Additional Guidance for Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States

Purpose of this Guidance

This interim guidance outlines goals and strategies suggested for U.S. ambulatory care settings in response to community spread of coronavirus disease-2019 (COVID-19). Ambulatory care settings are where health services or acute care services are provided on an outpatient basis and can include community health centers, urgent care centers, retail clinics co-located in pharmacies, grocery stores, or mass merchants, hospital-based outpatient clinics, non-hospital-based clinics and physician offices, and public health clinics. These settings, particularly those which offer primary care services, play an important role in the healthcare system’s response to the COVID-19 outbreak.

This guidance reflects the need to 1) minimize disease transmission to patients, healthcare personnel (HCP) and others, 2) identify persons with presumptive COVID-19 disease and implement a triage procedure to assign appropriate levels of care, 3) reduce negative impacts on emergency department and hospital bed capacity and 4) maximize the efficiency of personal protective equipment (PPE) utilization across the community health system while protecting healthcare personnel.

Public health guidance will shift as the COVID-19 outbreak evolves. All healthcare facilities should be aware of updates to local and state public health recommendations. These recommendations should be used with the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This information is provided to clarify COVID-19 infection prevention and control (IPC) recommendations that are specific to ambulatory care settings. This information complements, but does not replace, the general IPC recommendations for COVID-19.

Key Considerations for Healthcare Facilities

Currently there are no FDA-approved medications to treat or vaccines to prevent COVID-19. Therefore, community approaches to slowing transmission such as social distancing, and reducing face-to-face contact with potential COVID-19 cases are needed to slow disease transmission and reduce the number of people who get sick. In each healthcare facility, the primary goals include:

  • Provision of the appropriate level of necessary medical care.
  • Protecting healthcare personnel and non-COVID-19 patients from infection.
  • Preparing for a potential surge in patients with respiratory infection.
  • Preparing for PPE and staffing shortages.

Actions to Take in Response to Community Transmission of COVID-19

As a public health action to preserve staff, PPE, and patient care supplies and to ensure safety for patients and HCP, facilities should delay elective ambulatory provider visits and implement service delivery models such as telemedicine. (See information below under “Shifting Healthcare Delivery Modes during a COVID-19 Outbreak in the United States” and American College of Physicians: Telehealth Resourcesexternal icon). Provider visits related to prevention services that cannot be performed virtually such as routine adult immunizations, lipid screenings and cancer screenings should be postponed unless the risks of postponement are believed to outweigh the benefits.

  • Explore alternatives to face-to-face triage and visits for the acutely ill. The following options can reduce in-person healthcare visits and prevent transmission of respiratory viruses in your facility:
    • Instruct patients to use available telephone advice lines, patient portals, and on-line self-assessment tools, or call and speak to an office/clinic HCP if they become ill with symptoms such as fever, cough, or shortness of breath.
    • Identify sufficient HCP to conduct telephonic and telehealth interactions with patients.
    • Develop protocols so that HCP can triage and assess patients prior to entering the facility or immediately upon entering.
  • Implement algorithms to identify which patients have respiratory symptoms that may be due to COVID-19 and need to be advised to seek 9-1-1 transport, go to an emergency department, or come to your facility.
  • Implement algorithms to identify which patients with respiratory symptoms that may be due to COVID-19 can be managed by telephone and advised to stay home:
    • Assess the patient’s ability to engage in home monitoring, their ability to safely isolate at home, and the risk of transmission to others in the patient’s home environment.
    • Provide clear instructions to caregivers and sick persons regarding home care and when and how to access the healthcare system for face-to-face care or urgent/emergent conditions.
    • If possible, identify HCP who can monitor those patients at home with daily “check-ins” using telephone calls, text, patient portals, or other means.
  • Engage local community organizations and home health services to assist patients who are treated at home and may need support services such as delivery of food, medication and other goods.
  • Prepare your facility to safely triage and manage patients with respiratory illness, including COVID-19. Become familiar with infection prevention and control guidance for managing COVID-19 patients and preparation steps.
    • Place visual alerts such as signs and posters at entrances and in strategic places providing instruction on hand hygiene, respiratory hygiene, and cough etiquette.
    • Ensure supplies are available such as tissues, hand soap, waste receptacles, and alcohol-based hand sanitizer in readily accessible areas.
    • Ensure facemasks are available at triage for patients with respiratory symptoms. Create an area to physically separate patients with respiratory symptoms. Ideally patients would be at least 6 feet apart in waiting areas. If facility lacks a waiting area, then designated areas or waiting lines should be created by partitioning or signage.
    • To reduce crowding in waiting rooms, consider asking patients waiting to be seen to remain outside (e.g., stay in their vehicles, if applicable) until they are called into the facility for their appointment or set up triage booths to screen patients safely.
  • Work with local and state public health organizations, healthcare coalitions, and other local partners to understand the impact and spread of the outbreak in your area and any crisis standards of careexternal icon initiatives being implemented. Ambulatory care settings may also be leveraged to allow for diversion from hospital emergency departments of non-respiratory illnesses or minor trauma not likely to require hospitalization.
  • If your facility is called upon to screen and diagnose COVID-19, designate HCP who will be responsible. Ensure they are trained on infection prevention and control guidance for COVID-19 and proper use of PPE as well as any local guidance for testing strategies including implementation of, or referrals to, mobile or drive-thru testing venues.
  • Monitor HCP and ensure maintenance of essential healthcare facility staff and operations:
    • Facilities should implement sick leave policies that are non-punitive, flexible, and consistent with public health policies and allow ill healthcare personnel (HCP) to stay home. HCP should be reminded to not report to work when they are ill. Be aware of recommended work restrictions and monitoring based on staff exposure to COVID-19 patients.
    • Do not require a healthcare provider’s note for employees who are sick with respiratory symptoms before returning to work.
    • Advise employees to check for any signs of illness before reporting to work each day and notify their supervisor if they become ill.
    • Consider screening staff for fever or respiratory symptoms before entering the facility.
    • Make contingency plans for increased absenteeism caused by employee illness or illness in employees’ family members that would require them to stay home. Planning for absenteeism could include extending hours, cross-training current employees, or hiring temporary employees.
  • Plan to optimize your facility’s supply of PPE in the event of shortages. Identify flexible mechanisms to procure additional supplies when needed.

Other Considerations for Ambulatory Care Settings

  • Consider reaching out to patients who may be a higher risk of COVID-19-related complications such as the elderly, those with medical co-morbidities, and potentially other persons who are at higher risk for complications from respiratory diseases, such as pregnant women, to ensure adherence to current medications and therapeutic regimens, confirm they have sufficient medication refills, and provide instructions to notify their provider by phone if they become ill.
  • Eliminate patient penalties for cancellations and missed appointments related to respiratory illness.

Special considerations for clinics that are co-located in larger stores such as pharmacies, grocery stores, or other retail outlets

  • Post signs at the door instructing clinic patients with respiratory illness to return to their vehicles (or remain outside if pedestrians) and call the telephone number for the clinic so that proper triage can be performed before they enter the store.
  • It may be possible to manage patients with mild symptoms telephonically and send them home with instructions for care.
  • Clinic patients with respiratory illness that need to be seen should be told to wait outside the store until they can be brought directly into a clinic visit room or a designated waiting room. Facemasks should be provided, ideally prior to entering the store.
  • Where possible, provide separate entrances for all clinic patients. Otherwise create a clear path from the main door to the clinic, with partitions or other physical barriers (if feasible), to minimize contact with other customers.

Shifting healthcare delivery modes during a COVID-19 outbreak in the United States

Several major impacts can be anticipated during a severe outbreak that could affect the operations of healthcare facilities. These include surges in patients seeking care, the potential for workforce absenteeism for personal or family illness, and effects from community mitigation approaches such as school closures. Healthcare facilities will likely need to adjust the way they triage, assess, and care for patients by using methods that do not rely on face-to-face care.

Facilities can reduce exposure of HCP to ill persons and minimize surge on facilities by shifting practices to triaging and assessing ill patients (including those affected by COVID-19 and patients with other conditions) remotely using nurse advice lines, provider “visits” by telephone, text monitoring systems, video conferences, or other telehealth and telemedicine methods. Many clinics and medical offices already use these methods to triage and manage patients after hours and as part of usual practices. Recent reports suggest that approximately 80% of COVID-19 patients (of all ages) have experienced mild illness. Managing persons at home who are ill with mild disease can reduce the strain on healthcare systems, however, these patients will need careful triage and monitoring.

Promoting the increased use of telehealth

  • Healthcare facilities can increase the use of telephone management and other remote methods of triaging, assessing, and caring for all patients to decrease the volume of persons seeking care in facilities.
  • If a formal telehealth system is not available, healthcare providers can still communicate with patients by telephone instead of in person visits which will reduce the number of those who seek face-to-face care.
  • Health plans, healthcare systems, and insurers/payors should communicate with beneficiaries to promote the availability of covered telehealth, telemedicine, or nurse advice line services.

Shifts in the way that healthcare is delivered during a COVID-19 outbreak response will be complex. Thorough and consistent communications between all components of the public health and healthcare system will be needed in every community. Providers in medical offices, clinics, and other outpatient settings should be informed and know their roles as they evolve. Pre-hospital care by emergency management services (EMS) and public-safety answering points (PSAPs) will also need to be coordinated and consistent with current transport guidance so they can conduct in-home assessments and triage per local guidance.

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