The COVID-19 crisis is likely to include a series of recurring cycles over an extended period —a “pulsed recovery” that will result in a new normal in which clinical care operations have fundamentally changed. While Herculean efforts are focused on the immediate challenges, the deferred needs of the chronically ill (e.g., congestive heart failure, COPD, diabetes, cancer) and other patients with escalating health risks cannot be put off indefinitely.

Hospitals and ambulatory services need to immediately develop action plans to get those patients into care shortly after the peak incidence, even while COVID-19 continues to be present in delivery sites and when some of those patients with chronic conditions also have, or could be incubating, the virus.

We have highlighted activities that are required to restart care of those patients that are common to all ambulatory settings and a few examples of those that are specific to individual service lines.

Call to Action – All Ambulatory Services

While prioritizing potential actions and plans must begin immediately, hospital executives, service line directors and specialists will recognize it’s time to implement when: a) providers have adequate PPE, b) there is sufficient COVID-19 testing available to “clear” clinicians and patients for procedures (if indeed clearing proves to be feasible), and c) when patients can be convinced that it is safe to seek care at a provider site.

In the interim, seven key steps to take include:

• Within each service line, stratify individuals requiring inpatient and outpatient care by severity and diagnosis to configure provider schedules and to “front load” the patients most in need of treatment.
• Enhance severity-based scheduling through direct outreach while easing scheduling bottle necks, using centralized, on-line processes to the extent possible
• Assist ambulatory care sites and physician practices to implement/expand the use of telehealth to support remote monitoring (particularly for chronically ill patients) and pre-visit collection of health status information, and engage patients
• Work within each service line to develop protocols to safely bring surgical patients back into the hospital. This may also require educating state and local regulators about the availability of protocols enabling a safe return to surgical care
• Explore opportunities to temporarily rationalize selected services such that one community hospital is the center for elective/urgent cases in a specific service line (allowing those cases to be separated from continuing COVID cases)Re-organize waiting and clinical spaces to accommodate social distancing, shortage of PPE, patient screening (rapid testing/temperature) and train all staff on new policies and procedures

Service Line-Specific Calls to Action

Cardiovascular Services

• Extend home health options and telehealth to high-risk patient populations such as those with Congestive Heart Failure (CHF) and the frail elderly
• Develop specific clinical schedules with extended hours as necessary for the highest risk patient populations in a separate clinical space, eliminating office waiting and establishing protocols for patient and staff PPE
• Initiate the process to re-establish non-emergent procedures such as echocardiography, electrophysiology, pacemaker placement and battery replacement, and non-emergency cardiac catheterization
• Extend operating hours for cardiac diagnostic procedures to eliminate office waiting time
• Enhance role of physician extenders and telehealth for routine patients

Neurosciences

• Enhance use of telehealth services post-hospitalization for stroke patients in order to reduce readmissions
• Coordinate home-based rehabilitation and other post-acute services whenever possible
• Develop telehealth protocols to assist patients in managing pain associated with postponed surgical procedures

Orthopedics

• Actively seek approval within the service line and with regulators to perform joint replacements in an ambulatory setting outside hospital walls
• Identify patients by severity and length of waiting time to begin an enhanced ambulatory surgical schedule
• Establish protocols for remote/telehealth pain management for patients waiting for elective/non-urgent surgical procedures
• Work with home health providers to increase home-based PT, OT and DME distribution

Oncology

• Work with oncologists to prioritize patients for whom chemotherapy and radiation therapy must continue during COVID-19
• Estimate pent-up demand by severity and disease for patients who had p diagnostic and surgical procedures postponed, and expedite scheduling and treatment planning
• Develop protocols and provider schedules to meet the projected patient need for infusion and radiation treatments, and extend hours and home infusion as needed
• Estimate and communicate with vendors re potential increases in pharmaceuticals/biologics required to meet the demand associated with delays in diagnostics

Women’s Health

• Work with hospital service line members and infection control to develop appropriate protocols to bring families back into delivery and nursery
• Identify opportunities to expand the patient population eligible for ambulatory gynecological procedures and surgeries
• Implement plan to offer extended office hours to increase access for OB and high-risk gynecology patients
• Develop protocols for routine screening particularly for OB patients using telehealth with measurement tools available in the home as well as using Advanced Practice Clinicians to extend office hours to segregate the pregnant population

The lengthy closure of physician offices across most specialties and ambulatory care has increased the threat to the chronically ill and those with high risk conditions. We must plan now for the most rapid restart of those offices and ambulatory centers that is feasible. We urge providers to: 1) Consider the actions recommended above, and add/revise to match your organization’s dynamics 2) select those actions highest in priority; 3) establish a rapidly implementable action plan with clear accountabilities. Then act; the health of your patients and the financial viability of your care network depend on doing so.