Integrating Physiotherapists into Publicly Funded Primary Care: A Call to Action

Musculoskeletal disorders (MSDs) are a leading cause of disability, and they place a substantial burden on primary care services in Canada. Every year, almost one-quarter of the Canadian population consults a primary care physician for MSDs.¹ Yet most people with MSDs can be managed by a physiotherapist and do not need to see a physician.² Physiotherapists deliver cost-effective interventions for people with MSDs,³ and they have a comprehensive knowledge of this field.⁴ They have been recognized as key providers of primary care services for people with MSDs because of their expertise in assessing² and managing this patient population;⁵ for example, their interventions have been associated with a decrease in pain for various MSDs⁶ as well as with fewer medical consultations and drug prescriptions for individuals with knee osteoarthritis⁷ and low back pain.⁸ Furthermore, studies have shown that physiotherapists are regarded with a high level of satisfaction and confidence as primary care practioners.² They can contribute to the promotion of healthy lifestyles and the prevention of chronic diseases,^5,9 two main components of primary care services. Therefore, it is critical to ensure that physiotherapists are fully integrated into publicly funded primary care settings.

However, integrating physiotherapists into inter-professional primary care teams in publicly funded settings is not common practice in Canada. For example, in 2012, although 46% of Canadian physiotherapists worked in hospitals or residential care facilities and 20% worked in solo professional practice, only 3% worked in community health centres.¹⁰ The lack of physiotherapists on primary care teams was considered to be “a critical gap in current care provision,”^5(p.462) and 79% of Canadian family physicians reported unsatisfactory access to publicly funded physiotherapists.¹¹

Inter-professional models of care that integrate physiotherapists into primary care settings have been proposed as a way to improve the management of people with MSDs.⁵ Ontario's family health teams (FHTs) are considered to be a promising inter-professional primary care model,¹² and recent political efforts have resulted in the integration of physiotherapists into FHTs in that province. The results of a survey of decision makers, physicians, physiotherapists, and nurses have indicated that having a physiotherapist in an FHT is an optimal model of practice.¹³

The presence of an on-site physiotherapist can enhance communication with other members of the team;¹³ it can also facilitate physiotherapists' involvement in managing patients with chronic conditions and improve these individuals' access to physiotherapy.¹³ Furthermore, this model of practice enhances the coordination and continuity of care, and it promotes mutual trust among health care professionals.¹⁴ Some barriers, however, to integrating physiotherapists into FHTs have been reported: lower salaries compared with hospitals or private practice, challenges to providing the space and equipment needed to offer physiotherapy services, and difficulties in defining their roles and scope of practice.¹³

Integrating physiotherapists into primary care settings would improve the coordination of care for people with MSDs because locating physiotherapists and family physicians in the same working environment enhances inter-professional collaboration through formal and informal communications.¹⁴ These communications may include “team meetings, inter-professional committees, case conferences, brief daily ‘team huddles,' education rounds, team retreats, and hallway conversations.”^15(p.11) Moreover, inter-professional collaboration in primary care settings improves team members' understanding of each professional's scope of practice,¹⁵ a relevant argument considering that some family physicians reportedly lack knowledge about physiotherapy.¹⁶

Physiotherapists can contribute to primary care teams by playing many roles: manager, evaluator, collaborator, educator, and advocate.¹⁷ Dufour and colleagues¹⁷ found that most physiotherapists acted as managers, a role the authors referred to as the responsibility to respond to patients' needs using the various interventions (e.g., individual or group treatments) and resources available (e.g., alternative rehabilitation resources, community organizations). Physiotherapists' contributions also vary from one primary care setting to another, and they evolve according to the specific needs of each one.¹⁷ In a qualitative study conducted in Ontario, family physicians and nurse practitioners acknowledged physiotherapists' ability to give “meaningful advice related to self-management, specifically in the areas of physical activity counselling and exercise prescription.”^5(p.463)

Integrating physiotherapists into primary care settings is also a valuable opportunity for the health care system to extend the role of physiotherapists and advocate for advanced-practice physiotherapy models of care (e.g., triage in emergency and orthopaedic departments). These models have been found to increase access to care in a safe and efficient manner while maintaining the satisfaction of patients and medical providers.¹⁸ Advanced-practice physiotherapists in more autonomous roles are able to adequately provide a valid diagnosis for individuals with MSDs and efficiently refer them to other providers when required.¹⁸ Finally, integrating physiotherapists into primary care teams can improve the caseload management of physicians, reduce unnecessary diagnostic tests or referrals, and enhance the care of people with MSDs.⁵

We have presented several arguments that justify the need to increase efforts to integrate physiotherapists into primary care settings and to further promote developing and implementing models of care in which physiotherapists are key primary care providers. Ontario's experience of integrating physiotherapists into FHTs should inspire other Canadian provinces to follow through with such initiatives. The implementation, effectiveness, and sustainability of these models of practice will likely depend on sufficient financial investments and political support. Therefore, governments, professional organizations, and physiotherapists, among other actors, need to demonstrate strong leadership and work together to facilitate this emerging trend.