VIRTUAL CHIRO CARE RESOURCES

It is important to assess if this form of patient interaction is appropriate for you and your patients. Some patients will not be open to this form of care and that must be respected. Remember, patient values is an equally important aspect of evidence-based practice. Ensure you discuss this with your patients and give them the option for this type of care. Some patients may be un comfortable with this, nor have access to the required technology. Discuss what type of interaction they feel best suits their needs.

Are you as a practitioner comfortable with this? You may not feel that this form engagement is suited for you. Part of evidence-based care is also clinician expertise and clinical judgement. You know your patients and you know your expertise. It is important to self-reflect and ensure you are comfortable offering this service.

Patient considerations:

• Do they have access to the required technology? Can they use it?
• Do they have any physical conditions that will prevent them from being able to use this type of technology (e.g. vision or hearing deficits, physical disabilities)
• Is their condition conducive to this type of appointment? (e.g. is it too severe, are there any red flags that require an emergency referral)
• Do they have any mental health or psychological issues that may be aggravated by this type of interaction?

Through their training and experience, and a number of evidence-based options within their scope of practice, chiropractors can have a positive impact on people’s health even in the absence of hands-on assessment or manual therapy. Ruling out serious pathology, addressing psychosocial barriers to recovery, reassurance, education, exercise prescription and monitoring, behavior modification, and self-management strategies are essential first-line procedures and treatments for musculoskeletal conditions.^10-13

Evidence-based recommendations that can be delivered through virtual chiro care include:

1) Ensure care is patient-centered.^10-13

• Use a biopsychosocial approach to care that takes into account the individual patient’s context.
• Listen attentively to patients’ concerns, health goals, values and preferences.
• Communicate effectively and engage in shared decision-making with the patient.
• Offer preparatory recommendations prior to the appointment (e.g., comfortable clothing that allows ease of movement and visual inspection, and space and flooring for exercise prescription).

2) Screen for risk factors of serious pathology (“red flags”)

• Conduct a thorough history and document contemporaneously.
• If risk factors are present, refer the patient to the appropriate healthcare provider or services. Examples include suspicion of infection, malignancy, fracture, inflammatory causes of pain, severe and progressive neurological deficit (including cauda equina syndrome) and serious conditions that can present as musculoskeletal pain (such as aortic aneurysm).

3) Assess barriers to recovery (psychosocial factors, “yellow flags”)

• Screen for anxiety, depressive symptoms, sleep disturbances, fear/kinesiophobia catastrophizing, recovery expectations, and expectations of passive treatment. Patients with these findings may require co-management or referral.
• Be aware of the patient’s context – “yellow flags” may worsen during a period of crisis and/or further exacerbate pain (see examples of assessment tools at https://www.ccgi-research.com/outcomes-psychosocial).

• Address modifiable barriers.
  • Educate and reassure patients about the benign and self-limiting nature of their musculoskeletal condition and the importance of maintaining activity and movement.
  • Reassure patients that it is normal to feel some anxiety, distress or anger.
  • Listen to the patient’s concerns, discuss them and adjust their care plan accordingly.

4) Conduct a clinical examination

• Conduct a thorough health interview and document contemporaneously.
• Use patient-reported questionnaires and outcome measures (see examples https://www.ccgi-research.com/outcomemeasurements).
• Conduct a physical examination. While there are limitations to the lack of a hands-on physical exam possible with virtual chiro care, a modified exam may allow for a clinical impression and for an initial treatment plan to be started. A modified exam may include:
• Observing the patient’s appearance and emotional status (e.g., does the patient look well, unkempt, worried, well-rested, intoxicated; any signs of physical trauma?)
• Observing the patient’s posture, range of motion, movement patterns, and muscle strength.
• Asking the patient to self-palpate or self-examine under your guidance. You may send instructional photos or videos to facilitate this.
• You may recommend to the patient that it may be helpful to have a family member present during the examination (in case the patient falls, etc.)
• Once major pathology has been ruled out; and based on the interview and modified physical examination, you may classify the patient’s condition (e.g., non-specific neck or back pain, shoulder strain).

5) Provide patients with education/information about their condition and self-management strategies

• Communicate your clinical impression.
• Communicate the patient’s apparent progress (for subsequent visits).
• Communicate your recommendations.
• Promote shared understanding and shared decision-making regarding the patient’s care plan.

6) Address physical activity and exercise

• Prescribe exercise (e.g., maintenance of usual activities, mobility, range of motion, stretching, strengthening, aerobic or general exercises).
• Demonstrate and/or observe performance of exercise.
• Provide written, image or video exercise references (see examples https://www.ccgi-research.com/pr-vidiosandforms).

7) Address supportive self-management strategies and factors contributing to the patient’s experience

• Educate patients on up-to-date public health measures related to the current pandemic (as outlined by our national and provincial health authorities e.g., https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals.html).
• Educate patients on self-management strategies, such as:
• Promoting healthy lifestyle behaviours (e.g., being active, proper nutrition and sleep) / behaviour modification
• Active coping strategies for pain, anxiety, stress, and depressive symptoms
• Address sleep disturbances
• Teach mindfulness practices
• Teach pacing activities
• Help patients locate online social support programs
• Support patients to self-manage through techniques such as cognitive behavioural therapy (CBT) and motivational interviewing (or refer to other healthcare providers qualified in providing these services).
• Provide resources (see examples at https://www.ccgi-research.com/patient-resources).
• Many of the behavioural components of self-management are not only potentially helpful for managing pain and musculoskeletal conditions, but also for emotional distress related to the current pandemic.

8) Monitor patient progress

• Remind patients to contact you or another healthcare provider if certain signs and symptoms (“red flags”) occur (see patient handouts as examples https://www.ccgi-research.com/self-management-resources-handouts).
• Ask the patient’s permission to follow-up with them as appropriate (suggest timeframes).
• Evaluate patient progress using validated outcome measures (see examples https://www.ccgi-research.com/outcomemeasurements). These include pain intensity, function, quality of life, and self-rated recovery.

• Develop/update your clinical workflows, clinical protocols, referral forms, policies and guidelines to support virtual chiro care visits.
• Do research to determine a reliable third-party platform that protects privacy. The following two software options meet the privacy requirements and can be used without being linked to an EHR system. Your current EHR may also provide the technology required. Ensure that the software you use is PIPEDA/PHIPA compliant.
  Zoom Health
  MediSeen
• Complete your technical set-up and a technology plan (equipment, medical peripherals, internet connectivity). Ensure it meets the privacy requirements of your regulatory college.
• Develop a plan in case of emergency or adverse event.
• Do you have existing and potential relationships with partners such as:
  • Another Chiropractor providing in person emergent or urgent care
  • A medical doctor or walk-in clinic
  • Other providers or specialists
• Develop a communication strategy to promote the availability of your telehealth program such as social media posts, email and phone calls.
• Develop an evaluation and performance measurement plan
  • How will you track the number of appointments you conduct? Who will bill for them?
  • Will you send a satisfaction survey after the visit?

• Educate patients that:
  • All recent evidence-based clinical practice guidelines for the management of conditions such as back and neck pain; headache pain; shoulder, hip, knee and osteoarthritis pain recommend exercise and self-management strategies as an essential first-line therapy.
  • Chiropractors can monitor their progress, make modifications to the current care plan, address questions and issues related to the current complaint, address lifestyle-related behaviours (e.g., nutrition, sleep, stress management), and provide coaching and support.
• Let patients know the technical requirements for a virtual chiro care appointment including:
  • Email address
  • Internet access
  • Personal computer, smartphone or tablet with webcam, speaker and microphone.
• Send a patient outline and/or check list before the appointment based on your videoconferencing or webconferencing platform requirements.
• Communicate your expectations of how the visit will take place.

• Always remember to:
  • Maintain patient privacy at all times
  • Ensure decisions are collaborative
  • Ask the patient for an emergency local contact number (e.g., family member living with patient or neighbour) in case of an adverse event or health emergency during the appointment
• Prepare your documentation, ensuring you meet your regulatory college’s requirements, including those for clinical and billing records.
• Set up and test your devices (sound, video) prior to the appointment. Consider presenting your clinic logo, your regulatory body logo and your CCA member logo.
• Ensure your professional appearance in a private, professional-looking setting.
• Consider sending videos or images to demonstrate procedures you may want your patient to perform during the visit (e.g., if you wish to observe patient’s range of motion or movement patterns).

Check with your provincial regulator about their standards for virtual chiro care visits during the COVID-19 pandemic for both first visits or existing patients. Also check with your patient’s insurer to ensure you follow requirements for claims submissions.

In some jurisdictions, virtual chiro care may only be performed with existing patients with whom you have already conducted an in-person initial visit, including examination, and have a care plan and informed consent.

1) Confirm the patient’s identity:

• Name, date of birth and address.

2) Be clear about:

• The length of time you expect for the visit – letting them know that these appointments may take longer than expected.
• What you plan to cover.
• The clinical model of care you follow.
• The limitations of these appointments, such as the inability to perform hands on assessment or treatment.
• The efforts you have taken to ensure that the technology platform you use complies with privacy regulations.
• The patient’s goals and expectations for the visit. Document them.
• Your goals and expectations for the patient. Document them.

3) Obtain consent to provide services virtually

• Refer to and comply with your regulatory college requirements with respect to informed consent.
• Ensure that you and the patient are in spaces that will not compromise their privacy.
• Tell the patient that there will be a charge for this service and whether the service will be billed to their insurance company. Below is a list of insurance companies accepting billings for virtual chiro care visits:

• Ask the patient for consent to proceed.
  • For example, “I am asking for your consent to proceed with this virtual chiro care visit. There will be a charge of $___ for this appointment. If you have insurance, and depending on your insurer’s policies, you may be charged for the visit and you can then apply for reimbursement or we will directly bill your insurance provider. Also know that this appointment will be appropriately documented in your file and all privacy regulations are being respected to the best of my ability. Do I have your consent to proceed?”
• Document that consent was obtained.
  • For example, “Verbal consent to proceed with appointment was obtained from the patient after reviewing charge of $__ and ensuring privacy and documentation regulations are being followed to best of our ability.”

4) Conduct the visit:

• Document as you would any other visit. All your advice and recommendations must be noted in the file and meet the requirements of your regulatory college for virtual chiro care services.
• Be sure to discuss the risks, benefits and alternatives to your recommendations and note them in the file.
• When giving recommendations/advice, remember the CCPA’s Roadmap to Care. Ensure your objective findings justify your recommendations.
• Use the “Teach-back” method to ensure the patient understands what you have advised them to do. Ask them to repeat back what you have said.
• Include your plan moving forward.
• For example, will you check in by phone or another virtual chiro care visit? When?
• Are you sending follow-up resources? Keep a record of that in the file.
• Ensure that all information has been covered and documented prior to ending the appointment.

5) Choosing not to proceed with a virtual chiro care visit

As you proceed with the assessment, be aware of indications to not proceed, such as:

• If the patient presentations require confirmatory physical examination that you cannot carry out.
• Red flag situations that require referral to another health care professional.

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