During the COVID-19 pandemic both State and Local governments have worked together to respond to the pandemic. Stay-at-Home orders are in place and have supported the flattening of the curve in California. During this time, non-urgent health care has been deferred to support the State's efforts and to further prevent the spread of COVID-19. This deferral of services was essential in response to the surge of COVID-19 patients, but creates its own public health impacts, which must be addressed as soon as practicable.
Even though current evidence shows progress in suppressing the virus, there is much to consider for the future of the State and to protect against a surge, once Stay-at-Home orders are modified. One important focus will be resuming our existing health care system for non-emergent and non-COVID-19 health care, which has been deferred during this time. These services will include resuming elective and non-urgent procedures at hospitals; outpatient care including primary care and specialty care in physician offices and health centers; behavioral health, long term care, ancillary, pharmacy, and dental services. This is to restart the care that has been postponed including preventive care such as well-child visits and vaccinations, adult clinical preventive services, and routine dental services. Whenever appropriate for patient and condition, visits should maximize the use of telehealth/telephonic modality.
This guidance is intended to set a plan for California while understanding there may be local or regional circumstances that require different timelines for resumption of services.
The sections below outline considerations and guidelines that should be reviewed and met prior to resuming services. It is expected that specific regions of California may resume services before the entire State is able to; therefore, regional delivery systems will need to consult local public health officers in neighboring counties as they begin to resume services to non-emergent and non-COVID-19 patients.
It is important to continue to monitor COVID-19, including case counts and hospitalizations and their impact on the health care delivery system. It is also important to monitor local health officer orders and Governor's orders in the event that a different health care delivery system response is necessary.
Availability of testing with prompt results should be present for health care delivery situations when knowing the COVID-19 status of staff or patients served by the entity is important for clinical care and infection control.
Prior to resuming non-emergent and non-COVID-19 deferred services, offices and facilities should consult with local public health officers within counties served to determine if there are local COVID-19 patterns that could impact health care delivery.
Personal Protective Equipment (PPE) is essential to protect health care workers and patients; therefore, the following is recommended when resuming services. Facilities should have a plan for circumstances when patients or visitors when allowed arrive without face coverings.
PPE Minimum Requirements for outpatient settings:
PPE Minimum Requirements for Hospital settings:
Implement policies for PPE that account for:
PPE Minimum Requirements for Skilled Nursing Facilities (SNF) settings:
Providers and facilities are encouraged to gradually resume full scope of services when possible and safe to do so, based on these guidelines. It is encouraged that as many services as possible and appropriate be delivered by telehealth/telephonic even after loosening of the Stay-at-Home restrictions to protect patients and health care workers. The physical layout and flow of care delivery areas may change in terms of patient movement and waiting areas so that physical distancing is maintained; and there should be a process for determining the priority of types of services delivered initially as delineated below. Services should be available for both COVID-19 negative and COVID-19 positive assuming systems are in place to provide adequate testing, appropriate separation of the patients, and adequate PPE and training to protect health care workers.
Safeguards at facilities and offices will play an important role in continuing the fight against COVID-19. Therefore, facilities and offices resuming services should take additional steps to protect the workforce and patients being served.
Health Care Staff
Facilities and offices shall establish a prioritization policy for providing care and scheduling. Extended hours should be considered to limit the number of patients in an office at any given time. Facilities and offices should also consider scheduling special or reserved hours for elderly or immunocompromised patients, to minimize the risk of infection to vulnerable patients.
Clinical prioritization should consider clinical impacts of treatment delay and the current surge status of the health care infrastructure in a community. When considering community surge status, consideration should be given to capacity across the continuum of care. Consider additional guidance, including Joint Statement, California Medical Association and American Academy of Pediatrics guidance [reference #1,5,6] on care prioritization, scheduling, and outpatient guidelines.
Outpatient Visit Guidelines
Priority scheduling should consider**:
**Telehealth/telephonic modality should be used for all appropriate patients and conditions.
With respect to dental services, the California Department of Public Health will update the current guidance regarding the prioritization and delivery of following non-urgent dental services:
Hospital and Outpatient Surgery Guidelines
Priority scheduling should consider principles and considerations from the Joint Statement released by the American Hospital Association (AHA), American College of Surgeons (ACS), American Society of Anesthesiologists (ASA) and Association of periOperative Registered Nurses (AORN) providing key principles and considerations. All facilities should consider opening in phases to allow for any necessary staff training or adjustments to new policies.
Prioritization scheduling should consider:
Skilled Nursing Facilities (SNF) Guidelines
Priority for SNF should focus on admission and protecting existing patients and new patients from the spread of COVID-19.
Scheduling should consider:
The health care workforce and staff are essential to resuming the delivery of deferred and preventive health care services. All facilities and offices should be aware of the impact COVID-19 has had on many health care workers including fatigue and the impact of stress and should ensure they have an adequate workforce available prior to resuming services and that they provide needed resources to support health care workers.
Workforce considerations should take into account ancillary supports and downstream providers, such as potentially necessary referrals to SNFs.
Hospitals are encouraged to consider the need to take additional precautions to protect against the spread of COVID-19.
Skilled Nursing Facilities (SNF) have had higher rates of COVID-19 cases and extra precautions will continue to be necessary when considering placement. Special considerations should be considered to protect high risk patients residing in SNFs.
Additional materials are provided here to support the health care systems in resuming deferred and preventive services during this time.