Introduction
COVID-19 and primary care
COVID-19 and health policy
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determine how the targeted primary care clinics responded to the needs of their older adult patients during the pandemic;
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understand how primary care adapted to the ever-changing policy landscape.
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examine older persons’ experiences of receiving primary care in these clinics during the pandemic; and.
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understand the role of government COVID-19 policies and mandates on the provision and receipt of primary care for older persons.
Methods
Setting & context
Recruitment
Data collection
Sample Interview Guide Questions- all sites |
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HCP Interview Questions: • Can you tell me about your experience with the various public health policies/ measures put into place to minimize the spread of COVID-19? (e.g., stay at home orders, mandatory masking, handwashing, quarantine, physical distancing, social bubbles etc.) Sample Probe: what was your main source of information? • How has COVID-19 impacted routine care for your older adult patients? • What are your most pressing concerns about your older person population? • What resources did you need/acquire/put in place to support care of older persons during the pandemic? |
Older Adult Patient Questions: • Can you tell me about your experience with the various public health policies/ measures put into place to minimize the spread of COVID-19? (e.g., stay at home orders, mandatory masking, handwashing, quarantine, physical distancing, small social gatherings, etc.) Sample Probe: what was your main source of information? • How has the COVID-19 pandemic impacted your health care? Consider the lock down in the Spring – was health care impacted in March – June? Is it still impacted? • What would you say matters most right now for your health and wellness? • Looking ahead what is your biggest concern or worry related to the impact of COVID-19 on your health and care?• |
Analysis
Description of each province during the data collection period
Quebec |
• In Quebec, there are 8.6 million residents, 85% of whom are registered with a family doctor [34]. Primary health care is regulated at the central and regional levels (16 regions). GPs are mainly paid on a fee-for-service or flat-rate basis, while the other professions are paid on an hourly basis. Most GP services are provided in Groupes de Médecine de Famille (GMF, Family Medicine Groups). • Declared a state of emergency on March 13, 2020, and on that same day ordered the closure of all schools, post-secondary-educational institutions, and most daycares. • Order in Council 223–2020 in Quebec [35] paused non-emergent and non-urgent procedures and treatments in clinics. • March 14, 2020, the province reiterated that all residents over the age of 70 should stay at home as much as possible, except for things like medical appointments. It was also announced that the Régie de l’assurance maladie du Québec would cover the cost of health services offered virtually (including telephone) [36]. • For our period of data collection, Quebec experienced waves of COVID-19 that peaked in April/May 2020, January 2021, and April 2021. Throughout, the province has relied on a regional colour alert system, green (“vigilance”) being the lowest level of alert, and red (“maximum”) being the highest; each colour is associated with different restrictions and guidance related to social distancing, closures, private gatherings, visits to Long Term Care, etc. |
Ontario |
• In Ontario there are multiple primary care models, including Family Health Teams (which are often interdisciplinary), solo-practitioner and fee-for-service clinics, and Community Health Centers, that are compensated through a blended payment model (i.e., salaries based on roster size and additional fees for some services). • State of emergency was declared on March 17th, 2020, and this coincided with population-level interventions to reduce spread (e.g., closures of schools and many businesses) • Directive #2 for Health Care Providers in Ontario [37] resulted in pausing non-emergent and non-urgent procedures and treatments in clinics. Significant rise in positive case numbers during April/May 2020, January 2021, and April 2021. • ‘Digital First’ approach in Ontario [38], formal policy announcements urging physicians to use virtual care whenever possible, and the introduction of billing codes to compensate for these visits (including telephone) [33]. • Local response by the 34 Ontario public health units differed depending on the case numbers and hospitalizations. For example, Ontario used a colour coded system to communicate the level of risk in each public health unit; green (“prevent”) being the lowest risk and with the lowest restrictions on activities, and grey (“lockdown”) reflecting the highest risk and indicating to return to the strict measures put in place during the first wave to reduce transmission. • For our period of data collection, Ontario experienced waves of COVID-19 that peaked in April 2020, January 2021, April 2021, and September 2021. |
Alberta |
• In AB, primary care resides under Alberta Health (provincial Ministry of Health). Primary care clinics are owned and operated by family doctors, and most are members of a Primary Care Network (PCN), which essentially offers a multi-clinic collaboration to provide interdisciplinary programs and services based on agreed local priorities for the geographical area served. PCNs are a joint-venture agreement between physicians and Alberta Health Services (province’s single health authority) but governance and funding responsibility lie with the Ministry of Health. PCNs have been an essential component of transforming primary care in Alberta over the last two decades [39]. • State of emergency was declared on March 17th, 2020, and this was coupled with the closures of recreational facilities, and limitations on non-essential services; one day prior, on March 16th, all educational facilities were closed. Additional closures and restrictions for non-essential services were put in place two weeks later. • March 18th, 2020, family doctors were asked to switch to primarily virtual care to reduce spread, and to bill using temporary virtual care codes (which were made permanent billing codes in June 2020) [40]. Alberta Health Services announcements paused non-urgent and non-emergent primary care in clinics. • AB has experienced waves of COVID-19 that peaked in April 2020, December 2020, May 2021, and September 2021. |
Results
Theme 1: Navigating the noise: understanding and responding to public health orders and policies impacting health and health care
Volume of policies impacting health and health care
As you can well imagine, it was like walking on shifting sand [laughter] it’s there for the longest time, which was you know, it was wearing for everybody. (ON_HCP04)
Grey areas & ambiguities
When you make a broad-brush comment or instruction, the devil is in the details. And it’s very hard to interpret. I think- you know, I heard it often from my staff too- is people want guidance, that’s black and white, and concrete; and it’s just not possible! So, every advice is open to interpretation. I’m sitting here in the clinic right now. And for example, one of our goals would be to minimize cross traffic between patients and staff, people come in one door and out another, but we can’t do that because we have four entrances that face the carpark. And if we were to have people walking through the building to come in and out of each one of those doors in a flow kind of way, we’d actually increase the amount of cross traffic. (03_ON_HCP)
For sure, over time, things became clearer, but there were a few weeks where it wasn’t so obvious: “So, do we wear masks or don’t we? Do we change or do we not change? Is this okay or not?” I mean, we eventually worked things out, but there was always this kind of feeling of not being sure we were doing the right thing, what should we be doing, you know? (QC_HCP08).
Well, sometimes the challenge was… because patients had been told to go to their appointments on their own, except if they needed a caregiver with them, and sometimes that distinction isn’t easy to make, so since the epidemiology is favourable, we’re a little more lenient when it comes to caregivers, because sometimes when our older persons come on their own, they may not have all the background info and can have trouble following up. (QC_HCP06)
Policies differing by regional zone
There was one about … when you should be gloving and when you shouldn’t be gloving. And then so Public Health would send something out. And what I learned later was [that they] weren’t consulting…the two public health units were saying different things. (ON_HCP02)
And that’s to be expected, right? Because public health units are supposed to be responding to what’s happening in the communities they serve….And at the outset, [one local public health unit] had way more cases, so [that unit] was putting on stricter controls.(ON_HCP02).
Responses and strategies to support communication and clarity
AHS [Alberta Health Services]… I don’t know if they still are but was putting out a weekly summary of new directives and directions. Then our executive director would forward those out to us and highlight anything that was pertinent to us. So, we always had current information on changes, what was happening, direction from our leadership. (AB_HCP02)
So we would use Public Health Agency of Canada, Ontario Public Health, and then the community health centers have a sort of overarching organization called the Alliance for Healthier Communities. And the Alliance did a wonderful job …reviewing all of the information that was coming in from the two government agencies, and sort of summarizing them and making relevant documents available to us. So we didn’t have to go hunting through things to get the relevant information. So that was helpful.(ON_HCP01).
They actually did an afternoon information session, answering all of our questions so we could leave there feeling informed and also so we could educate our patients about some of the misconceptions or interpretations or just where they were getting their information … It was just more about empowering patients…that is where we got our biggest amount of information and I feel like I learned, more than I would have learned on any website … It was simple. (AB_HCP01)
Theme 2: Receiving and delivering care to older persons during the pandemic: Policy-driven challenges & responses
Delayed and delaying care
Probably a majority of our visits, particularly with seniors, would have been by telephone. We did continue to see patients with urgent issues. And I know, many seniors were very reluctant to come out or to come into clinic…. We did have some concerns that seniors were not following up on things they should have followed up on. Then we had a few calls where we, you know under normal circumstances the best course of action would be to go to emerg…We had a few situations where we really had to work with family members to get people to emerg because they were just afraid to go there. (ON_HCP01)
… my doctor got really upset with me, and indicated how important it was to try to maintain that schedule of testing… but I was I was, actually, I was afraid to even try to access or I didn’t even know that I could because with, with the medical resources being taxed to the limit, and, and not wanting to be exposed to, you know, to the public or others, it was a lot of unknowns. (AB_Pt03)
Interviewer: What is most important to you right now in terms of healthcare?Patient: Healthcare? I don’t need healthcare. I’d just like to have a medical opinion about my arthritis that’s been acting up. But I know that’s what it is, you see. It’s not a big deal; it’s just painful. I figure if I had a medical opinion, if I had medication to relieve the pain, maybe that would help me. But I’m not going to insist on seeing someone for that. I don’t think… I don’t think it’s serious enough for that. (QC_Pt05)
I had a cataract surgery scheduled for October, which was cancelled and now it’s supposed to be January, but who knows? … I had a CT scan done in February. And I was supposed to see him a couple months after that, and I mean it got held up for a couple more months later. (AB_Pt15)
We had really good service, but my problem is that I need injections in my spine and it’s harder to get an appointment… (…) it’s the anesthetists who give the injections. There’s a lot of demand, and when COVID really started in May at the hospital, they had to stop taking appointments (…). It was frustrating because I’d been waiting for my appointment for nearly two years, and then it got cancelled. I called, I’ve called them twice, and they don’t know when I’ll get to see him.(QC_Pt42).
Responses and strategies to support care for older persons
Seeking out and caring for older patients in the community
We had the nurses contact all patients over the age of 70. So probably a couple of weeks into the lockdown, we were doing that reaching out to them just to see how they were doing, if they had questions, if they knew that they could still contact us…I think it was really encouraging for both seniors and the staff. The staff felt that they were being useful, and they were really appreciative of the acknowledgement they got from the seniors. And certainly, the seniors were just delighted to have someone to talk to, sometimes.” (ON_HCP01).
It depended also on the level of vulnerability. For a number of my patients, this meant appointments ended up being in-home visits because it was just easier that way (…) If I was able to do some things over the phone then I did them over the phone, and if I needed to perform a technical act or if a physical exam was required, then sometimes I’d go and see them to do that at the end of the day or the end of the morning. (QC_HCP02)
We made sure that our geriatric nurses were still seeing people face-to-face. So for instance, our INR program (anticoagulant management), we kept seeing people, but we transitioned to parking lot visits. So, our nurse would put on PPE and she would schedule people, and she would go and do the finger prick INR testing while they were in the car. And, and so people really liked that because they didn’t have to be coming into buildings, where they had to touch stuff.(ON_HCP02).
There’s a protocol, if you’ve got to go to the clinic, … when I went to see Dr. [name] for the first time, … I would phone them as soon as I got to the, to the [clinic name], let them know I was in the parking lot. And, and I was to stay in my vehicle. And they would contact me as soon as he had finished seeing the previous patient. And, and then that way I would go up, and I would go directly into the exam room. … I must say, is, is pretty well in place, they give you the mask, they use sanitizer. (AB_Pt03)It is worse than getting into Fort Knox. You come up, they ask you 40 questions, all of what you say no, you come back the next day and it is the same 40 questions… then you get to go sit in a room after they call you from your car to go sit in a room. (AB_Pt14)
Pivoting to virtual care
I’m not excited about that [telephone visits], you know, you spend so many years then having a doctor see you and assess you, things like that, and I’m just a little concerned, you know? (ON_Pt02)
Seniors were comfortable with telephone. And we did have the capacity to do a virtual call, but most people it was just another level of technology that that they weren’t as comfortable with.(ON_HCP01).
Both my wife and I both had some online or virtual appointments…if we really needed or insisted on a face to face then they would do that. (AB_Pt07)There’s no problem to see my family doctor. She came to see me when everything was locked down tight. She came to see me at home. After that, she wasn’t allowed to anymore, so she would do her appointments over the phone. I thought that was perfect. And the times I had to go to the hospital for tests, I thought it went fast and everything worked really, really well. (QC_Pt30)