Insights (Essays)

Insights (Essays) June 2021

Supporting Primary Care Involvement in COVID-19 Vaccinations

J. Ross Graham, Sharon Bal, Sarah Farwell, Neil Naik and Joseph Lee

covid shots 

Abstract

At times, primary care providers have felt detached from COVID-19 vaccine rollouts. To support primary care involvement, we summarize key enablers that led the Waterloo Region to achieve the highest total vaccine output through primary care across Ontario. These key enablers included (1) identifying primary care leadership; (2) early engagement and communication; (3) a co-designed vaccine rollout plan; (4) offering mutual support; and (5) reinforcing primary care’s leadership role. Conversely, the key challenges included (1) unclear funding mechanisms; (2) directing the public to consult primary care on breaking news; and (3) misalignment of documentation systems. We hope that the enablers and barriers from the Waterloo Region experience can support primary care involvement in other jurisdictions.

Introduction

Primary care providers* play a key role in the vaccination of their patients and the public (Lam 2021; Wilkinson et al 2021). While estimates differ between jurisdictions on the amount of vaccinations provided by primary care, these providers also have important roles in addressing vaccine hesitancy (Shen and Dubey 2019). This includes individualized discussions with patients about vaccination options and risks as part of the patient-provider relationship. Primary care providers also engage in valuable activities to address vaccine hesitancy with the general public and specific groups (such as tailored information for a particular ethnocultural group). Evidence has demonstrated a relationship between the attitudes of primary care providers and regional vaccination rates, leading some to suggest that new immunization programs may be unsuccessful without primary care support (Arlt et al. 2021; Dubé et al. 2012). Together, these factors make primary care a critical public health partner in mass immunization programs, including current COVID-19 vaccination programs across Canada. Given the importance of their role, it is unfortunate that primary care providers have at times felt “left out,” “frustrated” and “disengaged” from COVID-19 vaccination programs (Abelson 2021; Duong 2021; Kiran 2021; Lam 2021; Ontario College of Family Physicians 2021). For example, a recent survey of Canadian physicians (all specialties, n=1648) found that while 80% of them saw vaccine distribution as a top priority, 40% were frustrated with the level of physician engagement (Duong 2021: e458).

Involving primary care providers should be central to all COVID-19 vaccination program initiatives with intentional engagement and co-design from inception. We acknowledge that implementing the COVID-19 vaccine has been a tremendous planning and operational exercise for all levels of government and segments of the health system. We have experienced this ourselves at a local level. Provider engagement requires effort, resources and additional coordination. We suggest that collaborating with primary care on mass immunization is valuable as it produces a significant return on these investments. At the time of writing this article, our jurisdiction – the Waterloo Region – had the largest total vaccine output through primary care of any public health unit jurisdiction in Ontario, outpacing all other public health unit areas. This output is the result of a strategic effort to deliver vaccines quickly while also addressing hesitancy and building a sustainable local vaccination model. To demonstrate the benefits of active primary care involvement in a COVID-19 vaccine response, we have shared some key success enablers that led primary care in the Waterloo Region to achieve such a large vaccine output. We have also outlined key barriers that were addressed to make this happen and should be considered more broadly as Canada is only past the halfway mark of first doses, and there is still a long way to go.

Key Success Factors

  • Identification of primary care leadership: At the outset of Waterloo Region’s vaccine response, primary care and community pharmacy positions were established in the most senior oversight body – the Waterloo Region Vaccine Distribution Task Force (VDTF). Primary care and pharmacy representatives were similarly added to prioritization and operations groups to ensure the availability of content expertise in a rapidly changing environment. These leads served as key contacts for the primary care community to liaise with for timely, curated information. Interestingly, similar representation from primary care is not part of Ontario’s VDTF (Government of Ontario 2020). 
  • Early, transparent and regular sector-wide engagement and communication: The primary care and pharmacy leads quickly convened regular engagements with their colleagues, thus providing local public health with a two-way venue to share information, solicit feedback and engage partners in clinic design, setup and staffing. A number of engagement approaches – from asynchronous WhatsApp groups and newsletters to synchronized virtual townhall meetings and communities of practice – afforded the widest reach to various practice types and sizes. Routine communications have continued throughout the vaccine response to support identification of best practices, celebrate successes, maintain motivation and manage near real-time issues. These forums provided channels for communication as changes to vaccine administration, group eligibility and dose intervals were announced. Similarly, they facilitated quick development and distribution of patient template letters and formal advisories. 
  • Co-design of the vaccine rollout plan: Primary care leaders and representatives were then involved in the design and implementation of the vaccine rollout master plan. This included early involvement with hospital- and public health-run mass immunization clinics as well as mobile vaccination teams. Primary care involvement enabled their capacity-building including increased familiarity with COVaxON, Ontario’s vaccination documentation system. This involvement also established early adopters who could then support their colleagues’ involvement in subsequent phases. 
  • Saying “yes” to in-progress strategies and offering mutual support: We have found that an engaged and informed primary care sector is key to readily implementing new provincial direction and seizing opportunities. For example, the Waterloo Region was notified on the Friday of an extended weekend about an AstraZeneca shipment to be delivered in three days for urgent distribution via primary care. It was crucial that primary care partners felt informed and supported by the VDTF so that they could accept risks of setting up clinics with many unknowns often in their own offices. Key supports included funding (through local public health), ongoing locally run hands-on COVaxON training and one-on-one clinic setup guidance. All the training available to public health and hospital staff at mass immunization clinics were offered to primary care partners to build capacity, scale-up rapidly and support late adopters.
  • Reinforcing primary care’s leadership role with vaccinations: It has been essential to communicate support for primary care’s leadership role in delivering vaccinations. This has increased involvement from the primary care sector as well as clarified that certain pandemic-related supports (including pandemic-related billing codes) are temporary and non-sustainable, with routine vaccinations in primary care offices and pharmacies being the long-term sustainable solution. Having local primary care leads promote how COVID-19 vaccines can be delivered and billed for private practice has been particularly important. Similarly, the VDTF prioritized getting as many primary care practitioners experienced with delivering vaccinations and utilizing COVaxONas possible. These practitioners were also able to partners with other settings needing vaccination support, such as long-term care homes. This included specific strategies to engage and support larger team-based primary care offices to set up clinics as well as smaller groups of providers and solo practitioners. 

Challenges and Barriers

  • Unclear funding mechanisms: Setting up a productive vaccination clinic is a sizeable undertaking for primary care providers with significant costs. Before the pandemic, it would have been unusual for local public health agencies to flow millions of dollars into primary care when it is traditionally funded by provincial health insurance plans and other provincial sources. However, without provincial funding channels for primary care to provide COVID-19 vaccinations, and with no time to delay, it was essential for public health to provide this funding (with hopes of provincial reimbursement). Funding was tailored to meet the needs of team-based primary care offices running weekly clinics versus smaller offices delivering vaccines to their patients.    
  • Directing the public to consult their primary care providers on breaking news: While primary care providers are well positioned to counsel their patients on health matters, it can be challenging when new provincial directives are communicated to the public with little advance warning to primary care or local public health. This challenge is exacerbated when the new directive instructs patients to engage with or seek documentation from their primary care provider. Subsequent confusion among providers and distrust of the system by providers and the public alike can result.
  • Misalignment between primary care roles and the documentation systems: The Ontario COVID-19 vaccination plan included the expectation that primary care providers would identify and communicate with vaccine-eligible patients within their roster, as well as provide immunization services to them. While this is a significant request, it resulted in some frustration as COVaxONdid not require immunized individuals to identify their primary care providers (if they had one) or communicate this information back to these providers. This created the scenario whereby, for several months, providers were unable to determine who in their rosters were already vaccinated. 

Additionally, it is worth mentioning that the vaccine supply chain “rollercoaster” has been a challenge for everyone involved in the COVID-19 vaccination programs. This includes primary care where frequent, even daily changes mean confusion for patients and providers. This being said, in Ontario, we are pleased to see recent positive signs of a steadier vaccine supply. 

Conclusion

While primary care involvement in mass vaccination programs requires in-depth investigation, we hope that the enablers and barriers from the Waterloo Region experience are useful to other jurisdictions and policy makers as COVID-19 vaccination programs continue. Primary care providers have been exceptional partners in the vaccine rollout plan, which is in addition to the many demands arising due to COVID-19 from navigating virtual visits to supporting congregate settings and assessment centres. Involving primary care from the outset has been essential for boosting the productivity of the Waterloo Region vaccine response as well as preparing for eventual transition to a sustainable local model of community vaccination.

Notes

* For this article, we have used the term “primary care providers” to predominantly refer to family physicians and nurse practitioners.

About the Author(s)

J. Ross Graham, MSc, MPA, is the planning lead for the Waterloo Region COVID-19 Vaccine Response, Public Health and Emergency Services in the Region of Waterloo in Waterloo, ON.

Sharon Bal, MD CCFP FCFP, is a family physician and a pre-clerkship coordinator in the Waterloo Regional Campus of Michael G. DeGroote School of Medicine, McMaster University in Kitchener, ON. Sharon can be contacted by e-mail at sharon.bal@medportal.ca or by phone at 519-590-6938.

Sarah Farwell, BSc MHS(c) DC is the Ontario Health West lead, COVID Response and Primary Care Collaboration and Strategy in Waterloo, ON.

Neil Naik, MB, BCh, BAO, CCFP, is a family physician and assistant clinical professor at McMaster University Waterloo Regional Campus in Kitchener, ON. He is the chair of the Primary Care Council for the Kitchener-Waterloo-Wilmot-Woolwich-Wellesley Ontario Health Team and the Interim Regional Primary Care lead for the Waterloo-Wellington Region. He is an advisor for a start-up company and an eHealth advisor for the eHealth Centre for Excellence and a variety of Ontario Health Working Groups.

Joseph Lee, MD, CCFP, FCFP, MClSc(FM), is chair and lead physician of The Centre for Family Medicine in Waterloo, ON; clinical lead for the KW4 sub-region, Ontario Health; chair of the Steering Committee for the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich Ontario Health Team; and clinical associate professor and assessment director at the Department of Family Medicine in McMaster University. 

Acknowledgment

The authors offer special thanks to Drs. Hsiu-Li Wang, Kelly Grindrod and Julie Emili and to Vickie Murray and Sharlene Sedgwick-Walsh for their leadership in and support of primary care’s involvement in the Waterloo Region COVID-19 vaccine response.

References

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Dubé, E., V. Gilca, C. Sauvageau, J. A. Bettinger, F. D. Boucher, S. McNeil et al. 2012. Clinicians’ Opinions on New Vaccination Programs Implementation. Vaccine 30(31): 4632–37. doi: 10.1016/j.vaccine.2012.04.100.

Duong, D. 2021. Canadian Physicians Frustrated with Vaccine Rollout. CMAJ 193: E458–59. doi: 10.1503/cmaj.1095929.

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Lam, V. January 21, 2021. Family Doctors are Key to Canada’s Vaccine Rollout. We Must Include Them in this Vital Process. The Globe and Mail. Retrieved June 1, 2021. <https://www.theglobeandmail.com/opinion/article-family-doctors-are-key-to-canadas-vaccine-rollout-we-must-include-them/>.

Ontario College of Family Physicians. March 23, 2021. With Vaccines Coming, Family Doctors Could Jab Millions More if Fully Involved. Retrieved June 1, 2021. <https://www.ontariofamilyphysicians.ca/news-features/family-medicine-news/~203-With-Vaccines-Coming-Family-Doctors-Could-Jab-Millions-More-If-Fully-Involved>.

Shen, S. C., and V. Dubey. 2019. Addressing Vaccine Hesitancy: Clinical Guidance for Primary Care Physicians Working with Parents. Canadian Family Physician 65(3): 175–81.

Wilkinson, E., A. Jetty, S. Petterson, Y. Jabbarpour and J. M. Westfall. 2021. Primary Care’s Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs. Annals of Family Medicine 19(3)doi: 10.1370/afm.2679.  

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