Primary Care Operations in the COVID-19 Context

Last Updated: August 26, 2021

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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:

Determining when to schedule in-person vs remote visits

In-person and virtual visits should continue to be assessed on an individual basis considering patient needs and their clinical condition. Local COVID-19 prevalence alone should not preclude an in-person visit when warranted (OCFP, 2021). 

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 OCFP proposes a balance of approximately 50% in-person care as a guidepost for many practices (OCFP, 2021). As well, the CPSO (2021) has stated that there is an increase in emergency departments seeing patients who would be better managed in other settings. 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, 2021):

  • 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.
  • Prenatal/newborn/immunizations. See Prenatal and postnatal care
  • 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, 2021)

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

Tips for providing in-person care (MOH, July 28, 2021)
  • Patients cannot be denied access to in-person care based solely on their vaccination status.
  • All patients and visitors (regardless of screening result) should wear a mask and perform hand hygiene. Symptomatic patients or individuals with a recent exposure must wear a surgical/procedure mask. If an individual does not have a mask, the clinic should provide a disposable mask for their use.
  • Physical distancing guidance states there should be enough space for patients to allow at least 2 metres from others. Providers should use clinical judgement to adapt patient flows based on factors such as space and community spread. See PPE section for more information.
  • Providers should consider ways to optimize ventilation within their space.

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
  • Primary care providers and all office/clinic staff must actively screen themselves daily before coming to the office/clinic. There should be an office/clinic manager responsible for ensuring all staff entering have passed screening.
  • Providers should post screening requirements on their website, send them to patients by email, or consider alternatives such as mailing by post (for patients without email or internet access).
  • When scheduling appointments, screen patients over the phone or with an appropriate online screening tool.
  • Screen patients (and accompanying individuals) at the point of entry to the office/clinic when they arrive for their appointment.
  • On site screening should be conducted from behind a barrier. If a physical barrier is unavailable, the health care worker should use Droplet and Contact Precautions (gloves, isolation gown, surgical mask, and eye protection).
  • Post signs at the entrance and throughout the office/clinic space reminding patients and those accompanying them to wear a mask and perform hand hygiene.
  • Use and adapt the latest MOH screening guidance.
Screen-positive patients
  • Patients cannot be denied access to in-person care based solely on their vaccination status. Similarly, it is not appropriate to deny in-person care to patients who screen positive, but have not yet had a COVID-19 test if in-person care is needed and adequate safety precautions can be implemented (CPSO, 2021).
  • For patients who screen positive, patient-contact surfaces (i.e., areas within 2 metres of the patient) should be disinfected as soon as possible. Treatment areas, including all horizontal surfaces, and any equipment used on the screen positive patient (e.g., exam table, thermometer, BP cuff) MUST be cleaned and disinfected before another patient is brought into the treatment area or used on another patient.
  • Symptomatic patients and HCWs should be tested for COVID-19 regardless of vaccination status (PHO, June 2021).
  • For more information, see: Interim Guidance on Infection Prevention and Control for Health Care Providers and Patients Vaccinated Against COVID-19 in Hospital and Long-Term Care Settings (PHO, June 2021).
Screen-negative patients
  • Patients who screen negative must still wear a mask inside the clinic/office and practice hand hygiene.
  • For patients who screen negative, standard cleaning processes can be used.
Screen-negative patients who later test positive

If a patient or staff member was in the office/clinic and later tests positive for COVID-19, primary care providers should call their local public health unit for advice on their potential exposure and implications for continuation of work.

For more information, see:

Delivering patient care remotely

To reduce community transmission during the COVID-19 pandemic and prevent the spread of the virus, family physicians and primary care nurse practitioners have been advised to practice remotely (MOH, March 13, 2020), when possible. To empower providers to do so, the national and provincial government have enacted temporary exemptions and have rolled out changes to the rules and regulations that govern the practice of medicine in Ontario.

The following formats can be used to conduct your remote patient encounter:
  • Telephone
  • Secure messaging (ONE Mail, DSG Secure, ProtonMail)
  • Provincial telemedicine platforms (e.g. Ontario Telemedicine Network)
  • EMR-integrated platforms (e.g. TELUS EMR Video Visits, VirtualClinic+ (Insig) – integrates to OSCAR, Medeo – integrated with Accuro EMR, Novari eVisit)
  • Standalone platforms created for medical care (e.g. VirtualCare, iTelemed, Adracare, Cloud DX, Doxy.me, InputHealth Collaborative Care Record, Livecare, MediSeen, OnCall Health, REACTS)
  • Other video calling platforms (e.g. Skype and Teams by Microsoft, Facetime by Apple, Zoom.us, Google Hangouts)
When deciding on the format of your remote patient encounter, consider the following:
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) New

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, May 20, 2021).

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, May 20, 2021).

What to wear, when

There are no changes to IPAC measures for COVID-19 variants of concern, as current evidence does not indicate that they are transmitted in different modes from other variants. However, due to the higher transmissibility of these variants, adherence to current IPAC measures remains especially important, with a lower margin of error (PHO, May 20, 2021).

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. At this time, vaccination status does not impact what PPE is required for HCWs or patients.

All patients (and those accompanying them) should wear a mask and perform hand hygiene while at the office/clinic, regardless of COVID-19 status. Patients who are symptomatic for COVID-19 or have a recent exposure MUST wear a surgical/procedure mask (MOH, July 28, 2021). A sample patient handout on wearing and disposing of masks is available on the OCFP’s Clinical Care – Office Readiness page.

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 follow Droplet and Contact Precautions for all interactions with and within 2 metres of patients. This includes wearing the following PPE:

  • Surgical/procedure mask
  • Isolation gown
  • Gloves
  • Eye protection (goggles or face shield)

If HCWs are not able to follow droplet and contact precautions or are not knowledgeable on how to properly don and doff PPE, they should divert the care of the patient (e.g., to the emergency department, or to an assessment centre) as appropriate (MOH, July 28, 2021).

The circumstances in which airborne transmission is possible are not clearly established, however, it is recommended that airborne precautions be used when performing aerosol generating procedures (AGMPs) on patients with suspected or confirmed COVID-19 (OH, February 25, 2021). An N95 mask (not a medical/procedural mask) is used as part of airborne precautions, all other PPE is identical to droplet and contact precautions.

When to discard PPE

Surgical/procedure mask
  • Extend use as long as possible.
  • Discard if wet, damaged, soiled, or removed (e.g. to eat or drink), or you exit the patient care area.
Eye protection (goggles or 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.
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.
N95 mask*
  • Discard after performing an AGMP on a patient who has suspected or confirmed COVID-19 (i.e. do not reuse for multiple AGMPs)
  • Discard if wet, damaged, soiled, or removed (e.g., to eat or drink), or you exit the patient care area.

PPE inventory and quality control

Accessing PPE

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

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

Regional Leads – PPE and Critical Supplies

Toronto

  • 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 initiatives

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).

Quality control

Health Canada is warning Canadians about counterfeit 3M N95 respirators in light of recent seizures of counterfeit products in Canada and at the United States border (Health Canada, April 15, 2021). Visit the 3M website for a hotline and published information on how to identify, prevent and report suspected fraud. Health Canada is warning not to use masks labelled to contain graphene or biomass graphene, due to the potential for wearers to inhale graphene particles (Health Canada, April 2, 2021).

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.

Infection monitoring and protocols for healthcare workers

Self-monitoring and self-assessment

Recommended risk assessments

Point of Care Risk Assessment for healthcare workers

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

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

Organizational Risk Assessment for health care entities

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

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

Pregnant healthcare workers

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

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

If healthcare worker develops symptoms (including atypical):

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

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

COVID-19 resolution and return to work

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

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

Healthcare workers should follow isolation and clearance with a non-test based approach (waiting 14 days from symptom onset (or 14 days from when swab was taken if persistently asymptomatic), unless they have required hospitalization during the course of their illness, in which case a test based approach is preferred. See detailed information on clearing cases at COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, June 9, 2021).

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

Ministry of Health guidance (June 9, 2021) has the following criteria for essential healthcare workers returning to work:

Positive test result

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

Negative test result

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

Positive test result

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

If there is a low pre-test probability (e.g. there has been no known recent potential exposures such as tested as part of surveillance and no other cases detected in the facility or on the unit/floor, depending on the facility size), see Management of Cases and Contacts of COVID-19 in Ontario (MOH, May 6, 2021) for repeat testing guidance. If follow-up testing is negative, the HCW is cleared and can return to work as per usual.

Practicing work self-isolation

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

At work: The healthcare worker should adhere to best practices listed in How to self-isolate while working (PHO, March 25, 2020).

New OHIP codes and updates to prescribing rules and regulations

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
    New 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).

Supports for providers

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.

Planning for flu season

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

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

September – October: before the start of flu season

Obtain and optimize PPE supply

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

Proactive outreach to all patients

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

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

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

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

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

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

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

Leverage your EMR to identify patients

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

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

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

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

October – December: prepare for flu season

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

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

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

Comparing COVID-19, flu, and common cold presentations

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

Flu vaccination and flu vaccination clinics during COVID-19

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

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

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

Reduced observation period post-vaccination

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

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

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

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

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

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

Vaccination in primary care

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

Putting it into practice

Opportunistic immunization

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

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

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

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

Vaccinator PPE

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

Other staff and volunteer PPE

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

Patients and visitors

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

Operating a flu vaccination clinic

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

Selecting a type of clinic

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

Clinic implementation checklists

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

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

Additional resources

Learn from another primary care vaccination clinic

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

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

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

Red lake sample schedule

Prep tips

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

Encounter Logistics

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

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