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Suggestions for Reopening

Dr. Brian Stagner, TPA Director of Professional Affairs, Associates for Applied Psychology

 

Suggestions for Reopening In-Person Services

 

The gradual lifting of social distancing restrictions raises challenges for psychologists about the future operations of their practices.

 

Deciding to Reopen

The American Psychological Association (APA) recently published practice information regarding resuming in-person services. The information contained within this article is a useful source in:

  • Determining whether an in-person visit is necessary,
  • Reviewing the physical and mental health risks,
  • Establishing new rules for patients attending in-person sessions,
  • Taking steps to reduce the spread of COVID-19 in your office, and
  • Implementing policies that protect employees.

Additionally, APA has published a sample informed consent form for resuming in-person services.

There is no single guideline regarding resuming face-to-face practice. Indeed, TPA takes no position on when or whether psychologists should resume face-to-face meetings. For some this is an individual decision, while others may be subject to the dictates of the groups or agencies where they work. Nobody should feel obliged to reopen an office until fully prepared. Here are some elements that may inform that decision.

  • Centers for Disease Control and Prevention guidelines or rules promulgated by health department authorities and the Occupational Safety and Health Administration
  • Epidemiological and medical developments, including:

 

  • Development of a reliable and safe treatment
  • Development of a vaccine
  • Wide deployment of testing with contact tracing
  • Reduction in the rate of deaths
  • Reduction (not just flattening) of the curve of new cases

 

  • Decisions by local authorities about gradual relaxation of isolation rules
  • Health risks to the psychologist and staff
  • Health risks presented by the office environment, including the ability to enforce physical separation and the availability of sanitation materials
  • The vulnerabilities of one’s patient populations
  • The capacity of the client to use and benefit from telehealth services

While each practitioner, group, or agency will place different value on each of these factors, deliberations about reopening practices should consider all these factors carefully. Ideally, this decision will be a mutual decision between the practitioner and each of his or her patients, as each patient’s situation should influence the decision to risk increased potential for exposure.

 

Regulatory Considerations

Regulatory waivers have provided a significant amount of flexibility to providers and clients. Psychologists should be aware not only of the new flexibilities, but also when those flexibilities end.

State law prohibits declarations lasting longer than thirty days. At this time it is assumed, but unknown if, the Governor will issue another proclamation extending his Disaster Declaration again. A federal emergency declaration, on the other hand, lasts a year unless it is terminated early by the President.

The following are a list of waivers with their current expiration dates.

Interjurisdictional Practice – This law allows providers in other states to render aid in Texas during a declared disaster. This authority will end when the Governor’s Disaster Declaration expires, which is currently June 12th.

Remote Supervision – TSBEP rule allows 50 percent of supervised experience to be performed remotely; this waiver allows all supervised experience to be performed remotely. This waiver will expire when the disaster declaration expires, which is currently June 12th.

Medicaid Audio-Only Services – This waiver allows psychologists to bill for therapy services, as well as CANS, ANSA, and the Uniform Assessment, provided through a telephone. It expires June 30th.

TDI Emergency Rule – This emergency rule requires state-regulated insurance plans to cover services provided through telehealth. It expires July 15th, but TDI can extend it for an additional 60 days.

Medicare Services – These waivers allow psychologists to provide many of their typical services through audio-only telephones. The waivers also add new services to the list of services that can be provided through traditional telehealth platforms. The waivers will expire when the federal emergency declaration expires in 2021.

HIPAA – The Office for Civil Rights (OCR) at the Department of Health and Human Services has indicated that it will not be enforcing HIPAA rules for telehealth communications against providers who in good faith use non-HIPAA compliant non-public facing remote communication apps or services to deliver services to patients. OCR has said that these flexibilities will continue throughout the public health emergency, and there is no specific expiration date.

 

Preparing the Practice Environment

Each practice setting presents different challenges, but every provider should evaluate the possible sources of risk in the practice environment and take steps to reduce that risk. Assume that, sooner or later, the office will be entered by a person who is asymptomatic but a carrier of COVID-19. What surfaces are most hazardous for transmission? Which interactions will breach the recommended social distance? What is the exposure risk to others?

We suggest developing a written protocol before reopening. Involving staff in writing the protocol and then following it consistently will offer some protection against both the spread of infection and the risk of legal liability, should exposure occur. Written protocols should be tailored to each practice.

 

Preparing Clients

The best way to prepare patients is a comprehensive informed consent document regarding resuming in-person services. Like the informed consent document that was recommended for telepsychology, this form would be used in addition to the psychologist’s regular informed consent procedures.

Resuming in-person services is a mutual decision. If either the client or the provider does not want to resume or continue face-to-face, it should be clear that the option remains to start, continue, or return to telehealth, subject to policies in place by insurers and state regulations. Clients should also be informed that coming to the office carries a risk of exposure to their health, as well as their responsibilities when coming to the office.

Clients need to understand that these procedures are in place to protect staff, clinicians, and other clients from potential infection. Psychologists need to model for our patients that, while zero risk is impossible, the actual risks are impossible to estimate. Until a great deal more is understood about COVID-19, it is wise to err on the side of caution.

 

Additional Resources

CDC Guidelines for Small Businesses

EPA List of Effective Disinfectants

OSHA Guidelines on Preparing the Workplace

APA’s COVID-19 Resources Page

APA Practice Directorate COVID-19 Information Hub

CMS Recommendations for Re-opening Facilities to Provide Non-emergent Non-COVID Healthcare

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