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

As more individuals receive the COVID-19 vaccine, some private practitioners may wonder if it’s OK to stop practicing telehealth and provide more in-person services. If feasible, APA recommends that psychologists providing routine outpatient care continue using telehealth to reduce the risk of coronavirus transmission, and new guidance from the Centers for Disease Control and Prevention (CDC) supports this practice.

While the CDC’s new guidance states that small groups of fully vaccinated family members and friends can gather indoors in a casual setting with or without masks, psychologists must follow the guidelines for health care personnel. Health care providers should continue to use telehealth; wear personal protective equipment and practice physical distancing when interacting with patients; and implement COVID-19 screening protocols.

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. It’s important to emphasize that the rules are for the safety of the patient, the psychologist, and anyone else in the practice.

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. 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 five minutes before their appointment time, not earlier.
• 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 interim guidance for employers (PDF, 1.14MB); 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.