Ontario COVID-19 assessment centre practices in patient counselling, education, and follow-up care: A provincial survey

Abstract

Background

In March 2020, COVID-19 assessment centres were launched across the province of Ontario to facilitate COVID-19 testing outside of emergency departments. We aimed to study the degree to which assessment centres provide education and follow-up care for patients with suspected COVID-19.

Methods

We conducted an online survey of Ontario COVID-19 assessment centre directors between September 15 and October 15, 2020. The primary outcomes studied were the types of educational modalities employed and information conveyed, methods and frequency of test result communication, and any follow-up care that was offered. Survey respondents were also asked to provide descriptions of barriers to patient education and test communication.

Results

A total of 56 directors (representing 73 assessment centres) completed the survey. The most frequent educational modalities employed were educational handouts (92%), direct in-person counselling (89%), and referral to website (72%). Seventy-one percent of respondents indicated patients with positive test results would be notified, and 61% of respondents indicated that follow-up care would be offered. The most frequently reported barriers to patient education were insufficient time and high volume of tests, while the most frequently reported barriers to communication of test results were difficulty accessing online health portals and high volume of tests.

Conclusion

The ability of many assessment centres to provide patient education is limited by both individual patient and system-level factors. Assessment centres may benefit from standardization of educational materials, improved accessibility to test results for patients in marginalized groups, and virtual pathways to facilitate additional counselling and care for individuals who test positive.

The COVID-19 pandemic has placed an unprecedented strain on health care systems worldwide. In March 2020, health care organizations across the province of Ontario began opening outpatient facilities to assess and test for COVID-19 (known as ‘assessment centres’) in order to minimize the burden on emergency department volumes and occupancy. Given the importance of self-isolation for individuals with suspected COVID-19, the visit to an assessment centre is often the first point of health care contact and serves as a prime opportunity for education and counselling. However, the extent to which this is being carried out and whether follow-up clinical care is being provided by assessment centres is not known.

We conducted a provincial survey to determine the degree to which assessment centres provide counselling, education, and offer follow-up care to patients with suspected COVID-19.

Methods

Design, setting, and participants

Between September 15 and October 15, 2020, directors of COVID-19 assessment centres in Ontario were invited to participate in an open online survey assessing COVID-19 counselling, education, and follow-up practices. At the time of survey deployment, 143 assessment centres were operating across the province, with approximately 30,000 to 40,000 tests conducted daily (¹). Contact information for the directors of each assessment centre was collected from Local Health Integration Networks, public health units, and hospitals. Directors were contacted by e-mail and invited to participate in the survey, and a follow-up invitation was sent 2 weeks later. As part of the informed consent process, potential participants were informed of the purpose of the study, length of the survey, and methods of data storage. No incentives were offered for survey participation.

Survey development and implementation

The survey content was developed by three study authors (AKC, ND, and PWL), with usability testing and additional feedback provided by a COVID-19 assessment centre nurse practitioner (SM) and an infectious diseases physician external to the study team. The survey consisted of 16 non-randomized items equally distributed over three pages, and included multiple choice, Likert scale, and open-ended questions pertaining to the location of the assessment centre, how COVID-19 testing is carried out, what educational modalities are employed, what information is conveyed to patients, how patients are informed of their COVID-19 result, and whether follow-up care is provided (Appendix 1). At the end of the survey, participants were asked to comment on what they perceived as the greatest barrier to patient education and test result communication at their assessment centre. A completeness check was performed at the end of each page; respondents were not given the ability to review or change answers once each page of the survey was submitted. The survey was administered using the Qualtrics Experience Management online software platform.

Statistical analysis

Only completed surveys were included in the analysis. Using location information provided in the survey responses, a map was generated to illustrate the distribution of assessment centre respondents within each public health unit across the province. The map was generated using the Easy Maps visualization tool that is publicly available through the Public Health Ontario website (²). For each question, the frequency and proportion of respondents who selected each item was calculated. Assessment centre directors responsible for the operation of multiple assessment centres were only allowed to complete the survey once; unique survey responses were tracked by internet protocol address and internet browser cookie. Therefore, the results reported use the number of respondents as the denominator rather than the total number of assessment centres represented. The free text responses related to perceived barriers were categorized into themes by identifying recurring words or phrases. All statistical analyses were conducted using Microsoft Excel, version 2011.

Ethics approval

Ethical approval for this study was obtained from the Sunnybrook Research Institute research ethics board.

Results

General characteristics

Survey invitations were distributed to 92 directors (representing 103 of 142 assessment centres) during the study period. Contact information for the remaining assessment centre directors could not be obtained The participation rate was 64.1% (59 of 92 directors). The completion rate was 94.9% (56 of 59) and represented 73 assessment centres. Respondents were well distributed across the province (Figure 1). The majority of assessment centres were associated with a hospital (68 of 73, 93%), with the remainder integrated within a family health team. Based on the limited information available, we were unable to identify any common features or geographic clustering in the non-responding assessment centres.

Figure 1:

Geographic distribution of participating assessment centres by public health unit

COVID-19 testing and educational modalities

The top five health care providers to perform COVID-19 testing and provide patient education were, in descending order, registered nurses (79% and 84%, respectively), registered practical nurses (75% and 75%, respectively), physicians (43% and 46%, respectively), nurse practitioners (30% and 32%, respectively), and paramedics (21% and 20%, respectively). The most frequent educational modalities used always or most of the time were educational handouts (92%), direct in-person counselling (89%), and referral to website (72%) (Figure 2). All educational handouts were available in English, but only half (47%) were available in French and a minority (9%) in other languages, such as Spanish, Arabic, Chinese, Italian, Korean, and Ojibway. Respondents indicated that educational materials were developed primarily by local public health units (83%), assessment centres (50%), and, less often, by the affiliated hospital (35%) or the Ontario Ministry of Health (15%).

Figure 2:

The various types of educational modalities employed by assessment centres (N = 56)

Educational content

The majority of assessment centres reported that their patient education addressed the following aspects always or most of the time: how to self-isolate (100%), signs and symptoms that warrant further medical attention (98%), and length of self-isolation for a negative result (91%) and a positive result (85%) (Figure 3). In contrast, over half of respondents indicated only sometimes or never addressing the expected timeframe to symptom recovery (59%) and potential complications of COVID-19 (60%) as part of their patient education (Figure 3). Of the 37 respondents who indicated that their centre provided specific recommendations on the duration of self-isolation in the event of a positive COVID-19 result, most (35 of 37, 95%) recommended 14 days of self-isolation from symptom onset (in concordance with provincial recommendations at the time of survey deployment).

Figure 3:

The degree to which various aspects of COVID-19 management were addressed by patient education at the assessment centre (N = 56)

Test result communication and follow-up

Seventy-one percent of respondents indicated that their assessment centre notified patients of a positive COVID-19 result, either by a telephone call from the assessment centre (88% of those notified) and/or by self-check via an online health portal (71%). Similarly, 63% of respondents indicated that their assessment centre notified patients of a negative COVID-19 result, but this was primarily in the form of self-check via an online health portal (100%) and, much less likely, by telephone (38%).

When asked whether follow-up clinical care is provided to patients, 61% of respondents indicated that follow-up care was offered to patients with a positive COVID-19 result, in contrast to 43% who indicated that follow-up care was offered to patients with a negative COVID-19 result.

Barriers to patient education and test result communication

Eighty-two percent of respondents reported barriers to patient education and test result communication at their assessment centre. From these respondents, the most commonly reported barriers to patient education and counselling were insufficient time (61%), high test volume (41%), insufficient human health resources (26%), assessment centre type (eg, drive-through test centres) (7%), language barriers (5%), and inconsistent messaging from regional and provincial health authorities (5%). Respondents reported difficulties accessing the online health portal (28%), high test volume (20%), insufficient human health resources (20%), and time lag in obtaining results (15%) as the most challenging barriers to communication of test results.

Discussion

This provincial survey provides an overview of assessment centre practices as they relate to patient counselling, education, and follow-up. Overall, this survey demonstrates that in-person counselling and written materials are the most used forms of patient education. Survey respondents indicated that the educational content provided at COVID-19 assessment centres focused on the initial steps in managing suspected COVID-19 (such as self-isolation) as opposed to counselling on COVID-19 itself. Respondents also reported that time constraints and the volume of patients being tested were the primary barriers to offering effective education and counselling.

Adherence to public health recommendations such as self-isolation and separation from asymptomatic household contacts are important measures to stem the spread of COVID-19. The degree to which counselling occurs at assessment centres is important to ascertain because inadequate education could result in poor adherence to infection prevention measures during the time from testing to public health contact, resulting in further community spread (³). The benefits of in-person counselling include assessing an individual’s comprehension of the information provided and addressing specific questions. However, it is unclear how often these benefits are realized in practice, given that previous research in urgent care settings, such as the emergency department, suggest that only 22% of health care professionals confirmed patients’ comprehension of discharge instructions (⁴). In addition, the retention of spoken medical information may be limited (⁵), and providing written materials may offer further reinforcement. Both formats of patient education are limited, however, by factors such as poor health literacy, low education level, and language barriers. These factors may also be more significant in immigrant and refugee populations and groups with lower socioeconomic status, which are already disproportionately affected by COVID-19 (^6,7).

Furthermore, assessment centres often rely on online health portals to communicate test results. While online platforms may improve the accessibility of test results in some patient populations, this modality can be a significant barrier for those who are inexperienced with technology (⁸), lack access to the internet, have limited English proficiency, or cannot access the platform because they do not have a health card. As such, these patient populations should be identified during test administration and offered alternative means of test result notification.

Respondents in this survey cited a variety of sources for their educational materials. Differences in guideline recommendations combined with the rapidly changing understanding of COVID-19 raises the potential for conflicting or inconsistent messaging, and this was cited by some respondents as a potential barrier to effective counselling and education. To date, published guidelines on the ideal patient counselling process for COVID-19 are limited. However, a recent tool outlines the following five-step process for health care providers: assessing a patient’s comprehension of the situation, providing information on self-isolation, offering other reliable resources for information, counselling on monitoring symptom progression, and checking the patient’s comprehension of the instructions (⁹). Standardization of educational materials from a unified source would reduce the duplication of work and risk of conflicting information. Achieving this, however, will require buy-in and collaboration from provincial, regional, and local stakeholders. The difficulties encountered in identifying assessment centre directors for this study highlights an important barrier that could impede effective collaboration.

The survey findings also suggest that the high volumes of COVID-19 tests being performed at assessment centres limit the extent of counselling that can occur during the allotted appointment timeframe. As such, other models of health care delivery are needed to provide supplemental counselling and, more importantly, maintain continuity of care once a diagnosis of COVID-19 is made. In this survey, only 61% of assessment centre directors indicated that patients with a positive COVID-19 result were offered clinical follow-up. While public health case workers contact each patient with a positive COVID-19 case, their ability to provide medical advice is limited, and the timeliness of their call may be impaired when case loads are high. This may result in patient visits to emergency departments that could otherwise have been avoided. It is also known that a proportion of the outpatients initially presenting with mild illness will have progression of symptoms requiring hospitalization (¹⁰). Virtual care models focused on providing follow-up care to patients with COVID-19 have been implemented with success in Ontario (¹⁰), but further work is needed to ensure equitable care.

Given these survey findings, we plan to engage assessment centre directors, public health authorities, and provincial government stakeholders to develop standardized best practices for education and counselling at assessment centres and to highlight the importance of ongoing care in outpatients diagnosed with COVID-19. Further studies are needed to evaluate the patient experience at assessment centres, including barriers to comprehension of educational material and the extent to which information is retained following a visit.

Limitations

This study had several limitations. First, respondents to the survey were directors, whose experiences with patient education may vary depending on whether they are directly involved in front-line work in their assessment centre. Second, the survey’s respondents may be affected by response bias; that is, there may be greater participation by assessment centres that provide more robust and comprehensive patient education as part of their care. Similarly, there may be an element of social desirability bias, since respondents were asked to reflect on their own centres’ performance (¹¹). The low proportion of survey respondents could also affect the generalizability of the study findings. Third, this study did not assess the quality of educational materials at each assessment centre or how well patients understood the materials. In addition, this survey only provides a snapshot of assessment centre practices up to October 2020. Since the survey was completed, for instance, assessment centres have moved towards appointment-based testing of symptomatic individuals only, based on provincial guidelines. This may affect the volume of tests being conducted and the ability to provide education. Moreover, this survey did not include community pharmacies that began to perform testing in asymptomatic individuals in September 2020. Finally, questions pertaining to clinical follow-up were answered by assessment centre directors who may only be familiar with formal follow-up programs associated with the centre but not individual follow-up care provided by the patient’s own primary care physician.

Conclusion

Ontario’s COVID-19 assessment centres have become a pillar in the province’s response to COVID-19. They often serve as the first in-person opportunity for patient education and counselling, ensuring individuals are aware of public health recommendations and preventing further viral transmission prior to the patient’s contact with public health authorities. However, the ability of many assessment centres to achieve these objectives is limited by both individual patient factors (eg, health literacy, language barriers) and system-level factors (eg, high patient volumes, insufficient human health resources). More importantly, there does not appear to be a standardized process for how outpatients are counselled at assessment centres across the province. Assessment centres may benefit from standardization of educational content and written materials, improved accessibility to COVID-19 test results for individuals in marginalized groups, and virtual pathways to facilitate additional counselling for those who test positive.

Ethics Approval:

The Sunnybrook Research Institute research ethics board approved this study.

Informed Consent:

N/A

Registry and the registration no. of the study/trial:

N/A

Funding:

No funding was received for this work.

Disclosures:

Dr Andany reports participation as a site investigator for HIV clinical trials sponsored by Gilead, Janssen and GlaxoSmithKline, outside the submitted work.

Peer Review:

This manuscript has been peer reviewed.

Animal studies:

N/A