BHHSURG COVID-19 Guidance featured image

 

COVID-19 Guidance for Behavioral Health and Homelessness Care Providers

 
Note: To access a copy of the recorded Q&As from previous Provider Webinars, please select from the list below:
August 24, 2020 | August 17, 2020 | August 10, 2020 | July 2020 | June 2020 | May 2020 | April 2020 | March 2020

 
Please Note – Information below is subject to change as content is updated frequently. (Last Update: June 30, 2020)
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Administrative & Contract Guidance by Division & Office

This section offers providers and state employees updates on (1) overall client services, (2) state division and offices, and (3) contractual updates.

Overall Client Services

Client Travel
All client travel is suspended until further notice, except for travel for placement or discharge – which requires approval by the Director of Health. At this time, we cannot authorize home passes or treatment visits and it is advised those be done over video.

Department of Health, Behavioral Health Administration

Adult Mental Health Division
The Adult Mental Health Division (AMHD) is committed to offering our providers flexibility to address the COVID-19 Pandemic. The AMHD is allowing Community-Based Case Management (CBCM) telehealth including the use of telephone and video as appropriate. The AMHD Clubhouses (psychosocial rehabilitation programs) will be providing services via telehealth. Staff will contact clubhouse members to inform them of this change. Although clubhouses are providing telehealth services, they will provide lunch meals daily as needed as well either by delivery or pick up.

Alcohol and Drug Abuse Division
The Alcohol and Drug Abuse Division (ADAD) is committed to supporting substance use disorder (SUD) Continuum of Care (COC) treatment and recovery support service providers in their administration of services to clients during the COVID 19 pandemic. ADAD has delivered guidance and links to resources, specifically regarding federal direction for Opioid Treatment Programs on the protocols of take-home doses of MAT for stable and less than stable clients, prescribing protocols for integrating telehealth in the MAT prescribing process for methadone, buprenorphine, and other MAT prescriptions. Guidance has also covered prioritizing the health and safety of staff and clients by expanding the use of telehealth for treatment services, as necessary and whenever possible. ADAD has provided clarification and resources for the use of multiple applications of telehealth (telephonic and video conferencing) and the various services for which telehealth may be functional. ADAD is also encouraging and facilitating all meetings by phone or zoom, as necessary and whenever possible.

Child and Adolescent Mental Health Division
The Child and Adolescent Mental Health Division (CAMHD) is committed to continuity of care for Hawaii’s youth and families during the COVID-19 pandemic. This is being accomplished by 1) sustaining all Family Guidance Center functions through telehealth services whenever possible and 2) supporting our providers in the flexible delivery of their essential services. We recommend the use of telehealth for all services whenever possible and tele-visitation between families and youth being supported in residential programs allowing these programs to shelter in place. CAMHD has furnished providers with additional telehealth resources. Furthermore, CAMHD is working to develop additional resources in anticipation of future needs. Finally, further guidance is provided by the Behavioral Health and Homeless Statewide Unified Response Group through weekly calls and posted resources.

Developmental Disabilities Division
On March 27, 2020, the Developmental Disabilities Division (DDD) received approval from the Centers for Medicare and Medicaid (CMS) to implement Hawaii’s application for the 1915(c) Home and Community Based Services Appendix K for Emergency Preparedness and Response. The CMS approval activates the flexibilities in Hawaii’s Appendix K application that are available under the Medicaid 1915(c) authority available during the federally declared disaster for COVID-19. The Appendix K Operational Guidelines, inclusive of service and programmatic guidance, will be available soon on the DDD website for COVID-19. Any updates to the Appendix K Operational Guidelines will be announced to providers by email from the DDD Community Resources Branch. Providers should check the link often for new postings or updates. The DDD COVID-19 page will include all information related to service authorization, billing guidance, and any new billing codes or rates. New billing codes for services such as telehealth will be added as they are approved by the MedQUEST Division.

Department of Human Services, Homeless Program Office

HPO recognizes the challenges providers are facing during the Novel Coronavirus Disease 2019 (COVID-19) pandemic. To support all HPO contracted providers with their continuity of operations plans, HPO will be modifying current contractual and payment requirements as specified below.
Performance Measures and Outcomes (PMO), staff-to-client ratios, and regular staffing patterns, and required face-to-face encounters and contacts will be suspended until further notice. HPO will allow the option of providing telephonic outreach, case management appointments, check-ins, and follow-up services. For households without access to phone service, homeless outreach providers should set up drop-in centers near identified encampments and/or partner with other government agencies to assist with administering services.

The final two-quarters of PMO-based payments will be paid in full for the remainder of each provider’s current supplemental contract. Providers will not be able to recapture any PMO payments that were not met during the first and second quarters. Providers may now mail payment requests to HPO for any outstanding quarterly or monthly payment requests identified on the payment schedule and payment requests for third and fourth quarter PMOs. Providers should not send their final 5% payment request unless notified by their assigned Program Specialist.

Providers are responsible to submit all quarterly and final financial reports as scheduled and shall continue data entry into the appropriate HMIS as required by HPO and the local Continuum of Care (CoC). The Provider shall refund to the State any funds unexpended or expended inappropriately.

Office of the Governor’s Coordinator on Homelessness

The Office of the Governor’s Coordinator on Homelessness (GCH) is committed to offering flexibility in the use of Ohana Zone funds to address the COVID-19 pandemic, including any contract or budget modifications to expand the scope of work for contracted County providers.  Ohana Zone funds were intended to be flexible to allow these funds to meet the needs of homeless individuals, and we believe the use of Ohana Zone funds during this time of crisis is consistent with the Legislature’s intent for this funding.

Examples of contract flexibility may include using Ohana Zone funds to support isolation spaces, transportation, hygiene facilities and services for the homeless, staffing costs to address the pandemic, and other costs as needed to expand the capacity of existing homeless programs.  Expanded crisis services related to the COVID-19 pandemic response will be tracked separately from any existing performance measures.  Counties should work with any subcontracted providers to arrange for temporary contract flexibility or budget modifications as needed.

GCH strongly encourages each County to consider using a portion of their Ohana Zone funds to support the immediate crisis needs of people experiencing homelessness.  GCH is requiring a written response from each County to document the plan for using Ohana Zone funds to enhance the COVID-19 response for people experiencing homelessness in their community. If Ohana Zone funds will not be used for this purpose, a written response describing how the County will be utilizing other funding sources to meet these needs is required.

Care Delivery During the COVID-19 Outbreak

How BHH Providers Ensure Care Delivery for Our Clients

Behavioral Health and Homelessness Services are Essential

  • Behavioral health and homelessness (BHH) services are essential. These services are essential for overall well-being during times of calm but especially during times of anxiety such as during a pandemic. As part of our BHH ʻohana, we all bear the crucial kuleana to facilitate access to such services.
  • Mental health and substance use services are essential not only for current clients, but also because of new clients as a result of the pandemic, e.g. bereavement, depression, post-traumatic stress disorder, and substance use when friends or relatives become seriously ill or die. Mental health professionals and social workers are essential to help reduce panic associated with a pandemic.
  • Homelessness services are essential during a pandemic as these populations are often the most vulnerable and at risk.
  • Please note that although all behavioral health and homelessness care services are essential, some staff have “essential” functions that require them to be in the office whereas some have “nonessential” functions, which require them to continue to telework.

BHH Staff & Providers are Called to Ensure Continuity of Care

  • Especially during an emergency period or an epidemic, staff and providers of behavioral health and homelessness services are called to serve in ensuring access to all these essential services. Behavioral health and homelessness services are asked to continue to operate with continuous coverage as much as possible and to make use of telehealth and other non- Face to Face options where you are able. During this period, staff and providers should make all efforts to maintain minimum levels of coverage where they are able.
  • Staff and provider safety is of utmost importance. We ask all to be mindful of the safety and protection of clients and staff through maximum physical distancing and hygiene practices and implement necessary preventive, containment, and mitigation measures to reduce the spread of COVID-19.

Flexibility via the Section 1135 Waiver

  • Under section 1135 of the Social Security Act, the Secretary may temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure that sufficient health care items and services are available during an emergency period.
  • Health care providers that provide sufficient healthcare items and services in good faith can be reimbursed for them and not subjected to sanctions for noncompliance, absent any fraud or abuse.
  • Examples of these 1135 waivers or modifications include:
    • Conditions of participation or other certification requirements
    • Program participation and similar requirements
    • Pre-approval requirements
    • Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State (this waiver is for purposes of Medicare, Medicaid, and CHIP reimbursement only – state law governs whether a non-Federal provider is authorized to provide services in the state without state licensure)
    • Emergency Medical Treatment and Labor Act (EMTALA)
    • Physician Stark self-referral sanctions
    • Performance deadlines and timetables may be adjusted (but not waived)
    • Limitations on payment for health care items and services furnished to Medicare Advantage enrollees by non-network providers
    • Program participation and similar requirements
  • These waivers typically end no later than the termination of the emergency period, or 60 days from the date the waiver or modification is first published.
  • Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers: Applicable to all 17 provider types, also requires inpatient providers to have policies and procedures that address the facility’s role under an “1135 waiver.”
  • The Emergency Preparedness Rule: Requires that some providers may include policies and procedures on what a facility would do if they had to provide care at an approved alternate site as well as processes on how would they let the community know they are operating at a different care site and any reporting they may need to do if they were under an approved 1135 Waiver.
  • This guidance will be reassessed regularly and adjusted accordingly.

Source: CMS 1135 Waivers

Considerations for Intimate Partner Violence and Child Abuse

Adapt Behavioral Health Group Therapy Models for Face-to-Face Services

In residential treatment centers, people may congregate in small or crowded spaces. For patients lacking telehealth connectivity, consider ways to mitigate exposure and spread of COVID19:

  • Minimize the number of people per group: Seek to control the spread of COVID-19 by converting behavioral therapy conducted in groups of more than 10 people to groups of no more than 5 people per group or when feasible into individual therapy.
  • Find a large well-ventilated space: All therapy should be held in a large well-ventilated room or outdoors or otherwise with adequate physical distancing between all individuals participating in the therapy.
  • Appropriately shift to patient-centered use of telehealth services (see below).

Ensure Access to Medications

  • Follow-up with patient’s medication stock: With the risk of lockdown and quarantine and with limited capacity by patients for self-care, providers should seek to follow-up with patients on the adequacy of their medication stock.
  • Seek exceptions to OTPs: Most patients on an Opioid Treatment Program (OTP) are required to come in daily to receive their medications. As a provider, you may seek individual or blanket exceptions from SAMHSA to decrease pickup schedules and reduce the number of in-person visits.
  • Opioid Treatment Program (OTP) Guidance for Patients Quarantined at Home with the Coronavirus:
    1. Document that the patient is medically ordered to be under isolation or quarantine. When possible confirm the source of information – e.g., doctor’s order, medical record. Ensure the documentation is maintained in the patient’s OTP record.
    2. Identify a trustworthy, patient-designated, uninfected member of the household to deliver the medications using the OTP’s established chain of custody protocol for taking home medication. This protocol should already be in place and in compliance with respective state and DEA regulations. OTPs should obtain documentation for each patient as to who is designated permission to pick up medication for them and maintain this process of determining a designee for any new patients.
    3. If a trustworthy member of the household is unavailable or unable to come to the OTP, then the OTP should prepare a “doorstep” delivery of take-home medications. Any medication taken out of the OTP must be in an approved lockbox.
  • Go to these links to make those requests and view official guidance:
  • Telemedicine for controlled substances:
    • After the US Secretary of Health Azar designated a public health emergency on January 31, 2020, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation under certain conditions.
    • For more information, see DEA Diversion on Coronavirus
  • Methadone and Buprenorphine: Under 42 C.F.R. § 8.11(h), SAMHSA has the authority to grant exemptions to Opioid Treatment Programs (OTPs) from certain requirements of the OTP regulations.
    • Concerning new patients treated with buprenorphine, SAMHSA has pre-emptively exercised its authority to exempt OTPs from the requirement to perform an in-person physical evaluation (under 42 C.F.R. § 8.12(f)(2)) for any patient who will be treated by the OTP with buprenorphine if a program physician, primary care physician, or an authorized healthcare professional under the supervision of a program physician, determines that an adequate evaluation of the patient can be accomplished via telehealth.
    • This exemption will continue for the period of the national emergency declared in response to the COVID-19 pandemic and applies exclusively to OTP patients treated with buprenorphine.
      Also, the treatment of OTP buprenorphine patients must be done per SAMHSA’s OTP guidance issued on March 16, 2020. See OPT Guidance.
    • The OTP provider caring for the buprenorphine patient under these circumstances must be a licensed healthcare practitioner who can, in his or her scope of practice prescribe or dispense medications and have a current, valid DEA registration permitting prescribing or dispensing of medications in the appropriate Controlled Substances Schedule.
  • This exemption does not apply to new OTP patients treated with methadone. For new OTP patients that are treated with methadone, the requirements of an in-person medical evaluation will remain in force.
  • For more guidance, see FAQs: Provision of methadone and buprenorphine for the treatment of Opioid Use Disorder in the COVID-19 emergency.
  • Long-acting injectibles:
  • Withdrawal symptoms: The Hawaii Health and Harm Reduction Center (HHHRC) has developed excellent guidance around substance detox and withdrawal procedures available here: HHHRC Detox & Withdrawal Protocols

Re-examine Visitation Policies

  • All behavioral health services are essential, and continuity of care must be maintained in the best interest of the patient, not the convenience of staff.
  • Familiarize yourself with telehealth policies and procedures before you offer phone or video visits to clients.
  • During the initial 15-day period issued by Governor Ige and until otherwise notified, providers are encouraged to work with clients to reschedule other client and/or family visits if family members or clients are sick.
  • Specific BHA Site Visitation Policies:
    • For youth at the detention home or Hawaii Youth Correctional Facility: No family or outside visitors are allowed at this time.
    • For clients at the Hawaii State Hospital: No family or outside visitors, other than those state workers deemed “essential” (e.g., case managers, court evaluators) are allowed at this time.
    • Dental Clinics (Diamond Head Health Center, Lanakila Health Center, Leeward Health Center, Windward Health Center, Hawaii State Hospital) – Postponing all elective dental procedures from March 17 to April 8, 2020. All Clinics are still open and will only provide emergency (emergent/urgent) dental care for patients. Emergency care includes but is not limited to dental pain or trauma, swelling, and infections. This was based upon the American Dental Association’s recommendation to all dental offices and clinics (03/16/20). Staffing is maintained in the ordinary course of business. Postponing all elective dental procedures from March 17 to April 8, 2020. All Clinics are still open and will only provide emergency (emergent/urgent) dental care for patients. Emergency care includes but is not limited to dental pain or trauma, swelling, and infections. This was based upon the American Dental Association’s recommendation to all dental offices and clinics (03/16/20). Staffing is maintained in the ordinary course of business.

Providing for Unsheltered Homelessness

Please refer to the most recent CDC Guidance.

Providing Services at Home

Please refer to the Home Visitation Guidance (April 13, 2020).

Offer Telehealth Services

(See section on Telehealth)

Remote and Telework Guidance

Personnel in Critical Infrastructure Positions

  • Some personnel fill critical infrastructure roles within communities. Based on the needs of individual jurisdictions, and at the discretion of state or local health authorities, these personnel may be permitted to continue work following potential exposure to SARS-CoV-2 (either travel-associated or close contact to a confirmed case), provided they remain asymptomatic. The Department of Homeland Security has provided guidance on identifying essential critical infrastructure workers during the COVID-19 response.
  • Persons in these essential positions will be notified they are in these critical roles.
  • Personnel who are permitted to work following exposure should self-monitor under the supervision of their employer’s occupational health program including taking their temperature before each work shift to ensure they remain afebrile. On days these individuals are scheduled to work, the employer’s occupational health program could consider measuring temperature and assessing symptoms before their starting work. Exposed healthcare personnel who are considered part of critical infrastructure should follow existing CDC guidance.

The Effects of Telework on BHH Service Provision

Emergency remote work/telework in response to social distancing and the COVID-19 pandemic should be done wherever possible. Programs are encouraged to identify essential vs. non-essential staff as a way toward mitigating prolonged contact. Generally:

  • “Essential” employees are required to report to their worksite and continue to perform work as usual. They may be able to perform work remotely if deemed appropriate by their supervisor.
  • “Nonessential” employees that can telework should work from their alternate/remote worksite for this specific period, follow their normal working hours, and follow their supervisor’s direction. They may be directed by their supervisor to report to the work if the situation changes and/or be reassigned to other duties within their job description and classification that can be completed remotely.
  • As much as possible, programs and centers should welcome visitors by appointment only. Face to Face services should be limited to those activities that are not feasible to conduct remotely or through telehealth options. HIPAA and 42 CFR restrictions have been significantly relaxed for these purposes.
  • As much as possible, work to hold all meetings by phone or video conference (e.g., treatment team meetings, community meetings, workgroups).
  • For those employees deemed eligible for telework, ensure supervisors have a plan to manage those employee’s workload, then have them meet with the employee to inform them of the situation and your expectations.

Resiliency and Emotional Wellness

The following are recommendations from the CDC:
During a Response: Understand and Identify Burnout and Secondary Traumatic Stress

Limit your time working alone by trying to work in teams.

Responders experience stress during a crisis. When stress builds up it can cause:

  • Burnout – feelings of extreme exhaustion and being overwhelmed.
  • Secondary traumatic stress – stress reactions and symptoms resulting from exposure to another individual’s traumatic experiences, rather than from exposure directly to a traumatic event.

Coping techniques like taking breaks, eating healthy foods, exercising, and using the buddy system can help prevent and reduce burnout and secondary traumatic stress. Recognize the signs of both conditions in yourself and other responders to be sure those who need a break or need help can address these needs.

Signs of Burnout

  • Sadness, depression, or apathy
  • Easily frustrated
  • Blaming of others, irritability
  • Lacking feelings, indifferent
  • Isolation or disconnection from others
  • Poor self-care (hygiene)
  • Tired, exhausted or overwhelmed
  • Feeling like:
    • A failure
    • Nothing you can do will help
    • You are not doing your job well
    • You need alcohol/other drugs to cope

Signs of Secondary Traumatic Stress

  • Excessively worry or fear about something bad happening
  • Easily startled, or “on guard” all of the time
  • Physical signs of stress (e.g. racing heart)
  • Nightmares or recurrent thoughts about the traumatic situation
  • The feeling that others’ trauma is yours

Get support from team members: Develop a Buddy System
In a buddy system, two responders partner together to support each other and monitor each other’s stress, workload, and safety.

  • Get to know each other. Talk about background, interests, hobbies, and family. Identify each other’s strengths and weaknesses.
  • Keep an eye on each other.
  • Set up times to check-in with each other. Listen carefully and share experiences and feelings. Acknowledge tough situations and recognize accomplishments, even small ones.
  • Offer to help with basic needs such as sharing supplies and virtual resources.
  • Monitor each other’s workloads. Encourage each other to take breaks. Share opportunities for stress relief (rest, routine sleep, exercise, and deep breathing).
  • Communicate your buddy’s basic needs and limits to leadership – make your buddy feel “safe” to speak up.

Responder Self-Care Techniques

  • Limit working hours to no longer than 12-hour shifts.
  • Work in teams and limit the amount of time working alone.
  • Write in a journal.
  • Talk to family, friends, supervisors, and teammates about your feelings and experiences.
  • Practice breathing and relaxation techniques.
  • Maintain a healthy diet and get adequate sleep and exercise.
  • Know that it is okay to draw boundaries and say “no.”
  • Avoid or limit caffeine and use of alcohol.

It is important to remind yourself:

  • It is not selfish to take breaks.
  • The needs of those you are caring for are not more important than your own needs and well-being.
  • Working all the time does not mean you will make your best contribution.
  • Other people can help with the response.

Responding to disasters can be both rewarding and stressful. Knowing that you have stress and coping with it as you respond will help you stay well, and this will allow you to keep helping those who are affected.

Additional Wellness Resources

The Center for the Study of Traumatic Stress has also created a handout on Sustaining the Well-Being of Healthcare Personnel During Coronavirus and Other Infectious Disease Outbreaks.

The Hawaii-based One Shared Future group has developed a list of professional and personal resources that focus on self-care, sustainability, productivity, connectivity, and positivity – on the job and at home.

Telehealth Guidance

Make Telehealth Services Available

  • This telehealth decision tree can assist you in determining when telehealth is appropriate.
  • Provide your clients with information on how to prepare for telehealth sessions.
  • Telehealth services are generally allowable: Some clients may wish to use telehealth services rather than in-person visits to maximize physical distancing in an epidemic. Telehealth services are allowable and approved for both direct providers in BHH as well as providers contracted by BHH. Effective immediately, BHH providers and staff should offer telehealth services as an option to all patients while ensuring continuity of coverage of all services.
  • Circumstances under which telehealth services are allowable: BHH will continue to provide patient-centered care, which means that care is tailored to a patient’s needs and circumstances. BHHwill seek to offer patient-centered care through telehealth services by its state-operated providers and contracted providers under the following circumstances:
    • only when a patient has telehealth connectivity and prefers telehealth consultation, and
    • if the visit can be safely rescheduled or moved into telehealth platforms or telephones without a significant impact on patient health over two months.
  • Identify clients who may not have access to technology: Some of BHA’s most vulnerable clients may not have access to technology, such as smartphones or other devices, that would allow them to receive services virtually. Enhanced efforts should be made to ensure these clients still access services either in person with adequate physical distancing or with other arrangements made for these clients.
  • Consider ways to maximize engagement during telehealth sessions with clients: Review research-informed recommendations from the University of Hawaii, Center for Cognitive Behavioral Therapy.
  • Refer to BHA and division standard operating procedures for providing telehealth services to clients. Please note that as of March 1, 2020, Hawaii Med-QUEST has begun to allow telephonic (audio only) sessions:
    • For ADAD: Currently, ADAD providers are not providing this service. Due to this pandemic emergency, ADAD is encouraging providers to utilize telehealth. ADAD is working with SAMHSA for guidelines to develop policies and procedures so providers would be able to continue to utilize telehealth services even after this pandemic emergency.
    • For AMHD: Refer to CMHC telepsychiatry P&P.
    • For the CAMHD, telehealth guidelines are listed in the Teal Book, page I-11.
    • For DDD: Currently, DDD providers through the 1915(c) Waiver do not provide this service. The DDD is working on an emergency response amendment (1135 Waiver, Appendix K) through CMS, and if approved telehealth could be an option for providers and case managers to use during the pandemic emergency.
  • General principles for offering telehealth services:
    • Providers should inform families of the risks and benefits of using telehealth. The risks include that clinical important information could be missed due to not being physically present with the clinician.
    • A conventional consent form for services is required for all treatment. Telehealth can be added as a service modality to your existing form. Temporarily, verbal consent may be documented in a service note, with the date, guardian name, and documenter name. Sample: “The family agrees to services offered via telehealth, defined as secure video and audio, in addition to in-person sessions.”
    • Ensure that your work-provided laptop has appropriate VPN configurations to access EMRs and other important and confidential client information.
      • AMHD and CAMHD are providing Zoom licenses for all interested providers and can be requested through the helpdesk.
      • CAMHD: (808) 733-9309 or [email protected]
      • AMHD: 236-8291 or [email protected]
    • Adhere to federal statutes (HIPAA, 42 CFR Part 2) regarding patient privacy and security. See guidance below regarding HIPAA and 42 CFR Part 2 considerations during the emergency period declared by the federal government. Briefly, during the COVID-19 nationwide public health emergency, providers can use any non-public facing remote communication tool (Zoom, FaceTime, Skype) to communicate with patients to provide telehealth without the risk that OCR might seek to impose a penalty for non-compliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. Providers should notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.
  • Your clients might need some orientation to use telehealth. See the “Using Telehealth” resource for clients and consumers.
  • If you are an out of state provider and are interested in providing services for a client within Hawaii, please consult the Hawaii Department of Consumer Affairs, Professional and Vocational Licensing Division.
  • Consider ways to maximize zoom support groups. To protect online Zoom meetings from unwanted participation and harassment, the American Society of Addiction Medicine COVID-19 Task Force recommends:
    • Muting audio and disabling video and screen sharing for attendees
    • Protecting meetings with passwords
    • Never using a personal meeting ID when scheduling a meeting
    • Modifying the participant’s log-in name
    • Using a virtual background
    • Enabling waiting rooms as host
    • Encouraging the group to communicate if they become suspicious of anybody
    • Refrain from recording the meeting
  • To promote a respectful and supportive online group experience, it is recommended that participants observe the basic rules of etiquette that apply to in-person meetings:
    • Contribute by sharing while being mindful of time and others’ need to share
    • Refrain from giving advice or “cross-talking”
    • Punctuality, civility, and avoidance of profanity
    • Include a moderator to keep the meeting on track and consistent with the group’s expectations
  • To promote confidentiality of online group participants, it is recommended that support group leaders and participants be aware of the risk and benefits to anonymity and confidentiality in online environments and be active in taking measures to promote online privacy:
  • Register with an anonymous username and email account. Turn off the video setting for live teleconference meetings if the participant does not want video to be captured and/or verify that the meeting is not being recorded
  • Be aware of what is visible in the background of the webcam and that it does not inadvertently reveal information the individual or others
  • Screen capture disabling: screen captures are disabled on participant’s device while logged into the meeting
  • Prevent participants logged into the meeting from sending images
  • Prevent device/user information from being logged and reported
  • Disable meeting recording

Source: ASAM

Providers May Bill for Telehealth Services

  • All telehealth services are allowable and expanded use of telehealth for as many procedures and services as possible are encouraged. Unless specifically established otherwise, telehealth services may be billed as if they were face to face within contract parameters.
  • As a payer of health services, BHA divisions and other BHH-SURG payors may choose to establish and calibrate telehealth billing policies and procedures as needed.
  • As a provider of health services, BHA providers who bill MedQUEST to seek reimbursement for telehealth services should follow MedQUEST policies and procedures regarding telehealth reimbursement:
    • State divisions and offices are making every effort to be flexible and allow providers to bill for video + audio as well as audio-only sessions. As of April 15, 2020, the Med-QUEST division is allowing telephonic (audio only) visits in addition to other telehealth modalities to provide medically necessary health care services during the public health emergency period. In alignment with CMS guidelines (CMHS-1744-IFC), these will be retroactive to March 1, 2020. Please contact the relevant BHA division to determine how to bill for the telephonic services that you provide. If not posted here, please submit a question via the website form to receive specifics about this:
      • CAMHD
        • Should providers be able to reach families and youth via phone calls, and telehealth is not possible (customers without smartphones or other youth circumstances), limited audio-only services are temporarily permitted.
        • Providers must document all services, and the specific reasons for audio phone calls and not telehealth in the first phone call service note. All services still must be completely documented in the DAP note format.
        • Service notes must be entered in MAX as “Telehealth = Yes”, and “Audio-Only = Yes”** (** CAMHD will notify providers once this field is added in the next week). These notes must also include filling out the “Provider site” & “Client site” details. Providers sending batch notes will need to enter these Audio-Only notes on the MAX Portal.
        • Services rendered via telephone are subject to additional CSO restrictions and/or limits. (CSO will monitor for appropriateness all notes exceeding 6 units.)
        • CAMHD is to reimburse for these services without a federal match from Medicaid.
    • Billing appropriately using CPT and HCPCS codes for telehealth services. See MedQUEST attachment on eligible CPT and HCPCS billing codes here:
  • All HPO services are essential. HPO will allow the option of providing homeless outreach and case management for applicable services telephonically for regularly scheduled appointments, check-ins, and follow up services. For households without access to a phone, homeless outreach providers are to set up drop-in centers near identified encampments and/or partner with other government agencies to assist with administering services.
  • Training staff to conduct telehealth services:
    • There are many resources available for telepsychiatry and telehealth that providers can consult, including from American Psychiatric Association Telepsychiatry resources, best practices, and toolkits and the Pacific Basin Telehealth Resource Center based at the University of Hawaii. The Department of Health Genomics Section has also created a helpful video.
    • In coordination with relevant experts and partners, BHA will offer training to direct providers and contracted providers for the use of telehealth services to rapidly train providers to:
      • Basic clinic flow (if needed)
      • Basic equipment i.e. smartphone, tablet, laptop or desktop computer connected with a camera and microphone
      • Rapid training – quick and short training videos

Federal Communications Commission COVID-19 Telehealth Funding Program

The CARES Act has appropriated $200 million to the Federal Communications Commission (FCC) to establish the COVID-19 Telehealth Program. This program was created to assist healthcare providers in their response to the COVID-19 pandemic with immediate and full funding for telecommunications services, information services, and necessary devices that will enable critical connected care services. Coverage will continue until the program’s funds are expended, or when the COVID-19 pandemic has ended. This program is limited to nonprofit and public health providers that fall under the health care providers category in section 254(h)(7)(B) of the 1996 Act. For questions regarding eligibility, applicants may contact the Universal Service Administrative Company (USAC) via telephone at (800) 453-1546 or via email. The online application may be accessed through the COVID-19 Telehealth Program online portal.

Prescribing

As of March 21, 2020, and until the public health emergency ends, the Drug Enforcement Administration (DEA) is allowing practitioners to have further flexibility with prescribing buprenorphine to both new and existing patients with opioid use disorder (OUD) via telephone, without requiring practitioners to conduct in-person or by telemedicine evaluations. Additionally, buprenorphine may be prescribed to new patients based on a telephone evaluation. This is in addition to practitioners being able to prescribe controlled substances to patients via telemedicine without a prior first time in-person evaluation during the public health emergency.

HIPAA

Effective on March 20, 2020, the Office of Civil Rights (OCR) will exercise its enforcement discretion to not impose penalties for HIPAA violations against healthcare providers in connection with good faith provision of telehealth using communication technologies. This notification applies to all HIPAA-covered healthcare providers, with no limitation on the patients they serve with telehealth. This includes patients that receive Medicare or Medicaid benefits and those that do not. Covered health providers will not be subject to penalties for violations of the HIPAA Privacy, Security, and Breach Notification Rules. There is no expiration date, though the OCR will issue a notice to the public when it is no longer exercising its enforcement discretion. For more information, visit the OCR’s FAQs on Telehealth.

Codes for Providers

The following links provide relevant codes for each organization:

Visit the Telehealth Services code list for the most up-to-date codes for providers.

Expanded Services for Behavioral Health and Patient Education

Retroactive to March 1, 2020, the Centers for Medicare and Medicaid Services (CMS) will permit many behavioral health and education services to be furnished via telehealth using audio-only communications. The payment of these services will increase from $14-41 to $46-$110.

Implementing Infection Control Measures

1. What immediate preventive measures should I take in my clinic or site?

Practice Healthy Habits

Keeping you and our community safe and healthy is a shared responsibility. To learn about healthy habits, check out the everyday prevention topics here.

Train and Educate Healthcare Personnel

  • Provide staff and health care providers with a job- or task-specific education and training on preventing transmission of infection agents, including refresher training.
  • Training and information can be found on the CDC Infection Control website.
  • Staff must be medically cleared, trained, and fit-tested for respiratory protection device use (e.g., N95 filtering facepiece respirators).
  • Ensure that staff are educated, trained, and have practiced the appropriate use of personal protective equipment (PPE) before caring for a patient, including attention to the correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.

Screen Your Clients for COVID-19

For behavioral health providers:

  • A few days before appointment: If clients are scheduled to come into a behavioral health or homelessness program office or center, call them to remind them of the appointment in advance and ask them to reschedule if they are sick, have been exposed to someone with COVID-19, or have traveled off-island in the past 2 weeks.
  • On the day of the appointment: Ideally, every client should be screened upon entry into the office or site. Check the temperature of every individual entering a facility and sanitize the thermometer according to the instructions before each use. If possible, use a no-touch thermometer. Screenings should include the following questions:
    • Do you have any of the following symptoms?
      • Fever or chills
      • Dry cough
      • Shortness of breath
    • Have you traveled in the past 14 days?
    • Have you had close contact with a person exhibiting the previously listed symptoms?
    • Have you had close contact with a person confirmed to have COVID-19 infection?
  • A sign should be posted on each site’s entrance with the screening questions above asking patients to call or alert the front desk if they are exhibiting any of those symptoms or fit the other screening criteria. The front desk number should be written on the sign.
    • Example: Aloha and welcome to [office name]! We are currently open by appointment only as we are working out of the office. Pleae call our front desk at [insert front desk number] to check in for or schedule your appointment. Before you come inside…If you or someone you are with have a fever, have a cough and/or shortness of breath, have recently been with someone who has COVID-19 or the flu, or has traveled outside of the state in the last 14 days, please call our front desk and someone will help you right away.
  • Ideally, medical sites should have a screening log of patients where staff can document if appropriate screenings were done. Minimally it should have the date, patient name, and a column for whether the patient was screened, and whether that patient responded “Yes” to any of the screening criteria.
  • If a patient responds with “Yes” to any of the screening criteria staff should:
    • Ensure the providers and patient both have masks and providers undertake all necessary protections for PPE.
    • Ensure that the patient is isolated from others or in a well-ventilated area spaced at least six feet apart from others.
    • Ensure that the patient is assessed for telehealth services if possible.
    • Minimize the number of staff that are interacting with the patient.

For homeless service and shelter providers:

  • Upon entering a facility, ask every individual – client, staff, volunteer, or visitor – to report any symptoms of COVID-19.
  • A screening document has been developed to assist with identifying clients who may need to be isolated, triaged for testing, and triaged for immediate medical attention. See a helpful resource here.
    • The screening document is available from the CDC.
  • Create a safe environment to allow disclosure of symptoms without penalty or stigma. Do not turn away clients merely because they have symptoms but adhere to appropriate spatial distancing (see below on sleeping accommodations).

Screen Clients for Vulnerability and Behavioral Health Conditions

  • Screen patients if they have elevated risk during COVID-19 or are vulnerable (see below).
  • As part of standard procedures, continue screening for behavioral health conditions as part of your routine clinical workflow. Consider screening for other conditions such as depression, anxiety, or suicidality which may be exacerbated during this stressful period.

Provide Enhanced Support for Vulnerable Populations

All individuals are at risk of COVID-19, but some individuals are more vulnerable to severe COVID-19 with a higher risk of death if they are infected. Hence, providers should make focused efforts to provide enhanced support for these vulnerable populations:

  • They have an underlying health condition such as diabetes, liver disease, kidney disease, cardiovascular disease, or other condition such as a mental health condition and substance use disorder;
  • They are seniors or are older individuals;
  • They are experiencing homelessness or at risk of experiencing homelessness;
  • They do not speak English or are limited-English speaking;
  • They are immuno-compromised (including pregnancy); or
  • They have physical or other disabilities.

Protect the Waiting Room

  • Advise people to sit 6 feet apart (e.g., place chairs 6 ft apart).
  • Ensure that patients with symptoms consistent with COVID-19 or other respiratory infections are masked and isolated in private rooms.
  • In some settings, medically-stable patients may opt to wait in their cars or outside and contacted by a mobile phone when it is their turn to be evaluated.

Communicate with Staff, Clients, and the Public

  • Post signs at entrances and in bathrooms sharing how staff and individuals can protect themselves and others at the facility.
  • Signs are available on the CDC website
  • Voicemail scripts for public-facing voicemails have been developed with information on the COVID-19 and how to ensure access to services:
    • Aloha, this is [Name and office site], if you are in a crisis, call Crisis Line of Hawaii at 1-800-753-6879. If you have a medical emergency, please call 911. Our offices are open by appointment only from 7:45 am to 4:30 pm, Monday through Friday and closed on weekends and holidays. You received this message because we are unable to take your call. As a reminder, if you are sick with cold or flu-like symptoms or have traveled out of the state in the last 14 days, please give us a call before coming in. If your symptoms are severe, please seek appropriate medical care. If you have questions about Coronavirus, a good source of the latest information is the Department of Health website https://hawaiicovid19.com. Please leave a message after the tone. Thank you.
  • Incorporate mental health messages to facilitate recovery and encourage self-care (see above).
  • Whenever possible and appropriate, facilitated meetings (e.g., treatment team meetings, community meetings, workgroups) should be conducted by phone or Zoom.
  • Encourage clients to participate in the same everyday protections.
  • Ensure that your office has an up-to-date emergency phone tree and ensure that your staff is familiar with the process.
  • The state has developed responses for various labor-related issues associated with COVID-19.
  • Encourage staff to ask questions and respond to the best of your ability.
  • Talk with your coworkers about official COVID-19 updates as they arise.

2. How do we implement infection control measures?

See the PPE decision tree for assistance in determining how to utilize personal protective equipment (PPE). Ensure that you are following CDC recommendations for donning and doffing PPE properly.

Protect Frontline Workers

  • Frontline workers are those who engage with clients within a 6-foot distance. These workers need to be prepared to protect themselves and their clients, provide health education information and help direct their clients to care as necessary (see PPE decision tree).
  • Staff interacting with symptomatic clients (see below) should wear face masks with face shields. If face shields are unavailable, wear a regular face masks plus reusable protective goggles and sanitize the goggles after each use.
  • When feasible, employers should limit which staff interacts with patients presenting with symptoms or with those rooms assigned for those with symptoms. Staff interacting with patients should wear PPE.
  • Check for the latest CDC guidelines on PPE including how to don and doff PPE.
  • Check for the latest CDC guidelines for extended use and limited reuse of N95 filtering facepiece respirators in healthcare settings.
  • Check the latest CDC guidelines for strategies for optimizing supplies of facemasks.

Ensure Adequate Stocks of PPE

  • Assess current stock of PPE including masks, face shields, gloves, tissues, alcohol-based hand sanitizer, and soap.
  • Provide supplies for respiratory hygiene and cough etiquette, including at least 60% alcohol-based hand sanitizer, tissues, no-touch receptacles for disposal, and facemasks at entrances, waiting rooms, and patient check-ins.
  • If there is a shortage of masks, alternatives such as bandanas, towels, handkerchiefs, scarves, and other clothes that are routinely washed each day can be used if properly covering both the mouth and nose.
  • Soap and water are adequate even in the absence of alcohol-based hand sanitizer.
  • If toilets or handwashing facilities are not available nearby, provide access to portable latrines with handwashing facilities for encampments of more than 10 people.
  • If your organization needs PPE, complete the BHHSURG Support and Supply Form.

Ensure Facility Hygiene and Maximum Physical Distancing

  • Maintain facility hygiene through frequent disinfection and implementation of maximum physical distancing between clients.
  • Disinfect any room where an individual with symptoms has occupied. You can use household chlorine bleach diluted in water (about 5 tablespoons per gallon of water), alcohol solutions, or most common EPA-registered household disinfectants.
  • For clients with mild symptoms, ensure maximum physical distancing through:
    • An isolated room; or
    • Creating physical barriers or buffers using curtains; and
    • Pursuing a “head-to-toe” sleeping arrangement.
    • Refer to the guidance below on when to refer clients and workers for testing.

Refrain from Clearing Encampments

  • Unless individual housing units are available, refrain from clearing encampments during community spread of COVID-19. Clearing encampments can cause people to disperse throughout the community and break connections with service providers. This increases the spread of infectious diseases. All populations should be encouraged to shelter in place in locations with adequate ventilation and maximum physical distancing.
  • Encourage the people staying in encampments to set up their tents/sleeping quarters with at least 12 feet x 12 feet of space per individual.
  • Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying materials) and bath tissue, and remain open to people experiencing homelessness 24 hours per day. If you are interested in supporting Hui Aloha’s bathroom brigades, please contact them via their website.
  • If toilets or handwashing facilities are not available nearby, provide access to portable latrines with handwashing facilities for encampments of more than 10 people.

Serving Individuals At Risk of or Suspected of Having Covid-19

1. How do we refer our clients to receive appropriate testing for COVID-19?

The criteria for testing continue to get updated over time. The BHHSURG has developed a helpful screening tool that incorporates federal and local guidelines as well as behavioral health and shelter screening questions. When in doubt, work with your client to contact their health care provider.

2. If my client meets the criteria for testing, should I transport my client?

If your client meets the criteria for testing, case managers should not provide transport to clients to prevent possible exposure and spread of COVID-19. Case managers should arrange for transportation through emergency medical services. Please review the BHHSURG PPE decision tree for specific recommendations. Please note that we are currently updating our guidance on transportation and will have more information soon.

3. If my client does not need to get tested, may I transport my client?

If your client does not meet the criteria for testing, then you may still transport your client. Please review the BHHSURG PPE decision tree for specific recommendations. In that situation:

  • The frontline worker should wear a mask and gloves
  • Ensure that your client puts on a face mask snugly
  • Transport your patient for the service that they need
  • Perform hand hygiene and sanitize the vehicle after transportation

4. What are the privacy rules if a client discloses that they have COVID-19?

42 CFR Part 2

  • Waiver: Under both federal and state declarations of the state of emergency, SAMHSA has deemed that the COVID-19 is a bona fide medical emergency that justifiably inhibits normal procedures required to obtain written patient consent. COVID-19 pandemic is therefore a bona fide emergency that allows providers to release information to medical personnel without consent if necessary.
  • Obtaining consent: Providers should nevertheless make an effort to keep their clients informed, including obtaining verbal consent and informing the patient of how their information was obtained/disclosed.
  • Typical documentation needed: Providers must nevertheless document in the patient’s record the name and affiliation of the medical personnel receiving the information, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency. See this SAMHSA resource or this more recent SAMHSA resource for more information.
  • For more information on COVID-19 Emergency Blanket Waivers for Healthcare providers, please see updated CMS guidance.

HIPAA

  • HIPAA Privacy Rule recognizes the legitimate need for public health authorities and others responsible for ensuring public health and safety to have access to protected health information that is necessary to carry out their public health mission. Therefore, the Privacy Rule permits covered entities to disclose needed protected health information without individual authorization:
    • To a public health authority, such as the CDC or the DOH that is authorized by law to collect or receive such information to prevent or control disease, injury, or disability. This would include the reporting of disease or injury; reporting vital events, such as births or deaths; and conducting public health surveillance, investigations, or interventions.
    • To persons at risk of contracting or spreading a disease or condition if other law, such as state law, authorizes the covered entity to notify such persons as necessary to prevent or control the spread of the disease or otherwise to carry out public health interventions or investigations. See 45 CFR 164.512(b)(1)(iv).
  • For health care providers, Secretary of the U.S. Department of Health and Human Services (HHS) Alex M. Azar declared a public health emergency on January 31, 2020, and exercised the authority to waive sanctions and penalties against a covered hospital that does not comply with selected provisions of the HIPAA Privacy Rule for hospitals only. Check out the limited waiver of the Privacy Rule for more information.
  • HIPAA applies only to health care providers or providers performing a health care services or function including billing for health care services.
  • The Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced that it will exercise its enforcement discretion and will not impose penalties for violations of the HIPAA Rules against covered entities or business associates in connection with the good faith participation in the operation of COVID-19 testing sites during the COVID-19 nationwide public health emergency. This exercise of enforcement discretion is effective immediately but has a retroactive effect to March 13, 2020.

Homeless Management Information System (HMIS)

  • Department of Housing and Urban Development (HUD), the Department of Health and Human Services (HHS), and the Department of Veterans Affairs (VA) Homeless Management Information System (HMIS) have issued Privacy and Sharing Standards. The HMIS Privacy and Security Standards gives providers a reasonable degree of flexibility regarding disclosure of information about participants without consent.
  • It is HUD’s position that under these Standards, it is permissible to share a participant’s COVID-19 status for the following purposes:
    • Coordinating Services;
    • Preventing/lessening threats to health or safety (see below); and
    • Complying with state or local law. If a local community has a privacy policy that is more restrictive than these standards, you must comply with the restrictions in your privacy notice OR amend your privacy notice.
  • The notice can be amended at any time and affect participant information obtained by providers before the change. As a best practice, HUD recommends seeking legal assistance when amending your privacy notice.
  • The HMIS Privacy and Security Standards offer a basis for disclosure of COVID-19 status (§ 4.1.3)
  • Two primary provisions in the HMIS Standard support the disclosures below:
    • Disclosures required by law: A CHO (Covered Homeless Organization) may use or disclose PPI when required by law to the extent that the use or disclosure complies with and is limited to the requirements of the law.
    • Disclosures to avert a serious threat to health or safety: Uses and disclosures to avert a serious threat to health or safety. A CHO may, consistent with applicable law and standards of ethical conduct, use or disclose PPI if:
      1. the CHO, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public; and
      2. the use or disclosure is made to a person reasonably able to prevent or lessen the threat, including the target of the threat.
  • Source: HMIS Privacy and Security Standards and COVID-19 Response

5. What if a client who visited my site/my office/my program is found to be infected with COVID-19?

  • If your client is later confirmed to have COVID-19 and if the case manager develops either a fever or other respiratory symptoms, the case manager should seek testing as they fulfill the criteria noted above.
  • Identify which staff was in close contact with the client (within 6 feet for a prolonged period) and:
    • Notify those staff.
    • Inform them of the testing criteria (i.e. if they have at least one symptom).
    • If these staffs have at least one, they should get tested.
    • Refer to CDC guidelines for hygiene.
    • Clean all frequently touched surfaces in the workplace, such as workstations, countertops, and doorknobs. Use regular cleaners and follow the directions on the label.

6. What if a staff member is exposed to or diagnosed with COVID-19?

  • Exposed health care workers are considered part of critical infrastructure and should follow existing CDC guidance.
  • If your staff member fulfills the criteria for testing because of contact with a confirmed COVID-19 case and displays at least one symptom (see criteria above), then they should be tested.
  • If your staff member was in close contact (within 6 feet for a prolonged period) but is asymptomatic, then they do not need to be tested though they should continuously self-monitor their symptoms. This staff member may continue to work provided they remain asymptomatic. This staff member should self-monitor including taking their temperature before each work shift.

7. What if a staff member is exposed to COVID-19?

There may be situations in which an employee is not symptomatic but has had COVID-19 exposure. The management of personnel work requests with COVID-19 exposure is separated into high, medium, and low-risk scenarios. The CDC defines high-risk exposure as close contact with COVID-19 direct or indirect (i.e. in the room during an aerosolized procedure) patient care without adequate PPE and patient unmasked or hand hygiene. Medium-risk exposures include prolonged patient encounters without adequate PPE while the patient was masked. Low-risk exposures are brief or prolonged patient encounters with both staff and patient masked; medically appropriate PPE makes this risk even lower. We recommend that agencies follow their administrative policies. The following link provides guidance and recommendations from the CDC.

Please go to the CDC website directly here for detailed risk category examples and self-assessment resources.

For more detailed information and flowchart of management protocol, visit existing CDC guidance.

8. When can my staff member return to work after developing symptoms?

Employer Discretion on Furloughing COVID-19 Confirmed Personnel

Organizations may request that healthcare personnel (HCP) with confirmed or suspected COVID-19, whether healthcare providers or other facility staff, continue to work if all of the following conditions are met:

  • Furloughing such HCP for the entire 14-day quarantine period would result in staff shortages that would adversely impact the operation of the healthcare entity.
  • To be eligible to return to work, HCP with confirmed or suspected COVID-19 must be cleared by either the Symptom-based strategy or Test-Based Strategy.

HCP who are furloughed due to requirements of isolation, or because they do not meet the above conditions for returning to work, may qualify for paid sick leave benefits and their employers may provide them with a letter of confirmation, to establish eligibility.

Related CDC guidance and recommendations can be found at the following links:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html

Return to Work Criteria

Decisions about the return to work for HCP with confirmed or suspected COVID-19 should be made in the context of local circumstances. Options include a symptom-based (i.e., time-since-illness-onset and time-since-recovery strategy) or a time-based strategy or a test-based strategy. Of note, there have been reports of prolonged detection of RNA without a direct correlation to viral culture.

Return to Work Criteria for HCP with Suspected or Confirmed COVID-19

Symptomatic HCP with suspected or confirmed COVID-19
(Either strategy is acceptable depending on local circumstances)

  • Symptom-based strategy. Exclude from work until:
    • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
    • At least 10 days have passed since symptoms first appeared
  • Test-based strategy. Exclude from work until:
    • Resolution of fever without the use of fever-reducing medications and
    • Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
    • Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens)[1]. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). Of note, there have been reports of prolonged detection of RNA without a direct correlation to viral culture.

HCP with laboratory-confirmed COVID-19 who have not had any symptoms
(Either strategy is acceptable depending on local circumstances)

  • Time-based strategy. Exclude from work until:
    • 10 days have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test. If they develop symptoms, then the symptom-based or test-based strategy should be used. Note, because symptoms cannot be used to gauge where these individuals are in the course of their illness, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive test.
  • Test-based strategy. Exclude from work until:
    • Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). Note, because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness. There have been reports of prolonged detection of RNA without a direct correlation to viral culture.

Note that detecting viral RNA via PCR does not necessarily mean that the infectious virus is present.

Consider consulting with local infectious disease experts when making a return to work decisions for individuals who might remain infectious longer than 10 days (e.g., severely immunocompromised).

If HCP had COVID-19 ruled out and have an alternate diagnosis (e.g., tested positive for influenza), the criteria for return to work should be based on that diagnosis.

Source: Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19

Return to Work Practices and Work Restrictions

After returning to work, HCP should:

  • Wear a facemask for source control at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer. A facemask instead of a cloth face covering should be used by the HCP for source control during this period while in the facility. After this time, the HCP should revert to their facility policy regarding universal source control during the pandemic.
    • A facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated, including when caring for patients with suspected or confirmed COVID-19.
    • Of note, N95 or other respirators with an exhaust valve might not provide source control.
  • Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen

Monitoring and Work Restrictions

To the extent possible, staff working under these conditions should preferentially be assigned to patients at lower risk for severe complications (e.g. on units established for patients with confirmed COVID-19) and restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until 14 days after illness onset.

Essential Workers with Irreplaceable Skills

In the rare instance when an HCP, with unique or irreplaceable skills critical to patient care, is affected by COVID-19, the healthcare entity may contact Hawaii State Department of Health to discuss alternative measures to allow such HCP to safely return to work before seven days have elapsed.

See the American College of Emergency Physician website for graphics outlined in this section.

9. How do we transport patients who are suspected or confirmed COVID-19 to needed services?

General Information

OSHA classifies any medical transport workers moving known or suspected COVID-19 patients as a high-risk exposure risk. Passengers and drivers can protect themselves by participating in important public health prevention methods.

  • Practice hand hygiene and respiratory etiquette:
    • Wash hands with soap and water for at least 20 seconds or use hand sanitizer with at least 60% alcohol before leaving the site, wash hands again as soon as possible upon arrival to destination, avoid touching face, and cover coughs or sneezes with tissue or elbow followed by discarding the tissue and hand washing.
  • Carry tissues in vehicles for coughing, sneezing, or touching face and always discard after use.
  • Know where access to facilities with soap and water exist during shift.
  • Ensure hand hygiene is completed before/during/after preparing food, before eating food, before/after using the bathroom, and after coughing or sneezing. Additional times for hand hygiene include before/after work shifts, before/after work breaks, after handling passenger personal belongings (if unavoidable), between rides, after touching face coverings, before/after wearing cold-weather gloves, and before/after pumping gas.
  • Practice social distancing of greater than 6 feet with non-household members.
  • Wear cloth face covertings when unable to physical distance unless person is younger than 2 years old, has difficulty breathing, is unconscious, or is incapacitated or otherwise unable to remove face covering by themselves.
  • Stay home (if possible) if you are sick or have close contact with someone with COVID-19.
  • Do not use public transportation if needing to leave for medical services.
  • Have enough sanitizing wipes and hand sanitizer (at least 60% alcohol) in case handwashing is unavailable and bring cloth face covering to wear when social distancing is difficult (public transportation).
  • Limit travel if at risk for severe COVID-19 illness (older adults, those with disabilities or serious medical conditions) or try to have a “transportation buddy” to assist while traveling, preferably from the same household. When possible, have the companion use a separate mode of transportation or have them use facemasks.
  • Remain aware of community transmission
  • Consider limiting passengers to those necessary and lowest risk.

Information for Drivers

Providers or programs may use personal vehicles in transporting patients with suspected or confirmed COVID-19 for medical services. Cleaning, social distancing, and ventilation are important in minimizing viral transmission. Drivers have an important role in preventing infection while providing an essential service to patients.

  • Stay home if sick (fever, cough, difficulty breathing), call a healthcare provider for medical advice, and do not return to work until return to work criteria met after provider approval.
  • Consider using alcohol wipes to disinfect parking meters or pay station surfaces or use hand sanitizer after use, and wash hands afterwards as soon as possible.
  • Maximize ventilation by opening the windows or having ventilation and air conditioning on non-recirculation mode.
  • Try to use the biggest vehicle available to ensure maximal social distancing for the driver.
  • Wear cloth face covering in public where social distancing is difficult.
  • OSHA and CDC encourage most workers to wear gloves, gown, face shield/goggles, and either a face mask or respirator if available. If a gown is not available, launder clothing using warmest heat setting and dry completely.
  • Limit contact as much as possible
    • Avoid multiple passenger pick-ups unless riding together
    • Do not allow anyone to ride in front seat
    • Keep at least 6 feet when outside of vehicle
    • Ask passengers to remain more than 6 feet away if using larger vehicles
    • Consider asking passengers to handle own bags and belongings during pick-up and drop-off
    • Avoid recirculated air setting on car’s ventilation – open windows or use car vents for fresh outside air
    • Avoid offering items such as water bottles and magazines
    • Avoid touching surfaces frequently touched by passengers or other drives before cleaning and disinfecting.
  • Clean and disinfect regularly
    • Clean and disinfect surfaces frequently touched regularly (like the steering wheel). Visit CDC’s guidelines on disinfection for more detail.
    • Keep cleaning and disinfectant spray or disposable wipes and disposable trash bags in the vehicle.
      Follow directions on cleaning supply labels.
    • Use detergent or soap and water before disinfecting if visibly dirty, but do not use compressed air or water sprays to avoid aerosolization.
    • Minimally clean and disinfect at beginning/end of shift, and between sick passenger transportation.
    • See EPA’s approved cleaning products against COVID-19 for use on non-porous surfaces. Diluted household bleach solutions and alcohol solutions more than 70% alcohol are also appropriate.
    • Keep doors open when cleaning.
  • After transporting the individual, keep the back doors open to allow for ventilation of potentially infectious particles. The time it takes to complete transfer of the patient should be enough time for ventilation.
  • Keep a set of clean clothes at the workplace in case clothes become contaminated. If contamination occurs, bag items and follow procedures for laundering work clothing.

When Using Drivers-for-Hire

Prevention of the spread of the virus is the responsibility of the drivers, passengers, and provider organizations. As such, there are many preventive measures that can be instituted on many levels to ensure the safety while maintaining services to those in need. These guidelines should be followed in addition to the above general advice for drivers.

Provider organizations should provide support for the drivers to ensure safe administrative controls.

  • Encourage all drivers who are sick to remain home and not to come to work.
  • Provide education and training (initial and refresher courses) about COVID-19 to drivers at scheduled work times with no cost to employees.
    • COVID Training: Source of exposure, hazards associated with exposure, appropriate workplace protocols in place to prevent or reduce likelihood of exposure, how to isolate suspected or confirmed COVID or other infectious diseases, and how to report possible cases.
    • PPE Training: When to use PPE, what PPE is necessary, how to don/use/doff PPE, how to dispose or disinfect/inspect for damage/maintain PPE, and limitations of PPE. See OSHA’s website for training videos and for more information.
    • Bloodborne Pathogens standard Training: How to recognize tasks involving exposure and methods to reduce exposure, including engineering controls, work practices, and PPE. See OSHA’s bloodborne pathogen page for more information.
    • Visit OSHA’s website for more training resources.
  • Encourage and provide assistance in maintaining adequate supply of hand sanitizer, disposable wipes, and cleaning supplies for regular vehicle cleaning. See EPA’s approved cleaning products against COVID-19. Provide additional equipment appropriate for such cleaning products from the labels and Safety Data Sheets.
    • OSHA is providing temporary enforcement flexibility under these health standards due to shortages.
  • If possible, install partition between driver and passenger in cars.
  • Ensure psychological and behavioral support is available for employee stress.
  • Identify workers with increased susceptibility to COVID-19 complications and adjust work responsibilities to minimize exposure.

Patients can be instructed to help minimize transmission by following these guidelines.

  • Have them wear cloth face coverings.
  • Instruct them to cover their mouth and nose with tissues when coughing or sneezing and to dispose of the dirty tissues after exiting the vehicle.
  • Report passengers not abiding to instructions to administration and/or authorities as appropriate.

Source links:

Reopening Guidelines (Updated June 15, 2020)

The following guidelines are based on recommendations from state and federal sources and are meant to serve as resources for providers. Agencies should develop their policies and procedures that fit best with their scope of practice. Additional updates are forthcoming as more is learned about best practice guidelines.

General Considerations

  • Behavioral health and homelessness services should continue to be offered to patients as clinically appropriate. Providers might consider talking with clients about their preferences about how to best continue services, given the dynamic nature of the COVID-19 pandemic.
    • As an alternative, would clients prefer continuing telehealth for a while?
  • Consider establishing Grey Zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility.
  • It is recommended that facilities prepare resources across phases of care to ensure capacity.

Personal Protective Equipment

  • Consistent with CDC’s recommendations for universal source control, CMS recommends that health care providers and staff wear surgical face masks at all times.
  • Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks. If they do not have access to cloth face coverings, consider having spare masks available and/or maintaining at least 6-foot separation. If you need additional PPE, please complete a supply and request form.
  • Those working in congregate settings including shelters and prisons should also wear masks at all times.
  • The risk of infection is increased with not only face to face time, but the length of interaction, whether in a closed room, with more crowding and people in the room, and potential for human touch or aerosolizing procedures. Staff should be mindful of the three Cs of Contact, Closed Spaces, and Crowds. As a result, it is recommended that community-wide mass gatherings be canceled if more than suggested by state leadership (currently advised no more than 10 people) or have smaller groupings. Also, it is advised to cancel gatherings more than 10 for organizations with high-risk individuals. Check the latest CDC guidelines for more information regarding large events.
  • Check for the latest CDC guidelines on PPE including how to don and doff PPE.
  • Check for the latest CDC guidelines for extended use and limited reuse of N95 filtering facepiece respirators in healthcare settings.
  • Check the latest CDC guidelines for strategies for optimizing supplies of facemasks.

Workforce Availability

  • Staff should be routinely screened for symptoms of COVID-19 using the current DOH testing criteria (insert a link to BHHSURG screening tool) and if symptomatic, they should be tested and quarantined.
  • Staff who will be working in grey zones should be limited to working in these areas and those working in a “COVID-19 Care zone” should limit contacting grey zones unless they have gone through a two-week quarantine.

Testing Capacity

  • All patients must be screened for potential symptoms of COVID-19 before entering the facility, and staff must be routinely screened for potential symptoms as noted above.

Supplies

  • Adequate supplies of equipment, medication, and supplies must be ensured, and not detract for the community’s ability to respond to a potential surge.

Facility Considerations

  • With a relatively low incidence rate of COVID-19 in Hawaii, when a facility determines to provide in-person, non-emergent care, the facility should create grey zones which have in place steps to reduce risk of COVID-19 exposure and transmission; these areas should be separate from other facilities to the degrees possible (i.e., separate building, or designated rooms or floor with a separate entrance and minimal crossover with COVID-19 areas).
  • Visitors should be prohibited but if they are necessary for an aspect of patient care, they should be pre-screened in the same way as the patients.

Source: Centers for Medicare & Medicaid Services (CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I

The Hawaiʻi Path Beyond Recovery- Continued Care and Adaptability (Updated June 15, 2020)

The following section details specific guidance on reopening from the state of Hawaiʻi.

Phase 1: Stabilization focuses on Healing Hawaiʻi by saving lives and flattening the curve in the communities. In the last few weeks, Hawaiʻi has stabilized by reopening low-risk businesses, such as floral shops, pet grooming services, and car washes. Because of the success, Hawaiʻi is preparing to transition from the Stabilization Phase to Healing Hawaiʻi into the Reopening of the Kamaʻāina Economy.

Phase 2: Reopening celebrates Hawaii’s Kamaʻāina Economy and is informed by “Acting with Care.” In this phase, Hawaiʻi starts to reconnect local activities by, first, reopening medium-risk businesses and activities; and, later on, reopening high-risk businesses and activities.

Phase 3: Long-term Recovery is where Hawaiʻi Renews and Rebuilds its economy through a planning and policy discussion to incorporate transitional workforce modernization opportunities, support economic diversification initiatives, target the development of emerging industries, and advance long-term resiliency planning.

Phase 4: Resilience is Hawaii’s intended outcome. United, Hawaiʻi will emerge stronger and more resilient as a result of learning from and overcoming this challenge.

Source: Governor David Ige’s Memo & Presentation Slides (May 18, 2020)

Phase 1: Stabilization-Reopening-Guidelines: Healing Hawaii

Healthcare & Social Assistance: Elective surgery, Non-emergent services, etc. (LOW RISK)

  • Open with health and safety precautions for employees, visitors, and patients, including physical distancing of 6 feet or greater between workstations/desks, enhanced sanitation measures and appropriate PPE
  • Facilities should frequently conduct thorough and detailed cleaning and disinfecting with focus on high-touch areas (e.g., door handles)
  • Visitors and patients by appointment only and should wait outside the facility (e.g., in cars) until employees are ready to work with them
  • Either disposable equipment or appropriate equipment disinfection protocols should be used
    Employees should wash hands before and after every appointment, and wear disposable gloves at all times that are changed frequently
  • Train all employees on the importance of frequent handwashing with soap and water, the use of hand sanitizers with at least 60% alcohol content, and give them clear instruction to avoid touching hands to face
  • Patients should fill out paperwork digitally in advance, where possible
  • Employees, visitors, and patients should wear face coverings at all times when on the premises
  • Employees should also wear face shields if possible when near others
  • Employees who develop symptoms of COVID-19 at work should be dismissed as soon as possible to self-isolate at home or seek medical attention as appropriate
  • Anyone visibly displaying symptoms of COVID-19 should not be allowed in the facility

Source: Phase 1 Stabilization-Reopening Guidelines

CMS Recommendations for Reopening Healthcare Facilities

If states or regions have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, then they may proceed to Phase I.

COVID-19 Employer Information for Office Buildings

Before resuming business operations, check the building to see if it is ready for occupancy

  • Check if ventilation systems in your facility operate properly.
  • Increase the circulation of outdoor air as much as possible.
  • Evaluate the building and its mechanical and life safety systems.

Identify where and how workers might be exposed to COVID-19 at work

  • Conduct a thorough hazard assessment of the workplace to identify potential workplace hazards that could increase risks for COVID-19 transmission.
  • Identify work and common areas where employees could have close contact (within 6 feet) with others.
  • Include employees and contractors in communication plans.

Engineering controls: Isolate workers from the hazard

  • Modify workspace (e.g., install transparent shields or other physical barriers).
  • Use methods to separate employees in all facilities (e.g., use signs, tape marks, or other visual cues to indicate where to stand when physical barriers are not possible).
  • Take steps to improve ventilation in the building, consider using portable high-efficiency particulate air (HEPA) fan/filtration systems.
  • Consider using ultraviolet germicidal irradiation (UVGI).
  • Ensure exhaust fans in restroom facilities are functional and operating at full capacity.

Administrative controls: Change the way people work

  • Employees who have symptoms of COVID-19 should notify the supervisor and stay home.
  • Consider conducting daily in-person or virtual health checks (e.g., symptoms and/or temperature screening) of employees before they enter the worksite.
  • Stagger shifts start times and break times.
  • Consider posting signs in parking areas and entrances that ask guests and visitors to phone from their cars to inform the administration or security when they reach the facility.
  • Consider signs in the parking area and entrance that ask guests or visitors to wear cloth face coverings, to not enter the building if they are sick, and to stay 6 feet away from employees, if possible.
  • Clean and disinfect high-touch surfaces, provide employees with disposable wipes and other cleaning materials.
  • Provide employees adequate time to wash their hands and access to soap, clean water, and single-use paper towels.
  • Establish policies and practices for social distancing.
  • Offer employees incentives to use forms of transportation that minimize close contact with others.
  • Allow employees to shift their hours so they can commute during less busy times.
  • Post signs and reminders at entrances and in strategic places providing instruction on hand hygiene, COVID-19 symptoms, and cough and sneeze etiquette.
  • Use no-touch waste receptacles when possible.
  • Wear a cloth face covering to cover their nose and mouth in all areas of the business.

Source: CDC COVID-19 Employer Information for Office Buildings

Governor Ige’s Reopening Plans:

Additional Mitigation Resources provided by Governor Ige:

Updates from System Partners (Updated June 15, 2020)

Child Welfare Service (CWS): CWS workers have been instructed to arrange all visitations via telecommunications.

Children with Special Health Needs: Resources for Children Ages 0-5 and Their Parents

Department of Education: Latest COVID-19 HIDOE information and updates | Grab and Go Student Meal Sites

Judiciary: Important Court updates related to COVID-19

Law Enforcement: (coming soon)

Public Safety: (coming soon)

If you have a question that is not addressed above, please complete this form or send us an email.

 
Last reviewed on September 21, 2020