Physiotherapy Services During COVID-19

Physiotherapists may be redeployed to a variety of settings and be asked to practice outside their normal area/scope of practice. This may occur as Physiotherapists are asked to, volunteer to, or identify the need to step into the needs created by this pandemic. While it is the responsibility of every Physiotherapist to ensure they are competent in their area of practice the College recognizes that how competency is ensured will look vastly different under pandemic conditions compared to normal conditions. To be clear, during the pandemic, Physiotherapists will not face disciplinary measures for working outside of their area of recent training, experience and education.

During redeployment there are some questions that Physiotherapists can ask themselves to ensure they have what they need in the moment to safely deliver the best care possible in the circumstances. The following questions to consider may not apply to varying degrees to all settings are only a guide of things to consider:

• What does competency look like in this area of practice?
• What orientation/training is provided by the employer?
• What is available through other organizations (ie CPA)?
• Did I learn enough to be competent for today?
• Do I have access to a resource for questions I may have (senior staff or PT)?
• Do I have enough theoretical information?
• Did I get enough practical feedback?

The preceding questions should not be considered a barrier to redeployment, however, should be used to remove potential barriers to redeployment through conversation and working with employers and other stakeholders.

To keep us informed of your redeployment you can simply update your online profile through your member profile. Instructions for updating employer information can be found here https://nsphysio.com/registration/renewal-reinstatement/employment-records.

Should you have questions please do not hesitate to contact us.

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.

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.

The intent of Public Health’s order is to ensure limiting viral spread. This can be done by:

• Reducing all unnecessary patient and physiotherapist travel;
• Reducing in-person contact.

All care services should be delivered by virtual means whenever possible for the following reasons:

• To avoid unnecessary trips to the clinic.
• To manage conditions that may not require a physical exam.

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

Urgent care services are when the risk of a patient not receiving in-person care in the next 24 hours outweighs the risk of transmission of the virus. In addition, there must be significant medical evidence to support the need for in-person care vs alternatives such as virtual care. When assessing risk physiotherapists must consider not only personal and patient risk factors, but also societal risk factors (i.e. the intent of current public health orders, current risk of transmitting COVID-19 to other patients and members of the community, and the need to preserve the integrity of the public health system).

Considerations to determine the appropriateness of in-person care 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
• Patient’s capability for participating in virtual care (access to phone/internet/video, familiarity with technology, cognitive status, etc.)

The following are examples of situations that may be considered urgent in private practice. Even in urgent cases, every effort must be made to provide care virtually if possible:

• situations where in-person physiotherapy treatment is needed to manage acute conditions where there is significant medical evidence that any postponement of care will negatively affect outcomes in the short and in the long term.
• acute conditions requiring in-person assessment/treatments prior to being able to self-manage their injury or condition until restrictions are lifted.
• Patients requiring immediate postoperative treatment.

The following are examples of situations that are not considered urgent in private practice:

• ongoing care
• functional scans
• management of chronic pain conditions

Patient’s occupation is not a consideration for urgent care currently. If Public Health deems it necessary to triage rehabilitation services based on occupation that will be laid out in orders from the CMO.

If in-person care is deemed appropriate all infection control and prevention (IPC) procedures including pre-screening, allowing for social distancing in public areas (waiting rooms, bathrooms, etc.), spacing out appointments to minimize density of people in the clinic, enhanced cleaning, hand washing and any other recommendations from public must be maintained. If IPC procedures cannot be maintained in-person care is not permitted.

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.

The procedures are regularly updated to reflect changes. Refer to these resources regularly for updates.

• Government of Canada Infection prevention Control
• 811 - Online Self-Assessment
• https://novascotia.ca/coronavirus
• Latest CMO Bulletin

Physiotherapists must follow the guidelines issued by their workplace establishment and those mandated by government and by legislation including orders by the CMO.

• 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.

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.

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.

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.

Virtual care task assignment may be appropriate depending on the nature of the task, the patient/client/resident, and the care provider. Physiotherapists must follow the task assignment and supervision standard when assigning virtual care tasks.

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.