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I went to our office for the first time in two months

Sharon Louise Cirone

Yesterday I went to our office for the first time in two months. In this practice, we see patients from a very vulnerable population who have mental health and addictions issues and disorders. Many are homeless and/or street involved and have significant histories of trauma, including experiencing loss as a result of the opioid epidemic.

This patient population may not have the same resilience as the general public. And the relationship with their provider is one of the primary relationships in their lives – a lack of access can shift their overall wellbeing.

With pre-screening, physical distancing in the office, PPE, lots of hand sanitizer and thin plexiglass shields newly erected between patient and provider in each clinical room, we forged ahead with in-person visits. Our practice is in downtown Toronto, we have been providing Methadone Maintenance Treatment (MMT) and Addiction Medicine care for nearly 3 decades now. They are the 'pioneers' of MMT care in the city, in Ontario, actually. I joined this team just over ten years ago, but they have proceeded me by many years offering concurrent primary care, mental health and alcohol and substance use care under one roof, providing committed long-term continuity. 

COVID has put a strain on all humans, no one is excluded. 

At this moment, however, my thoughts are with the patients and colleagues at our practice. We're trying our best to meet our patients’ and their community needs. We have responded to the need for physical distancing to protect from viral transmission by offering online visits and phone contact and decreased office and pharmacy visits. We have adapted the College of Physicians and Surgeons of Ontario (CPSO) professional directives for providing MMT to able to meet the needs and health and safety concerns of our patients in this time of COVID. All Opioid Substance Therapy (OST) and Addiction Medicine providers, across the province, are stepping up in similar ways.

The CPSO has been supportive of our adapting of the professional guidance with less patient contact in pharmacies and clinics, for now. The Ministry of Health (MOH) and OHIP have responded with SARS era billing codes that can support maintaining connection with our patients. But the shifts in practice and Fee for Service (FFS) funding will leave some clinics and providers in the lurch. Our group is a prime example.

The FFS system is very vulnerable in a time of distanced care. Many Family Practice and almost all OST and Addiction Medicine clinics are remunerated and run on FFS billings. The MOH FFS billing codes for COVID do not allow us to bill for our usual accompanying codes that allow us to provide care to a very high-risk population and to run our practices. The codes we have been blocked from using also block us from affording our overhead – paying our office rent and paying our staff. The office is a place of refuge, of nonjudgmental and kind care for our patients. It may not be sustainable for us to keep our doors open, to keep our skilled staff and to serve the patients we have worked with and alongside for decades!

It's difficult to watch, feel and sense the rug being pulled out from under our feet in providing committed and wholistic care to long-term patients, in person, directly engaged with their communities. This time of COVID is a tough reality facing many people, families and communities the world over. I am very worried about all persons affected. In this moment, I am sharing my worries for some of the most vulnerable patients and programs in the province.

Just wanted to share. I know this reality is shared by others, and worries others, so I thought I'd write it down and share.

Dr. Sharon Cirone