For Physicians

Recommended Best Practices

Ebola

If you are a healthcare professional going to an affected country to assist with outbreak control, or you would like specific guidance, consult CDC guidance for healthcare workers in Africa and in U.S. healthcare facilities and follow all advice above.

Print this CDC poster for staff: Sequence for Removing Personal Protection Equipment (PPE)

Testing & Diagnosis

If a person has the early symptoms of Ebola and there is reason to believe that EVD is a possibility (for example, the patient recently returned from travel to a region with an Ebola outbreak, and/or had close contact with an Ebola patient), then the following procedures should be followed:

Treatment

Ebola does not have a known, proven treatment. Standard care for EVD patients is limited to treating the symptoms as they appear and supportive care by trained healthcare professionals. This includes balancing fluids and electrolytes, maintaining oxygen and blood pressure, and treatment for any complicating infections. Treatments are in development by several companies, but are not are not widely available because they have not gone through the standard FDA approval process, which involves important tests for safety and effectiveness. During this current outbreak, the FDA has advised consumers to be aware of products sold online claiming to prevent or treat the Ebola virus.More

Timely medical care for those with Ebola symptoms is important. If a person develops symptoms of EVD and has recently traveled to one of the affected countries or has had contact with an EVD patient, the person should call a doctor immediately and report their symptoms and any risk factors, especially recent travel to one of the affected countries. More

Closing Practices

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

  • Try to resolve open patient cases;
  • Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);
  • Send a letter to patients that have been seen within the past year notifying them of the practice closure;
  • Notify the Rhode Island Medical Society and the Rhode Island Board of Medical Licensure and Discipline of location of medical records;
  • Create a way for patients to get their medical records for at least the next 5 years; (Though a fee can be charged for copying, the transfer of the record cannot be delayed due to lack of payment.)
  • Notify your malpractice carrier and make sure you have adequate coverage after you have stopped working.

Community Health Network Programs

All programs complement the clinical care of providers. By the end of the program, patients will have learned how to set goals to improve their health and lifestyle, manage their symptoms and medication, work with their health care team, talk with family and doctors, relax, eat well and handle difficult emotions. By gaining these skills, patients will become activated and engaged in their care. Healthcare providers will receive feedback on the status of any patient referrals.

  • Healthcare providers can set up an in-person academic detailing with Community Health Network staff to learn about resources that give your patients tools to take control of their health.
  • Refer your patients to a specific Community Health Network Program

Continuity of Care

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

  • Try to resolve open patient cases;
  • Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);
  • Send a letter to patients that have been seen within the past year notifying them of the practice closure;
  • Notify the Rhode Island Medical Society and the Rhode Island Board of Medical Licensure and Discipline of location of medical records;
  • Create a way for patients to get their medical records for at least the next 5 years; (Though a fee can be charged for copying, the transfer of the record cannot be delayed due to lack of payment.)
  • Notify your malpractice carrier and make sure you have adequate coverage after you have stopped working.

Infectious Disease Reporting

Immunization

The Rhode Island State-Supplied Vaccine program provides vaccine to healthcare providers to immunize people of all ages. A table with details about these vaccines, including their age indications, is available for healthcare providers.

Additionally, a series of immunization requirements are in place in Rhode Island to ensure that healthcare providers are properly immunized.

What you should do

Enroll in the State-Supplied Vaccine Program

Healthcare providers can enroll in the program to order vaccine for both pediatric and adult patients. Enrollment must be completed online annually and healthcare providers must agree to the terms and conditions of the program.

Know about requirements

Providers who participate in the State-Supplied Vaccine Program must agree to the program's terms and conditions and adhere to certain requirements for ordering, storing, and reporting on vaccines. (See Resource Manual below.)

Before administering any vaccine, healthcare providers must give the current Vaccine Information Statement to patients (or their parents or guardians). This must be documented in the patient's medical record.

Know about patient eligibility

Influenza vaccine

State-supplied influenza vaccine can be provided to all children (younger than 19 years of age). It can also be provided to all adult Rhode Island residents. For Medicare Fee-For-Service patients, healthcare providers can either:

  • Order influenza vaccine for their Medicare Fee-For-Service patients privately, or
  • Order and reimburse the Department of Health for the purchase of influenza vaccine for Medicare Fee-For-Service patients.

Medicare Fee-For-Service patients are patients with straight Medicare or Medicare Part B. This policy does not apply to individuals with a Medicare Advantage plan (such as HMO or PPO). (more)

See below for a Fluzone High-Dose influenza vaccine recommenation for patients who are 65 years of age and older.

Non-influenza vaccine

Non-influenza state-supplied vaccine can be provided to all children (younger than 19 years of age). Adult, insured Rhode Island residents and adults who are non-Rhode Island residents but who are covered by a Rhode Island employer’s health plan are also eligible for non-influenza state-supplied vaccine if they are:

  • 19 to 26 years of age, or
  • At high risk, regardless of age.

Adults who are not in one of these categories can be vaccinated as follows:

Patient type Where/how to vaccinate
Uninsured but able to pay Privately-purchased vaccine, St. Joseph Center for Health and Human Services, or at a pharmacy
Uninsured and unable to pay Patient Assistance Program sites and St. Joseph Center for Health and Human Services
Insured, but not through a Rhode Island employer Privately-purchased vaccine or at a pharmacy
Covered by Medicare Fee-For-Service SSV, but the practice must reimburse the state and coverage and reimbursement by CMS are limited (no Tdap for Medicare Part D)

Medical Orders for Life Sustaining Treatment (MOLST)

Medical Orders for Life Sustaining Treatment (MOLST) are instructions to follow a terminally ill patient’s wishes regarding resuscitation, feeding tubes and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions or a COMFORT ONE bracelet. more

A physician, registered nurse practitioner, advanced practice registered nurse or physician assistant who is authorized by the patient is authorized to sign Medical Orders for Life Sustaining Treatment.

  • Treat a patient in accordance with the patient's MOLST form, even if the healthcare provider who signed the MOLST order is not on staff at a facility.
  • Ensure a patient's Medical Orders for Life Sustaining Treatment are transferred with the patient if he/she is transferred to another healthcare provider.
  • If a new terminally ill patient comes under your care, you should ask about the existence of a MOLST form from the patient and/or the facility that is transferring the patient.
  • Review the Medical Orders for Life Sustaining Treatment on admission and ensure that the orders reflect the patient’s current wishes.
  • If the terminally ill patient does not have Medical Orders for Life Sustaining Treatment, you should offer them the opportunity to complete a form on admission to a nursing home, assisted living facility, home health agency, hospice program, kidney dialysis center, or hospital.
  • Document if a terminally ill patient does not file Medical Orders for Life Sustaining Treatment and explain the consequences of making no decision to the patient or their recognized healthcare decision maker. If there are no limitations on care, except as otherwise provided by law, cardiopulmonary resuscitation will be attempted and other treatments will be given. If a choice regarding cardiopulmonary resuscitation (CPR) is not made, cardiopulmonary resuscitation will be attempted using all available treatment options.
  • Void the Medical Orders for Life Sustaining Treatment if requested by your patient. To do this draw a diagonal line through the sheet, write “VOID” in large letters across the page, and sign and date below the line. Keep the voided MOLST form in the patient’s active or archived medical record, as appropriate.
  • Follow the most recent version of the Medical Orders for Life Sustaining Treatment if more than one form is found in the medical records.

Medical Records & Meaningful use

What Medical Practices Should Do

Store patient’s medical records for at least five years after the most recent patient encounter, regardless of whether the patient is alive or dead. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. more

Provide copies when requested. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. Records should be provided within 30 days.

Make sure that records are still available if the practice is closed.

Use Electronic Health Records which provide better way to see long term medical issues and track trends among groups of people. Healthcare providers who accept medicaid or medicare must meet "meaningful use" standards. more

Safe Opioid Prescribing

When prescribing opioid medications for patients, it is important that both the healthcare provider and the patient be aware of their responsibilities in prescribing and using these medications. An opioid treatment agreement between patient and provider will clarify expectations.

Definitions

  • Acute Pain- expected duration less than 5 days
  • Episodic/Procedural pain (varies depending on procedure, generally less than 30 days, after 30 days treat like chronic pain)
  • Chronic pain – duration of pain more than 30 days

What Healthcare Prescribers Should Do

Take a Medical History and Physical Examination: This includes an assessment of the pain, physical and psychological function, substance abuse history, assessment of underlying or coexisting diseases or conditions, and should also include the presence of a recognized medical indication for the use of a controlled substance.

Make a Treatment Plan : The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. The prescriber should tailor drug therapy to the individual medical needs of each patient. Several treatment modalities or a rehabilitation program may be necessary if the pain has differing etiologies or is associated with physical and psychosocial impairment.

Prescribe Proportionately: Only prescribe the amount of pain medicine reasonably expected to be needed. If you expect 3 days of severe pain prescribe only 3 days worth of medication. Acute Pain (< 5days) can often be managed without opioids.

Start an Opioid trial: Advise your patient to try the medication for a specified period of time and re-assess. Agree that if are not making reasonable progress, to consider stopping and trying a different approach.

Obtain Informed Consent : The prescriber should discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative. This discussion should be documented and signed by the patient, guardian or authorized representative. sample

Enter Into a Prescriber-Patient Agreement : The agreement will help you and your patient share information about medications and comply with controlled substance regulations.

Co-prescribe Naloxone : If your patient is at-risk for overdose.

Monitor your patients opioid utilization : Use the Prescription Monitoring Program before each appointment. Enroll Login Additionally, it is important to conduct random urine drug screens as well as have patients bring back pill bottles to monitor supply remaining.

Periodically Review Treatment : The prescriber should periodically review the course of opioid treatment of the patient and any new information about the etiology of the pain. Continuation or modification of opioid therapy depends on the prescriber's evaluation of progress toward treatment objectives. If the patient has not improved, the prescriber should assess the appropriateness of continued opioid treatment or trial of other modalities.

Make Consultations : The prescriber should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. In addition, prescribers should give special attention to those pain patients who are at risk for misusing their medications including those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse requires extra care, monitoring, documentation and consultation with addiction medicine specialists, and may entail the use of agreements between the provider and the patient that specify the rules for medication use and consequences for misuse.

Keep Accurate Records : The prescriber should keep accurate and complete records according to items 1-5 above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, agreements with the patient, and periodic reviews.

Be Compliant with Controlled Substances Laws & Regulations : To prescribe controlled substances, the prescriber must be licensed appropriately in Rhode Island, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. Physicians Manual of the U.S. Drug Enforcement Administration.

Addiction is a disease, chronic and relapsing. Patients with any chronic disease deserve appropriate treatment. There are many places to find treatment for addiction and substance abuse. partial list.

Continuing Education Courses

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Provider News

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07/15/2014 16:48 EDT
The Rhode Island Department of Health and Rutgers Global Tuberculosis Institute have opened registration for this continuing education conference on tuberculosis (TB) epidemiology, contact investigations, infection control, diagnosis, and treatment. The event is scheduled for Tuesday, September 23, 2014 (1 p.m - 8:30 p.m) at the Providence Marriott Downtown, Providence, RI. Continuing education credits are available for physicians and nurses. See complete brochure in the adjoining link for details.To register, visit http://www.eventbrite.com/e/rhode-island-tb-update-tickets-11793684227. For assistance, send an email to Rajita Bhavaraju at bhavarrr@rutgers.edu.
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Infectious Disease News

RSS
08/28/2014 17:32 EDT
The Centers for Disease Control and Prevention (CDC) is working with other U.S. government agencies, the World Health Organization, and other domestic and international partners in an international response to the current Ebola outbreak in West Africa. This document summarizes key messages about the outbreak and the response. It will be updated as new information becomes available and distributed regularly. Please share the document with others as appropriate.
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Immunization News

RSS
08/05/2014 09:16 EDT
HEALTH has updated its immunization regulations for preschools, schools, colleges, and universities.
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Public Health Grand Rounds

Held sessions held jointly with the Warren Alpert Medical School, can help you meet your continuing educations requirements.