Clinician's Commentary on Maharaj et al.

Primary health care (PHC) addresses a community's main health problems by providing preventive, curative, and rehabilitative services.² It also develops services based on economic, sociocultural, and political conditions.² Maharaj and colleagues¹ described how physiotherapists in Ontario have contributed to the evolution of PHC in this province. Specifically, they studied the perceived barriers to and facilitators of integrating physiotherapists into PHC teams. They interviewed physiotherapists hired into PHC organizations across the province after 2014 and analyzed the transcripts from the semi-structured interviews using qualitative, descriptive methods.¹

Maharaj and colleagues'¹ study identified the most influential factors related to the integration of physiotherapists into PHC organizations: (1) the diversity and novelty of the new physiotherapist's role, (2) other team members' understanding of the physiotherapist's role, and (3) physiotherapists' actions and values regarding PHC. They also recognize that as more physiotherapists fill PHC positions, the role will become increasingly common, and future physiotherapists may experience differences in the integration process. Throughout the article, Maharaj and colleagues¹ identified important concepts related to physiotherapists in PHC in Ontario; these are expanded on here.

Physiotherapists' Role in Primary Health Care

Physiotherapists face personal and team-based challenges during their integration into the new PHC roles in Ontario.¹ The lack of clarity of a role for physiotherapists in PHC is not new; for example, interviews with physicians and nurse practitioners about the roles they perceive for physiotherapists in PHC before 2013 identified a variety of needs.³ These clinicians identified roles for physiotherapists ranging from musculoskeletal experts to chronic disease management specialists who focus on activity counselling, exercise prescription, and self-management.³ In addition, physiotherapists from primary care teams in Ontario identified their roles as dynamic and requiring collaborative and inter-professional practice so that they could respond to the needs of the community and the population they serve.⁴

The diverse and dynamic nature of physiotherapists' role in PHC should be embraced. Physiotherapists have an advanced understanding of the importance of optimizing multi-system functioning to restore function and mobility.⁵ They are also well suited to assess and treat individuals with injuries or disabilities that affect multiple body systems across the lifespan.⁵ Few other health professions have the skills or evidence-based foundation to provide this specific role. More than 4 million Ontarians receive care from 294 inter-professional primary care teams, and these teams are expected to respond to the needs of the populations and individuals they serve.⁶ By displaying flexibility and the dynamic nature of their field's scope and knowledge, physiotherapists who work in PHC are not only educating other clinicians but also ensuring that Ontarians have improved access to care, reduced wait times, and an improved patient experience.⁴

Model of Service Delivery

Maharaj and colleagues¹ also highlighted variations in how PHC physiotherapy is delivered. Specifically, the physiotherapists interviewed delivered service using a 1:1 patient care model (e.g., a physiotherapist working directly with a client) and by developing and delivering group-based programs.¹ McColl and colleagues⁷ identified six components of a comprehensive model for integrating physiotherapy into PHC: clinic-based care, outreach, self-management, community-based rehabilitation, shared care, and case management.⁷ This model has been integrated into some PHC teams to ensure a focus on a population-based approach to care.⁵

Other studies have reported that physiotherapy can make important contributions to alleviating the health care issues of multiple morbidity and chronic pain. In a randomized controlled trial (RCT), Richardson and colleagues⁸ demonstrated that applying a combined, multifaceted occupational therapy and physiotherapy approach (e.g., individual exercise programmes, group self-management classes) to managing individuals with chronic conditions in PHC decreased the number of planned hospital days. This decrease in hospitalizations produced a conservative savings estimate of $490 per person per day, or an overall cost savings for the intervention group of $65,000.⁸ The results of an RCT by Miller and colleagues,^9,10 evaluating the effectiveness of Chronic Pain Self-Management Support with Pain Science Education and Exercise (COMMENCE) compared with a wait-list control, showed that COMMENCE improved function for people with chronic pain (mean difference=−8.0 points on the Short Musculoskeletal Function Assessment; 95% CI: −14.7, −1.3).

Because PHC teams provide services to a large number of individuals, delivering service only through a 1:1 physiotherapy model is not realistic. Physiotherapists in PHC must continue to exercise creativity so that they can maximize access and care for individuals with limited resources. Creative approaches can include using systems navigation to help individuals identify and access existing community resources, using technology to access rural or remote individuals, and continuing to balance a mix of individual and group care. Physiotherapists will also have to increase the sophistication with which patient population groups are stratified to prioritize and allocate services. The ideal composition of delivery is not prescriptive, nor is there a one-size-fits-all model that will facilitate maximal reach and access to service.

Preparing Physiotherapists for a Role in Primary Health Care

Before 2013, only a small number of physiotherapists worked in PHC;^1,5 thus, entry-level or postgraduate training may not have focused on a role for physiotherapists in PHC. Times have changed. With greater PHC employment opportunities comes an increased need to ensure that physiotherapists are prepared to play dynamic and diverse roles. Maharaj and colleagues¹ noted that physiotherapists were challenged by how to develop and implement programs in PHC. In addition, the physiotherapists they interviewed reflected on the diverse nature of their client population.¹ Thus, academic institutions must consider how to integrate into PHC the skills and knowledge related to delivering physiotherapy. Entry-level curricula must ensure that students are provided with foundational skills, such as programme development and evaluation. In addition, training for physiotherapists in PHC needs to include the assessment of multiple systems and individuals with complex needs. Postgraduate courses specific to the delivery of physiotherapy in PHC may also be required, and they should reflect the needs of diverse patient populations and provide accessible and evidence-informed information. Delivery of any postgraduate training needs to be congruent with physiotherapists' role as a busy practitioner.

Policy Change and Advocacy

Integrating physiotherapists more broadly into PHC in Ontario required a significant amount of advocacy by individuals and professional associations. Requests for physiotherapy positions that were not funded by the Ministry of Health and Long-Term Care were acknowledged before the 2013 policy changes.³ Maharaj and colleagues¹ recognized that recent policy changes (e.g., the removal of physiotherapy from the Health Insurance Act) were instrumental in increasing the integration of physiotherapists into PHC organizations across the province. These changes removed policy barriers that limited hiring physiotherapists into some types of PHC organizations and provided funds to implement program-based physiotherapy there.¹

It is now up to the profession to expand the foundation in PHC that current physiotherapists have created. Physiotherapists must generate evidence to support their role in PHC. This evidence may include programme evaluation or quality improvement initiatives using evidence-informed outcome measures, as well as qualitative patient reports. The generation of this evidence needs to be integrated into routine care so as to create a pathway for ongoing advocacy that demonstrates the essential nature of physiotherapy on PHC teams. Partnerships with academic institutions or other PHC staff can provide the resources to address time management demands perceived as barriers to generating this evidence.

Conclusion

Maharaj and colleagues¹ discussed the challenges associated with integrating physiotherapists into PHC organizations in Ontario, and it is an indication that the profession has reached a milestone. The long-awaited broader inclusion of physiotherapy in PHC in the province has been achieved. Physiotherapists in Ontario have risen to the challenge and are working with other PHC team members to put patients and people first by improving their health care experience and health outcomes.¹¹ However, the next generation of clinicians who choose to work in PHC have much to do to further the impact of the profession in this setting.