CORONAVIRUS | COVID-19 Toolkit for Independent Primary Care Providers Click here to view the most recent updates on COVID-19 and resources from Avance Care. December, 15, 2020 Dear Primary Care Provider, We at Avance Care strongly believe that information-sharing among medical professionals is essential during the COVID-19 (C19) pandemic, and we understand many independent practices do not have the resources to craft protocols or the time to find the latest information to care for our patient. In the spirit: Please share this toolkit with other professionals who may benefit. We created this toolkit in the early weeks of the pandemic to help you provide care to your patients during this national emergency. As the we enter the TENTH month of caring for our patients in this new world, we try to include information most pertinent to the primary care physician and provider. We have entered the dark winter forecasted by our public health officials. Daily COVID-19 deaths in the US are frequently over 3000 since December 9. The release of the Pfizer mRNA vaccine on December 14 gives us hope that transmission of the virus will be under control by mid-2021. Updates in this version of the toolkit include the December 2 guidance from the CDC allowing reduction in the length of quarantine based on local health conditions. The shorter period of quarantine is intended to reduce the burden of isolating and may increase community compliance. The modeling behind this decision is found here https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html There is little published data on treatment of COVID-19 in the ambulatory setting. I have included the treatment protocol from the Infectious Disease Society of America and Eastern Virginia Medical School. EVMS’s protocol does not have widespread support in academic centers, however it offers options for treatment considerations through shared decision making for certain patients, including recommendation for aspirin and ivermectin in COVID-19 positive patients in the ambulatory setting. We are running into situations where our patients are traveling and requesting telehealth services while in other states. Medicare allows physicians who are licensed in one state to treat a patient in a different state during the PHE, however individual states have begun to lift the waiver allowing out of state physicians to provider services in their states. Here is a link to stay updated on which states have lifted waivers. https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in- response-to-covid-19.pdf December 16, 2020 updates 1. Options to reduce quarantine for close contacts using symptoms monitoring and diagnostic testing 2. Infectious Disease Society of America (IDSA) guidelines on treatment and management December 2 3. Protocol from Eastern Virginia Medical School for treatment prophylaxis and home treatment of mild symptoms – Marik-Covid protocol https://www.evms.edu/media/evms_public/departments/internal_medicine/EVMS_Critical_Care_COVID_1 9_Protocol.pdf 4. Resources for telehealth across state lines https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving- licensure-requirements-for-telehealth-in-response-to-covid-19.pdf 5. Summary from a meeting December 15 with NC DHHS regarding vaccine distribution in NC Yours in health, Joanne Fruth, MD, MA, FAAFP Avance Care Chief Medical Officer 2 Toolkit Resources 1. Online COVID-19 Textbook 4 2. Infographic on treating “Long COVID” from BMJ 5 3. Infection Disease Society of American Treatment Protocols 6 4. Marik-Covid Protocol Eastern Virginia Medical School 7 5. Options to reduce quarantine after close exposure 8 6. Changes to who needs to quarantine 8 7. Communication to Avance Provider staff December 15, 2020 via NC DHHS 9 8. Patient Informatic handout from NC DHHS 10 9. Johns Hopkins Breathing Exercises for Managing Cough due to COVID-19 13 10. Curbside Flu shots and 4-Question Consent 15 11. Updated Indications for Testing and Revised Definition of Close Contact 18 12. Testing of Health Care Workers 18 13. Updated Summary of Conditions Suggestive of Infection 18 14. Update on Limitations of PCR and Antigen testing for SARS-CoV-2 19 15. NC DHHS Caution regarding Antigen Testing, Reporting and Practical Application 20 16. Practical Decision-Making for Offices Which Have Access to Rapid Antigen Testing 20 17. Strategy for Respiratory Illness Symptoms with and Without Fever in Ambulatory Setting 20 18. Self-swabs; Practical Protocol for Antigen Testing in the Office Setting 21 19. Patients Instructions After Testing; QR Code to Link to NC DHHS Instruction Sheet 21 20. No-Touch Workflow in the Office – Practical Considerations 22 21. Decision Tree for Pediatric Testing from Duke Medicine 23 22. Guidelines for Antibody Testing and Letter Templates for Results Interpretation 24 23. Updated Statement Regarding Value of Serological Testing 26 24. General Office Precautions 27 25. Updated Sample Scripts for Patient Coordinators – 28 26. Screening Questions to Triage Symptomatic Patients 29 27. Proper Application of PPE 30 28. DIY Cleaning Solution and Routine Room Decontamination after PUI 32 29. Return to Work Criteria for Healthcare Personnel with Suspected or Confirmed COVID-19 33 30. Suggested Workflow for Daily Fever Evaluation and Obtaining Vitals 34 31. Symptoms of COVID-19 Compared to Flu, Allergies, and the Common Cold 35 32. Letter to Employees Regarding Work Conditions for CDC-Defined High-Risk Patients 36 33. Common Questions Regarding NSAIDs, Steroids, and ACE/ARB 37 34. Business Letters for Employers and Employees a. Essential Staff Business Letter 38 b. Letters for Return to Work 39 35. Link to Current Assessment of COVID-19-Related Treatments 41 36. Considerations for Rapid Conversion for Telehealth 41 37. Rapid Adaption to Telehealth and Condition List and Guide for Telehealth 43 38. Coding a Televisit Based on the “No Touch Exam”/Components to allow 99214/99203 coding 55 39. Consideration to Reuse Albuterol MDI to Substitute for Albuterol Nebulizer in the Office 56 40. Policy for Performing Nebulizer Treatment When N95 Mask Not Available 58 41. Responding to Inquiries on Supplements and Vitamins for COVID-19 Prevention 59 42. Advance Directives, MOST Orders, and NC Advance Health Care Directory 66 43. COVID-19 FAQ for Workers Who Perform Essential Services 68 44. Symptom Stop Sign 75 3 Online Textbook From: https://emcrit.org/ibcc/COVID-19/ This online textbook is regularly edited with new information regarding evaluation and treatment of COVID-19. 4 5 Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19 – December 2, 2020 6 7 Options to Reduce Quarantine After Close Exposure Reducing the length of quarantine may make it easier for people to quarantine by reducing the time they cannot work. A shorter quarantine period also can lessen stress on the public health system, especially when new infections are rapidly rising. Your local public health authorities make the final decisions about how long quarantine should last, based on local conditions and needs. Follow the recommendations of your local public health department if you need to quarantine. Options they will consider include stopping quarantine • After day 10 without testing • After day 7 after receiving a negative test result (test must occur on day 5 or later) After stopping quarantine, you should • Watch for symptoms until 14 days after exposure. • If you have symptoms, immediately self-isolate and contact your local public health authority or healthcare provider. • Wear a mask, stay at least 6 feet from others, wash their hands, avoid crowds, and take other steps to prevent the spread of COVID-19. CDC continues to endorse quarantine for 14 days and recognizes that any quarantine shorter than 14 days balances reduced burden against a small possibility of spreading the virus. CDC will continue to evaluate new information and update recommendations as needed. See Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing for guidance on options to reduce quarantine. Changes to Who Needs to Quarantine People who have been in close contact with someone who has COVID-19—excluding people who have had COVID-19 within the past 3 months. People who have tested positive for COVID-19 do not need to quarantine or get tested again for up to 3 months as long as they do not develop symptoms again. People who develop symptoms again within 3 months of their first bout of COVID-19 may need to be tested again if there is no other cause identified for their symptoms. 8 Communication to Avance Provider staff December 15, 2020: Summary from a meeting December 15 with NC DHHS regarding vaccine distribution in NC Hello All: Here is a quick update of COVID-19 Vaccine status as it applies to Avance Care – based on a call tonight with NC DHHS. 1. Early distribution is limited; be patient; Everyone who wants to be immunized will be immunized. 2. The vaccine will be provided at no cost to patients. 3. Enrollment in the Covid Vaccine Management System (CVMS) is not open now for primary care; they anticipate Jan 2021. This means that Avance cannot order vaccine now. 4. Our Providers generally will be considered eligible in Phase 2; (see below and attached). We do not know yet how you will get your vaccine (example – will you go to the health department, a hospital?). 5. Providers who have two 2+ chronic conditions are in phase 1b. It is not determined where you will go to get your vaccine or when. 6. None of our providers qualify under phase 1a 7. Attached is a 1-page infographic and a 2-page patient information sheet. It will be available to you for your patients on the resource page.