COVID-19 Pandemic

Over the last few days, Physiotherapy Alberta has received a number of concerns and questions from stakeholders in the long-term care (LTC) and continuing care (CC) community in response to direction published on March 29 regarding urgent physiotherapy services. In response to these concerns, we would like to clarify earlier statements.  

Context matters

As in all things, the unique context of LTC and CC environments must be considered. This is what we know to be true:

• Patients:
  • This is not a homogeneous group. Some are relatively stable. Some are on a trajectory of gradual decline due to underlying conditions. Some are on a steeper trajectory of decline, with or without physiotherapy intervention.
  • In some cases, physiotherapy interventions decrease the speed of decline.
• Service providers:
  • Some settings have on-site physiotherapy services, some have limited physiotherapy consultation, others are unable to recruit physiotherapists.
  • In some cases, residents and families hire physiotherapists working in mobile practice to provide physiotherapy services.
  • Private providers delivering mobile services pose more risk to residents if they provide care in multiple settings, serving as a potential source of transmission between facilities.
  • Contractors who provide services to an entire facility may act in many respects as employees of the facility adhering to facility policies; however, those providing mobile services to individual patients are less likely to be subject to and adherent with facility policies.
  • Mobile practice physiotherapists are also subject to the Chief Medical Officer for Health’s directions regarding essential visitor restrictions.

Risk

Public health experts have clearly identified that COVID-19 poses a serious threat to people residing in communal living settings. Seniors and especially those with comorbidities, the very seniors who are commonly residents of LTCs and CCs, are at greater risk of severe disease and death from COVID-19.

During the April 2, 2020 press conference, Dr. Hinshaw identified that “there are nine outbreaks at continuing care facilities across the province” and “74 confirmed cases of COVID-19 in continuing care facilities” with more expected “to be confirmed in the coming days.” As Dr. Hinshaw said during that briefing, “we must all do our part in keeping the most vulnerable members of our society safe.”

As we have seen with the more notable national examples, such as Pinecrest Nursing Home in Bobcaygeon and the Lynn Valley Care Centre in Vancouver, people in these settings will die if we do not take this risk seriously.

This is not business as usual.

Defining urgent care in LTCs and CCs

Physiotherapists got into the profession to treat people, so not providing treatment (especially when a long-term patient-provider relationship is in place) is difficult and may create an ethical dilemma for many. That’s exactly the issue – treatment of this population, at this time, in this setting creates an ethical dilemma:

• Without treatment many patients will deteriorate and some may potentially die.
• With treatment, and despite clinicians’ best efforts, there is the real risk of exposing patients to COVID-19, with the potential of causing serious illness or death.

Direction provided on March 29, stated the following scenarios constitute urgent services in LTC:

• Physiotherapy care has been initiated as part of urgent discharge from acute care, subacute or rehabilitation settings, with the intent of preventing hospital readmission or establishing patient care needs to enable ongoing patient safety in the long-term care or continuing care environment.
• Physiotherapy interventions are required to maintain an individual in their current living environment and prevent hospital admission due to imminent functional decline.

We received many comments indicating that prevention of hospital admission did not resonate for many residents of LTCs and CCs as their goals of care often stipulate that the patient not be transferred to hospital under any circumstance. Physiotherapists also argued that many of their interventions help to delay or prevent functional decline. Regardless of the patient’s goals of care, clinicians must make reasonable and well-judged decisions about what constitutes urgent care in LTC.

Here are some concrete examples of urgent care in this setting:

• Wound care of new or chronic wounds.
  • Includes provision of pressure relieving devices, debridement and dressing changes and use of modalities to promote wound healing.
• Management of acute respiratory infection or exacerbation of chronic respiratory conditions.
  • Physiotherapists must use appropriate precautions when providing this type of care, and follow all facility protocols for screening, point of care risk assessment and PPE use.
  • Physiotherapists must apply evidence-informed practice. COVID-19 is not currently thought to result in increased sputum production or retention, and therefore is not considered amenable to airway clearance techniques. However, those with underlying respiratory conditions may demonstrate an increase in sputum production and may be appropriate for these interventions.
• Sudden decline in previously stable mobility or transfer status.
  • We talked before about this not being business as usual. We also acknowledged that most residents of LTC or CC are on a trajectory of declining functional ability. This is often why they are admitted to LTC or CC to begin with.
  • When the trajectory of decline changes precipitously, physiotherapist intervention becomes urgent to stave off further progression.
  • The objective is to prevent a patient’s decline to the point of no longer being appropriate for a supported living environment and requiring LTC level care or requiring additional staff resources and equipment to manage basic care, transfer and mobility tasks in LTC facilities.

What about ACOT’s direction to occupational therapists?

We are aware that ACOT sent out messages to their members that may be perceived by some to differ from Physiotherapy Alberta’s messages to registrants. Each regulatory College must define urgent services, with consideration of the profession’s scope of practice and typical practice.

Having reviewed the message, we don’t perceive a gap in direction. Both Colleges are urging that only urgent care continue.

However, there is a difference in typical practice and service availability in this setting. While physiotherapists and physiotherapist assistants are often involved in group exercise programs and mobility practice, with the goal of maintaining functional abilities, our understanding is that although occupational therapists may be involved in functional activities and BADL training they are most commonly involved with the provision of adaptive devices, the provision and monitoring of splints to prevent or manage contractures, and the performance of bedside swallowing assessments. ACOTs position is that these are urgent care needs. Physiotherapy Alberta agrees and believes that this is aligned with our prior statements.

I have no patients to treat. Do I just stay home?

We have heard of physiotherapists who have said just that. If you are a mobile physiotherapy provider, that may in fact be the right thing to do.

For employees of LTCs and CCs, we encourage you to consider what you can do.

• A sudden decline in mobility and transfer status is an indication of need for urgent service. How are you monitoring for that decline? Are you checking charts or connecting more frequently with nursing staff and HCAs or monitoring RAI-MDS scores?
• Are you providing patients and their designated visitors with activities and exercises they can do in their rooms?
• Are you providing suggestions to HCAs and nursing staff of things they can incorporate into their basic care activities to either monitor for change in status or sneak a little bit of exercise into basic care?

I’m being told to help with nursing care. What am I supposed to do?

We know that all facilities are currently facing staffing challenges due to illness, self-isolation and quarantine requirements. Meanwhile, patients still require basic care – dressing, bathing, toileting. These are not physiotherapy activities, however if you are an employee in a LTC or CC and none of your patients meet criteria for urgent care, your employer may reassign you to other duties.

Registered physiotherapists have a professional obligation to decline work they are not competent to perform; however, they also have a professional responsibility to use the skills they possess for the betterment of society and the benefit of those they serve. During a public health crisis, physiotherapists can be redeployed to assist with basic care activities and can apply their patient handling skills to do so. When doing so, appropriate precautions and facility protocols must be followed.

Helping with nursing tasks is not physiotherapy and therefore is not subject to current physiotherapy-related urgent care orders. This is an unprecedented situation in which the greater good calls all health professionals to contribute, as they are able.

This is not business as usual.

Date Posted: April 3, 2020

On March 29, 2020, Physiotherapy Alberta provided guidance to the profession on closure of businesses and urgent physiotherapy that may be offered. We are providing further direction for those in private practice community settings to determine urgent care. We have received concerns that the guidance provided on March 29, 2020 is not being applied correctly to determine urgency of care.

On March 27, 2020, the Chief Medical Officer of Health (CMOH) ordered all non-essential businesses to close including physiotherapy clinics. The order is attached here. Regulated health professionals may only provide urgent, critical and emergency care to patients. The Government of Alberta is trying to limit non-essential close interactions in the community in an effort to prevent the spread of COVID-19, while at the same time keeping people out of emergency departments for services that regulated health professionals can provide in the community.

Failure to comply with the orders of the Chief Medical Officer of Health, by providing non-urgent care could result in a fine under the Public Health Act as well as disciplinary action under the Health Professions Act.

Physiotherapy Alberta considered the CMOH order when developing guidance on urgent care. Emergency care services require immediate attention and there are very few, if any situations in which this would be provided by physiotherapists therefore urgent care direction has been provided.

First and foremost, the physiotherapist should determine if services can be provided using an alternate form of delivery, such as telerehabilitation. 

If it has been determined that telerehabilitation is not appropriate for the patient’s condition, physiotherapists are expected to screen patients to determine if in-person urgent care is required. This screening should be done remotely (via telephone or secure video conferencing). The physiotherapist must determine the need for urgent care. This decision should not be influenced by another health care practitioner determining urgent physiotherapy is needed or the patient’s preference for care.

There are two questions physiotherapists should ask themselves:

1. Will the inability to initiate in-person care or the withdrawal of care lead to serious or imminent harm?

AND

2. Is the client at risk for an emergency room visit, imminent hospital admission or re-admission?

Only if the answers to both are YES then face to face urgent care may be considered.

As noted in prior communications, essential service providers (EMS, health-care provider) are given special consideration in the CMOH’s orders. When acute injuries or exacerbations of pre-existing conditions prevent these individuals from working, in-person urgent care may be required. However, when possible these individuals should also be seen via telerehabilitation.

Private practice community settings have three options:

1. The practice closes and ceases services for all patients until further notice.

• Timelines of when non-urgent care can resume is unknown and this direction will be provided by the Government of Alberta.
  • Ensure your patients have access to urgent care services should they require care by referring them to another physiotherapist that is providing urgent care.
  • Communicate with patients by posting a notice on your door, website and having appropriate voicemail messaging.
• Respond to voicemail messages until the practice setting reopens.

2. In-person physiotherapy services are available for urgent care only.*

• Physiotherapy businesses should be closed and not accessible to the public.
• Communicate with patients how they may contact you should they be seeking urgent in-person care.
• Follow the guidance provided to assess whether urgent in-person care is required.
  • -The physiotherapist must determine the urgency regardless of the pressure from patients or others.

*This does not prevent the practice from also providing services via telerehabilitation when these services are appropriate for the patient’s condition (whether urgent or non-urgent).

3. Physiotherapy services are available via telerehabilitation

• Follow guidance previously provided.
• Communicate with patients that you are available to provide non-urgent services via telerehabilitation if it is appropriate for the patient’s condition.

Posted date: March 31, 2020. Edited April 1, 2020.

On March 27, 2020, Premier Kenney and Chief Medical Officer of Health Dr. Hinshaw announced new restrictions for businesses due to the COVID-19 pandemic, providing a list of essential workplaces that can continue to operate and directing closure of non-essential workplaces. Essential workplaces include hospitals, continuing care (long-term care, licensed supportive living, and home care), and home services for seniors, the disabled and the vulnerable. 

Non-essential workplaces that have been directed to close include those that provide close contact personal services, except when providing emergency and urgent services.

 “Albertans are prohibited from accessing close contact personal services, including personal services facilities, cosmetic enhancement services, wellness studios and clinics, non-emergency and non-critical health services. Non-emergency and non-critical health services provided by regulated health professionals or registered professionals include any non-emergency or non-urgent physiotherapy.”

The wording of the Public Health Order, and clarification provided by representatives from Alberta Health make the following clear:

• The only in-person physiotherapy services that may be provided at this time are those categorized as urgent or emergency.
• The task of defining what constitutes urgent or emergency care rests with the regulatory body.

As we previously stated, Physiotherapy Alberta does not have the authority to direct that physiotherapy clinics must close. That authority rests with the Chief Medical Officer of Health and the Government of Alberta. We also advised members that if the Chief Medical Officer of Health directed that clinics close, we would advise them of that change.

As of March 27th, the Chief Medical Officer of Health has directed that clinics and other settings where close contact physiotherapy services are provided must close, except for the provision of urgent or emergency care. It is no longer a recommendation it is now an order. Failure to comply with this order, by providing non-urgent or non-emergent care could result in a fine under the Public Health Act.

Physiotherapy Alberta recognizes that physiotherapists provide valued and important health services in a wide range of settings. It can be difficult for clinicians and patients to know when services constitute urgent or emergency physiotherapy. It is also essential that these decisions are consistent across the province. To that end, we are now providing direction regarding what constitutes urgent or emergency care by physiotherapists, categorized by health-care setting.

Acute Care

Acute care physiotherapy services are categorized as urgent services and must continue.

This includes services to individuals with respiratory, neurologic, or musculoskeletal system impairments requiring physiotherapy intervention to optimize health and function and facilitate discharge from the acute care environment. Existing facility protocols for prioritization of services should be reviewed.

Additional considerations for the delivery of in-person services in this sector should include:

• Prioritization of non-COVID-19 patients with functional impairments, with the intent of facilitating rapid discharge out of acute care and into community settings.
• Prioritization of COVID-19 patients on medical wards to address respiratory care needs, with particular focus on patients with co-morbid conditions who may experience a more severe illness trajectory or who may benefit from active respiratory interventions (e.g., patients with co-occurring COPD or similar respiratory illness).
• Prioritization of COVID-19 patients in ICU to address respiratory care needs or provide interventions to prevent or minimize post-ICU weakness and functional decline.
• Non-COVID-19 patients who are categorized as ALC and pending transfer to a continuing care or supportive living facility may be categorized as urgent, if ongoing physiotherapy intervention is required in order to maintain a patient’s functional status and eligibility for transfer to the designated community setting that they are awaiting. Physiotherapists are advised to use their clinical judgment when determining the need for ongoing intervention to support these discharge plans.

When providing services in this sector, physiotherapists are directed to follow facility protocols for patient screening, point-of-care risk assessment, frequent hand hygiene and use of PPE to limit the spread of COVID-19. Questions regarding appropriate use of PPE should be directed to facility-based staff with Infection Prevention and Control expertise.

Decisions regarding caseload assignment and patient care sequencing are best made at the facility level, with due consideration of human resources and other resource availability. However, Physiotherapy Alberta encourages managers and clinicians to consider the following actions:

• Reduce the potential for physiotherapists to spread COVID-19 by assigning patients with suspected or confirmed COVID-19 to a limited number of staff members.
• Sequencing patient care to minimize the risk of becoming a vector for transmission by providing services to patients who do not have/are not suspected of having COVID-19 prior to patients diagnosed with or suspected to have COVID-19.

Subacute and Rehabilitation Facilities

Physiotherapy services provided in this setting are categorized as urgent and must continue.

Patients with functional impairments for whom physiotherapy is required to facilitate discharge home or to community care settings are correctly categorized as having urgent needs requiring ongoing in-person physiotherapy intervention. This includes patients with:

• Recent diagnosis of neurological conditions such as stroke, brain injury, and/or spinal cord injury
• Deterioration of pre-existing neurologic conditions (e.g., Parkinson’s disease, MS) requiring admission for functional retraining and rehabilitation
• Recent amputation
• Post-surgical patients including multiple orthopedic trauma, total joint replacement and similar
• Generalized weakness and functional decline

The goal of physiotherapy services in both acute and subacute/rehabilitation settings is to facilitate transfer out of facility and into home or community care environments to create capacity in the health-care system for managing COVID-19 patients and to limit co-location and transmission risk among non-COVID-19 patients.

Recommendations regarding point-of-care risk assessment, hand hygiene, PPE use, human resource management and patient sequencing are the same as those identified for acute care settings.

Home Health Care Settings

Whether delivered by Alberta Health Services or private providers, physiotherapy services provided in this setting are categorized as urgent in the following situations:

• When physiotherapy care is initiated as part of urgent discharge from acute care, subacute or rehabilitation settings (e.g., early supported stroke discharge, following orthopedic surgery).
• When physiotherapy interventions are required to maintain an individual in their current living environment and prevent hospital admission due to health or functional decline, or injury (e.g., services to elderly, medically fragile or frail patients, patients with elevated risk of falls, those with chronic health conditions or multiple co-morbidities).
• To address post-operative care needs of patients with recent orthopedic trauma, total joint replacement or limb amputation when those services cannot be provided using an alternate means of delivery (e.g., telerehabilitation).

AND

• Services are provided in the home because the patient is unable to leave their home due to mobility or functional impairments.

Services delivered in the home environment because it is the patient or family’s preference to receive care at home should be categorized according to the criteria for private practice/ambulatory care services. Current restrictions on gatherings and provision of personal services do not constitute a physical inability to leave the home and are not an acceptable reason to provide home-based services on an urgent basis.

Clinicians who provide home health-care services are directed to follow employer protocols for patient screening, point-of-care risk assessment, hand hygiene and use of PPE. Questions regarding appropriate use of PPE should be directed to those with Infection Prevention and Control expertise.

Private providers of home health-care services must develop protocols for screening of patients and the home environment for appropriateness of in-person services, conduct point-of-care risk assessment, and employ hand hygiene and PPE according to the recommendations of Public Health Officials.

In the presence of suspected or confirmed COVID-19, physiotherapists must not deliver in-person services if they do not have the appropriate PPE to provide services safely.

Private Practice Clinics and Ambulatory Care Settings

Physiotherapy services in private practice or ambulatory care settings are only considered urgent if:

• Services cannot be provided using an alternate form of delivery, such as telerehabilitation.

AND

• In the absence of physiotherapy services, the patient will require health-care services in an emergency department setting (e.g., severe pain requiring physician intervention or prescription medication to manage that pain).
• The patient is an essential service provider (e.g., health care provider, first responder) who is unable to work  due to an acute injury or exacerbation or a pre-existing condition, whether that injury is WCB compensable or not.
• The patient is seeking services related to a recent surgery or removal of a cast/immobilizer.
• In the absence of physiotherapy services, the patient’s functional status will deteriorate to the point of requiring invasive management or hospitalization in the foreseeable future.

In the case where the treating clinician does not provide telerehabilitation, but services could reasonably be provided using this method, the physiotherapist is expected to provide a referral to a telerehabilitation provider.     

Clinicians who provide ambulatory care services in AHS or Covenant Health facilities (e.g., wound care clinics, cast clinic, chronic pain clinics) are directed to follow employer directions for provision of care and protocols for patient screening, point-of-care risk assessment, hand hygiene and use of PPE. Physiotherapists should direct questions regarding appropriate use of PPE to their employer’s Infection Prevention and Control experts.

Private providers (i.e., private clinics) must develop protocols for screening of patients for urgency of care need, screen urgent patients for signs/symptoms and risk of COVID-19 prior to patient attendance at the clinic, conduct point-of-care risk assessments, and employ hand hygiene and environmental cleaning measures according to the recommendations of Public Health Officials.

In the presence of suspected or confirmed COVID-19, physiotherapists must not deliver in-person services in private clinics.

Long-term Care and Continuing Care Environments

Physiotherapy services in these environments would not typically be considered urgent. Recognizing that the patient population residing in these settings is also one of the most high-risk patient groups for negative outcomes from COVID-19, service provision should be the exception, and should only be provided if:

• Physiotherapy care has been initiated as part of urgent discharge from acute care, subacute or rehabilitation settings, with the intent of preventing hospital readmission or establishing patient care needs to enable ongoing patient safety in the long-term care or continuing care environment.
• Physiotherapy interventions are required to maintain an individual in their current living environment and prevent hospital admission due to imminent functional decline.

Physiotherapists must follow facility protocols for patient screening, point-of-care risk assessment, and use of PPE. Questions regarding appropriate use of PPE should be directed to facility-based staff with Infection Prevention and Control expertise.

Physiotherapists must also engage in routine practices such as frequent hand hygiene and respiratory etiquette. Physiotherapy Alberta encourages managers and clinicians to consider the following actions to reduce the risk of becoming a vector for the spread of infection among this fragile patient group:

• Assigning patients with suspected or confirmed COVID-19 to a limited group of staff.
• Consider sequencing of patient care services to patients with confirmed or suspected COVID-19 after services to non-COVID-19 patients have been provided.

Other Methods of Service Provision

At present, telerehabilitation services may continue, as they do not include close personal contact. Physiotherapy Alberta acknowledges that telerehabilitation services may be employed to provide both urgent and non-urgent physiotherapy services at this time. Not all patients and conditions are well suited to telerehabilitation and clinicians may not have the individual competence to deliver services via telerehabilitation. Physiotherapists are directed to critically review their ability to deliver services using telerehabilitation, take action to address competence gaps and develop criteria for patients who are appropriate for this method of service delivery.

We note that there are several platforms available for physiotherapist use which also adhere to privacy and security expectations for patient health information, therefore our expectation is that physiotherapists will employ secure platforms when providing these services.

***Regardless of the information contained in this update, the orders of the Chief Medical Officer of Health and the Government of Alberta will always supersede the directions and guidelines provided by Physiotherapy Alberta.

Posted: March 29

As the implications of the COVID-19 pandemic have begun to be realized within the physiotherapy community, Physiotherapy Alberta has received a number of calls and inquiries regarding the provision of telerehabilitation services. We are also aware of the many comments made by individuals and organizations operating in other jurisdictions, and the rules and positions of regulatory bodies of other health professions providing health-care services within Alberta.

Physiotherapy Alberta’s perspective is that there is no “one size fits all” solution for addressing the health needs of all Canadians in the face of this pandemic. Direction from regulatory organizations, whether those of other professions from within Alberta, or physiotherapy regulators from other provinces, need to reflect the unique nature of the services provided by different health professions and the local context in which those services are being delivered.

Some health services cannot be delivered using digital technologies. All jokes aside, one simply cannot perform dental hygiene on one’s self. Fortunately, most physiotherapists have a range of tools in their toolkits for managing patient health needs. While some treatment methods, such as joint mobilization, spinal manipulation, or needling face the same barriers as those of dental hygienists, others such as patient education, exercise prescription and self-management recommendations are amenable to this format of service delivery.

For professions whose services can only be provided in-person (due to the nature of those services), the rules regarding the use of telerehabilitation will differ from those of Physiotherapy Alberta. While that may cause confusion or conflict in some cases, it is important to remember that each regulated health profession is governed by its own regulation under the Health Professions Act and its own set of Standards of Practice.

Registration considerations

As has been stated in prior Physiotherapy Alberta messages regarding telerehabilitation and COVID-19, our perspective is that this format of service delivery may be appropriate for some patients. However, it is unlikely to be appropriate for all patients seeking physiotherapy services.

Telerehabilitation services are subject to the same Standards of Practice as any other physiotherapy service. All members of Physiotherapy Alberta are authorized to provide telerehabilitation services as part of their existing registration. No special registration is required, provided you are delivering services within Alberta. If you are delivering services to patients residing in other jurisdictions, you need to contact the regulatory body in that jurisdiction to find out what rules apply to your practice. With individuals returning to their home provinces to weather the pandemic due to school and work stoppages, this becomes relevant, even if you are following your existing patients.

To better understand the rules regarding Cross-Border service delivery, refer to the Canadian Alliance of Physiotherapy Regulators guidance documents regarding cross-border services.

Getting started

While it may be tempting to jump in to providing telerehabilitation services in the face of declining ability to provide in-person services and declining patient attendances, business owners and clinicians alike are advised to take the time to set up their services in a way that is consistent with the Standards of Practice. Once established, it will be more difficult to correct any errors made during the set-up phase than it is to do it right the first time. Look at this as a new business offering and plan accordingly, as you would plan any other venture.

Platform selection

While Physiotherapy Alberta cannot provide direction on telerehabilitation platforms that are or are not acceptable for use by physiotherapists, members are urged to consider the following when reviewing potential platforms:  

• The relevant privacy legislation for private practice telerehabilitation services delivered within Alberta is PIPA, not PIPEDA or HIPPA.
  • Platforms often tout their compliance with PIPEDA or HIPPA, and there is some comfort in knowing a platform is compliant with this legislation, but it simply is not the legislation of note.
• It is essential that physiotherapists do some additional digging when deciding if a platform can address privacy requirements established by PIPA.
  • Is the platform “end-to-end” encrypted during transmission of the information?
  • Is the information collected and stored through the platform password protected and encrypted?
• What are the terms of service of the platform provider? What information does the platform collect and who has access to that information? How is information that the platform collects used by the platform provider?
  • Attentive readers may have heard about concerns raised recently in relation to the launch of Telus Babylon in Alberta and issues regarding the terms of service of the platform which reportedly grant access to private patient information to external organizations and governments.
  • As a rule, platform providers should not access patient private information and should not share that information with other parties.
  • Platform providers may track data related to business use (e.g., your behaviour when using the platform).
  • It is essential to read the terms of service, ensure that patient information is securely stored and protected from access by third parties, and ensure you understand what information the platform collects regarding your use/access to the platform and how that information is used.
• Where is the data stored?
  • There is no rule that requires data be stored within Canada or within Alberta, however; if data is crossing international borders that needs to be communicated to patients.
• What about patient records and video records of telehealth interactions?
  • Telerehabilitation visits are subject to the same Standard of Practice for Documentation and Record Keeping as other visits. Physiotherapists need to generate a record for each treatment or professional interaction completed. These records can be in paper or electronic format – consistent with the physiotherapy business’ usual practices.
  • Video recordings of telerehabilitation visits are not mandatory.
  • However, if the platform used generates a recording, that recording must be retained as part of the patient record. This has implications for ongoing record retention that physiotherapists and employers need to consider.

It is likely that physiotherapy businesses will be offered service contracts on a “take it or leave it” basis but that’s not an excuse to use a platform that is not secure. As we have stated before, patient health information is a regular target of computer hackers and attacks. With the significant influx of health information available online as a result of the rapid uptake of telerehabilitation by many health professions, clinicians and business owners are advised to use caution to ensure that private information remains private.

In recent days, some parties have suggested that the adoption of platforms that are not secure may be justified due to the extraordinary circumstances we find ourselves in. Physiotherapy Alberta does not share that perspective.

Remote working

The adoption of telerehabilitation services may also enable physiotherapists to work from home, consistent with the expectations articulated by the Chief Medical Officer of Health. While this is a good thing and may help physiotherapists to contribute meaningfully to flattening the curve, employers need to consider the privacy issues that can arise when having staff work from home using their own computers, tablets or phones to connect with patients or to complete record keeping duties. The Office of the Information and Privacy Commissioner has an excellent resource on the security risks of allowing employees to use their own devices for work purposes.

Physiotherapy businesses must also consider the risks involved in having employees store patient records in paper format within the physiotherapist’s home environment, and strategies to adopt to mitigate those risks.

Employers need to conduct a privacy threat assessment and employ policies and procedures to ensure the ongoing privacy of information that employees store within their homes or access from their own devices. This includes both the telerehabilitation visits and any recordings generated from them, and the patient records generated following a telerehabilitation visit.

Fees and billing

Physiotherapy Alberta has been talking about telerehabilitation since long before this pandemic became an international concern. We see these services as a key method for physiotherapists to provide care to patients with a wide range of needs and who face a range of barriers to access to service, (but we cannot claim that we anticipated a global pandemic would be one of them). We are adamant that telerehabilitation services must meet the same expectations for safety and quality as any other physiotherapy service and recognize the value that physiotherapy can offer to patients through telerehabilitation.

We believe that these services should be reimbursed accordingly. We have heard from members who have questioned whether it is justifiable to charge the same fee for a telerehabilitation visit as for in-person services. Our perspective is that there is no reason that the fees should differ based on the method of delivery, provided that the time spent with the patient and the quality of the services are equivalent, albeit potentially different in terms of the interventions provided.  

As with all physiotherapy fees, members are advised to set fees in accordance with their business model, the costs of providing service, and market forces. Fees must be transparently communicated and justifiable.

We do not support the provision of free services, whether telerehabilitation or other, as we see this as devaluing the services that physiotherapists provide and may have unintended impacts upon the quality of service provided. Members are reminded of the prohibition on advertising free services identified in the Advertising Standard of Practice.

Reimbursement for telerehabilitation services remains a concern for some providers. Physiotherapy Alberta is aware of recent changes by third-party payers to enable reimbursement of these services. Due to the fluid situation and reimbursement rules that they are currently faced with, members are advised to have their patients confirm with their extended benefit providers that telerehabilitation services are covered by their plan before providing these services.

In closing, it is important to recognize that not all patients will be appropriate to receive telerehabilitation services. Physiotherapists are encouraged to critically evaluate the services they provide and patient populations they treat, and to reflect on which patients can be managed using telerehabilitation technologies.

Physiotherapy Alberta recognizes that these are extraordinary times, and that new information arises each day. We will continue to provide updates as information relevant to physiotherapy practice becomes available and encourage members to check our website regularly.

Posted Date: March 26, 2020

While physiotherapy clinics may remain open until directed otherwise by the Government of Alberta and Chief Medical Officer of Health, they must also implement measures to limit the spread of disease. These measures include:

• Environmental cleaning and disinfection of surfaces.
• Screening patients for respiratory illness or risk factors for COVID-19 (e.g., recent international travel) before they attend their appointments and rescheduling patients as indicated.
• Use of frequent hand hygiene and respiratory etiquette by both staff and patients.
• Directing staff who are ill to stay home.
• Reconfiguring clinical spaces (treatment beds, waiting areas) and altering staff and patient booking practices to adhere to social distancing and maximum attendance instructions of public health officials.
• Conducting patient-specific risk assessments to determine patients who may need to be rescheduled for a later date due to their individual health needs or health status and discussing the results of the risk assessment with the patient.

Physiotherapy Alberta encourages members and clinic owners to take a risk-based approach to managing their business decisions regarding continuing or ceasing operations. Conducting a risk assessment of the practice environment, patient population and facilities available will help clinicians and business owners to determine their ability to continue to provide services.

Posted date: March 18, 2020

Physiotherapy is a touching profession – there’s no denying that. Social distancing recommendations are often not feasible to implement while providing active physiotherapy care.

Social distancing and self-isolation directions from public health work by limiting the volume of human interactions occurring in general and are believed to have their effect by doing so. These whole population interventions are in place to control the spread of infection.

Unlike the general population, during the provision of health services, health professionals have the ability to screen patients and to implement risk-informed controls specific to the patient in front of them to mitigate the risks of infection. These targeted controls should be implemented by clinicians thoughtfully and on a consistent basis.

In the private practice physiotherapy environment, patients with suspected or confirmed COVID-19 should be directed to follow the instructions of public health officials to stay home in self-isolation for the required time period. Clinicians should reschedule appointments for a future date. It is recommended that patients not be charged cancellation fees in such cases.

In the hospital environment physiotherapists implement point-of-care risk assessment and contact and droplet controls consistent with guidance from Infection Prevention and Control specialists. These controls include the use of gloves, gown, mask and eye protection for general care, and use of N95 masks for aerosol-generating procedures.

Controls such as masks and gloves should not be used when interacting with asymptomatic patients.

• PPE use is reserved for use with patients with suspected/presumptive or confirmed COVID-19. These patients should not be attending for private practice physiotherapy services.
• Inappropriate use of PPE for asymptomatic patients reduces the availability of PPE to manage cases of confirmed COVID-19 and may have serious implications for the protection of these who provide care to these patients.
• Frequent hand hygiene and avoiding touching one’s face are essential.

Posted date: March 18, 2020

COVID-19 has many people, clinicians and patients alike concerned about their health and safety. Developments of the last few days highlight the fact that this is a fluid situation with new information and recommendations emerging daily. Like all health professionals and health organizations, Physiotherapy Alberta is working to remain abreast of and consider the implications of new developments. We strongly encourage all clinicians, managers, business owners and organizations to do the same.

Click here for more information.

Posted date: March 16, 2020

Alberta-specific information (including travel restrictions, local actions, etc.)

• https://www.albertahealthservices.ca/topics/Page16997.aspx
• https://www.alberta.ca/coronavirus-info-for-albertans

Health Canada

• https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/being-prepared.html
• https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19.html

WHO

• https://www.who.int/emergencies/diseases/novel-coronavirus-2019

Posted date: March 18, 2020

Physiotherapy Alberta has been asked by Alberta Health Services to provide direction on the capacity for registered physiotherapists to undertake nasopharyngeal swabs. Although nasopharyngeal swabbing is not part of a physiotherapist’s typical range of practice activities, consideration for this change is motivated by the exceptional need for competent practitioners who can undertake this activity during the COVID-19 pandemic.

Regulatory considerations

Performing a nasopharyngeal swab is a restricted activity in accordance with the Government Organization Act and is therefore regulated under the Health Professions Act and the Physical Therapy Profession Regulations. 

As per Schedule 7.1 of the Government Organization Act, it is a restricted activity to "insert or remove instruments, devices, fingers or hands 

(ii) beyond the point in the nasal passages where they normally narrow, 

(iii) beyond the pharynx

These activities are identified as basic restricted activities in Section 13 of the Physical Therapists Profession Regulation. As such, any regulated member of Physiotherapy Alberta is authorized to perform the activity provided they are competent to do so. Regulated members who are on the Provisional Register must be supervised by a regulated member on the General Register if they perform the activity. 

Advice to employers

Employers should be aware that nasopharyngeal swabbing is not an activity that is taught in entry to practice physiotherapy education. Physiotherapists must only perform those activities that they are competent in. As such, a physiotherapist would require additional training and assessment of their competence to perform a nasopharyngeal swab before being deployed to do so. As highly educated and conscientious health professionals, physiotherapists are likely well suited to undertake this activity once sufficiently trained. Physiotherapists have a professional obligation to decline work they are not competent to perform. 

Advice to physiotherapists

Physiotherapists are considered critical infrastructure within the health system, and under the provisions of the Public Health Act they may be deployed by the Minister of Health to fulfill critical needs within the health system. Although performing a nasopharyngeal swab is a new activity for most physiotherapists, this is an unprecedented situation in which the greater good calls all health professionals to contribute, as they are able in order to manage and hopefully stop the spread of COVID-19. Registered physiotherapists have a professional obligation to decline work they are not competent to perform; however, they also have a professional responsibility to consider the public interest and undertake all reasonable steps to become competent before making a conscientious decision to decline the task.

Physiotherapists with questions regarding this memo can contact the Practice Advisor, Nancy Littke at nlittke@physiotherapyalberta.ca

Date posted: April 2, 2020