Episode 5: Resuming health services amid COVID-19

June 30, 2020 | Karima Kanani, Kristen Vandenberg

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Kristen: Hello everyone, thank you so much for joining us today for episode 5 of Morning Commute with Miller Thomson. Now you may not be commuting much these days but we invite you to grab a coffee or tea and join us for our discussion today on “Resuming Health Services Amid COVID-19”.

COVID-19 is a global pandemic. To respond to this crisis, the Ontario government has invoked various powers under public health legislation and emergency legislation. The province first declared a state of emergency back in March, which at present has been extended until July 15th.

Through this state of emergency, the government has been able to use its powers to issue various orders and directives, including requiring a reduction of health services to essential services only back in March.

However, since then, Operational Requirements for Health Sector Restart have been released by the province, and as of May 26th, the restriction to essential health services has been lifted.

I’m Kristen Vandenberg and I’ll be your host today. I’m an associate in Miller Thomson’s Toronto office and practice with our Health Industry Group. I’m joined today by my colleague Karima Kanani. Karima is a partner at Miller Thomson and one of the leaders of the firm’s Health Industry practice. She’s a frequent speaker and recognized thought leader in the health sector. Karima has been an advisor on health system transformation in the province and in supporting health providers to respond during the COVID-19 pandemic. Karima thank you so much for joining us today.

Karima: Thank you Kristen. I’m delighted to be here to chat with you today about the resumption of health services in Ontario.

Kristen: That’s great Karima, so we’ll dive right in then: With these restrictions lifted to enable the health sector restart, does that mean that in-person health services will now be available to the public?

Karima: No, Kristen, this doesn’t mean that all health services will be immediately available. “Health services” is a very broad term including everything from surgery in a hospital through to services that are provided by individual health professionals in their own private practices, like physiotherapy or occupational therapy, for example. Public hospitals don’t have the ability to simply resume surgeries and other procedures. They first have to develop a resumption plan that has to be approved by the province and they have to meet a number of different criteria within that plan. Criteria include things like the number of COVID-19 cases in their community, whether they have in-patient or ICU beds that are available, do they have a stable supply of personal protective equipment, is post-acute care available outside the hospital? In fact, one of the key requirements for hospitals before they can resume these procedures is that they must have 15% of their capacity available in case there’s a potential second wave of COVID-19.

Kristen: So what does that mean Karima? Based on all of these requirements, are surgeries and procedures then resuming in the province?

Karima: Yes, they are but it’s determined on a hospital-by-hospital basis and, while some have been able to meet this criteria and resume, others have not. Even for those who have resumed services, it doesn’t mean that surgeries and procedures will be available to everyone that has a need. Hospitals, as part of their planning, need to look at ethical prioritization of their wait list to determine which services are going to be accessible and which patients may receive care.

Kristen: I see what you’re saying and I hear the challenges that you’re describing with accessing hospital services right now. But what about other health services in the community, are we able to access those?

Karima: Health and social services in the community outside the public hospital environment, they aren’t subject to the same approval requirements over their resumption planning. But, they still need to engage in rigorous health resumption planning and the province has introduced a variety of requirements for resuming the delivery of in-person care. You can find those requirements, for example, in Ontario’s Operational Requirements for Health Sector Restart and various public health guidelines that have been released as well as service parameters that are being introduced by the various regulated health professional colleges.

Kristen: So what it sounds like you’re saying is that there are a lot of rules that need to be followed. Can you tell us a little bit about some of these rules and requirements?

Karima: I agree Kristen; there is a blanket of rules and requirements that every health provider needs to engage with in order to be able to deliver services in person. But you know, the public should also be aware of what these rules and requirements are so that they can have comfort around the safeguards that are being put in place when they are seeking services in person amid this COVID-19 pandemic. The purpose of all of these rules is to set out measures to meet public health guidelines and to promote a safe environment for in-person services. The requirements are quite comprehensive and they deal with a variety of items, like pre-screening for COVID, access to and use of personal protective equipment, physical distancing at all stages of the care journey including in the delivery of care itself, changes to the physical environment needed to promote infection prevention and control and occupational health and safety and more. Health service environments need to feel safe to the extent possible amid the pandemic for not only patients and clients accessing service but also for the employees and staff who are on the front lines delivering care. In fact, the law supports workers in this way through various rights of accommodation, rights to refuse unsafe work and new emergency leaves that have been created to address circumstances that are arising from COVID-19.

Kristen: Thanks Karima, that sounds like a lot of requirements. If I’m an organization looking to resume in person health services right now, how would I even know where to start?

Karima: For organizations resuming in-person health services, the key tool is the development of a comprehensive and rigorous health service resumption plan. The foundation of a good plan will be all of the legal requirements that we’ve been talking about together, whether they come from the government orders, directives, guidelines or legislation like the Occupational Health and Safety Act. With that foundation, a health service resumption plan should cover 4 key areas: facility and space, supply chain management, human resources and, of course, the clinical services itself.

Kristen: Can you tell us a little bit more about these 4 categories? Maybe we’ll start with facility and space.

Karima: Facility and space is a key category Kristen. Our health service providers will need to consider things like health and safety measures that may be required by the buildings within which they operate, how are people going to enter and leave the premises, where will you conduct COVID screening, and how will you manage the waiting areas given the physical distancing requirements. COVID-19 and all of these various health and safety requirements are going to essentially require a rethink on existing policies and procedures, especially those for the use of communal spaces that we usually take for granted, like the reception area, kitchens, meeting rooms, washrooms and more. To meet health and safety requirements, health service providers may need to make adjustments on how they are using their physical space.

Kristen: So you’re saying that when we go to access health services moving forward, things will look and feel pretty different than what we’ve been used to in the past. What about supply chain management? Can you talk a little bit about that?

Karima: Sure. Supply chain management involves looking at the impact to your business workflows and administrative processes and importantly your inventory management and control procedures. You’ll need to do this not only for personal protective equipment that we’ve talked about and certainly that we’ve been hearing a lot about in the province but also for other things like cleaning products and other sanitization and infection control tools that you might need in order to maintain your environment. It’s important that as providers that you make sure that you have a contingency plan in the event that your supply becomes delayed or it becomes unavailable during the course of the pandemic. We’ve certainly seen access to adequate supply of personal protective equipment be a critical issue in the province, especially at times when there’s a COVID-19 surge in the system.

Kristen: I see; so providers are going to need to make sure that they have access to the safety products needed in order to be able to open these spaces for services. What about human resources? That was I think the third component that you had mentioned.

Karima: Yes the availability of the workforce to resume in-person services must also be considered and we will also need to identify what are your human resource needs based on the services that you intend to deliver? It’s unlikely that all staff will immediately resume work and more likely that you’ll have a resumption plan with various stages and phases that will include increasing numbers of staff over time. But be mindful, as I mentioned earlier, there are legal obligations and procedures to follow when it comes to interacting with your staff on matters related to health service resumption and COVID-19. These include procedures for how and when you can recall staff that have been laid off and your ability to change their conditions of work. So your plan will also need to include new policies and procedures for COVID screening, use of PPE and the delivery of services and importantly, how you’re going to educate and train and implement these policies and procedures with your staff.

Kristen: That’s really informative, thanks Karima. So I think that’s three areas that we’ve covered so far. We’ve gone through space, supplies and human resources which leaves us with clinical service. So what about that?

Karima: Certainly and that’s last but certainly not least. For clinical services, each organization will have to determine for itself which services will be delivered and to whom and how those services will be adapted to meet these physical distancing and health and safety requirements. It won’t be one size fits all across the province or across organizations. There are some services that may be easily adapted whereas other health services may be more challenging to adapt to meet these rules.

Kristen: That’s great, thanks Karima. So once a provider has developed a resumption plan that addresses all of these items that you’ve just discussed, are they then clear to resume in-person services?

Karima: Well one would think so after all the rigorous planning but actually the resumption plan is only one part of the planning process. Every provider must also then look at their plan and determine what is feasible in the environment from an enterprise risk perspective.

Kristen: What do you mean exactly by enterprise risk? What are the risks that providers need to be aware of here?

Karima: Well, we’ve talked about the legal requirements extensively so of course legal compliance is one of the areas of risk but there are others as well. So when I say enterprise risk, enterprise risk is really a term of art and what it means is looking at the risk exposure to the organization from a 360 view to consider all of the potential implications of resuming the services in the way that’s been contemplated in the plan and where risks are identified, whether it’s possible to mitigate those risks. So for example, other risks from an enterprise risk perspective would include financial risk. Do you have access to funds to bear all of the additional costs that may be required to implement your resumption plan? And even aside from additional costs of the plan, what finances do you have available to support the delivery of those services? This is an especially important question for those organizations that are heavily dependent on fundraising, for example, where the economic impact of COVID-19 may place a significant strain on financial resources.

Kristen: I see, that’s really interesting. That’s a very helpful example. Could you give us another example of a risk factor here?

Karima: Sure. Another significant risk is liability risk management. The unfortunate reality is that even though everyone is trying to do their best to meet community needs in these very unconventional circumstances of a pandemic, there’s still a potential threat of litigation. And litigation can arise with employees, contractors, unions, patients, clients and other third party vendors. In fact, Kristen, there have already been some legal actions in the province in circumstances where access to personal protective equipment has been strained. So it’s critically important that health organizations ensure that they have effective internal and external engagement and communications on the resumption plan and all of their new policies and procedures.

Kristen: You raise a really interesting point there Karima and I think that that’s something that a lot of providers are thinking about right now. What happens if someone contracts COVID-19 and sues a health service provider?

Karima: Well Kristen, that’s not such a simple question and you’re right, it can have significant consideration for providers. There’s been a shift in the risk protection that’s been occurring within the insurance industry more broadly since the pandemic set in. Now in a normal situation, an organization would have insurance coverage that would kick in for their claims in the delivery of services. What has been happening recently is that insurers are revisiting the exclusions to that coverage with some insurers in the market actually introducing coverage exclusions related specifically to claims arising from COVID-19. So what that means is if as a provider, your insurer has a pandemic exclusion, then there would be no insurance coverage that would be available, which could pose a significant liability to the organization. So as a result, what you might see is that some organizations are going to go through this resumption planning and risk assessment exercise and then ultimately choose not to resume or to curtail the in-person services that they’re making available. And as a patient or a client, well this means that in order to access health services, you may in fact be asked to sign a waiver or release of liability related to COVID-19. Now there’s been significant advocacy that’s underway in the province by the various health service associations and they’ve been calling on the government to address this insurance risk issue. Now there’s some rumors of a potential government action to grant immunity to health service providers for claims that are arising from COVID. And we’ve seen this happen out in the west in British Columbia for example. So it’s certainly something that we’ll need to watch out for here in Ontario in the coming weeks.

Kristen: Absolutely Karima. We will definitely be keeping an eye out for that. In the interim, does this mean that some services might continue to be unavailable to the public throughout the pandemic?

Karima: Well in some cases, the answer to that may in fact be yes. And we talked earlier about all the restrictions on public hospitals so for surgical or other procedures in hospitals, they may not be approved to resume and for other hospital services, there may be long wait lists which may mean that services will continue to be unavailable to some. It’s the unfortunate collateral damage that has been created by the resource reallocation that was necessary to respond to COVID-19. As a result, there are thousands who have not been able to access care during the pandemic. The wait lists have grown exponentially and this will undoubtedly place significant future strain on the health system. Now for other health services, this doesn’t necessarily mean that they won’t be available, they just might not be available in person. The pandemic has accelerated the use of technology and the ability to deliver health and social services virtually. The continued delivery and availability of virtual care has in fact been recognized by the province as part of the considerations for resumption planning. So some form of virtual care is certainly here to stay for the future. Now there are a variety of considerations in both delivering and receiving virtual care but, Kristen, that’s a conversation for another day.

Kristen: Well thank you so much for this information Karima. You’ve given us a lot to think about. It’s been really helpful. I just have one last question for you before we wrap up and that is what do you think are some of the lessons that we’ve learned from COVID-19?

Karima: The number one lesson learned is that collaboration across the care continuum is essential to the effective and efficient functioning of our health care system. In fact, before COVID-19, we had begun a significant health system transformation in Ontario through the Connecting Care Act and the introduction of Ontario Health Teams. Now while these changes have been temporarily paused to respond to the COVID-19 pandemic, the underlying principles of these transformation initiatives have in fact been at the centre of COVID-19 response. This pandemic has required communities to organically come together rapidly out of necessity to find innovative and creative ways to support and treat patients across the continuum of care and to create system capacity. Much of this has resulted in some very positive advancements. For example, as I spoke of earlier, the provision of virtual care. System collaboration and co-design must continue in order to be able to deliver services amid COVID-19 and to hallway healthcare and the long wait lists that have been plaguing our health system.

Kristen: Wow, thank you so much Karima for sharing your insights today on resuming health services amid COVID-19. That brings up to the end of our podcast. If you are looking for more health industry resources for COVID-19, we invite you to please visit our COVID-19 resource hub at millerthomson.com. Thank you again for listening and have a wonderful day.

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