We recognize that providers are facing particularly challenging times responding to the COVID-19 pandemic. Responding responsibly means balancing the public and staff safety with providing critical services for individuals with life-threatening substance use and mental health disorders. Signal is working to align payment and policies with current operational challenges and to help providers access essential information, equipment and supplies. In recognition of the fast pace of changes in guidance, we have assembled information that will be updated regularly and relies heavily on links to expert sources. Below are specific sections to help providers navigate during this period. Each section includes the date it was last updated, as information is changing frequently.
We appreciate the creativity and commitment of our providers to client care, especially during these challenging times, and we intend to continue to support these efforts to the fullest extent possible.
(3/16) Overarching recommendations:
- Assessing an individual’s risk for suicide, homicide, or acute withdrawal remains paramount. All individuals seeking services through a crisis Walk-In Center or Mobile services must have at a minimum the Columbia Suicide Severity Rating Scale (CSSRS) completed to assess suicide risk and plan for the next most appropriate intervention.
- Any supportive care that can be provided is preferred to closing services.
(3/16) Evaluating risk and referring clients to the physical health system:
- The CDC publishes advice for healthcare facilities: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html. This advice includes specific information about screening people who are at high risk for COVID-19, referring people for follow-up care, and guidelines for reducing risk for infections in health care facilities.
- Colorado Department of Public Health and Environment information about when to refer people to other healthcare providers or facilities including emergency departments can be found here: https://www.colorado.gov/pacific/cdphe/2019-novel-coronavirus
- Consider the use of telephone health navigators to help people without a health care provider figure out where to go based on local resources and local health department guidance.
(3/17) Support for technology-delivered outpatient, crisis, and recovery services: To flatten the contagion curve and follow the spirit of the CDC recommendations, any individual who can safely be assessed and managed through telephone or video conferencing should be. This may be applicable across all crisis services and substance use modalities.
- We support the decision of many providers to move toward technology-delivered outpatient, crisis, and recovery services to reduce risks for patients and staff. While many providers and clients have access to the equipment and communication services needed to support technology-delivered services, if you have specific requests for assistance, please email Heather Dolan (firstname.lastname@example.org), with a subject of “COVID-19 Telehealth Support Request”. Understanding your needs more will help us mount a response.
- One provider of tele-/video-health services is Zoom, which has a product that is HIPAA-compliant: https://zoom.us/healthcare (please note that Signal does not endorse any products, but we are aware that a number of providers use this service).
- Additionally, it is important to remember that if telehealth services for outpatient are not covered by another payer, MSO/ASO funding via Signal likely is able to cover.
- HRSA has funded the Telehealth Resource Centers (TRCs) to provide assistance, education, and information to organizations and individuals who are actively providing or interested in providing health care at a distance. Their purpose is to assist in expanding the availability of health care to rural and underserved populations. And because they are federally funded, the assistance they provide is generally free of charge. Learn more at: https://www.telehealthresourcecenter.org/
(3/16) Licensing waiver requests: Colorado’s Office of Behavioral Health is reviewing licensing waiver requests daily and processing these as quickly as possible. You can find guidance on blanket rule waivers and processes for individual program waiver requests on the OBH COVID-19 website: https://www.colorado.gov/pacific/cdhs/article/covid-19-behavioral-health-info
(3/19) SAMHSA Guidance on 42 CFR Part 2: https://www.samhsa.gov/sites/default/files/covid-19-42-cfr-part-2-guidance-03192020.pdf
(3/16) Client and Community Engagement Recommendations:
- Daily telephone follow-up with every client discharged from residential until engaged in outpatient services
- Continue to offer assistance to clients who are refused admission or discharged due to COVID-19 symptoms or high-risk health status (chronic, serious medical conditions). Some examples: health navigation to locate the appropriate health agency to contact, locate a health care provider if the individual does not have a regular source of care, assist with finding safe location for shelter
- Ensure that clients and the community know how to reach you access services (there many excellent examples of this from providers currently)
- Notify the MSO and ASO of closures and diversions
(3/16) Clinical care in 24-hour/bed-based programs: Specifically, for 24/7 bed-based programs Signal recommends:
- Suspend outside visitation
- For programs like Transitional Residential or Therapeutic Community programs, consider strongly reducing or suspending outside work by clients
- Spread out clients, separating by at least 6 feet wherever possible
- For Crisis Stabilization Units and Acute Treatment Units, one individual per room is recommended in order to keep the risk of contagion at a minimum.
- In order to minimize face-to-face contact with patients admitted in bed-based care, the use of creative solutions for care delivery utilizing telephone or video conferencing while the patient remains isolated in their room is preferred. A second example: could be using quarantined staff who are well to provide telehealth services to patients who are isolated in their rooms, this could include group therapies.
(3/16) Withdrawal management programs: In addition to the items noted in the above section, Signal also recommends:
- Creative solutions to provide treatment in ambulatory settings rather than bed-based services is recommended when able individuals can safely tolerate support through video or telephone services and a responsible individual at home can help support recovery, if medically appropriate, both as an alternative to residential services or to conclude a withdrawal management course.
- Limit the number of individuals to no more than 10 per room adhering the 6-foot separation of beds between patients and following CDC guidelines for face-to-face contact and environmental precautions.
(3/16) Crisis Walk-In Center recommendations:
- Creative solutions to reduce face-to-face contact are encouraged. For example, if providers can supply flyers outside the facility entrance with instructions to use a video conferencing platform rather than coming into the building. Another example: providers could supply a contact number whereby the individual may be connected to a quarantined staff who is healthy but unable to meet with individuals, etc.
- When creative solutions as an alternative to face-to-face are not readily available, providers should follow the CDC guidelines for face-to-face intervention and precautionary measures.
(3/16) Mobile Crisis Response:
- We encourage mobile crisis response to minimize face-to-face contact through the use of creative solutions, for example leaving an electronic device with instructions at the doorstep of an individual’s home while the evaluator remains in their car but in close proximity (this aligns with the spirt of mobile response).
- When video conferencing in near proximity is not an option, virtual assessment or telephonic assessment is encouraged. Any care is preferred to closing services.
(3/16) MSO Priority populations: We acknowledge that the risk factors for COVID-19 will complicate outreach to priority populations in 24-hour programs. We will work with the bed-based programs to adjust their priority population targets as needed over the next few months.
Although we expect that outpatient providers will continue to prioritize their response to individuals who meet the priority population definitions, we will also work with outpatient programs to adjust their targets if they are not met due to circumstances outside the provider’s control.
(3/16) Opioid Treatment Programs (OTP): In addition to the guidance published on the (https://www.colorado.gov/pacific/cdhs/article/covid-19-behavioral-health-info) Please refer to federal guidance from the SAMHSA for OTPs: https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines/covid-19-guidance-otp (note that this information is being updated frequently).
(3/17) Information for Medicaid members and providers: The Colorado Department of Health Care Policy and Financing has information posted for both Medicaid and CHIP members and Medicaid providers. This includes updated information on status of waivers that have been requested from the Centers for Medicare and Medicaid: https://www.colorado.gov/hcpf/covid
(3/17) Medicare updates rules for expanded use of telehealth: Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances. Find more details here: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
(3/16) Access to critical supplies and equipment: We are currently working with our healthcare partners to facilitate our providers’ access to protective gear and sanitation supplies to protect the safety of clients and staff and continue to divert as many people as possible from hospital emergency departments. We do not yet know at this time what we may be able to achieve, but we are working hard to do what we can.
(3/16) Payment: Signal is considering the role that accelerated or expanded payments may play for providers at this time, due to increased burden and greater expense to organizations working hard to ensure services are sustained, including:
- Staff overtime
- Supply purchases
- Telehealth provision and start-up
- Increase in case management activities
- Increased support staff
- Decrease in referrals
We hope to be able to share more information on this soon.