Primary Care Operations in the COVID-19 Context

For more information, see Optimizing the Supply of Personal Protective Equipment during the COVID-19 Pandemic (OH, August 11, 2020)

Consider proactively contacting the following patients to schedule in-person or virtual visits (as appropriate):

• Those at risk for developing or worsening mental health or addiction.
• Those at risk of overdose. See CEP’s Opioid Overdose Risk and Prevention resource.
• Those who are not up to date for immunizations (children and adults). See Ontario’s Immunization schedule.
• Those with mobility issues.
• Those with poorly-controlled chronic conditions.
• Those with a scheduled procedure, test, or surgery that was postponed due to COVID-19.
• Those who have missed or are due for a cancer screening. See Cancer Care Ontario for tip sheets and COVID-19 Cancer Screening Tip Sheet for Primary Care Providers (OH) for detailed guidance; however, note that LifeLabs is not yet accepting routine colorectal cancer screening requisitions. Primary care providers should only send new fecal immunochemical test (FIT) requisitions to LifeLabs for the following higher-risk patient groups:
  • Average risk people over age 60 who have never been screened for colorectal cancer
  • Average risk people with previous unsatisfactory FIT results
  • Eligible average risk people awaiting organ transplant

Consider a mass mail or email reach-out to remind all patients to seek care if needed. Encourage patients it is safe to seek care when they need it, and describe new processes, virtual care options and safety protocols for in-person visits.

If you are unsure of how to use your EMR to support proactive panel management, there are free Ontario MD resources to help you:

• i4C Advisory Service: Free service providing hands-on support from OMD Practice Advisors and Peer Leaders to create an enhancement plan reflecting individual practice priorities.
• Peer Leaders: Peer Leaders work one-on-one to help providers get more value from their certified EMR.
• EMR Progress Assessment Tool: Free, evidence-based, online self-assessment for providers to assess their EMR use and make improvements to enhance patient care. The EPA investigates key functional areas: Practice management, information management, and diagnosis/treatment support.

For more further details on what’s new for 2020-2021, vaccination in primary care, and practical tips on operating flu vaccination clinics see: Wave 2: Flu vaccination and flu vaccination clinics.

Reduced observation period post-vaccination

• Evidence shows that many anaphylactic reactions occur between 0 to 15 minutes post-vaccination. Some but not all anaphylactic reactions will be captured in the first 5 minutes; syncope occurred very quickly, and seizures often occurred after 15 minutes.
• The risk of COVID-19 transmission in a given immunization setting will vary; a risk assessment should be used based on local COVID-19 prevalence to weigh the risks of not identifying serious adverse events vs. the benefits of less interaction between people.
• Cell-based vaccine recipients should not be considered for reduced post-vaccination observation time.

Deferral of immunization: During the COVID-19 pandemic, individuals with symptoms of acute respiratory infection should defer influenza immunization until they have recovered. This includes non-severe symptoms such as sore throat or runny nose. Symptomatic people can pose an unnecessary risk to others and healthcare providers if they have COVID-19. Individuals with suspected, probable, or confirmed COVID-19 and those who are close contacts of a COVID-19 case should also defer influenza vaccination during their period of isolation or quarantine.

Mammalian cell-based influenza vaccine: NACI recommends that Flucelvax® Quad may be considered among the quadrivalent influenza vaccines offered to adults and children >= 9 years of age.

Use of Live Attenuated Influenza Vaccine (LAIV) in HIV-infected individuals: LAIV may be considered as an option for annual vaccination of children 2-17 years of age with stable HIV infection on highly active antiretroviral therapy (HAART) and with adequate immune function. For more information, see Recommendation on the Use of Live Attenuated Influenza Vaccine (LAIV) in HIV-Infected Individuals (NACI, Aug. 25, 2020).

Opportunistic immunization

• Provide immunization to patients and their accompanying persons when they are seen for other reasons.
• Provide immunization during home care visits and, when feasible, in partnership with accompanying home care agencies.

All Ontarians over 6 months of age should be vaccinated. During the pandemic, concerted efforts should be made to vaccinate:

• Anyone who is at high risk of severe COVID-19 related illness:
  • Older adults, especially over 60
  • Those with chronic medical conditions (lung disease, heart disease, diabetes, hypertension, etc.)
  • Those who are immunocompromised, with an underlying medical condition or taking medications that lower the immune system
  • People living with obesity (BMI of 40 or higher)
• Anyone who is capable of transmitting influenza to those at high risk of severe and critical illness related to COVID-19, such as those with high-risk family members, or caregivers of high-risk individuals
• Essential workers: health care workers, teachers, bus drivers, retail workers, grocery store clerks, etc.

Personal Protective Equipment: During the COVID-19 pandemic, all staff should use PPE for the full duration of a shift. Limited re-use protocol should be followed, with the replacement of PPE when soiled, wet, or damaged.

For more information, see PPE At-a-glance poster (OMA, 2020) [login required] and PPE and Infection Control for In-office Assessments (OCFP, 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.

When deciding whether to schedule an in-person or remote visit, assess patient frailty in combination with self-management capability, in terms of both health and technological literacy, as well as technology access.

• Does the patient have a phone or internet at home?
• If the patient has access to internet, are they comfortable downloading and using apps, following links, watching videos, downloading attachments, taking and sending photos and videos?

Use the assessment guide Considerations for balancing in-person and virtual visits in Primary Care during COVID-19 (CMAJ blog, May 2020) to evaluate factors of staff and patient health, care efficiency and effectiveness, access, patient-centredness, and equity in the context of new protocols and practices.

At a minimum, all healthcare providers and settings must meet these requirements. See COVID-19 Operational Requirements: Health Sector Restart (June 15, 2020) for greater detail.

Ease of use (for you and your patient).

Subject of the clinical encounter (e.g. a dermatological issue may require video and/or picture exchange).

How the product/platform can help you keep patient information private and secure.

For an in-depth look at the different remote tools available, see OntarioMD’s comprehensive overview of the different virtual care options.

PPE is the last in the hierarchy of controls and should not be relied on as a standalone primary prevention program. See Delivering patient care remotely for information about remote visits, Operational requirements for in-person care and and Delivering patient care in person for environmental precautions to take when seeing patients in person.

An Organizational Risk Assessment should be performed in order to assess the efficacy of an organization’s hierarchy of controls, including the protocols for prioritizing and distributing PPE (PHO, July 27, 2020).

Due to community spread of COVID-19 within Ontario, and evidence for asymptomatic and pre-symptomatic transmission, it is recommended that (MOH, September 4, 2020):

• Surgical/procedural masks be worn for the full duration of shifts for HCWs who are providing direct patient care.
• Eye protection (e.g., goggles, facemasks) be considered for the full duration of shifts for HCWs who are providing direct patient care.
• For the purpose of source control, surgical/procedural masks be worn for the full duration of shifts by HCWs who are working outside of direct patient care areas, if physical distancing from other HCWs cannot be maintained.

A point-of-care risk assessment (PCRA) identifying the Task, Patient and Environment should be conducted for all patient encounters in order to determine the PPE required (PHO, July 27, 2020). See PHO’s advice on performing a risk assessment.

COVID-19 is known to spread through contact and droplet transmission, therefore droplet and contact precautions should be used for patients with suspected or confirmed COVID-19, (PHO, July 27, 2020). See PPE used for droplet and contact precautions (below) for details.

The possible role of airborne transmission is not clearly established, however, it is recommended that airborne precautions be used when performing aerosol generating procedures (AGMPs) on patients with suspected or confirmed COVID-19 (OH, August 11, 2020). An N95 mask (not a medical/procedural mask) is used as part of airborne precautions, all other PPE is identical to droplet and contact precautions. For a list of AGMPs that warrant airborne precautions, as well as those which should be avoided altogether during the pandemic, see Appendix C of Personal Protective Equipment (PPE) Use During the COVID-19 Pandemic (OH, August 11, 2020).

It is recommended that surgical/procedural masks be worn for all direct patient care. Eyewear (e.g., goggles, facemasks) should also be considered (MOH, September 4, 2020)

For a visual guide and tips on PPE use, see PPE and Infection Control for In-office Assessments (OCFP, June 2020).

For patients who screen positive for COVID-19, if HCWs are not able to follow droplet and contact precautions or are not knowledgeable on how to properly don and doff PPE, they should divert the care of the patient (e.g., to the emergency department, or to an assessment centre) as appropriate (MOH, September 4, 2020).

For patients who screen positive for COVID-19, if HCWs are not able to follow droplet and contact precautions or are not knowledgeable on how to properly don and doff PPE, they should divert the care of the patient (e.g., to the emergency department, or to an assessment centre) as appropriate (MOH, September 4, 2020).

PPE can be used for situations not listed below if determined during the point-of-care risk assessment (PCRA).

See Extended use and reprocessing guidance for information on contingency and crisis strategies for optimizing PPE.

As of August 4, 2020, Ontario Health has implemented the Pandemic PPE Transitional Support (PPTS) program, which will temporarily allow free access to PPE for primary care providers who do not have established PPE supply chains or whose supply chains have failed. This allows providers to effectively skip Step 3 of the escalation process below. For more information, see Pandemic PPE Transitional Support (PPTS) FAQs (OH, August 4, 2020).

The following escalation process provides steps for you to access PPE for your practice/organization (OH, 2020):

• Step 1: Implement conservation and stewardship strategies to reduce the need for resupplying PPE.
• Step 2: Use existing supply chain processes and collaboration with local partners to obtain supplies.
• Step 3: Explore alternate inventories to obtain supplies.
  • See the Ontario Workplace PPE Supplier Directory.
  • See OMA’s Guide to PPE Drives.
  • See the COVID-19 Personal Protective Equipment category of OMA’s eMarketplace.
• Step 4:
  • For Providers in Toronto, Central, North and East Regions: Use Ontario Health’s Critical PPE Intake Form to escalate to your Regional Lead.
  • For Providers in West Region: Use the Urgent Pandemic Supply Request form to escalate to your Area Hubs, who may in turn escalate to your Regional Lead. As long as the PPTS program is active, use the PPE Pandemic Transitional Supports Order Form to obtain free PPE from the Ontario Health West Supply Chain.

The MoH has issued an order for Mandatory Reporting of PPE Inventory, twice per week, on Mondays and Thursdays (in effect since June 8, 2020). To report your PPE supply to the ministry, access the inventory reporting tool. The tool is open from 8 a.m. to 5 p.m. daily. Instructions for participation are published on the Ontario Health website.

Ontario Health has asked for healthcare providers to save and store used, unsoiled N95 unsoiled N95 respirators for decontamination using validated sterilization and disinfection methods. Store N95 respirators separately in labelled and dated storage containers.

To help extend the supply of PPE, Ontario Health suggests that providers switch to reusable PPE options wherever they can be safely implemented (OH, September 22, 2020).

PHAC warns about the sale of fraudulent N95 respirators that do not meet industry standards.

Confirm NIOSH approval # in the NIOSH database.

Ensure package and respirator have markings & details, as required by NIOSH.

Check for obvious signs of counterfeit (i.e. incorrect spelling).

Refer to the Government of Canada Specifications for COVID-19 Products site to confirm quality standards for other PPE.

Consult the PPE Supplier Validation Checklist (OMA, June 6, 2020) [login required] if you are purchasing PPE from a new supplier.

As of March 30, 2020, the CDC recommends an additional handwashing step before putting on gloves. Frequent handwashing with or without adjunct antiseptics is a vital component of infection control.

Incorrect doffing is very common and leads to contamination of the healthcare worker, their clothes or the environment.

Common doffing errors:

• Doffing gown from the front.
• Removing face shield of the mask.
• Touching potentially contaminated surfaces and PPE during doffing.

How to don PPE properly (Public Health Ontario, video, 2 minutes).

How to doff PPE properly (Public Health Ontario, video, 1 minute).

Please note that extended use of surgical/procedural masks and eye protection (e.g. goggles or face shields) is now recommended in Ontario.

• Do not combine extended use and reuse practices.
• Take extra care when removing PPE, as this is when self-contamination may occur. If you touch or adjust PPE, immediately perform hand hygiene with soap and water or sanitizer for 20 seconds.
• During Crisis capacity, unused, expired PPE items that have been stored in accordance with manufacturers’ storage conditions may be used, following inspection and testing to ensure they are not damaged (OH, September 22, 2020).

COVID-19 environmental cleaning protocols are the same as for other common viruses. The cleaning products and disinfectants commonly used in healthcare settings are strong enough for COVID-19.

See Health Canada’s list of approved disinfectants to ensure your supplies are approved for disinfecting in a healthcare setting.

Disinfectant wipes that meet healthcare standards may be used for cleaning small noncritical items between patients (stethoscopes, blood pressure cuffs, etc.) (Public Health Ontario).

Disinfectant wipes that meet healthcare standards may also be used for items that cannot be soaked. However, family physicians and primary care nurse practitioners should do this with caution, as it may be difficult to reach adequate disinfectant contact time (Public Health Ontario).

See COVID-19: Cleaning equipment and Family Physician Offices (BC CDC) resource on cleaning frequency by type of surface and list of disinfectants and cleaning agents known to be effective against coronaviruses.

COVID-19’s transmission between people through close contact and droplets places healthcare workers and their medical staff at higher risk. Healthcare workers should regularly assess their exposure and monitor for symptom development (PHO, July 31, 2020).

Worksheet: Health Care Worker COVID-19 Exposures Risk Assessment Tool (BC Centre for Disease Control, 2020).

For conducting risk assessments, see Operational requirements for in-person care.

Pregnant women working in essential services, including healthcare workers, can continue to work during the pandemic (SOGC, May 15, 2020).

Pregnant healthcare workers should follow the same PPE recommendations as other healthcare workers. A pregnant healthcare worker who is required to wear an N95 respirator, and who has experienced significant weight changes during pregnancy, must ensure that their N95 respirator fit-test is up to date (SOGC, May 15, 2020).

They should immediately self-isolate and notify their local public health authority or family physician promptly so that they can coordinate testing.

They should be tested as soon as is feasible, if they develop any symptom compatible with COVID-19, including atypical symptoms (Ministry of Health, September 21, 2020).

Due to the evolving evidence surrounding the duration of symptoms, asymptomatic transmission, and duration of infectiousness of COVID-19, criteria for healthcare worker return-to-work is rapidly changing and may vary depending on individual circumstances and different healthcare facilities’ protocols. Please use the provincial guidance to adapt to your practice and local healthcare facilities.

Resolution of a case is defined as an individual having undergone isolation for the duration specified provided the individual is afebrile, and symptoms are improving. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. If an individual has tested positive but has never had symptoms, isolation recommendations should be based on date of test.

Healthcare workers should follow isolation and clearance with a non-test based approach (waiting 14 days from symptom onset (or 14 days from when swab was taken if persistently asymptomatic), unless they have required hospitalization during the course of their illness, in which case a test based approach is preferred. See detailed information on clearing cases at COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, October 1, 2020).

In circumstances where additional staff is critically required, earlier return-to-work of a COVID-19 positive healthcare worker may be considered following work self-isolation guidance (see below) and recognizing that the individual may still be infectious.

Outside of work: practicing self-isolation measures outside of work for 14 days from symptom onset OR positive specimen collection date if asymptomatic, to avoid transmitting to household members or other community contacts.

At work: The healthcare worker should adhere to best practices listed in How to self-isolate while working (PHO, March 25, 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. 

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. 

For telephone or non-OTN viritual visits: Bill the new temporary K codes.

Effective March 14, 2020, a new diagnostic code has been created for the COVID-19 outbreak:
Code: 080
Description: Coronavirus

The new diagnostic code should be used when treating patients with suspected or confirmed COVID-19 and/or when treating a patient by telephone/video for suspected or confirmed COVID-19. Use the appropriate diagnostic code when treating a patient for unrelated diagnoses by telephone/video due to COVID-19 related concerns.

Starting June 15, 2020, the Ministry of Health has ended the dispensing recommendations communicated on March 20th to lessen the risk of drug shortages. Pharmacists and dispensing physicians may dispense medications in accordance with pre-COVID-19 dispensing policies (i.e. maximum 100-days’ supply if the prescription allows).

Permit pharmacists to extend and renew prescriptions for controlled substances.

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

Permit pharmacists to adapt a prescription for a controlled substance, including part-filling or de-prescribing.

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).

Over time, the build up of stress can lead to feelings of extreme exhaustion and being overwhelmed. Signs of burnout include (CMA, 2020):

• Experiencing feelings of sadness, depression, failure, helplessness or apathy.
• Becoming easily frustrated.
• Blaming others or feeling generally irritable.
• Feeling disassociated, indifferent or apathetic.
• Isolating or disconnecting from other others.
• Practicing poor self care.
• Feeling tired, exhausted or overwhelmed.
• Using negative coping strategies (i.e. alcohol or substance use, poor eating habits, excess caffeine).

Control

Given the uncertainty around COVID-19, it is important to recognize what we can control and let go of things we cannot control.

• Things we can control: Being positive and kind, enjoying time at home, limiting time on social media, following up-to-date guidelines with trusted information.
• Things we cannot control and should let go: Predicting how long long this will last and what is ahead of us.

Commitment

It can be valuable to reflect on why you do the work you do as a family physician/primary care nurse practitioner and how it aligns with your values.

Connection

Maintain connections at work and in your personal life.  Spend time together with friends and family over text, email, phone calls or video calls.

It may be helpful to have a buddy system at work and use the “HELP” acronym to check in (CMA, 2020):

• H – Ask: “How are you doing?”
• E – Be empathic and understanding.
• L – Listen without judgement and state your concerns.
• P – Plan next steps: encourage them to seek formal support and/or ask what you can do to help.

Calming

Use the ABC123 – Psychological First Aid Tool (CMA) to reduce symptoms of acute anxiety and other emotional distress.

• Awareness – Notice your body, hands, legs and feet. Orient to self, place, date and time.
• Breathe – Three long comfortable deep breaths with prolonged exhale.
• Count – Three things you can see, hear, feel, smell and taste.
• 1 Thing – What is the one next thing for you to do right now?
• 2 Strengths – What are two strengths you can draw on (internal or external)?
• 3 Thanks – What are three things you are grateful for?

Care for yourself

Exercise, sleep, laugh, be kind and learn to enjoy down time.

• Ensure that your family has accurate information about COVID-19 and how they can protect themselves.
• Reinforce the importance of making time for one another and maintaining family routines.
• Inform your family on how they can support one another in managing the stresses associated with having a loved one working as part of the COVID-19 response.

For more information on managing the mental wellbeing of your child during the pandemic see Maintaining Regular Primary Care Practice in the COVID-19 Context > Child mental health.

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 OHIP Bulletin 4754 COVID-19 Advance Payment Program (MOH, April 22, 2020) for details.

See the OMA’s COVID-19 Advanced Payment Program FAQs [login required] (OMA, June 19, 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).

See CMA’s Financial guidance for physicians during COVID-19 (CMA, August 20, 2020) for details on COVID-19 financial supports for providers.

See OMA’s Financial relief for physicians (OMA, June 19, 2020) [login required] for a multitude of financial aid resources including key federal programs available for eligible physicians.

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