High-risk based on: 1) potential for serious consequences from COVID-19, influenza, and pneumococcal disease, and 2) potential for clinical deterioration of underlying chronic condition due to the direct or indirect consequences of the COVID-19 pandemic.# BC Care Bundle for Supporting High-Risk- Patients During COVID-19 Pandemic and Influenza Season ENHANCE IMMUNIZATION
Assess influenza and pneumococcal immunization status of high-risk patients 2 and ensure immunizations are up to date. Where possible, provide/recommend immunizations to occur at the time of an existing medical visit or health care encounter 3 . Discuss the importance of ensuring close contacts are also immunized.

# CONFIRM ACTION PLAN
With the patient and care provider, review self-preparedness 6 and action plan for intercurrent illness and potential for underlying disease decompensation, including: adequate food & medication supply, social supports/buddy system, disease-specific triggers, symptoms, escalation pathways, and appropriate emergency contacts (i.e., conditionspecific clinic, emergency room).

# EMOTIONAL WELL-BEING?
Isolation, economic hardship, and disruptions of daily routine can have an impact on psychological and emotional well-being 12 . Consider a discussion with patient and caregiver regarding coping mechanisms and review access to additional support services.

# IDENTIFY PATIENTS
Review current patient roster and identify patients deemed to be high risk 1 for complications from COVID-19, influenza, and pneumococcal disease.

# REVIEW GOALS OF CARE
Review goals of care and advanced care directives with patient and family. Where relevant, identify alternate decision-makers. Ensure patients have access to palliative care supports as required 5 .

# REVIEW MEDICATIONS
With the patient and caregiver, discuss current medications (especially those associated with respiratory illness) and review current supply levels, individual sick-day rules 10 , and the benefits of medication adherence 11 .

# PREPARE FOR INFLUENZA
Monitor local influenza rates 4 . Consider antiviral prescription (e.g. oseltamvir) within 12 hours of onset of symptoms if clinically indicated based on local influenza rates and clinically-compatible symptoms or severity.

# FLU/COVID-19 SYMPTOMS?
Determine need for in-person assessment and care management plan based on underlying condition and as clinically appropriate. Consider initiating influenza antiviral 7 and send for COVID-19 testing 8 . If COVID-19 positive, suggest stopping antiviral in accordance with current BC-CDC guidance 9 .

# DISCUSS DIET & EXERCISE
Diet and physical activity can be impacted by pandemic restrictions and/or intercurrent illness 13 . Patients may find value in discussions regarding self-management approaches for diet and exercise. 

# Context
Chronic diseases may increase a person's risk of infection or increase a person's risk of more severe disease should infection occur. Individuals with chronic disease are at higher risk of COVID-19, influenza, invasive pneumococcal disease (IPD), and related complications. Influenza and COVID-19 can present with similar symptoms, and can mimic many other illnesses such as the common cold or exacerbation of underlying respiratory conditions. To protect this high risk patient population and to conserve health system capacity during the COVID-19 pandemic, maximizing immunization uptake and optimizing management of patients with chronic conditions need to be an integral component of current care planning.

# References and Resources