COVID-19 Issues

Sharing Space in COVID-19 Times

Current BDTX policy for 2130 SW Jefferson Street Suite 300: Remote therapy and assessment procedures are the default/preferred method of service delivery until further notice. The reason for this policy is that health risks pose a greater threat to all involved [and to other community members as well] than do the risks of non-standard assessment results. When there is a substantial change in our health environment, we will review and make appropriate changes in this policy. 

We realize, however, that decisions about how best to administer psychological test procedures must be determined on a case-by-case basis. There may be occasions when the urgency of a patient’s need to be assessed outweighs the health risks outlined elsewhere in this document. Individual clinicians must make these decisions as best they can, balancing health risks against the need to obtain standardized assessment results. When clinicians judge it necessary to administer psychological tests face-to-face, they will need to do so in their own offices, taking care to follow safety procedures described elsewhere in this document. 

We have established the following BDTX-PDX office policies to address the possibility of re-opening, and phasing in of in-person psychotherapy sessions, and in-person psychological and neuropsychological assessments, to insure we have in place safety procedures to protect the safety for all of our collective patients, staff, sub-leasers, and anyone entering our suites. In arriving at these policies, we have studied materials from the IOPC[1], APA Trust[2], APA[3], and local and statewide references.

The APA Trust statement on re-opening suggested that when considering phasing into in-person care psychologists should engage in thoughtful, systematic, ethically-grounded risk management. In transitioning back to in-person services during this pandemic does add some degree of risk to patients, providers, and the broader community. Their advice was that if telepsychology is available as an alternative, it is the preferred method of service delivery, particularly among high risk categories of patients, staff, and psychologists.

The IOPC statement indicated there are three areas of risks that should be weighed against any possible benefits of conducting psychological assessments. These included

  1. Health Risks of conducting in-person NP or assessments
    1. Patient risk of contracting COVID-19
    1. Examiner risk of contracting COVID-19.
    1. Risk of transmission of coronavirus to patient, examiner and or community
  2. Risks of exam validity undermined by illness anxiety, manifested by examinee or examiner.
  3. Legal Risks: It should be recognized that the risks are not limited to health risks as noted above, but entail legal risks, including:
    1. exposure to litigation that may arise if an examinee’s or employee’s health is compromised;
    1. exposure to litigation if the conclusions of the examination are questioned or considered invalid
    1. the possibility that a clinician’s liability insurance coverage may not include practice under these circumstances

Therefore, we began from the standpoint of managing our Suite 300 shared space given our current constraints, and the eventual re-opening of in-person psychological services, and in-person neuropsychological or psychological testing to insure the safety of our current and future patients and family members, our sub-leasers, staff, we three as lease holders established these clinic wide policies, to limit, or mitigate health and safety risks, liability risks, and legal risks for all of us.

We are establishing these clinic guidelines that all tenants are expected to follow. These polices are not meant to preclude your exercise of clinical judgment about when in-person testing or in-person psychological are indicated. We expect these policies will have room for leeway, and of course individual clinician judgment. We have addressed issues that include under what circumstances in-person testing or other psychological services shall be determined as necessary, measures for patient safety and risk mitigation, measures to keep our patients and ourselves safe, and appropriately distanced. Further, we address the use of space for testing, and measures to clean and sanitizing testing, room, waiting room, as well as any equipment that might pose a risk of infection from COVID-19. We are open to always listening to requests that might differ from these policies and guidelines, and to discuss how to alter these policies as new information, or new situations arise.

We focused initially on assessment practices, as psychotherapy, for the time being, is allowed by insurers, and preferred by most providers, patients. However, our research has led us that psychotherapy services likely will need guiding policies for phasing face-to-face services back in, however long from now that might be.

The IOPC statement suggested there are several models of how to consider risk-mitigation if one has decided that in-person assessment is necessary and clinically warranted. All are based on the ideal of Standard In-Person Administration, which prior to COVID-19 were conducted without mitigation, and must be considered the “gold standard” procedure, and deviations is necessarily considered a non-standard administration.

Modified In-Person Administration using procedures to minimize risk of infection or transmission. The risks of in-person assessment are reduced by mitigation strategies…these alter standard administration practices and therefore may impact validity and increase risk of inaccurate diagnoses. Possible procedures designed to reduce risk of exposure but differ from standard practice that might impact test performance.

  1. Screening procedures to determine that the patient and the examiner do not have symptoms
    1. Use of masks, gloves or PPE by examiners and or examinees may have additional adverse impacts on validity.
    1. Increased distance between patient and examiner may make it more difficult for instructions to be delivered effectively
    1. Restricted use of manipulatives during testing, and other articles that are “high contact.”

In-Clinic TeleNP: Where both clinician and patient are in a clinic but in separate rooms using video-conferencing rooms could be in different clinic locations…or in other models the rooms are in the same building.

Clinicians control quality of platform, equipment, and are available to troubleshoot, can control the testing environment…Most TeleNP research has been conducted in the context of in-clinic TeleNP

Home TeleNP Assessments where the patient is located at their home:

  1. Evaluation is conducted with the patient in their own home or other remote location via audio or video conferencing technology. Most research not conducted in this context where examiners do not have control over ration.
  2. Factors may limit benefits of Home TeleNP assessment patient populations. Reduced patient access to technology [due to economic disparities and potentially widening health disparities is a significant problem.
  3. Socioeconomic disparities may further result in patients having limited access to a quiet, distraction free place

Combined, Hybrid or Staged Models combining elements of TeleNP with in-person face-to-face:

  1. Initial interviews, select testing measures, and feedback sessions might be conducted using telehealth platforms. Testing takes place with either face-to-face, or in-office remote setups.  
  2. Making treatment decisions based on a stepped-care model applies to psychological care. This model proceeds in a stepwise fashion from least intensive to most intensive.
  3. Delaying the assessment until it is possible to see the patient in person without modifications. This assumes that the time frame for the conditions to be safe is possible to know, with the development and wide availability of a safe vaccine.

There is consensus in the neuropsychology world that testing policy is needed to protect patients and providers from risks due to COVID-19, including health risks, liability risks, and legal. After review of recommendations from the IOPC, we found that all face to face testing increases risk as the amount of time a clinician spends in an enclosed room whether or not masking, or shielding is used. Thus, the first choice for assessments is to arrange assessments so that they do not need any face-to-face procedures. The science seems to indicate now that it is total amount of aerosol droplets that carry the highest risk of infection. In other words, the amount of time one spends with a person that is infected increases your risk of exposure and infection. Thus, there is no strong evidence that space alone mitigates risk of infection, unless it’s outside space without wind. Use of a HEPA filter is likely more effective. The most effective way to minimize risk is to minimize the amount of time spent in the same indoor space with another person. 

When face-to-face testing is required, we believe the best solution is brief in-office remote testing. In this approach, the clinician is mainly setting up, and most interaction takes place remotely from one office to another. This will require the use of two spaces, the clinician’s office and a testing room. We have selected our current testing office for the second space. Thus, we are assuming we will continue to conduct testing, for the most part, on a virtual basis, with remote in-office testing used only for those procedures that an examiner cannot reasonably complete without seeing [or having a psychometrician see] a patient face-to-face. Please refer to the in-office remote testing procedures for specifics. The current testing room, where many of our in-person testing has taken place in the past, seems to be the best, most centrally located space to conduct in-person remote in-office testing. This area will be optimized for ease of cleaning, and other sanitizing procedures. We shall also be providing a HEPA filter air purifier in that office as one aspect of this protocol. We shall also establish a scheduling protocol if and when we have more than one provider considering in-office remote testing. All providers should understand that this policy is in force, unless, they have express permission from all lease holders to alter these policies and established procedures.