Primary Care Operations in the COVID-19 Context

Last Updated: October 22, 2020

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This resource 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.

Your one-stop shop for all of your COVID-19 related needs, including clinical guidance, maintaining regular primary care practice in the COVID-19 context, social care guidance, local services and more.

Primary care is integral to an effective health care system and it is essential that patients continue to seek care during the COVID-19 pandemic. This resource outlines recommendations and tangible strategies to support you in providing optimal patient care during the COVID-19 pandemic.

Check back regularly for the latest updates.

Click on the sections below to get started:

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Wave 2: Planning for fall and winter

The following section was developed with input from and support by Ontario College of Family Physicians (OCFP), Association of Family Health Teams of Ontario (AFHTO), Ontario Medical Association (OMA) SGFP, Nurse Practitioners’ Association of Ontario (NPAO) and Registered Nurses’ Association of Ontario (RNAO).

It has also been reviewed and endorsed by the Provincial Primary Care Advisory Table established by the Ministry of Health. For more information, including organizations and members involved, see the Acknowledgement and legal section.

Last reviewed: September 3, 2020
Last updated: September 15, 2020

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September – October: before the start of flu season

Obtain and optimize PPE supply

  • PPE supply: Community-based family physicians and nurse practitioners can receive PPE at no cost through the province’s pandemic supply. Use Ontario Health’s Critical PPE: Intake Form or the Ontario Workplace PPE Supplier Directory.  This provincial stockpile is available on a transitional basis.
  • PPE optimization: Current Ontario Health guidance requests that where feasible, health care organizations:
    • implement the use of reusable instead of disposable PPE
    • re-use surgical masks, ensuring safe storage between use and hand hygiene after handling

Proactive outreach to all patients

Primary care providers in Ontario are facing diverse challenges across practice settings. Whether your practice has already expanded services and taken steps to address your backlog, or you’re still getting started, here are some resources to support this complex work.

Numerous resources have identified high-risk populations such as the frail elderly for visit prioritization – however, patients not included in these groups are at risk of ‘falling through the cracks’ – which may have the effect of patients presenting later in the fall, and in poorer health.  The compounding issues of concerns about COVID-19 transmission during visits, as well as patient delay or avoidance in seeking care, primary care providers are in a position where more proactive outreach on their part is needed to ensure patients receive the care they need – both routine and urgent care, virtually or in person.

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.

Putting it into practice
Determine appropriateness of virtual vs. in-person care

For information about determining appropriateness of virtual vs. in-person care, see:

Leverage your EMR to identify patients

When running reports in your EMR to identify patients consider the following:

  • Structured information (birthdate, sex) is typically the most easily queried.
  • • You can use your EMR to search for specific health condition, immunization history, last visit date and other information about your practice. You can generate a report to pull the data from the EMR.
  • Consider creating searches using the patient’s CPP (e.g. Problems/Diagnosis list).
  • Reports particularly useful at this time would include:
    • Specific chronic conditions
    • A combination of last date seen OR last note made OR last date billed within your chosen date range (last 6 months, last 9 months, etc)
    • Preventative Care Queries/Preventative Care Summary Reports for active patients in need of cancer screening

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.

October – December: prepare for flu season

In 2018-2019, only 43% of adult Canadians 18-64 with chronic medical conditions received the flu vaccine, far short of the national 80% target (PHAC, 2019). With those populations at greater risk for more severe illness, and acute care settings at risk for being overburdened due to the pandemic, , primary care has a critical role to play in the effort for a successful 2020-2021 flu campaign.

Aside from physically administering the vaccine, communication by trusted health professionals about the importance of the vaccine is directly linked to its uptake: 69% of survey respondents reported that the opinion of their family doctor, general practitioner or nurse practitioner was an important factor in their decision to get the flu vaccine. (PHAC, 2019). Key health professional groups should consider engaging in or supporting public education campaigns related to the importance of receiving the flu vaccination, the variety of options available, the safety precautions in place and the need to plan in advance.

Role of Assessment Centres: Coordination across local health providers has been led by the Ontario Health Regions and associated COVID-19 Regional Response Structures. Primary care practices can contact their Health Region, local Ontario Health Team (OHT) or hospital to discuss partnerships and Assessment Centre operations for fall/winter 2020-21.

Comparing COVID-19, flu, and common cold presentations

The table below compares the onset, incubation period, symptom duration, severity, symptoms and red flags for emergency care between COVID-19, flu and the common cold.

Wave 2: Flu vaccination and flu vaccination clinics New

The following section was developed with input from and support by Ontario College of Family Physicians (OCFP), Ontario Medical Association (OMA), Association of Family Health Teams of Ontario (AFHTO), Ontario Medical Association (OMA) SGFP, Nurse Practitioners’ Association of Ontario (NPAO) and Registered Nurses’ Association of Ontario (RNAO).

It has also been reviewed and endorsed by the Provincial Primary Care Advisory Table established by the Ministry of Health. For more information, including organizations and members involved, see the Acknowledgement and legal section.

Last reviewed: October 20, 2020
Last updated: October 22, 2020
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To support widespread flu vaccination during the COVID-19 pandemic, it is recommended that healthcare providers:
  • Receive influenza vaccine themselves to help prevent transmission of influenza to their patients.
  • Recommend patients receive the vaccine. Communication by trusted health professionals about the importance of the vaccine is directly linked to its uptake.
  • Use every opportunity to vaccinate people at risk, even after influenza activity has been documented in the community.
  • Discuss the risks and benefits of the vaccine with patients, as well as the risks of not being vaccinated.
  • Remind patients about influenza prevention practices.
  • Consider engaging in or supporting public education campaigns related to the importance of receiving the flu vaccination, the variety of options available, the safety precautions in place and the need to plan in advance.

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.

A shorter observation period should be considered only if the recipient:

  • has a past history of receipt of influenza vaccine;
  • has no known history of severe allergic reactions to any component of the influenza vaccine being considered for administration;
  • no history of other immediate post-vaccination reactions (e.g., syncope with or without seizure) after receipt of vaccines;
  • will not be operating a motorized vehicle or self-propelled or motorized wheeled transportation (e.g., bicycle, skateboard, rollerblades, scooter), or machinery for a minimum of 15 minutes after vaccination; and
  • is accompanied by a responsible adult/parent, who is not getting vaccinated at the same time, who will act as a chaperone to monitor the vaccine recipient for a minimum of 15 minutes post-vaccination. This is a requirement for children and adults. The vaccine recipient and chaperone must be aware of when and how to seek post-vaccination advice and given instructions on what to do if assistance and medical services are required; and agree to remain in the post-vaccination waiting area for the post-vaccination observation period (5 minutes) and to notify staff if the recipient feels or looks at all unwell before leaving which would necessitate a longer observation period.

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).

Vaccination in primary care

Though COVID-19 has created a complex environment for vaccination delivery, family physicians and nurse practitioners should maximize all opportunities to deliver the flu vaccine. Practices will need to consider alternate means of delivery for the 2020-2021 season and develop outreach strategies. In some regions, Ontario Health Teams, in partnership with local long-term care facilities and home-care agencies, hope to work with community-based practices to administer the vaccine to vulnerable or housebound persons and to those living in congregate settings.

Putting it into practice

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.

Vaccinator PPE

  • Wear a medical mask and eye protection when administering the vaccine; add gloves for intranasal influenza vaccine. Aerosol precautions not necessary.
  • Perform hand hygiene before and after providing immunization

Other staff and volunteer PPE

  • Wear a medical mask when unable to maintain a two-metre physical distance from others (staff and patients).
  • If not behind a barrier, staff conducting screening of patients should wear full droplet precautions (medical mask, eye protection, gown, gloves)

Patients and visitors

  • Wear non-medical mask or face covering. This may be waived for young children and others for whom mask use is problematic.

Operating a flu vaccination clinic

If your clinic doesn’t have the resources to run a vaccination clinic:
  • Consider forming a cooperative clinic with other local medical practices, NP clinics, or home care providers.
  • Consider dedicating time each week to home vaccination visits for seniors, patients with mobility issues, and children 6 months to 6 years who are not eligible for vaccination at a pharmacy.
  • Consider partnering with home care agencies or sending primary care physicians/nurses weekly to patient’s homes.
  • Direct patients to flu vaccination sites in your region. See Ontario flu vaccination clinics by region (CEP, TheHealthLine, 2020).

Selecting a type of clinic

General considerations during the COVID-19 pandemic:
  • Clinic locations and processes that were successful in previous years might not be appropriate due to new safety precautions. Even if the same space is used, it will likely need to be set up and function differently.
  • Outdoor clinics may provide the best option for staff and patient safety.
  • Smaller indoor clinics may reduce exposure risk for staff and patients as they allow for better physical distancing.
Consider populations to be served, environmental conditions, and individual site capability when selecting the type of clinic. Options include:
  • Office-based clinics
  • Offsite indoor clinics: held in indoor locations such as a school, church, auditorium, theatre, pharmacy, or inside a medical facility in a hallway, classroom, or cafeteria.
  • Walk-through clinics: held in an outdoor tent outside a medical facility.
  • Curbside or drive-through clinics: larger-scale operations held at fixed or rotating locations, including community buildings with a marquee, car washes, warehouses, insurance inspection stations, arena parking lots or drive-through tents erected for the occasion.
  • Mobile clinics: held out of vans or buses

Clinic implementation checklists

Click below on the implementation checklists for information and actionable advice on:

  • setting up your clinic: selecting a location, clinic layout, patient flow, accessibility, signage, supplies and utility considerations
  • operating your clinic: scheduling and booking appointments, staffing, cleaning, screening and vaccine administration
  • cold chain management: setup, storage, daily checklist and anticipating power outages

Additional resources

Learn from another primary care vaccination clinic

Flu shots and flurries: how Red Lake FHT organized a parking lot clinic during COVID-19

Tip: Use who you can. If nurses and other medical staff are burned out, use community health partners like social workers, dieticians, etc. to step in to support roles.

  • Team A: 1 vaccinator, 1 administrator
  • Team B: 1 vaccinator, 1 administrator
  • Team C: 1-2 staff to manage traffic and parking
  • Schedule in 45-minute blocks:
    • 15 min: Vaccinations
    • 15 min: Observation
    • 15 min: Team warm-up inside, redrawing, administrative tasks, etc.
  • Stagger teams by 15 minutes. (Example, Team A’s first block is 9 am, Team B’s first block is 9:15).
  • Patient flow: start with 8-10 patients per 15 minutes and increase as staff comfort/ability allows.
  • Tip: Ask patients to arrive 15 minutes early.

Red lake sample schedule

Prep tips

  • Outreach via Facebook 24-48 hours before clinic.
  • Set aside a dedicated cell phone # for vaccination patients, so they don’t tie up clinic phone lines.
  • Print billing sheets in the morning. Use highlighters to identify:
    • Patients over 65 who can receive high dose if available
    • Young children who might need a 5/8ths needle
  • Prepare trays in advance.
  • Weigh down or secure garbage bags and empty sharps containers so they don’t blow away.
  • Have rescue meds close at hand and ensure all staff know where to access them.
  • Leave 1 parking space empty between cars so teams can maneuver carts between and around.

Encounter Logistics

  • Administrator:
    • Have list ready, confirm names of patients
    • Screen for COVID-19 symptoms
    • Quick consent
    • Confirm observation period and instruct patients to honk if they have a problem
    • Document injection side with R/L on billing sheet
    • Assist with cotton ball/tape for injection site
  • Vaccinator:
    • Vaccinate car driver first, so their observation period is already underway

Determining when to schedule in-person vs remote visits

Last reviewed: June 19, 2020
Last updated: September 9, 2020
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Per the Ministry of Health (May 26, 2020), non-essential and elective in-person services carried out by health care providers may be gradually restarted, where appropriate.  

The determination of which services should be provided remotely and which should be provided in-person should be made by healthcare providers guided by best clinical evidence and according to the following 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.

Clinical scenarios

That can be safely assessed and treated remotely (Virtual Care Playbook, CMA, 2020):
  • Mental health issues.
  • Skin problems (have patient submit photos in advance as resolution is much better than a high-quality video camera).
  • Urinary, sinus and minor skin infections (pharyngitis too if you can arrange throat swabs).
  • Sexual health care, including screening and treatment for sexually transmitted infections, and hormonal/oral contraception.
  • Travel medicine.
  • 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).
  • Lab, imaging and specialist reports.
  • Other assessments that do not require palpation or auscultation.
That may warrant an in-person visit (OCFP, March 26, 2020):

Putting it into practice

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.

Readiness assessment for delivering in-person care

The following section has been reviewed and endorsed by the Provincial Primary Care Advisory Table established by the Ministry of Health. For more information, including organizations and members involved, see the Acknowledgement and legal section.

Last reviewed: June 19, 2020
Last updated: June 19, 2020
Jump to:

The full spectrum of primary care services can be provided if safety protocols are implemented and capacity exists within the practice and local healthcare community. The CEP has developed this section to support primary care providers and their staff as they gradually increase the provision of in-person services during the COVID-19 pandemic. Adapted from the Ministry of Health’s COVID-19 Operational Requirements: Health Sector Restart (June 15, 2020), this section applies to all primary care settings.

While remote services should form the cornerstone of practice during the pandemic, clinics offering in-person visits should complete a risk assessment as per the Ministry of Health’s Directive #2.  This section provides clear guidance on how to perform and implement a risk assessment in primary care. It represents the first step of an iterative process that will evolve in response to feedback and as COVID-19 evidence and best practices evolve. Feedback is encouraged and can be submitted here.

Step 1: Lay out a plan for mitigating COVID-19 transmission for in-person visits

COVID-19 hazards are:
  • Person-to-person transmission (patients, staff, and visitors)
  • Surface transmission
Identify

Under what circumstances can transmission happen?

  • Consider all aspects of the work conducted in a clinical setting – people, places, equipment, and supplies. Include non-routine activities such as deliveries, maintenance and repairs.
Anticipate

What are factors contributing to high-risk scenarios?

Consider:

  • Patients at particular risk for worse outcomes (patients with comorbidities, older adults).
  • Patients at risk for transmitting disease (children, essential workers).
  • Foreseeable risks (cleaning products running out, patient tests positive after visiting office).
  • Training, skill, and experience of healthcare workers.
Prioritize

How likely are the possible consequences to occur?

Consider:

  • Probability: the likelihood of the hazard or risk occurring.
  • Frequency: how many people will be exposed and how often.
  • Severity: the potential for the hazard to cause serious harm.
Assess controls

Is the risk controlled effectively, or is further action required?

  • If further action is required, see Step 2 to assess mitigation strategies.

Step 2: Assess possible mitigation strategies to determine feasibility for your practice setting

Clinics should assess strategies methodologically to determine what measures are feasible for each unique setting. Remember that where feasible, strategies should be adopted based on effectiveness and not ease of implementation.

Control strategies

Listed in order of effectiveness for risk reduction from most effective to least effective

Elimination

Can you physically remove the hazard?

Examples: reducing person-to-person transmission

  • Restrict patients from coming in person to the clinic. (See Step 3, balancing remote and in-person care)
  • Have staff self-monitor and not come to work if they develop symptoms. Consider using the provincial COVID-19 Self-Assessment.
  • Ensure there is space to isolate healthcare staff who develop symptoms.
  • Restrict extra visitors such as multiple family members, non-urgent services or deliveries, forms and paperwork pick up.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
Substitution

Can you replace the hazard?

Examples: reducing person-to-person transmission

  • Offer remote (virtual/telephone) visits. (See Step 3, balancing remote and in-person care).
  • Have people wait outside instead of in the waiting room, and text/call when ready.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
Engineering controls

Can you isolate people from the hazard?

Examples: reducing person-to-person transmission

  • Set certain days/times to see patients with acute respiratory/infectious illness. Send these patients directly to the exam room.
  • See populations at higher risk of COVID-19 complications at separate times (i.e. first thing in the morning).
  • Incorporate physical (plexiglass) barriers and spacing in the waiting area.
  • Screen all visitors for COVID-19 before entry into clinic and use signage to instruct patients about protocols.
  • Set specific times (when no patients are present) for non-clinical visitors (maintenance, repair, cleaning) to come to clinic.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
Administrative controls

Can you change the way people work/move through the clinic?

Examples: reducing person-to-person transmission

  • Set certain days/times to see patients with acute respiratory/infectious illness. Send these patients directly to the exam room.
  • Have only certain staff see patients with acute respiratory/infectious illness, maintaining physical distancing where possible.
  • Perform POC Risk Assessment before each patient encounter.
  • Have all patients/visitors practice hand hygiene and wear masks for source control.
  • Space chairs to ensure physical distancing and mark out spaces for lineups on the floor.
  • If staff have recently traveled or been exposed to COVID-19, contact your local health unit for directive.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
PPE

Can you protect people with protective equipment?

Examples: reducing person-to-person transmission

Is this strategy feasible?

  • No: Refer patient to a setting equipped with required PPE.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.

Step 3: Find a balance between remote and in-person care

Efforts should be undertaken to reduce in-person visits, particularly when local disease burden is high. This does not require an “either/or” approach, but a thoughtful analysis of what aspects of patient care can be performed remotely in order reduce patient time in-clinic. It is recommended that remote visits be conducted first, followed by a curtailed in-person visit only as necessary. For detailed information on condition-specific information, see CEP’s COVID-19 Resource Centre.

Consider:

Patient access
  • Does the patient have access to the technology necessary to participate in remote visits? Telephone, internet/computer access?
  • Do they have the financial resources to use technology for a remote visit? (Some patients don’t have/can’t afford a data plan that would support a consultation.)
  • Does the patient have sufficient technological literacy to participate in remote visits? Download attachments, follow links, watch videos, send photos/videos?
  • Does the patient have access to a quiet and private place, where confidentiality can be maintained?
  • Are there language or other communication barriers that would make remote care difficult?
Clinical concerns
  • Is a physical exam necessary for diagnosis, treatment, or management?
  • See Determining when to schedule in-person vs remote visits for a guide on the problems that can be safely addressed and treated remotely.
  • Can a provider do a brief check in to monitor any deterioration in symptoms and can patients easily update providers on any changes?
  • Are there necessary measurements, scans, samples that can only be taken in-clinic? How often do these need to be taken?
  • Do remote consultation tools allow for appropriate level of assessment? Do photos/videos allow for high enough resolution? What are the targets for home measurements?
  • What is a reasonable amount of time for the patient to spend on the waitlist without negatively affecting health outcomes?
  • Are self-management tools and supports available to help the patient manage their condition at home? Apps, worksheets, videos, patient educators, helplines?
Community capacity
  • Would it be feasible to form a local network to “share” patients, as a way of expanding beyond the capacity of your individual setting?
  • Are community services available for coordinated care? (Assessment centres, community laboratories, pharmacies, specialists, rehabilitation)
  • How will community partners be impacted by an increase in services?
  • Are provincial services available to support care (ie. If patient is requesting a pap test, are these currently being processed provincially?)
Patient communications
  • Ensure patients know the clinic is open for services, as well as how to contact the clinic. Use physical signage, as well as outgoing voicemail and email signatures, and clinic website. Use physical signage for screening, hand hygiene, proper mask use, and respiratory etiquette. Signage should be accessible to all patients and visitors, reflecting the cultural context of the region and patient community. CMA has signage on high-level protections and symptoms available in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.
  • Communications should be clear and timely for patients to ensure support across the full continuum of care. Set expectations about what to expect for in-person and remote (virtual and telephone) visits, how to provide information (consent documents, self-monitoring logs), how information will be shared (prescriptions, referrals, self-management resources), and the process for scheduling follow-ups.
  • Accept feedback and proactively request input. Identify patients/caregiver suggestions, expectations, and areas of concern.

Operational requirements for in-person care

The following section has been reviewed and endorsed by the Provincial Primary Care Advisory Table established by the Ministry of Health. For more information, including organizations and members involved, see the Acknowledgement and legal section.

Last reviewed: June 19, 2020
Last updated: October 6, 2020
Jump to:

Screening and testing

Active screening
  • Patients and visitors should be screened over the phone before coming to the clinic.
  • Where patients present in-person without phone screening, patients and visitors should be screened upon arrival at the clinic.
  • If they screen positive, appointment should be deferred if possible and the individual referred for testing. If the appointment is urgent, refer the patient to the emergency room.
  • If a patient screens negative, appointment can be made. Remind the patient that if they develop symptoms between the time of the phone screening and the appointment, they should call the clinic for further instructions instead of coming in person.
  • Patients and visitors should be screened on-site before entering the clinic.
  • Patients and visitors should wear their own face covering. If they do not have one, provide one prior to entrance.
  • In-person screening must include staff protection as follows:
    • Best option: staff should be behind a plexiglass barrier.
    • Second option: If a barrier is not available, a 2-metre distance should be kept between screening staff and individuals being screened.
    • Last resort: if a barrier is not available and 2-metre distance is not possible, screening staff should wear PPE according to Droplet and Contact precautions.
  • If an individual screens positive, appointment should be deferred if it will not compromise patient safety, and the individual referred for testing.
  • Visitors who screen positive should not be permitted to accompany or visit the patient, pending test results. If the patient cannot attend the visit without the visitor, reschedule the visit for when an alternative visitor can accompany the patient.
Passive screening
  • Information about screening should be included on outgoing voicemail and email signatures, appointment confirmations, and clinic website, with links to the provincial online self-assessment tool where applicable.
  • Signage must be posted at the entrance to the clinic and in the reception area, requiring all patients and visitors to wear face coverings (if available and tolerated), perform hand hygiene, and report to reception to self-identify.
  • Signage should be accessible to all patients and visitors, reflecting the cultural context of the region and patient community. Download signage on MOH site, or see CMA’s resources in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.
Care for positive-screened patients
  • Before every patient interaction, healthcare workers must conduct a point-of-care risk assessment to determine the level of precautions required.
  • Healthcare providers may provide care to patients who screen positive for COVID-19 only if they have the PPE required to follow Droplet and Contact precautions ((Surgical/procedural mask, isolation gown, gloves, eye protection -goggles or face shield)and the sufficient knowledge to follow proper donning and doffing procedures. Practice donning and doffing with a buddy if staff are still being trained on procedures.
  • If your setting does not meet these requirements, divert the care of the patient:
    • to the emergency department if the medical reason for the appointment is urgent
    • to assessment centre for assessment and testing if the medical reason for the appointment is not urgent. In the instance where the assessment centre is only able to provide a swab, and not manage the clinical presentation, a follow up appt should be booked when swab result is negative to finish assessment and management
  • Patients who screen positive should be given a surgical mask and perform hand hygiene.
  • The patient should be isolated.
  • If an exam room is available, place the patient in the room with the door closed, avoiding contact with other patients if possible.
  • If an exam room is not available, instruct the patient to wait outside the clinic and call/text them when a room is available.
  • In the exam room, the patient should have access to tissues, hand sanitizer, and a touch-free/foot pedal-operated wastebasket.
  • Instruct patient to take their mask home with them (do not leave in waiting room) and provide information on doffing procedures.
Care for negative-screened patients
  • Mask required and eye protection recommended for interactions with and within 2 meters of patients who screen negative.
  • No gown or gloves unless consistent with Routine Practices for specific patient symptoms.
  • Request all patients and visitors keep masks on.
Testing
  • All patients with at least one symptom should be tested.
    • Asymptomatic patients who are concerned they have been exposed to COVID-19 should be tested.
    • Asymptomatic patients who are at risk of exposure through their work (essential workers) should be tested.
  • If your setting is equipped, testing can happen on-site. All testing requires full droplet and contact PPE, even if the patient is asymptomatic.
  • If not equipped to offer testing, cases should be referred elsewhere (an assessment centre, Telehealth, etc.)

Risk assessment and mitigation

Operational assessment
Employer responsibilities
  • Have written measures for staff safety, including infection monitoring and control.
  • Ensure stable supply of essential supplies (drugs, PPE, hand hygiene and cleaning supplies).
  • Source and provide PPE through the regular supply chain, including regional leads or the provincial PPE Supplier Directory.
  • Ensure adequate staffing for services. Use information from Readiness assessment for primary care settings to ensure staffing needs are aligned with PPE availability.  Consider preserving staff capacity where possible in preparation for future outbreaks.
  • Ensure service offerings align with related services such as laboratory diagnostics, rehabilitation, etc.
  • Work collaboratively with local region and other primary care providers where possible to ensure coordinated service offerings.
Physical areas
  • Ensure there is sufficient space to maintain 2-metre social distancing between people.
  • Redesign physical settings and interactions to minimize contact.
  • Provide face coverings where physical distancing is not possible.
  • Request all patients and visitors wear face coverings if they have them.
  • Provide tissues and lined garbage bins for patients and staff.
  • Ensure sufficient supplies for proper hand hygiene: hand washing stations and 70% alcohol hand sanitizer.
  • Post signage about symptom screening, hand hygiene, proper mask use, and respiratory etiquette. CMA has signage on high-level protections and symptoms available in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.
Daily operations
  • Employers and healthcare workers should determine which visitors are essential, and restrict all other visitors from entering the clinic.
  • Where possible, schedule symptomatic patients for end-of-day visits.
  • Minimize the time patients spend in the waiting room. If possible for patient, have them wait outside or in the car – otherwise, stagger appointments so that social distancing can be maintained.
  • Minimize staff in the healthcare setting. Consider which roles can be performed remotely, or develop shifts to meet the necessary number of on-site staff while ensuring social distancing.
  • Ensure healthcare workers, staff, and patients use proper PPE across clinic settings and have adequate observed training in donning and doffing.
  • Healthcare providers should preserve the use of PPE by applying other mitigation strategies identified through the Readiness assessment for primary care settings.
  • If a patient comes into the setting and later tests positive, contact local health unit for advice and guidance about the risk of possible exposure for healthcare workers.
Healthcare worker infection control
  • Staff should self-monitor for symptoms and not come to work if they develop symptoms. Consider using a daily screening form, log or app for staff as a prompt for this.
  • Ensure there is space to isolate healthcare staff who develop symptoms.
  • If a healthcare worker develops symptoms at work, they should put on a mask if not already wearing one, isolate, and they should be sent home as soon as possible.
  • If they are critical to operations, healthcare workers who have returned from travel within the last 14 days (outside of Canada or from a COVID infected area within Canada) or had a confirmed exposure to a COVID-19-positive patient must self-monitor for symptoms but may continue to work with specific precautions.
Cleaning
  • After every patient visit (symptomatic or asymptomatic), sanitize treatment areas, horizontal surfaces and equipment before another patient is brought in. Remember to include administrative equipment – mouse, keyboard, printer, etc.
  • All common areas should be regularly cleaned, at least twice daily.
  • Plexiglass barriers should be integrated into cleaning schedule and cleaned daily.
  • Non-essential items should be removed from patient care areas to avoid contamination.

Resources for implementation

Foundational/broad overview resources
COVID-19 screening, assessment, testing, signage
Healthcare worker infection control
Decision-making supports for service expansion

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.

Delivering patient care remotely

Last reviewed: September 30, 2020
Last updated: June 25, 2020
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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 remotely (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 formats can be used to conduct your remote 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 remote patient encounter, consider the following:

Frequently asked questions (FAQs)

The technology required to conduct a remote 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 remote 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 remote patient encounter, 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.

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 when providing care over the phone.

Key recommendations:

  • Consider using earphones/headphones to improve sound quality and also to protect your patient’s privacy.
  • Limit any background noise
  • Speak slowly and clearly, taking frequent pauses to allow patients to ask any questions.
  • 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 if there is a silence in the call, you are still listening to them.
  • If your patient presents symptoms that require a visual, for example dermatological issues, schedule a follow-up appointment with them using a video platform, if feasible.

No, you are not required to use OTN.

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.

With many working remotely, it is important to ensure you have good cybersecurity measures in place. The Cyber Centre has seen an increase in reports of malicious actors using COVID-19 in phishing campaigns and malware scams.

Good cyber hygiene practices include:

  • Use unique passphrases and complex passwords.
  • Use anti-virus or anti-malware software on computers.
  • If you receive questions from your patients regarding suspicious emails that appear to be from health care providers, let your patients know the type of emails they can expect from you (scheduling and reminders for appointments) and also the email address from which your clinic is sending information.

For more information about cybersecurity and COVID-19, see the OMA’s page on Cybersecurity (OMA, 2020) [login required].

Putting it into practice

During your remote patient encounter

A remote 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 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 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
Best practices
  • 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 encounter
  • Regardless of the encounter format (telephone, videoconferencing, OTN, etc.), the services provided must be documented in the patient’s medical record or the service is not eligible for payment.
After completing your 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.

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.

Personal protective equipment (PPE)

Last reviewed: October 13, 2020
Last updated: October 1, 2020
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The hierarchy of controls refers to the availability, support and appropriate use of physical barriers between healthcare workers and an infectious agent/infected source to minimize exposure and prevent transmission (Public Health Ontario).

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).

What to wear, when

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).

Putting it into practice

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).

When caring for patients with suspected or confirmed COVID-19, use the following guidance to determine the level of PPE required (PHO, July 27, 2020):

* Public Health Ontario (2013) outlines Routine Practices for preventing the transmission of acute respiratory infections. Universal masking is not included as Routine Practice, however, for the purpose of source control the MOH now recommends that surgical/procedural masks be worn by HCWs for the full duration of shifts if physical distancing cannot be maintained with patients and/or other HCWs (MOH, September 4, 2020).

PPE used for droplet and contact precautions

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).

Scroll (left-right) for details

  • Surgical mask

    When to use

    • Use for all patient encounters that involve less than 6 feet of separation, regardless of COVID-19 status.

    When to discard

    • Extend use as long as possible.
    • Discard if wet, damaged, soiled, or removed (e.g. to eat or drink), or you exit the patient care area.
  • Eye protection (goggles or facemask)

    When to use

    • Use when providing care to a patient who has suspected or confirmed COVID-19.
    • Consider using for all patient encounters that involve less than 6 feet of separation, regardless of COVID-19 status.

    When to discard

    • Extend use as long as possible if caring for multiple patients using contact and droplet precautions.
    • Discard or sterilize according to manufacturer guidance after exiting patient room.
  • Isolation gown (disposable or cloth)

    When to use

    • Use when providing care to a patient who has suspected or confirmed COVID-19.

    When to discard

    • Extend use as long as possible if caring for multiple patients using contact and droplet precautions.
    • Discard after exiting examination room if not caring for multiple patients using contact and droplet precautions.
    • Launder cloth gowns according to routine practices (CDC). Do not take PPE home to launder.
  • Latex or nitrile gloves

    When to use

    • Use when providing care to a patient who has suspected or confirmed COVID-19.

    When to discard

    • Discard after any of the following: immediately after the activity for which they were used; when moving from a contaminated body site to a clean body site for the same patient; after touching a contaminated environmental surface; or when integrity of glove is compromised.
  • N95 mask*

    * Not part of Droplet and Contact precautions (Medical/procedural masks suffice and should be used if available)

    When to use

    • Use when performing aerosol generating procedures (AGMPs) on a patient who has suspected or confirmed COVID-19

    When to discard

    • Discard after performing an AGMP on a patient who has suspected or confirmed COVID-19 (i.e. do not reuse for multiple AGMPs)
    • Discard if wet, damaged, soiled, or removed (e.g., to eat or drink), or you exit the patient care area.

PPE inventory and quality control

Accessing 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):

Regional Leads – PPE and Critical Supplies
Toronto

Leads

  • Rob Burgess (Robert.Burgess@sunnybrook.ca)
  • Nancy Kraetschmer (Nancy.Kraetschmer@tc.lhins.on.ca)
Central

Leads

  • Debbie Roberts (Debbie.Roberts@lhins.on.ca)
  • Susan Gibb (Susan.Gibb@lhins.on.ca)
North

Leads

  • Matthew Saj (sajm@tbh.net)
  • Michael Giardetti (giardetm@tbh.net)
East

Leads

  • Paul McAuley (Paul.McAuley@3so.ca)
  • Leslie Motz (lmotz@lh.ca)
West

Lead

  • Toby O’Hara (Toby.OHara@hmms.on.ca)

Inventory management initiatives

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).

Quality control

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.

Donning and doffing PPE

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).

Putting it into practice

Donning
Doffing
Donning and doffing tips
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Donning and doffing tips

Eye protection should be worn over prescription glasses, as prescription glasses are not adequate eye protection (Public Health Agency of Canada, 2020).

Donning

Isolation gown (disposable or cloth)

  • Have a colleague tie your gown for you.

Latex or nitrile gloves

  • Choose the correct glove size.
  • Keep nails trimmed and polish free.
  • Avoid wearing jewelry on hands on arms.

Headbands, caps and other garments

  • Should only be worn if they do not interfere with proper fitting of PPE. Must be incorporated into the donning process and treated as another PPE item.
Doffing

Mask

  • The practice of removing only one side of the mask to eat, talk, or perform other activities introduces a high risk of self-contamination and contamination of the mask.
  • Always fully remove and discard (or appropriately store in the case of re-use) the mask, then perform hand hygiene.

Order of removal

  • After exposure to a patient who is positive for COVID-19, remove gloves and gown while in the patient care area, then exit room and perform hand hygiene (Use of PPE, Centers for Disease Control).

Headbands, caps and other garments

  • Must be incorporated into the doffing process.
  • Non-medical equipment worn in patient care settings must be subjected to the same washing/sterilization protocols as PPE.

Reducing discomfort associated with PPE use

Frequently asked questions (FAQs)
  • Maintain cool environment.
  • Topical moisturizers and petroleum jelly or baby napkin cream (only if use does not interfere with proper fit).
  • Use alternate mask type if one type is particularly irritating.
  • Take breaks from respirator use, with careful attention used when donning and doffing (especially when the respirator is being re-used).
  • Caps, headbands or fabric with buttons for straps of masks may reduce ear irritation but may increase pressure on front of face. This should only be done if it does not interfere with the proper fit of the PPE. These items must be integrated into proper donning/ doffing cycle and reprocessed or laundered appropriately with other PPE.
  • Use full face-shield.
  • Change to shorter, rotating shifts.
  • Lubricants to reduce friction between skin and goggles.
  • Avoid tight equipment.
  • Wet compression for severe skin indentations.
  • Avoid irritating agents when washing face.
  • For overheating: Avoid plastic gowns, maintain hydration, use shorter, rotating shifts and over-tight equipment.
  • For irritation: wear a barrier between body and PPE (unless overheating is issue) and avoid over-tight equipment.
  • Ensure hands are dry before donning gloves.
  • Choose non-irritating gloves (avoid latex).
  • Choose correct glove size.
  • Moisturize often, but avoid moisturizing immediately prior to donning gloves. Moisturizer is not sterile and can interfere with glove integrity.
  • Avoid hot water.
  • Rinse soap well.
  • Use hypoallergenic products (including at home).
  • Pat hands dry with paper towel instead of rubbing.
  • Moisturize often using a fragrance-free lotion or cream that contains humectants, fats and oils at least twice a day for prevention, and as often as feasible (including at work) for treatment.
  • Barrier cream efficacy unclear, such products are expensive, not removed by handwashing, and may = glove breakdown.
  • Avoid use of hand sanitizer immediately before or after handwashing.
  • Hand sanitizer is less likely to cause initial skin irritation than soap and water, but is more likely to cause acute pain once irritation occurs.
  • Ensure hands are dry before donning gloves.

Emerging evidence

PPE extended use, reuse and reprocessing

Extended use involves wearing the same PPE across multiple patient encounters WITHOUT taking it off. Extended use carries less risk of self-contamination and is therefore preferred to reuse.  
Reuse involves removal, storage, re-donning, and reuse of the same, potentially contaminated PPE items WITHOUT reprocessing in between. This is one of the principal sources of risk to health care workers (WHO). 
Reprocessing involves sterilizing equipment for reuse. In the context of PPE shortages, re-processing refers to sterilizing single-use equipment that was not designed to maintain integrity during cleaning or across multiple uses. If available and intact, expired stockpiles of single-use PPE are preferable to reprocessing single-use PPE. (PHO, April 4, 2020).

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).
Scroll (left-right) for details
  • Surgical mask

    Contingency capacity

    • Extend use of masks for repeated close encounters with several different patients without removing in between.
    • Restrict facemasks to use for HCP rather than for patients for source control.
    • When to discard: when the mask is wet, damaged, difficult to breathe through, soiled or removed.
    Click for Crisis capacity guidance
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    Crisis capacity

    Implement limited reuse of facemasks by ONE HCP for multiple encounters with different patients – removing the mask after each encounter.

    Selecting items for reuse: Facemasks with elastic ear hooks may be more suitable for reuse.

    Use beyond shelf life

    • Intact masks with no visible signs of damage can be used beyond their shelf life. There is no specific timeframe beyond the expiry dates for masks at which they would no longer be considered suitable for use. Health Canada (4/17/2020)
    • Do not use masks if they are damaged, soiled, discoloured, or if any of the materials are degraded.

    Removal and storage for reuse

    • As it is unknown what the potential contribution of contact transmission is for SARS-CoV-2, care should be taken to ensure that healthcare workers do not touch outer surfaces of the mask during care, and that mask removal and replacement be done in a careful and deliberate manner.
    • Face masks should be carefully folded so that the outer surface of the mask folds inward against itself, in order to prevent the outer surface of the mask from contacting other surfaces (including the storage bag/container).
    • The folded mask can be stored between uses in a clean sealable paper bag or breathable container. Consider adding a user identifier to the strap of the mask.
    • Storage containers should be labelled with the user’s name and disposed of or cleaned after each use.

    When to discard/discontinue use

    • When the mask is wet, damaged, difficult to breathe through or soiled.
    • Place unsoiled, undamaged masks in a clearly labelled, dated receptacle for possible reprocessing after use. Use the bin only for surgical procedure masks.

    Reprocessing

    • Currently there is no clear evidence supporting a validated method for sterilizing and disinfecting surgical/procedure masks

    When no masks available

    • HCP might use homemade masks for care of patients with COVID-19, only as a last resort. This is not considered PPE. See Homemade masks for warnings about the use of homemade masks in healthcare settings.

     

    Adapted from:
    Optimizing Supply of Disposable Face Masks and Respirators (OMA).
    Strategies to Optimize the Supply of PPE and Equipment (CDC, July 17, 2020).

  • Eye protection

    The reuse of eye protection without appropriate reprocessing is strongly discouraged. See WHO Rational Use of PPE During COVID-19.

    Contingency capacity

    • Shift supply from disposable to reusable devices (i.e. goggles, reusable face shields, and 3D-printed face shields).
    • Ensure appropriate cleaning and disinfection between users.
    • Extend use of disposable and reusable eye protection for repeated close encounters with several different patients without removing in between.
    • While the use of both disposable and reusable eye protection can be extended, only reusable eye protection should be sterilized and used again according to usual practice. At the end of a shift, disposable eye protection should be discarded.
    • When to remove: If it becomes visibly soiled or difficult to see through or if damaged (e.g. face shield can no longer fasten securely to the provider, if visibility is obscured and cleaning does not restore visibility).
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    Crisis capacity

    Consider using safety glasses (i.e. trauma glasses) that have extensions to cover the sides of eyes (CDC).

    Cleaning guidance: Use manufacturer instructions.

    When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields, consider:

    • While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.
    • Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.
    • Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.
    • Fully dry (air dry or use clean absorbent towels).
    • Remove gloves and perform hand hygiene.
  • Isolation gown (disposable or cloth)

    The reuse of gowns without appropriate reprocessing is strongly discouraged. See: WHO Rational Use of PPE During COVID-19.

    Contingency capacity

    • Shift gowns toward cloth isolation gowns. Reusable (i.e. washable) gowns are typically made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be safely laundered according to routine procedures.
    • Consider the use of coveralls.
    • When to remove: Disposable gown should be discarded after each patient encounter. Cloth gowns should be laundered after each patient encounter. Do not take PPE home to launder.
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    Crisis capacity

    • Extend use across multiple patients with the same infectious agent in the same location. This can be considered only if there are no additional co-infectious diagnoses transmitted by contact (such as C. difficile) among patients.
    • Reuse the same CLOTH gown after doffing without washing in between. Disposable gowns should NOT be reused as ties are likely to break during doffing process. Care should be taken to ensure that healthcare worker do not touch outer surfaces of the gown during care.
    • When to remove: If the gown becomes visibly soiled or after providing care to a patient (or cohort of patients) infected with the same infectious agent.
    • When no gowns available: Use labcoats, patient gowns, etc.

     

    Adapted from: Strategies for Optimizing the Supply of Isolation Gowns (CDC).

  • Latex or nitrile gloves

    Existing guidance advises against glove washing or reprocessing due to concerns over effectiveness of these practices due to potential loss of glove integrity (WHO, PHO, CPSBC).

  • N95 mask

    All PPE used for aerosol-generating medical procedures (AGMPs), including N95 masks, should not be used for multiple patients.

    Place unsoiled, undamaged masks in a clearly labelled, dated receptacle for possible reprocessing after use. Use the bin only for N95 masks.

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    Crisis capacity

    Use beyond shelf-life

    • Intact masks with no visible signs of damage can be used beyond their shelf-life. There is no specific timeframe beyond the expiry dates for masks at which they would no longer be considered suitable for use.
    • Do not use masks if they are damaged, soiled, discoloured, or if any of the materials are degraded.

    Reprocessing

    • In settings where decontamination can be safely implemented, reprocess N95 respirators using validated sterilization and disinfection methods (OH, August 11, 2020).

    Alternative respirators

    • If medical grade N95 masks are not available, consider using non-medical grade respirators, including N95, N99, N100, R95, R99, R100, P95, P99 or P100 masks. Do not use 3D-printed masks as an alternative.

Homemade masks

Most guidance available on the use of homemade cloth masks is intended for the public, not for healthcare workers.

However, some guidance can be applied to the healthcare setting.
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Homemade Masks

The use of cotton cloth masks as an alternative to medical masks or respirators is not considered appropriate for protection of healthcare workers (WHO, April 6, 2020). As with other PPE items, if production of masks for use in health care settings is proposed locally in situations of shortage, a local authority should assess the proposed PPE according to specific minimum standards and technical specifications.

The CDC suggests that cloth masks are better than no mask at all and can be used when providing care to patients with COVID-19 only if no other commercial masks are available. The CDC has further directions for healthcare providers about the use of cloth masks for source control when medical grade masks are unavailable.

  • If possible, homemade masks should be used in combination with a face shield covering the entire front (extending to the chin or below) and sides of the face (CDC).

Health Canada (2020) urges caution in the use of homemade masks, as they:

  • Have not been tested to recognized standards.
  • May not provide complete protection against virus-sized particles.
  • Do not have edges designed to form a seal around the nose and mouth.
  • Do not use the same fabrics as surgical masks or respirators.
  • Can be difficult to breathe through and can prevent the wearer from getting adequate oxygen.
  • May require frequent adjustment, increasing the amount of times hands come into contact with the face and increasing the probability of infection.

Most guidance available on the use of homemade cloth masks is intended for the public, not for healthcare workers. However, some guidance can be applied to the healthcare setting.

Masks should:

  • Cover and fit snugly around the nose and mouth. A mask that does not fit well around the nose and mouth will be of no benefit.
  • Fit snugly but comfortably against the side of the face.
  • Be secured with ties or ear loops.
  • Include multiple layers of fabric.
  • Allow for breathing without restriction.
  • Be able to be laundered and machine dried without damage or change to shape.

Use and care:

  • Clean cloth masks should be stored carefully to prevent contamination.
  • Proper donning and doffing should be completed, with extra care to not touch the front of the mask when doffing to prevent self-contamination.
  • It is unknown whether the life of a surgical mask can be extended by layering a cloth mask over top. This practice has not been studied and is not currently recommended in any guidelines. Risks of this practice include contamination of surgical mask through donning/doffing cloth mask, as well as moisture getting trapped between the two masks that can saturate the surgical mask and potentially cause microbial growth.
  • Dirty or soiled masks should be removed immediately and placed in secure container for reprocessing.
  • Cloth masks should be washed before re-use. Approved laundering procedures do not exist for cloth masks used in a healthcare setting. HCW may choose to follow the laundering guidance approved for other textiles used in a healthcare setting: A temperature of at least 160°F (71°C) for a minimum of 25 minutes. The use of chlorine bleach assures an extra margin of safety.

 

For greater details:
Strategies to Optimize the Supply of PPE and Equipment (CDC).
Personal Protective Equipment (PPE) use during the COVID-19 Pandemic (OHA, 3/30/2020).
Use of Cloth Face Coverings to Help Slow the Spread of COVID-19 (CDC).

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.

Environmental and equipment cleaning

Last reviewed: October 13, 2020
Last updated: October 21, 2020
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Environmental cleaning

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.

Equipment cleaning

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.

Cleaning schedule

Shared reusable medical equipment

E.g. stethoscopes, blood pressure cuffs, etc.

Clean in between patients and at the end of each shift.

All necessary equipment for treatment

Clean in between patients and at the end of each shift.

Patient contact surfaces

Whether symptomatic or not, after every patient visit, areas within 2 metres of the patient should be disinfected.

 

Clean in between patients and at the end of each shift.

Exam rooms 

E.g. chairs, tables, floors.

Clean at least twice a day.

Frequently touched surfaces

E.g. workstations, cell phones, light switches, door knobs, tables, chairs, door handles, clipboards, front office counter.

Clean at least twice a day.

Infection monitoring and protocols for healthcare workers

Last reviewed: October 7, 2020
Last updated: October 21, 2020
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Self-monitoring and self-assessment

Recommended risk assessments

Point of Care Risk Assessment for healthcare workers

A Point of Care Risk Assessment (PCRA) assesses the task, the patient, and the environment. A PCRA should be completed by the HCP before every patient interaction to determine whether there is a risk to the provider or other individuals of being exposed to an infection, including COVID-19. A PCRA is the first step in routine practices, which are to be used with all patients, for all care and all interactions.

See Point of Care Risk Assessment (PCRA) (AHS, 2020).

Organizational Risk Assessment for health care entities

Each health care entity should conduct an organizational risk assessment (ORA) as a precondition to restarting services. An ORA is a systematic approach to assessing the efficacy of control measures that are in place to mitigate the transmission of infections in a health care setting.

Organizations that employ healthcare workers have a responsibility to provide education and training to healthcare workers regarding the organization’s ORA.

Pregnant healthcare workers

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).

If healthcare worker develops symptoms (including atypical):

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).

COVID-19 resolution and return to work

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.

Ministry of Health guidance (October 1, 2020) has the following criteria for essential healthcare workers returning to work:

Positive test result

Work self-isolation could start after a minimum of 72 hours after illness resolving, defined as resolution of fever (without the use of fever-reducing medications) and improvement in respiratory and other symptoms.

Negative test result

May return to work 24 hours after symptom resolution. If the healthcare worker was self-isolating due to an exposure at the time of testing, return to work should be under work self-isolation (see below) until 14 days from last exposure.

Positive test result

If there has been a recent potential exposure (e.g. tested as part of an outbreak investigation or other close contact to a case), work self-isolation (i.e. return to work) could start after a minimum of 72 hours from the positive specimen collection date to ensure symptoms have not developed in that time, as the positive result may represent early identification of virus in the pre-symptomatic period.

If there is a low pre-test probability (e.g. there has been no known recent potential exposures such as tested as part of surveillance and no other cases detected in the facility or on the unit/floor, depending on the facility size), see Management of Cases and Contacts of COVID-19 in Ontario (MOH, September 8, 2020) for repeat testing guidance. If follow-up testing is negative, the HCW is cleared and can return to work as per usual.

Practicing work self-isolation

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).

New OHIP codes and updates to prescribing rules and regulations

Last reviewed: September 30, 2020
Last updated: October 21, 2020
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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.

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    Notes

    • The services must be documented on the patient’s medical record or the service is not eligible for payment.
    • Can include the provision of a new prescription or prescription renewal, if rendered.
    • Not eligible for payment for anticoagulant supervision by telephone (G271) or any other telephone advice services listed in the Schedule of Benefits for Physician Services.
    • Eligible for any applicable after-hours premiums.
  • 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.

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    Notes

    • The services must be documented on the patient’s medical record or the service is not eligible for payment.
    • Can include the provision of a new prescription or prescription renewal, if rendered.
    • Not eligible for payment for anticoagulant supervision by telephone (G271) or any other telephone advice services listed in the Schedule of Benefits for Physician Services.
    • Eligible for any applicable after-hours premiums.
  • 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).

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    Notes

    • The services must be documented on the patient’s medical record (including the start and stop times) or the service is not eligible for payment.
    • Can include the provision of a new prescription or prescription renewal, if rendered.
    • Not eligible for payment for anticoagulant supervision by telephone (G271) or any other telephone advice services listed in the Schedule of Benefits for Physician Services.
    • Eligible for any applicable after-hours premiums.
  • 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.

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    Payment requirements

    • The services must be documented on the patient’s medical record (including the start and stop times) or the service is not eligible for payment.
    • if claimed, no charge can be billed to, or payment received from, the patient or the patient’s representative.

    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.
    • 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).

    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.
  • 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
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    Payment requirements

    • The services must be documented on the patient’s medical record (including the start and stop times) or the service is not eligible for payment.
    • if claimed, no charge can be billed to, or payment received from, the patient or the patient’s representative.

    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.
    • The fee billed on the claim should equal the value of the service multiplied by the number of patients serviced. For example, if K088 is claimed for 3 patients seen during the same day, the fee billed should be $110.55 (3 x $36.85).

    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.
  • 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
    Close

    Payment requirements

    • The services must be documented on the patient’s medical record (including the start and stop times) or the service is not eligible for payment.
    • if claimed, no charge can be billed to, or payment received from, the patient or the patient’s representative.

    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.
      • 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.
  • 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
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    • “Eligible assessment centre” means a place designated by the Ministry of Health as eligible for COVID-19 sessional fees.
    • “COVID-19 sessional unit” means each one-hour period, or major part thereof, on any day (including weekends or holidays).
    • The amount payable for a COVID-19 sessional unit is for all insured services rendered during that hour and for being present in an eligible assessment centre and available to provide such insured services.
    • No other insured services are eligible for payment at an eligible assessment centre.
  • 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.

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    Notes

    • The services must be documented on the patient’s medical record (including the start and stop times) or the service is not eligible for payment.
    • Can include the provision of a new prescription or prescription renewal, if rendered.
    • Not eligible for payment for anticoagulant supervision by telephone (G271) or any other telephone advice services listed in the Schedule of Benefits for Physician Services.
    • Eligible for any applicable after-hours premiums.

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. 

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

Frequently asked questions (FAQs)

No, remote 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 new 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.

Adapted from:
OHIP Bulletin 4745, Changes to the Schedule of Benefits for Physician Services (Schedule) in response to COVID-19 influenza pandemic effective March 14, 2020 (MOH, March 13, 2020).
Virtual care telephone and video codes frequently asked questions (OMA, August 7, 2020).
Introduction of Fee Code for Physicians Providing Services by Telephone or Video or Working in Designated Assessment Centres (OMA, 2020).
Virtual Care Key Messages and FAQs (OntarioMD, 2020).
OHIP Bulletin 4756, Funding for physician and hospital services for patients who do not have provincial health insurance during COVID-19 effective March 21, 2020 (MOH, May 5, 2020).

New diagnostic code for COVID-19

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.

Updates to prescribing rules and regulations

In response to the COVID-19 pandemic, the Office of Controlled Substances has issued a short-term subsection 56(1) exemption from the Controlled Drugs and Substances Act in the public interest (March 23, 2020. This exemption authorizes pharmacists to prescribe, sell or provide controlled substances in limited circumstances, or transfer prescriptions for controlled substances. Please note that the CDSA exemption expires on the earliest of these dates: September 30, 2021, or the date in which it is revoked or replaced by another exemption (OCP, August 21, 2020).

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 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).

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).

Top resources

New fee codes

Prescribing

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.

Mental health, well-being supports and financial programs for providers New

Last reviewed: October 5, 2020
Last updated: October 21, 2020
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Identifying stress, anxiety and burnout

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).

Recognizing burnout

Start by assessing where your mood is on the self-assessment tool. Then use the resiliency tips below to help manage your stress.

Resiliency tips for providers

Stress can be managed by using the 5 Cs of Resilience Framework (CSPL, 2020):

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.

Supporting wellness of staff

Identifying and addressing the needs of staff is the first step to reducing the risk of burn-out. Organizations should express gratitude towards their health care professionals along with efforts to hear, protect, prepare, support and care for them especially during these unprecedented times.

Hear me

Arrange a variety of input and feedback channels and involve healthcare staff in decision making (e.g. listening groups, suggestion box).

Protect me

Reduce the risk of healthcare workers acquiring the infection by providing PPE, rapid access to COVID-19 testing if symptomatic, resources to reduce risk to family members, and workplace accommodations for providers at high risk due to age or medical conditions.

Prepare me

We are all in this together, therefore it is important healthcare workers are comfortable relying on others, and asking for help. Provide training to staff and access to experts in order to provide high quality of care to patients.

Support me

Support the physical needs, including access to healthy meals and hydration at work, lodging for providers who have rapid-cycle shifts, transportation assistance for sleep-deprived workers, assistance with other tasks and support for child-care. Support emotional and psychological needs, including general and individualized resources.

Care for me

Provide holistic support for healthcare workers and their families. This includes lodging for those living apart from family, support for tangible needs, check-ins, and paid time off if quarantine is necessary.

Home and family life

Discussing the COVID-19 pandemic with your family is difficult and these conversations can be more challenging if your work requires you to be exposed to the virus (CMA Joule Boldly, March 23, 2020). To help eliminate stress in your household (BCCDC, March 16, 2020):

  • 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.

Financial programs and supports

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 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).

Supports for providers

Top resources

General resources

Resources to help with parenting and reduce stress in the home

Local services

Health and wellness programs and supports

Health and wellness programs and supports

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.

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