Moving to mainstream

Ontario is moving ahead with several integrated health-care initiatives, and chiropractors are among the professionals expected to be involved.

Ontario is moving ahead with several integrated health-care initiatives, and chiropractors are among the professionals expected to be involved.

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The Ontario Ministry of Health and Long-Term Care is calling for proposals to design, plan and implement more effective management of low-back pain through a primary care low-back pain (PCLBP) pilot program (PCLBP). Minister Deb Matthews stated in October 2013 this initiative will be geared towards family health teams, nurse-practitioner-led clinics, community health centres and aboriginal access health centres. Under this program, leaders in these primary care settings will recruit allied health providers with the appropriate skills, including chiropractors, physiotherapists, occupational therapists and kinesiologists.

Under the ministry’s Ontario’s Action Plan for Seniors, the government commits to increasing the number of exercise and falls prevention programs throughout the province, ensuring that Local Health Integration Networks and public health units are able to provide a range of these initiatives. Part of this will be accomplished through the creation of as many as 75 “health links” across the province, where access to care for seniors and patients with complex conditions is improved. Greater collaboration and co-ordination between a patient’s different health-care providers is encouraged, with the development of a personalized care plan.

The Action Plan states: “These networks of linked health-care providers will work as a team to collectively manage the needs of those patients with the greatest needs, in partnership with family and community, so they move smoothly through the system.”

British Columbia Chiropractic Association (BCCA) president Dr. Jay Robinson says integrated care models can be more cost-effective and better for patients, but that the billing arrangement has to be organized accordingly.

“In mainstream health care, it’s a fee-for-service model where patients receive treatment and then billing occurs on this basis,” he notes. “It’s set up so there is incentive to involve as many practitioners as possible. However, in an integrated setting, if the team or clinic is given a set amount of payment for say, 1,000 patients, there is no such incentive. Things become very efficient and patients see only who they truly need to see. And this lack of duplication saves money.”

True integration, he says, is about removing the gatekeeper, where once a practitioner gets a patient, he or she needs to “own” the patient.

“In an integrated model, there is none of that,” Robinson explains. “The patients get to take a much more active role and theoretically get the best care. In an ideal integrated care model, the patient gets an initial assessment and diagnosis and then is seen by the most appropriate health-care provider for further complete diagnosis and treatment.”

The integrated care model also takes some of the guesswork out of the process of accessing health care for patients. Under the current system, Robinson says, patients require some knowledge of their condition and its potential treatments prior to accessing care. This can result in patients wasting time and resources going from one health-care provider to another until they find the most effective for their condition. Integration offers greater potential for getting the most appropriate provider and treatment to the patient more swiftly.

Possible models
Canadian Chiropractor asked the Ontario Ministry of Health and Long-Term Care (OMHLTC) how integrated family health teams or nurse-practitioner-led clinics are envisioned to function with chiropractors and other professionals on board. 

“As with other professions on the team, the role of chiropractors is to be defined based on the needs of the patient population and how their involvement in interprofessional programs and services will help to address these needs,” says OMHLTC spokesperson David Jensen. “The specific process through which patient needs are identified and met may vary across teams, but a team-based approach to care is common across all family health teams and nurse practitioner-led clinics.”

When asked who will define the role of chiropractors and identify patient needs, Jensen responds, “The board of directors is ultimately accountable for services and programs delivered by the family health team. However, as a team-based model of care, several team members (clinical and administrative) are likely to have input into the roles that are needed to be performed to address patient needs.”

With regard to the PCLBP, Jensen says, “interprofessional teams operating in a primary care setting can receive funding to create a new, or enhance an existing, low-back pain program that fits within their organizational context and addresses the needs of their patient population.”

Under the program, an interdisciplinary team will manage the assessment, referral, treatment and education of patients, says Jensen. 

Commenting on the chiropractic integration in the PCLBP initiative, the Ontario Chiropractic Association (OCA) says it’s important to first clarify the actual opportunity and context of these health-care initiatives.

Dr. Bob Haig, CEO of the OCA, points out the ministry has established a low-back pain strategy which includes new, innovative models of care that the OCA helped to design, and that the request for proposals in the pilot program is intended to eventually inform the implementation of one or more provincial models.

This, when combined with Minister Matthews’ October announcement that chiropractors will be added to the list of health professionals that are eligible to work in family health teams and nurse practitioner-led clinics, signifies to the OCA “that chiropractors are viewed by the ministry as an important component of the health-care system, and further paths for our inclusion are being explored,” says Haig.

“The approach to the RFPs, given that this is only the beginning of a pilot project, is that different primary care settings will likely have different needs depending on their patient population and their staffing complement. Either way, you can expect that there will always be someone who will complete an initial assessment, but the specific care approach will depend on the needs of the organization,” he adds. 

In terms of OCA’s preference, he says, “Ideally, a chiropractor would have a meaningful, fulsome role as part of the care cycle of assessment, diagnosis, planning, treatment, evaluation of a patient.”

Haig says the OCA expects there will be a wide range of diversity in the proposed models of care in the pilot program. One example could be a community health-care centre where the target population are vulnerable community members such as the homeless and low-income group.

“A chiropractor could be involved…providing patient education, assessment and treatment,” he says. “If referral to a specialist is needed, it [could be] done through one of the nurse practitioners. Also, kinesiology students [could] provide simple exercises and stretches following chiropractic treatment. Access to massage therapy by RMT students [could be] provided free-of-charge via a RMT program in the area, based on a referral by the chiropractor.”

The OCA works to ensure that every Ontarian who can benefit from chiropractic has the ability to do so, Haig notes.

“These announcements represent a very positive trend in that direction, but there is more work to be done. For example, there is a greater understanding and recognition by both governments and health-care stakeholders for disease prevention and health promotion programs. Chiropractic is known for both treatment of acute conditions but also for an educational, prevention-based approach to managing conditions. There is work to be done from within the profession and the health-care system so that chiropractors are seen as both musculoskeletal experts and experts in health promotion and disease prevention.”

BCCA’s Robinson says these types of inclusive government initiatives help sidestep “a big problem that has been developing slowly in Canadian health care. As more services become available to the public, outside of the provincial government coverage, the potential for inappropriate services being sold, or upsold to patients, increases. The best of the integrated care models ensure that patients receive exactly the care they need.”

“However,” he adds, “We are only at the beginning in creating and implementing integrated health care, and there are many years of development ahead.”

Treena Hein is a freelance writer and editor based in Eastern Ontario. Treena is the proud winner of two awards: the International Federation of Agricultural Journalists “Star Prize” and the Canadian Farm Writers Federation “Gold” feature award.