Primary Care Operations in the COVID-19 Context

• 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.

• 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.

• 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.

• 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.

• 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.)

• Use the Readiness assessment for primary care settings to develop strategies to mitigate risk of COVID-19 transmission.

• 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.

• 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.

• 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.

• 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.

• 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.

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].

• 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.

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, January 12, 2021) for repeat testing guidance. If follow-up testing is negative, the HCW is cleared and can return to work as per usual.

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.

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.

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