Maintaining Regular Primary Care Practice in the COVID-19 Context

Last Updated: May 29, 2020

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The COVID-19 Resource Centre is intended for family physicians and primary care nurse practitioners in Ontario. It is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

Do things look different? We’ve reorganized our COVID-19 Resources so you can easily find what you’re looking for and use it in practice.

COVID-19: Clinical and Practical Guidance for Primary Care Providers
Use this tool to help provide the best possible COVID-19 care for your patients. It pulls together and tangibly interprets the latest recommendations surrounding COVID-19 including assessment and testing, management, provider mental health, infection prevention and more.

Ontario COVID-19 Assessment Centres
Access our up-to-date list of COVID-19 assessment centres across Ontario.

Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

Navigate through patient care in a world where COVID-19 is the “new normal.” Use this tool to provide day-to-day care in a familiar but different environment. From child mental health to opioid use disorder and other conditions, this interactive tool covers topics providers see with their patients every day while considering present-day obstacles due to COVID-19.

Check back daily for the latest updates.

Click on the sections below to get started:
Primary care operations in the COVID-19 context
Last reviewed: May 29, 2020
Last updated: May 26, 2020

Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

Consider letting your patients know that you are available by telephone or video to provide a variety of care, and if it’s needed you can provide certain in-person care provided the right precautions are taken. You can notify your patients of this through your outgoing office voicemail, on your website, or through email.

Delivering patient care virtually

In order to reduce community transmission during the COVID-19 pandemic and prevent the spread of the virus, family physicians and primary care nurse practitioners have been advised to practice virtually (MOH, March 13, 2020), when possible. To empower providers to do so, the national and provincial government have enacted temporary exemptions and have rolled out changes to the rules and regulations that govern the practice of medicine in Ontario.

The following virtual formats can be used to conduct your virtual patient encounter:
  • Telephone
  • Secure messaging (ONE Mail, DSG Secure, ProtonMail)
  • Provincial telemedicine platforms (e.g. Ontario Telemedicine Network)
  • EMR-integrated platforms (e.g. TELUS EMR Video Visits, VirtualClinic+ (Insig) – integrates to OSCAR, Medeo – integrated with Accuro EMR, Novari eVisit)
  • Standalone platforms created for medical care (e.g. VirtualCare, iTelemed, Adracare, Cloud DX, Doxy.me, InputHealth Collaborative Care Record, Livecare, MediSeen, OnCall Health, REACTS)
  • Other video calling platforms (e.g. Skype and Teams by Microsoft, Facetime by Apple, Zoom.us, Google Hangouts)
When deciding on the format of your virtual patient encounter, consider the following:
Frequently asked questions (FAQs)

You can safely use virtual care to:

  • Assess and treat mental health issues.
  • Assess and treat many skin problems (have patient submit photos in advance as resolution is much better than a high-quality video camera).
  • Assess and treat urinary, sinus and minor skin infections (pharyngitis too if you can arrange throat swabs).
  • Provide sexual health care, including screening and treatment for sexually transmitted infections, and hormonal/oral contraception.
  • Provide travel medicine.
  • Assess and treat conditions monitored with home devices and/or lab tests (e.g., hypertension, lipid management, thyroid conditions and some diabetes care; in-person consultations will still be needed for some exam elements).
  • Review lab, imaging and specialist reports.
  • Conduct any other assessments that do not require palpation or auscultation.

The technology required to conduct a virtual patient encounter is widely available and cost effective.

Hardware

For telephone calls, you may consider using earphones/headphones for better sound quality and to ensure patient privacy. For video visits, reliant internet connection, a video camera and a microphone is needed. To ensure optimal connection speed, use hardwired internet.  You can use speedtest.net to test the speed. Hit “Go” and anything above 10 Mbps will be ideal for video calls. Consider using earphones/headphones/headset for better sound quality and to ensure patient privacy. Consider using a secure USB drive if you cannot save and edit third-party forms through your electronic medical record (EMR) and you still need secure electronic storage. Consider securing it with a strong password.

For more information and recommended hardware see: Virtual Care Hardware Considerations (Kaplan, 2020).

Software

For telephone calls, no software is required.  If you are using a Voice over Internet Protocol (VoIP) phone application (such as RingCentral, FanGo) ensure that you have received patient consent (verbal is sufficient) to use the application for your patient encounter. If you’re new to video visits, the key decision is whether to use general videoconferencing tools (e.g. Skype and Teams by Microsoft, Facetime by Apple, Zoom.us and/or Google Hangouts) or software platforms designed specifically for health care (e.g.EMR-integrated platforms, VirtualCare, iTelemed, Adracare, etc.). For more information, see OntarioMD’s comprehensive overview of the different virtual care options.

There are advantages to each:

  • General videoconferencing is widely available, there are versions for every computer and mobile device, and the platforms are supported by large companies that provide reliable service and can handle sudden surges in use (e.g., during pandemics).
  • Health care specific platforms are designed for virtual visits meaning that they can be more secure, have less configuration complexity and may integrate into your EMR.

Please note, if you opt to use a general videoconferencing platform you may need to configure the platform settings to protect the patient’s privacy:

  • Disable all meeting recording options.
  • Ensure that only one patient can enter a meeting at a time and/or that no patient can enter without specific permission from you.

Additionally, unless you are using virtual care technologies where consent is handled at sign-up, you must ask patients for their consent (verbal is sufficient).

An EMR is not required to conduct a virtual patient encounter. Any direct-to-patient telephone, telemedicine and video calling platforms can be used without an EMR.

Please note, Unless you are using virtual care technologies where consent is handled at sign-up, you must ask patients for their consent (verbal is sufficient). Once you’ve completed your virtual encounter, document, as before, in the patient’s medical record.

If necessary, you can save patient forms and documents onto a secure USB.

Much like providing care in-person, the provider and patient need to have an arrangement to meet at the same time, even if the patient has to first enter a “virtual waiting room”.

Depending on what platform you are using, the virtual waiting room can take the form of waiting in the “lobby” of a virtual platform until the host invites the patient in or entering the room first and giving the provider some time to join into the same link.

If you are using OTN, there is a “virtual waiting room” functionality built in.

Be prepared for longer visits, at first, as you and your patients become accustomed with the new visit format.  Consider spacing your scheduled appointments out to include “buffer”/”overflow” time.  Alternatively, give the patient a window of time for their appointment (e.g. “I will call you between 2pm and 4pm”).  This gives you some flexibility and manages expectations of the patient.

When confirming a virtual visit, ensure all of the necessary appointment information has been provided to the patient.  This includes:

When and where the visit takes place

  • Example: “You are scheduled for an appointment with Dr. [First Name] [Last Name] on [date] at [time]. Please use this link to connect [Virtual meeting link].”

How to cancel the appointment

  • Example: “If you need to cancel your appointment, please email or call the clinic at [clinic information] with at least ___ hours in advance notice to avoid missed appointment fees.”

How to address technical issues

  • Let the patient know of some alternatives if technical issues arise.
  • Example: if you are using a videoconferencing software, let them know that you can call them at their telephone number to continue the visit or re-book by phone if technical issues do not resolve after 5 minutes.

Healthcare offices provide many visible cues that assure patients that they are in a professional office to see a medical professional. Most of those cues are absent in virtual care.

Key recommendations:

  • Place your workstation in a location that protects the patient exchange from being seen, overheard or interrupted by others. That includes ensuring that there is no visibility of your screen(s) through a window.
  • Consider using earphones/headphones to improve sound quality and also to protect your patient’s privacy.
  • Use a professional/neutral backdrop and good lighting.
  • Consider wearing a white coat.  While many doctors resist wearing white coats, research shows that patients of all ages prefer their doctors to wear white coats and it reinforces for them that you are a health professional.
  • Make extra effort to engage with the patient at all times and assure them that they have your full attention. This includes eye contact, body language and attentiveness.  Make sure to look at the camera and not your computer screen.
  • Remind your patients of what you will be doing during the course of the visit (e.g. note-taking, looking at their chart, etc). That way your patient knows that even when you take your eyes off of them or the screen, you are still listening.
  • Collect/create patient education texts and links to share after the encounter to replace what you can show to patients when you are seated in the same room.

No, you are not required to use OTN for your virtual patient encounter.

Any direct-to-patient telephone, telemedicine and video calling platforms can now be used.  Please note, unless you are using virtual care technologies where consent is handled at sign-up, you must ask patients for their consent.

Allocate the appropriate amount of time based on patient’s indicated ailments and needs when they scheduled the appointment as you would when providing in-person care. The time will also depend on whether it is a routine visit or a follow-up visit.

Be prepared for longer visits, at first, as you and your patient become accustomed with the new technology.   For patients that may struggle with technology, try to arrange support and be prepared to troubleshoot tech issues.  But, don’t spend too much time trying to fix connection problems.  You can always switch to simpler solutions, such as the phone, when difficulties arise.

Virtual care is not exclusive to encounters handled over the internet.  You can always use the telephone to conduct your encounter.

Androids: To block an Androids number from being displayed, before entering the phone number, enter *67, and then the patient’s phone number.  Alternatively, open  voice app and go into Settings, under “Calls” turn “Anonymous Caller ID” on.

iPhone: To block an iPhone number from being displayed, before entering the phone number, enter #31#, and then the patient’s phone number. Alternatively, go into your iPhone Settings, scroll down to Phone, and tap “off” on “Show My Caller ID”.

Landlines: For landlines, before entering the phone number, enter *67, and then the patient’s phone number.

Yes. The ministry has made a policy change allowing physicians to accept scanned copies of completed and signed Patient Enrolment and Consent to Release Personal Health Information (E/C) forms from patients electronically via email or photo transmission by cell phone.

An original patient signature on the form is not required provided that the patient’s signature is legible on the scanned copy or picture of the E/C form. Physicians should ensure patients have their correct email address when transmitting the E/C form electronically as the completed E/C form contains the patient’s personal information including their birth date and health card number. If electronic submission is not possible, completed forms can also be returned by mail to the physicians’ offices.

During your virtual patient encounter

A virtual patient encounter is the same as an in-person one with a few additional key elements.

Be prepared, technology may fail you

Anticipate that technology may fail you and have a backup prepared (e.g. phone). 

To ensure optimal connection speed, use hardwired internet.  If video is not working well, switch to audio only as you/the patient may not have the necessary bandwidth to support both audio and video on the virtual platform.

Be prepared for longer visits, at first, as you and your patient become accustomed with the new technology.   For patients that may struggle with technology, try to arrange support and be prepared to troubleshoot tech issues.  But, don’t spend too much time trying to fix connection problems.  You can always switch to simpler solutions, such as the phone, when difficulties arise. 

Establish the patient’s identity and location

When initiating your virtual encounter, establish the patient’s identity (e.g. name and DOB) and location (in case of an emergency).

Ensure that the physical locations of both you and the patient offers adequate privacy, where the patient can comfortably share confidential information and where you can assess the patient and provide advice.

Gain patient’s consent

Unless you are using virtual care technologies where consent from the patient is handled from the onset, during your first virtual care patient encounter, you must ask the patient for their consent. Once received, record that verbally expressed consent was obtained in the patient’s medical record.

OntarioMD and the OMA Legal team have prepared short paragraph statements and information to provide to patients to initiate a virtual care patient encounter, which has also been vetted by the CMPA.

Tips to keep in mind during the virtual encounter

  • Mute the microphone when you are not speaking.
  • Take brief pauses between sentences to allow patient to have time to voice any questions or concerns.

Document your virtual encounter

Regardless of the virtual format, the services provided must be documented in the patient’s medical record or the service is not eligible for payment.

After completing your virtual encounter

Send the patient any information they may need (prescriptions, lab and imaging requisitions, patient education, weblinks, etc). Consider using Wellx, secure messaging such as NE Mail, DSG Secure, ProtonMail.

New fee codes

To support of the government’s efforts to limit the spread of COVID-19 in Ontario, the Minister of Health has made an Order under the authority of subsection 45(2.1) of the Health Insurance Act (March 13, 2020) to temporarily list, as insured services, the provision of assessments of, or counselling to, insured persons by telephone or video, or advice and information to patient representatives by telephone or video, as well as a temporary sessional fee code.

Additionally, as part of Ontario’s continued efforts to stop the spread of COVID-19, the Ministry of Health (May 5, 2020), established temporary payment mechanisms to facilitate hospital and physician payments for medically necessary services provided to patients who are not currently insured under OHIP or another provincial plan.

These new fee codes are not limited to COVID-19 screening or COVID-19 patients and came into effect March 14, 2020.

Effective May 1, 2020, physicians can now submit claims for services provided on or after March 14, 2020 using the new fee codes for insured patients.  

Effective May 5, 2020, physicians can submit claims for services provided on or after March 21, 2020 using the new fee codes for uninsured patients. 

New fee codes for insured and uninsured patients

Scroll (left-right) for details
  • For care of insured patients
    K080

    Service provider: Family physician

    Fee: $23.75

    Service description: Minor assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis.

    View notes
  • For care of insured patients
    K081

    Service provider: Family physician

    Fee: $36.85

    Service description: Intermediate assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes. Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video, if the service lasts a minimum of 10 minutes.

    View notes
  • For care of insured patients
    K082

    Service provider: Family physician

    Fee: $67.75

    Service description: Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video per unit (unit means half hour or major part thereof).

    View notes
  • For care of uninsured patients
    K087

    Service provider: Community-based physician (e.g. family physician)

    Fee: $23.75

    Service description: Minor assessment of an uninsured patient provided in-person or by telephone or video or advice or information provided in-person or by telephone or video to an uninsured patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis.

    View claim submission requirements
  • For care of uninsured patients
    K088

    Service provider: Community-based physician (e.g. family physician)

    Fee: $36.85

    Service description: Intermediate assessment of an uninsured patient provided in-person or by telephone or video, or advice or information provided in-person or by telephone or video to an uninsured patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes. Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video, if the service lasts a minimum of 10 minutes.

    View claim submission requirements
  • For care of uninsured patients
    K089

    Service provider: Community-based physician (e.g. family physician)

    Fee: $67.75

    Service description: Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted in-person or by telephone or video per unit (unit means half hour or major part thereof).

    View claim submission requirements
  • For care delivered in a COVID-19 assessment centre
    COVID-19 Sessional Fee

    Service provider(s): Family physicians and specialists

    H409 Fee: $170.00, per one-hour period, or major part thereof, Monday to Friday 7 a.m. to 5 p.m.

    H410 Fee: $220.00, per one-hour period, or major part thereof, Saturdays, Sundays, holidays, or Monday to Friday 5 p.m. to 7 a.m.

    View service description
  • For care of insured patients
    K083

    Service provider: Specialists

    Fee: $5.00

    Service description: Specialist consultation or visit by telephone or video payable in increments of $5.00.

    View notes
Putting it into practice

K080A-K083A require a diagnostic code to be submitted on the claim. If the claim is submitted without a diagnostic code the claim will be reject as “V21-Diagnostic Code Required”.

For current OTNInvite users (PEM physicians with rostered patients, GP focus practice designated physicians, and specialists): continue to bill as usual with the Ontario Virtual Care Program fee code(s) (see Virtual Care Billing Information Manual (MOH, 2020)) and any applicable automated premiums (e.g. age premiums, focus practice psychotherapy premium) will continue to be applied automatically to the payment.

For new OTNinvite (any physician) users: Bill the new temporary K codes.

If preferred, physicians eligible to bill under the Ontario Virtual Care Program (PEM physicians with rostered patients, GP focus practice designated physicians, and specialists)  must complete the OTN billing registration form to begin billing the virtual care program codes.

Frequently asked questions (FAQs)

No, virtual visits do not qualify for special visit premiums.

Yes, K080, K081 and K082 are included in-basket for capitated and salaried primary care enrolment models.

No, for those in a FHO/FHN, patients who obtain care outside the group will not count towards outside use. If the ministry is unable to complete the necessary computer programming, they will make any necessary access bonus adjustments retroactively.

No, for FHO/FHN provision of services to non-rostered patients, the application of the Hard Cap ceiling for these services will not be enforced.

Yes, A001 and A007 are the equivalent to K080 and K081.

For Alternate Payment Program contracts, K080, K081 and K082 will be shadow-billed and the appropriate flow-through and shadow-billing premiums (if applicable) applied based on the specific contract.

Yes, the virtual care K codes can be used for follow-ups. Use the code with the closest workflow and dollar value.

Yes K087 (minor assessment), K088 (intermediate assessment) and K089 (counselling) can be used for providing care to IFH/uninsured patients.  See above for details and claim submission requirements.

Claim submission requirements

  • Physicians can submit for these codes using their group billing number where the service was provided, or their solo billing number.
  • The codes cannot be billed using one of the COVID-19 Assessment Centre group billing numbers.
  • The codes cannot be billed with a Service Location Indicator of ‘OTN’.
  • Physicians will be paid Fee-For-Service.
  • No additional premiums or payment will be allowed with these codes.
  • For K087 and K088, the fee billed on the claim should equal the value of the service multiplied by the number of patients serviced. For example, if K087 is claimed for 3 patients seen during the same day, the fee billed should be $71.25 (3 x $23.75).
  • The number of services for K089 represent the total number of 30 minute intervals spent with all uninsured persons in a single day. For K089A, the current timekeeping rules for psychotherapy remain. See page GP54 of the Schedule for information time units and minimum time requirements.

Details for submitting your claim

  • The claim must be submitted with the Billing Number of the physician who provided the service.
  • The Health Number and Version Code fields on the claim must be left blank. If a physician submits these claims with a Health Number or Version Code, the claim will reject “VHB-No HN Required for FSC”.
  • The Birth Date field on the claim must be left blank. If a physician submits these claims with a value in the Birth Date, the claim will reject “VH1-Invalid Health Number”.
  • The Service Date on the claim will be the date the service was provided.

No, the new K codes only cover services rendered by telephone or videoconferencing.

Delivering patient care in person

While delivering patient care virtually can satisfy the majority of your patients’ needs, there are still times when a virtual consult is not adequate and an in-person visit cannot be deferred.

When determining if an in-person visit is necessary, balance the patient needs (e.g. encounter type, acuity/severity of complaint) and risk factors (e.g. patient’s age, comorbidities) against the risks of exposure (MOH, May 22, 2020).

  • Non-infectious complaints of an acute nature, e.g. neurological complaints, lacerations/incision and drainage, abdominal pain, gynaecological disorders, potential exacerbation of a chronic condition (like COPD or heart failure)
  • Low-risk prenatal care (see Prenatal and postnatal care)
  • Well baby visits (see Prenatal and postnatal care)
  • Allergy shots (for only those severely affected by deferring visit)
Putting it into practice

Create a safer environment for you, patients and staff

  • Scan health cards or identification visually (i.e. “hands free”).
  • Post MOH signage in waiting and examination rooms.
  • Consider having the patient call from outside the clinic (e.g. in car, waiting at a distance) once arrived, and put in a room when available to avoid time spent in the waiting room.
  • Consider erecting a plexiglass barrier at reception.
  • Interact with your colleagues at a two-metre distance and wash hands frequently, keeping your hands to yourself.
  • Space chairs in waiting room two metres apart and remove extra objects in the room.
  • Space your appointments to try to avoid any need for a wait in the waiting room.
  • Minimize people entering with the patient.
  • Use minimal number of rooms and clear rooms of extraneous objects and/or cover what you can’t move, such as wall-mounted ophthalmoscopes.
  • Keep direct patient contact solely to the family physician/primary care nurse practitioner so all vitals are done by the provider, as necessary.
  • Lead patients directly to the exam table/beds.
  • Thoroughly clean surfaces after the patient leaves.

Ensure your safety

  • Keep distance until executing the exam, and use appropriate personal protective equipment (PPE).
  • Determining the type of PPE (e.g. gloves, surgical mask, eye protection) used should be guided by the exposure type.
  • See Infection prevention and control: PPE, HCW infection control, cleaning for details on:
    • What PPE to wear, when
    • Donning and doffing PPE
    • Extended and reuse guidance for PPE
    • Environmental cleaning
    • Equipment cleaning
Updates to prescribing rules and regulations
Specifically, and subject to the laws and regulations of the province or territory in which the pharmacist is entitled to practice, this exemption will:

Permit pharmacists to extend and renew prescriptions for controlled substances.

Permit pharmacists to transfer prescriptions for controlled substances to other pharmacists.

Permit practitioners to verbally prescribe prescriptions for controlled substances.

Allow an individual to deliver controlled substances to patients (at their homes or an alternate location).

Putting it into practice

As always, ensure your prescriptions are complete, specific to your patient, and include both you and your patient’s identifying information so pharmacists can validate the authenticity of the prescription.

Established channels

Where possible, it’s important to continue to use established channels such as phone, fax, your EMR or other e-prescribing systems when issuing a prescription. This helps to prevent fraud, avoid undue pressure on pharmacists to verify the authenticity of prescriptions, and to deliver safe and timely care to patients.

New channels

If necessary, CPSO, CNO, and OCP have made an exception to allow the use unencrypted email for the purpose of sending prescriptions to pharmacists during the declared emergency. If you wish to use unencrypted email to send prescriptions to a pharmacist, you must obtain the consent of the patient for this purpose and explain that unencrypted email may not be secure.

Prescribing opioids/narcotics

Given the extra care required for prescribing opioids/narcotics for chronic pain, or within the context of addictions treatment, you must continue to use traditional routes of communicating prescriptions for these drugs.  However, you can adapt the above new protocols that allow for verbal authorization (Health Canada, March 23, 2019).

Financial supports and programs
COVID-19 Advance Payment Program

The ministry has established the COVID-19 Advance Payment Program to address any cash flow issues that may arise during the COVID-19 outbreak and sustain physicians’ practices and ensure business continuity that will enable them to return to regular practice as soon as the outbreak begins to subside.

The COVID-19 Advance Payment Program provides monthly, interest-free, automated advance payments to eligible physicians in May, June and July 2020 that will be recovered from physicians’ billings in five equal monthly instalments starting in November 2020.

Physicians will automatically receive the advance if their monthly payment is below the 70% of average payments over the previous 12 months (April 1, 2019 to March 31, 2020). Physicians do not need to apply to the program. If eligible, the program will automatically top up eligible physicians’ payments to 70% of the historical monthly average for each month of the 3 months that the program is in place starting in May 2020.

Physicians may opt out of the program at any time by contacting the ministry. Physicians who want to opt out for the month of May can do so by returning their payment to the ministry by submitting a cheque to the Financial Management Branch, 49 Place d’Armes, 3rd Floor Kingston, Ontario K7L 5J3. The cheque is to be made payable to the Minister of Finance. Providers should also indicate this cheque is for the re-payment of the advance payment, including the specified month. For other options to return the payment, you can contact the Service Support Contact Centre at 1-800-262-6524. Physicians are still able to opt out for the second and third payments (June and July RA) by contacting the Service Support Contact Centre as well.

See the OMA’s COVID-19 Advanced Payment Program FAQs [login required] (OMA, May 22, 2020) for program eligibility, payment calculation, repayment terms and details for providers under specific payment models (fee for service, patient enrolment models and alternative funding agreements).

Supports
Top resources

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Considerations for resuming healthcare services New
Last reviewed: May 29, 2020
Last updated: May 29, 2020
The decision to resume delayed healthcare services should be undertaken according to four principles (MOH, May 26, 2020):

Proportionality

  • Consider available capacity to provide those services, both real and anticipated.

Minimizing harm to patients

  • Strive to limit harm to patients wherever possible.
  • Activities that have higher implications for morbidity/mortality if delayed too long should be prioritized over those with fewer implications for morbidity/mortality if delayed too long.
  • Consider the differential benefits and burdens to patients and patient populations, as well as available alternatives to relieve pain and suffering.

Equity

  • All persons with the same clinical needs should be treated in the same way unless relevant differences exist (e.g., different levels of clinical urgency).
  • Special attention should be paid to actions that might further disadvantage the already disadvantaged or vulnerable.

Reciprocity

  • Certain patients and patient populations will be particularly burdened as a result of our health system’s limited capacity to restart services.
  • The health system has an obligation to ensure that those who continue to be burdened have their health monitored, receive appropriate care, and be re-evaluated for emergent activities should they require them.
  • All deferred and non-essential and elective services carried out by health care providers may be gradually restarted.
  • Restarted services must comply with the requirements as set out in COVID-19 Operational Requirements: Health Sector Restart (May 26, 2020), including, the hierarchy of hazard controls.
  • Consider which services should continue to be provided remotely and which services can safely resume in-person with appropriate hazard controls and sufficient PPE.
  • Source PPE through the practice’s regular supply chain. PPE allocations from the provincial pandemic stockpile will continue. PPE can also be accessed, within available supply, on an emergency basis through the established escalation process through the Ontario Health Regions.
  • The determination of which services should continue to be provided remotely and which should be provided in-person should be made by healthcare provides, guided by best clinical evidence.
Operational recommendations
  • Routine practices for infection control should be used at all times, for all patients, in all settings.
  • Limit the number of in-person visits.
  • Implement a system for virtual/telephone consultations.
  • Seek opportunities to modify the delivery of services to reduce patient time spent in healthcare settings. Conduct initial consultations via phone, video, or secure messaging to determine if an in-person visit is needed.
  • Perform risk assessments: both operational, clinic-level risk assessments and point-of-care risk assessments.
  • Perform in-person care of COVID-19 positive patients only if Droplet and Contact precautions can be followed, with complete required PPE and appropriate donning and doffing. Healthcare providers who cannot follow these precautions should divert the patient elsewhere for assessment (to emergency department, assessment centre, etc.)
Adult mental health New
Last reviewed: May 28, 2020
Last updated: May 29, 2020
Urgent care

Remind patients that if they are experiencing a mental health crisis, they should call 911 or report to their local emergency department (CAMH, April 6, 2020).

Consult COVID-19 and the Mental Health Act (CAMH, 2020) for information on the completion of Form 1s, and guidance on the completion of Form 1, 3, 4, 4A, 49 and capacity assessments via phone or video.

Strategies to maintain wellness

Discuss the following strategies with patients to help them maintain wellness throughout the pandemic (CAMH, April 6, 2020).

Accept that some anxiety and fear is normal: Reassure your patients that some stress and anxiousness surrounding the COVID-19 pandemic is normal and can help motivate them to protect themselves. Consider directing patients to the Coping with stress and anxiety during the COVID-19 pandemic worksheet (CAMH, March 2020), to help them to challenge their own anxious thoughts and worries, especially those seemingly based on fear and not facts.

Seek credible information: It is important to emphasize to your patients that although staying informed can help us to limit the spread of the virus, misinformation and excess information can cause stress and anxiety. Encourage your patients to stay tuned in to credible sources (such as Ontario Ministry of Health, Health Canada, World Health Organization), but to find a balance in terms of how often they seek information – especially as daily changes are not likely to affect how they should manage their individual risk.

Seek support: Remind your patients that physical distancing does not mean that they cannot contact their loved ones. Encourage them to:

  • Reach out and get support through phone calls, video calls or text messaging.
  • Look for formal supports, either online or by phone. For example, distress lines, online support groups, or resources in the community. See Top resources for more information on formal supports.

Practice a healthy lifestyle: Emphasize to patients that while social distancing, it is still crucial to practice healthy habits.

Identifying and supporting patients
Supporting patients with pre-existing mental health conditions

If the patient has already been diagnosed with a mental health condition such as depression and/or anxiety, their symptoms might be worsened by feelings arising from the pandemic. It is important to provide them with resources to cope, while adjusting treatment as required.

Opportunities to reach out to patients with pre-existing mental health conditions:

For patients with scheduled appointments (even those that are non-mental health related), consider using it as an opportunity to inquire about the patient’s mental health and how they are coping with the current situation.

When feasible, consider proactively identifying patients who have been diagnosed with a mental health condition and reach out to book a virtual appointment.

Managing pre-existing mental health conditions
Scenarios to consider for patients with pre-existing mental health conditions:
  1. Patient in active treatment and in an active phase of symptoms prior the pandemic (March 11, 2020).
  2. Patient was on maintenance treatment, but is now in partial remission.
  3. Patient had been in full remission and stable, and is now undergoing relapse.

In addition to existing pharmacotherapy and psychotherapy treatment, leverage existing tools and use the following guidance to manage patients with mental health conditions:

Ensure patient has access to services. Provide virtual resources for supports (see Top resources below).

Ensure patient has access to their medications: Let patients know they can refill their prescriptions online and use pharmacy delivery or curbside pickup to minimize contact. For a list of local pharmacies to arrange delivery or pick-up, see Local services below.

Provide patients with coping strategies to maintain wellness. See Coping with stress and anxiety (CAMH, April 6, 2020).

Increase monitoring of these patients by repeating assessment scales (e.g. PHQ-9, GAD-7) at regular intervals.

For patients undergoing a relapse, determine if presentation is consistent with prior diagnosis and treat accordingly. If the patient is presenting with different symptoms, conduct a formal assessment using:

Supporting patients with new cases of mental health conditions
New cases can include:
  1. Conditions now surfacing because of circumstances involving isolation, stress, and fear, but which were previously mitigated by activities and supports.
  2. Mental health conditions due to the patient’s response to an absence of regular routines, in addition to pandemic-induced stress.
Managing new cases of mental health conditions

Use virtual care to document and monitor patients with new mental health diagnoses. See Primary care operations in the COVID-19 context for details on delivering patient care virtually and in person.

Frequency of monitoring should be determined and/or adjusted when clinical decisions are being made or at scheduled follow-up appointments (e.g., if starting medication or when doses are being adjusted).

With respect to initiating treatment that may require regular blood work, such as lithium and valproic acid (CANMAT, 2020), take into consideration the patient’s ability to attend laboratory appointments during the pandemic.

Local services
Top resources
Alcohol use disorder (AUD)
Last reviewed: May 28, 2020
Last updated: May 28, 2020

See Primary care operations in the COVID-19 context for details on delivering patient care virtually and in person.

Patients with alcohol use disorder (AUD) are at increased risk for negative health outcomes during the COVID-19 pandemic.

Increased risk of contracting COVID-19: impaired immune function and reduced cognitive functioning associated with AUD may put patients at risk for contracting the virus. Consider providing patients with or at risk of developing AUD with the following infographic: Alcohol and the Immune System – 4 things you should know (CCSA, 2020).

Withdrawal potential: social distancing measures can cause disruptions in alcohol supply, leading to alcohol withdrawal, with potentially life-threatening consequences (BC Centre on Substance Abuse, April 9, 2020). Patients at risk of alcohol withdrawal should be identified, and plans to manage or avoid withdrawal should be made in the name of prevention and to help reduce demands on emergency departments at this time.

Seek support: The following information is for primary care providers who are proficient in AUD management. If you need support providing the best care possible for your patients, consult specialists via OTN eConsult or by contacting the physicians at your local RAAM clinic.

Proactively identify and follow patients with or at risk for developing AUD

For patients with already scheduled AUD follow-up appointments, provide their appointment virtually and maintain the existing management plan. For patients with already scheduled non-AUD appointments, where feasible, review their history for AUD (past or present) before their appointment, and if positive follow the steps under Managing patients with AUD below.

For patients without appointments, where feasible, proactively seek to identify those with (past or present) AUD (e.g. EMR searches) and follow-up to book a virtual appointment for an assessment following the steps under Managing patients with AUD below.

If you are newly screening a patient for AUD, use the Alcohol Use Disorder Tool (CEP, 2019).

Managing patients with AUD

Where possible, use virtual care approaches when conducting regular assessments in order to maintain social distancing while supporting patient and reducing overall risk (BC Centre on Substance Abuse, April 9, 2020).

Putting it into practice
  • Inquire into how the patient is doing. Provide non-judgmental and supportive care approaches.
  • For patients with current AUD, inquire whether usual access to alcohol has been disrupted (BC Centre on Substance Abuse, April 9, 2020). Discourage the abrupt discontinuation of alcohol use while also using the COVID-19 pandemic as an opportunity to motivate patients who drink to consider reducing alcohol consumption by informing them that high level alcohol use may suppress various organ systems, including the immune system, increasing vulnerability to COVID-19 infection (BC Centre on Substance Abuse, April 9, 2020).
  • If you are newly prescribing pharmacotherapy for a patient with AUD, see the Alcohol Use Disorder Tool (CEP, 2019) for steps.

For patients who you suspect are at risk of going into withdrawal or those planning to go into withdrawal, take a history virtually to determine (META:PHI, April 3, 2020):

  • Recent drinking pattern (number of drinks per day and number of drinking days per week in the past month)
  • Time of last drink
  • Daily withdrawal tremors quickly relieved by alcohol
  • History of emergency department visits for withdrawal symptoms
  • History of withdrawal related seizures
  • Concurrent use of other substances
  • Concurrent health conditions
  • Current medications
Managing withdrawal
Does patient report drinking daily and experiencing regular withdrawal symptoms?

Patient will likely require medical management.

  • If the patient HAS a history of severe withdrawal symptoms and seizures and/or complicating medical conditions (e.g., liver failure, COPD, advanced age, or on high doses of opioids) they will likely require withdrawal management in the emergency department.
  • If the patient DOES NOT HAVE a history of severe withdrawal symptoms, seizures and/or complicating medical conditions, the patient may be a good candidate for a day detox procedure at a local RAAM clinic. Contact the patient’s local RAAM clinic to check if they are accepting patients for on-site detox during COVID-19. If a local RAAM clinic is unable to offer on-site detox, ask if the RAAM clinic physician can provide you/your patient with support implementing a home detox (META:PHI, April 3, 2020). Alternatively seek support via OTN eConsult.

Patient likely DOES NOT need medication for withdrawal management.

Continue to prescribe naltrexone oral and acamprosate (if indicated) (CEP, 2019), arrange regular follow-up virtual appointments and direct to online non-pharmacological options (Canadian Society of Addiction Medicine, 2020).

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Child mental health
Last reviewed: May 28, 2020
Last updated: May 28, 2020
Talking to a child about COVID-19

Parents and caregivers should ensure children receive honest and accurate information during the COVID-19 pandemic (SickKids, March 31, 2020).

Talking tips:

  • Share ‘need to know’ information with the child, using age appropriate language.
  • Answer questions directly and honestly, and do not make false promises.
  • It’s okay if you don’t know all the answers. Focus on the short-term plan for the whole family.
  • If children are distressed, let them know that it is ok and understandable to have these feelings.
  • Model healthy coping skills and attend to your own physical and mental health.
  • Consider seeking out additional resources and supports for children with special needs or who are having trouble coping.
Answering children’s questions about COVID-19

“We wipe things down to keep them clean.”

You don’t need to explain more than this—young children don’t understand germs or infection transmission yet.

“Sometimes people wear masks to decrease sickness from spreading, when they aren’t feeling well or to help keep them safe from getting sick.”

“Everybody gets sick sometimes. If you get sick, your parents will take care of you until you are all better. I will help you, too.”

“Your child care/school is closed right now. Your teacher and your friends are home too, just like you. When child care is open again, you can go back and see your friends.”

Avoid going into details about illness so toddlers don’t develop fears about attending child care.

“Right now, there is a rule that families need to stay home for a little while and be together. That helps you and your friends stay healthy. I know it can be sad when you can’t see and play with friends, but there are lots of fun things you can do at home!”

Recognizing the signs of mental health distress

Changes in behaviour or emotions can indicate that a child needs more support (CPS, 2020; SickKids, 2020; School Mental Health Ontario, 2020).

If your child expresses thoughts of hurting themself or engages in suicidal behaviour, seek help from a mental health professional immediately.

Look out for:

  • Changes in behaviour or emotions that seem out of proportion even with the current circumstances (e.g. angry outbursts, depressed mood, sense of panic).
  • Problems sleeping.
  • Appetite changes.
  • Headaches, stomach aches/nausea and fatigue.
  • Infantile behaviours that aren’t common anymore for the child (bedwetting, thumb sucking, being afraid of the dark, wanting to be held).
  • Loss of interest in activities they enjoy.
  • Worry and/or fear of leaving the home.
  • Increased rebellion and/or complaining about schoolwork or chores.
  • Increased aggression towards others.
  • More frequent outward expression of emotions.
Managing depression
Managing stress and anxiety

Use the CARD System (Comfort, Ask, Relax, Distract) to help children cope:

  • Comfort: help the child accept negative thoughts and feelings.
  • Ask: listen and talk to each other.
  • Relax: model relaxation for the child.
  • Distract: try to keep normal routines and limit the amount of time the child focuses on whatever is making them anxious.

General actions to help support your child during the pandemic (WHO, 2020):

  • Support your children with at-home learning, and make sure time is set aside for play.
  • Help children find positive ways to express feelings such as fear and sadness. Sometimes engaging in a creative activity, such as playing or drawing, can help with this process.
  • Make sure children have time away from screens every day and spend time doing off-line activities together. Draw a picture, write a poem, build something, bake a cake, sing, dance, or play outside where safe to do so.

Actions to combat disconnectedness:

When a family member is self-isolating
Grief

Children experiencing the death of someone close to them are particularly vulnerable (Canadian Virtual Hospice, 2019). They need time to process their thoughts and feelings and to ask questions. Willingness to discuss difficult topics teaches children that hard conversations can happen safely, and that they can talk with you about difficult things (Canadian Virtual Hospice, 2019).

Talking to a child about the loss of a loved one:

  • Have the conversation in a safe, comfortable place where you won’t be interrupted.
  • Get down to eye level.
  • Tell them that you may be upset or cry while you talk because you’re feeling many emotions, and that this is natural and okay.
  • Explain that they may have strong feelings too and it’s okay to express them.
  • Start with what the child already knows and build from there.
  • Give the information in a straightforward way, using words they can understand.
  • Let them know their questions are welcome. Praise them for asking questions and sharing their thoughts and feelings.
  • Be gentle and sensitive, giving the information they ask for and need.
  • Watch for cues to guide you around pacing the conversation, signs that will help you gauge how much information to provide and when the child is ready to hear it.

Top resources

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Chronic non-cancer pain (CNCP)
Last reviewed: May 28, 2020
Last updated: May 25, 2020
Patients living with Chronic Non-Cancer Pain (CNCP) may be at an increased risk for:

Contracting COVID‐19. CNCP may cause immunosuppression in some individuals, while opioids and steroids used by patients experiencing chronic pain can also suppress the immune response, increasing the risk of infection.

Experiencing mental health concerns. Social isolation, stigma, loss of personal identity and financial stress, exacerbated during a pandemic, can negatively impact a patient’s quality of life and ongoing experience of pain.

Managing patients living with CNCP

Ensure continuity of care for those living with chronic pain during the COVID-19 pandemic.

Where feasible, minimize in-person visits to reduce their exposure risk.

  • For all non-urgent patient appointments, use virtual care for pain assessment and management, whenever possible.
  • For semi-urgent patient appointments, use virtual care approaches to evaluate the patient, triage the urgency and make suitable arrangements for further treatment and/or assessment that can include in-person care.

See Primary care operations in the COVID-19 context for details.

Emphasize biopsychosocial focus and multimodal management. Leverage virtual platforms to support patients to engage with their multidisciplinary pain management team (physical therapist, psychologist, social worker, etc.).

Encourage patients to become involved in online self‐management programs involving exercise, sleep hygiene, pacing and healthy lifestyle. See the Online Self-Management Program and Resources for Canadians living with pain during COVID-19 for resources and online workshops on managing pain.

Educate patients about their treatments and modify ongoing therapies to decrease COVID‐19 risk.

Management of patients by medication
Scroll (left-right) for details
  • Opioids
    • An in-person evaluation may not be needed for continued management.
    • An in-person evaluation is required for any significant, sustained increase in opioid prescribing.
    • Ensure patients receive their appropriate prescriptions to avoid withdrawal. Ensure availability of naloxone kits and training on their use.
    • Whether in person or virtually, assessments should still adhere to recommended opioid safe prescribing procedures (CEP, November 2017).
  • Non‐steroidal anti‐inflammatory drugs (NSAIDs)
  • Steroids
    • Consider the risks (immune suppression, altered immune response, adrenal insufficiency, etc.) and benefits of continued use.
    • Consider the use of a decreased doses if possible.
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Chronic conditions/disease management
Last reviewed: May 28, 2020
Last updated: May 28, 2020
Diabetes

No evidence that patients with diabetes are at higher risk of contracting COVID-19. (Canadian Healthcare Network, May 9, 2020 [login required]).

During acute illness, patients may be susceptible to adverse drug events due to comorbidities or medicine use. Older adults are at increased risk of adverse events (e.g. kidney), especially if they are also dehydrated, due to age related changes. The following medications (SADMANS) may be of concern in some patients (Can J Diabetes, 2018):

  • Sulfonylureas
  • ACE Inhibitors and angiotensin receptor blockers (ARBs)
  • Diuretics
  • Metformin
  • NSAIDs
  • SGLT2 Inhibitors
Holding diabetes medications
Chronic obstructive pulmonary disease (COPD)

Based on current evidence, COPD patients do not appear to be more likely to acquire COVID-19 infection, however they do appear to be at a significantly greater risk for developing severe COVID-19 if infected (CTS, April 8, 2020; Int J Public Health, May 25, 2020).

Continued inhaled maintenance therapies. These medications help to minimize risk of a COPD exacerbation and optimize lung function (UpToDate, 2020).

The use oral prednisone or other systemic corticosteroids (if clinically warranted) to treat acute exacerbations of COPD. The usual guidelines for prompt initiation of systemic glucocorticoids for a COPD exacerbation should be followed, as delaying therapy can increase the risk of a life-threatening exacerbation (UpToDate, 2020).

Patients should continue using their oxygen as prescribed and should call 911 if they’re experiencing extreme distress. See the position statement for more information about following manufacturer instructions, the routine cleaning of equipment, and increasing the flow rates of home oxygen.

Against the use of nebulized therapy.

For patients who are already using nebulizers at home, they should continue to do so until they discuss switching to an alternative with their family physician/primary care nurse practitioner. Alternatives to nebulized therapy include:

  • Metered dose inhaler (MDI) with spacing device
  • Dry powder inhaler
  • Soft mist inhaler

Approximate equivalent of nebule vs puffers (MDI)

Salbutamol

1 nebule (2.5mg / neb)

4 puffs (100mcg / puff)

Ipratropium

1 nebule (500mcg / neb)

4-8 puffs (20mcg / puff)

See RxFiles’ Table of comparative medication doses for how to manage medication shortages.

In the event of a salbutamol shortage (as of April 17th, there is a shortage in Canada):

Asthma

Patients with asthma should restart or continue to use their prescribed inhaled maintenance therapy to improve disease control and to reduce the severity of exacerbations.

There is no current evidence that inhaled corticosteroids increase the risk of acquiring COVID-19 or that they increase the severity of infection.

There is no available evidence of harm caused by using prednisone to treat asthma exacerbations.

Biologics should be continued during the COVID-19 pandemic. If biologic therapies are interrupted temporarily, it is suggested to step-up other controller therapies on an individualized basis. Where available, family physicians/primary care nurse practitioners may consider switching patients to self-administration of biologics at home.

Against the use of nebulized therapy.

For patients who are already using nebulizers at home, they should continue to do so until they discuss switching to an alternative with their family physician/primary care nurse practitioner. Alternatives to nebulized therapy include:

  • Metered dose inhaler (MDI) with spacing device
  • Dry powder inhaler

Consult the Canadian Thoracic Society’s 2012 table of comparative ICS medication doses to help guide alternate prescribing in the event of shortages of asthma medications.

In the event of a salbutamol shortage (as of April 17th, there is a shortage in Canada):

Cardiovascular disease

Use telehealth or video conferencing for assessments where possible to limit possible contact with others who may have COVID-19. See Primary care operations in the COVID-19 context for details.

Encourage patients to visit the ER if they experience symptoms or signs suggestive of acute coronary syndrome.

Limit routine blood work unless absolutely necessary, particularly for older adults (≥ 65 years).

Conduct regular follow-up (e.g. every 4 weeks) virtually or by phone with patients who have had cardiac procedures postponed and encourage patients to report any escalation of symptoms.

For cardiovascular medications:

  • Ensure regular renewal for patients who have a 30-day restriction on prescriptions, by automatically renewing with their pharmacy.
  • Consider SADMANS rules for medications that may be temporarily stopped, but do not discontinue ACE/ARBs to reduce the risk for COVID-19 (see Emerging evidence: Asymptomatic shedding, paediatric symptoms and Rx research >  Medication misconceptions: COVID-19 and ACE inhibitors/ARBs for information).
  • Consider switching appropriate patients from warfarin to direct oral anticoagulants to limit INR monitoring.
Immunocompromised patients

Immunocompromised patients include:

  • Individuals using immunosuppressant medications.
  • Bone marrow or solid organ transplant recipients.
  • Individuals with inherited immunodeficiency.
  • Individuals living with poorly controlled human immunodeficiency virus (HIV) infection (CDC, 2020a).

General practices to encourage for immunocompromised patients:

Immunocompromised healthcare providers must make decisions that reflect their own unique situations, while also considering public health advice and the best available evidence (CPSO, 2020).

Older adults
Last reviewed: May 28, 2020
Last updated: May 19, 2020
Managing chronic conditions

Older adults are at increased risk of adverse events (e.g. kidney), especially if they are also dehydrated, due to age related changes.

See Chronic conditions/disease management for information to help manage individual older adult patients with chronic conditions.

Immunization guidance

Avoid asking older adults to visit a clinic only for vaccinations at this time. However, if the opportunity arises, please vaccinate.

If possible offer immunization when it can be combined with another medical visit. Offer multiple vaccines if required in order to minimize the risk of acquiring COVID-19 and to reduce the number of health care encounters (Government of Canada, May 13, 2020).

Ages 65+: Pneumococcal (pneu-C13 & penu-P23).

It may be possible to adjust the timing of scheduled vaccines as long as the injection series is eventually completed (Canadian Pharmacist Association, March 26, 2020).

For adults 50+ who have received the first dose of recombinant zoster vaccine, the second dose can be deferred until the 6-12 month interval (doses are typically recommended 2-6 months apart, and may be considered up to 12 months apart) assuming that COVID-19 risk will be lower by that time.

If an interval longer than 6-12 months after the first dose has elapsed, the vaccine series does not need to be restarted; the decision when to complete the series should take into consideration the local COVID-19 community transmission risk, recognizing that individuals may remain at risk of herpes zoster during a longer than recommended interval between doses 1 and 2 (Government of Canada, May 13, 2020).

Consult the Canadian Immunization Guide (Government of Canada, 2017) for more detailed guidance on specific vaccines.

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Opioid use disorder (OUD) New
Last reviewed: May 28, 2020
Last updated: May 29, 2020

See Primary care operations in the COVID-19 context for details on delivering patient care virtually and in person.

Individuals with opioid use disorder (OUD) are at greater risk of overdose, withdrawal and other harms due to limited or toxic illicit drug supply during the COVID-19 pandemic (BC Centre on Substance Abuse, March 11, 2020).

Seek support: The following information is for primary care providers who are proficient in OUD management. If you need support providing the best care possible for your patients, consult specialists via OTN eConsult or by contacting the physicians at your local RAAM clinic.

Proactively identify and follow patients with or at risk for developing OUD

For patients with already-scheduled follow-up appointments, keep those appointments where possible or reschedule to accommodate any changes, and maintain the existing management plan. For non-OUD interactions, as feasible, review the patient’s history for OUD (past or present) before their appointment. Follow the Managing patients with OUD steps below, as appropriate.

Where feasible, proactively identify patients with past or present OUD (perhaps through a EMR search) and follow-up to book a virtual appointment for an assessment. Use the Managing patients with OUD guidance below.

If you are screening a patient for OUD, see the Opioid Use Disorder Tool (CEP, 2018) for steps.

Managing patients with OUD

Use virtual care approaches when possible to conduct regular assessments in order to support physical distancing and reduce overall risk. Frequency of assessments should be based on when clinical decisions are being made (e.g. doses and take home doses are being adjusted) and when support is needed for patients who may no longer have access to meetings, groups or counselling.

See Primary care operations in the COVID-19 context for details on delivering patient care virtually and in person.

Putting it into practice
  • Inquire into how the patient is doing. Provide non-judgmental and supportive care approaches.
  • Ensure availability of naloxone kits and training on their use.
  • If you are newly prescribing opioid agonist therapy (OAT) for a patient with OUD, see the Opioid Use Disorder Tool (CEP, 2018) for steps. Contact the patient’s local RAAM clinic to check if they are accepting patients for on-site OAT induction during COVID-19. If a local RAAM clinic is unable to offer on-site OAT induction, ask if the RAAM clinic physician can provide you/your patient with support implementing a home induction (CEP, 2018). Alternatively, seek support via OTN eConsult.
Managing opioid agonist therapy (OAT)

Work to ensure uninterrupted access to OAT medications (BC Centre on Substance Abuse, March 31, 2020). During the pandemic, exemptions have been put in place to permit providers to verbally provide prescriptions for controlled substances and allow home delivery of controlled substances to patients (Government of Canada, 2020). See Primary care operations in the COVID-19 context > Updates to prescribing rules and regulations for more information.

For patients with suspected or confirmed COVID-19, all reasonable measures should be explored to support patients to remain in self-isolation. Arrange delivery of prescriptions where feasible through pharmacy delivery services. See Local services below for pharmacies in your area.

Virtual communication may be used to support witnessed dosing. If pharmacy delivery is not available, support patient to arrange a reliable, designated agent (e.g., family member or friend) to pick up or receive the take home doses or closely coordinate patient attendance with pharmacy staff so that appropriate precautions can be taken. All modifications should be based on an individual basis, applying clinical judgment to weigh risks and benefits to patient and public in each case (CAMH/META:PHI/OMA, March 22, 2020).

Urine drug screens are not required and should only be performed at the time of a clinical visit when the results can be discussed to guide care and not as a requirement for prescribing. Clear/negative urine drug screens are not needed with either of buprenorphine-naloxone or methadone (CAMH/META:PHI/OMA, March 22, 2020).

Considerations for take-home doses

During COVID-19, exceptional OAT take home doses should be considered. Balance the facilitation of physical distancing by reducing pharmacy and clinic visits with considerations of patient and community safety.

Assess patient’s suitability for exceptional OAT take home doses based on their social stability, access to safe housing and ability to manage and safely store take home doses (i.e. a locked box).

Patients not suitable for take home doses if:

  • Intoxicated or sedated when assessed.
  • Unstable psychiatric comorbidity (acutely suicidal or psychotic).
  • Has had a recent overdose.
  • Currently using illicit substances in high-risk ways; particular caution to be exercised with methadone if patients are using alcohol or benzodiazepines in high-risk ways or injecting high-dose intravenous illicit opioids.
Is patient deemed suitable for take-home doses?

Buprenorphine-naloxone take home-doses

  • Prescribe up to four weeks of take home doses, regardless of how long patient has been on buprenorphine-naloxone. Buprenorphine-naloxone take home doses are considered differently from methadone due to safety profile with overdose risk and diversion, therefore patients can receive longer duration take home doses.
  • Use clinical judgment to determine whether to be progressive with take home doses (e.g. advancing from one to four weeks).
  • Very stable patients may be assessed less frequently (e.g. every six to 12 weeks).

Methadone take home doses

Continue with regular OAT witnessed doses.

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Prenatal and postnatal care
Last reviewed: May 28, 2020
Last updated: May 26, 2020
Prenatal care

Virtual visits should be offered where appropriate. Recent literature supports some reduction in frequency of visits in the later trimesters if the first trimester screening indicates a low-risk pregnancy (SOGC, April 6, 2020).

Postnatal care
Well baby visits
Immunizations

Routine childhood immunizations should be kept up to date through in-person visits, since delay or omission could put children at risk for common and serious childhood infections (CPS, April 30, 2020).

While some jurisdictions may defer the 18-month visit based on their COVID-19 epidemiological situation, PHAC suggests that these immunizations still be given at 18 months when possible (National Advisory Committee on Immunization, May 13, 2020).

A Children’s Immunization Clinic will operate every Tuesday-Thursday at the Children’s Hospital of Eastern Ottawa for children < 2 years of age in the Ottawa region who are unable to get their routine first series of immunizations due to COVID-19 closures.

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Social care guidance New
Last reviewed: May 29, 2020
Last updated: May 29, 2020

During pandemics, historically marginalized and minoritized individuals suffer disproportionately. The Centre for Effective Practice (CEP), in partnership with Upstream Lab and the Department of Family and Community Medicine at the University of Toronto, developed the COVID-19: Social Care Guidance to assist health and social care providers as they support individuals exposed to COVID-19-related social risks that impact health.

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