Updated June 2, 2021
The ability to continue to offer physiotherapy services relies upon compliance with the Guidance for Resuming Physiotherapy Practice During a Pandemic issued by Physiotherapy Alberta, sector specific private business guidance issued by the Government of Alberta, and AHS operating procedures and measures in use in public health care facilities.
It is the adherence with all infection prevention and control measures that offers robust protection against virus spread within physiotherapy practice environments. No one measure alone will be enough to protect patients and staff and prevent a physiotherapy practice site from becoming a source of virus transmission.
The Infection Prevention and Control Visual Guide helps to summarize these measures into a brief checklist that can be used to review day-to-day operations and ensure that the measures put in place when in-person services were first allowed to resume are still being rigorously followed today.
Despite widespread vaccine uptake and use of infection prevention and control measures to limit the spread of COVID-19, no measure is perfect, and some risks remain when services are provided in-person. Every close contact that a physiotherapist has with another person is another opportunity for the physiotherapist to become exposed to COVID-19 and to subsequently become a vector for virus spread. In addition, every visit to the practice setting necessitates countless contacts with other members of the public as the patient travels to and from their appointment. The risks posed by in-person services increase when physiotherapists work with patients more likely to experience severe outcomes from COVID-19.
Although risks are mitigated by vaccine uptake and robust infection prevention and control measures, they are not completely eliminated. Physiotherapists are encouraged to employ a risk-based approach to determining when in-person services are indicated for a given patient and practice setting, and when the risk of in-person service outweighs the foreseeable benefits.
Physiotherapists adopted telerehabilitation rapidly in response to the restrictions on in-person services that were in place in the spring of 2020. Physiotherapists should continue to employ telerehabilitation to the greatest extent practicable to achieve desired patient outcomes and protect patients, themselves and others in the practice environment from exposure to the virus.
Physiotherapists are encouraged to:
- Complete a point of care risk assessment prior to any in-person service delivery.
- Educate patients on the benefits of telerehabilitation services, including the reduced risk of contracting COVID-19, and positive patient outcomes that these services can provide.
- Consider telerehabilitation as the sole means of service delivery when practicable and indicated by the patient’s condition and/or the risk assessment.
- Adopt blended models of service delivery using telerehabilitation visits to augment judicious use of in-person care as appropriate, with the aim of achieving the best patient outcomes possible.
- Recognize when physiotherapy assessments or treatments cannot reasonably be delivered via telerehabilitation. This format of service delivery may be appropriate for many 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 visiting or 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 this is 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.
Business owners and clinicians alike are advised to take the time to set up their telerehabilitation services in a way that is consistent with the Standards of Practice.
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 is not the legislation of note.
- Determine if the 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?
- It is essential to read the terms of service of the platform provider, 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.
- Platform providers should not access patient private information and should not share that information with other parties including external organizations and governments.
- Platform providers may track data related to business use (e.g., your behaviour when using the platform).
- 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 from platform providers on a “take it or leave it” basis but that’s not an excuse to use a platform that is not secure. Patient health information is a regular target for cyber attacks. With the significant influx of health information available online as a result of the pandemic, clinicians and business owners are advised to use caution to ensure that private information remains private.
Some parties have suggested that the adoption of platforms that are not secure may be justified due to the extraordinary circumstances of the pandemic. Physiotherapy Alberta does not share that perspective.
Remote working (updated June 10)
The adoption of telerehabilitation services may enable physiotherapists to work from home. Employers are advised to consider the privacy issues that can arise when 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 related to allowing employees to use their own devices for work purposes. Employers should also consider the risks involved in having employees store patient records in paper format within the home environment, and strategies to adopt to mitigate those risks.
Employers are advised 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’s perspective is that there is no reason that the fees for physiotherapy services 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.
Physiotherapy Alberta’s Telerehabilitation Guide provides additional information regarding telerehabilitation service delivery.
Private Clinics (updated June 11, 2021)
Effective November 27th, health services provided by regulated health professionals “can remain open by appointment only as long as public health orders and sector guidance is followed. Appointments should be limited to one-on-one services.”
It is important to keep in mind that personal and wellness services are distinct from health, social and professional services, and have been for the duration of the pandemic. Recent changes to the rules for personal and wellness services, which take effect with Stage 2 of the Open for Summer Plan, do not affect health service provision and the rules that apply to physiotherapists. The requirement for one-on-one service provision remains in place across the province for physiotherapists and other regulated health professionals.
Some regulated members have asked how this rule effects the provision of physiotherapy services by physiotherapist support workers. Physiotherapy Alberta’s perspective is that when support workers provide physiotherapy services, they are doing so under the supervision and direction of a regulated physiotherapist and in accordance with the standards and requirements established for the provision of physiotherapy services during the pandemic. The support worker is acting as an extension of the physiotherapist and is able to provide physiotherapy services due to the active supervision provided by the physiotherapist.
The physiotherapist remains accountable for the services assigned, the appropriateness of that assignment, and the quality and safety of the services provided.
If a physiotherapist employs support workers, regardless of the education or credentials of the support worker, Physiotherapy Alberta expects that:
- All expectations outlined in the Standard of Practice – Supervision are met, including:
- services are assigned by the physiotherapist,
- the patient understands the roles of the physiotherapist and support worker respectively,
- the patient consents to the support worker’s involvement,
- the physiotherapist provides ongoing monitoring and re-assessment of the patient’s status and progress,
- supervision strategies are in use to ensure quality and effective services are provided by the support worker.
- The booking record clearly identifies that the patient is booked with the physiotherapist.
- The patient reports seeing the physiotherapist for a component of the treatment session and understands and can describe the supervisory relationship between the physiotherapist and the support worker.
Neither the physiotherapist or the physiotherapist support worker may be responsible for the care and treatment of more than one patient at any time.
The notable exception is in the delivery of group exercise interventions. The updated rules allowing gyms to open as part of Stage 2 of the Open for Summer Plan may be relevant to physiotherapists who offer group exercise-based physiotherapy interventions such as GLA:D programs, falls and balance classes, or Parkinson’s group classes.
Although Physiotherapy Alberta’s view is that group exercise interventions may be provided to these groups, where appropriate measures can be implemented, we also know that the populations served by these programs are different from that of the general population seen in the gym environment. As such a higher standard of care is required.
Physiotherapists who offer these interventions may be able to transition back to offering group classes, however it is important that those who do so continue to follow the health sector specific guidance provided by Physiotherapy Alberta regarding the provision of services:
- The physiotherapist completes a risk assessment of the activity and identifies appropriate measures to mitigate the risks.
- The risk profile of individual participants supports their safe return to the exercise group.
- Group classes are appointment-based and scheduled.
- Attendees are screened at the time of booking and upon arrival.
- Measures such as continuous masking and routine, vigorous hand hygiene are employed, as with all other in-person physiotherapy services.
- 3-meter physical distancing is maintained between all participants and class sizes are limited to the number of participants that will fit within the space while maintaining 3-meter distancing from each other at all times.
- Equipment is not shared between participants.
- Instructor close contact with participants and movement between participants is avoided.
- Class cohorts are not mixed, and
- Limiting participant socializing before and after class.
Providers who are unable to meet these expectations and mitigate relevant risks to providing group exercise-based interventions are directed to continue providing these interventions on a one-on-one basis.
Long Term Care (updated June 11, 2021)
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 long-term care and continuing care facilities, are at greater risk of severe disease and death from COVID-19.
However many, if not most residents of these settings have now received both doses of the COVID-19 vaccine and effective May 10, 2021, the Government eased restrictions in place in long-term care and continuing care facilities in the province to allow small indoor gatherings and larger outdoor gatherings, in accordance with CMOH Order 16-2021.
CMOH Order 23-2021 explicitly enables the return to group activities in continuing care environments for residents who are not isolated or quarantined due to COVID-19, provided the facility operator has public health measures in place to mitigate relevant risks and has not been directed by a local Medical Officer of Health to take other action (e.g., due to a site outbreak).
Physiotherapists working in long-term or continuing care environments are directed to conduct a point of care risk assessment related to the group interventions they provide, and to implement appropriate measures to mitigate the risks identified (e.g., physical distancing of participants, limiting class sizes based on physical space available).
Order 23-2021 also enables the provision of mobile health services in continuing care environments to residents who are not symptomatic, isolated, or quarantined, provided the physiotherapist adheres to workplace and sector specific requirements, CMOH Orders and the regulatory requirements established by Physiotherapy Alberta. Physiotherapists will need to work with continuing care operators to address questions regarding access to the site and the ability to provide in-person services that are arranged by the patient or family. Where possible and appropriate, telerehabilitation services should be provided.
Private providers delivering mobile services in continuing care settings may pose more risk to residents if they provide care at multiple sites, serving as a potential source of transmission between facilities. They are therefore expected to avoid movement between sites on the same day, where feasible.
Mobile practice (AHS and Private Businesses) (Updated June 11, 2021)
Physiotherapists working for Alberta Health Services and Covenant Health in home care environments are subject to the operational procedures their employers have in place and will be directed by infection prevention and control experts on staff.
Physiotherapy Alberta is aware that many physiotherapists provide private mobile practice services. As stated on the Government of Alberta website, health services provided by regulated health professionals “can remain open by appointment only as long as public health orders and sector guidance is followed. Appointments should be limited to one-on-one services.”
Home-based businesses providing regulated health services can also continue to operate and “should follow the restrictions in place based on the type of service they provide.” In other words, the restrictions and practices established for physiotherapy community services (private practice) apply to physiotherapy home-based or mobile services.
The provision of mobile health services in continuing care environments to residents who are not symptomatic, isolated, or quarantined, is enabled through CMOH Order 23-2021, provided the physiotherapist adheres to workplace and sector specific requirements, CMOH Orders and the regulatory requirements established by Physiotherapy Alberta.
Physiotherapists offering private mobile services in continuing care environments will need to work with continuing care operators to address questions regarding access to the site and the ability to provide in-person services that are arranged by the patient or family. Where possible and appropriate, telerehabilitation services should be provided.
Private providers delivering mobile services may pose more risk to residents if they provide care at multiple sites, serving as a potential source of transmission between facilities. They are therefore expected to avoid movement between sites on the same day, where feasible.
Schools and Early Learning Centres (Updated June 2, 2021)
With the return to in-person learning on May, 25th, 2021, physiotherapists are reminded that the principles related to limiting the spread of COVID-19 are unchanged as is the duty to implement measures to limit the spread of COVID-19.
Physiotherapists working in the school sector are encouraged to employ telerehabilitation, if appropriate for their patient’s condition, to address ongoing physiotherapy care needs of students who are engaged in online learning.
In instances where students are engaged in in-person learning, physiotherapists working in the school sector are:
- required to adhere to the same measures to prevent the spread of COVID-19 as other regulated members of Physiotherapy Alberta, as identified in the Guidance for Resuming Physiotherapy Practice During a Pandemic. This includes the continuous use of medical grade masks, physical distancing, rigorous hand hygiene using soap and water or alcohol-based hand rub and point of care risk assessment.
- advised to provide interventions to their patients on a one-on-one basis when practicable.
- advised to complete a point of care risk assessment to determine the appropriateness of concurrent treatment with a subset of students from the same classroom cohort.
Hospitals (Updated May 5)
Over the past 14 months, most of the direction provided by Physiotherapy Alberta has been directed to regulated members employed in the private sector, such as private clinics and other physiotherapy businesses. This is due to the fact that physiotherapists in the private sector have faced restrictions on their ability to operate their businesses and have limited access to infection prevention and control experts to direct their practice.
Physiotherapists working for Alberta Health Services and Covenant Health are subject to the operational procedures their employers have in place and will be directed by infection prevention and control experts on staff.
Personal protective equipment use in AHS/Covenant settings is based on the point of care risk assessment conducted by the physiotherapist and the organization’s guidance re: PPE when working with patients with known or suspected COVID-19, in accordance with the interventions planned and the risks inherent with those interventions. When questions or conflicts arise regarding the appropriate PPE to use for a specific intervention within this practice setting, physiotherapists are directed to discuss their concerns or questions with infection prevention and control experts on staff.
Similarly, operational decisions and actions to limit the spread of COVID-19 between patients within the acute care environment, such as limiting staff movement between units and scheduling patients in a manner that limits the risk of virus transmission, are best made at the facility level. Questions regarding operational matters should be directed to facility and AHS leadership.
While physiotherapists working in acute care environments will not have experienced business closures in the same way as private physiotherapy business owners, Physiotherapy Alberta is aware that some programs and services have experienced significant operational disruptions and many physiotherapists in these environments have experienced redeployment as a consequence.
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, when faced with redeployment.