Primary Care Operations in the COVID-19 Context

Last Updated: November 18, 2022

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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.

Primary care is integral to an effective healthcare system and it is essential that care is delivered in the manner most appropriate for patients during the COVID-19 pandemic. This resource outlines recommendations and strategies to support you in providing optimal care during the COVID-19 pandemic while balancing your patient’s best interests.

Click on the sections below to get started:

Preparing for fall and winter in primary care

Over the past two and a half years, primary care providers in Ontario have continued to provide high levels of care to patients in the challenging environment of a global pandemic. During fall and winter, primary care providers should continue to see patients who are due for care, while taking measures to prevent the spread of COVID-19.

The following is a list of considerations for preparing for fall and winter in primary care. For most practices it may not be feasible to address all these considerations, so practices will need to prioritize what is most important within the time and resources available, while allowing for staff time off and illness.

All sectors are encouraged to:  

  • Work with Chief Regional Officers and regional tables to coordinate and support local surge capacity (this includes enhanced Health Human Resource Response/Models of Care tables). 
  • Partner regionally to support timely access to care for patients. 
  • Implement strategies to maximize influenza and bivalent COVID-19 vaccine uptake among health care workers. 
  • Encourage patients to use Health Connect Ontario for non-urgent health advice. Registered nurses are available 24/7 via telephone (811) or online chat at ontario.ca/HealthConnectOntario. 

Within primary care and community support services, it is important to: 

  • Continue delivering timely immunization, early identification, and referral of patients who would benefit from COVID-19 therapies (e.g., Paxlovid). 
  • Support emergency department diversion by prioritizing care for children and adults with COVID-19, influenza, and other respiratory illnesses. 
  • Continue to focus on preventative care (e.g., cancer screening) and the provision of comprehensive primary care. 
  • Ensure community support service organizations continue to participate and collaborate on regional response and recovery efforts. (Ontario Health, November 1, 2022).

Vaccinations

  • We will continue to monitor for emerging information on vaccination in children under 5, booster eligibility and new vaccines
  • See Vaccine rollout in Ontario for information on vaccine eligibility, including 4th doses
  • See Vaccination in primary care for guidance on offering vaccinations in primary care and identifying eligible populations in your practice
  • Multiple vaccinations can be given at the same time, but you must follow Ontario’s immunization schedule.
  • For individuals 5 years of age and older, COVID-19 vaccines may be given concurrently with (i.e., same day), or at any time before or after, non-COVID-19 vaccines (including live and non-live vaccines) (Ontario Health, November 7, 2022).
  • Many local public health units are running catch-up clinics for students who may have missed school-based immunizations and patients can be directed there
  • School-based vaccines can be ordered from local public health units through standard vaccine ordering processes to administer in primary care offices

For more information on where to get your flu shot, please click here. Two enhanced products are specifically indicated for those 65 years and older (a high-dose quadrivalent and an adjuvant trivalent), noting that all products protect against influenza and patients should not delay vaccination to wait for a particular product (Ontario Health, November 3, 2022).

  • If you are vaccinating patients in your practice, provide immunization to patients and their accompanying persons when they are seen for other reasons (including COVID-19 vaccination) and during home care visits.
  • Concerted efforts should be made to vaccinate:
    • Anyone who is at high risk of severe COVID-19 related illness:
      • Older adults, especially over 65. See AVOID frailty (Canadian Frailty Network, 2020) for more information on the importance of vaccines in frail older adults.
      • 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.

Infection Prevention and Control (IPAC)

COVID-19 testing, assessment and treatment

Continuity of care

    • Refer to #10 for a list of patient populations to consider prioritizing
  • 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 conditions, 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
  • The eHealth Centre of Excellence offers free EMR coaching, and a collection of automated solutions that can help clean up, standardize and search through data in your EMR.
  • If you are unsure of how to use your EMR to support proactive panel management, there are free OntarioMD 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.

Social prescribing

Testing and isolation requirements for healthcare workers

The MOH provides separate isolation guidance for individuals who live, work, volunteer or are admitted in the highest risk settings, including (MOH, August 31, 2022):

  • Hospitals (including complex continuing care facilities)
  • Home and community care workers and congregate living settings with medically and socially vulnerable individuals, including, but not limited to, Long-Term Care, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional institutions, and hospital schools
  • Employer-provided living settings of International Agricultural Workers.

Isolation requirements for primary care providers

Primary care providers who do not work or volunteer in such high risk settings should follow the same isolation guidelines as other community members (described in detail in Testing and isolation requirements). Having immunocompromised patients in one’s primary care practice does not constitute a highest risk setting, however it is recommended that primary care providers wait an additional 5 days after returning from a 5 day isolation before seeing immunocompromised patients.

Testing and isolation requirements for highest-risk settings

Step 1

Presume any household members with COVID-19 symptoms have COVID-19.

All household members should isolate (stay home) UNLESS any of the following apply**:

  • They tested positive for COVID-19 within the prior 90 days
  • Are 18+ and boosted
  • Are under 18 years old and are fully vaccinated.

Healthcare workers should follow any work self-isolation policies.

Step 2

Obtain COVID-19 testing for the symptomatic person:

  • Serial rapid antigen test (RAT): 2 tests, taken 24 – 28 hours apart; OR
  • Polymerase chain reaction (PCR) test (household members of HCWs working in highest-risk settings are eligible for PCR testing as of Jan 13/22)
Step 3

If COVID-19 testing is NEGATIVE, the HCW can discontinue isolation.

If COVID-19 testing is POSITIVE, asymptomatic HCWs who have not had a positive COVID-19 test in the last 90 days should:

  • Obtain PCR testing per local Public Health guidance
  • Isolate (stay home) while the symptomatic person is isolating. If the HCW is immunocompromised, they will need to isolate for 10 days (20 days if they are severely immunocompromised
  • Not work for 10 days from their last exposure to the symptomatic person during their infectious period (from 48 hours prior to symptom onset until the end of their isolation period) unless they can complete RAT tests (see below).
  • Follow guidance for COVID-19 cases if symptoms develop or they test positive for COVID-19

Healthcare workers who are following workplace self-isolation should:

  • Stay home for the isolation period and only leave home for essential work;
  • Wear recommended personal protective equipment including a fit-tested N95 mask while at work
  • Stay 2 meters away from others at work except to provide direct patient care;
  • Take breaks alone and wash their hands often
  • Ideally, work at one facility only;
  • Follow testing requirements.


Under routine operations asymptomatic close contacts that work in highest-risk settings may return to work:

  1. Following a negative molecular test (e.g., PCR, rapid molecular) collected on/after day 5 from last exposure
    OR
  2. Following a negative molecular test (e.g., PCR or rapid molecular) collected before day 5 after last exposure AND performing daily rapid antigen tests for 10 days after last exposure or until a second negative molecular test is collected on/after day 5 after last exposure
    • Asymptomatic close contacts who are returning after a negative molecular test collected before day 5 after last exposure are recommended to follow the Workplace Measures below for reducing risk of exposure.

Please see Management of Cases and Contacts of COVID-19 in Ontario (August 31, 2022) for guidance during critical staff shortage


* highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, and correctional facilities.
**Wear a well-fitted mask in public, physical distance and maintain other public health measures for 10 days following last exposure if leaving home. HCW should NOT visit or attend work in any highest risk settings and not visit individuals who may be at higher risk of illness (i.e., seniors or immunocompromised) for 10 days after your last exposure.

Healthcare workers (HCWs) with a positive COVID-19 rapid antigen test (RAT) or polymerase chain reaction (PCR) test must isolate (stay home).

  • HCWs who have had at least 2 COVID-19 vaccine doses must isolate for 5 days from the day of the positive test (day of positive test is Day 0).
  • HCWs who have NOT had at least 2 COVID-19 vaccine doses AND healthcare workers who are immunocompromised must isolate for 10 days from symptom onset (day of symptom onset is Day 0).
  • If symptoms develop, follow isolation guidance for symptomatic HCWs
  • HCWs can exit isolation once their isolation period is complete EVEN IF other household members are still isolating.

Healthcare workers who are close contacts who have previously tested positive for COVID-19 in the last 90 days (based on positive rapid antigen test or molecular test results) can attend work in the highest-risk setting, as long as they are currently asymptomatic. These individuals are advised to self-monitor for symptoms for 10 days after last exposure.

For early RTW:
Under routine operations, asymptomatic close contacts that work in highestrisk settings may participate in testing for early return to work:

  • Following a negative molecular test (e.g., PCR, rapid molecular) collected on/after day 5 after last exposure
    OR
  • Following a negative molecular test (e.g., PCR or rapid molecular) prior to first shift (if collected before day 5) AND perform daily rapid antigen testing for 10 days after last exposure or until a second negative molecular test is collected on/after day 5 from last
    exposure

Please see Management of Cases and Contacts of COVID-19 in Ontario (April 11, 2022) for guidance during critical staff shortage

 

** highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional facilities and home and community care settings.

Step 1

Healthcare workers (HCWs) with COVID-19 symptoms should presume they have COVID-19 and isolate (stay home) while awaiting test results.

Step 2

Where possible, the HCW should obtain COVID-19 testing:

  • Serial rapid antigen test (RAT): 2 tests, taken 24 – 28 hours apart; OR
  • Polymerase chain reaction (PCR) test
Step 3

If COVID-19 testing is NEGATIVE, the HCW can discontinue isolation when they have been fever-free for 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).

If COVID-19 testing is NOT AVAILABLE or POSITIVE, the HCW must isolate (stay home):

  • HCWs who have had at least 2 COVID-19 vaccine doses OR who have had a COVID-19 infection within 90 days must isolate for at least 5 days from symptom onset (day of symptom onset is Day 0).
    Isolation can end after 5 days IF they have not had a fever in 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).
  • HCWs who have NOT had at least 2 COVID-19 vaccine doses AND healthcare workers with immunocompromise must isolate for at least 10 days from symptom onset (day of symptom onset is Day 0). HCWs with severe immunocompromise must isolate for at least 20 days from symptom onset (day of symptom onset is Day 0).
    Isolation can end after Day 10 (or Day 20) IF they have not had a fever in 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).
  • HCWs can exit isolation once their isolation period is complete EVEN IF other household members are still isolating.

HCWs in highest risk settings* should follow workplace guidance to return-to-work (RTW). In general, HCWs who are not immunocompromised can RTW:

For routine operations, COVID-19 positive cases that work in highest-risk settings may return to work:

  1. 10 days after symptom onset or date of specimen collection (whichever is earlier)
    AND
  2. Provided they have no fever and other symptoms have been improving for 24 hours (or 48 hours if vomiting/diarrhea). 

Note: Testing for clearance is generally not recommended.

Please see Management of Cases and Contacts of COVID-19 in Ontario (August 31, 2022) for guidance during critical staff shortage

 

* highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional facilities and home and community care settings.

Determining when to schedule in-person vs remote visits

Consider patient needs along with the presenting condition. Whether delivering care virtually or in person, the fundamental principle is that the quality of care is not compromised, and the standard of care is met (OCFP, 2022).

While virtual care is a helpful tool to access care during the pandemic, the pressures that existed earlier on have now diminished (e.g., unavailability of COVID-19 vaccines, lack of personal protective equipment). In most cases, in-person care can now be provided safely and appropriately and can resume based on clinical need and patient preference.

It is important to consider the patient’s best interests when balancing the type of visit. Take into consideration the patient’s preferences and clinical condition.

Frequently Asked Questions (FAQs)

No (CPSO, 2021). Even in the absence of a negative test result or vaccination, in-person care can be provided safely by taking appropriate precautions (screening patients and using necessary PPE). While you can encourage eligible patients to get vaccinated, patients cannot be denied access to necessary in-person care based solely on their vaccination status.

The right balance between providing in-person and virtual will vary by physician practice. Every practice is unique, and the decision about the care provided will require judgment on the part of the physician to determine how best to serve their patients’ needs. The pressures that existed at a different stage in the pandemic (e.g., lack of PPE, high number of cases) have now diminished. When taking appropriate precautions, in-person visits can now be provided safely and appropriately, and may be in your patient’s best interest in some instances.

Your patient’s best interests will include taking into consideration the type of visit they would prefer. In this situation an in-person visit should be offered as long as you are able. To ensure that the appropriate safety precautions are in place, see the PPE section for more information.

Clinical scenarios

Examples of when in-person care is recommended (OCFP, 2022):

  • Medical issues: such as undifferentiated acute problems, unstable mental health conditions or chronic diseases, joint injections, incision and drainage, and IUD insertions.
  • Physical examinations as normally would be required before making referrals or ordering tests.
  • Cancer screening: Ontario Health recommends gradually resuming routine breast and cervical screening. Primary care providers can also begin sending new fecal immunochemical test (FIT) requisitions to LifeLabs for all eligible people at average risk for colorectal cancer. For full guidance see Ontario Health’s COVID-19 Cancer Screening Tip Sheets (2021).
  • Confidential assessments for patients who cannot speak privately at home, on issues such as intimate partner violence, etc. 
  • When virtual care is too challenging or not possible, such as for individuals with hearing loss, or who have technology, language, or cognitive barriers.
  • Palliative and end-of-life care to ensure appropriate management of pain and other symptoms.

Putting it into practice

Consider the following principles as a guide for determining whether in-person care is appropriate (OCFP, 2022)

See patients in person for conditions where:

  • Physical contact is necessary to provide care (e.g., newborn care, prenatal care). 
  • Physical assessments are necessary to make an appropriate diagnosis or treatment decision (e.g., undifferentiated conditions, physical examinations that cannot be done virtually, language barriers). 
  • You can provide high-impact prevention strategies, such as cancer screening and immunization that prioritize those at higher risk. 

Consider patient needs

  • Even if it is appropriate to provide care virtually, your patient’s best interests may be served by providing care in person. 
  • Patient age, language and communication barriers may all mean in-person care is preferable. 

Delivering patient care in person New

Providers should determine appropriate PPE based on the patient’s positive or negative screening results. PPE is not determined by vaccination status. See PPE section for more information.

Active and passive screening procedures
  • Patients should be screened over the phone, or suitable online screening tool such as the Self-Assessment Tool, for symptoms of COVID-19 when scheduling appointments.
  • Patients and those accompanying them (if applicable) should be screened by staff at the point of entry to the office/clinic to assess for COVID-19 symptoms and exposure history on the day of their scheduled appointment.
  • Staff conducting active screening on site should adhere to routine practices (including wearing a surgical/procedure mask or better alternative) and ideally be behind a barrier.
  • Signage should be posted at the entrance to the office/clinic and at reception areas reminding all patients of the symptoms of COVID-19 and to self-identify to clinic/office staff if they have had a recent exposure to any symptomatic household member or a case of COVID-19.
Screen-positive patients
  • Positive screening over the phone
    • Patients who identify as having severe symptoms (including severe difficulty breathing, new onset confusion or reduced level of consciousness, severe chest pain, or increasing significant fatigue) over the phone should be directed to the emergency department
    • Patients who screen positive for symptoms of COVID-19 over the phone and whose symptoms are not severe should be instructed to self-isolate as per current guidance.
Positive screening in the office/clinic
  • As soon as the reception staff is aware that a patient screens positive for COVID-19, the patient and those accompanying them should be provided a surgical/procedural mask or a non-fit tested N95 or KN95 respirator (if not currently wearing one) and advised to change masks away from other patients and staff. The patient should be immediately placed in a separate room with the door closed, where possible, to avoid contact with other patients in common areas of the office/clinic (e.g., waiting rooms).
  • Symptomatic patients should not be cohorted together; rather, each symptomatic patient should be isolated individually unless they are from the same household.
  • Primary care providers may offer clinical assessment and examination to patients who screen positive by following appropriate precautions.
  • If primary care providers are not able to follow the recommended precautions, they should divert the care of the patient as appropriate. This includes to the emergency department if the reason for the medical visit is urgent, to a COVID19 Clinical Assessment Centre if necessary, to testing centre if indicated, or delay the visit/provide virtual care until the patient meets criteria to end selfisolation if the issue is non-urgent. The primary care provider should use clinical judgement to ensure that the original reason(s) for the medical visit are managed appropriately and in a timely manner.
Vaccination in primary care
  • Primary care providers and their office/clinic staff are strongly recommended to be fully vaccinated and boosted.
  • Primary care providers should consider implementing staff vaccination policies for their practice.
  • Primary care providers should consider discussions of vaccine status with their patients and, where possible and appropriate, recommend and offer COVID-19 vaccinations.
  • Primary care providers that are participating in Ontario’s COVID-19 vaccination program should refer to the Ministry of Health’s COVID-19 Vaccine-Relevant Information and Planning Resources
For more information, see:

Delivering patient care remotely

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:
  • Ease of use (for you and your patient).
  • Subject of the clinical encounter (e.g. a dermatological issue may require video and/or picture exchange).
  • How the product/platform can help you keep patient information private and secure.

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

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 the 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)

The fundamental method of protecting workers is through the application of the hierarchy of hazard controls (NIOSH, January 13, 2015). Although PPE is the most visible of the hierarchy of controls, it is the last tier and should not be relied on as a standalone primary prevention program. The PPE tier 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 (PHO, March 2022).

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, March 2022).

As of June 11th, 2022, all mask mandates have been lifted for indoor settings in Ontario, with the exception of long-term care and retirement homes (CPSO, November 18, 2022).

  • However, the Chief Medical Officer of Health continues to recommend that clinicians, staff, and visitors wear masks in all healthcare settings.
  • Primary care practices may continue to implement masking policies that ask all staff, patients, and other visitors to wear a mask.

Masking of patients in primary care settings

Despite mask mandates being lifted, primary care practices may continue to implement masking policies that ask all staff, patients, and other visitors to wear a mask (CPSO, November 18, 2022).

If a patient who does not need an accommodation/exemption refuses to wear a mask, explain the expectation in your practice is that a mask be worn. If the patient still refuses, consider that in most cases, the following strategies will limit your risk (CPSO, November 18, 2022):

  • Ensuring that you safely don appropriate PPE (see What to wear, when)
  • Isolating patients
  • Providing care to patients with suspected/confirmed COVID-19 during set times of the day
  • A virtual appointment, if appropriate

Physicians have a duty of care where care is urgently needed, and redirecting patients to other parts of the system may exacerbate existing and significant resource challenges (CPSO, November 18, 2022).

What to wear, when

Public Health Ontario recommends PPE when providing direct care for patients with suspect or confirmed COVID-19 including a fit-tested, seal-checked N95 respirator (or equivalent or greater protection), eye protection, gown, and gloves. Other appropriate PPE includes a well-fitted surgical/procedure (medical) mask, or non-fit tested respirator, eye protection, gown and gloves for direct care of patients with suspect or confirmed COVID-19 (PHO, June 2022).

Before every patient interaction, conduct a point-of-care risk assessment to determine the PPE required. See PHO’s advice on performing a risk assessment. Examples of risk factors to consider in your risk assessment that may increase transmission risk include:

  • HCW: Vaccination status
  • Patient: Unable to mask for source control, unvaccinated
  • Interaction: prolonged, close contact (i.e.,< 1 m for > 15 minutes), performing a high-risk procedure
For patients who screen negative for COVID-19

HCWs should wear a surgical/procedure mask for all interactions with and within 2 metres. If the patient is unmasked, eye protection (goggles or a face shield) is required. If the patient is masked for the entirety of the visit, eye protection may be used based on clinical discretion.

For patients who screen positive for COVID-19 (suspected or confirmed COVID-19 infection or contact)

HCWs should wear the following PPE:

  • Fit-tested, seal-checked N95 mask (if unavailable, a well-fitted surgical/procedural mask, KN95 mask, or non-fit tested N95 mask may be used)
  • Isolation gown
  • Gloves
  • Eye protection (goggles or face shield)
Performing aerosol generating procedures (AGMPs)

Fit tested N95 respirators (or equivalent or greater protection) should be used when aerosol-generating medical procedures (AGMPs) are performed or anticipated to be performed on patients with suspect or confirmed COVID 19 (PHO, June 2022).

Choosing a surgical/procedure mask, N95 mask or KN95 mask

The use of a fit-tested, seal-checked N95 mask is recommended for healthcare providers who are caring for patients with suspect or confirmed COVID-19, and must be worn when performing AGMPs. In instances where a fit-tested N95 mask is unavailable, or not required (e.g., when caring for patients who screen negative for COVID-19), healthcare providers should wear a well-fitted surgical/procedural mask, KN95 mask, or (non-fit tested) N95 mask (PHO, March 2022).

KN95 masks are similar to N95 masks, with the main difference being that they are not tested to North American standards (they are tested to Chinese standards) (Health Canada, November 29, 2021). This can lead to more variability among KN95 masks; some may be equivalent to N95 masks and some not. Overall, when deciding between a surgical/procedure mask, KN95 mask, and non-fit tested N95 mask, the better the mask fits in terms of minimizing air gaps, the more protection it will likely provide. In many instances, KN95 masks will minimize air gaps better than a surgical/procedure mask, but this must be determined by the individual wearing the mask. Healthcare providers should consider mask fit, mask availability, and their organizational and personal risk assessments when choosing a mask (PHO, March 2022).

When to discard PPE

Surgical/procedure mask, KN95 mask and N95 mask

If caring for patients who screen negative for COVID-19:

  • 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.

If caring for patients who screen positive for COVID-19 (suspected or confirmed COVID-19 infection or contact):

  • Discard after each encounter with patients with suspected or confirmed COVID-19.
  • Discard after performing an AGMP on a patient who has suspected or confirmed COVID-19 (Reminder that N95 mask must be used when performing an AGMP).
  • Discard if wet, damaged, soiled, or removed (e.g., to eat or drink), or you exit the patient care area.
Isolation gown (disposable or cloth)
  • Discard after each patient encounter. Do not extend use of disposable isolation gowns between multiple patients with confirmed COVID-19 infection unless gown supplies are limited.
  • Launder cloth gowns according to routine practices (CDC). Do not take PPE home to launder.
Latex or nitrile gloves
  • 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.
Eye protection (goggles or face shield)
  • 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.

Updated PPE inventory and quality control

Accessing PPE

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

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

  • Step 1: Implement conservation and stewardship strategies to reduce the need for resupplying PPE.
  • Step 2: Use existing supply chain processes and collaboration with local partners to obtain supplies.
  • Step 3: Explore alternate inventories to obtain supplies.
  • Step 4:
    • For Providers in Toronto, Central, North and East Regions: Use Ontario Health’s Critical PPE Intake Form to escalate to your Regional Lead. Multiple PPE requests may be addressed in one form submission; however, please ensure all fields are accurately filled out to avoid shipment delays or lack of fulfillment. Orders continue to be processed Monday to Friday during regular business hours with a minimum 2-business day delivery time (MOH, August 24, 2022).  
    • For Providers in West Region: Use the Urgent Pandemic Supply Request form to escalate to your Area Hubs, who may in turn escalate to your Regional Lead.
Regional Leads – PPE and Critical Supplies

Toronto

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

Central

  • Susan Gibb (Susan.Gibb@lhins.on.ca)

North

  • Matthew Saj (sajm@tbh.net)

East

  • Paul McAuley (Paul.McAuley@3so.ca)
  • Shelley Moneta (Shelley.Moneta@lhins.on.ca)

West

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

Inventory management

The Ministry of Health manages an emergency stockpile containing PPE. The new guidance focuses on how to access the pandemic stockpile, who is eligible, and product availability (MOH, August 24, 2022).

Stockpiling guidance
  • Health care entities keep a four-week stockpile of PPE based on high transmissibility & low clinical severity scenarios.  
  • Health care entities should have supplies of both N95 respirators and medical (surgical/procedure) masks for health care workers, so they are prepared to implement routine practices and additional precautions and any added pandemic measures. 
Routine Stockpiling Operations

The MoH recommends that all health care entities incorporate modern inventory management and control practices into their routine stockpiling operations, including (MOH, August 24, 2022):

  • Monitoring and tracking inventory quantities;
  • Monitoring and tracking expiration dates; 
  • Monitoring and tracking lot codes;
  • Performing regular turn-over and replacement of aged inventory prior to expiration;
  • Disposing of expired stock in an ethical and environmentally friendly way.   

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, February 25, 2021).

Ethical Allocation Framework

The Ethical Allocation Framework highlights criteria to guide prioritization of PPE in instances of limited supply. One of the prominent criteria is the urgency of need determined by current PPE supply, number of confirmed cases, consumption or “burn” rate of PPE, and projected need of a facility. Despite the Framework’s COVID-19 purpose, it can be a helpful guide for related pandemic pathogen cases beyond COVID-19 (MOH, August 24, 2022).  

Donning and doffing PPE

How to don PPE
Donning tips

Eye protection

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.
How to doff PPE

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.
Doffing tips

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, CDC, 2020).

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.

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

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.

New OHIP codes and updates to prescribing rules and regulations

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. 

The Ministry of Health and the Ontario Medical Association (OMA) have reached an agreement to extend existing temporary physician funding initiatives (including K-codes) under the Ontario Health Insurance Plan (OHIP) to September 30, 2021 (March 8, 2021).

New fee codes for insured and uninsured patients
Scroll (left-right) for details
  • For care of insured patients
    G593 (COVID-19 vaccine)

    Service provider (s): Physicians, family physicians

    Fee: $13.00

    Service description: G593 is payable for the administration of each dose of vaccine when multiple doses are required to complete the initial vaccination series. G593 is not eligible for payment for subsequent booster COVID-19 vaccination doses. G593 is not eligible for payment to a physician for services rendered during any time period for which H409/H410 is payable to that physician.

    View Notes
  • For care of insured patients
    K080

    Service provider: Family physician

    Fee: $23.75

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

    View notes
  • For care of insured patients
    K081

    Service provider: Family physician

    Fee: $36.85

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

    View notes
  • For care of insured patients
    K082

    Service provider: Family physician

    Fee: $67.75

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

    View notes
  • For care of uninsured patients
    K087

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

    Fee: $23.75

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

    View claim submission requirements
  • For care of uninsured patients
    K088

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

    Fee: $36.85

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

    View claim submission requirements
  • For care of uninsured patients
    K089

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

    Fee: $67.75

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

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

    Service provider(s): Family physicians and specialists

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

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

    View service description
  • For care of insured patients
    K083

    Service provider: Specialists

    Fee: $5.00

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

    View notes

Putting it into practice

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

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

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

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

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.

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

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

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, 2021):

  • 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.
  • LListen without judgement and state your concerns.
  • PPlan 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 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).

Top resources

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