Volume 6(1), January/February 2004
Increasing access to occupational therapy in primary health care
Donna Klaiman, CAOT Director of Standards and Professional Affairs
For the past decade, Canadian policy makers have been concerned with primary heath-care reform and renewal. In 2000, the Government of Canada announced the $800-million Primary Health Care Transition Fund (PHCTF) to offset transitional costs of moving to a more effective and sustainable primary health-care system. This fund has already successfully built momentum for primary health-care renewal. In 2002, the report of the Commission on the Future of Health Care in Canada (Romanow Report) was released and primary health care was given high priority on the health agenda. The First Ministers agreed to the Health Accord in February 2003 and, with the Government of Canada, created a five-year, $16-billion Health Reform Fund targeted to primary health care, home care and catastrophic drug coverage. First Ministers agreed to make primary health care an integral component of the health-care system reforms (Government of Canada, 2003).
This article will address the developments in primary health care and the initiatives of CAOT to increase access to occupational therapy services in primary health care for the people of Canada.
What is primary health care?
Primary health care is typically the first point of entry to the Canadian health system. It is linked to, and often provides a referring or coordinating function for other specialized health-care sectors as well as community services. Primary health care involves responding to illness within the broader determinants of health. It also includes coordinating, integrating and expanding systems and services to provide more population health, illness prevention and health promotion by all disciplines. It encourages the best use of all health providers to maximize the potential of all health resources (Mable & Marriott, 2002).
Primary health care is delivered in many settings such as the workplace, schools, home, health-care institutions, homes for the aged, nursing homes, day-care centres and community clinics. It is also available by telephone, health information services and the Internet such as www.otworks.ca.
What are CAOT’s interests in primary health care?
Primary health care is high on the agenda of CAOT. Primary health care and occupational therapy share a common comprehensive view of health. Both support the integration of primary health care, health promotion and disability prevention within a continuum of services that meet the needs of people in the most appropriate and cost-effective environment (Canadian Association of Occupational Therapists [CAOT], 2000, 2002b, 2003b).
The primary health-care model (Figure 1) developed by the Canadian Institute for Health Information (CIHI) (CIHI, 2003) entitled Bringing Together Health and Health Care is consistent with our Canadian Model of Occupational Performance (Figure 2). Both place the individual and/or population at the centre of health and health services. The CIHI model illustrates the dynamic relationship among the clients, the primary-care providers, the health concern, the intervention and the environment. Primary health-care providers are active throughout the cycle, promoting health, working with people living with health problems, preventing injury and disease and maximizing their ability to perform their important occupations.
CAOT is working to increase access to occupational therapy services to improve health outcomes and to contain rising health-care costs. CAOT’s 2002 membership statistics reveal that approximately 87 percent of the members work in some aspect of primary health care (CAOT, 2002a). CIHI lists occupational therapists as one of 19 regulated and non-regulated providers of primary health care (2002). While the ratio of occupational therapists to the population is very small in relation to larger professions, CAOT advocates for a significant expansion of occupational therapy services in primary health care.
Despite the increased evidence to support the positive impact of occupation on health (Egan, 2003; Missiuna, 2002; Gowan & Strong, 2002) we continue to experience a shortage of occupational therapists in this area. In fact, many occupational therapists throughout Canada are working in primary health care. The following list includes only a few examples of the services they provide:
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Early identification and treatment of learning disabilities before secondary academic, social and emotional problems occur (Cameron, 2002; Johal, 2002).
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Improving an individual’s ability to return to work or sustain work performance through ergonomic assessments, individual work conditioning programs and other interventions (CAOT, 1997).
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Applying universal design principles to homes, buildings, parks and other public facilities so people of all abilities can participate in all the activities of daily living. This prevents unnecessary dependency and unemployment (CAOT, 2003c).
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Using technology so clients have a chance to maximize their potential and the freedom of increased independence. Occupational therapists ensure the proper fit for individuals in their environment to enable them to do what’s important to them. This may mean simple adaptations to a seniors’ home to prevent falls and conserve energy. It could also be the prescribing of high-tech equipment that enables a person with a high-level spinal cord injury to live independently (CAOT, 2003a).
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Designing stress management, assertiveness training and other lifestyle-management programs to assist people to cope with the stresses of everyday living (Krupa, Radloff-Gabriel, Whippey, & Kirsh, 2002; Lamb 2003).
The issues
There are numerous systemic issues that CAOT will be working on within the next two years to ensure more access to occupational therapy in primary health care. CAOT has entered into discussions with two consortia of health professions and consumers to develop primary health-care-funded projects through Health Canada’s PHCTF. Through this process, CAOT will have the opportunity to influence the debates on some very important aspects of primary health-care delivery. These could include the effectiveness of teamwork versus the individual provider; the need for continuity of client information and relationships and case management; the impact of the current funding structures on primary health-care delivery; clarification of roles and relationships; and occupational therapy human resource planning.
1. Teamwork effectiveness
As the provinces work to deliver better primary health care, they will have the choice of many delivery models of which some have been proposed and developed in Canada and others are emerging through new research. Some primary health-care professionals work independently; others are part of a health-care team. Many experts argue that interdisciplinary primary health-care teams are key to effective health reform. For example, the World Health Organization’s Alma-Ata Declaration Article (1978) points to the importance of teamwork in primary health care. According to the Romanow Commission teamwork is one of the factors that will contribute to transforming the health system: “Teamwork and interdisciplinary collaboration are expected from health-care providers either working in primary health-care organizations or participating in networks of providers” (Commission on the Future of Health Care in Canada, 2002).
While there is widespread support for multidisciplinary and collaborative approaches to the delivery of primary health care some may argue that more evidence is needed to establish whether a multidisciplinary model result is more effective and efficient care (CIHI, 2003).
2. The importance of continuity
CAOT supports a coordinated approach to client service with continuity of relationships, information and management as essential components for the effective way of working with people who are living with complex health problems such as the frail elderly. Reid, Haggerty, & McKendry (2002) describe continuity of care as a broad concept that includes three components:
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Relational continuity: the maintenance of a client-provider relationship over time and consistency of personnel;
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Informational continuity: information on prior events is used to provide service that is appropriate to the client’s current circumstance; and
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Management continuity: service received from different providers is connected in a coherent way.
To ensure continuity for clients, there are programs that tend to rely on interdisciplinary teamwork that are effective in breaking down the barriers between care in the community, long-term care and hospitals. These programs also use case managers to coordinate services, and may include on-call service 24 hours a day, 7 days a week. The goals are to use resources efficiently, rapidly and flexibly to respond to peoples’ needs. One such model is the Services Integres pour les Personnes Agées (SIPA) developed in the Montreal area that uses an interdisciplinary team model. An evaluation of SIPA services revealed that clients of this program tended to:
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make more visits to the primary health practitioners, Centre locaux de services communitaires (often referred to as CLSCs), as well as various community services such as occupational therapy and physiotherapy;
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have fewer visits to emergency departments;
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spend less time in acute care beds while awaiting for housing; and
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use more nursing home and support services.
Overall, the clients perceived that they received a better quality of care (Lebel, 2002).
3. Financing and infrastructure
Canada’s universal health-insurance system was first set up to cover hospital care and later it included physician fees. As a result, public funding now covers almost all physician services, but covers less than half the cost of services provided by a variety of other health professional services (CIHI, 2003). Under the Canada Health Act, occupational therapy services are not covered outside hospitals (Government of Canada, 1985). Under special circumstances, provincial or regional programs may fund primary health-care occupational therapy services. Clearly, Canada lacks a national primary health-care framework with equitable funding mechanisms for primary health-care professions.
A recent study (Starfield & Shi, 2002) revealed that countries with strong primary health-care infrastructures tended to spend less on health overall. Some researchers suggest that how we organize and deliver primary health care will affect not only the costs of the services but also outcomes costs. Canada ranked in the middle group among 13 countries according to its primary health-care infrastructure rating, whereas England and Denmark obtained the highest scores. Canada’s rating suggests that further investments in primary health-care infrastructure to improve overall health outcomes and reduce costs in other parts of the health system.
4. Roles and relationships among primary health-care providers
CAOT recognizes that defining the roles and relationships among the numerous practitioners in primary health care has been noted as one of the most significant and persistent challenges in primary health-care reform (Commission on the Future of Health Care in Canada, 2002; Standing Committee on Social affairs, Science and Technology, 2002). These roles and relationships are affected by many factors, including:
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The predominant focus of the health-care system on hospital and medical care and the consequent lack of value placed on chronic disease management, health promotion, illness and injury prevention;
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The lack of an effective system of transmitting health information to support information and management continuity of the client; and
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A funding model that focuses on fee-for-service for physicians and rewards acute episodic care more than continuing care and health promotion and disease prevention (Steering Committee for Enhancing Interdisciplinary Collaboration in Primary Health Care, 2003). Far too often funding for occupational therapy services are cut to finance more acute, medical services. Unfortunately these decisions provide only short-term relief and can result in greater costs in the long run.
With a few exceptions, as in the case of SIPA, many efforts to reform the primary health-care system have been confronted with the fact that there has been no broadly shared understanding among the many professions delivering primary health-care services. This is with respect to their roles with one another as well as the integration of primary health care with other elements in the health system.
5. Health human resource planning
In spring 2002, CAOT participated in the development of a marketing proposal to encourage students to pursue careers in health. This was submitted to the PHCTF by the Canadian Nurses Association on behalf of many health professional groups. Unfortunately, funding was not granted but the consortium has appealed to the Health Minister to reconsider the decision due to the growing problem with health human resources recruitment and retention. Nevertheless, CAOT has initiated other projects with Health Canada to develop a plan for human resource planning in occupational therapy.
Initiatives
The development of two very extensive proposals with consortia of health professionals and consumers provided CAOT with the opportunity to advocate and achieve agreement to work towards improvements in teamwork, continuity, funding, roles and relationships in primary health care. The consortia are seeking funding from Health Canada’s PHCTF for the following two initiatives. Each consortium expects a response from Health Canada, regarding funding for the studies, early in 2004.
1. Enhancing Interdisciplinary Collaboration in Primary Health Care
The focus of the project is to enhance the effective and efficient delivery of primary health care in Canada. This will be accomplished through a comprehensive change process that will involve the major stakeholders: primary health-care practitioners (and their national and provincial/territorial associations), governments, regional health authorities, the public, regulators and funders (Steering Committee on Enhancing Interdisciplinary Collaboration in Primary Health Care, 2003).
To support and orient the change process, a set of principles and a framework will be developed to better define the relationship between the various practitioners that make up a primary health-care system, and how primary health care integrates with other elements in the health system. This will not be a delivery model for primary health care, per se; given the multiplicity of jurisdictions and conditions across the country, developing one model to fit all needs would not be realistic. Rather, the principles are intended to guide the development of the primary health-care system, and the framework will describe the characteristics of a systemic approach to primary health care and the elements required to support the operation of such a system.
The principles and framework developed through this project will be shared through several media including a national web site. A final report will be distributed to the members of the consortium, provincial partners and other organizations.
For more information, contact by e-mail.
2. The Canadian Collaborative Mental Health Care Project (Steering Committee, 2003)
This project will develop strategies for implementing collaborative care approaches to meet the mental health needs of Canadians by drawing upon the expertise of existing primary health-care providers within communities. This project is developed by a consortium of 12 national organizations to develop a charter on the shared vision of collaborative care. As these organizations represent primary health-care providers, specialized mental health-care providers, consumers and other providers from across Canada, commitment to the charter will facilitate changes to how primary health-care providers work with individuals living with mental health problems and how they are linked to mental health-care providers. To ensure that collaborative care approaches are sustainable over the long term, recommendations and strategies to financially support collaborative care activities will be an important component of this project.
The project has been designed to assist communities with special needs in developing local, and as such, relevant strategies to adapting collaborative care approaches to meet the mental health needs of the members of their community. Within this context, the term “community” is not limited to a geographic definition, but includes a group of people that share one or more characteristic. For example, collaborative care strategies will be developed to assist in addressing the mental health needs of special populations, which may include ethno-cultural communities, First Nations communities, homeless populations, people with serious mental illness, as well as communities defined by geographical area, such as rural or isolated communities. Although these strategies will be local and community driven, many of the strategies will have common characteristics that can be generalized to other communities or groups of Canadians.
If funded, the strategies developed through the project will be shared in a similar way as described in the interdisciplinary collaboration project. By ensuring access to the information gathered through this project, other organizations and individuals can continue to build on its findings. For more information, contact e-mail.
References
Cameron, D. (2002). Occupational therapy in action: Using the CO-OP program. Occupational Therapy Now, 4(5) 6-7.
Canadian Association of Occupational Therapists. (1997). Position statement on occupational therapy and ergonomics. Retrieved November 18, 2003, from http://www.caot.ca/default.cfm?ChangeID=165&pageID=155
Canadian Association of Occupational Therapists. (2000). Position statement on primary health care. Retrieved on October 31, 2003, from http://www.caot.ca/index.cfm?ChangeID=2&pageID=188
Canadian Association of Occupational Therapists. (2002a). CAOT Membership Statistics 2002. Ottawa, ON: Author.
Canadian Association of Occupational Therapists. (2002b). Enabling occupation: An occupational therapy perspective - Revised Edition. Ottawa, ON: CAOT Publications ACE.
Canadian Association of Occupational Therapists. (2003a). Position statement on assistive technology and occupational therapy. Retrieved November 18, 2003, from http://www.caot.ca/default.cfm?ChangeID=23&pageID=598
Canadian Association of Occupational Therapists. (2003b). Position statement on everyday occupations and health. Retrieved October 31, 2003, from
http://www.caot.ca/default.cfm?ChangeID=164&pageID=699
Canadian Association of Occupational Therapists. (2003c). Position statement on universal design and occupational therapy. Retrieved November 18, 2003, from http://www.caot.ca/index.cfm?ChangeID=1&pageID=622
Canadian Institute for Health Information. (2003). Health care in Canada. Ottawa, ON: Author.
Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada - final report. Ottawa, ON: Government of Canada.
Egan, M. (2003). Occupational therapy at home and in the community for people with sub-acute conditions. Occupational Therapy Now, 5(5), 13-15.
Government of Canada. (1985). Canada Health Act. Retrieved November 5, 2003, from http://www.hc-sc.gc.ca/medicare/chaover.htm
Government of Canada. (2003). The health care renewal accord. Retrieved November 3, 2003, from http://www.hc-sc.gc.ca/english/hca2003/primary.html
Gowan, N., & Strong, S. (2002). The expanding world of occupational therapy. Occupational Therapy Now, 4(5) 9-13.
Johal, H. (2002). Primary care: Early identification of DCD. Occupational Therapy Now, 4(5) 7-8.
Krupa, T., Radloff-Gabriel, D., Whippey, E., & Kirsh, B. (2002). Reflections On…Occupational therapy and assertive community treatment. Canadian Journal of Occupational Therapy, 69(3), 153-157.
Lamb, M. (2003). A light heart is a healthy heart: Stress management for people with cardiac problems. Occupational Therapy Now, 5(5), 23-24.
Lebel, P. (2002). Les résultats de l’évaluation du projet de demonstration SIPA: Qualité des sois et des services. Paper presented at L’éxperience SIPA: Une practique interdisciplaire, ancrée dans la communauté, Montréal, QC.
Mable A. L., & Marriott, J. (2002). Sharing the learning — The health transition fund synthesis Series: Primary health care. Ottawa, ON: Health Canada.
Missiuna, C. (2002). Poor handwriting is only a symptom: Children with developmental coordination disorder. Occupational Therapy Now, 4(5), 4-6.
Reid, R., Haggerty, J., & McKendry, R. (2002). Defusing the confusion: Concepts and measures of continuity of health care. Prepared for the Canadian Health Services Research Foundation, the Canadian Institute for Health Information and the Advisory Committee on Health Services of the Federal/ Provincial/Territorial Ministers of Health. Ottawa: ON.
Standing Committee on Social affairs, Science and Technology. (2002). The health of Canadians – the federal role. Final report, Volume 6: Recommendation for reform. Ottawa, ON: Government of Canada.
Starfield, B., & Shi, L. (2002). Policy relevant determinants of health: An international perspective. Health Policy, 60(3), 201-218.
Steering Committee on Enhancing Interdisciplinary Collaboration in Primary Health Care. (2003). Enhancing interdisciplinary collaboration in primary health care 2003: Proposal to the primary health care transition fund, Health Canada. Unpublished document.
Steering Committee. (2003). Canadian Collaborative Mental Health Care Project. Proposal to the Primary Health Care Transition Fund, Health Canada. Unpublished document.
World Health Organization. (1978). Alma-ata declaration (Article V1). Geneva: Author.
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