Physiotherapy Services During COVID-19

What does the Chief Medical Officers order mean for Physiotherapists in Nova Scotia?

March 24, 2020 Nova Scotia’s Chief Medical Officer of Health, Dr. Strang, issued an Order under Section 32 of the Health Protection Act (2004, c. 4, s. 1). It is the responsibility of all Physiotherapists to be aware of and understand the order and how it impacts delivery of Physiotherapy services in Nova Scotia as well as any other civic responsibilities contained in the order. The Nova Scotia College of Physiotherapists has prepared the following information to provide guidance when implementing the order in their practice. This document is complimentary to and does not replace the requirement to read the written orders and any follow-up or clarification documents issued by Public Health.

As per the order, Section 20a - Effective March 23, 2020 self-regulated health professions may provide in-person emergency or urgent care services and may provide virtual care for non-emergency/elective care within their scope of practice as established by their governing college.

What is Virtual Care?

Virtual care is any care provided remotely. This includes rehabilitation services that use any form of technology (including but not restricted to video conferencing, internet and telephone) as an alternative to face to face interventions. It may also be referred to as Telehealth or Telerehabilitation.

What does emergency/urgent care services mean?

Emergency care services require immediate attention and are unlikely to apply to Physiotherapy.

Urgent care services are where the risk of not receiving care at this time outweighs the risk of transmission of the virus. Urgent is also often used if the care service is required within 24 hours to avoid worsening outcomes or long-term negative outcomes. Situations that could be considered urgent include:

  • situations where physiotherapy treatment is needed to manage acute conditions where any postponement of care will negatively affect outcomes in the short and in the long term.
  • acute conditions requiring assessment/treatments prior to being able to self-manage their injury or condition until restrictions are lifted.
Further considerations to determine the urgency of a patient’s need for physiotherapy or for medical referral may include:
  • Presence of neurological signs and symptoms
  • Signs of trauma
  • Signs of Traumatic Brain Injury (TBI)
  • Significant pain or loss of function
  • Patients requiring immediate postoperative treatment
  • Cardiorespiratory or pediatric conditions requiring sustained treatment or monitoring
Note this definition does not include the nature of a patient's occupation. If Public Health deems it necessary to triage rehabilitation services based on occupation that will be laid out in orders from the CMO.

Further, for clarification, functional scans are considered in-person care. Under the current orders from the CMO, and NSCP's definition of urgent care, functional scans would not meet the criteria for urgent or emergency care in almost all cases.

If, in your professional assessment and judgement, in-person care needs to be provided then following all needed precautions including spacing out appointments to minimize density of people in the clinic is important. The determination of urgency will be unique to each patient and to each organization/clinic/individual provider based on what can be accommodated within the recommended precautions from Public Health authorities.

The well-being of patients and staff must continue to guide the clinical decisions made by physiotherapists in each of their practice settings.

How can the public find out about private practice clinic services during the pandemic?

To find out availability of services refer to our Private Practice Services. The directory can easily be sorted or searched by city, clinic name, service, or status (open, closed or reduced hours). Each clinic can update their status and the directory will updated in real time. For Clinic Owners instructions on how to update your status can be found here.

What are the latest Infection Control Procedures?

The procedures were updated as of March 24, 2020 to reflect changes to pre-screening questions related to travel, now including any travel outside of Nova Scotia. Refer back regularly for further updates. Physiotherapists must follow the guidelines issued by their workplace establishment and those mandated by government and by legislation including orders by the CMO.

How should Physiotherapists decide when to cancel appointments?

  • Non-emergency/elective appointments scheduled during the COVID-19 pandemic should be cancelled/postponed or delivered via virtual care.
  • Physiotherapists are urged to assess individual appointments for urgency and consider alternative treatment measures such as: Consult and provide treatment by telerehabilitation; Offer a home exercise program with verbal check-ins etc.
  • Schedule appointments so that there are never more than social distancing requirements in their waiting room or other non-clinical areas and follow the cleaning protocol.

How does a Physiotherapist determine eligibility for the provision of services?

By telephone, the physiotherapist can ask specific questions about the patient's condition. This telephone interview will allow the physiotherapist to:
  • Determine if the patient is at risk and should be isolated vs physical distancing
  • Briefly document the patient's condition, age and current health issues that may influence care
  • Determine whether physiotherapy consultation is urgent and needs to be done face-to-face or can it be done remotely.
Do not forget to document the telephone or in-person exchanges that led to your decision.

How can a Physiotherapist in Private Practice provide in-person services safely?

All Physiotherapists are required to stay up to date on the current evidence and recommendations for meeting the requirements laid out by the Chief Medical Officer of Nova Scotia. This means that all Physiotherapists are required to regularly update their understanding of the virus based on the most up to date, authoritative, and evidence-based sources. Due to the plethora of misinformation being propagated through various media there are three sources that meet this criteria; World Health Organization, Public Health Canada and Nova Scotia Public Health (particularly for information relevant for requirements in Nova Scotia). Also, the Nova Scotia Health Authority and IWK have produced excellent resources based on these resources.

Physiotherapists must be aware of the current protocols for office-based care (Pre-screening, enhanced cleaning protocols, universal precautions and enhanced hand hygiene, etc.). Refer to the latest Bulletin from the Chief Medical Officer for current protocols.

If in person care is required Physiotherapists must be able to meet social distancing requirements in their waiting room or other non-clinical areas and follow the cleaning protocol.

How does a Physiotherapist deliver Virtual Care / Telehealth / Telerehabilitation?

When providing virtual care, you must first ensure that it is appropriate and does not expose the patient to greater risk than other possible service delivery methods. We have adapted the process for use during the COVID-19 pandemic as found below. If you are crossing provincial borders you need to check with the other jurisdiction for their processes associated with this.

NS College of Physiotherapists (NSCP) expects the physiotherapist to:

  • consider and mitigate the risks to the privacy of the patient’s health information or patient safety depending on the physical environment and context in which services are provided.
  • comply with the expectations defined in the Standards of Practice and Code of Ethical Conduct.
  • ensure that interventions, referrals, or consultations delivered using virtual care technologies are held to the same standards and expectations as those delivered in person.
  • use their professional judgment to determine if virtual care is appropriate, taking into consideration:
    • whether virtual care is the most appropriate available method to deliver services.
    • whether a direct physical examination is required to complete the assessment and determine a physiotherapy diagnosis and treatment plan.
    • the ability to deliver substantively similar quality care as physiotherapy delivered face-to-face.
    • if patient factors such as physical, sensory, or cognitive deficits may impact the ability to deliver appropriate care via virtual care.
    • informs the patient of the process to follow if they have a concern or complaint about their physiotherapy care.
    • obtains informed consent as appropriate for virtual care
Before the consultation, NSCP recommends contacting the patient and offering them relevant information, such as:
  • the tool that will be used for the session: ie. telephone, videoconference or another platform
  • the need for someone to be present for safety or assistance if appropriate
  • the duration of the meeting
  • privacy protection, consent and anticipated resources needed.
  • the cost of the visit and proposed payment options
Following the consultation
  • The Physiotherapist must take care to document the interactions as they would if it was a face to face visit.
  • The fees for the services rendered can be collected at the end of the consultation.

Does Insurance cover virtual care for Physiotherapy?

The decision to reimburse physiotherapy services offered through virtual care lies with the private insurer, and the insurance contract held by the policy holder. You should suggest that your patient contact their insurer to verify that the insurer accepts invoices for virtual care services and take note of the requirements in this regard.

You should also check with your own insurance provider to determine if virtual care is covered by your policy.