Collaborative Models of Care Primary Care Relationships

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Shared by the Ontario Chiropractic Association: 

COLLABORATING WITH CHIROPRACTORS IN PRIMARY CARE

When patients have musculoskeletal (MSK) issues, they often begin their health journey in a primary care setting. In 2006-07, 23% of Ontario’s population (2.8 million persons) saw a physician for an MSK disorder. 83.2% of those 2.8 million Ontarians visited a primary care physician at least once for their MSK issue, a number that highlights MSK’s impact on Ontario’s primary care system.1 Chiropractors can assess, diagnose and provide appropriate conservative care for a broad range of MSK conditions.

Recent studies indicate that 75% of family physicians in Canada refer to chiropractors and 78% percent of Canadian spine surgeons are interested in working with non-physician clinicians in screening LBP patients referred for elective surgical assessment.3 Family physicians and nurse practitioners can use chiropractic referrals to free up time for more complex cases and potentially reduce reliance on diagnostic imaging for many MSK disorders.

Many chiropractors are already collaborating with primary care providers in various kinds of referral relationships. Many chiropractors work in multidisciplinary clinics with other manual therapists. Others have referral networks with primary care physicians and nurse practitioners. Some chiropractors have co-located their practice with a primary care team.

CHIROPRACTORS IN INTERPROFESSIONAL PRIMARY CARE TEAMS

All interprofessional primary care teams in Ontario—Aboriginal Health Access Centres (AHACs), Community Health Centres (CHCs), Family Health Teams (FHTs) and Nurse Practitioner-Led Clinics (NPLCs)—may employ chiropractors as allied health professionals. The ability for interprofessional primary care teams to hire chiropractors is a relatively recent development. The number of such formal relationships is small, but growing.

For example, there is an NPLC that has been approved to use unspent salary funding to hire a chiropractor. The chiropractor works at the NPLC several days each week providing care and rehabilitation to their patients. Another NPLC has funded chiropractors within the context of an acupuncture program over the last couple of years.

Multiple CHCs in Ontario are working with chiropractors, who are leading pilot clinics. These clinics are offering assessment, guided exercise support and manual therapy for a range of patients. One AHAC has employed a chiropractor for many years. The chiropractor sees patients referred from primary care providers in the team, as well as patients who self-refer.

In one FHT, a chiropractor has been working as the project lead at the team’s mobility clinic for several years. This chiropractor also serves as a team member in his community’s recently established Health Link and he sees FHT patients at his co-located private practice.

These examples are distinct from the opportunities for interprofessional teams to employ or contract chiropractors through the government’s Primary Care LBP Pilot Program. This pilot will inform the government’s strategy for enhancing LBP care in Ontario and could increase the number of opportunities for chiropractors within the public health care system.

CHIROPRACTORS IN REFERRAL ARRANGEMENTS

The most common type of collaboration between chiropractors and primary care physicians or nurse practitioners is through some sort of referral relationship. Collaborative Models of Care Primary Care Relationships Collaborative Models of Care Primary Care Relationships 2

In most cases, this is an informal partnership wherein family doctors and nurse practitioners develop a relationship with one or more local chiropractors to refer patients they see with MSK conditions. These referred patients usually pay privately for chiropractic care, either through extended health insurance or out-of-pocket. In these informal referral networks the chiropractor has an open, two-way referral relationship with their partners, while working from another location. Most such relationships are ad hoc in nature, though some involve high levels of communication and coordination about shared patients.

Referral networks can become more formalized. Some chiropractors have co-located their private practice within primary care team settings, working alongside MD/NPs. In these models, the chiropractor pays overhead to the practice and in some cases provides pro bono care to patients who do not have extended health benefits and cannot otherwise afford to pay for chiropractic care. The chiropractor and the team may even share administrative functions, maintaining integrated scheduling and electronic medical record (EMR) systems.

CHIROPRACTORS IN VOLUNTEER CLINICS

Not every CHC is currently able to afford to provide chiropractic services. Some chiropractors have established volunteer clinics with these teams to ensure patient access to chiropractic. These volunteer clinics typically operate for two to four hours over the course of a couple of days each week. In some cases there is a single chiropractor providing pro bono services; in other cases a group of chiropractors are working together to share these duties. The patients seen in these clinics face very challenging socioeconomic circumstances and quite frequently have other comorbidities, including mental health issues and chronic conditions like diabetes. Though the models vary, in most cases the patients are referred from other providers working in the CHCs or nearby clinics.

The CHCs at which the volunteer clinics have been established have been able to provide space as well as administrative support in the form of managing referrals, wait lists and appointment bookings. There have even been opportunities to include the chiropractor(s) in the team’s EMR system.

Notably, some volunteer clinics have evolved into funded programs. Establishing these volunteer clinics can position the CHC well should they seek to hire a chiropractor.

Notes 1

MacKay, C., Canizares, M., Davis, A. and Badley, E. (2010). Health care utilization for musculoskeletal disorders. Arthritis Care & Research, 62(2), 161-169. Retrievable from: www.ncbi.nlm.nih.gov/pubmed/20191514

2 Busse, J., Canga, A., Riva, J., Viggiani, D., Dilauro, M., Kapend, P., Harvey, M., & Pagé, I. (2011). Attitudes towards chiropractic: A survey of Canadian family physicians. Oral Presentation Family Medicine Forum November 2011, Montreal.

3 Busse, J., Riva, J., Nash, J., Hsu, S., Fisher, C., Wai, E., Brunarski, D., Drew, B., Quon J., Walter, S., Bishop, P., & Rampersaud, R. (2013). Surgeon attitudes toward nonphysician screening of low back or low back–related leg pain patients referred for surgical assessment. Spine, 38(7), E402-E408, 2013.

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