publication date: Mar. 20, 2020
Trials & Tribulations
What community cancer centers need to know about COVID-19
By Jeff Patton
Acting chief executive officer,
President of physician services, OneOncology
By Lee Schwartzberg
Chief medical officer,
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.
As the incidence of the COVID-19 pandemic increases in U.S. communities, the needs of cancer patients, and those caring for them, are at the forefront of our attention and action.
Cancer patients are among those at a high risk of developing serious illness or death from COVID-19 pneumonia regardless of age, due to immune system suppression caused by their disease or therapy.
As the pandemic has spread across Asia, exploded in Europe and emerged as a serious threat in the United States, the oncology community has activated to prepare for patient care and to communicate clearly with patients, caregivers, colleagues and staff about how we can best mitigate the risks for those living with cancer as patients, caregivers and providers.
Community cancer centers play an important role in this conversation and in the fabric of caring for those with cancer across the United States. As two oncologists in the community setting and as leaders of a national oncology practice partnership, we’ve spent the last few weeks with our practices and leaders in our communities, to set in place strategies to flatten the curve of the virus’ exponential spread, care for our vulnerable patients, and mitigate exposure to those providing lifesaving care.
Importantly, all acute care settings, including community cancer centers, cannot become COVID screening sites. We’re encouraged by the developing public-private partnership and public health response (especially in metropolitan areas with a track record of strong health care coordination) to stand up and organize testing facilities to triage our most vulnerable citizens for symptomatic screening. All communities need plans for screening symptomatic patients so high acuity care, including oncology care, can continue to be provided.
With the developing nature of this crisis, our strategy and discussion for community cancer centers is organized by risk and focused on our patients and the physicians and staff who care for them. These recommendations are subject to change on a daily basis in this fluid and rapidly changing environment.
Low-risk patient strategy
Appointment rescheduling: We recommend rescheduling all non-essential treatments, such as screenings, six-month or annual check-ups for those without active cancer, while focusing on treating those with active cancers. We also recommend bringing a maximum of one family member/caregiver with each patient, none under the age of 16.
Utilization of telehealth services: Since community cancer centers are a different type of cancer center from hospital based and academic centers where we see more patients with low acuity than other sites of care, communicating with patients who are not in active treatment to keep them out of cancer centers and practicing social distancing is important.
The Centers for Medicare and Medicaid Services’ (CMS) waiver issuance on both HIPAA sanctions to improve data sharing and to allow for Medicare reimbursement providers for telehealth services are significant.
These waivers will allow providers to move six-month and annual checkups to virtual visits, helping keep patients at home. With Medicare reimbursements for telehealth services, providers will be able to utilize platforms, such as FaceTime, Zoom, or Doxy, to remain in constant contact with their patients.
Screening: Practices should be screening patients for the following prior to or immediately upon arrival to the clinic:
Been in close contact with someone who has been diagnosed with COVID-19 during the last 14 days.
History of travel to or have been in close contact with someone who traveled to areas of widespread or community COVID-19 transmission during the last 14 days.
Symptoms of COVID-19 (fever, cough, shortness of breath).
Optional screening for fever for all individuals entering our clinics is at the discretion of each site but encouraged at sites with higher incidence of documented COVID-19 infections.
Those that screen positive should contact their health care provider. Importantly, screening centers are beginning to get stood up in some communities around the country.
Medium-risk patient strategy
Active non-symptomatic patients: Physicians are best equipped to work with their patients regarding treatment regimens during this time, but generally patients on active treatment without symptoms should continue with their treatments. Patients and care teams must be in regular communications with patients in active treatment to ensure their treatments continue and so their exposure risk is minimized.
Patients with fever on active treatment: Patients who call in with fever who are on chemotherapy need to be seen by their oncologist or a designated provider who is assigned to evaluate these patients. These patients will need to be triaged—to their homes, isolation or area hospitals when necessary depending on their history and symptoms. These patients will likely undergo testing for influenza and COVID-19.
High-risk patient strategy
Vulnerable patients: Patients with neutropenic fever need to be seen by their physician and treated with IV antibiotics and other neutropenic precautions to prevent sepsis. Some of these patients could be sent to hospitals, but isolating them in community clinics may be preferable.
If a patient is suspected of having COVID-19:
Immediately move the patient from the general waiting area into a well-ventilated space at least 6 ft or more away, preferably to an Airborne Infection Isolation Room (AIIR).
If an AIIR is not available, then the patient should continue to use a facemask for the duration of the visit.
Perform nasal swabs for influenza and COVID-19.
Notify appropriate clinic staff (provider, IPC staff, and administrators).
The patient’s provider will determine the plan of care, including the recommended disposition (home or hospital).
If the patient does test positive for COVID-19:
Daily telephone and/or telehealth visit with the patient, with disposition based on evolving symptoms.
Notifying the local or state health department.
Instill universal public health precautions: Perform hand hygiene (use 60% – 95% alcohol-based hand sanitizers or wash with soap and water for 20 seconds). Implement respiratory hygiene and cough etiquette including the use of a face mask, tissues, and coughing into sleeve, if tissues aren’t available.
Wear full protective gear: Protecting those caring for patients is essential. As such, caregivers must use personal protective equipment (PPE), including gowns, gloves, and face masks for patients receiving chemotherapy.
Patient rooms: Clean and disinfect the room and equipment with a health care-grade disinfectant in the same manner used for other airborne illnesses before reusing. Staff cleaning rooms should use full PPE if patients were confirmed or suspected of contracting COVID-19.
Self-monitor and report: Staff and providers who use appropriate PPE or who have brief interactions with patients with suspected or confirmed COVID-19 are considered to be at a low exposure risk. All staff who have traveled overseas or whose families have traveled abroad must report that to the HR department.
Staff should also self-monitor and report acute respiratory symptoms to their provider and appropriate clinic leadership. And, of course, stay home if they have acute respiratory symptoms until cleared by their provider. Employees who stay at home with acute symptoms receive paid time off, so they don’t put others at risk.
Exposed staff: Staff who believe they’ve been exposed to COVID-19 must follow the Centers for Disease Control and Prevention (CDC) protocol to help prevent the disease from spreading and to care for themselves. These steps include self-quarantining by staying at home, separating yourself from other people and animals in your home. Also, staff need to call their health care provider, monitor their symptoms, and seek medical care if the symptoms worsen. Lastly, ensure your health care providers contact the local or state health departments.
Non-clinical staff/meetings: Change administrative meetings and tumor boards to virtual meetings to the extent possible. Utilize physician communication platforms to discuss patient cases.
Non-clinical staff work from home: Non-clinical departments should implement work-from-home policies.
Call to action
Sometimes, crises catalyze change. While remaining optimistic that by working together (and staying apart), our health care system can help mitigate the damage and protect our most vulnerable, we also hope our health care system can be improved by being tested.
Telemedicine, specifically remote patient communication and monitoring, are areas we believe will be recognized for their value during this pandemic. While community practices are early adopters of technology to improve patient communication outside the clinic, now is the time for practices to lean into this technology and for all payers to recognize the long-term value of remote monitoring with adequate reimbursement, not just during this crisis.
We hope the positive steps we take now to care for our patients and protect our citizenry can also spur change that will strengthen our ability to care for patients, when they are in our clinics and when they remain at home.