Comments from our Chief Medical Officer, Dr. Puckett, regarding COVID-19

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Tuesday September 8, 2020

COVID-19 Comments with Dr. Puckett: Community Level and Change in Level

First, I must be clear that the following comments are my own and while I do have interaction with R-III Administration, the following represents my opinion only and I am not writing on behalf of anyone other than myself.

The COVID dashboard (available at cfmcares.com/covid) was established as a way for all of us to have an idea where cases are and what they are doing in our community, both from a perspective of disease burden and spread (number of new cases) and morbidity, severity, (number of hospitalizations).  Today the number of new cases reached Level 3 for the first time.  We remain at a Level 0 for hospitalizations.   From a physician’s perspective, we are seeing spread and we need to be ever vigilant to do what we can to limit the spread of the virus.  The good news remains that those who are getting the virus are younger and healthy and we have seen little complications, and thank God, no deaths.  To me this indicates we are finding  a new normal.  We are seeing increased spread as we move into a new normal, but we have been successful protecting those most vulnerable in our community, our elderly.

When we set up our plan to be as objective and real-time as possible, we used the Harvard guidelines for the number of new cases and number of hospitalizations for each level.  These guidelines are meant to help guide communities but are not end all recommendations and require correlation with what is happening at the local community.  When we set up the plan to look at both numbers, and average or balance them, it was simply an objective way to look at both spread and severity.

As the school administration looks to adjust the Community Level, there are many things that are taken into account.  Last week, strictly from the number of new cases and hospitalizations, using our process of averaging the two score, we could have been at a Level 1.  But the last 3 days in the review period showed an uptick in number of cases and appropriately so (in my opinion) the decision was made to remain at Level 2.  As the average score sits today, we would remain at Level 2.  This points to the importance to take the overall picture into consideration when reviewing a pivot from level to level.

Now that we are at Level 3 for new cases, some would ask, does no hospitalizations really offset this level of spread.  I think there are more to consider than just this.  Here are a few of the additional facts taken into consideration.  1) More than half of the new cases in the last 2 weeks are from Higher Education.  While not entirely exempt from community interaction, the risk of spread is minimized by their already collective culture on campus.  Most meaningful interactions are happening on campus and not in the greater community.  2) Several of the other cases are outside of the R-III district.  Again, while they may have some interaction with our community, that is minimized.  3) While there have been positive cases identified within the R-III student population, these cases have originated from exposure outside of school.  At this point, with all the precautions in place, we have not seen spread occurring within the district.  All of the students placed into quarantine due to a possible exposure at school have remained COVID free.

Kirksville R-III continues to work to balance the data as well as what is happening in our community.  The vast majority (85.5 percent) of R-III parents favor on campus education.  I hope this continues to be the safe option, but time will tell.  Today, I support the R-III efforts.  The work they have done to place students in groups that don’t mix has proven very powerful when contact tracing is done.  There is still so much we don’t know, but I am confident that R-III Administration will work to balance the safety regarding COVID with the need for education and social interaction.

 

Sunday August 23, 2020

COVID-19 Comments with Dr. Puckett: What if my child is exposed to COVID-19 at School?

While much effort has been put in place to prevent any infection and spread, it is important to understand what will happen if you child is found to have been potentially exposed to COVID-19.

What is the definition of Exposure?
Current guidelines dictate that any exposure for 15 continuous minutes or more within 6 feet is considered exposure. While masks may help prevent transmission, their use does not impact the definition of exposure. Anyone who meets this criteria should be quarantined to reduce the risk of viral spread.

How will I know if my child is exposed?
As soon as a positive case is identified, contact tracing will begin immediately. The health department is responsible for all contact tracing for a positive case within the community. In Kirksville R-III, each building has identified and trained multiple contact tracers. They completed training from John’s Hopkins on contact tracing. The school staff will use all resources available to track the child or staff member thru their school day. Those who came into contact with the known positive will be recorded and reported to the health department. A determination will be made as to who meets the criteria for exposure and all students and staff who meet the criteria will be immediately notified and removed for quarantine.

​What if my child was in the same classroom but not recommended for quarantine?
Only those students or staff who were identified as exposed will be notified and placed in quarantine. The guidelines and data do not recommend that any other action, other than ongoing due diligence with symptom monitoring etc., be done with those who do not meet the quarantine guidelines.

What if my child has been in contact with someone who was in contact with a known positive?
If you are have had contact, even if that exposure is more than 15 minutes within 6 feet, with someone who has been placed on quarantine but is not yet symptomatic or known positive, the guidelines and data do not recommend that any other action, other than ongoing due diligence with symptom monitoring etc. be done. If person A is known positive, and had exposure with person B who is without symptoms, person B would be placed in quarantine for 14 days. If person C had exposure with person B, until person B becomes symptomatic/positive, person C has no restrictions.

What if a staff member is found to be positive COVID?
The same rules apply. Anyone who was within 6 feet for 15 minutes or more would be placed in quarantine. If that staff member had no prolonged exposure, it is possible that there would be no one who meets the criteria to quarantine. Anyone with even brief interaction should monitor closely for symptoms and take action if they present.

If there is a positive COVID case in my child’s classroom, will I be made aware?
Schools and other entities must be careful to follow all rules related to protected health information. Since the public health recommendations call for no further action for those who are not classified as exposed (Persons C in the above example), others would not be made aware of the positive case. This is not a district policy but is dictated by Federal and State privacy laws.

​CFM continues to offer COVID-19 care and testing at all our locations. If you feel you might need COVID-19 testing, please contact any of our locations or text the COVID-19 Hotline at 660-620-8237 and we will get back in touch with you.

The CARES Center (Care at R-III for Every Student) provides on-campus care for students and staff of the Kirksville R-3 School District and is available Mon-Fri from 7:30-4:30. The CARES center offers preventative and acute care, and is available to assist in COVID-19 management and testing. Contact the CARES Center Direct at 660-956-7011.

Saturday August 22, 2020

COVID-19 Comments with Dr. Puckett: What to do with my Sick Kid

Kids get sick. It is a well known phenomenon that when children return to school, we see increase in symptoms that can include everything from the common cold to strep throat, and in a few short months influenza will come into play. What are the guidelines for managing symptomatic children? What should I do if my child is sick? I hope to help make sense of some general guidelines. Most importantly, if your child is sick, do not send them to school. All parents need to have plans in place for what to do if their child becomes sick at school and needs removed from the school.

Guidelines from the CDC, expanded and clarified by Washington University, have given fairly clear guidance to schools and other community groups that interact with children regularly.

Chronic Symptoms that could look like COVID:
If your child has allergies and has long standing congestion and runny nose that is unchanged and has been present without any new features, there is no reason to be concerned. This is true for other longstanding chronic conditions that could look like COVID. These symptoms should be monitored and if there is any change, new symptom, or worsening then action may be called for as below. The presence of chronic, stable symptoms should be closely monitored but does not exclude the child from being present at school.

Child has 1 new low risk symptom and no known exposure:
If your child has developed a symptom that may be consistent with COVID, but that symptom is isolated and not one of the MAJOR symptoms (Cough, difficulty breathing, loss of taste/smell) and they have had no known COVID exposure and they are stable and not worsening, then they can be observed at home and my return to school 24 hours after the symptoms has resolved. If the one symptom progresses, fails to improve, or if they gain other symptoms on the COVID spectrum, then they should consider seeing a healthcare provider and consider COVID testing.

Child has 2 new low risk symptoms or 1 high risk symptom (cough, difficulty breathing, loss of taste/smell) and no exposure:
It is recommended that these children be evaluated by a healthcare provider. If after evaluation, these children have been found to have another condition or very low likelihood of COVID, then the student should not return to school until afebrile (without medication use) for 24 hours and with symptom improvement. If another condition is not identified, COVID testing should be performed. If that COVID test is negative, then they should not return to school until afebrile (without medication use) for 24 hours and with symptom improvement. If the student is found to be COVID positive, then the student would be immediately isolated and could not return to school until they are afebrile without medication for 24 hours, symptoms have improved, and they are released from quarantine (at least 10 days from diagnosis). Of course a positive diagnosis will result in contact tracing by school and public health officials. More on this in a future post.

What if I don’t want my child to have a COVID test:
If your child meets the above criteria for testing and you decline to get tested, then the child should be treated as if they were positive and should be removed from school, placed in Isolation for 10 days from symptom onset and before release, be 24 hours afebrile (without medication) and with symptom improvement.

What about the cost associated with the above care?
The above guidelines will result in more children being seen that might have occurred in previous years. If as a part of the visit, COVID is considered or discussed, and if proper billing practices are undertaken, the visit should be without out of pocket expense(If you have insurance). COVID testing being completed at CFM is currently being offered without out of pocket cost to the patient in most situations. Please see my previous post that examines this issue more in depth. We do not want cost to be a deterrent from evaluation and testing regarding potential COVID. As a community, we all have to work together to reduce the spread of COVID.

CFM continues to offer COVID-19 care and testing at all our locations. If you feel you might need COVID-19 testing, please contact any of our locations or text the COVID-19 Hotline at 660-620-8237 and we will get back in touch with you.

The CARES Center (Care at R-III for Every Student) provides on-campus care for students and staff of the Kirksville R-3 School District and is available Mon-Fri from 7:30-4:30. The CARES center offers preventative and acute care, and is available to assist in COVID-19 management and testing. Contact the CARES Center Direct at 660-956-7011.

Friday August 21, 2020

COVID-19 Comments with Dr. Puckett: Cost of COVID Testing and Care

There have been lots of questions about the cost of COVID-19 testing and the cost of care surrounding the virus. This has been just one more component of the ever changing COVID-19 landscape. The following are general statements, and do not guarantee coverage but are as accurate as possible and current as of 8/21/20. I will do my best to keep the community updated as things change.

COVID-19 Testing (for acute illness):
Currently CFM has resources in place to insure that COVID-19 testing is provided to patient with no out of pocket expense. For insured patients (Medicare, Medicaid, Private Insurance etc), when proper billing processes are followed and medical necessity is proven and an order has been generated, the test should be covered at 100 percent. This is true regardless of deductible etc. It is treated like a preventative medicine item and is paid outside. This is in part due to requirements set on the insurance companies as a part of the recent COVID Legislation. For those without insurance, we have means to bill the tests to the federal government. If someone wanted a test without medical necessity they might be responsible. It is our job to help determine that medical necessity and if we order a COVID test, it is because it is medically necessary and therefore should be covered.

COVID-19 Antibody Testing (to look for previous infection to aid in Plasma Donation):
In cooperation with one of our reference labs, Lab Corp, we are able to offer, for at least the next 3 months, free testing for any adult who is eligible to and willing to donate plasma to aid in the treatment of COVID positive patients. If you are interested in this, call any of our CFM offices to discuss with our providers.

Office Visits or Other Care for COVID related needs:
In order to obtain an order for a COVID test or to receive care for COVID or similar symptoms, an office visit (virtual or in person) is necessary. When an offive visit has a primary complaint that involves COVID, even if it turns out to be something else (within reason of course) then this care can be billed in a way that will also result in no out of pocket expense to insured patients (Medicare, Medicaid, Private Insurance etc). For those patients who do not have insurance there is no way for us to bill this care to the Federal Government. CFM does offer same day payment discounts for those without insurance, and for those that qualify, we offer a Sliding Scale Program that may reduce this type of care by a 100 percent discount. Learn more about our sliding scale program and apply at: https://cfmcares.com/patient-resources/patient-forms

CFM continues to offer COVID-19 care and testing at all our locations. If you feel you might need COVID-19 testing, please contact any of our locations or text the COVID-19 Hotline at 660-620-8237 and we will get back in touch with you.

The CARES Center (Care at R-III for Every Student) provides on-campus care for students and staff of the Kirksville R-3 School District and is available Mon-Fri from 7:30-4:30. The CARES center offers preventative and acute care, and is available to assist in COVID-19 management and testing. Contact the CARES Center Direct at 660-956-7011.

Thursday August, 20, 2020

COVID-19 Update from our Chief Medical Officer regarding Return to Learn:

Every day is a new day. One thing we have learned to expect is an ever changing landscape when it comes to COVID-19. What we know today is vastly different and more refined than just a few short months ago when this all began. I have had the great pleasure and opportunity to be a part of the process that the Kirksville R-III District has taken to examine and balance all the science regarding COVID-19 and the re-opening of schools, the data from our community on where and how we educate, socialize, and aid in the development of the most important asset in our community, our children. ​I can assure you hundreds of hours and many voices, including the collected survey data from district parents, review of the science literature, examination of guidelines and suggested protocols and procedures have all been combed over and over. As new information has become available, it has been examined and plans adjusted accordingly.

There is much uncertainty about returning to school. There are a few things I know from the data. First, this is a bit of an experiment that will require us to be vigilant, to watch the data, to learn from the experiences of ourselves and others, and will require us all to be patient and understanding with one another. None of us can see with any certainty what will face us in the future. The players in school administration, faculty and staff, community and health leaders, public health leaders, and many others have proven themselves, from my perspective, to have the best in mind for each of our students in the district.

For those students and parents who, for a variety of legitimate reasons, feel that onsite school is not best for them, the district has established strong online platforms to deliver the best at home education possible. Using the best mix of local and outside the district resources, an at home education is available for those who choose it. For those who see the benefits of in person education, the district has developed a detailed process of looking at local and regional data to develop a strategy to mitigate risks and yet maximize an onsite educational offering. As a physician, I join my professional organizations in recognizing the value of onsite education for many of our students and commend the district for developing onsite opportunities. The district has elected to follow the proven Harvard pandemic classification systemic to examine where our community is at with viral spread and morbidity.

The two primary factors that will be examined will be 7 day running averages of the a) number of new diagnosis in the county and b) the number of hospitalizations reported by the county. In cooperation with local health groups, hospitals, and the county health department, we have access to this data near real-time. We have been tracking this data since the beginning of May, watching how it changes, trends, and what has impact on these numbers. It has given me confidence that this two step evaluation gives us good guidance and has been vetted as reliable. We have created a Community COVID Dashboard at http://www.cfmcares.com/COVID. We will update our community COMBINED Risk level (based on number of new cases and number of hospitalizations). The level listed corresponds directly with district Levels 0-3 which will guide school processes and procedures. This is not a CFM generated process or number. It comes from a wide range of community players. We invite other entities within the community to use this objective Harvard based level of pandemic impact to guide your operations. If I can be of assistance with answering questions or providing further insight to your business, organization etc, please let me know. Please feel free to link or share this Dashboard. We want this to be of value and service to our entire community and feel it is evidence based and valuable. It is the community plan to update the level every two weeks, unless something drastic occurs that requires an immediate adjustment. Our current Level 2 will be in effect until Monday September 7th. We anticipate a decision to pivot, if warranted, to be made the week prior, to allow for preparation of the new level the following week.

At Complete Family Medicine, we continue to be committed to our community as we navigate forward thru the COVID pandemic. We have performed over 2500 Covid tests at our drive thru testing sites. Thanks to the help of the Adair County Health Department, we now have onsite access to rapid molecular testing providing a result same day. As school opens we will continue to serve. As of August 1, our CARES Center (Care at R-III for Every Student) located on the Kirksville R-III District reopened to provide acute and chronic care needs for students, faculty, and staff. While we are only one of many valuable healthcare resources in our community, we provide onsite and easy access to quality care, and will continue to work with district officials to have a positive impact on evaluation, management and testing regarding COVID and other acute illnesses. Our CARES center is well integrated into our overall Complete Family Medicine operations making for seamless management for those who are on campus and need services, or those off campus or even those needing services when our CARES Center is closed. Our Urgent Care Centers continue to serve 8am to 8pm EVERY DAY of the year.

I am confident that, when we work together, we will navigate thru this challenging time. One thing the makes this certain in my mind is the motivation I have seen in district administration, staff, faculty and other Return to Learn coalition members. Their focus is clear and simple, what is best for our students. While opinions will vary, and the lack of an absolute clear ‘right answer’ will continue, we can support one another, remain respectful, and be motivated by doing what we feel is in the best interest of the children of our community. I feel that information and dialogue is powerful in a challenging time, and I am committing to continue to provide dialogue at least from the medical perspective. If you have questions, a topic, something you feel a post would be helpful to address from a medical perspective, questions about testing, the services offered by our CARES center etc, I openly invite you to reach out to me here or email me at CARES@cfmcares.com. Together, we got this!

Justin D. Puckett, DO, FAAFP, FACOFP, FOMA
Chief Medical Officer, Complete Family Medicine, a service of Hannibal Regional