Background

As a result of the challenges that practitioners are facing during the COVID-19 pandemic, we are working to establish guidelines for continuing care for our Health2Work (H2W) patients. Public health bodies continue to recommend saving in person visits for those truly acute patients, and we support these guidelines. However, we know that our Health2Work population comprises a vulnerable sector that continues to need support. As such, we have been looking into ways to maintain contact with our Health2Work patients while respecting these guidelines. One option is virtual appointments. Please note that this is document will be updated as new information is available. First and foremost, any virtual appointments must meet the CCO guidelines for providing this type of service. Please see Appendix A for the most current guidelines. You can also visit the College of Chiropractors of Ontario website at https://www.cco.on.ca/ for up to date information.

As long as you meet the requirements of the College of Chiropractors of Ontario, CCPA has confirmed that your liability insurance will continue to cover you.

What might these appointments look like?

• Phone calls
•  Video conference appointments

If you are going to use video conferencing as a means to connect with patents, you need to ensure that you are meeting PHIPA requirements. That means that you need to ensure that you are using encrypted video. Fortunately, there are a number of platforms that already support this. Please let us know if you need some advice in this area. It will be important to let the H2W client know that any data charges incurred as a result of a virtual appointment are the responsibility of the client. These additional data charges will not be paid for by the Region of Waterloo. Please mention this when you reach out to the clients to see if they are interested in having a virtual appointment.

I do hands on treatments-how do I make virtual appointments work?

Our preference is to provide hands on treatments in person. However, sometimes we need to adapt. Things that you might look at providing in a virtual follow up appointment:

• A check in to see how patients are doing overall; this is important as many are struggling
  with mental health issues more than ever
• A check in with respect to their nMSK issues
• Touch base to see how their exercises are going
• Provide modifications to home management strategies if needed; this might include use
  of hot/cold, positions of relief, and activity management/pacing
• Provide progressions to home exercise programs where appropriate; you may need to
  email copies of things that you have handed out in your office previously, for those not
  used to using exercise prescription software, one option is Hep2Go which is an easy,
  free program to use. You can save exercises sheets as PDF’s and then email them when
  using the free version
• Ongoing assessments to monitor progress including use of objective assessment tools
  that are available in many software programs and apps
• Self-administered techniques such as soft tissue massage or frictions under the direction
  of the health professional including patient education on how to do and at what
  intensity
• Support for self-management, education, coaching and reassurance for patients and for
  caregivers
• Assessment of how patients are functioning and adapting in their home environments
  including assessment of fall risks and other functional/activities of daily living
  assessments
• Bracing donning and removal and check in on fit and outcomes for bracing
• These appointments may also serve as a screening tool to determine which patients are
  doing ok with their home management strategies and can wait to be seen when things
  calm down and which ones would really benefit from an in-office visit (if you are
  continuing to provide them)

Components of a Virtual First Visit

1. Patient would fill out intake form so the chiropractor has background (e.g., demographic information). This would be the standard Health2Work intake forms as well as any additional forms required based on the patient’s complaint (Oswestry, NDI, pain scales). Depending on the approach/system used by the chiropractor and the patient’s access to technology, this could be done electronically or a paper copy could be provided for the client (while observing social distancing requirements). If necessary, 3 forms such as the Oswestry or NDI could be incorporated into the history portion of the assessment.
2. The chiropractor would send a consent form to the patient that explains it is not typical appointment and identifies that at any time if the patient or the chiropractor does not feel comfortable, the appointment will be suspended. When appropriate options will be discussed including seeking care at the chiropractor’s clinic (for those who require urgent care) or family doctor/emergency department (for emergency care and/or concerns outside of the chiropractor’s scope of practice).
3. A patient history is taken including discussing the injury or the issue. This could be done via video appointment or by phone. If done via video platform it should meet all PHIPA requirements.
4. Seek consent from patient to confirm they are comfortable doing the physical tests.
5. Conduct tests; muscle function testing (gross exam); neurological testing (some) orthopedic testing (ROM, some speciality tests); posture evaluation (modified); malingerer testing (mostly based on observation and inconsistencies observed).
6. Develop the report of finding including diagnosis or clinical impression.
7. Discuss treatment options which may include home management or in clinic treatment.
8. Obtain consent to the plan of management and document in the patient record.
9. Discuss the specific recommendations (e.g., specific exercises, lifestyle modifications)

Invoicing

You will be able to bill for these visits within the Health2Work program. The fee for these visits is the same as the regular fees. However, please note that as we are not providing hands on care for these visits, follow-up visits done virtually will not count towards the visits that you have had approved as part of your plan of management. The Region of Waterloo recognizes that these are trying times for many people and are looking at this as a temporary way to provide support for vulnerable clients.

How to get going?

You may want to start by reaching out to your patients by email or by phone. Check in and see how they are doing. You may find that they are not focussing on their nMSK issues right now because they are more concerned about other things. That’s fine. However, if they would like to book something further then go ahead with that.

Additional Help

For H2W clients who are struggle with pain, there are online resources available including the self-management program:

www.selfmanagement.ca supports for people within the Waterloo-Wellington LHIN living with chronic pain. Their in-person workshops have been suspended for the time being due to COVID-19, but there are online resources that can be accessed.

www.here4help.ca provides mental health resources specifically developed for COVID-19 by the Waterloo Wellington CMHA.

Want to refer your patients to Health2Work?

Ontario Works caseworkers, employment facilitators and community agency partners can use the Referral/Consent Forms to start the referral process. Primary care providers can use the Primary Care Provider Referral Form.

Health care providers, local health agencies and social services within Waterloo Region that are interested in discussing potential partnerships and referral pathways are invited to contact:  

info@health2work.ca

For Primary Care Providers:

Referral Form

For Caseworkers, Employment Facilitators and Community Agencies:

Health2Work Chiropractic Referral

Pre-test Survey

Consent to Collect and/or Release Information

Consent to Communicate with the Region using Email or Texting 

For Health2Work Chiropractors:

Referral/Consent Form

Intake Form 

Assessment/Re-assessment/Discharge Form

Report of Findings Form

What types of patients can I refer to the program?

If your patient has a MSK condition and is receiving Ontario Works or is a non-disabled family member of a person receiving support from Ontario Disability Support Program, you can refer them to the program. Please use this referral form, which also indicates who to send the form to in order to complete the referral.

Where in Waterloo Region is this program available?

We are rolling out the program throughout the Waterloo Region in several phases. As of December 2018, the program is available in Cambridge. The program is expected to expand to Kitchener and North Dumfries in November 2019. By September 2020, it is anticipated that the program will be available throughout the Waterloo Region.  

Who will assess my referred patients?

Your patient will receive an assessment from a chiropractor. During an assessment the chiropractor will ask about health history, chief complaints, functioning and complete a physical examination. With patient consent, the results of the assessment and the treatment plan will be sent back to the patient’s primary care provider to ensure a collaborative circle of care. 

Will the chiropractors follow up with my patients?

Yes. After the initial assessment, the chiropractor will develop a treatment plan with your patient, with up to ten follow up visits depending on their condition. There will also be a formal discharge after treatment is completed.

Will my patients be referred to specialists other than chiropractors?

Chiropractors are trained to refer to other health care professionals for assessment and treatment of conditions outside of their scope of practice and when interdisciplinary care would benefit the patient. 

Request for Expressions of Interest for Fee-For-Service Chiropractors in Waterloo, Wellesley, Wilmot and Woolwich