To Work or Not to Work

NEW REQUIREMENTS FOR NON-URGENT HEALTH CARE IN WASHINGTON DECONSTRUCTED
By Julie Johnson, LMT
December 2020

As Washington State Massage Therapists grapple with a global pandemic, they are finding that to work or not to work is not a binary decision that can be applied equally to all massage therapists across the state. Regionality has a great influence as counties see major COVID-19 outbreaks, while others do not.  Availability of Personal Protection Equipment (PPE) is also a major consideration. Outside of those concerns, our regulatory body has given us the freedom to exercise our clinical judgement to make the best decision for ourselves and our clients/patients, assuming that we adhere to some strict rules of engagement. This article is designed to assist WA massage therapists to make those critical decisions about whether to go back to work, whether it’s time to temporary suspend work, which cases to accept depending on the status of the pandemic in their region or if working as a massage therapist during pandemic is the right decision for you.

First and foremost, one primary clarification needs to be understood by all Licensed Massage Therapists in Washington State and their employers. 

All Massage Therapists are “Health Care Workers.” They fall under the guidance and authority of the WA Department of Health (DOH), specifically the Health Systems Quality Assurance (HSQA) Division and the Board of Massage (BOM).

While massage therapists may work in spas, salons and gyms where hairdressers, estheticians, manicurists and athletic trainers are employed, we are not regulated the same. We have different oversight, regardless of our employer or environment/facility where we maintain a practice. The employer is responsible for maintaining best practices for all employees. If they employ both hairdressers and massage therapists, the employer must accommodate all oversight regulations for both licensed professions. If they contract with or rent to massage therapists, it is the massage therapist’s responsibility to uphold best practices in their work environment and provide necessary supplies unless they have negotiated other terms with the employer or landlord. In either situation, it is the massage therapist’s sole or shared responsibility to uphold best health care practices in order to keep their license with the DOH/BOM in good standing.

Throughout this article, Governor Inslee’s Proclamation 20-24.2, Requirements for Non-Urgent Medical and Dental Procedures, will guide the critical process of deciding if massage therapists should be in practice.  This proclamation goes into effect December 3rd, 2020 and amends previous versions of Proclamation 20-24. It provides further clarification as new information about the COVID-19 virus is discovered and the evolving impact on our health care system changes with the increase in cases in Washington state. Italicized blue text contains direct language from the proclamation that has been edited down and reorganized to remove wording irrelevant to the field of Massage Practitioners, but it’s highly encouraged that all health care practitioners review the original Proclamation in its entirety. 

Urgent vs. Non-Urgent

"Until there is a widely available effective vaccine or herd immunity…the following must be met by health care practices and practitioners in order to provide non-urgent services. If a health care facility, practice or practitioner cannot or does not comply with any of these requirements, non-urgent services must be reduced or stopped until compliance is achieved and in accordance with the direction, order, requirements, or guidance issued by the Department of Health (DOH) or Department of Labor & Industries (L&I).

- Exercise clinical judgment to determine the need to deliver a health care in the context of the broader health care of patients and communities and in the context of the pandemic, and within the parameters of operation provided by the health care practice or practitioner setting in which they are providing services.

- Continuously monitor the COVID-19 status in the communities they serve.

- Continuously monitor capacity in the health care system to ensure there is sufficient PPEto combat any potential surges of COVID-19.

- Continuously monitor the facility’s, practice’s, or practitioner’s supply of PPE and maintain sufficient access to PPE."

The three major requirements for working on non-urgent cases during this pandemic are:  exercising clinical judgement; monitoring the region and health care system for COVID-19 surges and; PPE supply.  These are the primary considerations we will explore in further detail through further clarification provided in Proclamation 20-24.2.

Clinical Judgement

"The decision to perform any procedure in health care facilities or offices should be weighed against the following criteria when considering potential harm to a patient’s health and well-being if care is delayed beyond 90 days:

- Expected advancement of disease process

- Possibility that delay results in more complex treatment

- Increased loss of function

- Continuing or worsening of significant or severe pain

- Deterioration of the patient’s condition or overall health

- Delay would be expected to result in a less-positive ultimate medical outcome

Exercise clinical judgment to determine the need to deliver a health care service, in the context of the broader health care needs of patients and communities and in the context of the pandemic, and within the parameters of operation provided by the health care practice or practitioner setting in which they are providing services."

Part of massage therapists’ responsibilities as soft tissue specialists is to assess each clients/patient not only for their specific concerns and/or complaints, but also their overall health to ensure safe and proper treatment. 

With these unprecedented times, there are several clinical judgement considerations to make before a massage therapist should enter the treatment room with a client/patient.

1. Is the massage therapist, the patient/client and those they live with healthy enough to risk working or receiving massage therapy during a pandemic? Underlying health issues that put the massage therapist, client/patients and/or household members at greater risk if COVID-19 is contracted are: age (65 or older); suppressed immune system; history of some respiratory conditions; history of some heart and/or circulatory conditions; obesity; cancer; certain blood disorders; kidney or liver disorders. Make sure you have a recent health history on file with current updates that make specific inquiries about these conditions. 
   
   

2. Both the massage therapist and the client/patient should avoid risky situations.  These situations could, but are not limited to air/bus/train travel, large gatherings, exposure of someone who is COVID-19 positive, etc. Exposure to any one of these situations requires quarantine for 14 days prior to working or receiving massage, regardless of testing results. 
    

3. If a patient/client has had COVID-19, there is building evidence that massage treatment should be delayed at least three months after a negative COVID test. This is regardless of initial severity of the COVID infection due to some symptomless secondary complications, like blood clots. (see current information from Ruth Werner) Blood clots are a major contraindication for many types of massage or manual therapies which can put our patient/clients lives at risk.
   
   

4. If you choose to work during a Crisis Care phase in your region, additional considerations need to be made. Patients/Clients that are receiving care during this phase should be emergent or will be harmed if treatment does not take place within three months. Make sure the patient/client is assessed by you to meet these criteria and document them carefully. It could be recommended to have a documented diagnosis from a physician, nurse practitioner, chiropractor, psychologist, etc. who concurs with your assessment of an emergent condition. 

Regional Considerations

"When making health system care capacity decisions, health care practices and practitioners must consider the level and trending of COVID-19 infections in the relevant geography, the availability of appropriate PPE and the surge capacity of the hospital/care setting.

Given the geographic diversity of Washington, the variability in COVID-19 disease burden within the state, and health care system capabilities and capacity, no uniform approach to expanding access to care is possible nor would any such approach be effective or wise. It is essential that health care system participants act with good judgment within the context of their patients’ needs, their environment, and their capabilities and capacity."

The Governor and Department of Health are giving every health care practitioner the freedom and ability to assess the COVID-19 impact in their own specific region/county. This is why some statewide directives do not always apply to health care workers and massage therapists. The recent proclamation from the Governor’s office “Stay Safe-Stay Healthy” Rollback of County by County Phased Reopening Responding to a COVID-19 Outbreak Surge 20-25.8 given on November 15, 2020, doesn’t directly apply to massage therapists, but may apply to others in their practice location. Health care practitioners need to follow what is outlined in Proclamation 20-24.2 that was made specifically for those in the health care field.

A tool for assessing your Local Health Jurisdiction (typically, your county) is the COVID-19 Risk Assessment Dashboard. This breaks down key metrics county-by-county for testing and hospitalizations for your local area. Many counties also have this information available on their own public health websites. Getting consistent and immediate data from these sources has been a challenge as the number of cases goes up in our state and testing increases. However, it remains our best resource to monitor the outbreak situation in our own regions. Assessing this data on a county level allows all health practitioners to have the flexibility to expand, contract or temporarily stop work based on the number of cases in their local area and the surge capacity available in their local hospitals. The primary number to pay attention to is the “percent of licensed beds occupied by patients.” This number tells us how many of our hospital beds are fully occupied in our county. If the occupancy percentage goes above 80%, allowing less than a 20% surge capacity in the hospitals in case there is a COVID-19 outbreak, that is the moment to seriously consider reducing care to emergent and certain types of elective care, which is defined in the next section. 

The Phases of Health Care

"Each health care practice or practitioner must develop an expansion and contraction care plan that should be operationalized based on the standards of care that are in effect in the health care facility, practice, or practitioner’s relevant geography as determined by that region’s regional healthcare coalition, as follows: 

- Conventional Care Phase – All appropriate clinical care can be provided.

- Contingency Care Phase – All appropriate clinical care can be provided so long as there is sufficient access to PPE and, for hospitals, surge capacity is at least 20%.

- Crisis Care Phase – All emergent and urgent care shall be provided; non-urgent care, the postponement of which for more than 90 days would, in the judgment of the clinician, cause harm."

There are two different “phase” systems being utilized by the state of Washington which has caused a great deal of confusion among massage therapists. One is a phased approach to reopening the state that individuals and businesses are to follow for their specific county. The second are the phases of health care that dictate our expansion or contraction of care based on our specific region. These phases are Conventional, Contingency and Crisis and they apply only to health care practitioners. Massage therapists should primarily follow the health care phases as they relate to their practices and whether or not they should continue to practice. 

As a sole practitioner or employer of massage therapists, there should be a plan in place for the type of services/care offered based on what phase of care the local health jurisdiction is in. Currently, all of Washington State left the “Conventional Care Phase” in March of 2020 and will not return to that phase until a vaccine, herd immunity or more effective treatment for COVID-19 is widely available. We received clarifying information in April 2020 from the Department of Health clearly classifying massage therapists as essential health care workers that could work on emergent cases if supplies of PPE were available. After Mid-May of 2020, we received clarifying information in the form of Proclamation 20-24.1 and most counties began to enter the “Contingency Care Phase” because necessary equipment and supplies were becoming available. 

Current trends at the time this article is being written (late-November 2020) and the release of an amended Proclamation is suggesting some regions may need to return to the “Crisis Care Phase” as the virus is quickly spreading and hospitalizations are on the rise in many Washington counties. At this time, most regions remain in the Contingency Care Phase. 

Personal Protection Equipment Availability

"The health care personal protective equipment (PPE) supply chain in Washington State has been severely disrupted by the significant increased use of such equipment worldwide, such that there are now shortages of this equipment for health care workers. To curtail the spread of the COVID-19 pandemic in Washington State and to protect our health care workers as they provide health care services, it is necessary to prohibit all medical facilities, practices and practitioners in Washington State from providing non-urgent health care unless specific procedures and criteria are met."

You must have access to PPE in order to work with your patients/clients. If it is unavailable and quantities are limited for those providing more critical health care, non-urgent health care is prohibited. Any care provided must meet the definitions of “emergent or urgent” under the Crisis Care Phase.  In order to monitor the availability of PPE in our state, visit the Department of Health website or your local health jurisdiction website (your county’s public health district).

The Washington State Massage Therapy Association (WSMTA) has put together a comprehensive document called Interim Guidance on Personal Protective Equipment (PPE) outlining what PPE should be used to keep yourself, your staff/co-workers and your patients/clients as safe as possible. The recommendations made in these documents were drawn from resources at the CDC, OSHA and from two professional associations that have similar physical proximity to their patients, The American Dental Association and the American Academy of Ophthalmology.

Best Practices, Cleaning, Sanitation and Other Considerations

There are several other considerations to be addressed by a massage therapist employer and practitioner that are outlined in Proclamation 20-24.2. The WSMTA has put together additional comprehensive documents on their website (mywsmta.org) called Return to Practice Introduction; Interim Guidance on Sanitation and Interim Guidance on Practice Guidelines, in addition to the guide on PPE. These documents make recommendations on best practices specifically for massage therapists during this pandemic. It is recommended that you start with the “Return to Practice Introduction” which provides a framework and discussion of the sources used to compile these recommendations.  

"Promptly offer and make available, either on-site or by directing to an external local testing location, testing to employees who have signs or symptoms consistent with COVID-19."

An amendment in Proclamation 20-24.2 discusses COVID-19 testing, which an employer must offer immediately if symptoms are present. In addition, it would be wise for a sole practitioner to be aware of testing sites available in their local region where tests can be administered quickly.  

Hard Decisions

I made a recent inquiry to Megan Maxey, the Program Manager from the Health Systems Quality Assurance with the Washington State Department of Health who works with the Board of Massage, on the topic of surge capacity and how it directly impacts massage therapists. Her reply, given on December 1st, 2020, was as follows:

“The Department isn’t able to provide interpretation of proclamation 20-24 as it’s issued directly by the Governor’s office. All healthcare providers must use their best judgement to meet the requirements detailed in that document as there isn’t a simple formula given there for yes/no decisions around providing care. The crux of the matter as it currently stands rests in the closing sections of the proclamation:

...It is essential that health care system participants act with good judgment within the context of their patients’ needs, their environment, and their capabilities and capacity.

I understand that this response may not be satisfying, nor simple, but I believe the intention was to allow for health care providers to act with their clinical best judgement as each decision to treat is individual to the patient’s circumstances.”

The hard, ethical questions are how best to go above and beyond the legal minimum in order to complete the higher level recommendations to do the best for our patients/clients, our overwhelmed front line health care providers in the hospitals and our communities. At what point we are doing enough? Even if we are not legally compelled by the government to stop working on non-urgent cases in our county when we enter a Crisis Care Phase, should we? If a massage therapist chooses to keep working on all cases and someone brings a complaint to the BOM or sues for an outbreak in their office, the burden of proof is on the massage therapist to say they exercised good clinical judgement to keep working. Professional judgement, i.e income, is not a consideration allowed in the Governor’s proclamation. Acting conservatively, documenting and strictly adhering to the rules around contracting and expanding care laid out for other health care workers may protect us and our patients/clients from contracting and spreading COVID-19, as well as reduce any liability or negligence claims that could be brought up in the future. 

Whether a massage therapist has an individual practice, is a contractor or an employee, it falls on the massage therapist to ensure that what is being practiced in a health care setting is meeting the standards set. If a massage therapist has concerns that best practices are not being exercised, bring it to the attention of an employer, landlord or co-worker for your safety and that of your patients/clients. If changes are not made, a massage therapist might need to make some hard, professional decisions about where they continue to work. Seek out the advice of mentors, find documentation that supports your concerns and claims of best practices and do all you can to stay healthy until we can happily return to a Conventional Care Phase in health care in the State of Washington. 

See additional supporting documentation from the DOH at “Massage Therapy Services under the Governor’s New Proclamation.”