Ministry of Health

COVID-19 Guidance: Primary Care

Providers in a Community Setting
Version 5 – May 22, 2020

Highlights of changes

• Expanded guidance for in-person care for essential visits

• Expanded guidance on testing and specimen collection, including
hyperlinks to COVID-19 virus test requisition and assessment centre locator
• Additional details on occupational health and safety, including summary of
required personal protective equipment (PPE) precautions, and infection
prevention and control guidance

• List and hyperlinks to key resources

This guidance provides basic information only. It is not intended to take the place of
medical advice, diagnosis, treatment, or legal advice. In the event of a conflict
between this Guidance and a Directive of the Chief Medical Officer of Health, the
Directive prevails.

• Please check the Ministry of Health (MOH) COVID-19 website regularly for
updated versions of this document, the case definition, testing guidance,
mental health resources, and other COVID-19 related information.

• The latest version of the COVID-19 Reference Document for Symptoms and
COVID-19 Patient Screening Guidance Document are available and updated on
the MOH COVID-19 website.

• Please check the Directives, Memorandums and Other Resources page

regularly for the most up to date directives.

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General
Virtual Care

1. All primary care providers are encouraged to continue to implement a system

for virtual and/or telephone consultations as a preferred option, when and
where possible.
2. When possible, primary care providers should conduct a consultation over the
phone, video or secure messaging to determine if a virtual/telephone
consultation will suffice or if an in-person appointment is necessary and
essential. The purpose of this is to support physical distancing and minimize
contact of persons who may have COVID-19 with health care settings.
3. All primary care providers should continue to be available for medication
renewals (office coverage, phone/fax, communication with local pharmacies,
etc.), including for those patients on controlled substance regimes or opioid
agonists who will need their measured renewals by their main prescriber (in
most cases their family doctor) and should not be forced to seek controlled
substance renewal elsewhere.

In-Person Care for Essential Visits

4. Certain patients or acute conditions will require in-person visits. This includes
vaccine administration for infants and children. Some helpful ‘In-Person
Considerations’ related to in-person visits are available under the Ontario
College of Family Physicians (OCFP)’s COVID-19 Tips for Family Doctors.
Primary care providers should exercise clinical judgement to determine
whether an in-person visit is necessary.

5. Primary care providers should consider providing some care virtually even if an
in-person visit is needed in order to minimize the in-person time required (i.e.,
an essential prenatal visit could be divided into a virtual discussion of
testing/screening options with a brief in person physical assessment).
6. Primary care providers should ensure that there is enough space to follow
physical distancing guidelines of maintaining at least 2 meters from other
people. This includes the following:

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 • Minimize the need for patients to wait in the waiting room (e.g. spreading
out appointments, having each patient stay outside the clinic until the
examination room is ready for them and then call in, by phone preferably).
• Space out chairs in the waiting room to allow for physical distancing
• Ensure that patients do not leave their masks in waiting areas.
• Consider ways to minimize traffic flow for common spaces (e.g. physical
markings in hallways, limiting the number of people in an elevator, etc.)
• Reduce the number of examination rooms being used.
• Minimize staff in the office/clinic. Consider what tasks can be done from
home or outside of regular hours to minimize staff interactions with each
other and patients.
• Minimize the number of individuals in the office/clinic at one time. For
example, limit the number of non-essential individuals that may
accompany a patient for their appointment (excluding minors and support
persons).

Screening
7. Primary care providers should post information on their clinic website or send
an email to all patients advising them to call prior to coming to the office/clinic
where applicable.
8. If an in-person visit is necessary and feasible, the primary care setting should
undertake active and passive screening as defined below.
9. If an in-person visit is offered, patients should be advised to wear their own
mask (cloth or other) to the office/clinic if they have one available to them.
Active Screening

• Patients should be screened over the phone for symptoms of COVID-19 before
scheduling appointments.
• Where patients present in-person without phone screening, staff should
screen patients (and those accompanying them, if applicable) upon entry to
assess for symptoms and exposure history.
• Staff conducting screening on site should ideally be behind a barrier to protect
from droplet and contact spread. A plexiglass barrier can protect reception
staff from sneezing/coughing patients. If a plexiglass barrier is not available,

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 staff should maintain a 2-metre distance from the patient. If the office is unable
to provide this physical barrier for those screening, the health care worker
(HCW) doing the screening should use Droplet and Contact precautions. This
includes the following PPE – gloves, isolation gown, a surgical/procedure
mask, and eye protection (goggles or face shield).
• The latest COVID-19 Patient Screening Guidance Document on the MOH
COVID-19 website should be used and may be adapted as needed and
appropriate for screening purposes. Note that the case definition is primarily for
public health surveillance.
• For reference, a full list of common COVID-19 symptoms is available in the
COVID-19 Reference Document for Symptoms on the MOH COVID-19 website.
Atypical symptoms and signs of COVID-19 are also available on this document
and should be considered, particularly in children, older persons, and people
living with a developmental disability.
Passive Screening
• Signage should be posted at the entrance to the office/clinic and at reception
areas requesting patients with symptoms to put on a surgical/procedure mask
(if available and if tolerated), perform hand hygiene and then to report to
reception to self-identify. Sample signage is available on the MOH COVID-19
website (scroll to the bottom of the page). If the office/clinic is in a shared
building, signage should also be posted at the entrance to the building.
• Where possible, primary care providers should have signage outside the
office/clinic asking patients to call the clinic before entering to allow for
appropriate screening and direction.

Positive Screening: What to do

Positive screening over the phone

10. A patient who screens positive for symptoms of COVID-19 over the phone
should be offered a telephone consultation with a primary care provider ideally
on the same day. Patients with severe symptoms should be directed to the
emergency department. Otherwise, patients should be instructed to self-
isolate until further discussion with their primary care provider. This discussion
should include a thorough history-taking and assessment of symptoms and
managing them, even if COVID-19 testing is being considered as part of the

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 diagnostic plan. COVID-19 testing should be offered to all patients with
compatible symptoms where possible.
11. Based on the telephone consultation:
• If testing is needed, refer the patient to a local testing location or
emergency department as appropriate for where testing is offered in your
community.
a. Primary care providers should be familiar with local testing locations
(e.g., emergency departments, drive-thru testing centres, and/or
assessment centres) and their specific protocols. Assessment
centres should accept all symptomatic patients referred for testing
by a primary care provider.
b. Patients should be instructed to self-isolate immediately and until
test results are received and further instructions are provided by the
primary care provider.
• If resources limit the ability to test, patients should advised to self-isolate
for 14 days following symptom onset. Patients can be advised to
discontinue isolation at 14 days after symptom onset, provided that the
individual is afebrile and symptoms are improving. Absence of cough is
not required for those known to have chronic cough or who are
experiencing reactive airways post-infection.
Positive screening in the office/clinic

12. Patients who screen positive should be given a surgical/procedure mask and
be advised to perform hand hygiene. Ensure patients do not leave their masks
in waiting areas. As soon as the reception staff is aware that a patient screens
positive, the patient should be immediately placed in a room with the door
closed (do not cohort with other patients), where possible, to avoid contact
with other patients in common areas of the office/clinic (e.g., waiting rooms). If
it is not possible to move a patient from the waiting room to an available exam
room, the patient can be instructed to return outside (e.g. vehicle or parking lot,
if available and appropriate) and informed that they will be texted or called
when a room becomes available.
13. Patients should be provided with hand sanitizer (if available), access to tissue
and a hands-free waste receptacle for their used tissues and used masks. All
patients should be instructed to cover their nose and mouth with a tissue when
coughing and sneezing, dispose of the tissue in the receptacle and to use the

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 hand sanitizer right afterwards. Patients may also be instructed to take their
surgical/procedure mask home with them with instructions for doffing masks.
A sample patient handout on wearing and disposing of masks is available on
the OCFP’s Clinical Care - Office Readiness page.
14. Primary care providers may offer clinical assessment and examination to
patients who screen positive only if they are able to follow Droplet and
Contact precautions and are knowledgeable on how to properly don and doff
PPE. This includes the following PPE: gloves, isolation gown, a
surgical/procedure mask, and eye protection (goggles or face shield).
15. If primary care providers are not able to follow Droplet and Contact
precautions and/or are not knowledgeable on how to properly don and doff
PPE, they should divert the care of the patient as appropriate. This includes: to
the emergency department, for testing and patient care, if the reason for the
medical visit is urgent; or to an assessment centre, for testing, if the medical
reason for the medical visit can be deferred.

Testing for COVID-19

Testing Guidance
16. Testing should be offered to all patients with compatible symptoms where
possible. The exception being runny nose or nasal congestion related to an
underlying condition such as seasonal allergies or post-nasal drip. Primary
care providers should reference the COVID-19 Provincial Testing Guidance
Update for guidance on assessing and managing patients considered to be at
higher risk.
17. Primary care providers should be familiar with local testing locations (e.g.,
emergency departments, drive-thru testing centres, and/or assessment
centres) and their specific protocols. Assessment centres should accept all
symptomatic patients referred for testing by a primary care provider. Testing
options are outlined below.
• Referral to the nearest emergency department or testing location:
Primary care providers should follow their local testing location’s protocol
about referrals for testing; or
• Testing in the primary care office/clinic: Can be performed only if the
primary care provider is able to follow Droplet and Contact precautions as
outlined above, has the appropriate tools and knowledge of how to test,

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 and can ensure coordination of sample delivery to a laboratory providing
COVID-19 testing.
18. If patients are referred to a hospital or a testing location, the primary care
provider should make efforts to ensure that the patient has safe arrangements
for travel to the hospital or testing location that maintains isolation of the
patient (i.e., patient should wear a surgical/procedure mask and should not
take public transit). Primary care providers should follow their local testing
location’s protocol about referrals for testing.
Clearing Cases
19. For guidance regarding diagnosing and managing cases in primary care,
including discontinuing isolation and returning to work, primary care providers
should consult the COVID-19 Quick Reference Public Health Guidance on
Testing and Clearance on the MOH COVID-19 website. This document also
outlines the recommended approaches for HCWs who are returning to work
after symptom resolution and/or COVID-19 testing.

Specimen Collection, Handling, and Submission

• Specimens should be sent to a PHO Laboratory, or another suitable laboratory
with testing capacity.
• A suspect COVID-19 case should be tested by collecting a single upper
respiratory tract specimen. Upper respiratory tract specimens include a
nasopharyngeal (NP) swab, deep nasal swab, anterior nasal swab, or a viral
throat swab. When appropriate swabs are available, NP swabs are the preferred
specimen, followed by a deep nasal swab.
• NP swab collection is not considered an aerosol-generating procedure (AGMP)
and therefore can be performed using Droplet and Contact precautions (i.e.,
gloves, isolation gown, surgical/procedure mask, and eye protection). This is
important as many people will cough or sneeze when the NP swab is done. Links
to resources on properly conducting NP swabs are available under ‘In-Person
Care’ on OCFP’s Clinical Care - Office Readiness page.
• Specimens must be placed in the specimen bag with the fully completed
COVID-19 virus test requisition placed in the attached pouch, so it is not exposed
to the specimen. It is recommended that the swab is pre-labelled so that it can
simply be dropped into the bag without further handling once the swab is
obtained.

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Reporting of COVID-19 Cases
20. COVID-19 is a designated disease of public health significance (O. Reg. 135/18)
and thus reportable under the Health Protection and Promotion Act.
21. Regulated health professionals should contact their local public health unit to
report any probable and confirmed cases of COVID-19

Occupational Health & Safety

Personal Protective Equipment (PPE)

22. Summary of required HCW precautions are displayed in the table below

Activity HCW Precautions

Before every patient interaction HCW must conduct a point-of-care risk

assessment to determine the level of
precautions required

All interactions with and within 2 metres Droplet and Contact precautions:
of patients who screen positive • Surgical/procedure mask
• Isolation gown
• Gloves
• Eye protection (goggles or face
shield)
• Perform hand hygiene before and
after contact with the patient and
the patient environment and after
the removal of PPE

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 Activity HCW Precautions

All interactions with and within 2 metres • Surgical/procedure mask required

of patients who screen negative • Use of eye protection (goggles or a
face shield) should be considered
• Perform hand hygiene before and
after contact with the patient and
the patient environment and after
the removal of PPE

23. HCW precautions should take into consideration both COVID-19 and other
potential communicable diseases as part of the point-of-care risk assessment.
For patients who screen negative and coming to the office/clinic for vaccine
administration, gloves should be worn in addition to a surgical/procedure
mask with consideration for eye protection, as above.
24. Given community spread of COVID-19 within Ontario and evidence that
transmission may occur from those who have few or no symptoms, masking
(surgical/procedure mask) for the full duration of shifts for HCWs working in
direct patient care areas is recommended. Masking is also recommended for
HCWs working outside of direct patient care areas when interacting with other
HCWs and physical distancing cannot be maintained. The rationale for full-
shift masking is to reduce the risk of transmitting COVID-19 infection from HCW
to patients or other office/clinic HCWs, at a time when no signs or symptoms
of illness are recognized, but the virus can be transmitted. This is a form of
source control.
25. The use of eye protection (e.g., goggles or a face shield) for the duration of a
shift should be strongly considered in order to protect HCWs when there is
COVID-19 infection occurring in the community.
26. Primary care providers should be knowledgeable on the proper sequence of
donning and doffing PPE. A visual factsheet for Putting on and taking off PPE is
available on PHO’s website. Videos are also available on PHO’s website.
Infection Prevention and Control

27. Primary care settings should have measures and procedures for worker safety
including measures and procedures for infection prevention and control (IPAC).

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28. Online learning on IPAC is available on PHO’s website.

29. All staff in the office/clinic should self-monitor for COVID-19 symptoms at
home and not come to work if feeling ill. Primary care providers should ensure
that all staff who work in their settings are aware of the symptoms of COVID-19
and are instructed to remain at home, or return home from work, if symptoms
develop. The COVID-19 Quick Reference Public Health Guidance on Testing
and Clearance has specific guidance on how to ensure a safe return to work for
HCWs.

30. Primary care providers who are asymptomatic and have returned from travel
outside of the province, in the last 14 days and/or have had unprotected
exposure to a person with COVID-19 and have been identified critical to
operations in their organization, should refer to the How to Self-isolate while
Working fact sheet and the Quick Reference Sheet Public Health Guidance on
Testing and Clearance available on the MOH COVID-19 website.

31. After every patient visit, whether the patient is symptomatic or not, patient-
contact surfaces (i.e., areas within 2 metres of the patient) should be
disinfected as soon as possible. Treatment areas, including all horizontal
surfaces, and any equipment used on the patient (e.g., exam table,
thermometer, BP cuff) should be cleaned and disinfected before another
patient is brought into the treatment area or used on another patient. Refer to
PIDAC’s Best Practices for Environmental Cleaning for Prevention and Control
in All Health Care Settings for more information about environmental cleaning.
Additional resources and overviews are available under ‘Office Readiness’ on
OCFP’s Clinical Care - Office Readiness page.

32. Plexiglass barriers are to be included in routine cleaning (e.g. daily) using a
cleaning product that will not affect the integrity or function of the barrier.

33. Non-essential items are recommended to be removed from patient care areas
to minimize the potential for these to be contaminated and become a potential
vehicle for transmission (e.g., magazines and toys).

34. If a patient or staff member was in the office/clinic and later tests positive for
COVID-19, primary care providers, if aware, are encouraged to call their local

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 public health unit for advice on their potential exposure and implications for
continuation of work.

Key Resources
• IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or
Confirmed COVID-19 (PHO)
• Infection Prevention and Control Fundamentals (PHO)
• Best Practices for Environmental Cleaning for Prevention and Control in All
Health Care Settings (PHO)
• Droplet and Contact Precautions for Non-Acute Care Facilities (PHO)
• Recommended Steps for Taking Off PPE (PHO)
• Aerosol Generation from Coughs and Sneezes (PHO)
• How to Self-Monitor (PHO)
• How to Self-Isolate (PHO)
• How to Self-Isolate When Working (PHO)
• How to Wash Your Hands (PHO)
• Infection Prevention and Control – Online Learning (PHO)
• COVID-19: Clinical and Practical Guidance for Primary Care Providers (CEP)
• Maintaining Regular Primary Care Practice in the COVID-19 Context (CEP)

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