Finalize the Implementation of the Bill 179 Scope of Practice Changes for Ontario Physiotherapists

Transcription

1 Submissin t the Ministry f Health and Lng-Term Care t Finalize the Implementatin f the Bill 179 Scpe f Practice Changes fr Ontari Physitherapists December 20, 2017

2 Scpe f Practice Changes Abut Which Additinal Infrmatin Has Been Requested: 1) T rder certain labratry tests 2) T rder x-rays 3) T apply sundwaves fr diagnstic ultrasund under certain cnditins NOTE: The request submitted in 2008 did nt request the authrity t apply sundwaves. What the prfessin requested was the authrity t rder the applicatin f a prescribed frm f energy, in this case sundwaves fr diagnstic ultrasund. The prfessin specifically indicated that it had n intent t apply this frm f energy. 1 Review f 2009 Submissin In 2008, as part f the Minister f Health and Lng-Term Care agenda t imprve inter-prfessinal care and t ptimize the health care wrkfrce, the Cllege f Physitherapists f Ontari (the Cllege) and the Ontari Physitherapy Assciatin (OPA) were asked t submit t the Health Prfessins Advisry Cuncil (HPRAC) a scpe f practice review fr physitherapy in Ontari. After extensive cnsultatin and research, the reprt was submitted n June 30, HPRAC prceeded with a full public cnsultatin including nline psting f the submissin and jurisdictinal review and in-persn twn hall meetings held in Windsr, Thunder Bay, Trnt and Ottawa. HPRAC recmmended all but ne requested change in their reprt Interprfessinal Cllabratin Interim Reprt - Phase II, Part I, September All recmmended changes frm this reprt were included in Bill 179, which was subject t debate in the legislature and review by the Standing Cmmittee n Scial Plicy. The legislatin passed with all-party supprt. Ryal Assent was granted in December 2009 and the majrity f the scpe changes were prclaimed in September Remaining changes included in Bill 179 awaiting implementatin are the rdering f labratry tests and diagnstic imaging. Yu have asked fr the infrmatin set ut belw. 1 OPA & CPO, 2008, p. 17 Final Implementatin: Scpe Changes (December 20, 2017) Page 2 f 37

3 GENERAL INFORMATION: 1. An updated list f labratry tests the prfessin is requesting access t, the settings in which the tests wuld be used in (e.g., cmmunity practice, lng-term care, acute care settings, etc.), a brief descriptin f the purpse f each test and relevance t the practice f physitherapy. The use f a defined list f tests in a regulatin has the ptential t limit the ability fr patients t access apprpriate testing. This scenari results in a number f prblems including: The need t find alternative health prfessinals wh can rder the needed tests The waste f health care resurces simply t have these investigatins rdered A ptential fr the fragmentatin f care and a cnsequent increase in the number f care transitins which are knwn t increase patient risk Delay in the prvisin f needed care The Cllege is prpsing a regulatin change that reflects physitherapists current scpe f practice and cmpetencies and is flexible in rder t allw care t adapt t innvatins in physitherapist s practice. Clinical standards fr the chice f apprpriate diagnstics and labratry testing change quickly and are ften based n research and evidence-based best practices. Tests that were nce cnsidered t be ptimal are frequently replaced with new and mre reliable nes. Current and evlving physitherapy practice and best practice standards ften require testing fr cnfirmatin f diagnsis and t ensure patient safety befre prceeding with a recmmended curse f actin. Recmmendatin: Revise s.9(1)(a) f Regulatin 682/90, Labratry and Specimen Cllectin Centre Licensing Act, Labratries, t permit physitherapists t rder labratry tests as apprpriate fr patients, as fllws: 9. (1) The wner and the peratr f a labratry shall ensure that the staff f the labratry, (a) examine specimens frm humans nly, (i) at the request f a legally qualified medical practitiner r a dentist, (ii) at the request f a midwife, in respect f a test specified in Appendix B; (ii.1) at the request f a persn wh lawfully practises a health prfessin in a jurisdictin utside Ontari, if in that jurisdictin a labratry may lawfully examine specimens at the request f that persn, (iii) at the request f an insurer r an agent within the meaning f the Insurance Act, in respect f HIV Antibdy testing, (iv) at the request f a registered nurse wh hlds an extended certificate f registratin under the Nursing Act, 1991, (v) at the request f a persn wh is a participant in the prvincial clrectal cancer screening prgram, in respect f a test r tests fr the purpses f the prgram, r Final Implementatin: Scpe Changes (December 20, 2017) Page 3 f 37

4 (vi) at the request f a member f the CIIege f Naturpaths f Ontari, in respect f a test specified in Appendix C; (vii) at the request f a physitherapist wh hlds a certificate f registratin under the Physitherapy Act, Ratinale: Physitherapy patients shuld have timely access t all diagnstic tests that are needed during their physitherapy care. As primary health care prviders, physitherapists require authrity t rder the labratry tests needed fr patients during physitherapy care. Physitherapists have the knwledge and skill t safely and effectively rder labratry tests within their scpe f practice. The use f a list f tests that will quickly becme bslete des nt accurately reflect physitherapists respnsibilities nr the public's expectatins f quality care, and presents a barrier t access t care. There is n increased risk t the public by having physitherapists rder tests within their scpe f practice, since physitherapists already wrk within the bundaries f the Physitherapy Act, the prfessinal miscnduct regulatin and the standards f the prfessin. The experience f ther prfessins, such as nurse practitiners, demnstrate that the resurces required t maintain test lists is nt sustainable nr is it necessary t maintain public safety. Since 2011, nurse practitiners wh were nce limited t rdering tests t a list in Appendix A, are nw permitted t rder tests as apprpriate t client care and n issues relating t this revised practicing authrity have been identified by the Cllege f Nurses f Ontari. 2. Updated prfile f the prfessin and its practice, specifically addressing the fllwing cnsideratins: a) Hw many members are registered t practice with the cllege? As f Nvember 22, 2017, there are: 9304 members in the independent practice categry 359 in the prvisinal practice (i.e. resident ) categry. Final Implementatin: Scpe Changes (December 20, 2017) Page 4 f 37

5 b) Hw many registered members will be impacted by this change? 26% f physitherapists surveyed indicated that they already request labratry tests and/r diagnstic imaging in rder t frmulate a diagnsis within their scpe r t develp a treatment plan. 2 If autnmy were t be cnferred, recent research n the tpic suggests that up t 72% f Ontari physitherapists wuld rder diagnstic imaging. Respndents with mre than a 50% caselad in rthpaedics were the mst interested in rdering these investigatins, hwever thse in ther areas f practice als expressed a significant degree f interest. 3 Diagnstic Imaging With respect t current educatinal activities, Physitherapists in Ontari have pursued pst graduate degrees and/r certificate prgrams t acquire additinal skills and cmpetencies related t rdering diagnstic tests. Sme mre cmmn surces fr this type f educatin are as fllws: Apprximately 120 physitherapists have graduated frm Western University s Advanced Health Care Practice Manipulative Therapy Prgram (MClSc). All have received training that wuld meet the Cllege s requirements t practice the authrity fr rdering diagnstic imaging. The University f Alberta Diagnstic Imaging fr Physical Therapists nline curse has been cmpleted by 20 Ontari physitherapists. Apprximately 45 Advanced Practice Physitherapists (APP) practicing in Ontari have received training thrugh the University f Trnt, Faculty f Medicine, Advanced Clinician Practitiner in Arthritis Care (ACPAC) prgram r thrugh residency prgrams ffered thrugh hspital sites. 4 Nte: the number f rles fr physitherapists with these additinal cmpetencies is expected t cntinue t grw with patient demand. Sme examples f this trend include: It will cntinue t grw t apprximately 70, with the expansin f the CIAC mdel fr all LHINs as part f the MOHLTC Patients First Act, Access t Specialists and Specialty Care Strategy. 5 2 OPA, Chng et al, p. 4 4 Lundn, Rbarts, 2017 Final Implementatin: Scpe Changes (December 20, 2017) Page 5 f 37

6 The expansin f the ISAEC mdel t all LHINS as part f the MOHLTC MSK strategy will add a significant number f APPs (e.g. 26 in Champlain LHIN). 6 Changes in the use f medical directives at Trnt Central LHIN Cmmunity Health Centre netwrk has ptential t expand the use f physitherapists with these additinal cmpetencies prvince-wide. 7 Ordering Lab Tests The rster des nt fully represent thse wh may be practicing in these specialized areas because physitherapists wh perfrm these acts under directin r delegatin frm anther practitiner are nt required t rster. The practice areas mst affected by the authrity t rder labratry tests are rthpaedics, rheumatlgy, cardirespiratry and wund care. Since 2008, 8 physitherapists have graduated frm Western University s Advanced Health Care Practice, Wund Care Prgram (MClSc). Numerus thers have taken advanced training in the use f mdalities in wund care management and 14 physitherapists have cmpleted levels 1 and 2 f the OPA Wund Care Management fr Physitherapists prgram. Physitherapists wrking in advanced practice rles with hip and knee arthrplasty patients rder labs tests t mnitr fr abnrmal cbalt and chrmium levels in patients with hip arthrplasty t btain indicatins f cmpnent lsening r misalignment which can lead t metallsis, as well as ther ptential health prblems f the 9663 physitherapists in Ontari are rstered t administer a substance by inhalatin; which gives an idea f hw many wrk in cardirespiratry practice. This may be an underestimate since sme hspital still use medical directives. c) Practice Setting (e.g., % f members practicing in cmmunity r acute settings) We are unable t distinguish between acute and cmmunity settings. Hwever, accrding t the Canadian Institute fr Health Infrmatin data n physitherapist demgraphics in Ontari, 3,113 r 44.3% f physitherapists practice in the public sectr and 3,909 r 55.7% f physitherapists are in the private sectr including selfemplyed. 9 6 Crreal, Stevensn, Hpe, CIHI, 2016 Final Implementatin: Scpe Changes (December 20, 2017) Page 6 f 37

7 OPA data indicates that apprximately 80 physitherapists are currently emplyed r in partnership with 60 primary health care settings (i.e., cmmunity health centres, family health teams, abriginal health access centres) acrss the prvince, and the number is grwing. d) Practice Characteristics (e.g., % in independent practice, % practicing in interprfessinal teams) The Cllege des nt cllect data n the percentage f peple in independent practice versus practicing in interprfessinal teams. Anecdtal feedback indicates increasing prevalence f multidisciplinary teams. March 31, 2017, data indicates that 68.74% f physitherapists practice with at least ne ther prfessinal. A 2014 reprt indicates the prfessins that physitherapists mst cmmnly interact with. 10 In descending rder f degree f interactin: Occupatinal therapists Nurses Family dctrs Orthpaedic surgens Other physician-specialists Dieticians Massage therapists Physical medicine and rehabilitatin physicians (physiatrists) Psychlgists Kinesilgists Chirpractrs. OPA data indicates that apprximately 80 physitherapists are currently emplyed by r in partnership with 60 primary health care teams (i.e., cmmunity health centres, family health teams, abriginal health access centres) acrss the prvince, and the number is grwing. e) Gegraphical Distributin (e.g., % practicing in rural/remte lcatins, % in urban lcatins) The mst recent data available frm the Canadian Institute fr Health infrmatin indicates that physitherapists are: % urban 5.3% rural. 10 Nrman, p CIHI, 2017 Final Implementatin: Scpe Changes (December 20, 2017) Page 7 f 37

8 A recent Cllege study determined that the distributin f physitherapists reflects general ppulatin distributin: 12 LHINs 1-4 (Suthwestern Ontari) 26% LHINs 5-9 (Central Ontari) 43% LHINs (Eastern Ontari) 22% LHINs (Nrthern Ontari) 9%. f) General demgraphics f principal patient grups treated by the prfessin (e.g., age, mrbidities, gegraphic distributin) Physitherapists prvide care under fur categries f mrbidity: neurmusculskeletal (a brad categry including rthpaedics, rheumatlgy, amputatins etc.) neurlgical cardipulmnary-vascular multifunctin. 13 N gegraphic distributin data is available abut patient grups. g) Descriptin f remuneratin mdel fr the prfessin (e.g., % OHIP-insured services, % privately insured services, % uninsured services) Peple can access physitherapy services directly withut the need fr a physician referral. Hwever, in sme circumstances, such as publicly funded Cmmunity Physitherapy Clinics r sme extended health insurance plans, a physician r nurse practitiner referral is required t access funding. Further details abut the distributin f care by funding surces: Primary health care rganizatins Hspital in-patients Eligible hme care patients thrugh the LHINs Residents f publicly funded Lng-Term Care hmes under a per bed, per annum funding allcatin Eligible patients 14 at apprximately 256 Cmmunity Physitherapy Clinics. The Interim Federal Health Prgram (IFHP) prvides limited cverage fr specific grups in Canada, including refugees. Publicly-Funded insurance prgrams ffering cverage fr physitherapy care include: 12 Nrman, p Nrman, pp Eligibility requires: a physician s r nurse practitiner s referral fr physitherapy services and fall within ne f the fllwing categries: 19 years ld r yunger, 65 years ld r lder; r receiving benefits under the Ontari Disability Supprt Prgram r Ontari Wrks, r have been vernight in a hspital fr a cnditin that nw requires physitherapy treatment. Final Implementatin: Scpe Changes (December 20, 2017) Page 8 f 37

9 Wrkers Safety and Insurance Bard (WSIB) Mtr Vehicle Accident (MVA) cverage thrugh autmbile insurers Veteran s Affairs benefit packages fr veterans. PATIENT AND/OR SYSTEM NEED: The 2008 plicy submissin primarily links the expanded scpe t the cmpetency f the prfessin. The Ministry is seeking mre infrmatin and supprting evidence n hw the prpsed changes t scpe f practice meet patient and/r health system needs. Fulfilling Ontari s Patients First: Actin Plan fr Health Care demands imprving access t care t ensure that patients receive the care that they need frm the right prfessinal at the earliest visit. System waste prevails where physician r nurse practitiner referrals are required t justify funding fr physitherapy appintments, when there is n clinical r regulatry requirement fr the referral itself. This prblem is perpetuated when patients are diagnsed by a physitherapist but are required t schedule an appintment with anther health prfessinal t btain rders fr test results t cnfirm the physitherapist s diagnsis. There is n clinical justificatin fr these visits, as physitherapists are enabled t diagnse within their scpe f practice. Accrdingly, in every case, an unnecessary visit t the nurse practitiner r physician adds cst t the public system and takes space in the busy practitiner s schedule. This culd have been filled by a patient with a clinical need, and fr the patient wh is likely t have undergne physical hardship, travel expenses, lss f incme and travel csts in rder t attend the appintment. Further patient hardship arises due t delays in btaining cnfirming diagnstic test results when they are unable t access thse with rdering authrity and/r physitherapists are unable t arrange t have ther health care prfessinals rder these tests. An verview f changes t the health system that underpin patient expectatins f better care is prvided by Waddell, Mat and Lavis. 15 While their paper is intended t prvide backgrund n the discussins f new ways t regulate health prfessins, the changes they identify are als significant when cnsidered in the cntext f patient needs and desires. Patients express changing expectatins abut the services that shuld be prvided by health prfessinals: the health wrkfrce requires flexibility and a nimbleness tward patient care that the current legislative apprach des nt prvide. The public is cncerned abut the ability f the health system t deliver quality patientcentred care, especially the nging restrictins in scpes f practice which hamper the increasing need fr prfessinals t adapt hw they prvide care. 15 Waddell et al, p. 11 Final Implementatin: Scpe Changes (December 20, 2017) Page 9 f 37

10 The shift away frm acute institutinal care t mre cmmunity and team-based inter-prfessinal care creates different demands n the system, which has significant implicatins fr the rles f health prfessinals. The physitherapy scpe f practice changes apprved by the Legislature (Bill 179) in 2009 represented an integrated package and anticipated the enhancements referenced abve in terms f what patients want and need frm the Ontari health care system, and what the system needs t meet thse prmises nw and int the future. IMPACT ASSESSMENT: The Ministry is seeking further infrmatin fr an evidence-infrmed impact assessment f each change in scpe f practice. Impact t Patients Fr the fllwing questins cnsider and make nte f whether impacts are different fr certain patient ppulatins. 3. Describe the impact f the prpsal n patient utcmes. The clinical diagnstic accuracy and the care prvided by physitherapists fr rthpaedic cnditins is mre accurate than that ffered by a wider range f ther health prfessinals, including family physicians and physician assistants. 16 With the scpe changes, physitherapists can have significant impact n the system, n patient utcmes, and n the prductivity f ther prfessinals. 17 The use f specially trained physitherapists in hspital rthpaedic settings is cst-effective and increases patient satisfactin. 18 In a 2011 survey f members cnducted by OPA, 67% f respndents experienced difficulty in btaining the diagnstic imaging r labratry test results that they require t frmulate a diagnsis r develp a treatment plan within their scpe f practice. 19 Repercussins f experiencing difficulty in accessing tests included: delayed recvery and treatment, financial hardship as patients are nt able t return t wrk, decreased quality f care and verall patient utcmes. The use f medical directives t rder diagnstic imaging in a Trnt-based Cmmunity Health Centre has imprved efficiencies by reducing the need fr patients t return t their 16 Ramji, et al OPA & CPO, 2008, p OPA & CPO, 2008, p OPA, 2011 Final Implementatin: Scpe Changes (December 20, 2017) Page 10 f 37

11 primary care prvider fr a requisitin. Althugh this mdel is successful with the use f a directive, it wuld be even mre effective if physitherapists were able t rder them withut the use f a directive Describe the impact f the prpsal n timely access t care. Delay in patient treatment is the reprted cnsequence f physitherapists difficulty in btaining diagnstic imaging r labratry test results. 21 This results in negative utcmes including: delayed diagnsis, increased cmplicatins, nset f secndary cnditins, increase and prlnging f pain, delayed return t wrk, and feelings f frustratin fr bth patients and care prviders. Permitting physitherapists t rder investigatins will: increase timeliness f care delivery reduce care needs arising frm treatment delays reduce unnecessary expenditures such as transprtatin t and frm appintments, cst f care-givers, and pprtunity csts such as missed time at wrk. 22 Use f physitherapists practicing with these additinal cmpetencies can reduce wait times and imprve access t patient care, while als maintaining a high level f patient satisfactin. 23 Significant reductin in wait times was assciated with the use f physitherapists taking n rles with additinal cmpetencies in diagnstics in an rthpaedic shulder clinic. Thrugh the incrpratin f physitherapists services int the clinic, wait times fr surgery drpped frm 198 days t 75 days ver a three-year perid. 24 In the 2008 Physitherapy Scpe f Practice submissin t HPRAC, the OPA and the Cllege indicated that an expanded scpe f practice fr physitherapy wuld prmte increased efficiencies by eliminating the need fr medical directives where nt warranted, and permit a physitherapist t fully cllabrate, using a prven skill set, with all health care prviders t imprve access t care and better utcmes fr Ontarians. 25 In a study cnducted by Davis et.al. as reprted in the OPA/CPO 2008 HPRAC submissin, Health prfessinals, such as physitherapists, with advanced skills and training wh wrk in an interdisciplinary team, have the ptential t facilitate timely and apprpriate access t the right prvider fr peple with arthritis and musculskeletal cnditins. Further, this study bserved that utilizatin f such prviders in primary care fr patients with musculskeletal cmplaints and thrughut the cntinuum f care fr peple with all 20 Stevensn, OPA, OPA, Razmju, et al Razmju, et al p 6 25 OPA & CPO, 2008, p. 23 Final Implementatin: Scpe Changes (December 20, 2017) Page 11 f 37

12 types and severity f arthritis has the ptential t imprve access t care by the right prvider and ultimately imprve patient and system level utcmes. 26 When a patient presents directly t a physitherapist with a prblem that may require diagnstic imaging, the patient must be referred t a physician wh can rder the test. In a hspital withut medical directives permitting physitherapists t rder diagnstic tests, time is spent btaining rders rather than caring fr patients. 27 When physitherapists act as primary health care prviders and rder diagnstic imaging and lab tests, they prvide increased access and better treatment utcmes fr marginalized grups such as senirs, the Abriginal ppulatin, thse living with a disability, and thse living in rural and remte areas. Case Example: an elderly client living in remte nrthwestern Ontari cmmunity has been cmplaining f leg pain and is having truble walking after a fall he had a week ag in his hme. He is seen by a physitherapist wh flies int a neighbring cmmunity clinic nce every 3 weeks t prvide physitherapy care t the cmmunity and surrunding area. The PT suspects that the patient has sustained a fracture and immediately rders an x-ray t cnfirm their diagnsis. In a recent TC LHIN evaluatin n physitherapy services prvided in Cmmunity Health Centres, ver 78% f the cnditins identified fr clients assessed ver the 2-year perid were fr musculskeletal cnditins. 28 In sme primary health care rganizatins, these referrals are being directed t the physitherapist as the primary care prvider fr these cases. Patients requiring diagnstic tests culd have these tests rdered by the physitherapist, directly leading t mre timely access t the tests, results, and changes t treatment apprach as needed. This has the ptential t imprve utcmes fr the patient and imprve the patient s verall health care experience and satisfactin with the system. 5. Describe the impact f the prpsal n equity f health care. The changes will: Enhance and expand public access t apprpriate care. 29 Increase patient access t services, particularly in rural and remte regins and amng marginalized ppulatins. 30 Needed care will nt be delayed as the physitherapist can immediately respnd t cmmunicate abut r act n functins invlving cntrlled acts OPA & CPO, 2008, p HPRAC, 2008, p TCLHIN, OPA &CPO, 2008, p OPA &CPO, 2008, p OPA &CPO, 2008, p. 22 Final Implementatin: Scpe Changes (December 20, 2017) Page 12 f 37

13 Withut having t take r repeat extra steps t see a physician r nurse practitiners t btain an rder fr a needed diagnstic prcedure, patients will be able t receive care faster, and physitherapists will be able t prvide care t mre patients Describe the impact f the prpsal n patient preferences. Direct access t diagnstic infrmatin rdered by physitherapists can impact diagnsis and treatment apprach, which in turn impacts utcmes fr the patient. Reduces cyclical referrals t physician r nurse practitiner t have tests rdered, tests ften identified/recmmended by physitherapists, which impacts access t care. Thse wh d nt have access t specialist care in rural remte cmmunities will have access t timely diagnsis and (equity f health care). Thse withut a primary care prvider (physician/nurse practitiner) r thse wh experience barriers t accessing their primary care prvider (wait times, incnvenient hurs) will have access t diagnstics infrmatin rdered by physitherapists, which will help direct care r need t refer t specialist care. Impact t the Health System Fr the fllwing questins cnsider and make nte f whether impacts are different based n the different practice lcatins and/r characteristics f the prfessin. 7. Describe the impact f the prpsal n gvernment strategic bjectives. Patients First: Actin Plan fr Health Care. The plan has fur key bjectives: 1. Imprve access prviding faster access t the right care. 2. Cnnect services delivering better crdinated and integrated care in the cmmunity, clser t hme. 3. Supprt peple and patients prviding the educatin, infrmatin and transparency they need t make the right decisins abut their health. 4. Prtect ur universal public health care system making evidence-based decisins n value and quality, t sustain the system fr generatins t cme. 33 The changes are directly linked t the first tw bjectives since enabling physitherapists t perfrm diagnstics will give patients faster access t health care, and will allw physitherapists t prvide care clser t hme (in sme cases, in hme) and t integrate this care with care prvided by ther health care prviders. 32 OPA &CPO, 2008, p Patients First: Actin Plan fr Health Care, 2017 Final Implementatin: Scpe Changes (December 20, 2017) Page 13 f 37

14 In 2011, OPA cnducted a survey f its members n the use f diagnstic imagining in practice. Only 8% f respndents were able t access the authrity t rder diagnstics thrugh medical directive r delegatin; the rest had t refer patients t anther health prfessinal in rder t btain the diagnstic tests required t frmulate a diagnsis within their scpe f practice, r t develp a treatment plan. Of the 92% f respndents requiring a referral fr these tests, 70% reprted having experienced difficulty in btaining the diagnstic imaging r labratry test results required fr patient care. The cnsequences f this difficulty were reprted almst unanimusly as a delay in treatment. This delay was reprted as resulting in a range f negative utcmes fr patients and families such as delay in diagnsis f cnditin, increase f cmplicatins and nset f secndary cnditins, increase and prlnging f pain, delayed return t wrk and feelings f frustratin fr bth patients and care prviders. The changes als indirectly supprt the third bjective by supprting patients being able t access infrmatin thrugh their practitiner f chice, rather than requiring them t attend at ther caregivers t btain health infrmatin. Practically, this might mean that if a physitherapist can cnfirm the cause f a patient s symptms by rdering the necessary diagnstic investigatins, the physitherapist can als cmmunicate this t the patient instead f having t send the patient t anther prvider t btain this infrmatin. Implementatin f the changes als supprts the furth bjective given that there is adequate evidence t demnstrate that there wuld be imprved systems efficiency and patient experience. Further, as part f the Ontari Gvernment s Patient s First agenda, n September 20, 2017, the Ministry f Health and Lng-Term Care annunced its intentin t mve frward with implementing utstanding scpe f practice changes that wuld expand health prfessins respnsibilities and rles. As stated in the news bulletin thrugh this initiative, peple in Ontari will benefit frm imprved access t safe and high-quality health services clser t hme, particularly in rural, remte and nrthern cmmunities. 34 In crrespndence t the Ontari Physitherapy Assciatin and the Cllege f Physitherapists f Ontari, the Minister f Health and Lng-Term Care, Dr. Eric Hskins wrte that fr the physitherapy prfessin, the authrity t rder lab tests, specified x-rays and diagnstic ultrasund, aligned specifically with achieving the first bjective (access t right care) f the Patient s First agenda MOHTLC, Hskins, Crrespndence, 2017 Final Implementatin: Scpe Changes (December 20, 2017) Page 14 f 37

15 8. Describe the impact f the prpsal n Ministry prgrams r initiatives. Full infrmatin abut Ministry prgrams and initiatives is nt available t the Cllege, but these changes will fster all prgrams develped pursuant t the Patients First Act (imprving access and quality care) and Access t Specialists and Specialty Care Strategy (including the prvincial expansin f the CIAC mdel fr MSK cnditins). 9. Describe the impact f the prpsal n the use f health technlgy and the uptake f innvative health care delivery practices. The changes culd make a significant difference nw and in the future fr the ppulatin served, fr system perfrmance verall, fr clleagues in inter-prfessinal practice, and fr physitherapists capacity t cntribute t system refrm. 36 The past ten years have been a particular perid f grwth in innvative pprtunities fr physitherapists t extend their cmpetence within practice scpe and cntribute t system need. Physitherapists are cntributing t strategies related t reducing wait times, increasing access t specialty care, imprving system triage fr apprpriate interventin, and increasing cnsumer satisfactin with health utcmes. 37 Thrugh innvative practice, physitherapists are able t extend treatment ptins available t their patients. 38 Fr physitherapists wrking in remte r rural settings and wh rely n telehealth services, being able t rder diagnstic imaging and lab tests will expand their use f technlgy t imprve timely access t care. 10. If applicable, describe hw the prpsal is linked t recent legislative r regulatry changes. The changes t scpe passed in Bill 179 are linked t r related t numerus recent legislative r regulatry changes that have been cmpleted r are in prcess: In 2009, the fllwing changes were made t the Physitherapy Act, which require additinal changes t existing regulatins t fully implement the scpe f practice changes passed in Bill 179: The scpe f practice statement was changed t permit physitherapists t diagnse. 39 Authrity t rder investigatins t supprt diagnsis is a necessary adjunct t this scpe change. 36 OPA & CPO, 2008, p OPA & CPO, 2008, p OPA & CPO, 2008, p Physitherapy Act, S. 4 Final Implementatin: Scpe Changes (December 20, 2017) Page 15 f 37

16 The list f cntrlled acts was expanded t include the authrity t rder prescribed diagnstic tests. The authrity t rder investigatins is nt fully enacted because the regulatins that wuld enable physitherapists t rder diagnstic ultrasund have nt yet been incrprated in the Frms f Energy Regulatin under the RHPA. 40 The Healing Arts Radiatin Prtectin Act 41 (HARP Act) has been amended t permit physitherapists t rder x-rays, hwever these changes have nt yet been prclaimed int frce. With respect t the changes that will allw physitherapists t rder x-rays and diagnstic ultrasund, there is als a link t the changes made by Bill 160, the Strengthening Quality and Accuntability fr Patients Act, specifically the Oversight f Health Facilities and Devices Act. 42 Since this new act will ultimately prvide the authrity fr health prfessinals t use any frm f energy, if current changes t the RHPA regulatins and the HARP Act are made, these changes will require updating when the new legislatin fr regulatin f the use f energy cmes int effect. Updates t O. Reg. 682/90, Labratry and Specimen Cllectin Centre Licensing Act, Labratries, are needed t permit physitherapists t rder labratry investigatins. 43 Updates t O. Reg. 207/94. Medical Labratry Technlgy Act, Part II, Persns Prescribed t Order Tests, are needed t prescribe physitherapists as persns wh labratry technlgists may receive test rders frm. 44 Ecnmic Impact Fr the fllwing questins cnsider and make nte f whether impacts are different fr certain patient ppulatins r based n the different practice lcatins and/r characteristics f the prfessin. OPA and the Cllege s 2008 HPRAC submissin p , speaks t the ecnmic implicatins in great detail. Sme key pints and summaries have been included belw. 11. Describe the knwn, likely, and/r future ecnmic impacts f the prpsal n patients. If tests rdered by physitherapists are being publicly funded, n future ecnmic impacts have been identified, as these tests are already being rdered either thrugh delegatin r 40 O. Reg. 107/96. Regulated Health Prfessins Act, Cntrlled Acts 41 Healing Arts Radiatin Prtectin Act, s.6 42 Strengthening Quality and Accuntability fr Patients Act, O. Reg. 682/90. Labratries 44 O. Reg. 207/94. Persns Prescribed t Order Tests Final Implementatin: Scpe Changes (December 20, 2017) Page 16 f 37

17 by referring back t physicians r nurse practitiners wh then rder physitherapistrecmmended tests fr the patients. If tests rdered by physitherapists are nt publicly funded, future ecnmic impacts relate t the need fr patients t pay fr the investigatins rdered. These impacts culd be mitigated by cverage prvided thrugh extended health care benefit plans and ther insurance prgrams, such as mtr vehicle accident insurance r Wrkplace Safety and Insurance Bureau where cverage exists. Thse nt cvered wuld be required t self-pay, r culd request a referral t a physician r nurse practitiner. When patients are unable t access the right prvider in a timely fashin fr the right services, the patient bears persnal csts due t cmplicatins (e.g. lst time frm wrk, cst f supprt) and the system may bear additinal cst due t health cmplicatins due t delays. 45 The changes fr the scpe f practice fr physitherapists will cntribute t imprving access t physitherapists in hspital, cmmunity and primary health care settings. Imprved care management and system navigatin will assist in reducing assciated csts t patients. 46 Physitherapists directly accessing testing enable interventins at the earliest pssible mment, mitigating the csts f secndary r permanent cnditins that may result frm delayed treatment. This change wuld als prevent unnecessary expenditures fr patients, such as transprtatin t and frm referral visits and appintments, the csts f care-givers and pprtunity csts such as missed time at wrk Describe the knwn, likely, and/r future ecnmic impacts f the prpsal n the public health care system. There will be savings by reducing the number f visits by patients t nurse practitiners and physicians fr the sle purpse f rdering diagnstic tests n behalf f physitherapists. This is demnstrated by US, Eurpean and Australian data, which shws a reductin in number f diagnstic tests rdered when rdered by physitherapists and reduced csts in physician services by eliminating the need fr patients t have appintments with ther prviders fr the sle purpse f btaining an rder fr investigatin. 48 Overall, it is anticipated that the changes will enhance and expand public access t apprpriate care, and cntribute t the prductivity f ther health prfessinals, bsting verall system perfrmance OPA & CPO, 2008, p OPA & CPA, 2008, p OPA, OPA & CPO, 2008, p OPA & CPO, 2008, p. 7 Final Implementatin: Scpe Changes (December 20, 2017) Page 17 f 37

18 A study by Carr indicates that physitherapists are less likely than physicians t rder diagnstic imaging, and less likely t make a referral fr surgery and/r secndary care. This results in reduced expenditures fr the system and fr patients and families Describe the knwn, likely, and/r future ecnmic impacts f the prpsal n the prfessin. N direct financial benefit wuld accrue t individual physitherapists fr rdering f investigatins because the rdering f investigatins is nt billed fr as a separate act as in the case fr sme prviders under public funding. Ordering investigatins is included within the general billing fr physitherapy. There may be sme negative ecnmic impacts fr individual physitherapists wh need t undertake sme additinal educatin in rder t use the expanded authrities in their practice. 51 These ecnmic impacts will be mitigated by the fact that physitherapists will be better able t engage in innvative and emerging rles, have greater mbility in the system, and be mre respnsive t the needs f health care teams and patients t imprve recruitment and retentin in Ontari Describe the knwn, likely, and/r future ecnmic impacts f the prpsal n ther health wrkers (bth regulated and unregulated). Physicians and nurse practitiners will nt receive payment fr visits frm patients wh are being referred back t their primary care prvider fr the sle purpse f having a diagnstic test rdered. This is mitigated by the increased capacity f these health prfessinals t see ther patients and reduce wait times fr ther patients. Draker-White et al., randmized-cntrl trial f patients referred fr specialist rthpaedic pinin in tw hspitals in England fund that patients assessed and managed by physitherapists with specialized training were less likely t underg diagnstic imaging tests. The mean cst-per-patient was nearly half fr patients managed by the physitherapist cmpared t the physician. This direct cst-savings t the hspital was fund t be the result f reduced use f imaging services and referral fr surgery amng the physitherapists cmpared t the physician Carr, Chng et al, p OPA & CPO, 2008, p Draker-White et al, 1999 Final Implementatin: Scpe Changes (December 20, 2017) Page 18 f 37

19 A 2004 Australian Physitherapy Assciatin (APA) reprt n the behaviur f physitherapists btaining the x-rays they required indicated that: 54 Based n the (Medicare Benefits Schedule) rebates at the time, it was fund that the current referral arrangement fr physitherapists was csting Medicare at least $1,040,567 per year. Additinal csts are incurred by patients in payment f gap (i.e. cpayment) fees fr GP visits. Unquantifiable csts include the patients time and the lst pprtunity fr timely interventin caused by the delay in patients receiving an x-ray examinatin. It was als estimated that apprximately 9460 hurs f GP time was wasted per year, the equivalent f almst five fulltime GPs. The study fund that small changes in referral arrangements wuld save Medicare ver $1 millin and 10,000 hurs f GP time per year. 15. Describe the knwn, likely, and/r future ecnmic impacts f the prpsal n affected businesses in Ontari. The prfessin anticipates nly limited ecnmic impacts f the changes n business. The mst bvius impact is the pssibility that injured wrkers may be able t return t wrk sner if their access t care and the care itself is mre effective and efficient thrugh the ability f physitherapist t rder the apprpriate diagnstic care. Prfessinal Cmpetencies Fr the fllwing questins, identify mitigatin strategies fr any gaps in cmpetencies. 16. D members f the prfessin currently have the cmpetencies t perfrm the prpsed change t the scpe f practice? Describe these cmpetencies. Nte that the scpe f practice was changed in The current changes finalize the regulatry steps required t implement the changes. Perfrmance f these acts des nt require develpment f new cmpetencies. Physitherapists wh chse t perfrm these activities will rster t d s and will be required t demnstrate tw kinds f cmpetencies: (1) Basic knwledge required f a health prfessinal wh diagnses within their scpe f practice Includes knwledge in anatmy, physilgy and interpretatin f results f investigatins These are entry level educatin cmpetencies. 55 (2) Knwledge, skills and judgement with respect t the indicatins, cntraindicatins, and apprpriate use f specific types f investigatins 54 Australian Physitherapy Assciatin, HPRAC, 2008, pp Final Implementatin: Scpe Changes (December 20, 2017) Page 19 f 37

20 This are nrmally learned in pst graduate training. 56 Nt all physitherapists intend t pursue these additinal cmpetencies r perfrm the additinal activities t be authrized t physitherapists. The prfessin s research clearly demnstrate that such pst graduate prgrams are available Describe the impact f the prpsal n entry-t-practice (didactic and clinical) educatin and training requirements f the prfessin. There will be n anticipated impact n the entry-t-practice educatin and training requirements f the prfessin, since their current training already prvides backgrund in assessment, diagnsis, and ther clinical skills psitining them t pursue additinal training in these activities. 18. Describe the impact f the prpsal n members f the prfessin already in practice. Independent perfrmance f these scpe activities requires rstering (an additinal registratin-related declaratin). While many physitherapists express an interest in rdering diagnstic investigatins, nt all intend t pursue this interest. 58 Thse wh wish t perfrm these additinal activities will chse t pursue readily available pst graduate training that meets the Cllege s standard fr the perfrmance f cntrlled acts. Fr thse wh d chse t perfrm these additinal activities, there will als be an additinal impact f having a significantly imprved ability t serve the needs f their patients withut the need t refer them n t ther practitiners when diagnstic investigatins are required. Fr thse wh are already in practice and wh d nt chse t perfrm these additinal activities, there will be n impact. 56 HPRAC, 2008, pp OPA has reviewed Appendix C f the HPRAC submissin (OPA & CPO, 2008) and ensured all educatinal prgrams listed in Appendix C are included in OPA s envirnmental scan f diagnstic imaging and labratry test prgrams 58 Chng et al, p. 5 Final Implementatin: Scpe Changes (December 20, 2017) Page 20 f 37

21 Impact t Safety and Quality Fr the fllwing questins cnsider and make nte f whether impacts are different fr certain patient ppulatins r based n the different practice lcatins and settings, and/r type f care prvided by the prfessin. 19. Describe the impact f the prpsed scpe f practice change n the quality f care delivered and the patient experience. Research demnstrates that physitherapists wrking in the areas f practice that wuld be authrized by the full implementatin f the scpe changes prvide quality care fr cnditins including hip and knee arthritis, hip and knee replacements and a variety f shulder cnditins. 59 Patient satisfactin with care was significantly imprved when physitherapists were prviding the care, which included rdering diagnstic investigatins where indicated. 60 There is ptential t reduce the time patients spend in emergency departments when a physitherapist is used t triage rthpaedic cases, and culd rder tests that wuld be available fr the physician as sn as the dctr was able t see the patient. 61 In a UK study, the intrductin f a physitherapist with additinal cmpetencies t an acute knee screening services was fund t imprve the quality f care f acute knee injuries, save medical time, and fster cperatin acrss the services with NHS (rest f the health system) Describe the impact f the prpsed scpe f practice change n patient safety. The prfessin des nt anticipate that the change will impact patient safety 63 since the actual perfrmance f the activities will cntinue t rest with the health prfessinals wh wuld have perfrmed the actual investigatins if they had been rdered by a physician. Fr example, physitherapists are nly anticipating perfrming the rdering f the investigatin, nt the actual investigatin, which wuld cntinue t be perfrmed by sngraphers, labratry technicians r medical radiatin technlgists. Physitherapists are and will be trained t rder these investigatins nly when they are safe and necessary fr diagnstic purpses and when patients d nt demnstrate cntraindicatins t the investigatins. 59 Razmju et al, p Razmju et al, p OPA & CPO, 2008, p OPA & CPO, 2008, p OPA & CPA, 2008, p. 35 Final Implementatin: Scpe Changes (December 20, 2017) Page 21 f 37

22 Physitherapists will als nly be rdering these investigatins in the cntext f assessing r diagnsing cnditins that are within their scpe f practice as required by the Cllege prfessinal miscnduct regulatins 64 and standards 65, as well as the Cllege s peer assessment prgram in its quality assurance prgram. These general principles will apply t all patient ppulatins and in all practice lcatins r settings. The kinds f care that are authrized by these changes and prvided by physitherapists will nt put patients at increased safety risk. This is supprted by the research studies referenced by Razmju et al, as well as their wn research utcmes, nne f which encuntered any patient safety cncerns. 66 By reducing the number f care transitins, a demnstrated risk factr in patient safety, the change will imprve patient safety. 21. Hw des the prpsed change f scpe impact risks f ver-testing and ver-utilizatin? Hw des the prfessin intend t mitigate these risks? The Cllege has mitigated any risk f duplicatin f testing r verutilizatin thrugh its regulatins, standards and its quality assurance prgram. Research demnstrates that physitherapists are less likely t rder diagnstic imaging and less likely t make a referral fr surgery and/r secndary care, resulting in the reductin f unnecessary expenditures fr the system and fr patients and families. 67 The Cllege has a cllabrative care standard that requires physitherapists t cllabrate with ther caregivers t understand their administered care and prvide relevant infrmatin t the caregivers t minimize inadvertent duplicate test rders. 68 The educatinal requirements inherent in the rster system will minimize the rdering f diagnstics that are nt clinically indicated. N tangible r intangible incentive exists fr physitherapists t rder unnecessary tests. The Cllege s miscnduct regulatin prhibits the prvisin f unnecessary care, which wuld encmpass rdering unnecessary tests O. Reg. 388/08. Prfessinal Miscnduct 65 Cllege f Physitherapists, Cntrlled Acts and Other Restricted Activities 66 Razmju et al, p Carr, CPO, 2017, Cllabrative Care Standard 69 O. Reg. 532/98. Prfessinal Miscnduct Final Implementatin: Scpe Changes (December 20, 2017) Page 22 f 37

23 It shuld als be nted that the changes may als have the effect f reducing verutilizatin f ther health care prviders. Fr example, currently a patient wh attends a physitherapist as a direct access prvider is unable t btain an ultrasund, x-ray r labratry investigatin t identify r cnfirm the physitherapist s diagnsis. Permitting physitherapists t rder investigatins has the ptential t remve the unnecessary step f btaining a requisitin fr the test thrugh the patient s primary care prvider while als reducing the number f visits a patient has t make t health prfessinals. 22. Describe the impact f the prpsal n any delegated authrities fr cntrlled acts. The impact f the changes n delegated authrities will be highly dependent n the care setting. Regulatin 965 under the Public Hspitals Act 70 establishes restrictins n wh can rder care in hspitals and prevents physitherapists frm exercising autnmy ntwithstanding ther regulatry changes. Accrdingly, delegatin wuld still be required in hspital settings. Tday in cmmunity settings, physitherapists may nly rder diagnstics under delegated authrity. These changes wuld eliminate this requirement and permit autnmy. The impact n delegated authrities has the strng ptential t be viewed favurably by health prfessinals wrking in a cllabrative envirnment due t the significant effrt required t develp and update apprpriate and cmplete delegatin prtcls. It is likely that the remval f the need t develp and mnitr delegatin prtcls will enable health prfessinals mre time t prvide direct patient care. This prblem is supprted by research int the perfrmance f the activities supprted by the scpe changes, specifically diagnstic imaging. Chng et al., explre the current mdel that permits physitherapists t rder diagnstic imaging thrugh the use f delegatin via medical directives r direct rders. 71 They nte that these frms f delegatin are nt a sustainable slutin t changing health care system needs given the administrative lad and cst f develping, implementing, maintaining and changing them. 23. What new r amended versight mechanisms are necessary t ensure cntinued safety and quality f the care prvided by the prfessin? N new r amended versight mechanisms are required. Full implementatin f this change t the physitherapy scpe f practice will require nly minr amendments t the Cllege database system. 70 O. Reg. 965/90. Hspital Management 71 Chng, et al, 2015 Final Implementatin: Scpe Changes (December 20, 2017) Page 23 f 37

24 The Cllege has established versight mechanisms fr physitherapists wh perfrm cntrlled acts including a requirement t rster, an established and prven quality assurance peer assessment prgram, standards, prfessinal miscnduct rule and educatinal requirements. 72 The rster is a widely accepted mechanism by which physitherapists with cmpetencies exceeding entry t practice may register t perfrm cntrlled acts. T rster, physitherapists must prvide the Cllege with infrmatin abut their qualifying educatin. The rster has substantial benefits including: Enabling the Cllege t mnitr physitherapist use f the rstered activities. Enabling the Cllege t assess members cmpetencies in the perfrmance f the activities. Prviding transparency t the public as t which members are permitted t perfrm the activities. 24. Identify the current standards f practice r plicy guidelines set ut by the regulatry cllege in Ontari that are relevant t the prpsed scpe f practice change. The standards and ther rules that are mst relevant t perfrming the new activities are: 73 Cntrlled Acts and Other Restricted Activities Cllabrative Care Cnsent Essential Cmpetencies Prfile fr Physitherapists in Canada O. Reg. 388/08, Physitherapy Act, Prfessinal Miscnduct. 25. Identify whether any new standards f practice r plicy guidelines wuld need t be develped by the cllege relating t the change in scpe f practice. Many Ontari physitherapists already perfrm new scpe activities that were previusly authrized t physitherapists in the previus rund f scpe expansin. The Cllege has identified, develped and implemented all the standard and plicy changes regarding scpe changes that wuld ensure public prtectin. As a result, n new standards r plicy guidelines are required t prvide additinal public prtectin. 26. Describe, withut prviding persnal identifiers, any cmplaints, miscnduct reprts, quality assurance assessments, r inspectin reprts the prfessinal cllege has received that may be related t the prpsed scpe f practice change. The Cllege has received n cmplaints r reprts related t this expanded practice area. 72 Nrman et al, Final Implementatin: Scpe Changes (December 20, 2017) Page 24 f 37