#3/#6 The AAP does not have a recommendation what practices should do in terms of delaying visits vs. doing visits. It certainly does not have a recommendation that well visits “should” be done by telehealth.
The following is my personal opinion.
- Prioritize checkups for ages <=2 years. Not only are these visits at which vaccines are required, there are also other time-sensitive screenings (development, lead, growth/FTT, autism, hemoglobin) where delay significantly increases the child’s risk of a bad outcome. And since “delay significantly increasing the child’s risk of a bad outcome” sounds a lot like “urgent,” these visits are totally justified even during a lockdown. Checkups age 30 months and under accounts for 43% of your Bright-Futures recommended checkups, assuming a more-or-less equal age distribution amongst your patient panel.
- Consider your PPE. If you have hardly-any-to-no PPE, you should probably stop here. We know COVID-19 is community spread, and many people early in the disease are asymptomatic and/or don’t have fever or cough. You will be exposed to patients and parents with COVID, and without PPE, you’re at high risk of having to sit out for 2 weeks - and that’s the best case scenario. If you have enough PPE to wear (at least) surgical masks during all patient visits, then you have reduced the chance of patients infecting you, and you infecting patients.
- Consider what your physical plant permits. If you can eliminate your waiting room, check patients in from their car, and clean surfaces well after every visit in an exam room, then you have significantly reduced the chance of patients infecting each other on visits to your office.
- Consider how many appointment slots you have. If you want to leave your afternoon open for sick visits, and not have sick patients in the office at the same time as well visits, then you can only see well patients in the morning. This necessarily limits the number of well slots you can have in a day. If you have little demand for sick visits (or at least, in-office sick visits), but you’ve furloughed 1.5 providers of your 5, this will also effectively reduce your potential well visit throughput. You don’t want to book 6 yo and 14 yo well visits so tightly that you’ll won’t have any room to add in 4 mo visits.
- Based on factors 2-4, judiciously add checkups from the remaining 57% of age ranges remaining, until your well visits approach saturation. Consider your patient population and consider targeted recall for:
- Patients with mental & behavioral health challenges (anxiety, SUD)
- Patients with physical comorbidities putting them at risk for complicated COVID (e.g. asthma, DM)
- Patients at risk for unintended pregnancy/STDs
- Patients whom you haven’t seen in a while for anything and can’t assess their risk
Even if you do the interval history, screening, counseling and anticipatory guidance by telemedicine (billing 9940x or 9921x based on time), you’ve touched base with patients who are most at-risk. If you can bring them in for an exam, vision/hearing screening, and labs safely, that’s even better.