should still apply for adequate and appropriate documentation and timely billing practices. 

Be proactive with telehealth! Communicate with your respective clinics on all available options, workflow challenges, and the best way to communicate patient needs (as well as your own) when working from home. I highly recommend combing through your schedule ahead of time to review which patient visits can be converted to a telehealth visit, delayed if appropriate, and which need to still happen in the office for active treatment. With workflows and scheduling in a state of chaos, performing a thorough review of your schedule will decrease confusion and appointments being canceled unnecessarily.

In addition, I would encourage APs to review a list of appointment cancellations over the past few weeks. Personally, I have found that patients who had their appointment canceled early on in the COVID-19 crisis welcomed the opportunity to touch base and ask questions, which reduced their anxiety overall. Keep in mind, this approach may also help even out your schedule when the pandemic subsides and reduce a mass influx of patients who have missed an appointment and need to get in quickly.

Oncology APs can provide a wide variety of services through telehealth, including short- and long-term follow-up and surveillance, toxicity checks, symptom management, survivorship visits, chemotherapy education, diagnostic and lab review, as well as hospital follow-ups and distress screening. Supportive care can also be conducted on a telehealth platform, including treatment and disease education, pre-op teaching, and genetics. These supportive care programs continue to provide vital care to patients, especially those who have recently been diagnosed and may feel exceptionally isolated and scared. Warfarin (Coumadin) clinics can also be done via telehealth.

Virtual Warfarin Clinics

Virtual warfarin clinics require more work logistically but can keep patients sheltered at home for an extended period of time. Labs, including prothrombin time/international normalized ratio (PT/INR), can be drawn in a variety of ways. Bloodwork can be drawn at your clinic during non-peak hours such as early in the morning or late afternoon, scheduled at another lab, or involve home health services. Even if a patient must come into your clinic for labs, converting the office visit portion to telehealth reduces the amount of time in clinic and reduces potential exposure to other patients, staff, and you.

Advance Care Planning Discussions via Telehealth

As COVID-19 challenges continue and normal clinic routine remains altered, anxiety and stress can significantly affect our lives and the lives of our patients. Our patients are at higher risk for complications and death with COVID-19. Telehealth is a way we can maintain a connection with our patients and continue to discuss what is important to them and their families during this time of uncertainty.

I encourage all oncology APs to take this opportunity to engage in advance care planning discussions. Advance directive document completion may be exceptionally challenging via telehealth. Therefore, I advise that you focus advance care planning on the conversation at hand. Now is not the time to shy away or avoid these crucial conversations, and in my experience, they have been welcomed.

There are several ways you can initiate and navigate the conversations with patients by engaging your team in huddles and communicating often, especially with triage staff. Patients who frequently call in with significant concerns should be offered advance care planning via telehealth. Advance care planning counseling performed via telehealth can be even more effective, as the patient may find increased comfort in their home without the hustle and bustle of the clinic and can have their spouse/partner, children, and/or caretaker with them on the call.

Concluding Thoughts

I urge every oncology AP to learn and understand the new rules and regulations affecting telehealth services. CMS is a great resource and provides up-to-date information on the evolving landscape. It is in our best interest to fully support these initiatives and remain proactive. I also encourage you to be a leader during this time of uncertainty. Lead by example and stay calm. Be a team player, lend a hand to your co-workers, assist with patient triage and phone calls when needed, and don’t be afraid to ask for help. Leaders emerge in times of crisis and set a standard for others to observe and follow. Lastly, thank you for your continued compassion and fierce dedication to your loved ones, your community, your colleagues and co-workers and your patients. Stay safe and healthy.

Read more from the APSHO Advance: Special COVID-19 Series