The Future is Now for Advanced Practice Physiotherapy in Canada

Advanced practice physiotherapy (APP) is a rapidly expanding level of practice impacting the health care system on an international scale.¹ Collaboration is urgently needed to secure and promote the future of APP in Canada. The aim of this editorial is to generate national discussion around key APP issues to ensure sustainability and a successful integration into the Canadian health care system.

Origin of App Roles

APP can be traced to the Vietnam War, when the United States military implemented an APP model of care in response to insufficient physician capacity managing injured soldiers.^2–3 The "upskilling” included learning to triage, order, and interpret diagnostic imaging and provide medical diagnoses, all tasks beyond entry-to-practice education at the time.² In the 1980s, the United Kingdom (UK) adopted APP in response to surging musculoskeletal (MSK) caseload demand.⁴ England subsequently developed post-licensure clinical competencies, mechanisms for regulation of educational programs, and credentialing processes for advanced practice practitioners.^5–8 In 2017, England established a multi-professional framework for advanced practice defining capabilities across the four pillars of clinical practice, leadership and management, education, and research.⁵

Where are We in Canada?

A 2018 survey by World Physiotherapy (WPT) indicated 14 countries, including Canada, recognized APP, although definitions, regulations, and competencies vary by country.² The emergence and growth of APP in Canada has origins in two models, both stemming from health human resource crises in the early 2000s.

The first Canadian APP model was trialed in pediatric rheumatology between 1996 and 2000 at SickKids in Toronto, Ontario.⁹ This model was the foundation for the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program currently credentialled through the University of Toronto's Temerty Faculty of Medicine's Continuing Professional Development.¹⁰ ACPAC education is a post-licensure, competency-based certificate program encompassing advanced assessment and management of MSK and rheumatic diseases. It is Royal College of Physicians and Surgeons of Canada accredited, with 119 graduates working in adult and pediatric orthopedics and rheumatology in various settings.^11,12

The Sunnybrook Holland APP model was established in 2006 to address surging wait lists for adults with hip and knee MSK disorders.¹³ Following a quality improvement framework, education was implemented to develop competencies through a 3-month internship with evaluation by orthopedic surgeons.¹⁴ This project led to the 2018/2019 roll out of Hip and Knee Rapid Access Clinics (RACs) in Ontario, which now exist in over 50 settings.¹⁵

Two decades of research demonstrated the value of APP within Canada providing an evidence-based framework supporting APP models of care and their integration into our health care system.¹⁶ Systematic reviews consistently demonstrate diagnostic accuracy capabilities, reduced wait times, equivalent or improved clinical efficiency, and high patient satisfaction with APP.^1,17,18 Ever-expanding APP roles now exist across multiple care settings in Canada including primary care, emergency departments, specialized medical and surgical care; and opportunities are growing fast.¹⁹ However, with no standardization of APP supported by the physiotherapy profession, confusion persists amongst patients, other health care providers, administrators, and within our own profession as to what defines APP and the opportunities it offers to the Canadian health care system.

A Call to Action

We propose a collaborative inclusive national discussion on APP, working towards common goals that ensure patient needs are met and safety ensured. Immediate priorities include the establishment of (1) a definition of APP; (2) APP core competencies; and (3) accredited education pathways.

Definition of APP

To date, APP in Canada has been developed and defined to meet the specific needs of services, programs, or institutions. This has manifested in disparity in job descriptions, autonomy, responsibilities, and remuneration causing confusion both within the profession and how APP is conveyed to the public and other health care providers.

In Canada, patients have direct access to physiotherapists who practise autonomously, with capabilities to identify medical issues and divert care back to physicians.²⁰ APP moves beyond entry-level of practice to address and lead the care of complex clinical MSK cases that would be typically managed by a physician. This model is supported by WPT's 2019 definition of APP; “the advanced practice physiotherapist has broader knowledge and skills in managing complex patients, often with multimorbidity.”²¹ The UK illustrated this broader practice and contribution to the health care system by emphasizing responsibilities in four pillars of advanced practice – clinical practice, education, leadership and management, and research. Agreement on foundational pillars should also be fundamental to the Canadian definition of APP.⁵

APP Core Competencies

The Canadian physiotherapy profession must now consensually define a minimum competency set for APP. Competencies bring credibility and integrity to professional roles, facilitate regulatory oversight and ultimately protect the patients we serve. While competency frameworks exist in individual countries, currently there are no globally defined APP competencies.²² Tawiah et al. proposed APP competencies developed through qualitative research with international APP leaders including those within Canada.²² With this preliminary work completed, there is opportunity to collaboratively implement these competencies in a Canadian context. This will support an APP definition and provide the framework for high quality education pathways to strengthen our position with key stakeholders in the Canadian health care system with the aim to provide more efficient access and safe care to Canadians.

Accredited Education Pathways

Establishing high quality APP education pathways in Canada will enable career progression and transferability of APP roles across settings and provinces. Until recently, the ACPAC program was one of only 11 accredited programs in the world for APP competency-based education and the only one in Canada.²³ There are now two other APP university-based programs in Canada. Western University in London, Ontario offers master's level programs in Advanced Health Care Practice preparing for APP roles across MSK, orthopedic, and sport settings.²⁴ The Université de Montréal in Québec offers two postgraduate level competency-based training programs to practise in advanced roles in MSK in primary care, emergency departments, or specialized medical care.²⁵

Distinct advantages of programs that are housed in universities are the breadth and knowledge of faculty delivering the curriculum; standardized assessment of learner competencies; evaluation of the program, and robust clinical mentorship. A recent study reviewing existing education pathways supported the notion that APP should be at a postgraduate (post-licensure) masters level of education and assessment processes must be rigorous.⁶ For APP educational programs in the UK and Australia, physiotherapists are required to have several years working experience as a licensed physiotherapist before applying to a post-licensure masters or doctorate degree encompassing the four advanced pillars of practice.^5,6,26 High quality standardized educational pathways then create opportunity for national regulation.

What Next?

The Canadian health care system is struggling to meet patient needs with often inadequate care pathways exacerbated by the COVID-19 pandemic, an ageing population, limited workforce, and constrained health care budgets. There is a precedented need for health care reform and we can offer bold and innovative solutions with APP models of care. As physiotherapists, the time is now to unite and recognize the potential magnitude of the impact of APP on the healthcare system. This requires immediate attention and will involve thoughtful discussion, leadership, and collaboration of stakeholders including patients, physiotherapists, policy makers, and our provincial regulatory bodies. Leadership is paramount and we urge the Canadian Physiotherapy Association to acknowledge and facilitate this urgent call to action to ensure APP opportunities are realized and led from within our profession.