Scope of Practice & Credentialling in Osteopathic Practice - iO/OIA Convention London 2014

Stiofán Mac SuibhneOCNZ Project Officer

Healthcare Megatrends The changing demographic – Western

societies are graying.

Increased demands on resources may mean reduced public sector involvement in direct service provision.

Reduced doctor time will require maximising the services delivered in primary care by allied health professionals.

Osteopathic skill set becoming dated. Need to align the osteopathic scope of practice with the strategic direction.

Globalisation and workforce mobility

Life long learning

Clear Skies Thinking Workshop Wellington September 2009 - OCNZ

OCNZ Statutory duty to determine scope.

Facilitate leadership on scope issues

Professional Bodies: AOA, BOA, ISOP, OSNZ.

Australian (NZ) Osteopathic Council

Senior students & faculty from Unitec

NZ Ministry of Health, ACC Podiatry Nursing Medicine Psychology

NZ Scope Reform

Osteopathy is a maturing and diversified profession – needs to be reflected in vocational scopes.

No clear relationship between training pathways and competency in practice: Vocational / Extended Scopes.

30% of NZ Osteopaths were using needling techniques in practice without standards / minimum training requirements being determined.

ACCORB accreditation standards specify no minimum requirements for paediatric practice.

The debate on Scope

Osteopathy is a weak brand – we need a USP

Field of manual medicine is crowded.

Osteopathy is defined by its philosophy not technique.

Mission creep / Healthcare Ecosystem (professional identity and post modernism)

Stakes a claim for Osteopaths and their role in the healthcare system.

The formless no scope scope of practice is not serving us well.

The formless scope or a restricted scope statement is a form of prohibition.

Discourses on the Osteopathic SOP

Techniques vs philosophy Evidenced based vs Belief - based /

experiential Structural vs Cranial Totality belief system vs regulated

healthcare profession Place of AT Still – legacy of the aphorisms CAM vs Manual Medicine – Orthodoxy /

Heterodoxy?

Scope of the Problem Highly restricted view of practice

Unintentionally placing many osteopaths outside the SoP

Technical and practitioner centric

Failed to communicate skill set

Curriculum focus rather than practice focuses

Why would a patient consult an osteopath?

Why would another healthcare practitioner refer to an osteopath?

Scope of practice = work in progress

OCNZ must specify SoP duty to consult

Scope of Practice

Consensus Position

Need to reform the pre-professional training pathway and determine minimum skill set to commence professional life.

Single Scope of Practice is unrealistic.

Additional scopes of practice required to formally recognise skills acquired in post pre-professional training through post-graduate study.

Formal training ought not to stop at the point of registration. Current approach to CPD entirely unsatisfactory.

Need an externally recognisaible hierarchy of knowledge.

Public register ought to allow patients / third party refers to identify practitioners with advanced standing in certain areas of practice

Multiple Scopes of Practice Act does not distinguish between general /

extended / vocational SOP

Reference to other NZ healthcare professions

Acknowledging the realities of a maturing profession

Osteopathy at a junctional point

Low quality CPD / lack of career pathways

Diverse pre-professional training pathways

Clinical complexity

New SOP Schema

Patient centred Protection of title – do we create additional titles? Informative to other Healthcare Professionals Broadly defined Allows acquisition / incorporation of PG learning Inclusive

General Osteopathic Scope

Vocational SOPs Extended SOPs Special Purposes SOPs

Vocational Scopes

Advanced standing and post graduate study / specialisation in areas of practice that remain within the general scope of practice.

There is a continuum of skills / knowledge from novice to expert. Pre-professional training prepares osteopaths to commence practice.

Means of addressing issues of clinical competency for referrers / best fit of practitioners : patient.

Currently there are means of credentialling practitioners.

Failure of professional associations to develop clinically focused special interest groups.

Osteopathic invisibility

Child & Infant health (Paediatrics) Gerontology Occupational Health Pain management Rehabilitation Sports science

Extended Scopes

An extended scope of practice is required when it is explicit that pre-professional training does not prepare a registrant for competent practice.

These areas are excluded from the general scope.

Western Medical Acupuncture & Related Needling Techniques

Osteopath Prescriber (Reform of the Medicines Act)

Injection therapies (Prolotherapy? Requires prescribing rights)

Advanced Diagnostic Competencies

Prescribed Qualifications Vocational scopes

Interdisciplinary – using existing resources Formal Learning & Learning in Clinical

Settings Accessibility – mixed mode delivery Creative learning pathways Defining / Refining Capabilities Patient safety Career Development Responding to changing healthcare

environment Liberal CPD Regime for Vocational SOP Holder

General Osteopathic Scope of Practice Osteopaths are primary healthcare practitioners

Osteopathy is a person-centred form of manual medicine

Osteopaths conceptualise health and disease within a broad holistic bio-psycho-social and environmental context

Osteopathic practice may be situated within the continuum of healthcare - wellness

The competent practice of osteopathy requires broad diagnostic competencies

Osteopaths work with patients from across the lifespan

Osteopaths are primary healthcare practitioners

Osteopaths are primary healthcare practitioners. Central to the competent practice of osteopathy is an understanding of the role of the primary care team and referral routes within primary care and to hospital based service.

Rogers, F., D'Alonzo, J., GE. , Glover, J., Korr, I., Osborn, G., Patterson, M., et al. (2002). Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc, 102, 63-65.

Osteopathy is a person-centred form of manual medicine

Osteopathy is a person-centred form of manual medicine informed by osteopathic principles. Osteopathic medicine is not confined to historical osteopathic knowledge; rather osteopathic philosophies and concepts inform the interpretation and application of interdisciplinary knowledge and the basic medical sciences.

Osteopathic medicine is an evolving field of knowledge and incorporates new concepts as our understanding of health and disease progresses.

…holistic bio-psycho-social and environmental context

Osteopaths treat people and conceptualise health and disease within a broad holistic bio-psycho-social and environmental context. Most osteopaths have a particular interest in conditions of the neuromuscular system and the management of pain.

Osteopaths seek to prevent disease, promote health and give patients control over their health by applying the principles of salutagenesis in practice.

Option A

…holistic bio-psycho-social and environmental context

Osteopaths treat people and conceptualise health and disease within a broad holistic bio-psycho-social and environmental context.

Osteopaths have a particular interest in conditions of the neuromuscular system and the management of pain.

Osteopaths seek to prevent disease and promote health by empowering patients through sharing knowledge on lifestyle choices that improve health outcomes.

Option B

Osteopathic practice may be situated within a continuum healthcare and wellness

Osteopathic practice may be situated within a continuum healthcare and wellness, with osteopaths applying evidence based approaches to the management of named pathologies and conditions through to promoting wellbeing through supportive treatment.

The competent practice of osteopathy requires broad diagnostic competencies

The competent practice of osteopathy requires broad diagnostic competencies. Osteopaths employ broad diagnostic competencies and a differential diagnosis is required to determine if a structural diagnosis and the use of osteopathic manipulative treatment (OMT) are appropriate.

Although osteopathic practice is often defined by OMT, the practice of osteopathy it is not limited to a structural diagnosis and OMT. Whilst there may well be a somatic component to disease, OMT may not be a suitable or principal modality in every presentation.

Osteopaths work across the lifespan

Osteopaths work across the lifespan and may treat individuals from birth to old age, or deliver services in group settings.

Professional knowledge may be applied in a range of settings not limited to clinical practice, such as health promotion, education and research, health policy and healthcare management.

Proposed Tenets of Osteopathic Medicine A person is the product of dynamic interaction between

bio, psycho, social and environmental factors.

An inherent property of this dynamic interaction is the capacity of the individual for the maintenance of health and recovery from disease.

Many forces, both intrinsic and extrinsic to the person, can challenge this inherent capacity and contribute to the onset of illness.

The musculoskeletal system significantly influences the individual’s ability to restore this inherent capacity and therefore to resist disease processes.

The patient is the focus for healthcare.

The patient has the primary responsibility for his or her health.

Tenets of Osteopathic Medicine

A person is the product of dynamic interaction between bio, psycho, social and environmental factors. The human body functions as unit, with structural and function being reciprocally interrelated between all systems and levels of organisational complexity. Alterations in the structure or function of any one area of the body influence the integrated function of the body as a whole.

An inherent property of this dynamic interaction is the capacity of the individual for the maintenance of health and recovery from disease. Osteopathic medicine views health as the natural state of the body. The health of the individual is determined by complex, self-regulating homeostatic systems that are strongly influenced by the structure of the individual. These regulatory systems are capable of compensatory alterations in the face of disease, yet can be self-healing and restorative when their function is optimised.

Tenets of Osteopathic Medicine

Many forces, both intrinsic and extrinsic to the person, can challenge this inherent capacity and contribute to the onset of illness. A realistic view of health focuses on wholeness, understanding and situating the person in his or her context, and appreciating his or her efforts to maximize health status and cope with disease or disability. Osteopaths recognise that each individual is uniquely vulnerable to stressors that place him or her at risk for loss of health. Illness represents the body’s inadequate, self-regulatory responses to challenges from the internal and external environment.

Tenets of Osteopathic Medicine

The musculoskeletal system significantly influences the individual’s ability to restore this inherent capacity and therefore to resist disease processes. Historically orthodox medicine has conceptualised health and disease primarily in terms of internal organs and their disturbances, the musculoskeletal system being relegated to a secondary role as an organ system that is primarily related to locomotion.

Osteopathic medicine considers the musculoskeletal system to play a primary role in health and disease. Derangements in the musculoskeletal system are common and represent significant public health concerns. Abnormalities in the structural system affect its function and that of related circulatory and neural elements. The interventions directed to the musculoskeletal system include osteopathic palpatory diagnosis and manipulative treatment, therapeutic and recreational exercise, and physical therapy modalities.

Tenets of Osteopathic Medicine

The patient is the focus for healthcare. Osteopaths are trained to focus on the individual patient and resit reducing the focus to the abstractions of presenting symptoms, body parts and named disease entities.

The relationship between clinician and patient is a partnership in which both parties are actively engaged. The osteopath is an advocate for the patient, supporting his or her efforts to optimize the circumstances to maintain, improve, or restore health

Tenets of Osteopathic Medicine

The patient has the primary responsibility for his or her health. Although the patient-osteopath relationship is a partnership, and the osteopath as a healthcare professional has obligations to the patient, ultimately the patient has primary responsibility for his or her health.

The patient has inherent healing powers and must nurture these through diet and exercise, as well as adherence to appropriate advice in regard to stress, sleep, body weight, and avoidance of substance misuse.

Vocational scopesIn order to apply for registration in a vocational scope of practice the osteopath must hold a prescribed qualification, be registered in the General Osteopathic Scope of Practice and have held an annual practising certificate for three years.

Suitably qualified overseas applicants will be considered if they have been registered and practising as an osteopath in an overseas jurisdiction for 3 years. Review if elective pathways.

Vocational scopes of practice are drawn from key areas of osteopathic practice and will allow registrants to pursue career development aspirations and hopefully improve the quality and relevance of professional development activities.

The healthcare needs of the population are changing and it is important that the scope of practice framework is such that it guides the development of relevant professional knowledge and skills.

Gerontology In the midst of the demographic changes it is important

that healthcare provision considers the needs of older patients and seeks to work with then to maximise their health and quality of life.

If the healthcare system is to rise to the challenge of meeting the healthcare needs of an ageing population it is important that healthcare professionals develop the necessary skills and knowledge to help maintain independence and health seeking behaviours in older patients.

A vocational scope for gerontology will signal to older patients that the osteopath has a particular interest and advanced knowledge base that supports this area of their practice.

Gerontology

The centrality of the patient to models of practice within the osteopathic paradigm, a conceptual framework that places the patient within their own context and seeks to maximise health within a structural-functional continuum make osteopaths particularly well suits to working with older patients.

Protection of Title: Osteopaths registered in the Vocational Gerontology Scope of Practice are entitled to use the title of Osteopathic Gerontology Practitioner

AUT Post Grad Cert Health Science - Older Adult Health and Wellness

Postgraduate Certificate in Health Science in Older Adult: Health and Wellness (AK3484) 60 points

 The PgDipHSc provides you with the opportunity to undertake an approved course of study to advance your specialty discipline, knowledge and scholarly development. This programme comprises three 20-point papers, which can contribute 120 points towards a , Master of Health Science or Master of Health Practice.

Core Papers:Contexts of AgeingCognitive Health in AgeingResearch Methods Reflective Practice

 Electives:

Exercise PhysiologyScience for Advanced PracticeEnhancing Muscular PerformanceApplied Human Movement StudiesMotor Control in Rehabilitation Concepts of RehabilitationParticipation in HealthStroke Management

Pain ManagementThe management of pain is key professional interest for many osteopaths.

Although osteopathy was initially conceptualised as a drug-free therapeutic system, in the intervening years more effective and less toxic drugs have emerged and professional knowledge of such developments is required.

In addition pain management as an area of practice has developed a rich body of interdisciplinary knowledge and practice.

Pain ManagementThis vocational scope will allow those that have a particular interest in working with chronic pain conditions to be identified in the register and be given credit for their further studies.

 Protection of Title: Osteopaths registered in the Pain Management Scope of Practice are entitled to use the title of Osteopathic Pain Management Practitioner.

Gerontology

The centrality of the patient to models of practice within the osteopathic paradigm gives a framework that places the patient within their own context. Ageing / death not prominent within AT Still’s thinking?

Seeks to maximise health within a structural-functional continuum make osteopaths particularly well suits to working with older patients.

Protection of Title: Osteopaths registered in the Vocational Gerontology Scope of Practice are entitled to use the title of Osteopathic Gerontology Practitioner

Univ of Otago School of Medicine Muscular Skeletal Medicine Programme

The endorsement in Pain and Pain Management is open to medical practitioners and allied health care professionals and can be studied part-time / by distance.

It is designed to present an understanding of the importance of pain to the individual and to society, and how best to optimise its management.

It provides candidates with the necessary skills to better understand and manage pain problems that pertain to their particular discipline within health care. At Master’s level, it provides a knowledge and understanding of research methodology and its practical application

Pain Management

Psycho-social Aspects of Pain Introduction to Pain Introduction to Pain Management Pain Assessment Neurobiology of Pain Biomedical Pain Management Pain in Special Circumstances Musculoskeletal Rehabilitation Cognitive Behavioural Therapy

Post Grad Diploma

Child and Infant Health

As entry level / minimum standards have yet to be developed for paediatric practice it would be previous for Council to develop a vocational scope for this area of practice.

By determining a set of knowledge, skills and attitudes for competent paediatric practice the Council will be meeting its obligation to ensure competence frameworks are developed. This will help ensure one of the most vulnerable patient groups is protected.

Professional practice needs to be informed by risk management strategies, be situated in contemporary understanding of normal child development developmental and adequate knowledge of congenital and developmental disorders in children.

Special Purpose SOP

The Osteopathic Council recognises that osteopathic practice is not limited to the direct provision of clinical services to patients. Osteopaths may use their professional knowledge in a wide range of settings:

Direct non-clinical relationships with patients; such as in group exercises programmes, health promotion activities or health care systems administration (ie working for ACC as a case manager or doing clinical audit).

Clinical educators / clinical preceptors; in pre-professional teaching clinics or practice based settings

Research – undertaking or directing research activities

Teaching – faculty working in the tertiary sector on professional qualifications leading to registration as an osteopath or other regulated health profession and post graduate osteopathic / health science programmes.

Policy development and regulation

Visiting Osteopathic Presenter / Educator

Where to from here?

Gerontology / Pain Management SOP notices Gazetted

Next up Rehabilitation.

Rx Injection Therapy, Paediatrics

Building partnerships with stakeholders – Interdisciplinary learning pathways

International considerations – USA

Integrate with CPD / Recertification