Return to Non-Emergent Care: Common Reopening Challenges Facing Your Practice

July 16, 2020

As practices begin to reopen to serve the needs of patients and begin delivering non-emergent care, many physicians may be wondering what the appropriate protocols in the pandemic environment are and how best to support their patients at this time. In addition, the new clinical setting presents its own set of challenges that require a strategic and unified approach. Physicians must now balance the need for in-person visits – which are crucial for critical medical care and revenue generation – with the risk of COVID-19 spread. Telemedicine has proven an adequate solution to patient management, however, it may not be a sufficient method of delivering care for all patients and some demand in-office appointments despite the ongoing virus spread.

Dr. Sachin Dave, an internist of the Indiana Internal Medicine Consultants stresses the importance of educating patients and communicating the risks to them. “My older patients actually insist on coming to see me in person,” he told Medscape in an interview, “I have to tell them it’s not safe.” Minimizing risk is paramount in the process of reopening medical practices across the United States and the globe; physicians must weigh the risks of increasing patient volume with patient and staff safety.

To assist healthcare practitioners in safely transitioning back to in-person care, Medscape has outlined some common challenges they may face in the reopening process, and how best to mitigate them.

1.     Unclear or Nonexistent Policies and Protocols

While physicians and other staff members may be aware of the COVID-19 prevention rules implemented to help mitigate virus transmission, patients need to be made aware of them preferably in a readily available document; it is important to develop formal protocols for all to follow to minimize confusion and ensure safety.

This includes enforcing mandatory mask wear for both staff and patients, setting up facilities in accordance with social distancing guidelines, having alternate waiting areas or asking patients to wait in their cars if the space gets too crowded, and other protective strategies.

Ensure all patients understand and agree to adhere to your new policies before they come in; in addition, they should be triaged over the phone per CDC guidelines before attending an in-office visit. Without a formal framework, refusing care or assessment of patients who do not comply with guidelines may lead to patient abandonment claims, making clear policies paramount at this time.

2. Too Many Patients, Too Soon

According to data from the Medical Group Management Association (MGMA), practices report an average 55% decrease in revenue and 60% decrease in patient volume since the COVID-19 crisis began. As a result, experts believe practices may be tempted to ramp up capacity immediately to restore prior patient volume. However, this period requires slow and carefully implemented safety protocols.

Physicians and their patients are encouraged to take advantage of telehealth services while they remain reimbursable at parity. The elevated demand for online care is forecasted to continue growing as more patients become comfortable with the technology and services become more advanced. While some doctors want to see an overload of patients immediately upon reopening, there has to be a limit on the number of patients coming into an office as welcoming too many patients too fast can have dire consequences.

3. Lack of Communication

Another potential pitfall is under-communication; patients may not be aware that your practice has reopened or plans to do so. It is important to consistently update your practice’s website, send out letters or newsletters to patients, maintain phone and email contact, post signs explaining reopening protocols, and keep everyone in the loop. The CDC has provided phone advice line tools that practices can adapt to their needs to keep patients informed.

Instead of under-communicating, physicians are encouraged to over-communicate to their patients as well as their staff, making sure they are made aware of the extra precautions being taken to prioritize their health and safety. Practice staff should also be aware of policy changes to minimize confusion.

Experts believe that practices can emerge stronger from the pandemic if they promote strong patient education and build up goodwill at this time. Leverage the patient portal, using it as a trusted resource to inform patients about COVID-19 and preventative measures being taken at your practice.

4. Inadequate Staff Training

Some staff members may be apprehensive about returning to work as a result of virus-related fears. Clear guidance is needed to ensure safety, manage expectations, and offer flexibility with scheduling to address potential challenges before they occur.

Properly training staff members is essential to their safety and that of your patients; specific guidelines for staff – such as designating eating areas, staggering appointments – should be clearly articulated and readily available. Many staff members may not be used to donning and removing personal protective equipment or wearing masks when working with patients. Training staff members will help reassure patients that safety protocols are being adhered to.

5. Neglecting Documentation

With the changing standard of care, a consistent workflow is paramount. This includes proper documentation, communication with staff and patients, and the use of established systems aimed at mitigating COVID-19 risk. Experts recommend keeping an administrative file used to track new protocols, policies, and any incidents or breaches for future use.

6. Forgetting About Personal Mental and Physical Health

Physicians should be cognizant of the high potential of burnout and mental health state  of their staff, their colleagues, and themselves. Mental exhaustion as a result of the persisting COVID-19 crisis and ongoing societal tensions is affecting all members of the population and has the potential to carry over to medical practices. To protect their mental and physical health as well as that of their staff members, physicians are encouraged to prioritize maintaining a positive culture at their practice – one in which everyone feels safe, taken care of and helps each other.

Practices and healthcare professionals located in areas which have deemed non-emergent care facilities eligible to reopen safely should take into consideration the aforementioned challenges and common pitfalls that may impede a smooth return to routine care. For those in search of comprehensive reopening recommendations and guidelines, The Doctors Company has developed an extensive checklist outlining the necessary steps for transitioning to in-person care – accessible here.

Inflammaging: Chronic Inflammation and Healthy Aging

July 9, 2020

In recent years, the scientific community has been increasingly focused on a rarely recognized yet widely prevalent condition that contributes to an array of diseases, including cardiometabolic diseases, arthritis, Alzheimer’s, and depression. Chronic inflammation, although it may progress slowly, is the root cause of most chronic diseases and poses a significant threat to public health and longevity.

Trending in many medical specialities chronic, low-grade inflammation associated with changes in stem cell structure and deterioration is being referred to as “inflammaging”. The condition, which often results from an accumulation of health risk factors such as environmental causes, dietary habits, UV exposure, and sleep patterns, is linked to a number of age-related diseases – including diabetes, cardiovascular disease, and cancer. To delay and support healthy aging while protecting the body from illness, medical experts continue to investigate the prominent role of chronic inflammation and its implications on the development of anti-aging therapies.

Causes of Chronic Inflammation

Current literature has identified several underlying molecular causes of the phenomenon of inflammaging. The condition stems from a failure of the immune system to mitigate responses to illness or injury; factors can include the body’s failure to eliminate bacterium or fungus, exposure to a toxic substance, or the presence of an autoimmune condition. With age, immune responses tend to become less well-regulated and thus, may result in consistently elevated levels of inflammatory agents such as C-reactive protein, chemokines, interleukin-6 (IL-6), and tumor necrosis factor-a.

Further, inflammaging can have a direct impact on skin health and vitality. Chronic oxidative stress can cause accelerated tissue damage, weakening skin structure and leading to the breakdown of elastin and collagen, ultimately impairing the skin’s barrier function. This contributes to the development of many unwanted dermatologic symptoms – wrinkles, hyperpigmentation, uneven skin tone, and textural changes.

Preventative Techniques 

As chronic inflammation is difficult to treat, employing adequate preventative measures is of utmost importance. Improving overall health by maintaining a balanced diet, regular physical activity, and consistent sleep patterns can be beneficial to supporting optimal functioning of stem cells in the body.

Highly processed foods contribute to the inflammatory response, increasing the risk of and worsening existing chronic inflammation. On the other hand, consuming a diet rich with anti-inflammatory foods – high in nutrient–dense vegetables, fruit, and unprocessed foods – can aid the body in regulating the immune response which becomes more challenging with age.

Additionally, experts emphasize the role of the gut microbiome in preventing chronic inflammation; research has found that the gut microbiota of elderly patients often has decreased diversity, leading to weakened barriers against bacteria and thus, increased risk and prevalence of chronic inflammation. To help maintain gut health it is recommended to increase the consumption of probiotic-rich foods – yogurt, kefir, and fermented products – and maintain a well-rounded diet.

Another important preventative measure to consider is the routine and careful use of sunscreen to protect the body against harmful UV exposure, which drives pro-inflammaging factors. To aid this, skincare products with the right ingredients can shield skin stem cells from the negative effects of environmental stressors and break the cycle of inflammaging.

While knowledge in the relatively novel field of inflammaging is continuously expanding, the role of chronic inflammation in the biological aging process and development of age-related disease has become well-known. Clinicians looking to gain a better understanding of current clinical evidence and strategies for targeting inflammatory activity are invited to attend the Inflammaging – Ways to Slow the Clock session taking place during our Longevity, Aging, and Immuno Competency Virtual Event.

Living in Disadvantaged Neighborhoods Increases Risk for Brain Atrophy

July 1, 2020

Continuous scientific efforts contribute to the emergence of new information revealing the intricate complexities of neurological functions and their surprising connection to a wide range of external factors. Protecting neurological function can be made possible through the growing identification of risk factors for neurodegeneration during the aging process and can help inform new preventative protocols for dementia and cognitive decline.

The latest data suggest an association between living in a disadvantaged neighborhood and developing brain atrophy, or experiencing a decrease in the number of brain cells or connections over time. Neighborhood disadvantage functions as a social determinant of health, reflecting the education, income, employment, and quality of housing within a particular geographic area. As brain atrophy typically predisposes individuals to dementia and cognitive decline, this finding has significant implications for protecting cognitive function as individuals age.

Impact of Neighborhood on Neurological Health

Examining the impact of neighborhood socioeconomic disadvantage on brain volume in a cognitively unimpaired population, researchers conducted a study of over 950 individuals without a history of cognitive impairment in Wisconsin. In their cross-sectional study, the research team evaluated participants living in the most socioeconomically disadvantaged neighborhoods using data from the Wisconsin Registry for Alzheimer’s Prevention and the Wisconsin Alzheimer’s Disease Research Center to assess T1-weighted structural MRI scans.

At the beginning of the trial, participants were not cognitively impaired based on the National Institute on Aging-Alzheimer’s Association diagnostic criteria, however, the cohort was enriched for Alzheimer’s disease risk based on a family history of dementia.

Led by Amy J.H. Kind, MD, PhD from the University of Wisconsin, researchers calculated total hippocampal volume by combining both left and right measurements and based total brain tissue volume measures on total white and gray matter volumes. Additionally, they computed both the Area Deprivation Index – a geospatially determined index of neighborhood-level disadvantage – and cardiovascular disease risk indices for each participant. Linear regression models were used to test the relationships between neighborhood disadvantage and hippocampal and total brain tissue volume – as assessed by magnetic resonance imaging.

Neighborhood Disadvantage Linked to Loss of Brain Volume

Earlier this year, the team published their findings online in JAMA Neurology which reveal that living in socioeconomically disadvantaged neighborhoods was associated with markedly decreased hippocampal and total brain tissue volume. Other middle-aged and older adults who lived in areas with lesser disadvantage experienced comparatively lower risks of both neurological outcomes. Researchers found that individuals living in the most disadvantaged neighborhoods experienced a mean of 7 years of age-related hippocampal atrophy.

Furthermore, they also noted that men living in these neighborhoods experienced a higher risk for brain atrophy than women, although the reasons for this correlation remain unknown.

Cardiovascular risk was found to mediate the association in the case of total cerebral volume, indicating that neighborhood-level disadvantage may be associated with the two neurological outcomes via distinct biological pathways.

However, investigators acknowledged potential limitations of the trial which included the “enriched risk study cohort” – including older participants and those with a family history of dementia. They note that this population “might be particularly vulnerable to the deleterious effects of neighborhood-level disadvantage on the hippocampus.” In addition, the study’s findings reveal associations and not causality due to its cross-sectional, observational nature and require further validation.

Different from the implications of individual-level socioeconomic status on neurological function, this is the first study to reveal a robust association between neighborhood-level disadvantage and hippocampal volume, according to researchers. The latest findings indicate that neighborhood disadvantage may be associated with brain tissue volume throughout the aging process even in the absence of clinical cognitive impairment.

These results may suggest new population markers to leverage in future research studies; neighborhood-level disadvantage could be considered in clinical decision-making or used to guide public health efforts that support healthy brain aging in such geographic areas.