03-23-2020
Colleagues,
The ongoing COVD-19 pandemic is a rapidly evolving and challenging situation. Delivering professional, appropriate care remains the utmost priority, and it is our professional and ethical duty to ensure our patients have continued access to primary care to the best of our ability. While we do not know how many weeks or months this will go on, we cannot postpone the delivery of primary care.
In order to support you in your practice and to provide direction on measures you can take when caring for patients, a number of strategies for practice operations are provided below.
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Telephone Triage
All office appointments should be booked over the phone, and
COVID-19 screening questions must be asked at the time of booking. If there is concern that patients are not forthcoming, consider asking your front desk staff to make a firm statement before they proceed with the screening questions:
- "During this pandemic, the safety of our staff and healthcare professionals is paramount. It is crucial that you answer the following questions honestly."
Patients should be reassured that they can be offered an appointment by phone with their primary care provider even if they screen positively, in addition to being referred to the
nearest assessment centre.
Many patients may have hesitations and would prefer to speak with their provider, not clerical staff. If patients know they can still have the option of an appointment by phone, this may make them feel safer, and encourage them to answer the screening questions truthfully.
Consider the following when triaging for appointments by phone:
- Call patients the day before to pre-screen/triage for appointment appropriateness. In addition to administrative staff, team members such as family practice nurses can help with triaging.
- Schedule patients for phone triage every 15 minutes.
- Use any available time in your schedule to call and triage those already on the schedule. Offer telephone visits where possible.
- Move existing pre-booked appointments that still require an in-person visit to better address the need for social distancing.
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Telephone Prescriptions
Prescribing medication is a medical act. It is the result of a clinical decision based on an evaluation of the patient. This evaluation (whether virtual or in-person) must include an appropriate clinical assessment. The patient record should clearly describe the assessment and the diagnosis that led to the prescription.
Prescriptions required for long-term or chronic conditions that are likely to remain stable for the duration of the current pandemic should include renewals or repeats of the required medication(s).
When physicians are part of a group practice or a call group, they may choose to accept a previous patient evaluation by an associate as the basis for further prescribing. However, in such situations, each physician remains responsible and accountable for any prescriptions he or she has written.
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Virtual Care
Virtual care is an important way for family physicians to continue to care for their patients while ensuring the safety of the patient, providers, and staff. Virtual services reduce the risk of disease spread by keeping people in their homes and out of family practices.
Providers should use their professional judgment to determine whether an in-person appointment or telemedicine appointment is appropriate in each case. Patients should be provided the opportunity for in-person care whenever it is needed.
Consider virtual care in the following situations:
- Triaging patients prior to an office encounter, to avoid unnecessary trips to the office;
- Managing acute illnesses that may not require a physical exam (remembering that they can always be asked to come in for an exam, if it is deemed necessary);
- Managing patients with chronic disease.
Regardless of the method by which care is delivered, all conversations should be appropriately documented in the patient chart.
Note that for telephone visits, in order to bill the new 03.03X fee, you must include the time of the phone call.
Resources
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Telehealth Zoom
To help support patient care and health care providers in the current COVID-19 pandemic, Telehealth Zoom has been approved as a virtual care platform for use on an
interim
basis for all health care providers (physicians, nurse practitioners, allied health professionals and staff).
Telehealth Zoom is a secure, web-based virtual care video conferencing platform.
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Altering the Office Schedule and Limiting Physical Examinations
Office schedules should be adjusted to limit the number of patients in the waiting room. While the limit of five people in a group does not apply in a health care setting, it is prudent to think critically about how this can be best accomplished given the variability of each respective practice (i.e. clinic layout, exam rooms, number of doctors and staff, etc.).
Some suggestions include:
- Ask for patients to wait in their cars, not in the waiting room, and have your staff call them in when you are ready.
- Limit family members/friends accompanying patients to their appointments (i.e. one support person only). Remember that for some patients, it is not safe or feasible for them to attend appointments alone.
- Remove all toys / magazines / books from waiting rooms.
- Separate chairs to maintain physical distancing (2m/6ft).
- Stagger in-person and telephone appointments to minimize the number of patients in the office, and to allow extra time for cleaning between patients.
- If a telephone or virtual visit appointment requires a physical exam, the patient can be asked to come in later for that exam. Consider leaving a few 'in-person' appointments open in the afternoons to allow for this.
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PPE and Office Cleaning
If your office is effectively screening your patients, there should be very few patients coming in who pose a risk to the clinic staff.
N95 masks should only be used for aerosol-generating procedures on ILI/COVID-19 suspected patients, and those aerosol-generating procedures should not be a part of your office practice. If we use gowns, gloves, eye shields and N95 masks for every patient, we will soon run out of these critical supplies. Evidence-based medicine should be our guide: using protective equipment when it is not needed not only wastes valuable supplies, it sends an inappropriate message to the public. We need to be cautious, but not panicked.
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Working with Colleagues
As family physicians, we are responsible for ensuring that our patients continue to have access to primary care. Typically, if you were ill or on vacation, you would discuss your situation with your closest colleagues and ask for help with caring for your patients.
If you are personally unable to provide telephone visits and/or face-to-face visits when a physical exam is required, it is your responsibility to make arrangements for your patients to get that care elsewhere. We cannot send all patients requiring a physical exam to the emergency department.
Physicians must make reasonable efforts to work with colleagues to deliver medical care for all patients, especially complex patients. This includes:
- Arranging cross-coverage of your patients when the office is closed for any reason;
- Ensuring that all outstanding reports and work in progress (investigations, tests and consultations) are reviewed and acted upon, by yourself or a colleague, even when the office is closed;
- Consider locations in the community where in-person care can be safely delivered by a primary care provider, without defaulting to the emergency department.
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Thank You
With good screening and scheduling, you should be able to maintain primary care delivery for your patients, minimize the numbers of patients in your waiting area, maintain your patients' access to care, and still provide a safe environment for yourself and your staff.
At times like these, the public looks to health care workers for guidance and leadership. It is important that as physicians, we continue to adhere to our professional and ethical responsibilities. Whatever fears or trepidations we may have individually, it is crucial that we present a calm front, and do not promote panic or hysteria.
Our patients and our profession trusts that we exercise sound professional judgement, and that any information we share with our patients, neighbours, or colleagues, either through conversation or on
social media, is both accurate and evidence-based. As well, we collectively uphold an ethical obligation to avoid discrimination against COVID-19 suspected or positive patients.
Provincial
Central Zone
Western Zone
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