UP[PLZ 7YPTHY`/LHS[O*HYL! 7O`ZPV[OLYHW`HUKumanitoba.ca/rehabsciences/media/pt_primary_care.pdf · coincide. The role of physiotherapy at the primary care level, which has traditionally

Physiotherapy andPrimary Health Care:Evolving Opportunities

Acknowledgements

The Manitoba Branch of the Canadian Physiotherapy Association, the College of Physiotherapists of Manitoba and the Department of Physical Therapy, School of Medical Rehabilitation, University of Manitoba would like to thank those who contributed to the development of this paper. In particular, they would like to thank the participants of the physical therapy focus group and those who completed the survey. The following concurrent project is acknowledged for its contribution in the development of this initiative: The integration of occupational therapy and physiotherapy services in primary health care in Winnipeg (Restall, G., Leclair, L., & Fricke, M., 2005). The author would also like to express sincere appreciation to family and colleagues who assisted throughout this project with their unending patience and insight. Cover Design: Julie Creasey

Physiotherapy and Primary Health Care: Evolving Opportunities

Submitted by

Moni Fricke1, BMR (PT), MSc

2005

Manitoba Branch of the Canadian Physiotherapy Association

College of Physiotherapists of Manitoba

Department of Physical Therapy, School of Medical Rehabilitation,

University of Manitoba

1 Department of Physical Therapy, School of Medical Rehabilitation, University of Manitoba. For e-mail correspondence: [email protected]

TABLE OF CONTENTS

Executive Summary ____________________________________________________ ii

1. Introduction to primary health care ______________________________________1

1.1 Background_______________________________________________________ 2

1.2 Population health and the broader determinants of health ___________________ 5

1.3 Health promotion _________________________________________________ 10

1.4 Primary health care reform __________________________________________ 11

2. Models of primary health care__________________________________________14

2.1 Community physiotherapy __________________________________________ 15

2.2 Primary care models and physiotherapy________________________________ 18 American military model ____________________________________________ 19 Physiotherapy consultant model (United Kingdom and the Netherlands) _______ 20 Private industry model ______________________________________________ 20

2.3 Primary health care models and physiotherapy __________________________ 21 Canadian Aboriginal health model _____________________________________ 21 Geriatric Program Assessment Team model______________________________ 22 Community pre-school wellness screening ______________________________ 23

3. Potential roles of physiotherapy in primary health care_____________________25 Chronic lung disease________________________________________________ 27 Diabetes__________________________________________________________ 27 Fall prevention ____________________________________________________ 28 Mental health _____________________________________________________ 28 Navigator role - Case management_____________________________________ 29 Physical inactivity and obesity in children and adults ______________________ 30 Rheumatoid arthritis ________________________________________________ 30 Urinary incontinence________________________________________________ 31

3.1 Barriers _________________________________________________________ 32

4. Preparation of physiotherapists for a primary health care setting ____________33

5. Conclusion __________________________________________________________36

References ____________________________________________________________38

Appendix A: Physiotherapy focus group participants ___________________________46

Appendix B: Focus group questions ________________________________________47

Appendix C: Physiotherapist electronic survey________________________________48

Appendix D: Accompanying information for the survey ________________________50

Appendix E: Glossary of terms ____________________________________________52

Physiotherapy and primary health care: Evolving opportunities i

Executive Summary

Primary health care reform is felt to be essential to the transformation necessary to maintain the viability of the Canadian public health care system (Romanow, 2002). Emphasizing health promotion and disease prevention has the potential to help individuals and communities live healthier and put less strain on the health care system (National Primary Health Care Conference Steering Committee, 2004). Primary health care is about shifting the focus “upstream”, before individuals get sick or injured and seek urgent medical intervention. Services can occur in an assortment of settings, such as health clinics, schools, and community health centres. A wide variety of health care professionals provide services at this level, including physicians, nurses, dentists, pharmacists, social workers, occupational therapists, and physiotherapists. Physiotherapy, or physical therapy2, is a health care discipline well positioned to take on an increased role in primary health care. Physiotherapy is an independent self-regulated profession. Physiotherapists have the necessary university education and experience to address the needs of health promotion and disease prevention, both on an individual basis as well as that of a community. Physiotherapists understand the importance of the broader determinants of health and their impact on individual and population health status. As an integral part of a collaborative interdisciplinary primary health care team, physiotherapists can assist in health promotion and disease prevention strategies, as well as in the identification and remediation of a myriad of health conditions. Primary care is an integral component of primary health care, but the two concepts must be distinguished from one another as it pertains to the delivery of physiotherapy. Primary care is the point of first contact with the heath care system. The term “primary care” includes the diagnosis, treatment and management of health problems with services delivered in Canada predominantly by physicians. Alternatively, primary health care “incorporates primary care, but also recognizes and addresses the broader determinants of health including population health, sickness prevention, and health promotion with services provided by physicians and other providers often in group practice and multi-disciplinary teams” (Health Canada, 2000). In order to explore the roles that physiotherapy can play in primary health care reform, three methods were utilized to gather pertinent information. Firstly, an extensive literature review provided the background and evidence of the role for physiotherapy in primary health care. Secondly, a focus group was held with physiotherapists working in a wide variety of clinical and educational settings to explore the current and potential role of physiotherapy in primary health care. Thirdly, a survey was conducted of key physiotherapists working primarily in a rural setting in Manitoba. It was felt that they would be in a position to provide a perspective unique from their urban counterparts. Two levels of participation can be used to consider existing models of physiotherapy in primary health care. They are not mutually exclusive and in fact, they most frequently 2 The terms physiotherapy and physiotherapist are considered synonyms for physical therapy and physical therapist respectively and will be used interchangeably in this document.

Physiotherapy and primary health care: Evolving opportunities ii

coincide. The role of physiotherapy at the primary care level, which has traditionally been based on the biomedical model, is well supported by the literature. The public enjoys direct access to physiotherapy services across Canada for a wide variety of services, including neuromuscular and cardiopulmonary rehabilitation, workplace consultation, as well as home therapy. In some jurisdictions, however, this role has expanded further, challenging current scopes of practice. Particularly in the area of musculoskeletal evaluation, physiotherapy has developed an expertise not shared by other general practitioners (Connolly, DeHaven & Mooney, 1998; Roberts, Adebajo & Long, 2002). This expertise in musculoskeletal assessment and treatment has lead to an expanded role for physiotherapists in many international jurisdictions. Physiotherapists have been found to provide care more quickly than the conventional route, and may reduce hospital costs (Dininny, 1995). International examples include the American military model, the European primary care consultant model and in private industry. In the American military model, physiotherapists have taken on an expanded role since the Vietnam War. The physiotherapists’ expanded function includes the timely evaluation and treatment of patients with non-surgical neuromuscular conditions, under the supervision of a physician, but without referral. Additional training has been implemented for the ordering of diagnostic imaging tests and prescribing non-steroidal anti-inflammatory medications. Army physiotherapists are not expected to diagnose non-musculoskeletal pathologic conditions, but are expected to make appropriate referrals on to those who can make the appropriate diagnosis. The resulting outcomes have included shorter wait times and a more rapid return to duty (Boissonnault, 2005). Physiotherapists have also been recently utilized as consultants and triage specialists in the area of musculoskeletal conditions in both the United Kingdom, as well as the Netherlands. Hattam and Smeatham (1999) found the majority of patients on an English orthopaedic waiting list could be effectively managed by a physiotherapist with extensive experience in musculoskeletal disorders and additional training in the use of corticosteroid injections. Daker-White, Carr, Harvey, Woolhead, Bannister, & Nelson, et al (1999) found similar results in another study in the United Kingdom, concluding that orthopedic physiotherapists were as effective as post-fellowship junior orthopaedic staff in the initial assessment and management of new referrals. Physiotherapists also generated lower indirect hospital costs. Jibuike, Paul-Taylor, Maulvi, Richmond & Fairclough (2003) found similar positive results in a study of physiotherapists assessing soft tissue knee injuries in an English accident and emergency department. In yet another study of physiotherapists working in general practitioners’ offices, on-site physiotherapy services resulted in 8% fewer referrals to Orthopaedics and 17% fewer referrals to Rheumatology over a one-year period (O’Cathain, Froggett, & Taylor, 1995). Hendriks, Kerssens, Nelson, Oostendorp, and van der Zee (2003) explored the use of physiotherapy consultation services by a group of primary care physicians in the Netherlands. The physicians were satisfied with the physiotherapy consultation and changed their management in almost 50% of the cases that they referred. An increase in referrals to physiotherapy was noted with a simultaneous 50% reduction in referrals to medical specialists (Hendriks, Kerssens, Heerkens, Elvers, Dekker, & van der Zee, 2003). This reaffirmed the author’s finding in a previous study, where general practitioners

Physiotherapy and primary health care: Evolving opportunities iii

referred only 14% of an intended 28 to a medical specialty, following a physiotherapy consultation (Hendriks, Brandsma, Wagner, Oostendorp, & Dekker, 1996). Physiotherapy in private industry has been shown to reduce the number of workdays lost by as much as 60% (Monahan, 1994). Additionally, workers’ compensation claims and overall medical costs have been lowered. This practice model incorporates traditional physiotherapy practices, such as evaluation of employee neuromuscular conditions and work-related soft tissue injuries. Additional responsibilities in this model may include ergonomic evaluation of the worksite, as well as injury prevention strategies. Examples of physiotherapists currently working in a primary health care model in Manitoba include northern and Aboriginal health, the Geriatric Program Assessment Team (GPAT) of the Winnipeg Regional Health Authority (WRHA) and community preschool wellness fairs. In each of these models, the physiotherapists are an integral partner in the primary health care team. The public has direct access to the health care provider, and the practitioners work in consultation with the rest of the team, formulating client goals together where needed. This sort of partnership must be extended to other primary health care teams, particularly where it is supported by the scientific literature. In areas such as fall prevention, arthritis, chronic lung disease, incontinence, diabetes, physical inactivity and obesity, osteoporosis, workplace safety and mental health, the role of exercise “upstream” is well documented. Physiotherapists are the ideal health professionals to act as both providers and consultants in the area of specialized exercise programming. As part of the health care team and possessing a broad understanding of community participation, they are also well suited to act as case managers or navigators for the public as they steer themselves through the health care system. It is acknowledged that physiotherapists bring unique skills to the primary health care team, but barriers to an expanded role have also been identified. Obstacles such as inadequate resources need to be addressed through the re-prioritization and allocation of physiotherapy services to primary health care. However, this should not be at the expense of the role that physiotherapy currently plays in secondary and tertiary care. A holistic approach to health care should integrate all three levels of health promotion and disease prevention. Several recommendations are made as a result of this project.

1. Physiotherapists make a valuable contribution in the pursuit of the goals identified by the intercollaborative health care team. As such, physiotherapists should be recognized as a key member of the primary health care team. This should occur at all levels of program planning and implementation.

2. Physiotherapy should be integrated into the primary care team, either as a

consultant or as first contact with the public, particularly in the area of

Physiotherapy and primary health care: Evolving opportunities iv

musculoskeletal conditions. This already occurs in private clinics but should be expanded to incorporate interdisciplinary primary health care teams in publicly funded community health centres. Additional education could be considered to expand the physiotherapist’s current scope of practice, as has been done in other international jurisdictions.

3. Resources should be allocated to the development and implementation of

physiotherapy services beyond the current tertiary level of care to incorporate primary and secondary level care. These services should be provided in the community, with participation by the community.

4. Any new program strategies should be accompanied by formal and valid

evaluation tools. Data must be gathered that can measure both the short- and long-term impact of primary health care delivery, and physiotherapy specifically. Quantitative and qualitative evidence can be used in the consideration of future expansion of service delivery.

Physiotherapy is part of today’s health care team faced by the multitude of challenges in the delivery of Canada’s public health care system. Physiotherapy can also be part of the solution if given the opportunity.

Physiotherapy and primary health care: Evolving opportunities v

1. Introduction to primary health care Canada’s publicly funded health care system began with the financing of hospital care and subsequently, physicians’ services. Today, almost 40 years later, the universal health care system as we have grown to depend on it, is facing mounting challenges. All levels of government, federal, provincial and municipal, recognize that action is needed to remain responsive to Canadian consumers and to curb escalating costs. As of 2001, about 9.3% of our economic output (as measured by Gross Domestic Product [GDP]) was spent on health care, compared to 7.3% in 1981 (Canadian Institute for Health Information [CIHI], 2003, p. ix). Three G8 countries spent more in 2000 – the United States (13.0% of GDP), Germany (10.6%), and France (9.5%). From 1997 to 2002, Canada spent an additional 43% on its health care, an increase of almost $34 billion (Ibid.). Primary health careG, 3 reform is felt to be essential to the transformation necessary to maintain the viability of the Canadian health care system (CIHI, 2003, p. vii).

Primary health care is about fundamental change across the entire health care system. It is about transforming the way the health care system works today – taking away the almost overwhelming focus on hospitals and medical treatments, breaking down the barriers that too frequently exist between health care providers, and putting the focus on consistent efforts to prevent illness and injury, and improve health.

Romanow, 2002, p. 116

Emphasizing health promotionG and disease prevention has the potential to help individuals and communities live healthier and put less strain on the health care system (National Primary Health Care Conference Steering Committee, 2004). Primary health care is about shifting the focus “upstream” or earlier in the health care continuum, before individuals get sick or injured and seek urgent medical intervention. Services are not limited to a physician’s office, but can occur in an assortment of settings, such as health clinics, schools, and community health centres. A wide variety of health care professionals provide services at this level, including physicians, nurses, dentists, pharmacists, social workers, occupational therapists, and physiotherapistsG. Care at this level not only includes the diagnosis and treatment of the problem, but can also incorporate rehabilitationG, support maintenance, health promotion and disease prevention, as well as social integration. Services can include fall prevention programs, well-baby clinics, telephone help-lines, immunization programs, or school screening programs (CIHI, 2003). Physiotherapists are actively engaged at all levels of care: acute and rehabilitative care, as well as health promotion (Higgs, Refshauge, & Ellis, 2001). The National Physiotherapy Advisory Group has stated that a competency requirement for all future Canadian physiotherapists will be the ability to play a key role in primary health care (Beggs, 2004,

3 A Glossary is included in Appendix E of this document; the first time each word in the Glossary appears in the document, it will be indicated with “G”.

Physiotherapy and primary health care: Evolving opportunities 1

p. 6). Given the focus of current health care reform across Canada, the Manitoba Branch of the Canadian Physiotherapy Association, the College of Physiotherapists of Manitoba, and the Department of Physical Therapy, School of Medical Rehabilitation, University of Manitoba embarked on the development of this document. The goals of this paper are twofold:

1. to help physiotherapists in Manitoba understand the current context of primary health care reform

2. to facilitate a better understanding of how physiotherapists can play an

integral role in the primary health care teamG. Three methods were utilized to gather the information for the development of this paper. Firstly, an extensive literature review provided the background and evidence of the role for physiotherapy in primary health care. Secondly, a focus group was held with physiotherapists working in a wide variety of clinical and educational settings to explore the current and potential role of physiotherapy in primary health care. Thirdly, a survey was conducted of key physiotherapists working primarily in a rural setting in Manitoba. It was felt that they would be in a position to provide a perspective unique from their urban counterparts. Meetings were held with the Primary Health Care Unit of Manitoba Health (November, 2004), as well as the members of the College of Physiotherapists of Manitoba at their Annual General Meeting (April 6, 2005) to share the initial concept of such a document. 1.1 Background In the background paper for the National Physiotherapy Advisory Group vision project for the current and future competency requirements for physiotherapists, it is stated that “Physiotherapy is a first contact, autonomous, client-focused health profession and as such, physiotherapists are primary health care providers.” (Beggs, 2004) If physiotherapists are to play a key role in primary health care reform, then individual therapists need to gain a thorough understanding of the term primary health care and all that it encompasses. The term is often interchanged with primary careG and a clear delineation will help foster future discussion. The term primary care includes the diagnosis, treatment and management of health problems with services delivered predominantly by physicians. Primary care is the point of first contact with the heath care system. Alternatively, primary health care “incorporates primary care, but also recognizes and addresses the broader determinants of health including population health, sickness prevention, and health promotion with services provided by physicians and other providers often in group practice and multi-disciplinary teams.” (Health Canada, 2000)


The first International Conference on Primary Health Care held in Alma-Ata, USSR, in 1978 resulted in an international call for action on the development and implementation of primary health care. The World Health Organization member states recognized the need for broad health care services which could address the main health problems of a community, providing promotive, preventive, curative and rehabilitative services: Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain. It forms an integral part of the country’s health system. It is the first level of contact of individuals, the family, and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

WHO, 1978, Para VI.

The three pillars of primary health care have been described as equity, intersectoral collaborationG and community participation (MacDonald as cited in Hannay, Sunners & Platts, 1997). While most Canadians enjoy equitable access to primary health care services, those living in rural and remote parts of Canada may not. Intersectoral collaboration may exist in certain programs or services, such as rehabilitation programs provided in schools, but this is not universal across all jurisdictions. Community participation in primary health care is certainly encouraged, but has often been limited in the past to volunteer opportunities that have had little lasting impact on the planning of future service delivery. The role of community health councils continues to evolve but certainly has the potential to make community involvement meaningful. Despite differing interpretations of primary health care, six objectives have been cited for primary health care (Lamarche, Beaulieu, Pineault, Contandriopoulos, Dens & Haggerty, 2003). These include:

1. effectiveness: the ability to maintain or improve health. 2. productivity: the relationship between the services produced and the

resources used to produce them. 3. accessibility: promptness and ability to visit a primary healthcare

physician, and ease of accessing specialized and diagnostic services. 4. continuity: the extent to which services are offered as a coherent

succession of events in keeping with the health needs and personal context of patients.

5. quality: perception and degree of conformity with recognized professional standards.

6. responsiveness: consideration and observance of the expectations and preferences of service users and/or providers.


The transition from primary medical care to pimary health care can be illustrated by the following chart. Primary Medical Care Primary Health Care Illness Focus Health Cure Prevention, care, cure Treatment Content Health promotion Episodic care Continuous care Specific problems Comprehensive care Physicians in sole practice Organization Health professional teams Health sector alone Responsibility Intersectoral collaboration Professional dominance Community participation Passive reception Joint responsibility

Starfield, as cited in CIHI, 2003, p. 21

The U.S. Pew Health Professions Commission’s report Recreating Health Professional Practice for a New Century, made a set of recommendations affecting the scope and education of all health professional groups in the U.S.A. (O’Neil & the Pew Health Professions Commission, 1998). The report provided a list of 21 competencies which the authors felt were required for effective health care service delivery in the 21st century. Among the 21 competencies listed, are the following, which have been identified as being integral to the profession of physiotherapy (Beggs, 2004):

embrace a personal ethic of social responsibility and service incorporate the multi-determinants of health in clinical care understand the role of primary care rigorously practise preventive health care integrate population-based care & services into practice partner with communities in health care decisions work in interdisciplinaryG teams ensure care that balances individual, professional, system & societal

needs.


The essential competencies identified for physiotherapists in Canada by the Accreditation Council for Canadian Physiotherapy Academic Programs, the Canadian Alliance of Physiotherapy Regulators, the Canadian Physiotherapy Association, and the Canadian Universities Physical Therapy Academic Council (2004, p. 10) have been divided into seven dimensions. Essential competencies are defined as “the repertoire of measurable knowledge, skills, and attitudes required by a physiotherapist throughout his or her professional career (Ibid., p. 1).

Dimension one: Professional accountability Assumes professional responsibility and demonstrates safe, ethical, culturally sensitive and autonomous professional practice. Dimension two: Communication and collaboration Communicates with clients ands professionals in other disciplines to collaborate and coordinate services. Dimension three: Professional judgment and reasoning Applies principles of critical thinking, while solving problems and making decisions. Dimension four: Client assessment Assesses client’s physical and psychosocial status, functional abilities, needs and goals. Dimension five: Physiotherapy diagnosis/clinical impression and intervention planning Analyzes data collected, establishes the physiotherapy diagnosis/clinical impression and prognosis, and develops a client-centred physiotherapy intervention strategy. Dimension six: Implementation and evaluation of physiotherapy intervention Implements physiotherapy interventions to meet client/patient needs, evaluates their effectiveness for the client and incorporates findings into future intervention. Dimension seven: Practice management Manages the physiotherapist’s role and implements physiotherapy services within the diverse contexts of practice.

1.2 Population health and the broader determinants of health Much of the literature on primary health care discusses the need for population-based care and/or an acknowledgement of population health. A population health approach tries to explore and thereby understand why some groups of people are healthy and others not.


Population health is an approach to health that aims to improve the health of the entire population and to reduce health inequities among population groups. In order to reach these objectives, it looks at and acts upon the broad range of factors and conditions that have a strong influence on our health.

Health Canada, 2002a

It is well recognized that the health and well being of individuals, as well as groups of individuals, are influenced by many factors, none of which exist in isolation. These factors are referred to as the broad determinants of health. It is their combined impact that determines health status. For example, unemployment can lead to social isolation and poverty, which in turn influences one's psychological health and coping skills. Together, these factors can then lead to poor health (Health Canada, 2002a).

Following is the list and description of 12 different key determinants which Health Canada acknowledges as contributing to one’s health status.

1. Income and Social Status

There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be the most important determinants of health.

2. Social Support Networks

Support from families, friends and communities is associated with better health. Such social support networks could be very important in helping people solve problems and deal with adversity, as well as in maintaining a sense of mastery and control over life circumstances. The caring and respect that occurs in social relationships, and the resulting sense of satisfaction and well-being, seem to act as a buffer against health problems. Some experts in the field have concluded that the health effect of social relationships may be as important as established risk factors such as smoking, physical activity, obesity and high blood pressure.

3. Education and Literacy

Health status improves with level of education. Education is closely tied to socioeconomic status, and effective education for children and lifelong learning for adults are key contributors to health and prosperity for individuals, and for the country. Education contributes to health and prosperity by equipping people with knowledge and skills for problem solving, and helps provide a sense of control and mastery over life circumstances. It increases opportunities for job and income security, and job satisfaction. It also improves people's ability to access and understand information to help keep them healthy. Canadians with low literacy skills are more likely to be unemployed and poor, to suffer poorer health and to die


earlier than Canadians with high levels of literacy. People with higher levels of education have better access to healthy physical environments and are better able to prepare their children for school than people with low levels of education. They also tend to smoke less, to be more physically active and to have access to healthier foods.

4. Employment/Working Conditions

Unemployment, underemployment, stressful or unsafe work are associated with poorer health. People who have more control over their work circumstances and fewer stress related demands of the job are healthier and often live longer than those in more stressful or riskier work and activities. Employment has a significant effect on a person's physical, mental and social health. Paid work provides not only money, but also a sense of identity and purpose, social contacts and opportunities for personal growth. When a person loses these benefits, the results can be devastating to both the health of the individual and his or her family. Unemployed people have a reduced life expectancy and suffer significantly more health problems than people who have a job.

5. Social Environments

The importance of social support also extends to the broader community. Civic vitality refers to the strength of social networks within a community, region, province or country. It is reflected in the institutions, organizations and informal giving practices that people create to share resources and build attachments with others. The array of values and norms of a society influence in varying ways the health and well being of individuals and populations. In addition, social stability, recognition of diversity, safety, good working relationships, and cohesive communities provide a supportive society that reduces or avoids many potential risks to good health.

6. Physical Environments

At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments. In the built environment, factors related to housing, indoor air quality, and the design of communities and transportation systems can significantly influence our physical and psychological well-being.

7. Personal Health Practices and Coping Skills

These skills refer to those actions by which individuals can prevent diseases and promote self-care, cope with challenges, and develop self-reliance, solve problems and make choices that enhance health. Definitions of lifestyle


http://www.phac-aspc.gc.ca/ph-sp/phdd/docs/healthy/index.html

include not only individual choices, but also the influence of social, economic, and environmental factors on the decisions people make about their health.

8. Healthy Child Development

New evidence on the effects of early experiences on brain development, school readiness and health in later life has sparked a growing consensus about early child development as a powerful determinant of health in its own right. At the same time, we have been learning more about how all of the other determinants of health affect the physical, social, mental, emotional and spiritual development of children and youth. For example, a young person's development is greatly affected by his or her housing and neighbourhood, family income and level of parents' education, access to nutritious foods and physical recreation, genetic makeup and access to dental and medical care.

9. Biology and Genetic Endowment

The basic biology and organic make-up of the human body are a fundamental determinant of health. Genetic endowment provides an inherited predisposition to a wide range of individual responses that affect health status. Although socio-economic and environmental factors are important determinants of overall health, in some circumstances genetic endowment appears to predispose certain individuals to particular diseases or health problems.

10. Health Services

Health services, particularly those designed to maintain and promote health, to prevent disease, and to restore health and function contribute to population health. The health services continuum of care includes treatment and secondary preventionG.

11. Gender

Gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. "Gendered" norms influence the health system's practices and priorities. Many health issues are a function of gender-based social status or roles.

12. Culture

Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as


marginalization, stigmatization, loss or devaluation of language and culture and lack of access to culturally appropriate health care and services.

Health Canada, 2002b

The Canadian Physiotherapy Association (CPA) supports public policy that recognizes and considers the determinants of health. Public policy can influence how financial, material and other resources flow through society and therefore can affect the determinants of health. Advocating for healthy public policies is one of the most important strategies society can use to impact on the determinants of health. CPA believes that the education of individuals, health professionals, governments and policy makers on the determinants of health is a fundamental requirement for responsible decision-making that is conducive to promoting health. The health sector cannot impose its agenda on other sectors, however, it can initiate dialogue and collaborate in collective efforts to improve the well-being of all Canadians. This will become more important as we increase our understanding of the determinants of health. As health care professionals, physiotherapists should understand the effect of the determinants of health on their client's outcomes, as well as how physiotherapists can affect the determinants of health in their daily professional practice. Physiotherapists must be sensitive to their clients, and adapt their treatment approach to the range of life experiences each client brings to the therapeutic relationship, including employment, family environment, education, and physical and mental health. Physiotherapists, as primary health care providers, practice within their own professional competency and refer clients to other professionals as appropriate. CPA supports ongoing interprofessional research and education on the factors that determine health. Health research must take into account variables such as income and social status, education, gender, race, culture, sexual orientation, age, disabilities, etc, and their effect on therapeutic outcomes.

Position Statement on the Determinants of Health, CPA, 2001

Steven Lewis, in his synthesis on the Proceedings of the National Primary Health Care Conference in Winnipeg (2004), has written that it is not clear how far Canadians are willing to go in pursuing primary health care reform in its broadest terms. Primary health care reform in Canada seems to have become synonymous with reform of “primary care”. Canada may not be alone in this position. In most prosperous countries, people are preoccupied with primary care; their “determinants of health” are not so problematic. The World Health Organization (2003) acknowledges that in high-and middle-income countries, primary health care is mainly understood to be the first level of care. Alternatively, where there are still significant challenges in access to health care, such as in developing countries, primary health care is seen as a system-wide strategy.


To put it starkly, those near the bottom of the socio-economic spectrum in Canada stand to benefit greatly from primary health care, while most others’ needs can be largely met by high quality primary care. And those at the bottom are precisely those whose voices struggle to be heard in debates about how programs should be organized and resources allocated. Hence the real question is the extent to which public policy should focus exclusively or mainly on primary care, or expand to include primary health care.

Lewis, 2004

1.3 Health promotion Health promotion and disease prevention are two key components which characterize primary health care. Health promotion has been defined as the “science and art of helping people change their lifestyle to move toward a state of optimal health” (O’Donnell, 1989, p. 5). The foundation of health promotion is grounded in the World Health Organization’s first international conference on health promotion in Ottawa in 1986. That conference resulted in the publication of the Ottawa Charter for Health Promotion, which defines health promotion as

the process of enabling people to increase control over, and to improve their health. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to wellbeing.

WHO, 1986

The Ottawa Charter outlines five strategies to achieve success in health promotion. 1. build healthy public policy 2. create supportive environments 3. strengthen community action 4. develop personal skills 5. re-orient health services.

In the Jakarta Declaration on Health Promotion into the 21st Century (WHO, 1997) resulting from the fourth international conference on health promotion, increased cooperation between the various sectors was deemed essential for the success of such activities. Priorities identified for health promotion in the 21st century include the following.

1. promotion of social responsibility for health 2. increased investments for health development 3. consolidation and expansion of partnerships for health 4. increased community capacity and empowerment of the individual 5. a secure infrastructure for health promotion.

Health promotion and disease prevention together include all those purposeful activities meant to improve both personal, as well as public health. These activities may include health education, health protection measures, detection of risk factors, enhancement of


healthy living and maintenance of health, both on an individual level as well as the community as a whole (McCloy, 2001).

Health promotion is contiguous with disease prevention. McCloy (2001, p. 314) has described the three different levels of prevention as follows: Primary Prevention - Preventive measures that forestall the onset of illness or injury during the prepathogenesis period. Practice focuses on the identification of potential risk factors for disease or disability in healthy individuals & targets factors that are amenable to change. Examples include wearing seatbelts, diabetes public education programs, back schools, & the identification of workplace risk factors. Secondary Prevention - Measures aimed toward the early detection of underlying disease when overt clinical symptoms are not yet apparent. Early detection allows for prompt treatment. Examples include mammograms, prostate examinations, physiotherapy assessment of joint flexibility & alignment. Tertiary Prevention - Treatment is implemented after the disease becomes symptomatic. Focus is on the restoration or maintenance of maximal function & the prevention of further disease or disability. Examples include surgery to treat lung cancer, rehabilitation after a stroke, & cardiac rehabilitation post-myocardial infarction.

1.4 Primary health care reform In a national survey of RHAs conducted in 2004, almost half of the regional health authorities (RHAs) across Canada reported that they were undergoing primary health care renewal (Kouri & Winquist, 2004). Problems that were identified with the current system and which are to be resolved by reform include access, fragmented services and the predominance of the medical model. The most frequently reported initiative in primary health care reform was the development and/or enhancement of multidisciplinaryG teams. The major impediment to change was professional resistance, or “turf protection.” Primary health care is meant to shift the focus away from a purely biomedical model to one of prevention and increased consideration of the non-medical determinants of health. However, most surveys reported that their primary health care teams were physician-centered and focused more on the curative/rehabilitative aspects of illness. While it is true that the composition of primary health care teams needs to reflect local needs, it will be important to monitor this in the process ahead (Kouri & Winquist, 2004). In her review of primary health care reform across Canada, Fooks (2004) cites five common elements in Canadian provincial policy documents that advance reform.


1. a team approach to service delivery - This usually revolves around the physician and/or nurse practitioner.

2. rostering of patients - This entails registering patients or clients with a specific group practice or team of providers.

3. 24-hour access, 7 days a week - Usually this equates to after hour access to a nurse by telephone.

4. mixed funding formulas for service and programs - Proposed funding models include capitation (where remuneration is based on the number of persons cared for in a particular region or area) , salary and/or combinations with fee-for-service payments. Fee-for-service payments account for 89% of total clinical earnings across Canada.

5. increased emphasis on health promotion and prevention - This is emphasized in all available provincial policy materials.

Fooks cites several facilitators and barriers to primary health care reform in Canada. Barriers include the fee-for-service payment structure which is based on single services delivered by one professional at a time. The author states that this funding model does not facilitate holistic services delivered by a team of health professionals. Nor does it necessarily compensate for time spent doing administrative, educational or communication activities. Existing funding arrangements where programs may be co-funded from different departments or ministries, such as Health, Education, or Social Services, ties the funding to providers rather than the clients. She feels that this cannot support integration and a team approach. Fooks also cites distinct professional regulations as a threat to an integrated approach, as well as professional liability schemes which do not favour shared accountability. The lack of a health human resources plan integrated with local primary care delivery is an additional challenge to reform across the country. Another barrier is the propensity to use pilot or demonstration projects in Canada. This leaves such projects vulnerable to policy reversal. Sicotte, D’Amour and Moreault (2002) also acknowledge professional autonomy and jurisdiction as one of the major barriers to interdisciplinary collaboration. Rather than working together towards shared goals, making collective decisions and sharing responsibility and tasks, professionals still tend to work in a traditional model of disciplinary parallelism. The authors investigated the extent of interdisciplinary collaboration in Quebec community health centres, which have been in existence for more than 25 years. They found only moderate success at collaborative practice, despite the longevity of this objective. Internal dynamics of the work group seem to have played the most significant role in hindering its success.


Rehabilitation team work is essential for effective comprehensive care. Team work can take on one of three different forms. In all forms, the rehabilitation professionals work towards a common goal. Multidisciplinary teamwork – members carry out their assessments and treatments of the client individually and communicate the outcome of their intervention and recommendations to the other team members. Interdisciplinary teamwork –members formulate and plan solutions to the client’s needs as a team; treatment goals are set and reviewed jointly. This approach is regarded as the preferred model of team activity. Transdisciplinary teamwork – this is particularly important in community rehabilitation. This is an approach in which one discipline is able to take over the tasks of another when the latter is not available.

Eldar, 2000, p. 271

Facilitators to primary health care reform across Canada also do exist. These comprise the openness of Canadians to new models of care and service delivery, including a non-physician as point of first contact; a strong interest in health promotion and prevention activities; and a choice of delivery models which health providers can accommodate to their own local setting (Fooks, 2004).


2. Models of primary health care Despite the call for interdisciplinary collaboration as early as the mid-1970s, physician- lead primary health care teams are still the norm in most industrialized countries (Sicotte, D’Amour & Moreault, 2002). Over the years, nurses and social workers have joined the teams, and more recently, dietitians, physiotherapists, occupational therapists, and psychologists. Interdisciplinary collaboration is typified by the primary health care team. The World Health Organization has defined the primary health care team as

a group of persons who share a common health goal and common objectives determined by community needs, to which the achievement of each member of the team contributes, in a coordinated manner, in accordance with his/her competence and skills and respecting the functions of others.

WHO, 1985 as cited in Sicotte et al 2002, p. 992 Hannay, Sunners and Platts (1997) assessed patients’ perceptions of primary health care in a primary health care centre located in a low-income inner city practice in the United Kingdom. They surveyed 248 patients, and conducted 74 home interviews for those who had requested house calls. Results indicated that patients were more satisfied with primary care than with other aspects of primary health care, such as housing. Physiotherapy, chiropody and pharmacy were the services most requested at the health centre. Lamarche et al (2003) have described four different types of primary health care models that are relevant to the Canadian context. The integrated and non-integrated community models differ in the degree of their integration with the broader health care system. They are both based on a geographically defined population, as well as supporting community development. Its focus is to meet the healthcare needs of a population and to provide it with all the medical, health, social, and community services necessary. This approach is characterized by public representatives in the governance structure; multi-disciplinary healthcare teams; and a sessional payment structure. The integrated community model tends to use information technology to promote communication between providers; takes responsibility for longitudinal continuity of care; offers services 24 hours a day, seven days a week; and works collaboratively to ensure a wide range of services are available to their clients. The non-integrated community model also offers the public a wide range of services, but does so directly without any established partners in the other aspects of the health care system, without any integrated information technology, ensured continuity of care, or 24/7 service availability. Finland and Sweden both use community models: Finland the integrated model and Sweden the non-integrated model. The two models which follow a professional approach to primary health care are characterized by the delivery of medical services to patients seeking these services. In the coordinated professional model, the focus is on the provision of continuous service to patients. Most often, there is a healthcare team made up of a physician and a nurse. The nurse is often the liaison with other components of the system and co-ordinates clinical integration of services. This approach is used in Denmark, the Netherlands, the UK, and the HMO staff model of the U.S.A. In the professional contact model, the purpose is to


ensure accessibility of primary health care. This is the dominant form of primary health care in Canada, where primarily physicians working alone serve as the patient’s gateway to the healthcare system. This model is also followed in Belgium and the open model of the U.S.A.

Highlights of the Recommendations • The integrated community model should be used as a benchmark for

primary health care reform in Canada. Shortcomings in accessibility and responsiveness must be addressed in this model.

• Where a professional approach to primary health care is used, the professional co-ordination model should be followed.

• Funding of primary health care should be allowed on a per capita formula and should include specialized medical and hospital services, drugs, diagnostic and rehabilitative services, homecare and palliative services.

• A strong focus should be placed on multidisciplinary work. • Priority should be placed on integrated information systems.

Lamarche et al, 2003

2.1 Community physiotherapy Community physiotherapy in the continuum of health care is well established. Wade (2003, p. 875) defines community as

the physical and social environment of the patient in the place that she or he lives. It is usually set in contrast to a hospital, or other institutional setting where the patient may go or reside for short periods while receiving a service.

Twible and Henley (2000, p. 119) write that the process of therapy in the community should be based on a problem-solving approach that is functional in orientation and is driven by the environment, cultural, social, and other contextual factors. Because of the nature of the disabilities encountered in the community, the emphasis in therapy is on management of the disability rather than on ‘treatment or cure’.

Enderby and Wade (2001) investigated the extent and nature of community rehabilitation services in the United Kingdom. The authors identified six benefits of community rehabilitation. They include easy access by patients to services; more effective rehabilitation with more appropriate goals; inclusion of care providers, thereby reducing caregiver stress; greater patient satisfaction; and the development of local links with community agencies. Five distinct disadvantages were also acknowledged. These were physical limitations to the home environment; travel time for staff; professional isolation; concerns about team member safety; and caregiver stress with early hospital discharge. Community services there were characterized by small, often short-term teams with poor identity. The term “community rehabilitation” had no clear or consistent meaning;


however, in terms of this study, it most frequently referred to rehabilitation provided in the home setting. Litchfield and MacDougall (2002) cite a further challenge to physiotherapists working in a community-based family-centered setting. In their qualitative study of 10 physiotherapists working in such a setting in Australia, physiotherapists reported struggling with the balance between the need for evidence-based practiceG and the desires of the client’s family, for which there may or may not be evidence of effectiveness. The authors suggest that this dilemma can be addressed by an approach which acknowledges the need of client input in patient-centred care, a perspective essential for successful physiotherapy intervention. Finn and MacAirt (1994) compared the physiotherapy services provided in private practice with that provided in community health centres employed by health boards. The results of their study indicated that the majority of the clients seen in private practice were young or middle-aged and represented a mobile population. The conditions seen were mainly acute in nature, for example sports-related, low back pain and whiplash injuries. The publicly funded community physiotherapist on the other hand, saw mainly the very young (0-15 years old) and elderly clients. Conditions were mostly long-term, including strokes, and cerebral palsy. The community therapist saw roughly half of the clients in their own homes, while the private practitioners saw 93% of their clients in their clinics. Human resource planning for community-based rehabilitation services must consider these potential differences between publicly-funded and privately-funded service models. Despite all physiotherapists being licensed as “generalists” in Manitoba, private practitioners in the community often focus their practices on their own particular areas of clinical interest, for example, urinary incontinence, ballet injuries, or sports-related injuries. Publicly-funded community therapists are not generally in a position to dictate what type of client they will focus their marketing strategies on. Derick Wade (2003) states that physiotherapists working in the community should not be considered “generalists” but rather be acknowledged as having valuable expertise in community therapy. Community-based physiotherapists have the skills to develop the appropriate community partnerships and linkages to best serve their clients. There is strong evidence supporting the role of secondary prevention of further disablement for those persons with arthritis, coronary heart disease, chronic lung disease, diabetes, osteoporosis, frequent falls, chronic low back pain and incontinence in symptomatic women (Restall, Leclair & Fricke, 2005). Other areas of service in the community are also supported by the literature but either to a lesser extent or the evidence is inconclusive. Worsfold, Langridge, Spalding and Mullee (1996) compared community-based physiotherapy with that provided in the hospital. A total of 238 persons were randomly allocated to one of two groups, with a high proportion of patients complaining of spinal pain. The community therapy group consisted of education and a home-based exercise program, while hospital-based intervention included education, a home program, as well as individual treatment. The community-based physiotherapy group exhibited a slightly better outcome than the hospital-based group, despite lower


attendance rates. Whether the intervention or the setting had a greater impact is not clear, but community-based therapy is effective in improving patient status. The current scope of practice outlined in section 2(1) of The Physiotherapists Act of Manitoba (Province of Manitoba, 2001) states that

The practice of physiotherapy is the assessment and treatment of the body by physical or mechanical means for the purpose of restoring, maintaining or promoting physical function, mobility or health, or to relieve pain.

This broad range of physiotherapy practice empowers therapists to be fully engaged at the primary health care level. Two levels of participation can be used to consider existing models of physiotherapy in primary health care. They are not mutually exclusive and in fact, they most frequently coincide. The role of physiotherapy at the primary care level, which has traditionally been based on the biomedical model, is well supported by the literature. The role of physiotherapy in health promotion and prevention in the broader context of primary health care has been established, but supporting evidence specific to physiotherapy warrants expansion.


Canadian Physiotherapy Association Rules of Conduct

Premise: The provision of effective quality care, while respecting the rights of the client, shall be the primary consideration of each member of the profession.

Responsibilities to the Client

1. Physiotherapists shall respect the client's rights, dignity, needs, wishes and values. 2. Physiotherapists may not refuse care to any client on grounds of race, religion, ethnic or

national origin, age, sex, sexual orientation, social or health status. 3. Physiotherapists must respect the client's or surrogate's right to be informed about the

effects of treatment and inherent risks. 4. Physiotherapists must give clients or surrogates the opportunity to consent to or decline

treatment or alterations in the treatment regime. 5. Physiotherapists shall confine themselves to clinical diagnosis and management in those

aspects of physiotherapy in which they have been educated and which are recognized by the profession. (Physiotherapists are responsible for recognizing and practising within their levels of competence. The clinical diagnosis is established by taking a history and conducting a physical and functional examination. The identification of the client's problems and the physiotherapeutic management is based on this diagnosis in conjunction with an understanding of pertinent biopsychosocial factors. This rule does not restrict the expansion of the scope of physiotherapy practice.)

6. Physiotherapists shall assume full responsibility for all care they provide. 7. Physiotherapists shall not treat clients when the medical diagnosis or clinical condition

indicates that the commencement or continuation of physiotherapy is not warranted or is contraindicated.

8. Physiotherapists shall request consultation with, or refer clients to, colleagues or members of other health professions when, in the opinion of the physiotherapist, such action is in the best interest of the client.

9. Physiotherapists shall document the client's history and relevant subjective information, the physiotherapist's objective findings, clinical diagnosis, treatment plan and procedures, explanation to the client, progress notes and discharge summary.

10. Physiotherapists shall respect all client information as confidential. Such information shall not be communicated to any person without the consent of the client or surrogate except when required by law.

11. Physiotherapists, with the client's or surrogate's consent, may delegate specific aspects of the care of that client to a person deemed by the physiotherapist to be competent to carry out the care safely and effectively.

12. Physiotherapists are responsible for all duties they delegate to personnel under their supervision.

CPA, 2001-2005a

2.2 Primary care models and physiotherapy Physiotherapists currently play an active role in primary care. Boissonnault (2005) distinguishes the typical patient population in primary care clinics from those in a typical hospital out-patient setting. The course of treatment is generally shorter, and the physiotherapy addresses primary sources of symptoms as opposed to various contributing


factors. The scope of intervention can be similar, but the patient population in primary care clinics is generally less willing or able to return for as much follow-up care. Initial goals of treatment are therefore rapid resolution of symptoms and degree of disability to a level that the patient can self-manage and minimize recurrence. The public enjoys direct access to physiotherapy services across Canada for a wide variety of services, including neuromuscular and cardiopulmonary rehabilitation, workplace consultation, as well as home therapy. In some jurisdictions, however, this role has expanded further, challenging current scopes of practice. Particularly in the area of musculoskeletal evaluation, physiotherapy has developed an expertise not shared by other general practitioners (Connolly, DeHaven & Mooney, 1998; Roberts, Adebajo & Long, 2002). This expertise in musculoskeletal assessment and treatment has lead to an expanded role for physiotherapists in many international jurisdictions. Physiotherapists have been found to provide care more quickly than the conventional route, and may reduce hospital costs (Dininny, 1995).

Physical therapy, also known as physiotherapy, is a health care profession dedicated to rehabilitation, prevention and education. In performing these roles, physiotherapists take the holistic approach to the individual. Physical agents and specialized techniques are used to help the individual attain maximum functional independence with minimum complications. Education of patients, families and the public plays an important role in both the rehabilitation and prevention aspects of physiotherapy.

University of Manitoba, School of Medical Rehabilitation

American military model Physiotherapists working in the American military have taken on an expanded role since the Vietnam War from 1962 to 1973. Their expanded role was initiated in support of the Orthopedic surgeons assigned to the Army hospitals in Vietnam, who could not keep up with the non-surgical demands of their practice. The physiotherapists’ expanded function included the timely evaluation and treatment of patients with non-surgical neuromuscular conditions, under the supervision of a physician, but without referral. The resulting outcomes included shorter wait times and a more rapid return to duty (Boissonnault, 2005). This model continues today. Army physiotherapists now receive appropriate training to order diagnostic imaging tests and prescribing non-steroidal anti-inflammatory medications. Army physiotherapists are not expected to diagnose nonmusculoskeletal pathologic conditions, but are expected to make appropriate referrals on to those who can make the appropriate diagnosis. Outcomes of this model have been reported as early as 1975 by James and Stuart, who found that not only was physiotherapy a feasible alternative for care of low back pain for patients, their physicians and their physiotherapists, but it also resulted in faster service and a reduction in radiographic examination by 50%. Orthopaedic surgeons fully supported this model in an adult population, but did not support physiotherapy screening


in the areas of pediatrics, geriatrics and trauma (James & Stuart, 1975). The advantages of this model have been reported as (1) prompt evaluation and treatment for patients with neuromuscular conditions (2) promotion of quality health care (3) decrease in sick call visits (4) more appropriate use of physician services, and (5) more appropriate use of physiotherapist education, training and experience (Boissonnault, 2005). Physiotherapy consultant model (United Kingdom and the Netherlands) Physiotherapists have been more recently utilized as consultants and triage specialists in the area of musculoskeletal conditions in both the United Kingdom, as well as the Netherlands. Hattam and Smeatham (1999) found the majority of patients on an English orthopaedic waiting list (72.4% of 76 persons), could be effectively managed by a physiotherapist with extensive experience in musculoskeletal disorders and additional training in the use of corticosteroid injections. Four individuals (5.3%) needed to re-consult with their family doctor with the same problem within one year. Daker-White, Carr, Harvey, Woolhead, Bannister, & Nelson, et al (1999) found similar results in another study in the United Kingdom, concluding that orthopedic physiotherapists were as effective as post-fellowship junior orthopaedic staff in the initial assessment and management of new referrals. Additionally, they generated lower indirect hospital costs. Jibuike, Paul-Taylor, Maulvi, Richmond & Fairclough (2003) found similar positive results in a study of physiotherapists assessing soft tissue knee injuries in an English accident and emergency department. In yet another study of physiotherapists working in general practitioners’ offices, on-site physiotherapy services resulted in 8% fewer referrals to Orthopaedics and 17% fewer referrals to Rheumatology over a one-year period (O’Cathain, Frogett, & Taylor, 1995). Hendriks, Kerssens, Nelson, Oostendorp, and van der Zee (2003) explored the use of physiotherapy consultation services by a group of primary care physicians in the Netherlands. The physicians were satisfied with the physiotherapy consultation and changed their management in almost 50% of the cases that they referred. An increase in referrals to physiotherapy was noted with a simultaneous 50% reduction in referrals to medical specialists (Hendriks, Kerssens, Heerkens, Elvers, Dekker, & van der Zee, 2003). This reaffirmed the author’s finding in a previous study, where general practitioners referred only 14% of an intended 28 to a medical specialty, following a physiotherapy consultation (Hendriks, Brandsma, Wagner, Oostendorp, & Dekker, 1996). Private industry model Physiotherapy in private industry has been shown to reduce the number of workdays lost by as much as 60% (Monahan, 1994). Additionally, workers’ compensation claims and overall medical costs have been lowered. This practice model incorporates traditional physiotherapy practices, but also integrates additional responsibilities. A physiotherapist hired by a private industry may or may not work along side a physician, but is generally a member of a broader primary care team. Professional responsibilities may include evaluation of employee neuromuscular conditions, work-related soft tissue injuries, ergonomic evaluation of the worksite, as well as injury prevention strategies.


Kaiser Permanente, the largest non-profit HMO in the United States, was founded in 1945 and operates in five states and serves almost 9 million Americans (Boissonnault, 2005). It is based on a pre-payment system, and was initially designed for workers and their families of the Kaiser-managed shipyards and steel mills in 1942. They recently re-designed their adult primary care clinics, with an interdisciplinary team approach in mind. After piloting physiotherapy services in several of their clinics, physiotherapists were hired in approximately half of their 100 clinics in northern California in 1997. After initial triage by a trained staff member using referral processes and algorithms, patients can be directly referred to the physiotherapist on staff. The KP model has integrated the services of physiotherapists, clinical health educators, pharmacists, behavioural medicine specialists, in addition to physicians, nurses, and medical assistants (Boissonnault, 2005). 2.3 Primary health care models and physiotherapy To fully engage themselves as primary health care providers, physiotherapists must embrace the role of community therapist. Echsner Gahimer and Morris (1999) advocate for the role of physiotherapy in community health education. They state that “adopting a community health education approach will expand the roles of physical therapists, improve the effectiveness of physical therapy services, and positively influence patient outcomes”. Canadian Aboriginal health model Aboriginal peoples made up 4.4% of the Canadian population in 2001, about 14% in Manitoba alone (Statistics Canada, 2003). Canada’s indigenous peoples consist of three distinctly different groups: First Nations, Métis, and Inuit. Each has further subgroups, with their own language and cultural practices. What these groups do have in common is a unique relationship with the federal government and disproportionately high morbidity and mortality trends (Fricke, 1998). Aboriginal health care is unique from that of the rest of Canada, in terms of the fiduciary responsibility that the federal government has taken on for Aboriginal health care. The organization and delivery of health services to Aboriginal communities differs across Canada, but several elements are shared. Where communities are geographically located close to their non-Aboriginal counterparts, individuals are expected to access provincial programs and services. But where geographical isolation has made that impossible, programs have developed inconsistently with varying degrees of community participation. Many of the challenges faced by individuals residing in these communities are similar to those faced by Canadians in many other rural and isolated communities. This situation is compounded by the role of the federal government in a provincial jurisdiction, that is, health, as well as the overall poor health status of Canada’s Aboriginal peoples. Primary health care services are typically provided by nurses working in an expanded role, augmented by itinerant physicians or through telecommunications support. Physiotherapists are not typical members of this team, but there are examples of itinerant physiotherapists working in this model (Fricke, 1998).


Physiotherapists have been working in northern isolated First Nation communities in Manitoba since the 1970s on an itinerant basis. More recently, the University of Manitoba in partnership with the Department of Health and Social Services of Nunavut, implemented a comprehensive rehabilitation program in the central Arctic in 2000, including physiotherapy services (Fricke, Achtemichuk, Cooper, Martin, Macaulay, & Durcan, 2004). Primary care services in the Kivalliq Region of Nunavut have been incorporated into primary health care programming. Interdisciplinary teamwork, as well as transdisciplinaryG teamwork is part of a daily reality. Where resources are limited, team members take on roles that would otherwise be delegated to other healthcare providers. Primary health care services may include well-baby screening, fall prevention programs, chronic lung disease exercise programs, prenatal fitness programs, and work injury prevention strategies, continuing education opportunities for community members on the role of rehabilitation or to other health care providers on the evaluation of musculoskeletal conditions, in addition to primary care services. Venues for prevention programs may include broad band radio and telephone call-in shows, community television shows, and presentations at the local schools or community hall. Geriatric Program Assessment Team model The Geriatric Program Assessment Team (GPAT) has been in existence since 1999 under the auspices of the Winnipeg Regional Health Authority (personal communication, M. Graceffo, April 20, 2005). The goals of the GPAT are to facilitate older adults to reside in the community longer, at the most functional level possible, while partnering with community caregivers (see Textbox). Geriatric services have typically been characterized by an interdisciplinary approach, and the GPAT has shifted this approach to the community level. There are six such teams across Winnipeg, which in addition to the geriatrician are made up of two to three disciplines each, representing nursing, social work, occupational therapy and physiotherapy. Team members receive an additional 12-week intensive education period in order to expand their scope of practice to meet the needs of this geriatric consultative program. Older adults are evaluated in their own home by one of the team members, whichever discipline seems most appropriate given the initial request for intervention. For instance, a mobility issue would be earmarked for the physiotherapist on the team; an agility issue would be addressed by the occupational therapist and so on. After an initial assessment, the clinician reviews the case with the team and appropriate provisions are made for follow-up, including forwarding the recommendations to the client’s family doctor. Referrals are accepted from family members, acquaintances, caregivers or anyone with a concern for the individual.


Goals of the GPAT

To ensure the “right care, in the right place at the right time.”

Maintain functional ability in their home Partner with community caregivers for management to prevent hospital

admission Facilitate the transfer of appropriate clients to geriatric medicine and

rehabilitation units Assist in-patient teams with the discharge planning of complex, frail

elderly Provide care management/follow-up, short term intervention.

(personal communication, M. Graceffo, GPAT Manager/Clinician, April 20, 2005)

Community pre-school wellness screening Across Manitoba, wellness programs directed at children and youth integrate the knowledge of professionals from such sectors as health, education, justice, and emergency services to offer primary preventionG services for children. Injuries are the primary cause of death and disability for children and youth in Canada (Sick Kids, 2005). Every spring, Safe Kids Canada, a national program affiliated with the Hospital for Sick Children in Toronto and Johnson & Johnson, coordinate a national campaign on children’s safety. Topics include the safe use of car seats and booster seats, helmet use, playground safety, pedestrian and water play, safe toys for children, and burn/scald prevention strategies. Physiotherapists play an active role in these wellness fairs every year, adding their own expertise to this health promotion activity. In the Central Region of Manitoba, a preschool wellness screening day was first initiated in 1997 as a partnership between health and education. This was “to address the need for early identification of children with developmental concerns, and to increase parental awareness of the resources available” (Central Regional Rehabilitation Services, 2000, p.1). These wellness screening days are directed towards pre-school children aged three to five years old and act as a means of screening for children with special needs before they enter Kindergarten. Priority is given to those children not already receiving therapy services. Partners have included physiotherapy, occupational therapy, speech language pathology, optometry, public health, dietetics, audiology, home and school liaison (education), dentistry, library, family resource centres, farm safety, emergency services, the RCMP and community clubs. This intercollaborative initiative has since been moved out of the health care setting and into the community, and has incorporated new partners from the private sector.


Physiothe

The Canadian Physiotherapy Association website provides the public with 20 different informational fact sheets for education, prevention, and/or self-management in a wide variety of conditions. These include:

Children & backpacks Fall prevention in seniors Computer ergonomics Incontinence Juvenile Ideopathic Arthritis Osteoporosis Rheumatoid Arthritis Ankle sprains Plantar fasciitis Back pain Osteoarthritis Repetitive strain injury S.M.A.R.T. running Stroke rehabilitation Whiplash Knee injuries Walking S.M.A.RT. gardening Gardening tips & techniques S.M.A.R.T. golfing

CPA, 2001-2005b

rapy and primary health care: Evolving opportunities 24

3. Potential roles of physiotherapy in primary health care Physiotherapists are movement specialists (Newfoundland Branch of the Canadian Physiotherapy Association, 2005). They have historically worked principally in acute and rehabilitative care in Canada, with primary prevention efforts integrated into their current practice. Primary prevention has typically been addressed at the physical realm (Fruth, Ryan and Gahimer, 1998). This is dictated by a number of factors – resource allocation, practice preference, and limited resources. Despite examples of expanded practice models nationally and internationally, public access to physiotherapy expertise in health promotion and disease prevention has been limited. The scientific literature is abundant with examples of where primary, secondary and tertiary preventionG have been proven effective in a wide variety of conditions.

We’re the experts in movement, in pathokinesiology, in knowing how to get people – especially senior citizens and people with orthopedic or medical problems - to exercise in ways that will benefit them and won’t create other health problems. I really see it as our duty to offer wellness and fitness services to the public. As PTs we are uniquely qualified to create individualized wellness and fitness programs. We can help patients and clients get or stay fit and prevent injuries in ways that no other provider of wellness and fitness services can.

Welsh, as cited in Ries, 2003, p. 44 An examination of the current literature can help inform health care planners, as well as physiotherapists about potential roles that physiotherapy can play in primary health care reform. Evidence-based practice “aims at ensuring that decisions are made on evidence that has been appraised critically and presented in understandable terms rather than research jargon” (Dawes, 2005, p. 4). Despite the encouragement of practitioners to base all clinical decision-making on best practiceG, many individual therapists may find it difficult to do so consistently. There may be a number of reasons why practitioners may not adhere to interventions supported by the evidence. This may be due to a lack of familiarity with electronic databases for example. Dawes also cites a number of other reasons for non-evidence based practice, including a lack of time, an over-abundance of literature, or an inability to apply the knowledge to clinical practice. Restall, Leclair and Fricke (2005) carried out an extensive review of the literature to ascertain specific areas of practice where the evidence supported rehabilitation services at a primary health care level. Strong evidence was found to support physiotherapy at the primary health care level in the areas of arthritis, coronary heart disease, chronic lung disease, incontinence, diabetes, osteoporosis, fall prevention and low back pain. There are also areas in rehabilitation practice where the supporting evidence is weak or not yet available. Limiting physiotherapy to the areas where there is strong evidence only, precludes the expansion of services into promising areas where either the evidence is inconclusive due to limited research in the past, or in which research has yet to be pursued.


In order to explore the areas where physiotherapy could play a role in primary health care, expert input was sought from physiotherapists working in Manitoba. A focus group was held in Winnipeg on November 23, 2004, with a group of 11 physiotherapy clinicians who were identified as either interested in primary health care or currently working in such a model. A complete list of participants can be found in Appendix A. After a brief description of primary health care was provided, facilitated discussion ensued. Hand-written notes, as well as audio-tape recordings of the discussion were made and later transcribed for evaluation. The list of open-ended questions used as a guide for the focus group can be found in Appendix B. To garner the input of rural therapists, as well as key physiotherapists absent from the initial focus group, an electronic questionnaire was sent out to 11 therapists from different regional health authorities in Manitoba, representing both publicly funded and private practice physiotherapy, clinical as well as administrative practice. A copy of the questionnaire can be found in Appendix C, and the accompanying explanatory notes about primary health care are in Appendix D. A response rate of 82% was achieved. Although this sample size is admittedly limited, the responses were able to contribute to a deeper understanding of what some of the rural issues may be. Therapists were asked to name areas of practice in primary health care where they felt that physiotherapy could play a more significant role than it is currently playing. The following areas were identified:

Chronic lung disease Diabetes

Fall prevention Mental health

Navigator role – case management Osteoporosis

Physical inactivity and obesity in children and adults Plagiocephaly in infants

Pre-natal care Primary care

Rheumatoid Arthritis Urinary incontinence

Workplace safety

Physiotherapy is already involved in most of these conditions or areas of practice. But this involvement is generally limited to tertiary prevention, typically only once the individual is referred by their physician. In a collaborative interdisciplinary primary health care model, physiotherapy intervention would occur much earlier in the health continuum. Elaboration of a select number of conditions recognized above can assist in the understanding of how and when physiotherapy can be involved at the primary care level.


Chronic lung disease

More than 750, 000 Canadians have chronic lung disease, or chronic obstructive pulmonary disease, and this number is expected to increase (The Canadian Lung Association, 2004). Chronic Obstructive Pulmonary Disease (COPD) refers to a number of chronic lung disorders that obstruct the airways. The most common form of COPD is a combination of chronic bronchitis and emphysema. Community-based rehabilitation of persons with asthma or chronic lung disease has been shown to improve shortness of breath, endurance, and health-related quality of life (Cambach, Wagenaar, Koelman, van Keimpema, & Kemper, H. C., 1999; Lacasse, Wong, Guyatt, King, Cook, & Goldstein, 1996). Leg training has been shown to improve exercise tolerance, while strength and endurance training improves arm function, and pulmonary rehabilitation improves shortness of breath, health-related quality of life and reduces the number and length of hospitalizations (Ries, Carlin, Carrieri-Kohlman, Casaburi, Celi, & Emery, et al., 1997).

Pulmonary rehabilitation programs have typically involved physiotherapy. Community programs such as Catch your Breath run by the University Of Manitoba in partnership with the Lung Association of Manitoba, target individuals with chronic lung disease living in the community. Increased access for the public to such responsive programming would benefit both individuals with lung disease as well as their families and care providers.

Diabetes While physiotherapy is involved in the rehabilitative phase of care, for instance, after amputation of an affected limb, rarely is an individual referred to physiotherapy for lifestyle modification or a supervised exercise program to prevent or to delay secondary complications of diabetes. In Dagogo-Jack’s 10 strategies for the prevention or education of diabetes-related morbidity and mortality at a primary care level, he concludes that effective diabetes management entails a multi-modality approach that uses lifestyle and pharmacological interventions (2002). Exercise has been shown to improve glycemic control, reduce cardiovascular risk factors and improve psychological wellbeing in persons with diabetes (Betts, Betts, & Betts, 1995). More recently, it has been stated that exercise has been shown to reduce glycosylated hemoglobin (HbA1c) by an amount that would be expected to significantly reduce the risk of diabetic complications (Boulé, Haddad, Kenny, Wells, & Sigal, 2001). Physiotherapists are ideally suited to take on an increased role in diabetes management. Some individuals may not follow their physician’s advice to “go for frequent walks” and may necessitate a more individual approach to a supervised activity program. Physiotherapy management for diabetes could be located in wide variety of settings, including primary care clinics, outpatient departments, or in community locations partnered with community agencies, such as the Canadian Diabetes Association.


Fall prevention Falls are relatively common in older adults and increase with advancing age (Mackenzie, Byles, & Mishra, 2004). They are associated with an increase in mortality, a reduction in mobility, premature nursing home admissions, and greater dependence in activities of daily living (Tolley & Atwal, 2003). Gillespie, Gillespie, Robertson, Lamb, Cumming, and Rowe (2004) completed a systematic review of fall prevention strategies for the Cochrane Library of Systematic Reviews. They found that beneficial interventions included those that were multidisciplinary, multifactoral, health and/or environmental risk factor screening programs regardless of fall history. Individual programs of muscle strengthening and balance retraining, home assessments, withdrawal of psychotropic medications and Tai Chi exercise classes were also beneficial. Campbell, Robertson, Gardner, Norton, and Buchner, (1999) investigated the effectiveness of an exercise program for women over the age of 80 over a two-year period. After two years, the rate of falls stayed significantly lower in the exercise group. The authors also recommended that a regular six-month follow-up visit be instigated to monitor for any changes and adherence with the program. Physiotherapists are currently engaged in the primary prevention of falls in the elderly, but most commonly they are involved only after an individual has already had at least one fall. This involvement most typically occurs at the request of the individual’s physician or through the Home Care program, either in someone’s home, or in an institutional setting. A Seniors Health Promotion program has been developed and implemented in one neighbourhood of north Winnipeg, which includes this focus. This team of a nurse and occupational therapist does not, however, include the expertise of a physiotherapist. Physiotherapists could be engaged more fully in fall prevention programs at the primary health care level by providing appropriate evaluation and remedial exercise programs either on an individual basis or for group interventions. This must not be limited to age-specific groups, as other population groups may also be at high risk of falls. This could either occur in the primary care setting where physicians and nurse practitioners have direct access to physiotherapists, or in the community, such as community halls, or senior citizen residences. Partnerships could be established with appropriate community agencies or organizations, such as Age and Opportunity and the Seniors Health Promotion programs. Mental health Throughout history, exercise has been used as a means of preventing disease and promoting health and well-being. There is evidence that exercise is beneficial for mental health by reducing anxiety, depression, and negative mood, and improving self-esteem and cognitive functioning (Callaghan, 2004; DiLorenzo, Bargman, Stucy-Ropp et al, 1999). Exercise is also associated with improvements in the quality of life of those persons living with schizophrenia (Callaghan, 2004; Campbell & Foxcroft, 2003). Physiotherapy involvement with persons with a history of mental illness has typically been limited to co-morbid physical conditions. Primary and secondary prevention of


mental health illness and its complications have not been a focus of targeted programming. This is an area that with adequate resource allocation, could be integrated into current community mental health programs. Navigator role - Case management Case management roles and responsibilities differ according to the organization, the population served, the level of physician involvement, the culture of the organization, the client mix, the case manager’s education and training, and the type of case management offered (Rossi, 2003). Essential components of this role have been identified by Rossi (2003) as the following:

• Identification of appropriate clients • Assessment of clients for the services they require • Coordination, planning and identification of the level of care and then the

level of services and scope of resources required to meet patient care needs • Implementation, coordination, and linkage of clients expeditiously to the

resources they require • Direction, oversight, and monitoring of the distribution of services clients

require and ensuring that appropriate and effective services have been established as clients move through the continuum of care

• Advocacy and the ability to act on behalf of clients to ensure that needed interventions are obtained and clients are progressing as anticipated

• Evaluation and continuous monitoring to ensure the usefulness and effectiveness of the case management plan and that outcomes and goals are reached.

The common characteristics of case managers, regardless of discipline, include (Rossi, 2003):

• Educational level • Experience and expertise in the practice specialty to be case-managed and the

total professional experience • Ability to have a holistic perspective and see the patient as a whole person • Knowledge of protocols and systems and how to procure resources to

accomplish care goals • Communication skills and the ability to effectively interact with the patients

and health care team • Ability to problem-solve and overcome hurdles and obstacles • Ability to be creative and innovative • Ability to be self-directed, because there is often no role model to follow • Personal vision of the role.

Pearson (2001) describes the development of a rehabilitation liaison position in an American joint replacement centre. As this person followed clients from the acute to subacute setting, continuity of care improved, transdisciplinary teams shared resources, the subacute length of stay decreased significantly and clients gained a sense of support


through their continuum of care. Although a nurse filled this position in this example, physiotherapists would be suitable candidates for such a role. Physiotherapists with their current education and experience, would make ideal case managers. This could be in the areas of cardiology, respirology, orthopaedics, neurology, paediatrics, general medicine, or disability management. Their experience with discharge planning makes them suitable case managers as clients try to navigate themselves through a complicated health care system. Physical inactivity and obesity in children and adults The public health care burden of the propensity of Canadians to be increasingly physically inactive and obese is growing at an alarming rate. Tremblay, Katzmarzyk and Willms (2002) compared data for overweight and obesity in Canada over the time period from 1981 to 1996. They found that the prevalence of overweight adults aged 20 to 64 years of age increased from 48 to 57% among men and from 30 to 35% among women. Simultaneously, the prevalence of obesity rose from 9 to 14% in men and 8 to 12% in women. Much more alarming, however, was the corresponding data for children aged 7 to 13 years of age over the same 15 year period. The increase in overweight rose from 11 to 33% in boys and from 13 to 27% in girls, while the increase in obesity rates rose from 2 to 10% in boys and 2 to 9% in girls. The costs alone of physical inactivity and obesity represented 2.6% and 2.2% respectively of the total health care costs in Canada in 2001 (Katzmarzyk & Janssen, 2004): $5.3 billion associated with physical inactivity and $4.3 billion with obesity. Chronic diseases associated with physical inactivity include coronary heart disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes, and osteoporosis. Conditions shown to be linked with obesity include coronary heart disease, stroke, hypertension, colon cancer, postmenopausal breast cancer, type 2 diabetes, gall bladder disease, and osteoarthritis (Katzmarzyk & Janssen, 2004). Secondary prevention programs in the way of targeting physically inactive adults, youth and children who are already overweight or obese are necessary to help address this concern. Wittmeier (2004) has identified an additional substantial population of children who are physically inactive but not yet overweight or obese. Tremblay and Willms (2003) have demonstrated a link between physical activity and obesity in Canadian children. Primary prevention measures are crucial in this subpopulation while appropriate lifestyle modification strategies can promote healthy living and prevent physical inactivity. Physiotherapists are ideally situated to play a key role in with this population. As experts in movement and the prescription of exercise programs, physiotherapists can facilitate positive and permanent change in the physical activity levels of both adults and children. There are currently physiotherapists in the community who focus a portion of their practice on this type of intervention. Rheumatoid arthritis Rheumatoid arthritis affects one in 100 Canadians, or roughly 300,000 individuals (Arthritis Society, 2005). Dynamic exercise therapy has been shown to safely improve


endurance and strength in persons with rheumatoid arthritis (Van den Ende, Vliet Vlieland, Munneke, & Hazes, 2004). While physiotherapy is frequently involved at the tertiary care level once secondary symptoms and disability have set in, physiotherapy is rarely involved at the primary or secondary prevention levels. Glazier, Dalby, Badley, Hawker, Bell, and Buchbinder (1996) discovered that family physicians in Ontario only refer 39% of their patients with early rheumatoid arthritis to physiotherapy, despite the strong evidence supporting the role of exercise in the management of rheumatoid arthritis. Four hours of community-based physiotherapy over a six-week period has been shown to significantly improve self-efficacy or confidence, disease management knowledge, and morning stiffness in persons with rheumatoid arthritis (Bell, Lineker, Wilkins, Goldsmith, & Badley, 1998). Physiotherapy should be accessed earlier in the disease trajectory. Secondary prevention measures in the way of supervised exercise and education before the onset of significant signs and symptoms could be provided either in primary care settings or through community partnerships, such as the Arthritis Society.

Urinary incontinence

Over 1.5 million Canadians experience incontinence: 10% of six-year olds, 25% of middle-aged women and 15% of all men over the age of 60 (Canadian Continence Foundation). In one study of 4500 women aged 18 to 65 in nine different countries (France, Germany, Italy, Spain, Sweden, UK, Canada, Mexico and the USA); one third of the women had suffered stress urinary incontinence (SUI) in the previous 12 months (Wirthlin Europe, 2003). Canada had the highest prevalence of SUI in all nine countries studied: 42% of Canadian women studied experienced involuntary urine loss with coughing, laughing, sneezing or during physical activity in the past 12 months. Almost two thirds of the women in the study with SUI had never consulted a physician, and of those who did, one third still believed that there was nothing that could be done to alleviate their symptoms. The World Health Organization estimated that the annual societal cost of urinary incontinence is US$27.8 billion worldwide. Bø, Talseth, and Holme (1999) compared the effects of various interventions in a group of 107 women with genuine stress incontinence, aged 24 to 70 years. Improvements in pelvic floor muscle strength were greater in the pelvic floor exercise group, compared to electrical stimulation, vaginal cones or no treatment. In the Cochrane Database of Systematic Reviews, it is stated that pelvic floor muscle training appears to an effective treatment for adult women with stress or mixed incontinence (Hay-Smith, Bø, Berghmans, Hendriks, de Bie, & van Waalwijk van Doorn, 2001). Physiotherapy is actively engaged in the assessment and treatment of urinary incontinence (Berzuk, 2002). With specific education in this condition, intervention includes a detailed history, manual assessment of the pelvic floor muscles, patient education for pelvic floor muscle exercises and bladder healthy diets, and the use of bladder diaries to monitor progress. While individual therapists and clinics may target this population group, it is unclear how many men and women go undiagnosed and


untreated. Greater secondary prevention in the way of education about medical and self-management options to specific community groups by physiotherapists could alleviate this under-acknowledged condition. 3.1 Barriers Physiotherapists in the focus group and surveys of this project identified the following areas as potential barriers to an increased role of physiotherapy in a primary health care setting.

• Funding infrastructure aimed at a hospital setting instead of at the community level

• Resource allocation • Professional tradition of working in a biomedical model in acute and

rehabilitative care • Systems-based model of current entry-to-practice physical therapy program at

the University of Manitoba • Misconceptions of health promotion offered by other health disciplines • Prioritization of tertiary prevention in current physiotherapy positions • Lack of awareness of physiotherapy scope of practice (public & medical) • Lack of creativity around current resource allocation • Professional focus on treatment skills rather than on client • Lack of role clarity in primary care environment

These barriers can be addressed with greater communication between health care planners, researchers, and providers to establish the best practice for resource allocation. Population health necessitates a global perspective on health care delivery and rehabilitation services should be no exception.


4. Preparation of physiotherapists for a primary health care setting Carol Davis (in Boissonnault, 2005) writes that physiotherapists are ready to take their rightful place along side physicians and nurse practitioners as primary care practitioners, specifically for disorders in movement. She states that

(physiotherapists) must not only use accurate interviewing and evidence-based diagnostic testing and treatment skills, but also must embody the identity of a mature healing professional with well-developed communication skills, negotiation and assertiveness skills, knowledge and appreciation of culturally diverse behaviors, and confidence in (their) ability to develop rapport with patients and their families and with (their) colleagues in the professions. (p. xii)

Physiotherapy participants in the focus group and surveys identified the key characteristics that make physiotherapists ideally suited for a primary health care setting. One respondent stated that “we are movement specialists. We do analysis of movements, not just exercise.” Another affirmed that a unique trait of physiotherapists is “the ability to understand and anticipate what some responses to movement might be, given an individual with three different systems altered, and integrate a safe activity or program.” One physiotherapist acknowledged that physiotherapists possess a unique strength in their assessment skills, particularly of a musculoskeletal condition, “combining it from a pathological background, physiological background, medical background, as well as movement, kinesiology and combining all that, the strength in assessment is something that we do possess.” Other attributes and behaviours contributing to the strength of physiotherapists working in primary health care included:

• A sound knowledge of anatomy and physiology of normal and abnormal movement

• Physiotherapy as a self-regulated profession • Knowledge of normal stages of development • Physiotherapy is activity-based • A focus on an individual’s functional independence • Self-management strategies • Acceptance and integration of team approach • Active role in injury prevention • Good communication skills • Problem-solving abilities • Integration of a holistic approach • Familiarity with continuum of health care

With the current thorough education in anatomy, physiology, the development of normal and abnormal movement, as well as an understanding of the broader determinants which impact upon an individual’s health status, physiotherapists are well positioned to play an active role in primary care.


According to Echsner Gahimer and Morris (1999), the following areas have been identified as responsibility areas for entry-level health education practitioners:

• Assessing individual and community needs for health education • Planning effective health education programs • Implementing health education programs • Evaluating effectiveness of health education programs • Coordinating the provision of health education services • Acting as a resource person in health education • Communicating health and health education needs, concerns, and resources • Applying appropriate research principles and methods in health education • Administering health education programs • Advancing the profession of health education.

Echsner Gahimer and Morris state that preparation of physical therapists in these areas will enhance the delivery of physical therapy. They write that

physical therapy curricula should incorporate aspects of health behaviour, mass communication, and health programming (ie, planning, implementing, evaluating, and funding). Within the context of these challenges and opportunities, community involvement must be clearly identified and conveyed to students in an understandable and practical way. (p. 42)

Physiotherapists in the focus group and surveys of this project identified the following areas of importance in the preparation of physiotherapists to work in a community setting at a primary health care level.

• Group education and intervention • Preparation and implementation of health promotion / disease prevention

strategies • Community needs assessments • Public speaking • Leadership development • Increased emphasis on preventative medicine • Role of physiotherapist in primary care • Advocacy • Case management skills

Education and training of health professionals involves service to the community and in order for it to be relevant to the health needs of the communities, students should be exposed to these in real-life situations and not within the walls of academic institutions... It allows students to understand people’s lifestyles and living conditions and the social, cultural, economic, political and ecological factors that influence the health of individuals.

Futter, 2003, p. 13


One strategy to strengthen student preparation for community health is to increase the opportunities for community practice. There are several examples in the literature of physiotherapy students involved in community health. Futter (2003) describes a group of South African physiotherapy students providing rehabilitation services to a group of persons with severe disabilities in their homes. University of Manitoba physiotherapy students currently have similar experiences in their community placements with Community Therapy Services Inc. who are integrated with Winnipeg’s Home Care program. Boucault (1998) describes one-day health promotion outreach activities by physiotherapy students to underserved rural communities in South Australia. Physiotherapy and occupational therapy students of the School of Allied Health Science of the University of Texas Medical Branch ran a seven-week health promotion program on the health behaviours of 35 older inactive, overweight, or physically limited adults (Haber, Looney, Babola, Hinman, & Utsey, 2000). While short-term gains were observed in exercise behaviour, follow-up at eight months revealed no long-term behaviour change. The implication is that maintenance programs may be necessary to ensure lasting impact of these types of services. Opportunities for education in community health should be made available for both student physiotherapists, as well as graduate physiotherapists in the form of continuing education. Community health is a key component of primary health care strategies and all health care providers must be well versed in the potential that a population health perspective can afford.


5. Conclusion Physiotherapy is a health care discipline well positioned to take on an increased role in primary health care. Physiotherapy is an independent self-regulated profession with the necessary education and experience to address the needs of health promotion and disease prevention, both on an individual basis as well as that of the community. They are eager to extend their expertise beyond tertiary prevention to avenues of primary and secondary prevention where physiotherapy is not yet already engaged. In the Canadian Physiotherapy Association’s vision for the Canadian health care system (2002), it is recognized that

health care is broader than acute care and institutional services and must include self-care, health promotion, disease prevention, community support, ambulatory primary care and rehabilitation services. Physiotherapy is an essential, core health service and contributes to all these components of health care.

Physiotherapists understand the importance of the broader determinants of health and their impact on individual and population health status. As an integral part of a collaborative interdisciplinary primary health care team, physiotherapists can assist in health promotion and disease prevention strategies, as well as in the identification and remediation of a myriad of health conditions. The evidence supports an increased role of physiotherapy in primary care, both as first contact for the public, and in a consultative role for other members of the health care team. International models have demonstrated the feasibility and cost savings of such a role in primary care, particularly in the area of musculoskeletal conditions. Not only does it provide the public with easier access to physiotherapy services, but it also alleviates some of the burden of long waiting lists from the physicians and the health care system as a whole. Physiotherapists in Manitoba are active members of primary health care teams in rural and northern health care, as well as specific urban program areas. This partnership must be extended to other primary health care teams, particularly where it is supported by the scientific literature. In areas such as fall prevention, arthritis, chronic lung disease, incontinence, diabetes, physical inactivity and obesity, osteoporosis, workplace safety and mental health, the role of exercise “upstream” is well documented. Physiotherapists are the ideal health professionals to act as both providers and consultants in the area of specialized exercise programming. As part of the health care team and possessing a broad understanding of community participation, they are also well suited to act as case managers or navigators for the public as they steer themselves through the health care system. While the skills that physiotherapists bring to the primary health care team are well established, certain barriers to an expanded role have also been identified. Resources must be prioritized and allocated to physiotherapy in primary health care. But this should not minimize the role that physiotherapy currently plays in secondary and tertiary care. A holistic approach to health care should integrate all three levels of health promotion and disease prevention.


Several recommendations can be made as a result of this project.

1. Physiotherapists make a valuable contribution in the pursuit of the goals identified by the intercollaborative health care team. As such, physiotherapists should be recognized as a key member of the primary health care team. This should occur at all levels of program planning and implementation.

2. Physiotherapy should be integrated into the primary care team, either as a

consultant or as first contact with the public, particularly in the area of musculoskeletal conditions. This already occurs in private clinics but should be expanded to incorporate interdisciplinary primary health care teams in publicly funded community health centres. Additional training could be considered to expand the physiotherapist’s current scope of practice, as has been done in other international jurisdictions.

3. Resources should be allocated to the development and implementation of

physiotherapy services beyond the current tertiary level of care to incorporate primary and secondary care. These services should be provided in the community, with consultation from the community.

4. Any new program strategies should be accompanied by formal and valid

evaluation tools. Data must be gathered that can measure both the short- and long-term impact of primary health care delivery, and physiotherapy specifically. Quantitative and qualitative evidence can be used in the consideration of expansion of service delivery.

Physiotherapy is part of the health care team faced by the multitude of challenges to today’s health care system of delivery. Physiotherapy can also be part of the solution if given the opportunity.


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Appendix A

Physiotherapy focus group participants held November 26, 2004 at the University of Manitoba

Alison Baldwin, Wellness Institute, WRHA Mary Eaton, Home Therapy Services Susan Gerlach, Grace General Hospital, WRHA Marlene Graceffo, Geriatric Program Assessment Team, WRHA Cindy Grant, River East Physiotherapy & Sports Fitness Clinic Sandy Loewen, Rehabilitation Centre for Children Merle MacAulay, Manitoba Branch of the Canadian Physiotherapy Association Mike McMurray, Department of Physical Therapy, School of Medical Rehabilitation,

University of Manitoba & McMurray Physiotherapy Service Gisele Pereira, Department of Physical Therapy, School of Medical Rehabilitation,

University of Manitoba, Catch Your Breath program Dr. Barbara Shay, Manitoba Branch of the Canadian Physiotherapy Association Marlene Smith, South Eastman Health/Santé Sud-Est Inc. Jenneth Swinamer, Department of Physical Therapy, School of Medical Rehabilitation,

University of Manitoba Margrèt Thomas, First Nations Therapy Program, Community Therapy Services Inc.


Appendix B

Focused Questions of the physiotherapy focus group November 23, 2004

1. Is anyone aware of examples of physiotherapy (PT) working in a primary heath care context, that is, in a direct access, interdisciplinary collaborative practice, with a focus on wellness promotion & disease prevention? This can be either on an individual or a community basis. 2. Do you feel that there are any areas in primary health care where PT could play a greater role? 3. What are some of the strengths or unique skills/traits that PT can bring to primary health care? If we were to propose pilot projects around primary health care, what type of experience do you think the ideal physiotherapist should possess to work in such a setting? 4. What are some of the barriers to PT getting more involved in primary health care? Can you think of ways to resolve those barriers? 5. Is there any particular area where you feel physiotherapists need more education in order to better prepare themselves for an expanded role in community-based primary health care? This can pertain either at the undergraduate level or as post graduate continuing education. 6. Are you able to suggest any initiatives and/or actions that either CPM or CPA could undertake locally to better position PT for a role in the expansion of primary health care services?


Appendix C

Physiotherapist electronic survey

Please complete the following questions to the best of your ability. What best describes your current clinical practice? (please check all that apply)

publicly funded hospital-based position publicly funded community-based position private practice

From which institution did you obtain your physiotherapy diploma/degree

University of Manitoba other (please specify) ______________________________________________

How many years have you been licensed as a physiotherapist?

0-5 years 6-10 years 11-15 years 16-20 years >20 years 1. Are you aware of examples of physiotherapy working in a primary heath care

context, that is, in a direct access, interdisciplinary collaborative practice, with a focus on wellness promotion & disease prevention? This can be either on an individual or a community basis.

2. Do you feel that there are any areas in primary health care where PT could play a

greater role?

3. What are some of the strengths or unique skills/traits that PT can bring to primary health care?

4. If we were to propose pilot projects around primary health care, what type of experience do you think the ideal physiotherapist should possess to work in such a setting?

5. What are some of the barriers to PT getting more involved in primary health care? Can you think of ways to resolve those barriers?

6. Is there any particular area where you feel physiotherapists need more education in order to better prepare themselves for an expanded role in community-based primary health care? This can pertain either at the undergraduate level or as post graduate continuing education.

7. Are you able to suggest any initiatives and/or actions that either CPM or CPA could undertake locally to better position PT for a role in the expansion of primary health


care services?

8. Would you be willing to provide feedback to a draft copy of the final report?

Thank you for completing this questionnaire. Any other comments or feedback you may have would also be appreciated. Please fax this completed form back to Moni Fricke at 204-284-9877.


Appendix D

Accompanying information for the physiotherapy survey on the role of Manitoba physiotherapists in primary health care

Thank you for your willingness to complete a questionnaire on physiotherapy and primary health care. Your responses will assist in the development of a position paper for Manitoba physiotherapists on primary health care, initiated and sponsored by MBCPA, SMR, and CPM. Please fax your responses back to:

Moni Fricke

At (204) 284-9877 By Friday, March 31, 2005

Please read the following information about primary health care before completing the attached questionnaire. This information may clarify certain terminology for you.

Primary Health Care

Primary health care is not a new concept by any means. Physiotherapists have been working in this model nationally and internationally for years, but only recently has there been much discussion in making this shift a priority in Canada. One must first be able to distinguish primary care from primary health care in order to move forward in exploring the potential for physiotherapy to be increasingly involved in this trend. Primary care is the point of first contact with the health care system, where diagnosis, treatment and management of health services occur. In contrast, primary health care includes primary care, but acknowledges the broader determinants of health and is built upon the foundation of equity, intersectoral approach and community participation (MacDonald, 1993). Comprehensive services which emphasize preventive and promotive care rather than curative services are the basis of primary heath care (WHO, 1987). “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.” (Declaration of Alma-Ata, International Conference on Primary Health Care, World Health Organization, Alma-Ata, USSR, 6-12 September 1978) “The Declaration of Alma-Ata outlines the strong connection between population health and the actions required by social and economic sectors, in addition to the health sector.


It identifies that the promotion and protection of health is essential to sustained economic and social development. Citizens and communities must participate in the planning and implementation of their health care. The re-orientation of service delivery from program silos and centralized locations to service delivery organized around populations and community stems from this concept. (Winnipeg Regional Health Authority (2003) Winnipeg Integrated Services Initiative. p. 4) Cathy Fooks (2004) has described the common elements of primary health care reform across Canada to include:

• Team approach to service delivery • Roster of patients • 24 hour access 7 days a week • Mixed funding formulas for services & programs • Increased emphasis on health promotion & prevention.

Catherine Beggs (2004) feels that the above elements which have the most impact on the profession of physiotherapy are a team approach to service delivery, and an increasing emphasis on health promotion and prevention. The different levels of prevention practice terminology have been described as follows (McCloy, 2001):

Primary Prevention Preventive measures that forestall the onset of illness or injury during the prepathogenesis period. It includes health care that focuses on the identification of potential risk factors for disease or disability in healthy individuals & targets factors that are amenable to change.

Secondary Prevention Measures aimed toward the early detection of underlying disease when overt clinical symptoms are not yet apparent. Early detection allows for prompt treatment.

Tertiary Prevention Treatment implemented after the disease becomes symptomatic. Focus is on the restoration or maintenance of maximal function & the prevention of further disease or disability. This is the level at which rehabilitation measures are most commonly initiated.

Some examples where physiotherapists are already working in primary health care are

1. private practice 2. northern and rural health care 3. National Health Services Trusts in the United Kingdom 4. American military


Appendix E

Glossary of terms

Best practice - in health care is the “‘best way’ to identify, collect, evaluate, disseminate, and implement information about as well as to monitor the outcomes of health care interventions for patients/population groups and defined indications or conditions. Information is required on the best available evidence, social and ethical values and quality of the health care interventions.” (Perleth, Jakubowski, & Busse, 2001, p. 237-238) Collaboration – or collaborative patient-centred practice, is designed to promote the active participation of patient, family, and each discipline in patient care. It enhances patient- and family-centred goals and values, provides mechanisms for continuous communication among care-givers, optimizes staff participation in clinical decision making (within and across disciplines), and fosters respect for the contributions of all disciplines. (ACCPAP, The Alliance, CPA, CUPAC, 2004, p. 24) Evidence-based practice – is the integration of best clinically relevant research evidence with clinical expertise and patient values. (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000, p. 1) Health promotion – is the process of enabling people to increase control over, and to improve, their health. (WHO, 1986) Interdisciplinary – team members formulate and plan solutions to the client’s needs as a team; treatment goals are set and reviewed jointly. This approach is regarded as the preferred model of team activity. (Eldar, 2000, p. 271) Multidisciplinary – team members carry out their assessments and treatments of the client individually and communicate the outcome of their intervention and recommendations to the other team members. (Eldar, 2000, p. 271) Physical therapy – also known as physiotherapy, is a health care profession dedicated to rehabilitation, prevention and education. In performing these roles, physiotherapists take the holistic approach to the individual. Physical agents and specialized techniques are used to help the individual attain maximum functional independence with minimum complications. Education of patients, families, and the public plays an important role in both the rehabilitation and prevention aspects of physiotherapy (University of Manitoba, School of Medical Rehabilitation [n.d.]) Primary care - is the point of first contact with the heath care system. It includes diagnosis, treatment and management of health problems with services delivered predominantly by physicians. (Health Canada, 2000, p. v)


Primary health care - incorporates primary care, but also recognizes and addresses the broader determinants of health including population health, sickness prevention, and health promotion with services provided by physicians and other providers often in group practice and multi-disciplinary teams. (Health Canada, 2000, p. v) Primary health care team – is a group of persons who share a common health goal and common objectives determined by community needs, to which the achievement of each member of the team contributes, in a coordinated manner, in accordance with his/her competence and skills and respecting the functions of others. (WHO, 1985 as cited in Sicotte et al 2002, p. 992) Primary prevention – includes preventive measures that forestall the onset of illness or injury during the prepathogenesis period. Practice focuses on the identification of potential risk factors for disease or disability in healthy individuals and targets factors that are amenable to change. (McCloy, 2001, p. 314) Rehabilitation - is a goal-oriented and time-limited process aimed at enabling an impaired person to reach an optimum mental, physical and/or social functional level, thus providing her or him with the tools to change her or his own life. It can involve measures intended to compensate for a loss of function or a functional limitation (for example by technical aids) and other measures intended to facilitate social adjustment or readjustment. (United Nations, 1983, p. 3) Secondary Prevention – are measures aimed toward the early detection of underlying disease when overt clinical symptoms are not yet apparent. Early detection allows for prompt treatment. (McCloy, 2001, p. 314) Tertiary Prevention - incorporates treatment implementation after the disease becomes symptomatic. Focus is on the restoration or maintenance of maximal function and the prevention of further disease or disability. (McCloy, 2001, p. 314) Transdisciplinary – team members are able to take over the tasks of another when the latter is not available. This is particularly important in community rehabilitation. (Eldar, 2000, p. 271)


Physiotherapy and Primary Health Care: Evolving Opportunities

2005

Manitoba Branch of the Canadian Physiotherapy Association

College of Physiotherapists of Manitoba

Department of Physical Therapy, School of Medical Rehabilitation,

University of Manitoba

Documents

UP[PLZ 7YPTHY`/LHS[O*HYL! 7O`ZPV[OLYHW`HUKumanitoba.ca/rehabsciences/media/pt_primary_care.pdf · coincide. The role of physiotherapy at the primary care level, which has traditionally