(Dawn) Hello everyone, I'm Dawn Glossa,
director of communications at the Joint Commission.
I want to thank you for joining us
for Preparing Behavioral Health Organizations for Coronavirus.
This webinar will provide an overview
of the spectrum of clinical presentations of Coronavirus
and specific suggestions for decreasing the risk of transmission
in the behavioral health care setting.
We will also be emailing a replay of today's webinar
in the next five to seven business days,
actually we're going to increase that for you,
and we're going to mail that out to you today
to all the registered participants
and we're also going to send it to those who weren't able to register.
We hope you enjoy today's presentation
and that you share your knowledge with your colleagues.
Today, we'll hear from Sylvia Garcia-Houchins,
she is our Director of Infection Prevention and Control
in the division of Health Care Improvement at the Joint Commission,
and Peter Vance,
he is our Field Director for Behavioral Health Care,
Surveyor Management and Development
and our Accreditation and Certification Operations at the Joint Commission.
Additionally, we will be joined by Kathryn Petrovic
our Field Director in Survey Management and Development
in Accreditation and Certification Operations.
Thank you for joining us today.
I'll turn it to our presenters.
(Sylvia) Thank you, Dawn.
I think Dawn has already gone over who our intended audience is
and thank you for doing that.
We will be covering the epidemiology and the symptoms of Coronavirus
as the first part of this presentation so that everyone can digest and understand
why it is that we are asking organizations and just the whole public to do.
All right. We've got a...
OK, I would like to start with an acknowledgment.
The Joint Commission would like to acknowledge Joe Clark
and his colleagues at the National Council for Behavioral Health
for bringing the need for additional education and resources
related to Coronavirus to our attention.
This organization is the nation's voice for mental health
and addiction providers
who care for over ten million adults and children.
We also want to acknowledge your work and the work of all health care providers
and support personnel who are working together
to provide excellent care for the patients at this time.
We are truly learning, I think every one of us,
that in times of crisis like this, everyone has a role,
including our loved ones.
Everyone we know needs to pitch in at this time.
So we generally start with a disclaimer
that talks about the current-- how current these slides are.
They are current as of yesterday.
We want to make sure that you understand that these are provided as cue points
and that there are going to be updates as this pandemic evolves.
But they should provide you with the basic knowledge
that we know about at this moment.
So I want to start out talking about Coronavirus in general,
and I think the thing that has taken most people really by storm
is how quickly it seems that we are having progression of cases.
If you look back on March 11th,
total cases in the world were about 126,000 cases had been identified,
and now, here we are eight days later and it's really almost doubled.
In the U.S. we've also seen more than a doubling of cases,
but I think it's important for people to know
what these numbers are telling us.
This is about people who have been tested, confirmed cases.
These numbers tell us how far the virus has made it through our community thus far
and we need to all be aware
that the numbers are going to increase probably dramatically
over the next week, week and a half maybe, even two weeks.
As we increase the amount of testing that's going on,
many of those cases are already infected today
but do not have access to testing.
So as these numbers go up,
we want to make sure that the population who's looking at these numbers
doesn't think that we're not being successful in our prevention efforts.
If you look at the number of cases by state
and these are from CDC and you'll notice that on every one of these slides,
where we have a reference we have provided it to you
so that you can keep up to date on this information.
You can see that some of the areas that are most populated
and would be therefore most at risk are really those showing up on the map.
New York and California are really good examples,
really important to think about population density
and how close these areas are, how many people are in there,
and you also need to think as you look into these cases,
we have them in clusters.
Why are we seeing evidence of transmission of such high numbers?
We've all heard, I'm sure, about the cruise ship,
close contained environments, conferences where people gather in groups
and then long term care facilities where people live together
as you would in a household.
So places where people congregate or live in close proximity to each other
really are areas where we are seeing risk.
The other thing that's important is when we look at the spectrum of disease,
we need to think about what disease looks like.
China has provided us with probably the most important data,
very careful tracking of the cases
as the initial pandemic was evolving,
as those original case were evolving.
This data is based on over 55 documented laboratory confirmed cases
through February 20th of this year.
Based on the data that they were able to collect,
when we look at what happened in China,
when the government was really swift in identifying, isolating and tracking
not only the cases but also following up on family
and contacts of those cases.
We have some really good data.
Based on this information, most of the people who were infected
had mild to moderate disease and when we say mild to moderate,
I'm including those people who had pneumonia
and those who didn't develop pneumonia
because yes, we all think of pneumonia as a severe outcome,
but from a severity of treatment,
it really is something that many patients recover from
or can be treated in their home if they have pneumonia.
When we really think about those people with serious symptoms,
we're thinking about people who need hospitalization,
who need medical care,
rather than just one visit but extended medical care.
We need to think about this because we need to try to use this information
to decrease the anxiety and the confusion that's being reported out there.
The other thing that's important to note when we're thinking about symptoms
is what we're hearing on the media, and I want to dispel that...
some of what's been heard.
When you actually look at the report of symptoms,
there's been a lot of news media and reports and blogs and things like that
going around talking about asymptomatic cases.
But when you look at the data that's been provided by WHO and China,
in this report, you will find that they were proactively looking for cases.
So they were testing contacts of confirmed cases
who did not have symptoms but in that report,
they go on to say that the majority of those people who tested positive
and were listed as initially asymptomatic went on to develop disease.
This is very important as we reassure our clients
and our family members and anybody else
how transmission is really occurring and what symptoms to look for.
The other thing that I think is creating a lot of anxiety
is mortality information and mortality and risk of that,
and this graph is a great one,
it tells you who's most at risk for death from this disease.
And you can see it's primarily patients or residents
who are older than 60 years of age.
That doesn't mean that there are no deaths in the younger populations
but it does mean that we need to focus on who can we protect the most,
who do we need to worry about the most.
The other thing that we need to look at is the preliminary data from China.
As we think about this,
we need to think about other co-morbidities that place people at risk
and I think the media's done a good job of identifying
that if you have other underlying health problems,
your risk of mortality is higher.
You combine the age with underlying medical conditions,
it really is quite scary for some of our loved ones
and our clients.
I think the other important thing is we need to think about time.
So how long does it take for people to die.
It's really about getting access to resources
to help you through that critical or severe illness.
What they are finding is that most people were feeling better after about a week,
sometimes as long as two weeks.
But for those people who were ill, it really took them three to eight weeks
or two to eight weeks to really start to feel better
and this is important as we think about how do we keep preventing disease,
how do we keep people safe,
how do we not overwhelm our health care system.
Part of the question that people are asking is:
"Why is Coronavirus spreading so quickly?"
"Why is this organism moving?"
And part of the issue is that we need to think about
is what the symptoms are.
The most common symptoms are fever and cough.
And so as we think of those symptoms,
many many people can be experiencing those symptoms.
How many people do you know who are coughing right now
and they say:
"Oh, I always have this cough, it's post-nasal drip."
Or "I have an allergy and that's why I'm coughing."
At this point in time,
part of the issue is some of those may actually be disease,
and some of them may not,
but we need to make sure that we don't inadvertently have someone
who does have disease transmitting it.
So this is a nice summary that was done of the data
from World Health Organization and China of those initial 55,000 cases,
and when you look at this, 90%, 90% of the people who were identified
as having laboratory confirmed Coronavirus infection
had fever and or a dry cough.
Those were the predominant symptoms.
So it really does help us narrow down
where we think we need to focus our efforts.
So these are the most typical symptoms.
not to say people didn't experience other symptoms,
but these are the big ones to think about as we work on prevention strategies.
So why is Coronavirus spreading so quickly?
Everybody's been making the comparisons on the news
and wherever you look at, why is it spreading so quickly?
Well, we need to think about how organisms spread
or how diseases spread.
So the first thing we think about is well, isn't this just like the flu,
it's the same symptoms, but when you think of the flu,
think of that one person who has an infection.
The data shows that one person with infection, with influenza infection,
will probably infect about 1.3 people.
So if we look at that
and we look at how many people that person could infect,
so after one cycle of exposing other people,
maybe three people are infected, and we keep going.
Now we've hit the second or third cycle, and we keep going,
and now, we're in yet another cycle,
four cycles of people getting infected from that one person.
And now, after five cycles,
we have about 45 to 48 people infected from influenza.
Now when we look at Coronavirus, it's a lot more worrisome.
The number of people that a person with Coronavirus can infect
is thought to be more along the lines of two to four people.
So if we start with one person who's infected
and they infect four, and then those four infect another four,
you can see that after five cycles, we have a lot more people who are infected
and a whole lot more people who are out there spreading Coronavirus.
I'd also like to talk a little bit about, while we're talking about transmission
is how does this spread.
What are the main routes of transmission.
I'm going to do that next,
but I also need to talk about why is it so important to slow the spread.
So we've all heard about flattening the curve.
No matter which news agency you look at they talk about flattening the curve.
It's a very important concept.
We are trying to delay infection of those people
who are most likely to need our health care system to provide care.
We're trying to delay those cases and spread them out
so that we don't overwhelm the capacity of our health care system.
And as we've seen in other countries like Italy,
that is a real possibility.
So all of this is very important to protecting the general population.
So how can you help prevent the spread?
The first thing is knowing and remembering how transmission occurs
and really helping to dispel the myths.
Very, very important.
The main way that Coronavirus is being spread
is person to person via droplets.
And I know that there's a lot of information out there,
"Wait, wait, wait, you know everybody's saying,
wait, it's airborne, I just read an article,
I just read a paper."
But when you go back to that original information
that was provided to us on those first 55,000 cases,
laboratory confirmed cases where they did contact tracing,
of anywhere from 80 to 90% of the people who were exposed to those cases,
what they found is the main route of transmission is via droplets,
people in close contact with those cases within that six feet distance,
and I think this picture really shows it.
When you sneeze or cough, you expel droplets.
Those droplets are what people can then breathe in
or what can contaminate surfaces around them.
When you do aerosol generating procedures for example in a hospital setting,
in a procedural setting, where you intubate somebody,
you actually put a tube down their throat, you can then create aerosol.
That is what is thought to be the route of transmission
in the health care setting when aerosol generating procedures are done.
So trying to put this in perspective for everybody,
we need to reassure people
that airborne transmission is not happening in the community,
and how can you explain that to them?
Well, so you can think about diseases that are transmitted via airborne transmission,
so let's think about transmission of Coronavirus,
how many people in China had transmissions to contacts?
So the estimated rate is somewhere between one to five percent of the contacts
developed disease.
Pretty low when you think about it,
one to five percent as compared to diseases that are truly airborne.
Then what I want you to think about truly airborne diseases,
we've all had the experience in the U.S.,
we have measles.
Somebody walking through the airport
gives someone who was unvaccinated measles.
Chicken pox.
Someone in a classroom
gives all the other kids in the classroom the chicken pox.
When you compare true airborne diseases like measles and chicken pox
and you think about who's susceptible,
the rate of transmission for measles is about 90%,
so 90% of the people who are within 100 feet
of that person who has measles will develop measles.
With chicken pox,
it's about 67% of the people who are within 100 feet of that person.
That's what airborne means,
able to sustain itself on long distance and still be able to infect somebody.
There's a lot of information,
there was this great article in The New England Journal of Medicine
that was published, I believe yesterday
that talks about the possibility of airborne transmission,
but we need to put that into what is really happening
and what are we seeing.
We are seeing person to person via droplets.
If it's at a bar setting, not everyone in the bar is getting sick,
only some of the people, those people who are close by.
We also need to think about transmission via surfaces.
Many, many viruses can live on surfaces for hours to days.
There is now data coming out that this organism can live,
depending on the surface, for hours to days, we know that.
But think about influenza
which is another organism that is transmitted via droplets.
You get influenza from the box that you handle.
No, we don't hear about transmission that way.
Are we worried about doorknobs?
Well, if the person just sneezed, touched the doorknob,
and then you come by,
hold the doorknob and touch your eyes, your mouth, your nose,
you can inoculate yourself,
but we really need to think about it that way
and relieve the fear and anxiety that is being seen in the media today.
We really have to take a step back.
So how can we use what we know about transmission to stop transmission.
I think the No. 1 thing--
I don't think it was a word we really talked about
two, three weeks ago,
but we really all know now we're hearing about social distancing,
and I want to make sure that as behavioral health professionals,
that you know that we are not talking about quarantine,
we are not talking about isolation.
We are not talking about social isolation, we're talking about physical distancing,
keeping a physical separation between people.
I had the opportunity yesterday
to go to the grocery store at seven in the morning
when I thought not many people would be there,
and I watched people social distancing.
The person in front of me put his items on the conveyor,
he tried to stay away from the person at the register
who was charging him for his items.
I stayed six squares-- six tiles behind him
and the person behind me was at least 6 tiles behind.
That is social distancing.
We can still talk to each other,
and we actually had a very nice conversation,
far enough away to still talk to each other,
far enough away to still be able to have that moment of contact.
Again, really important that we think about that.
As we go through this,
we need to think about putting it into perspective,
giving people real examples so that decreases their anxiety.
We also want to think about respiratory etiquette
and this is something that infection prevention professionals
have been talking about and the CDC has has been talking about
for at least 10 or 15 years, is respiratory etiquette.
What does that mean?
That means being polite, not letting someone sneeze on you
and you not sneezing on somebody else or coughing on somebody else.
There's been this poster available at the CDC website
for, I'd say a long, long time,
and it's really practicing respiratory etiquette,
which is covering your cough,
it may be with your sleeve, it may be with a tissue,
it may be with a mask, but that will stop droplets.
Anything that is going to stop the sneeze from spraying out
is going to be good respiratory etiquette and is worth doing.
That's going to stop infection
from people who are infected from exposing those who might be susceptible.
The other thing we want to make sure that we do is good hand hygiene.
And good hand hygiene is different for everybody these days.
We teach our kids and others to sing the happy birthday song,
I think everybody is now getting down to:
"I really have to wash my hands and do it thoroughly."
Simple tactics like when you go outside
and you touch a lot of surfaces and then you come back to your home,
as you walk in the door, go and wash your hands,
simple things that you can do every day
are going to prevent transmission of this disease.
And then finally cleaning and disinfecting surfaces.
We need to think about that as a routine.
I have three kids who work in health care, three nurses,
and my words to them were:
"When you get to work, wipe down your work area.
When you're ready to leave, wipe down your work area
so you left it clean for the next person."
Those are simple basic things that we can do when providing care.
It works in food services,
it works in all of our other communal spaces
which is clean and disinfect as you go.
I'm now going to turn it over to Peter Vance.
(Peter) Thank you, Sylvia.
On this slide and over the next few slides
we really wanted to incorporate these concepts
into the various settings that we know
our behavioral health care providers are working within.
The key concept here is communicating with your clients, your patients.
So calling them ahead of time
is actually going to be one of the first steps
that you want to do to help them understand what you are doing
to keep yourself safe and them safe during all of this process.
You'll also let them know what your processes are
and how you've made decisions about whether you'll see them in person or not,
and we'll talk a little bit more about that.
So planning for ill clients,
you already want to have that plan in place
about what you are going to do,
how are you going to change your waiting room situation
and things like that.
And consider the alternative possibilities that you have.
We'll talk a little bit more about that in a moment,
but you have phone and virtual visit possibilities
especially for the outpatient setting.
Now within your organization, you want to provide clear signage
for what your processes are
and also you want to screen for symptoms when they come in.
Ideally, you have asked that over the phone
since you contacted them ahead of time to see if they're symptomatic
but also check if they come in just to make sure.
Now for folks in the waiting room, generally, just ask them to wait outside.
If it's spring time, it's getting warmer in most places
that should be OK to just be outside,
if not, they can also sit and wait in their car
until you come out to bring them inside.
If they are in your waiting room,
make sure that you have, again, appropriate signage
and keeping them at least six feet apart
by considering limiting the actual wait room numbers that you have
and separating them at that same time.
Also having the PPE available, masks issued
and other hand hygiene products
so people can actually follow the precautions.
And again that education
about all this social distancing that Sylvia talked about.
Again, social distancing is physical distancing, really,
because you, as a behavioral health care professional
are continuing to make that connection with them
and they are hoping to keep that connection with you.
Now after the visit, cleaning--
you're going to need to increase your housekeeping for a period of time
to ensure that you're cleaning and disinfecting surfaces
as as much as possible.
During that, certainly opening doors and windows,
letting some of the air come in,
it's going to be also a good way to just keep the areas,
offices, etc., ventilated throughout this whole time period.
Of course we just mentioned the connection
and you want to continue providing the appropriate care.
So to do that you really do want to assess the client.
It's going to be key to assess the clients who are more at risk for relapse
and decompensation and then prioritize those people
whether they come into the facility or not.
So maybe some of the higher risk folks need to come into the facility
and maybe some of the others can benefit by remaining home
and utilizing phone and telehealth services.
We also recommend the possibility of increasing case management services.
Again, the connection and the education for these people
are going to be vital.
These people meaning, in general,
the individuals we serve in Behavioral Health Care.
Now, those who are experiencing homelessness,
who may be transient or indigent,
they are likely also in need of the highest outreach
and they're likely also the most vulnerable people.
So if there's a way that you can increase that case management outreach
whether by phone or in person utilizing precautions,
then that's going to be best for this population.
Also hotline information.
You want as many ways for these folks to connect as possible.
If your organization doesn't maintain a hotline or crisis services,
there are many national hotline services that are available that you can access.
Telehealth has been suggested and rightfully so
as a key component to alternative ways
you can meet the needs of the people you serve.
Currently, federally, it's what CMS is making some--
well, the 1135 waiver for.
Right now, you'll have to go to the CMS website
and see how that's updated,
but there are many of those waivers coming in,
they're coming in per state and what that really does,
it allows alternative settings to be used for telehealth.
It also allows for not meeting pre-authorization for telehealth.
So focus on that.
The other aspect of this is that the Department
of Health and Human Services has relaxed the HIPAA rules.
I want to be clear when I say relaxed HIPAA rules,
security and privacy is still being upheld but the part that they have opened up
is how telehealth can be utilized.
So now,
organizations can use services like Skype or FaceTime.
These are nonpublic types
of video chatting services.
So what it generally means
is that your staff would be able to use a device at their home
while having a session with a client using a device at their home.
You can go on the HSS website and find more of those examples
of Skype and FaceTime.
I do want to be clear about the nonpublic.
An example of a public type of video interaction
would be Facebook, that is not approved.
So I just want to be clear about that.
But it does give you the opportunity to utilize telehealth
whether you have before or not, and utilize it in a much more flexible way
to meet the needs of people who may be just distancing,
quarantined or isolated.
So Sylvia, I'll turn it back to you, she has some examples here.
(Sylvia) Sure, so we've provided some examples
of best practices.
So here is sample sign that's from Washington State Health Department.
I think you'll find that there's a variety of resources available on the web
that you don't have to reinvent the wheel,
take a look and see what is out there that you can use.
There's also great guidance from CDC.
So there's a lot of information about health care facilities,
what to actually do in an actual hospital.
But a lot of organizations are struggling what to do in these community settings,
what do you do in your office.
So CDC has provided guidance for community settings.
Some of the most important things are cleaning.
Surfaces need to be cleaned.
In order to disinfect something, it must be clean.
Some organic matter or dirt
will end up inactivating the disinfectant, so if the surface is dirty,
the recommendation is that you clean it with a detergent or soap and water
prior to disinfection.
The other important thing that happens when people do cleaning
is they fail to follow the manufacturer's instructions
for cleaning and disinfection.
It's very important that you follow the concentration,
how the manufacturer is saying it should be applied and the contact time.
Why is that so important?
Because studies have found that
if you don't follow those manufacturer's instructions,
for example you put double the amount, because many people think more is better
and you use more,
you could actually be doing less disinfecting
because of how that product works.
The other thing we want to make sure people don't do is don't mix products.
That's another case if somebody thinks:
"Well, this is good so if I add this too, it's better."
Please don't mix products unless instructed by the manufacturer.
Dangerous chemical interactions can happen.
Remember that more is not better.
Some of us have been struggling to get just normal household disinfectants.
If you can still get them or you already have them,
there is a list that the EPA has provided of very common disinfectants
that can be used against Coronavirus.
So if you click on that link or if you Google list and disinfectants
and the words SARS or COV,
you will come up with the appropriate list
and you can compare:
"What do I have? Is that what is being recommended?"
An alcohol solution with at least 70% alcohol
should also be effective against Coronavirus.
However, you need to think about the safety of who's using it
and sparks and open flames and things like that.
And so, a really easy alternative
that doesn't require a big concentration of bleach,
it's five tablespoons
or a third of a cup of bleach, and a gallon of water,
or four teaspoons of bleach and a quart of water.
Now, here I will tell you a little bit about using bleach,
which I'm sure you're most familiar with, if you go to a public pool,
the first thing you smell before you even get to the pool is chlorine.
The reason is that chlorine, when it's added to water,
starts to dissipate into the air.
So if you are making up your bleach solution,
it is recommended that if you are using an open container
that you make it fresh daily,
and if you have a closed container,
you probably don't want to use it for more than about a week.
So bleach is a wonderful alternative,
and this is a quite low concentration that's effective
and shouldn't damage most of your surfaces.
Now there's a lot of questions about soft or porous surfaces.
We have kids coming in who may do therapy on the floor
with carpets and rugs,
how do we keep those from becoming a source for Coronavirus spread?
What do we do if someone who was coughing and sneezing and had a fever
all of a sudden gets nauseous and throws up on the carpeting?
Well, in general,
we're not thinking that this is a big source of transmission
is the first thing that you need to reassure everyone.
First thing is remove any visible contamination present,
put on some gloves and clean up.
Those can be household gloves that you have or the exam gloves,
just something to protect your hands.
I've been known to use a paper bag because I don't have gloves.
At home, I don't have gloves
and I am the care provider to two elderly people and a dog.
And so, if something happens
and I need to clean it up, I don't have gloves,
a plastic bag to protect my hand is just as good.
So you want to make sure that you clean
with the appropriate cleansers for that surface.
If it's carpeting, you're going to use carpet cleaner.
Then to disinfect.
Carpeting is going to be very hard to disinfect.
Remember, the organism is not going to be viable forever
and very quickly on certain circumstances dies.
This is not one where you need to panic and worry,
but if you do need to disinfect soft surfaces like rugs
that you're going to reuse,
launder them if it's allowed by the manufacturer,
and in the warmest temperature setting that you can,
and then allow them to dry completely or dry them in the dryer.
Otherwise there are products with EPA approval,
that are again common products that are out there on the market,
and you can go to this list for novel Corona fighting products
that are suitable for porous surfaces.
So what we'll try to do is provide you with some resources.
The thing to remember is keeping it clean,
washing your hands is going to prevent transmission.
There's also been questions
because many organizations provide laundry or linen access for our clients.
So think about linens and clothing
and other things that go into the laundry, basic infection control.
No matter what it is,
even if the person doesn't have Coronavirus,
we should not encourage shaking of laundry.
Why?
Because other organisms of the Coronavirus might be present,
like scabies, lice, things like that.
When you start shaking in the laundry area,
you could contaminate surfaces.
We want to wash laundry and clothing
in accordance to the manufacturer's instructions
using the warmest setting but we don't want to destroy them.
No need to add bleach or anything else
unless that's what the manufacturer recommends
as part of the cleaning process.
The other thing we want to make sure
that the dirty laundry that's been in contact with the ill person
doesn't start piling up
and everybody thinks: "Oh, we can't touch that."
You can touch that.
You want to use gloves or good hand washing
as you're carrying it over to the laundry to put it in.
The other thing we want to remind people
is just routine cleaning and disinfection of laundry surfaces.
That should be happening anyway.
That should be the routine between your clients
and in these community settings, and even when we do it as therapy.
Clean and disinfect your laundry surfaces frequently,
the washer surfaces, the hampers,
any cart that you're using to transport dirty laundry.
Use the recommendations whether it's a hard or soft surface,
but all of that will prevent transmission.
There has been guidance provided in community settings
with overnight stays.
This is not on health care community settings.
The current recommendation from CDC
is that you follow interim guidance for U.S. institutions of higher education.
So dormitories, school type settings,
and we provided you with the link for that,
and again, these slides will be going out.
We need to ensure that there is continuity
of safe housing for residents and our clients.
We need to identify the spaces to house
and provide services to ill individuals in advance.
This is that preparation part.
We need to make sure that we've thought about:
"Hmm, if suddenly someone develops a fever or cough,
where are we going to put them?"
Spatial separation, six feet apart.
This is not the time to throw someone out in the street, to overreact.
We want to make sure that you've thought about this,
if you have a separate room where they could be housed.
We've got to make sure that we have that continuity of safe housing.
If there are no cases happening in your organization
and its community based setting with overnight stays,
think about educating the residents on measures to decrease transmission,
that physical separation, staying six feet away.
If you're putting out cots for the night, are they six feet away from each other?
How can you arrange the environment to support that physical distancing?
Think about hand washing and incorporating that into the routine;
hand washing before meals,
hand washing periodically throughout the day,
hand washing when they come in from outside.
And if there are cases that occur in your situation,
please work with your local public health department,
they are going to be your best resource for assessing the situation
and providing good information to your residents and to your staff
on how to protect everybody.
Now is the time to identify your local public health authority,
even to let them know:
"Hey, just to let you know,
we have a community and this is what we're doing."
Peter and I, as we were going over these slides
had a good discussion about cottages and use of houses
where you have multiple settings within a larger setting.
Things like not having people move from cottage to cottage,
keep them as a family unit, provide resources as a family unit.
If someone gets sick, do they stay within a room?
Do they move to another cottage?
Really think those things through now.
We also want to ensure that we continue to provide meals
for people who need them.
All the routine food services sanitation procedures that we currently follow
will be effective in stopping the spread of Coronavirus.
So sanitizing your dishes and your utensils,
all of that routine will continue to provide a safe and sanitary situation
for people that you are providing meals.
The important part here is how do we distribute food in settings
where people might gather in crowds or groups.
So things to consider is the grab-and-go's.
Pre-distribute into some type of container
and hand them to people and then have them sit,
they can still sit socially, but with some social distancing,
remember that six feet.
Think about how you arrange the area where people eat.
Doing meal delivery is another great option.
Either way you do it,
think about adapting to ensure that social distancing.
And people can get really creative,
and sometimes it's important if you have that residence,
that community setting, is taking it to the group and saying:
"Hey, this is what they are saying so that we can protect everybody,
let's problem solve this as a group.
How do you think we might achieve this,
of social distancing but still staying together
and providing support to each other?"
I'm going to turn it over to Peter.
(Peter) Thank you, Sylvia, and just as you were saying,
that's exactly what we're looking at.
If you're providing psychosocial rehab or some type of dayhab
or day treatment type service,
those people really tend to thrive on that routine,
and that's where you may want to keep these services up and running.
You might limit the amount first,
but you can put all of these other precautions into place.
Having a routine for the populations in these settings
really may prevent a mental health crisis from occurring later on.
Residential settings, similarly,
you heard Sylvia talk about the family unit,
generally, if these people are there, whether it's a group home
or even a more extended stay residential setting,
then these people it is
as you're going to treat them almost as if it's your family
although you do have staff obviously coming and going
and so you have to be mindful of that.
So you can also eliminate
or limit visitation hours to the organization
and furloughs if you send a resident out and then come back
so you can eliminate those.
Again you want to base all of this on the clinical aspect
of what's going on with your person you're serving.
And if you do eliminate visitation,
that's where phone and Skype opportunities will come back in to play as well.
I keep using Skype,
I don't have a preference for that but it's just an easy example.
So then again, they are able to keep contact with family and friends
outside of the treatment setting.
If you're working with people in the community,
if you have in-home services, again, take precautions,
determine who really needs a face to face visit,
and limit those as much as possible
and increase use of phone or Skype type contact.
Often self-help and support groups are housed in organizations.
That might be something that you, again, limit or eliminate altogether.
Often in peer support type settings,
people have phone numbers of other members in those groups,
and that's exactly what should be utilized and that's where you can connect with them
to make sure that they're using those opportunities.
When it comes to opioid treatment programming,
we put a couple of references here.
Washington state really out of the box with some information.
We do know that SAMHSA CSAT is encouraging telehealth use
that we mentioned earlier.
They've also made some exceptions as far as their current rules
in regards to eliminating
the need for physical assessment if you are prescribing buprenorphine.
Now it still stands for methadone
but there're eliminating that currently for buprenorphine.
Also one of the things is take home medication.
SAMHSA's asking that for...
If you've assessed someone to be stable that they could have the 28-day take home
and if you've assessed someone that is maybe not quite as stable,
that they're still available for a 14-day take home,
so keep those opportunities in mind and check on the SAMHSA website
as they have updated that recently.
If the person does come into your opioid treatment program,
remember signage and giving them the direction.
Offer all of the PPE that you may have if that's possible
as well as a hand sanitizer, and again, the distancing.
This is always good in an OTP just for privacy issues,
and now it's even better, physical distancing for health issues.
- [inaudible]. - (Sylvia) Yeah.
(Peter) Sylvia, you can step back in, and we can talk a little bit about this,
- (Sylvia) Sure. - (Peter) as far as
reassurance and some some ideas about stigma.
(Sylvia) Yeah so Peter, as we talked about yesterday,
everybody on this phone call
has the unique ability to address potential concerns,
fears and anxieties regarding this disease.
Initially, by reiterating simple hygienic precautions and practices
we can broadly promote helpful information and manage fear and stigma.
And the biggest thing we can do is restore that sense of calm
in everyone's life.
I mean if you've been watching the media, which I have,
it really raises that anxiety level.
We need to think about giving people the...
"OK, turn off the news,
only look at it once a day every other day.
Don't worry, you're not going to miss something crucial
because most of it is already out there."
Right now, it's a lot of speculation and it's a lot of fear.
We really need to think about how do we reduce that fear and anxiety.
Having the news on for your kids all day long,
probably not the best practice.
(Peter) In the piece, I just wanted to add was,
and Sylvia, you mentioned this earlier,
the idea of teaching your clients
and your patients about all of these things,
this is certainly a case where knowledge is power,
and you can empower them,
and this should really be part of your infection control planning
as you always go about doing.
But this is also an opportunity
to really help them understand the seriousness of it,
help them be a part of the solution and really empower themselves
to help themselves throughout all of this period,
and it should help decrease that anxiety that they may be having about this.
And then perhaps you will see as you're teaching them
that it will continue and will be something that they carry on
even after COVID-19 has diminished through the year.
(Sylvia) So it's very important that you plan ahead.
At this point, what we really want to make sure
is that everybody's making plans to stay connected
no matter how this crisis evolves, that is essential to providing care.
We need to make those plans to provide ongoing care and services
no matter what happens to support those clients.
If someone does come up with Coronavirus in your community setting,
what are you going to do, think about it now.
One of the challenges for health care facilities,
in hospitals and outpatient centers,
really has been making plans ahead of time.
Don't wait.
And then make sure you have plans that maintain your operational continuity,
that you're supporting your support staff.
What are they doing with their kids? What are they doing if they get sick?
Don't forget them, in addition to those whom you serve.
And finally, make plans to partner.
Who you are going to work with? Know your health department.
What happens if something happens with food delivery?
What happens if the ventilation goes down or something else?
Start thinking ahead because as more and more resources are contracting,
we need to make sure that we absolutely are focusing on those things
and making plans.
There are some final instructions
that I think will be very helpful to most people.
These are the current instructions for people who do get sick.
So these are available on the CDC website if you are sick and what to do.
They provide information for people who have been tested
as well as those who have not been tested.
In general, the reason I provided those for those people who have not been tested
is because of the small number of people that have been tested at this point.
This guidance may change over time,
so it's important that as the reported cases go up,
that you keep yourself abreast of them.
But really, you want to protect caregivers and others from exposures
and that's what we talked about, spatially separating people.
It could be using a curtain, that will provide some separation.
Make sure that people know to treat the fever,
maintain hydration and get good rest.
Many or most people do not require medical care.
They don't need to go to the doctor to get tested
or to get told: "You need some Tylenol."
But they also need to know when to seek medical treatment
because their symptoms are worsening;
they have difficulty breathing, shortness of breath, chest pain,
that is when you want to make sure that your clients know:
"You need to speak up, you need to let people know,
we need to get you the care you need
or you need to go to your health care provider."
If it all possible,
all health care providers are asking if someone who has suspected Coronavirus,
please call in so that they can plan for that person's arrival.
Again, that advice may change.
If the person has not been tested but they are symptomatic,
the recommendation is that people stay home until they have no fever
for at least 72 hours, three days
without the use of any medication that will reduce their fever.
So no Tylenol, fever medicine, ibuprofen, none of those things,
for at least three days and no fever, and that their symptoms are improved.
And it's important for us to realize that
if someone has underlying asthma for example,
and they are coughing because of Coronavirus,
their cough may continue for several weeks,
sometimes even months after the infection.
So what we want to see is that they have symptom improvement,
that cough got better not worse.
And that at least seven days have passed since their symptoms first appeared.
This sometimes can be hard for people to remember
when their symptoms appeared but err on the side of caution.
Around when do you think they started coughing?
Around when do you think the fever...
If they say:
"Oh, it might have been Tuesday it might have been Thursday,"
then pick Thursday, be conservative.
We have also provided you with some resources
that were used in the development of this presentation.
If you click the links, you should get to other resources.
The CDC has provided excellent resources for us to use.
It can sometimes be somewhat difficult to navigate
because we're all looking for something a little different.
The Joint Commission has provided some resource pages
in their infection control
including a list of frequently accessed sites
that you might need.
Kathryn, do you want to say a little bit more?
(Kathryn) Yes, thank you, Sylvia.
I actually have a new role at the Joint Commission
as the director of the Department of Standards and Survey Methods
and the executive vice president of our division, Dr. David Baker,
actually leads our COVID-19 resource work group at the Joint Commission.
So we are all working diligently with other leaders within the Joint Commission
such as Sylvia to provide clear, concise resources to all of you.
As we are inundated with information as Sylvia has talked about,
we really have spent a majority of our time, really,
vetting a lot of that information through this work group
to ensure that we're giving you the most updated information out there.
And we also have very close contact with important partners such as the CDC
and CMS on a daily basis.
So just to highlight, please go to www.jointcommission.org
and front and center,
you will see what your organization needs to know about the Coronavirus,
and so we have been keeping resources there
for all of you to look at, and Sylvia and Peter have both mentioned
that this has really been an evolving situation
where things have changed as far as what we're learning about this virus.
So it's really important to stay connected, be looking
as we change the recommendations out there.
So pretty regularly,
we recommend that you're looking at this website.
Also, on jointcommission.org, on the top, you will see the heading Standards
and if you press on that, it says Standards FAQs.
If you go to the lefthand side and click New,
most of the FAQs that have been posted
are all related to the COVID-19 or Coronavirus.
You can also search "Coronavirus," "COVID-19"
and all of those FAQs will come up
and they are separated out by what is applicable
according to our standards for each of our programs.
So for our Behavioral Health Care Manual for our Hospital Manual, etc.
So Sylvia, I will turn it back to you.
(Sylvia) Thank you, Kathryn.
We are at the end of our presentation, and I'm going to let Dawn take over.
(Dawn) We want to thank everybody for joining us today.
We know things are very stressful right now for you,
and we appreciate you spending some time with us.
I do want to let everyone know that we went over on time,
and to respect that, we're going to take questions via email,
so thank you and have a great day.