1 1 Health Committee Brief: Health Human Resources Planning by: the Canadian Association of Occupational Therapists Dr. Claudia von Zweck Executive Director Canadian Association of Occupational Therapists September, 2009
2 2 Executive Summary Occupational therapy is an essential health service that enables Canadians to maximize their productivity, reduce lifestyle restrictions and avoid unnecessary dependency. A sense of wellbeing and meaning in one s daily occupations is an important determinant of health and an effective means to reduce health care costs for the public purse. Occupational therapists, as the primary service providers for occupational therapy, are faced with similar human resource challenges as are other health professionals such as nurses and doctors. Initiatives are needed to improve their workforce shortages and to optimize utilization. Labour market information and workforce studies indicate that there is a strong and persistent demand for occupational therapy services across Canada to address the challenges of ageing, mental health issues such as Post Traumatic Stress Disorder (PTSD) and chronic disease management. Accessing vital occupational therapist services is limited due to therapist shortages, despite the fact that the use of occupational therapy is underutilized when compared with countries with similar health systems. This underutilization is primarily due to both a shortage of therapists, and limited use or exclusion of occupational therapy from appropriate health care settings. The Canadian Association of Occupational Therapists believes that the answer to human resource concerns for their profession lies in effective health human resource planning and greater utilization of occupational therapists in many areas of health care under federal jurisdiction, including: services provided to military personnel and the Royal Canadian Mounted Police; veterans; public service employees; and, aboriginal populations. In an effort to improve the health human resource planning for occupational therapy in Canada, CAOT proposes the House of Commons Standing Committee on Health recommend to the Government the following: 1. Promote collaborative interdisciplinary health care: Interdisciplinary collaborative practice can result in better health, improved access to services, more efficient use of resources and better satisfaction for the people of Canada. While variations of interdisciplinary practice are being introduced throughout Canada, most people still do not receive health services in a team setting. To ensure all people living in Canada have access to the most appropriate health care services wherever they live, CAOT advocates for the following action: Integrate occupational therapists within interdisciplinary health care services to maximize the independence of an ageing population, enhance the delivery of holistic mental health services, provide effective and efficient case management. Develop funding models that promote interdisciplinary collaboration. Continue support for interdisciplinary education at the entry level to the profession and in professional development initiatives.
3 3 Support profession specific and interdisciplinary research studies to expand the knowledge base for interdisciplinary collaboration in Canada. Develop change management resources that facilitate the transition to collaborative interdisciplinary practice. 2. Promote workforce recruitment and retention: Occupational therapists are concerned about the impact of organizational and workplace demands on the quality of the services they to deliver to their clients. They report that workplaces have demands for high productivity while providing few resources to support service provision and limited opportunities for professional development. Professional requirements for an evidence based service are frequently placed in conflict with employer demand to assume high caseloads, while reducing the costs associated with service delivery. CAOT recommends support to: Invest in research and resource development to promote workplace health and appropriate workload assignment. Establish a unique identifier for occupational therapists to track career progression and identify and address issues related to workforce attrition. Develop a health human resource modeling plan to ensure an adequate supply of occupational therapists in Canada. 3. Support initiatives that assist international graduates to work as occupational therapists in Canada: Internationally educated occupational therapists play an important and growing role in meeting service demands for occupational therapy in Canada. Many employers are actively recruiting occupational therapists educated outside of the country to meet staffing needs. CAOT has undertaken a number of initiatives to work with occupational therapy partners to address barriers experienced by international graduates. Support from the federal and provincial/territorial governments have been and will continue to be integral for the initiation and continued success of these projects. Recommendation: Continued government funding for project initiatives aimed at assisting international graduates to successfully work as occupational therapists in Canada. Occupational Therapy in Canada The promotion of healthy development is a key concept underlying health promotion at the community level. The task of promoting optimal human development so that everyone develops as fully as possible and achieves their maximum potential as a human being is, or should be the central purpose of all levels of government (Hancock, 2009.).
4 4 Introduction The Canadian Association of Occupational Therapists recognizes that a health human resources workforce that is both sustainable and effective is critical for meeting the health needs of the Canadian population. All people of Canada should have access to the right professionals at the right time in their communities, throughout their lifetimes. CAOT believes that health human resources planning are best informed by evidence, thereby allowing the profession to respond to existing and projected population health needs. Occupational therapy is an essential service and resource to promote health and support the well being of the people of Canada. Information describing the role and occupational therapy workforce, in combination with research on current demands for occupational therapy services in Canada supports a goal of developing workforce capacity. CAOT has therefore identified the development of workforce capacity in occupational therapy as a strategic priority. In addition, to ensure ongoing effective workforce capacity planning, CAOT also recommends a review of current practices in health human resources demand modelling. The Role of Occupational Therapy Occupational therapy is the art and science of enabling engagement in everyday living through occupation; of enabling people to perform the occupations that foster health and well being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life (Townsend & Polatajko, 2007). CAOT strongly supports initiatives that enable all persons of Canada to have the opportunities and resources to engage in occupations for their health and well being, an important determinant of health. Occupational therapists play a role in health promotion, illness and accident prevention as well as recovery and resilience of the human spirit. For example, occupational therapists are currently a key part of the health care team supporting active duty members of the Canadian Forces. Under the direction of an occupational therapist, Canadian Forces Base Valcartier has developed a highly successful Return to Work program, providing support to injured members of the Canadian Forces through provision of services from an entire health care team. The program, has demonstrated exceptional results in returning members of the Canadian Forces to duty without restrictions. Please refer to Appendix A for information on the Canadian Forces Base Valcartier Return to Work Program. Occupations are fundamental to a person s self worth and as such are a strong determinant of health and ability to contribute to the social and economic fabric of their communities. In a professional sense, occupations include everything that people do to occupy themselves work, self care, leisure, and improving quality of life. The current recession provides numerous challenges that can be effectively and efficiently addressed by occupational therapists, clinicians that possess the skills and knowledge for assisting people in developing new career plans, as well as for addressing physical, emotional and psychosocial issues and other related barriers to a successful return to work or remaining an active member of the workforce. Occupational therapists are skilled at facilitating and negotiating the return to work of ill or injured employees, as well as at assisting employees in
5 5 exploring and developing new opportunities for work or managing reduced employment. Occupational therapists are skilled case managers and able to collaborate with all stakeholders, so as to successfully support the employee transition back into the work environment, thereby optimizing the retention of a highly valued resource Occupations are the core domain of concern and the therapeutic medium of occupational therapy. The social and physical environment as well as personal health practices, income, education and literacy have a major impact on occupation and health (Government of Canada, 1999). The issue of an ageing population in Canada is a growing concern for government and service providers. Occupational therapists are able to respond to current and growing older adult population health needs, addressing issues such as maximizing independence, so as to keeping older adults in their homes longer and ensuring safe operation of motor vehicles, to optimum management of chronic disease. For instance, seniors are the fastest growing segment of the driving population, with driving being a vital part of their independence. However, older driver mortality and morbidity is on the rise. The leading cause of accidental deaths for persons 65 to 75 years old in Canada today is driving related accidents (Canada Safety Council, 2005). CAOT received funding for the development of a National Blueprint for Injury Prevention in Older Drivers from the Public Health Agency of Canada, developed with a 21 member National Advisory Committee consisting of key stakeholders for older driver safety and including consumers, researchers, educators, clinicians, law and government. The Blueprint outlines a vision and directions for action for promoting safe driving among older drivers in Canada. The Blueprint is directed towards increasing the capacity of older adults to drive safely for as long as possible and maintain their engagement in the occupations which give meaning and purpose to their lives. Occupational therapists broad vision is to enable people who face emotional, physical or social barriers to develop healthy patterns of occupation, and the profession demonstrates an ability to meet the population health needs of the Canadian people. However, as will be shown, there are significant health human resource barriers to adequate service provision by occupational therapists. The Occupational Therapy Workforce Occupational therapists are regulated health professionals and university educated at the master s degree level in Canada. Many occupational therapists in Canada also have advanced degrees. In 2005, over 13% of occupational therapists who were members of CAOT had advanced degrees, including over 100 occupational therapists with a doctoral degree. The entry level education of occupational therapists is devoted to the study of occupation and occupational engagement. As an expert in occupation, they understand the effects of factors such as disease and injury on the ability of individuals, groups and communities to engage in the occupations of life. Occupational therapists use evidence based processes that focus on their clients goals to participate in valued activities (Townsend & Polatajko, 2007). The knowledge, skills and abilities required by occupational therapists are outlined in the Profile of Occupational Therapy Practice in Canada (3rd edition) (CAOT, 2007). The profile, shown in
6 6 Diagram 1, provides a definition and description of the seven main roles of occupational therapists in Canada. Diagram 1. Profile of Occupational Therapy in Canada There were 12,000 practicing occupational therapists in Canada in 2007, with an average of 33 occupational therapists per 100,000 populations. Approximately 800 students graduate from the 14 Canadian university education programs for occupational therapists annually (CIHI, 2008). Demand A review of labour market information and workforce studies indicates a strong demand for occupational therapy services across Canada. The ageing population, advances in technology, greater emphasis on quality of life issues and better recognition of the value of rehabilitation are expected to drive demand for more occupational therapy services in the future. The number of healthy seniors is expected to increase by 2.6 million between 2001 and 2021 (Casey & Jongbloed, 2007). The increasing lifespan of Canadians and the rise in numbers of people with disabilities will result in higher demand for occupational therapy services to enable people to engage in the activities that are important for them. People 65 years and older are expected to seek health care services earlier and remain in care longer thereby utilizing a large portion of the health care budget. Consumers of services will be increasingly egocentric, demand better timelines, choice and quality regarding service delivery (Pierre, Pollack & Fafard, 2007). Occupational therapists play a vital role in keeping the ageing population healthy and independent, and therefore less likely to place such a great demand on the healthcare system.
7 7 Generalized shortages of occupational therapists are reported in areas across Canada. For example, labour market reports currently document shortages of occupational therapists in British Columbia that are prevalent in both urban and rural parts of the province (HRSDC, 2007). Occupational therapists reported the third highest number of paramedical vacancies in a recent survey conducted by health employers in the province, with over thirty vacancies identified as difficult to fill after three months of active recruitment (CAOT & British Columbia Society of Occupational Therapists, 2007). Similar shortages are reported by employers in Alberta, Saskatchewan, Ontario, Quebec and northern New Brunswick. In many parts of Canada, long standing workforce shortages have resulted in migration of occupational therapy services away from traditional areas of practice. For example, in the province of Saskatchewan only 2.8 % of occupational therapists work in the area of mental health, in comparison to the national average of 12% (CIHI, 2008). To address such workforce shortages, CAOT is engaged in initiatives directed toward increasing the supply of occupational therapists in Canada. Such initiatives include expansion of entry level education programs for occupational therapists in Canada, promotion of occupational therapy as a career, retention of occupational therapists within the profession, appropriate utilization of the existing workforce and improved workforce integration of internationally educated occupational therapists. Distribution The distribution of occupational therapists varies greatly among provinces, ranging from 49 occupational therapists per 100,000 populations in Quebec to 21 per 100,000 in Saskatchewan (CIHI, 2008). In addition, 95% of occupational therapists reside in urban areas. Rural areas in Canada are particularly underserved by occupational therapy (CIHI, 2008). Population health need, measured in terms of the rate of disability within each province does not appear to explain variations in the distribution of occupational therapists in Canada. Disability rates for adults and children reported in the 2001 Participation and Activity Limitation Survey were lowest in Quebec, with highest rates of disability in the provinces of Nova Scotia and Saskatchewan (Statistics Canada, 2002). Health Human Resources Demand Modelling Occupational therapists are one of five health professions included in the Health Canada funded Health Human Resources Database Development Project coordinated by the Canadian Institute for Health Information (CIHI). This project developed a database of supply information for health human resources planning. In 2008, CIHI published the second annual version of Workforce Trends of Occupational Therapists in Canada which summarized information from the Occupational Therapy Database for the use of government, researchers, stakeholders and occupational therapists. The aim of the document data and data analysis was to enable informed decision making and policy formulation. An analysis of this document and other recent occupational therapy workforce research confirms shortages of occupational therapists currently exist despite apparent underutilization of occupational therapists in comparison with countries with similar health systems (von Zweck, 2008). In addition, when compared with other regulated health
8 8 professions in Canada, occupational therapy has the lowest per capita rates of utilization in Canada. Only the health professions working with specific populations, such as midwives and audiologists have lower rates of utilization, (CIHI, 2007). Over the past decade, the supply of occupational therapists in Canada has increased faster than the population growth. For example, Quebec recently initiated two new university education programs to supplement the existing supply of occupational therapists. Increases in education capacity have been undertaken in many existing occupational therapy education programs and are also under consideration in provinces such as Alberta and Saskatchewan. Although there has been an increase, the supply of occupational therapists in Canada significantly lags behind many European countries such as the United Kingdom, Belgium, Sweden, and Denmark that report between 43 and 105 occupational therapists per 100,000 populations (Council of Occupational Therapists for European Countries, 2005). Despite CIHI and occupational therapy research indicators, current health human resource modeling methods have not been able to account for the well defined issues reflected by the documented demand and distribution information. Recommendation: Projecting workforce needs has traditionally been estimated by adjusting counts of existing health providers for population growth and age. This approach is limited by the premise that the current average distribution of health providers is optimal for serving population health needs. In order to address the issues of demand and distribution not accounted for by current health human resources demand models, CAOT strongly recommends the development of needs based modeling as the preferable human resource planning approach as this method uses identified health needs within a population to predict workforce requirements. Collaborative/ Interdisciplinary healthcare A key feature of the changing health care system in Canada is the shift from health care professionals moving from working from within their respective professions to inter professional teams of providers who are accountable for providing comprehensive services to their clients. There is a growing consensus that inter professional collaborative practice will result in better health, improved access to services, more efficient use of resources and better satisfaction for both clients and providers. Research evidence shows that teams are well positioned to focus on health promotion and improving the management of chronic disease (EICP, 2006). CAOT actively supports inter professional education at entry level to the profession and in professional development initiatives as demonstrated by: 1) Participation in a Health Canada funded project involving a partnership of eight national organizations representing the disciplines of physiotherapy, occupational therapy, pharmacy, social work, nursing and medicine that accredit pre licensure education. The project objective was to create and support the use of core joint principles/guidelines in formulating accreditation standards for inter professional education.
9 9 2) Participation in two Health Canada funded initiatives (2006) to develop a national framework with guiding principles to enhance inter professional collaboration in primary health care and mental health services. Both initiatives were aimed at significantly impacting the reform of Canada s primary health care system by identifying and creating awareness of conditions necessary for health providers to work together effectively, in order to produce best possible outcomes for clients (CCMHI, 2006 & EICP, 2006). CAOT notes that while variations of inter professional practice are being introduced throughout Canada, most people residing in Canada still do not receive health services in a team setting. Teamwork continues to be primarily a voluntary process throughout Canada (Health Council of Canada, 2007). Recommendation: Promotion of collaborative, inter professional health. To promote collaborative interdisciplinary health care CAOT recommends: The integration of occupational therapists within inter professional health care to ensure to appropriate service access for the people of Canada. For example, Primary healthcare is one teamwork model in which occupational therapy services can be offered. Primary healthcare can be the first point of entry for people into the healthcare system, and offers access to a range of services, all aimed at providing population health, illness prevention, and health promotion through access to a range of health care disciplines. This model promotes best use of healthcare providers and resources (Mabel & Marriott, 2002). A teamwork model such as that of primary healthcare may be offered in many community settings. Funding models that allow health professionals to practice according to the principles of inter professional collaboration. Continued support for inter professional education at entry level education and in professional development initiatives. Support for profession specific and inter professional research studies that expand the knowledge base for inter professional collaboration in Canada. Development of change management resources, such as that of the Community Healthcare and Resource Directory (CHARD), a collaborative pilot project developed by the BC Ministry of Health and B.C. Medical Association. CHARD was developed as an easily accessible database for information for available services and service providers for people with addiction issues in the lower mainland British Columbia. Resources such as CHARD have been shown to encourage and make feasible the transition to collaborative inter professional practice. Promotion of Workforce Recruitment and Retention Attrition of the occupational therapy workforce has been identified as a significant issue. Over 90% of occupational therapists in Canada are female, with the average age reported to be 38.9 years, reportedly younger than many other health professions (CIHI, 2008). Within this younger workforce, maternity leaves of absence are common. Additionally, the rate of part time work among occupational therapists varies in different provinces from a low of 14.2% to a high of
10 % (CIHI, 2008). All of these factors influence the productivity of the workforce. Finally, the career span for occupational therapists is short, with many leaving the profession after 20 to 30 years of practice. Trending analysis shows a steep decline in the percentage of occupational therapists who are over the age of 45, with a similar decrease in members over the age of 55 (CIHI, 2008). Research by CAOT in 2009 indicated that the greatest practice problems reported by occupational therapists in Canada are related to their work environment. Practice problems identified by respondents include: unrealistic workloads, inadequate staffing, limited resources, and restricted professional recognition. Almost one quarter of survey respondents did not expect to be working as an occupational therapist within five years, with the majority of respondents citing the following reasons for the anticipated move away from the profession: workplace burn out, lack of advancement opportunity, feeling low respect in the workplace, too many challenges in the workplace, and unstable job security (CAOT, 2009). Information from the survey articulated the concerns of occupational therapists in Canada regarding the impact of organizational and workplace demands on the quality of health care. They reported that workplaces have demands for high productivity with few resources to support service provision and professional development. As well, professional requirements for evidence based service were frequently described as placed in conflict with employer demand for managing high caseloads and cost effective services. In addition, many occupational therapists described leaving rural and remote geographical areas of practice due to overwhelming demands for services and a lack of support and mentoring for program development and delivery. To address workforce retention concerns, CAOT has identified the following quality service guidelines occupational therapy services in Canada: Provision of sufficient financial and human resources to carry out effective occupational therapy services within an evidence based, client centred framework. Implementation of hiring practices that ensure competency and promote leadership opportunities in occupational therapy. Usage of standardized processes to appropriately determine caseload assignments. Implementation of mechanisms and resources for mentoring and continuing professional education. Provision of recognition and support for inter/intraprofessional collaborative teamwork. Support within organizational processes for workplace health. Performance of quality monitoring and improvement mechanisms to ensure the integrity of occupational therapy practice. Development of mechanisms to provide quality fieldwork and education experiences to students in occupational therapy. To move towards developing quality service guidelines, and address concerns shared by interprofessional colleagues, CAOT, the Canadian Physiotherapy Association, and the Canadian Association of Speech language Pathologists and Audiologists are working together on a project for the development of a caseload management framework. Funded by Health Canada, the Caseload Management Tool is intended to be an evidence based tool designed to assist individual professionals, organizations and policy makers in determining effective
11 11 caseload/workload management for occupational therapy, physiotherapy and speech language pathology services in Canada. Recommendation: Continued support and resources are needed to promote workforce retention, including: Adoption of CAOT quality service guidelines for occupational therapy. Funding of telehealth resources to facilitate professional development and provide access to research based evidence for occupational therapy practice, particularly in rural and remote areas of practice. Research and resource development for mentoring and leadership within occupational therapy. Continued research and resource development to promote workplace health and appropriate workload assignment. A unique identifier for occupational therapists to track career progression and identify and address issues related to workforce attrition. Internationally Educated Occupational Therapists Existing shortages and the continued expected growth in demand for occupational therapists in Canada reinforce the importance of promoting the workforce integration of international graduates in occupational therapy. Internationally educated occupational therapists that come to work in Canada can play an important and growing role in meeting service demands for occupational therapy in Canada. Many employers are actively recruiting occupational therapists educated outside of the country to meet staffing needs. Over 8% of occupational therapists outside of Quebec and Alberta currently working in Canada received their entry level education outside of the country. Most of these internationally educated occupational therapists are living in the provinces of Ontario and British Columbia. In collaboration with key stakeholders, CAOT has undertaken a number of initiatives to address the barriers to professional practice experienced by international graduates. These include: 1) A project that investigated issues and solutions for helping international graduates to work as occupational therapists in Canada in November 2006, and 2) A project with the Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO) and the Association of Canadian Occupational Therapy Education Programs (ACOTUP), which identified the pathways followed by international graduates from the point of initial consideration of immigration to successful registration and integration into practice. 3) CAOT continues to work with ACOTUP and ACOTRO on a third project, funded by the Government of Canada s Foreign Credential Recognition Program, aimed at developing a unified electronic information gateway to centralize information for internationally educated occupational therapists. International graduates frequently require assistance or academic remediation to meet regulatory requirements for practice in Canada. Research indicates that the current network of resources available to skilled immigrants new to Canada encounter a confusing and fragmented system for bridging and financing. A national vision, which integrates immigrants into learning opportunities available to all Canadians would allow for these much needed health care