Physiotherapy and Primary Health Care: Evolving Opportunities

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1 Physiotherapy and Primary Health Care: Evolving Opportunities

2 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

3 Physiotherapy and Primary Health Care: Evolving Opportunities Submitted by Moni Fricke 1, 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 correspondence:

4 TABLE OF CONTENTS Executive Summary ii 1. Introduction to primary health care Background Population health and the broader determinants of health Health promotion Primary health care reform Models of primary health care Community physiotherapy Primary care models and physiotherapy 18 American military model 19 Physiotherapy consultant model (United Kingdom and the Netherlands) 20 Private industry model Primary health care models and physiotherapy 21 Canadian Aboriginal health model 21 Geriatric Program Assessment Team model 22 Community pre-school wellness screening 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 Barriers Preparation of physiotherapists for a primary health care setting 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

5 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 therapy 2, 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 multidisciplinary 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

6 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 nonmusculoskeletal 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

7 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

8 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

9 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 care G, 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 promotion G 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 physiotherapists G. Care at this level not only includes the diagnosis and treatment of the problem, but can also incorporate rehabilitation G, 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

10 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 team G. 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 care G 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 multidisciplinary teams. (Health Canada, 2000) Physiotherapy and primary health care: Evolving opportunities 2

11 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 collaboration G 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. Physiotherapy and primary health care: Evolving opportunities 3

12 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 Professional dominance Passive reception Responsibility Intersectoral collaboration Community participation 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 21 st 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 interdisciplinary G teams ensure care that balances individual, professional, system & societal needs. Physiotherapy and primary health care: Evolving opportunities 4

13 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. Physiotherapy and primary health care: Evolving opportunities 5

14 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 Physiotherapy and primary health care: Evolving opportunities 6

15 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 Physiotherapy and primary health care: Evolving opportunities 7

16 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 prevention G. 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 socioeconomic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as Physiotherapy and primary health care: Evolving opportunities 8

17 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. Physiotherapy and primary health care: Evolving opportunities 9

18 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. 1.3 Health promotion Lewis, 2004 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 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 21 st 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 21 st 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 Physiotherapy and primary health care: Evolving opportunities 10

19 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 multidisciplinary G 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. Physiotherapy and primary health care: Evolving opportunities 11

20 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 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 cofunded 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. Physiotherapy and primary health care: Evolving opportunities 12

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