PLTC continues to be at the forefront of advocating for it’s members! Last week, PLTC President Lisa Lind wrote a letter to CMS administrator Seema Verma on the subject of the recent telehealth waiver (which we discussed in our previous post, below).
There’s a lot Dr. Lind’s letter (text below, at the end of the post), and a lot that’s been going on with COVID-19 and mental health services provision in long-term care that go even beyond telehealth.
For one thing, on the PLTC listserv, many of our members have reported that they have been unable to gain entrance to their facilities since the COVID-19 outbreak. This is concerning on a couple of different levels – for one thing, CMS has traditionally regarded psychologists as “essential personnel” who would be exempted from any ban on outside visitors or staff. Second, obviously, COVID-19 has created significant mental health stressors on our residents (due to anxiety, increased isolation, etc.) that are not going away anytime soon. So, we are asking CMS and Administrator Verma to clarify what has already been codified – that long-term care psychologists are “essential” personnel and need to be allowed to see our residents!
Second, as we noted in our last post – regarding the recent telehealth waiver (or Waiver 1137) – President Lisa Lind also asks in her letter for CMS to relax enforcement of the audiovisual requirement for telehealth. It’s difficult enough for our largely cognitively and functionally impaired population to navigate telehealth, but to require it to be only delivered via “video chat” makes this even more difficult a hurdle. If our providers are forced to rely on telehealth to see our residents because of COVID-19 – we need the flexibility to simply give them a phone call!
Please read the letter, and understand that PLTC is advocating tirelessly for our members, and for psychologists in long-term care at large. This is a challenging time for us as providers, and our clients in particular.
As always – if you have anything to share about COVID-19 or how practice with older adults is changing in the face of this pandemic, please comment on this article below.
If you are a psychologist who practices in long-term care, or work with older adults in your practice and would like to learn more, we have an active Listserv, Newsletter, and other resources. Please consider joining PLTC!
***** TEXT OF LETTER BELOW *****
Centers for Medicare & Medicaid Services
CMS-1715-P 7500 Security Blvd.
Baltimore, MD 21244-8016
March 16, 2020
Re: COVID19 and the Importance of Allowing Mental Health Providers to Continue to Provide Medically Necessary Psychological Services to Residents in Long-Term Care Facilities During This Time of Restricted Visitation
Dear Administrator Verma:
Psychologists In Long Term Care, Inc. (PLTC) is a national organization of several hundred psychologists who contribute to improving the mental health of older adults through practice, research, education, and advocacy. Our organization represents psychologists across the nation who serve the mental health needs of older adults, particularly Medicare and Medicaid beneficiaries in need of long-term care services. As such, we are in a strong position to speak to the mental health needs of the residents of long-term care facilities.
On March 9, 2020 the Centers for Medicare & Medicaid Services (CMS) issued to State Survey Agency Directors revised guidance for Infection Control and Prevention of Corona Disease 2019 (COVID19) in nursing homes (Ref: QSO-20-14-HN). On the same day, the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) issued a joint statement entitled “Taking Reasonable Efforts to Prevent COVID-19 from Entering Your Skilled Nursing Center”. Various state healthcare associations and Departments of Public Health have also issued similar guidance. On March 13, 2020 the Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes included revised guidance for visitation, which indicates that “facilities should restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation” but suggested that individuals should be able to enter if they meet the CDC guidelines for health care workers.
CMS and AHCA guidance include the recommendation to limit visitors to nursing facilities. AHCA specifically stipulates that essential healthcare providers should not be considered visitors and should not be restricted from entering facilities unless screening processes trigger concerns. Psychologists are considered as essential healthcare providers by CMS and therefore should be allowed access to nursing facilities in order to treat patients residing in long term care facilities. In addition, AHCA has indicated that facility contractors and consultants who are needed to assure the residents’ needs are met should be allowed entry. However, as an immediate result of published recommendations and subsequent media coverage, psychologists and other mental health providers have experienced a wide variety of responses from nursing facilities in response to COVID19 precautions. To help mitigate the risk of exposing nursing home residents to possible exposure to COVID19, some nursing facilities have implemented reduced visitation, restricted all visitation, and/or restricted facility staff to only essential staff members. Many facilities across the country are interpreting the guide to restrict visitors to include the restriction of mental health providers. As you may know, a large number of nursing home residents have a mental health diagnosis, and the current media coverage of COVID-19 combined with mandatory decreased in-person visits from family are contributing to observed increased anxiety in residents. Individuals with a history of trauma, even if the trauma is completely unrelated to the current situation, can be triggered in circumstances like this. In order to provide essential behavioral health services to meet the needs of nursing home residents, mental health professions will need to be able to have consistent and reliable access to entry into nursing home facilities.
I am reaching out to you, on behalf of psychologists across the United States, to request consideration of acknowledgement for the need for mental health professionals to be allowed access into nursing homes and not be considered “visitors”, rather essential healthcare workers, during the COVID19 pandemic. If this message is communicated from a government official in an esteemed position such as yours, I am optimistic that nursing homes across the country will feel more confident in allowing mental health clinical providers to continue to provide consistent mental health care to Medicare and Medicaid beneficiaries without interruption, particularly at a time when stress and anxiety is high.
In addition, many psychologists across the country have begun investigating the potential use of telehealth services in the event that it becomes increasingly difficult to provide in-person services to their patients. However, many clinicians report difficulty understanding the possible exceptions to previous rules and regulations, and when they reach out to their local MACs they are either receiving mixed information and/or being told that the new guidelines have not been communicated to them yet. As we await Secretary Azar to exercise his authority to grant the Emergency Telehealth Waiver, we look forward to additional CMS guidelines to confirm that telehealth services will no longer be limited to Medicare beneficiaries located in a designated rural health professional shortage area; and Medicare beneficiaries will not have to go to a designated “originating site” in order to receive telehealth services. This way, we can assure that beneficiaries in all nursing facilities will be eligible for telehealth services.
One potential concerning issue is the continued device requirement for “both audio and video capability”. Having the requirement for video capability will be a serious obstacle for many psychologists who want to continue to provide psychological services without interruption. Not every resident in nursing facilities has access to a smartphone. A requirement for audio and video capability would require ordering equipment and training nursing home staff to facilitate the process. Given the current circumstances, nursing facilities will continue to experience staff shortages as staff either test positive and/or have to self-quarantine due to possibly being exposed, and it will become extremely difficult for nursing homes to be able to have staff who could assist with facilitation of telehealth services if the usual equipment is required. I would ask that you consider waiving the requirement for video capability and consider allowing the use of both smart phones and traditional telephones for services during this unprecedented health crisis in order to allow for continuation of care to assist those Medicare beneficiaries who are likely experiencing increased anxiety and other mental health symptoms during this time of uncertainty. It is prudent for us to remove potential barriers to accessing mental health care in order to minimize potential increases in mental health conditions as a result of current stressors.
Finally, we believe additional directives to the telehealth waiver will also significantly improve the provision of telehealth to Medicare beneficiaries:
1) We support waiving the current requirement that providers be licensed in the State in which a patient is located, as long as they are holding an equivalent license in another State.
2) We support a directive that the waiver applies to all Medicare beneficiaries needing medical and mental health services, not only beneficiaries seeking counseling or treatment related to COVID-19.
Thank you in advance for your time and consideration.
Lisa Lind, Ph.D.
Psychologists In Long Term Care, Inc.