COVID-19: When is it OK to provide more in-person services?

Centers for Disease Control and Prevention Updated Guidance as of April 27, 2021

The latest guidance issued by the Centers for Disease Control and Prevention (CDC) related to COVID-19 includes recommendations of particular importance for health care providers. The guidance includes two updates. The first allows fully vaccinated people to congregate without masks or physical distancing in non health care settings. Psychologists, however should consult the second update, which applies to individuals and providers who work in health care settings, when deciding how and when to see patients in their practice.

The April 27, 2021 update for health care settings includes guidance directed toward acute and postacute facilities, including when masks and physical distancing are not required during visitation, and added guidance for communal activities.

More importantly, the guidance reiterates the need for health care providers to continue using personal protective equipment (PPE) in health care settings. Continuing to use telehealth strategies while maintaining high-quality patient care remains the prudent option in many circumstances.

When deciding whether to provide in-person sessions, take these steps before opening your office to patient care.

Some patients may request, or even insist, on seeing you in person, but that does not professionally or ethically obligate you to offer services face-to-face.

To determine whether telehealth is a good option for the patient, consider these factors:

• Does the patient have access to a telehealth platform, and is he or she able to use it?
• If this is ongoing treatment, is the patient making progress? Is there decline?
• Is the next phase in treatment feasible for continuing remotely, or does it require face-to-face contact?

Documentation is key, especially if the patient insists on seeing you in person and you don’t believe it is safe yet to do so. Record patients’ clinical progress, discussions about the benefits of telehealth, plans for next steps and rationale for why you believe providing services via telehealth is clinically appropriate (e.g., there is no history or indication of suicidality or other crisis).

Keep in mind that psychologists can refuse to see patients face-to-face, especially if they are older or have health conditions, or live with family members who have heightened risk factors. Do not unnecessarily jeopardize your health, or the health of your family, your staff or your patients.

As health care professionals, psychologists need to be aware of the physical health risks and possibility for virus transmission during in-person sessions. Assess the health of the patient and whether their occupation, health status or behaviors put them at heightened risk of contracting the virus and then spreading it through an in-person visit. Also consider that some individuals may be at greater risk of severe illness should they contract COVID-19 and therefore should be advised to continue with telehealth.

From a mental health standpoint, consider whether a small subset of your patients would benefit from resuming in-person therapy, such as those who appear to be worsening or are in acute crisis, and those who need a more intense level of care that is not being met via videoconferencing.

Practices may want to explicitly state in patient forms that decisions related to providing in-person services instead of telehealth are made by factoring in possible risks for specific patients and clinicians and are made on a case-by-case basis.

If you decide to see patients in person, it will be crucial to protect your practice through informed consent. APA has developed a customizable informed consent template for in-person sessions during the public health emergency.

Discuss the risk of exposure to the coronavirus with patients and document their understanding of those risks and their agreement to proceed with in-person care.

Be sure to include a clearly defined set of rules to protect physical safety. For example, require the patient to wear a mask, and do not shake hands or make physical contact.

Agree that the patient will take their temperature before leaving home and will only attend treatment if there is no sign of fever (generally 100 degrees Fahrenheit or above).

Make it clear that you will require a session via telehealth if there is any suspicion of a fever or exposure to someone who has tested positive for COVID-19. It’s important to emphasize that the rules are for the safety of the patient, the psychologist, and anyone else in the practice.

As vaccines become more widely available, it may be tempting to require patients to be vaccinated before seeing them in person. This is a legally untested area and states have differing approaches to mandatory vaccinations. Until the issue is settled, it may be better practice to take vaccination status into consideration with other health risk factors as you assess the situation. Vaccines are not 100% effective and may lead to a false sense of security. Patients may also have valid reasons for not being vaccinated (e.g. difficulty accessing vaccination, they have medical issues prohibiting them from being vaccinated, etc.). Because vaccination status does not negate your responsibility to take other precautions (for example, masks, distancing, and sanitizing common surfaces), you should instead treat this as one of the many screening factors you use when deciding how to proceed. If you decide not to see unvaccinated patients, be sure that you are not being discriminatory and that you are able to provide treatment via telehealth or refer those patients to other providers. 

Practitioners should also consult with their professional liability insurer for specific risk management guidance.

The CDC and World Health Organization have developed guidelines for minimizing the spread of the coronavirus. Based on their guidance, APA recommends taking precautions in your practice, including:

• Arrange office seating in the waiting room and in therapy/testing rooms to encourage physical distancing. Consider removing the chairs in the waiting room, positioning them far apart, or placing “do not sit here” signs.
• If feasible, open windows or take other steps to increase ventilation.
• Wear a mask and ask your patients to do the same, regardless of vaccination status. You should keep some in the office for those who may not have one.
• Schedule appointments at intervals to minimize having too many people in the waiting room.
• Ask patients to come into the office no earlier than five minutes before their appointment time.
• Keep hand sanitizers that contain at least 60% alcohol in the office, the waiting room, and check-in counter.
• Post notices encouraging people to wash their hands and to avoid touching their face.
• Tell patients and office staff to stay home if they have a fever, shortness of breath or a cough, or have been exposed to someone who shows signs of COVID-19.
• Avoid hugging or handshaking.
• If you use a credit card station, sanitize it after each use. If staff runs the credit cards, they should wear gloves.

Publish your office policies about COVID-19 and efforts to keep patients safe on your website and in the office.

Responsibility to employees differs from the responsibility owed to patients. The Occupational Safety and Health Administration (OSHA) has issued guidance for employers; the CDC has also issued guidance for health care settings.

Employers should have policies and procedures in place to respond to a crisis, including how employees should inform you when they are sick. To protect your employees and patients, consider implementing these processes in your office:

• Encourage sick employees to stay home, partly by having liberal sick leave policies.
• Allow employees to telework, if possible.
• Enable flexible work schedules, especially for those who have high risk factors or are caring for or living with sick or high-risk family members.
• Take steps to minimize employees’ contact with each other, such as moving chairs and work areas farther apart (or to separate rooms if possible).
• Provide appropriate personal protection equipment (PPE), such as N95 masks or cloth masks.
• Keep tissues and trash cans within reach.
• Install high-efficiency air filters.
• Don’t share computer keyboards or phones. If shared, sanitize after each use.
• Promote frequent handwashing and ensure that soap and sanitizers are available.

You should consult with an employment attorney for specific requirements.

Businesses are also encouraged to coordinate with state and local health officials for information and appropriate action.