Nurse practitioners in primary care community settings are finding COVID-19 cases are changing just about everything. And some of those changes could be long-lasting.
Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, is president of the American Association of Nurse Practitioners (AANP). She’s also a family and pediatric nurse practitioner at a New Orleans practice focused on providing care to medically underserved families. Thomas said she’s experiencing the widely publicized personal protective equipment shortage caused by the surge in COVID-19 cases and knows colleagues are too.
“We’ve done a survey collecting information from our colleagues around the country, and the shortage of personal protective equipment is really at dire straits,” Thomas said. “In my own office, for example, we can’t get any more masks. We actually had an episode early last week where our cleaning crew that came in the night before had taken several of our masks, and we were already in short supply.”
In an attempt to stop the virus’s spread, community practices are trying to mask everyone with symptoms, including a cough or fever. Providers are going through masks quickly, according to Thomas.
NPs aren’t the only community-based providers with dangerously low levels of PPE. More than half of primary care clinicians in the U.S. have little to no PPE, according to a survey by The Larry A. Green Center.
Thomas said she’s hopeful that with ramped-up mask production, practices like hers could be seeing some relief soon. In the meantime, the Centers for Disease Control and Prevention has changed its tune on using only N95 masks for COVID-19.
“We’ve been told that you can use a regular mask and a surgical mask,” Thomas said. “And now the new guidance is you can use bandanas if you’re out of regular masks. The evidence doesn’t show that these are as effective, but we’re at the point where something is better than nothing.”
Heeding the CDC recommendation is vital. The problem for many community health providers is they often don’t know if the patient before them has COVID-19 and can transmit it, Barry Bloom, PhD, research professor of public health at Harvard University’s T.H. Chan School of Public Health said during a March 19 media briefing on the coronavirus.
The first priority for providers should be to protect themselves, according to Bloom. “I would start with masks,” he said. “I’ve not been a fan of (surgical) masks, but there are a few scientific experiments that I can’t dismiss that suggest surgical masks are not that bad. In fact, in two studies in hospitals … they were essentially as good as N95 masks. I wouldn’t count on that, but it’s better than nothing. And in this case, anything that would protect the front-line people might be something to try and utilize.”
PPE relief could, in fact, be on the way.
On March 21, the American Nurses Association, American Hospital Association and American Medical Association sent a letter to President Trump urging him to immediately use the Defense Production Act. DPA would increase domestic production of medical supplies and equipment that hospitals, health systems, physicians, nurses and all front-line providers so desperately need, according to the letter.
On April 3, the President invoked the act.
Increased testing uncovers more COVID-19 cases
Like many of her colleagues, Thomas experienced a surge of COVID-19 cases in recent weeks. She said part of the upswing in cases is because of more widespread testing.
Thomas and her staff conduct COVID-19 testing at her federally qualified healthcare center. Twelve of the patients she tested March 20, for example, had positive results three days later.
Thomas recommends patients in her practice who test positive stay home unless they have symptoms, including difficulty breathing. If they’re not able to control the symptoms and they’re getting worse, Thomas recommends patients go to the emergency department. They should go wearing their masks and letting the ED staff know they’ve tested positive.
If patients notify the office that they’re going to the ED, Thomas said she and her team will make the call and give ED staff the positive test information.
“It’s a seamless transition,” Thomas said. “It’s always good for the emergency department to know what is going to be coming through the door, so they can anticipate what those needs may be.”
That collaboration between community practices and acute care is especially important during a pandemic.
“We’re all in this together,” she said.
Good news about telehealth, HIPAA
It’s important that community practices embrace telehealth to give patients better access to care. The technology might also help protect staff from exposure to COVID-19 patients, according to Thomas.
She and her staff converted to telehealth in late March.
“It’s going to be an adjustment because I’m used to putting my hands on patients,” she said. “But this is our new normal.”
There’s good news about telehealth for NPs and other community providers. The Centers for Medicare and Medicaid Services announced March 17 that it had expanded access to Medicare telehealth services, making it easier for providers to use telehealth. The waiver will allow patients not just in rural areas but anywhere to receive telehealth services at any time, according to AANP.
Telehealth could help keep COVID-19 patients at home and away from other people. In the long term, patients with chronic health conditions would benefit with better access, as well.
CMS also has loosened HIPAA requirements for telehealth services.
“Care can be provided through FaceTime, not necessarily through the technology in the electronic medical record,” Thomas said. “We’re looking at all types of things that we can do to get access to care for patients who so desperately need it, while keeping them in their homes so they can practice social distancing. We know that social distancing is going to be the only thing that prevents spread of this disease.”
Regular patient care takes a backseat
It has been anything but business as usual for NPs during this pandemic.
Thomas said she and colleagues are being reimbursed for services related to COVID-19 cases. But overall office visits have gone down, as primary care providers urge patients coming in for routine care to stay home until the pandemic is under control.
“We’re also seeing that in some offices that are very slow, nurse practitioners have been furloughed because they’re no longer needed,” Thomas said. “This would be the sites that aren’t doing telehealth services. Certainly, for sites that convert to telehealth there’s a role for them and a position for them. It’s very unfortunate because we have many NPs out there in the workforce that could be providing care to people.”
NPs in many states can’t take jobs at other clinics because their states don’t allow full practice authority for NPs, which is the ability to practice without needing a written agreement with a physician, according to Thomas.
In a March 18 statement on its website, AANP said it is hoping to remedy the situation by convincing the nation’s governors to immediately suspend all legislative and regulatory barriers that prevent NPs from providing patients with full and direct access to NP care.
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