COVID-19 in 2023: Care and Operations Guidance
Last Updated: September 6, 2023
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Managing fall/winter 2023-2024 in primary care
Outlook for 2023-2024 fall/winter respiratory virus season (MOH, July 2023)
For 2023-2024, the MOH Health System Emergency Management Branch anticipates atypical risk from respiratory viruses.
Since the pandemic, seasonal respiratory pathogens (including COVID-19) have exhibited atypical timing, with higher rates of infection starting earlier in the fall and circulating longer into the winter and spring, and more severe infections presenting in certain populations, including older adults.
Similar to the 2022-2023 season, an environment of overlapping peaks as well as increased burden of illness are likely to create pressures for the health system as a whole.
- COVID season: Late September to November, smaller surge December-January
- RSV: October to April/May
- Flu: October to May (based on data from Southern hemisphere, a dual peak is expected with Influenza A in Nov/Dec, and Influenza B into Feb/March)
Testing for respiratory season
Testing for respiratory viruses varies depending on the virus and setting.
RSV & Flu (PHO, 2022)
Testing for RSV and Flu is available only in acute care settings and limited to specific eligibility criteria.
COVID (MOH, 2023)
In Ontario, there are two types of publicly funded testing options for COVID-19 that are available in the community: rapid antigen tests and molecular testing (PCR test or rapid molecular test).
Questions related to COVID-19 testing
Rapid tests are generally less effective than PCR tests but remain effective testing options for those that are ineligible for PCR testing. While evidence concerning sensitivity to the new variants is still developing, early data from the FDA suggests that rapid antigen tests may have reduced sensitivity while remaining effective (FDA, 2023).
Rapid tests are available for free through pharmacy and grocery retail locations, local public health units as well as targeted distribution to high priority communities. For more information, please visit the Ministry of Health Rapid testing for at-home use page.
Both PCR and rapid molecular tests are highly effective forms of testing for COVID-19. Molecular testing is available for free to those who are at higher risk of severe outcomes of COVID-19. For full eligibility, please see the Ministry of Health COVID-19 testing and treatment page.
If eligible, direct patients to an open COVID-19 testing location or clinical assessment centre to get tested for COVID-19.
Preparedness for older adult populations
Risks to older adult populations
Older adults are at high risk for severe disease from flu, RSV, and COVID-19.
- Flu: In 2022-2023, older adults accounted for 31% and 76% of influenza-related ICU admission and death rates, respectively (PHAC, 2023).
- COVID-19: Overwhelmingly, the majority of COVID-19 deaths and hospitalizations in Ontario are seen in individuals over 60 years of age. (PHO, 2023)
- RSV: While much of RSV-related seasonal preparedness focuses on paediatric populations, there is an equally high risk for older adults. Unlike with young children, RSV can be more unpredictable in the older adult population due to underlying comorbidities or weakened immune systems. RSV infection is more likely to cause serious complications like bronchiolitis and pneumonia in older adult populations, and make chronic health problems worse. (NCCID, 2022)
Seasonal vaccination is critical for older adults. The immune system changes with age, making it harder for the body to fight off infections. As well, people over the age of 65 are also more likely to have health conditions which can both affect the immune system, and worsen with respiratory infection (PHAC 2023).
New vaccines for the 2023-2024 season
- In September 2023, Health Canada authorized two new vaccines. Moderna’s SPIKEVAX™ COVID-19 vaccine and Pfizer’s Comirnaty® Omicron XBB.1.5 COVID-19 vaccine, both targeting the Omicron XBB.1.5 subvariant. For more information on new formulations from Moderna and Pfizer, see COVID-19 Vaccines 2023.
- New formulations are the recommended COVID-19 vaccines for the 2023-2024 season. Compared with previous formulations, patients are expected to benefit from a better immune response against currently circulating variants (NACI, 2023). A new formulation from Novavax is also currently under review by Health Canada.
- Availability: Currently available in primary care and pharmacy settings.
- Health Canada has recently approved the new Arexvy vaccine, specifically designed to protect adults over age 60. While specific NACI guidance on Arexvy is forthcoming, the product monograph is available (Health Canada 2023, GSK 2023).
- Availability: Ontario has rolled out the first publicly funded RSV vaccination program for those 60 years and older residing in long-term care homes, Elder Care Lodges, and in some retirement homes. For older adults outside of long-term care and retirement homes, the RSV vaccine is available for purchase in pharmacies.
- Free flu shots are available for individuals 6 months of age and older who live, work, or go to school in Ontario. Clinicians should encourage all Ontarians to get a flu vaccine as soon as it is available to them. To learn more about the flu shot, visit Ontario.ca/flu.
Mitigating vaccine fatigue
Primary care clinicians have a critical role to play in mitigating vaccine fatigue, or the feeling of being overwhelmed by vaccine information and frequency of immunizations (Nature, 2023). Below are some responses in patient-friendly language to address questions related to vaccine fatigue.
Questions related to vaccine fatigue
Yes. There are a few reasons why:
- Within a few months of infection, vaccination or booster, COVID-19 vaccine effectiveness drops.
- New vaccines authorized this fall target current variants and offer more protection than previous versions of the vaccine
- There is early evidence that suggests multiple COVID-19 infections might be associated with greater risk of developing Long COVID (Nature, 2023).
- Yes. COVID-19 and flu shots can be given at the same time.
- Most pharmacies that offer vaccines will have both COVID and flu vaccines available.
- Visit https://www.ontario.ca/vaccine-locations and search by postal code to find pharmacies offering COVID and flu vaccination, and filter by age and dose needed (COVID primary series vs. booster).
- RSV: CMOH recommends a 2-week window between receipt of the new RSV vaccine and other vaccines, out of an abundance of caution to improve identification of any adverse events.
Isolation requirements New
- Self isolate until symptoms have been improving for 24 hours (or 48 hours if gastrointestinal symptoms) and no fever present.
- Asymptomatic individuals with a positive test result do not need to self-isolate unless symptoms develop. If symptoms develop, they should self-isolate immediately.
- For a total of 10 days after the date of specimen collection or symptom onset (whichever is earlier/applicable), cases should:
- Wear a well-fitted medical mask in all public settings (including schools and childcare, unless under 2 years old) and avoid nonessential activities where mask removal is necessary (e.g., dining out, playing a wind instrument, high contact sports where masks cannot be safely worn)
- Avoid non-essential visits to individuals who are immunocompromised or at higher risk of illness (e.g., seniors).
- Avoid non-essential visits to highest risk settings such as hospitals and long-term care homes (see below for further guidance when case is an employee in high-risk settings).
- Where visits cannot be avoided, cases should wear a medical mask, maintain physical distancing, and notify the highest risk setting of their recent illness/positive test. If the individual being visited can also wear a mask, it is recommended they do so.
- Cases with immunocompromise may be infectious for longer and are generally recommended to isolate for 10 days from symptom onset (or positive test, whichever is earlier)
Household and non-household close contacts
For a total of 10 days after the last exposure to the case, the individual should:
- Self-monitor for symptoms and self-isolate if they develop any symptom of COVID-19;
- Wear a well fitted mask in all public settings;
- Avoid non-essential visits to anyone who is immunocompromised or at higher risk of illness (e.g., seniors);
- Avoid non-essential visits to highest risk settings such as hospitals and long-term care homes.
- Where visits cannot be avoided, close contacts should wear a medical mask, maintain physical distancing, and notify the highest risk setting of their recent exposure. If the individual Page | 12 being visited can also wear a mask, it is recommended they do so
Those who live in the setting
Close contacts who live in a highest risk setting (e.g., long-term care homes, retirement homes and congregate living settings) should follow setting-specific guidance
- Where there is no setting-specific guidance, contacts may follow guidance as above.
Those who work in the setting
Close contacts who work in a highest risk setting (e.g., acute care, long-term care, etc.), should follow any relevant workplace guidance on return to work.
- Where feasible, additional workplace measures during the 10 days of self-monitoring may include:
- Active screening for symptoms ahead of each shift, where possible
- Close contacts should avoid removing their mask when in the presence of other staff to reduce exposure to co-workers (e.g., not eating meals/drinking in shared spaces) and maintain physical distancing if mask removal is required
- Working in only one facility, where possible
- Ensuring well-fitting source control masking for the staff to reduce the risk of transmission (e.g., a well-fitted medical mask or fit or non-fit tested respirator or KN95)
For more information, see Case Definitions and Disease-Specific Information (MOH, Sept, 2023)
PPE and IPAC considerations 2023
For the high-risk 2023-24 respiratory season, CMOH recommends using additional precautions when appropriate. See OMA’s short, easy-to-read visual guide on how to select precautions in high-risk periods: Safely providing in-person care for community-based practices (OMA, 2023)
Also, see the OCFP’s latest guidance on masking, screening, PPE, office flow, cleaning and ventilation: IPAC Considerations for Infectious Respiratory Diseases for Community Practices (OCFP, October 2023)
COVID-19 Vaccines 2023 New
Updated vaccine guidance
In fall 2023, individuals should receive a dose of the XBB. 1.5 COVID-19 vaccine if it has been at least 6 months since:
- their last COVID-19 vaccine dose; or,
- their last COVID-19 infection (whichever was most recent)
Individuals who have NOT been previously vaccinated may use the XBB.1.5 COVID-19 vaccine to initiate the series.
Staying Up to Date: Individuals 6 months and older are considered up to date with their COVID-19 vaccines if they have received a fall 2023 COVID-19 dose (MOH, Sept 22, 2023).
New! Health Canada authorizations, September 2023:
Compared with earlier versions, individuals vaccinated with new formulations are expected to benefit from a better immune response against currently circulating variants (NACI, Sept 12, 2023).
Moderna XBB.1.5 COVID-19 vaccine recommendations
2 doses: 25 mcg
1 or more previous doses
1 dose: 25 mcg
Vaccinated or unvaccinated
1 dose: 25 mcg
Vaccinated or unvaccinated
1 dose: 50 mcg
Adapted from Moderna Biopharm Canada Corp., Sept 12, 2023.
Pfizer XBB.1.5 COVID-19 vaccine recommendations
3 doses: 3 mcg
1 dose received
2 doses: 3 mcg
2 doses of received
1 dose: 3 mcg
Vaccinated or unvaccinated
1 dose: 10 mcg
Vaccinated or unvaccinated
1 dose: 30 mcg
Adapted from Health Canada, Sept 28, 2023.
A new formulation from Novavax targeting the Omicron XBB.1.5 subvariant is currently under review (Health Canada, Sept 28, 2023).
Timing of other vaccinations
Individuals 6 months and older can receive a COVID-19 vaccine before, after, or simultaneously with other vaccines (i.e., non-COVID-19 vaccines). This includes both live and non-live vaccines. Patients should be informed of the benefits and risks, given the limited data available on administration of COVID-19 vaccines at the same time as, or shortly before or after, other vaccines. In the case of co-administration, individuals should be immunized on separate arms to minimize the risk of interaction.
Imvamune (mpox): A 4-week interval is recommended either before or after receiving a COVID-19 vaccine. If needed, individuals should receive the Imvamune vaccine pre- and post-exposure, regardless of the timing of a COVID-19 vaccine.
COVID-19 vaccines and consent for children and youth under 18
Consent requirements differ between Public Health Units, with some requiring parental consent but not others.
In Ontario, there is no defined age of consent for vaccinations. Generally, children can consent to medical treatments as long as they are deemed capable of making an informed decision. This means that they must be able to understand information about the vaccine and what will happen if they accept or refuse vaccination. Children should talk about the benefits and risks of getting the vaccine with a trusted caregiver and their health provider.
For a more detailed overview, see CMPA’s updated “Vaccination” section (May 2023).
Outpatient management of patients with COVID-19
Who can be managed at home?
Patients can safely self-manage at home if they have mild to moderate symptoms of COVID-19 and do not have any co-morbid conditions or complications (HFAM, 2023).
Who should be hospitalized?
Instruct patients to seek an urgent follow-up assessment with their family physician or hospitalization if they experience any of the following red flag symptoms (HFAM, 2023):
- Severe shortness of breath at rest (e.g. Breathlessness RR >30 despite normal O2 sats)
- Difficulty in breathing (work of breathing)
- Reducing O2 saturation
- Pain or pressure in chest
- Decreased oral intake or urine output (dehydrated, needing IV fluids)
- Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
- Cold, clammy or pale mottled skin
- New onset of confusion, becoming difficult to rouse, syncope
- Blue lips or face
- Coughing up blood
Monitor other symptoms possibly associated with COVID-19, including:
- Abdominal pain
- Not related to other known causes or conditions (e.g., menstrual cramps, gastroesophageal reflux disease)
- Conjunctivitis (pink eye)
- Not related to other known causes or conditions (e.g., blepharitis, recurrent styes)
- Decreased or lack of appetite
- For young children and not related to other known causes or conditions (e.g., anxiety, constipation)
For patients experiencing a more severe case of COVID-19 and cannot safely self-monitor at home (but not experiencing red flag symptoms), consider close monitoring by a family physician or refer to an open Clinical Assessment Centre (CAC).
Managing patients at home
For patients with symptoms compatible with COVID-19 and those who have tested positive for COVID-19 (HFAM, 2023):
- Counsel all patients about self-monitoring for red flag symptoms of worsening disease (see Who should be hospitalized?) and provide clear guidance on who to call.
- Assess patients for pre-existing conditions that may put them at a higher risk of deterioration and monitor these patients closely. See Symptom management and comorbid considerations.
- Provide treatment as necessary to patients with COVID-19. For information on recommended treatment and evidence see Therapeutic management of mild COVID-19.
- Determine an appropriate follow-up frequency based on the patient’s risk for severe disease, severity of respiratory symptoms, and your comfort level with their ability to self-report worsening symptoms (HFAM, 2023).
- For patients assessed at low risk, consider self-monitoring only with check-ins determined by individual patient;
- For patients assessed at average risk, monitor every few days for 7 days, then recommend self-monitor for additional 7 days spending on progress;
For more guidance, see Assessment, Monitoring and Management of COVID (HFAM, 2023).
For patients assessed at high risk, monitor daily for 7 days, then every few days depending on progress until symptoms resolve.
Therapeutic management of mild COVID-19
The following recommendations apply to adult patients who do not require new or additional supplemental oxygen from their baseline status.
- For more information on recommended treatments for adult patients with mild, moderate and severe COVID-19 and further prioritization of groups listed below, see Ontario COVID-19 Science Advisory Table’s Recommended Drugs and Biologics in Adult Patients with COVID-19.
- To check for interactions with COVID-19 medications, see COVID-19 Drug Interactions (University of Liverpool).
- For therapies that can be used to manage symptoms, see Symptom management.
Below is a general pathway for how primary care providers can access outpatient therapies for people at higher risk of severe disease, specifically remdesivir and Paxlovid. Local pathways may vary based on availability of services and pre-existing pathways.
Pathway to accessing outpatient therapies
Proactively inform potentially eligible patients to contact a health care professional if they develop symptoms of COVID-19. This is done during appointments, via email or telephone, or by updating the practice’s website or online booking portal. See I think I have COVID. When should I call my doctor? for a handout to give patients at higher risk of severe disease.
Individuals are at higher risk of severe outcomes if any of the following (Ontario Health, April 13, 2023):
- 60 years of age or older
- 18 years of age or older and are immunocompromised
- 18 – 59 years old and at a higher risk of severe COVID-19 including having:
- one or more underlying medical conditions (such as diabetes, heart or lung disease), or
- inadequate immunity against COVID-19 from:
- not receiving a full primary series of the COVID-19 vaccine
- having received a full primary series but no COVID-19 vaccine or COVID-19 infection within the past six months
- Indigenous people, Black people, and members of other racialized communities may be at increased risk of disease progression due to disparate rates of comorbidity, increased barriers to vaccination, and social determinants of health. They should be considered priority populations for access to COVID-19 drugs and therapeutics.
For more detailed information on determining a patient’s risk of disease progression, see Ontario COVID-19 Science Advisory Table’s Recommended Drugs and Biologics in Adult Patients with COVID-19.
Pathway to accessing outpatient therapies
Try to connect virtually or in-person with patients at higher risk of severe disease who have developed symptoms of COVID-19 within 24 hours of the patient seeking support.
Assess the patient and determine an appropriate treatment course, considering patient eligibility and contraindications and local availability of therapies. See Recommended drugs for patients with mild COVID-19.
- Prescribe Paxlovid to eligible patients if they are within 5 days of symptom onset. See Guidance for the prescription of nirmatrelvir / ritonavir (PaxlovidTM) for information on prescribing Paxlovid.
Follow-up provided after treatment will vary depending on local arrangements and may include handoff back to primary care for ongoing monitoring (e.g., via COVID@Home). See Assessment, monitoring and management of COVID-19: Monitoring and follow-up (tab 6) for information on monitoring and follow-up based on risk level.
Recommended drugs for patients with mild COVID-19
While evidence is still emerging, prescribers should feel confident that Paxlovid is effective for patients at high risk of severe COVID-19 when initiated within the first 5 days of symptom onset. Evidence suggests continued efficacy in the latest Omicron subvariants.
Due to increased supply, Paxlovid is now available in community pharmacies and can be prescribed by a pharmacist. There is no cost to patients and no health care is required.
Role in therapy
- Recommended for patients with mild to moderate COVID-19 at higher risk of severe disease who present within 5 days of symptom onset.
- May be considered in pregnant or lactating patients if the benefits of treatment outweigh the potential risks.
- Indicated for the treatment of mild-to-moderate coronavirus disease (COVID-19) in adults with positive results of direct severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.
- For more information, see Nirmatrelvir/Ritonavir (Paxlovid): What Prescribers and Pharmacists Need to Know.
Assessing eligibility and appropriateness
Paxlovid is intended for patients with mild to moderate COVID-19 who are not on supplemental oxygen but are at risk of progressing to severe COVID-19 infection. Primary care clinicians should engage in shared decision-making with every confirmed COVID-positive patient eligible for Paxlovid.
To be eligible for Paxlovid, patients must:
- have tested positive for COVID-19 by PCR, rapid molecular or rapid antigen test. At-home rapid antigen test with provider verification is acceptable (in-person, virtual, picture or video) AND
- be within 5 days of symptom onset (symptom onset is considered day 0)
Paxlovid should be strongly considered for individuals in these categories:
- 60 years or older
- Living with comorbidities: See Health Canada’s list of underlying medical conditions associated with more severe COVID-19 disease
- Those with lowered Immune status: Either unvaccinated or with an incomplete primary series, or completed primary series with last COVID-19 vaccine dose more than 6 months ago AND last COVID-19 infection more than 6 months ago
- Groups with poorer COVID-19 outcomes including Indigenous people, Black people and other members of racialized communities, Individuals with intellectual, developmental, or cognitive disability, people who use substances regularly, who live with mental health conditions, and who are underhoused
Dosage, cost and administration
- Normal renal function: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all three taken together orally twice daily for 5 days.
- Mild-moderate renal impairment (eGFR 30-60 mL/min): 150 mg nirmatrelvir (one 150 mg tablet) with 100 mg ritonavir (one 100 mg tablet), taken together orally twice daily for 5 days.
- Not recommended for patients with severe renal impairment (eGFR <30 mL/min) or severe hepatic impairment.
- Altered sense of taste, diarrhea, muscle pain, vomiting, high blood pressure, headache.
Key drug interactions
- Contraindicated in patients taking drugs that are:
- Highly metabolized by CYP3A4 where elevated concentrations can be life-threatening
- Potent CYP3A4 inducers which may reduce the effectiveness of nirmatrelvir/ritonavir and contribute to the development of drug resistance.
- Nirmatrelvir/ritonavir have many drug interactions. See Nirmatrelvir/Ritonavir (Paxlovid): What Prescribers and Pharmacists Need to Know
Role in therapy
- Recommended as an alternative to Paxlovid for patients with mild COVID-19 at higher risk of severe disease who present within 7 days of symptom onset.
- Recommended for patients who cannot take Paxlovid due to contraindication (medical contraindication or drug interaction that cannot be safely managed) or >5 days after symptom onset.
- Available evidence indicates similar effectiveness to Paxlovid.
Dosage, cost and administration
- 200 mg IV x 1 day, then 100 mg IV daily x 2 days.
- Price of drug in Canada currently not publicly available. Administration costs must also be considered.
- Allergic reaction or infusion reaction (rare): changes to blood pressure or heart rate, low blood oxygen levels, high temperature, shortness of breath or wheezing, swelling of face, lips, tongue or throat, rash, nausea, sweating, shivering.
- Infusion site reaction: Pain, bruising swelling or redness at the infusion site.
- Other adverse events: increased transaminases, nausea, headache, rash
Key drug interactions
- Avoid use with:
- Chloroquine and hydroxychloroquine (antagonize the effects of remdesivir)
- Drugs which reduce renal function
- Strong inducers of CYP450 (e.g., rifampinin)
- The potential for drug interactions with inhibitors inducers of CYP2C8, 2D6 or 3A4 (remdesivir is a substrate of these enzymes) has not been studied.
Effective 2023-24, the Ontario Ministry of Health has established community-based ways for individuals to access Remdesivir as a treatment for COVID-19 through Home and Community Care Support Services (HCCSS). Refer patients to their local HCCSS branch for a nurse to administer Remdesivir infusions. Please note, in Northern Ontario, hospitals and assessment centres continue to operate and provide COVID-19 assessments in the majority of communities.
For more information please visit Ontario Health: COVID-19 Health System Response Materials
Symptom management (Common symptoms (MOH, August 31, 2022))
Potential management strategies (NICE, March 29, 2023)
- Drink fluids regularly (no more than 2 litres/day).
- Take paracetamol or ibuprofen if a patient has a fever and other symptoms antipyretics help treat.
Potential management strategies (NICE, March 29, 2023)
- Avoid lying on back (makes coughing ineffective).
- A teaspoon of honey.
- Only if cough is distressing, short-term, limited supply prescription for codeine linctus, codeine phosphate tablets or morphine sulfate oral solution may be considered.
Potential management strategies (NICE, March 29, 2023)
- Keep the room cool.
- Encourage relaxation and breathing techniques (positioning, pursed-lip breathing, breathing exercises and coordinated breathing training).
- Improve air circulation by opening a window or door (avoid using a fan because this can spread infection).
For more information on dosing and techniques, see the COVID-19 rapid guideline: managing COVID-19 (NICE, March 29, 2023).
Post COVID-19 condition
What is “post COVID-19 condition”?
Post COVID-19 condition (or long COVID) includes a wide range of symptoms following a probable or confirmed history of a severe, mild or asymptomatic COVID-19 infection usually occurring beyond 12 weeks (Ontario Health, December 2022).
- Dyspnea or increased respiratory effort
- Decreased mobility
- Menstrual cycle irregularities
- Memory deficits
- Difficulty concentrating
- Joint Pain
- Muscle pain
- Abdominal pain
- Loss of taste or smell
- Skin rashes
Patient evaluation for suspected post COVID-19 condition
To avoid over investigation, consider a conservative diagnostic approach in the first 4 to 12 weeks after COVID-19 infection. Currently, there are no definitive tests to determine the presence of post COVID-19 condition. Consider laboratory tests based on patient history, physical examination and clinical findings. Tailor testing to a person’s signs and symptoms to understand if they are caused by an ongoing case of COVID-19, post-COVID 19 condition or an unrelated diagnosis (Ontario Health, December 2022).
As multiple organ systems are possibly involved in post COVID-19 condition, a thorough physical examination is recommended (Ontario Health, December 2022).
Reminder for providers to convey empathy, listen and validate
It is important to approach patients possibly dealing with post COVID-19 condition with empathy, listen to what symptoms they are experiencing, and validate what they are going through (NICE, November 11 2022). Many patients report feeling like their symptoms are not taken seriously or they do not realize that what they are experiencing is connected to COVID-19, making a holistic approach to assessment highly important (NICE, November 11 2022).
Guidance for how to help patients recover
The primary recommendation for managing patient recovery is self-management and supported self-management through several techniques. It is important to note that care plans are recommended to be developed using a shared decision making approach, ensuring that the patient’s preferences, support network, and goals are taken into account to create a management plan that works best for them (NICE, November 11 2022).
Supported self management techniques for symptoms (Ontario Health, December 2022):
- Encouraging patients to keep diaries or calendars that document their symptom severity and any changes to health conditions. This can help identify any possible triggers such as physical exertion, medical treatments, medications, or menstruation. Examples include mood diaries which can aid in the screening and diagnosis of related or comorbid mental health conditions.
- Develop a comprehensive plan based on patient symptoms that incorporates their treatment goals.
- Consider providing referrals to other support services such as home care, mental health support, employment, housing, or financial support depending on patient needs. Patients can also be directed to call 211 to be referred to relevant social service supports.
- Provide education and support materials for at-home self-care including nutrition, physical activity, sleep, stress, and chronic disease management. See “Self-management techniques for symptoms” tips below.
- If initial symptoms are moderate to severe, or continue worsening in severity, consider a referral to an interdisciplinary rehabilitation program or a relevant specialist. Note that COVID-19 and Post-COVID Condition advice is available through eConsult.
- Consider providing resources to support caregivers.
- Consider supporting an application for short or long term disability income support if unable to work or if work hours are reduced.
For further guidance, BC ECHO for COVID-19 Recovery has a collection of videos and resources for practitioners addressing management of patient recovery from various clinical perspectives. The Ontario College of Family Physicians also has resources available for both clinicians and patients including tools and videos that cover the Post-COVID condition.
Self-management techniques for symptoms:
There are many health promotion education resources available to share with patients when developing their self-management care plan. Consider the following resources and guidance:
- UHN’s COVID-19 Resources for Patients and Families: post COVID-19 condition
- Ottawa Hospital: Post-COVID Rehabilitation Self-Management
- CANCOV: Patient Resources
- Alberta Health Services: Self-Care and Universal Information Resources for post COVID-19 condition
- Shared Health Manitoba: Getting Back to Life After COVID-19 (post COVID-19 condition)
- NHS Your COVID Recovery: I Think I Have post Long COVID
- WHO Support for Rehabilitation: Self-Management After COVID-19 Related Illness
What to do if patients aren’t getting better
How to support patients completing disability applications
- if missing work: EI Sickness
- if has private insurance: Short and long term disability
- if there was workplace transmission: WSIB
- if has a history of workplace contributions: CPP Disability
- if living at low income or ineligible for other programs: Ontario Disability Support Program or Ontario Works
Disability support programs generally look toward impact on day to day life and function as opposed to medical proof of diagnosis.
Reminder, presentation of post COVID-19 condition symptoms can look different from patient to patient and can present on different timelines. It is important to keep this in mind when assessing for post COVID-19 condition and providing corresponding documentation for disability claims.
Palliative care and COVID-19 New
The role of primary care
To help address palliative care services related to COVID-19, family physicians and community palliative care nurse practitioners will have to:
Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care
Providers need to ensure the patient understands the nature and severity of their illness, and explore their goals of care to support decision-making and enable person-centred care.
- COVID-19 Advance Care Planning Toolkit (Hamilton Family Medicine, 2020).
- Plan Well Guide: online tool for learning about medical treatments and preparing patients for decision-making during a serious illness (2020).
- Palliative Care Resources to Support Frontline Providers During the COVID-19 Pandemic (Ontario Palliative Care Network, Feb 9, 2022)
Document decisions regarding do not resuscitate (DNR)
If a patient decides they do not want resuscitation when their heart stops beating or they stop breathing, (i.e. provides consent for a Do Not Resuscitate order), complete the Do Not Resuscitate Confirmation Form (DNR C) (Government of Ontario, 2008).
Manage symptoms, and address other palliative care needs for patients with COVID-19
Family physicians and community palliative care nurse practitioners need to be prepared to address the palliative care needs of their COVID-19 patients. Dyspnea, delirium, nausea and vomiting, and pain will be particularly relevant for patients with COVID-19.
Provide end-of-life care for COVID-19 patients
When patients with COVID-19 are in their final weeks and days of life, family physicians and community palliative care nurse practitioners need to be prepared to support and provide end-of-life care.
- It is important to ensure rapid access to palliative medications that are often at higher doses than seen in standard practice
- Dose ranges should be considered to allow for urgent decision-making regarding escalation of dose for distressing symptoms.
- The most common terminal symptoms (fever, rigors, severe dyspnea, cough, delirium and agitation) can develop rapidly and be distressing.
Provide grief and bereavement support
For many people, the time following the death of a loved one can be filled with a range of emotions and physical reactions. It is important in the grief journey that people are able to openly talk about these experiences, reactions and feelings. Providers can recommend the following resources for those who have lost a loved one:
- Bereaved Families of Ontario for group support, one-to-one sessions and telephone support.
- MyGrief.ca, an online resource that can help one understand their grief and work through some of the difficult issues they may be facing.
- Kidsgrief.ca, a free online resource that helps parents support their children when someone in their life is dying or has died.
- Connect grieving individuals to local services for mental health and counselling support.
Acknowledgement and legal
The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach.
They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.
Clinical Working Group
A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:
• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CHE
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP
In addition to our clinical working group the CEP also obtained feedback from others, including:
• Angeline Ng, B.Sc.Phm, R.Ph.
• Arun Radhakrishnan, MSC, MD, CM, CCFP
• Ashley Verduyn, MD, CCFP, FCFP
• Central Region Primary Care Leadership
• David Daien, MD, CCFP
• David Makary, MD, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Gary Bloch, MD, CCFP, FCFP
• Farah Tabassum, MD, CCFP
• Jim Wright, MD, MPH
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Moira Sarah Selke, MB MCh BAO, CCFP
• Noah Ivers, MD, PhD, CCFP
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH
Thank you to everyone who supported the development of this resource.
Conflict of interest
• Clinical Leads receive compensation for their role
• Clinical Working Group receive an honorarium for their participation
• Focus group and usability participants receive a small token of appreciation (e.g. gift certificate)
The COVID-19: Clinical Guidance for Primary Care Providers resource is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the COVID-19: Clinical Guidance for Primary Care Providers resource for commercial purposes or any modifications of the Tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: firstname.lastname@example.org).
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