Defining Evidence-based Chiropractic Care to Enhance Patient Outcomes

Canadian chiropractors have positive attitudes toward evidence-based practice (EBP).[1]

What is evidence-based chiropractic care?

That said, if you ask Ontarians, including chiropractors and other health care professionals, how they define evidence-based chiropractic care, you’ll hear a range of answers.

This scenario is not new. Since the inception of the evidence-based medicine movement in the early 1990s, there’s been extensive debate within health care professions about ‘what’ evidence-based care should entail in practice.[2]

Mixed perceptions of evidence-based chiropractic care also raise questions, such as:

  • What role do patient values and preferences play in the planning and delivery of evidence-based care?
  • How do clinicians discover patients’ values and preferences and what happens when they conflict with best available research evidence?
  • What are the barriers to successfully integrating research evidence into clinical practice and how can they be overcome?

These challenges underscore the imperative to support better patient care and advance the profession through a shared understanding or framework around what exactly ‘evidence-based practice (EBP)’ means for chiropractic care.

OCA Evidence-Based Framework Advisory Council (EBFAC)

As part of our association’s mission to advance the understanding and use of chiropractic care, we are leading this important work.

To draw on a wide range of experienced practitioners’ expertise, we created the OCA Evidence-Based Framework Advisory Council (EBFAC). Comprised of 13 members, it represents a diverse cross-section of chiropractors engaged in clinical practice, as well clinical and/or basic sciences research, and a patient.

What are the EBFAC’s Goals?

1Develop a comprehensive and inclusive definition of chiropractic care

Our first goal is to explore the evidence-based framework to develop a comprehensive and inclusive definition of chiropractic care. Up until now, we’ve been significantly focused on high-quality research and guidelines to support low back pain as the key area that chiropractors treat, even though we know they contribute to much more.

Based on clinical expertise, scopes of practice and other evidence, we know chiropractors are also effectively treating other parts of the spine, joints and related nervous system, such as neck and shoulder pain, as well as chronic conditions like arthritis.

Part of this goal is also to increase stakeholders’ understanding of spinal manipulative therapy or adjustments, as well as other chiropractic treatments, and how they help relieve a person’s pain and improve their function.

2Identify and gain a clearer understanding of research priorities to fund

Our second goal is to leverage this work to help us identify and gain a clearer understanding of the research priorities our association should fund. As we move forward with our research agenda, this work will build on the important work of the Canadian Chiropractic Guideline Initiative (CCGI) and the Canadian Chiropractic Research Foundation (CCRF) to provide needed support in a timely manner.

3Strengthen OCA support for ‘knowledge translation’

Our final goal is to strengthen our support for ‘knowledge translation,’ which is the two-way process of integrating emerging research into clinical practice and using clinicians’ questions and challenges to help inform research. Strengthening knowledge translation across the chiropractic profession will help our members enhance patient care, while it continues to generate new evidence.

Together, we can expand research and amplify knowledge translation to set a new direction for the profession in terms of advocacy and the research agenda. Achieving these latter two goals should also help us and our chiropractic members understand how to better partner with key stakeholders in the chiropractic ecosystem.

Enhancing Interprofessional Collaboration and Outcomes

Having a comprehensive and inclusive definition for chiropractic care will give us a common language and tools that enable chiropractors to interact more with physicians, as well as nurse practitioners. This will help pave the way for chiropractors to share their evidence-based plans of care with these primary care providers.

Currently, patient referrals from physicians and nurse practitioners often go to health care professionals covered by Ontario’s publicly funded system. I think a shared understanding of evidence-based chiropractic care will also build confidence among those primary care professionals to refer patients to chiropractors and include them in their circle of care.

Appropriate inclusion of chiropractors in a patient’s circle of care enhances patient outcomes. In fact, in its ‘Prescription for Ontario,’ the Ontario Medical Association (OMA), stated that “Patients do better when they have a team of care providers, including not only family doctors and specialists.” Furthermore, this report suggests “Where these teams exist, patients have faster and easier access to specific care they need so are healthier, have fewer hospital admissions and are more satisfied. System costs are also reduced.”[3]

Understanding the science behind chiropractic care should also open opportunities for chiropractors to collaborate with other regulated health professionals and neuromusculoskeletal (nMSK) experts like rheumatologists and physiatrists to further enhance patient outcomes.

Beyond health care professionals, a shared definition of evidence-based chiropractic care will also help us effectively communicate with payers, like extended health care (EHC) benefits insurers, about how chiropractors deliver care and its benefits to patients. And an enhanced understanding of chiropractic care may also help these insurers better understand the value of aligning EHC plans with nMSK guidelines, as explained in my last post on helping Ontarians access the care they need.

Raising Patients’ Understanding

Beyond helping more patients access needed care, enhancing it and improving their outcomes, this work will also give us new evidence-based tools to better educate patients on their options.

With a comprehensive definition, chiropractors can explain the breadth of care that chiropractic care delivers, from assessment and diagnosis to prescribing exercises and other therapies and why care is delivered the way it is.

And it will help patients better understand that chiropractic care involves more than spinal manipulative therapy or the spinal adjustment. That said, this framework can be used to provide the evidence that adjustments are a safe and effective intervention, while dispelling misconceptions.

For patients, it’s also important that others in their circle of care like their family doctor or rheumatologist, understand how chiropractors can support their condition.

Graphic depiction of Haynes model for evidence-based clinical decisions
Depiction of Haynes model for evidence-based clinical decisions (Haynes, Devereaux, et al. 2002) [4]

Haynes Model for Evidence-Based Practice

One of the EBFAC’s first priorities was to identify the most effective model of evidence-based practice to underpin its work. Following a thorough review of several options, it adopted the Haynes four-part model, which views clinical expertise as the lens to integrate the three components of:

  • Patients’ preferences and actions
  • Clinical state and circumstances
  • Research evidence [4]

This model describes what evidence-based practice ought to look like but not necessarily its actual state.

Based on the Haynes model and its elements, the EBFAC will develop a series of research papers on evidence-based chiropractic practice and a decision aid to help guide clinical chiropractic judgment in instances where little or no high-quality research evidence exists.

In developing these papers, the EBFAC is integrating leading Canadian and international researchers’ expertise, as well as exploring leading practices from other professions globally. Its work also aligns with the work of the World Federation of Chiropractic’s EPIC model of care – bringing our profession in line with global health care best practices.[5]

Starting with Patient Preference

When the EBFAC first met in early 2020, there was an almost immediate consensus that this work must benefit patients.

And we know the voice of patients in Ontario is very powerful in effecting change, as we’ve seen over and over again. That’s likely why key organizations that drive quality in health care, such as Health Quality Ontario, have started to prioritize the voice of patients. For example, they’ve integrated patient preferences in their work, such as developing practice guidelines or advice for clinicians. 

Yet patient preference is one of the least explored and least understood elements in the evidence-based framework model.

In fact, up until recently, it was felt that only focusing on the best available evidence was what mattered. With their preference given a low priority, many patients weren’t complying with care plans and subsequently, they weren’t getting the outcomes they were looking for. So, in Ontario, there’s now a growing recognition of the voice of patients in influencing care, advocacy and policy.

As enhancing the patient experience including outcomes is our priority, patient preference was an important place for us to begin our investigation of the Haynes model components in an in-depth manner.

The EBFAC is currently focused on developing research papers that explore patient preference and other evidence-based practice components, along with pertinent scenarios. Our intention is to release these papers and the decision aid concurrently, so they serve as robust, integrated resources to support all chiropractors in the science and art of practice.

But these resources are just the beginning. We will build on them to develop programming and partnerships to evolve the chiropractic profession, provide supports to our members and ultimately enhance patient-centred care.

While this work will benefit various stakeholders, I think it will provide the most value to patients with spine, muscle, joint or related nervous system conditions.

I look forward to sharing the EBFAC’s work, as it evolves, and my perspectives with you. And as always, I welcome your feedback.

[1] Bussières A.E., Terhorst L., Leach M., Stuber K., Evans R. & Schneider M.J. (2015). Self-reported attitudes, skills and use of evidence-based practice among Canadian Doctors of Chiropractic: a national surveyThe Journal of the Canadian Chiropractic Assoc. 59(4). 332-348.

[2] Guyatt, G., Cairns, J., Churchill, D., et al. (1992). Evidence-based medicine. A new approach to teaching the practice of medicineJAMA. 268(17). 2420-2425.

[3] Ontario Medical Association (OMA). (2021). Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care. 45.

[4] Haynes, R.B., Deveraux, P.J. & Guyatt, G.H. (2002). Clinical expertise in the era of evidence-based medicine and patient choice. BMJ Evidence-Based Medicine. 7. 36-38.

[5] World Federation of Chiropractic. (2019). Quarterly World Report.

Helping Ontarians Access the Chiropractic Care They Need

Working with Insurers, Patients and Employers to Support Ontario’s Recovery and Beyond

Covers of OCA-produced Understanding Extended Health Care guide for chiropractors, Patient's Guide to Extended Health Care Coverage and example infographic titled EHC Insurance 101.
To support a growing understanding of extended health care (EHC) among Ontario chiropractors, our EHC Advisory Council recently produced an Understanding EHC Guide for chiropractors, A Patient’s Guide to EHC Coverage and a series of infographics.

With COVID-19 pandemic restrictions easing, Ontario’s economic recovery is in motion but much of its success will hinge on maintaining a healthy and productive workforce.

As impaired spine, muscle and joint or musculoskeletal (MSK) health has been found responsible for the greatest loss of productive years in the workforce, now more than ever it’s important for employees to access the chiropractic care they need.[1] In turn, chiropractors also play a key role in helping employers provide ergonomically safe work environments, supports and processes to keep their employees healthy and productive, be they onsite or at home.

We can take pride in Ontario’s publicly funded health care system, but it doesn’t cover everything. We know 72 per cent of Ontarians pay for their chiropractic care and treatments privately through extended health care (EHC) insurance plans. [2] They are also called supplementary medical/health coverage plans or employee benefit plans and employers typically provide them as part of a total compensation package, but self-employed people may purchase them individually.

The more effective and comprehensive support EHC plans offer for chiropractic care, the greater opportunity there is for employees to get the expert care they need for their spine, muscle, joint and related nervous system or neuromusculoskeletal (nMSK) conditions. This broad availability also gives employees a choice about who they seek for that care from the growing number of chiropractors listed with EHC insurers.

That said, employees must navigate through the private pay, as well as the publicly funded system to receive the care they need to live their best lives. And this care can be limited by the amount of coverage for effective treatment plans.

Ensuring Employees Access the Care They Need

As the chiropractic profession evolves, research evidence continues to build on its positive benefits in treating nMSK conditions. This knowledge is translated into care plans for each patient’s condition, including treatments and timelines.

To ensure satisfactory patient outcomes, EHC plans should support employees to complete their specific course of treatment.

Most guidelines for nMSK conditions recommend care for four to six weeks. Unfortunately, many EHC plans have inadequate coverage for employees to complete their treatment plans, unless they opt to pay out of pocket.

When this happens, the employee may not complete their care and subsequently experience poor treatment outcomes. This scenario may also cost the employer more in the long term, as well as potentially hinder the employee’s job attendance and retention.

A recent survey of Partnership4BetterHealth, our patient and family advisory council, reinforces this position, as 64 per cent of respondents told us health care benefits factor in their employment-related choices and decisions.[3]

Flexible EHC Plans Foster a Productive and Attractive Workplace

Conversely, when EHC plans align with guidelines so employees can complete their treatment, they’re more able to keep working or return to work, if they’ve been off due to an nMSK issue. In fact, it’s been found that patients receiving chiropractic care have lower disability recurrences and for shorter durations, compared to those receiving care from other health care professionals.[4]

Data also tells us that employees who access chiropractic care tend to incur fewer costs because they’re less likely to be prescribed medications or end up with complex medical procedures.[5]  Similarly, as I outlined in my previous post, interprofessional collaboration between publicly funded medical doctors or nurse practitioners and privately funded chiropractors can help patients effectively manage their MSK pain, while reducing their reliance on opioids.

Given the pent-up demand for publicly funded care due to the pandemic, an efficient program of private care that helps employees get back to work and stay at work serves everyone’s best interests.

Employees are also likely to favour employers with EHC plans that give them the coverage they need to complete their treatment. And according to a 2019 AON survey, compared with past expectations, employees today expect increased flexibility and 56 per cent of respondents expect a high degree of benefit personalization.[6]

With current labour shortages across Canada, employers’ recruitment and retention efforts need to focus on compensation packages that highlight health care and meet needs and expectations across generations.[7]

Helping Patients and Others Through Our Extended Health Care Strategy

To help ensure more Ontarians have access to the effective chiropractic care they need and build internal expertise, we developed an EHC strategy, which complements the Canadian Chiropractic Association’s national EHC strategy.

Recognizing insurers must be accountable to the employers who purchase their plans, a key part of our strategy is to help our chiropractic members work effectively within this system. By helping our members engage effectively with EHC plans and guide their patients to do the same, we aim to support insurers to meet their mandates.

Building Internal Expertise and Providing Practical Resources

Our members know how important EHC coverage is to their patients. In fact, through our 2019 Environics study we learned that four in five chiropractic patients have private health care coverage, the vast majority being EHC.[8]

Members also tell us how they’re sometimes challenged by the complexity of the conditions or limitations that vary across EHC insurers.

Addressing this complexity and building EHC literacy was the genesis of our Extended Health Care Advisory Council. This council aims to develop EHC expertise within our association to best support our members, their patients and collaborate with insurers, while advancing our strategy.

This support includes helping our members to understand and follow leading practices in billing, receipts management and other priorities for EHC insurers, such as virtual care, orthotics and assistive devices.

We also recognize that it’s essential to help our members understand and follow each insurer’s processes as required. Otherwise, the insurer may request an audit and in extreme cases, cease to cover care the chiropractor delivers – leaving their patients to stop their treatment or pay out of pocket.

Based on our organization and others’ requests over the past couple of years, we are seeing more openness to transparency and improved clarity in processes within the insurance sector. We welcome this approach because a practitioner can only be as successful as their understanding of what’s expected of them.

According to the Canadian Life and Health Insurance Association (CLHIA)’s latest data, there are 72 insurers providing EHC coverage in Ontario alone.[9],[10] As patients may have coverage with any one of these, that’s a lot of insurers’ policies for busy chiropractors to keep track of.

To support a growing understanding among Ontario chiropractors, our EHC Advisory Council has recently produced:

  • An Understanding Extended Health Care Guide as a leading practices OCA member resource with practical tools to help patients get the most out of their chiropractic care and chiropractors to fully understand the EHC system.
  • A Patient’s Guide to Extended Health Care to help patients understand their EHC coverage for chiropractic care.

These comprehensive resources help our members, and their teams to effectively structure their clinic’s administrative processes. They also give them accurate tools to inform their patients about the insurance process and answer their questions.

To complement these resources, we produced this podcast on EHC trends and what they mean to Ontario chiropractors.

And we’re in the process of developing an EHC audit tool to help chiropractors provide the information insurers need to be accountable to employers and their EHC investments.

Opportunities to Enhance Patient Care and Outcomes

We also know that EHC insurers have incredible amounts of data that they use to analyze trends and look for opportunities but it’s not readily available.

If that data was shared with health care leaders, it could help private pay and the publicly funded system planners to collaborate on what’s in the best interest of patients and our overall health ecosystem. For example, this data could help inform areas of research that we should be pursuing within chiropractors’ nMSK expertise. We are working towards this ideal among other goals.

In the meantime, our aim is to continue to grow these relationships and become a trusted advisor among EHC insurers and major employers in Ontario.

Future of EHC and What’s Next

Since launching our strategy, we’ve been learning a lot from working with EHC insurers about what employers and patients are looking for.

We need to keep listening to patients about what they want from EHC plans because after all, we all contribute to this private pay system – from the employers who purchase them to the practitioners who deliver care. And as our Partnership4BetterHealth community grows, we want to continue to hear from our patients about their expectations, and what’s working or needs to improve.

Given our pandemic experience and the changes it’s prompting, I think we also have some important questions to address about future working conditions and employee needs that will impact EHC insurance. For example: Will employees continue to work from home? If so, how will the role of employers change vis-à-vis the occupational health and safety of their teams? What supports will employers need to safeguard their employees’ nMSK health and meet occupational health and safety mandates in this new world of work?

As Ontario’s recovery moves forward, we’ll need to be flexible, as we help to shape future strategies that respond to employees’ expectations and how employers, as well insurers, adapt to support Ontario’s workforce.

What are your thoughts about our current EHC system and how Ontarians access the chiropractic care they need? How can our members best support insurers and employers? I welcome your feedback.

In my next post, I’ll discuss our evolving evidence-based framework for chiropractic care and how patient preference plays a key role.

[1] Briggs, A., et al. (2018). Reducing the global burden of musculoskeletal conditions. Bulletin of the World Health Organization.

[2] Environics Research – Study commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractors.

[3] Partnership4BetterHealth. OCA Patient and Family Advisory Community (council).

[4] Allen, H., Wright, M., Craigh, T., Mardekian, J., Cheung, R., Sanchez, R., Bunn, W. & Rogers, W. (2014). Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. Journal of Occupational and Environmental Medicine. 56(6), 604-620.

[5] Allen et al. (2014). Tracking low back problems in a major self-insured workforce.

[6] AON Hewitt Inc. (2019). Employee Benefits: Rethinking objectives in the age of flexibility and choice.

[7] Express Employment Professionals. (2021). Help Wanted – Labour Market in Crisis.

[8] Environics Research – Study commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractors.

[9] Canadian Life and Health Insurance Association (CLHIA). (2021). Canadian Health and Life Insurance Facts: 2021 Edition.

[10]This number excludes property and casualty insurers that are currently actively providing health coverage.

Addressing the Opioid Crisis with Interprofessional Collaboration

Word cloud of keywords related to spine. muscle and joint pain and the opioid crisis, including: Spine, Muscle & Joint Pain, MSK Pain, Low Back Pain, Manual Therapy, Addiction, Pain Management, Mental Health, Prescriptions, Co-ordinate Care, Collaboration, Interprofessional, Families, Economic Impact

Among its consequences, the COVID-19 pandemic is an unplanned experiment in what it means to have reduced access to care. Sadly, while it’s occurring, Ontarians’ need for care is rising. This increased need is not directly related to COVID-19 but because of it.

Pandemic’s impact on patients

Ontario Medical Association president Dr. Adam Kassam recently advised that due to restrictions during COVID-19’s three deadly waves, “more than one health care service was not performed for every Ontario resident this year.”[1]

This hugely diminished access to care affected primary care, emergency departments, as well as regulated health care professionals, such as chiropractors, registered massage therapists and physiotherapists, who could have provided relief.

As mentioned in my last post, the pandemic’s demands on essential workers and added stress was high, increasing their risk of injury and need for care. Those in labour-intensive roles also had to keep working in less-than-ideal conditions and in moving to makeshift home offices, knowledge workers faced new challenges. These pandemic-driven demands, stress and challenges exacerbated back pain and other spine, muscle, joint and related nervous system or neuromusculoskeletal (nMSK) conditions.

And as musculoskeletal (MSK) conditions and related pain account for the largest share of global disability burden,[2] there’s no doubt reduced access to care impacted many Ontarians with these issues.

In fact, our members have told us of patients who turned to or increased their use of pain management medications to compensate.

Opioid-related deaths increased by more than 75 per cent

Tragically, the fallout of reduced access to health care and other services is notably evident in the number of monthly, opioid-related deaths in Ontario, which rose by 79.2 per cent between February and December 2020.[3]

Some of these fatalities are pandemic related. Others are indicative of the ongoing crisis. For example, almost one third of opioid-related deaths among employed individuals comprised those in the labour-intensive construction industry both before and after the pandemic started.

More than 50 per cent of opioid users have reported back pain

What may come as a surprise to some is that back pain has been reported in more than half of regular opioid users.[4] It’s also one of the most common diagnoses emergency and family physicians cite for prescribing opioids.[5]

And even though many patients are prescribed opioids for pain, a 2016 systematic review and meta-analysis found that opioid medications provide modest, short-term pain relief for people with chronic back pain but evidence of long-term efficacy is lacking.[6] Fortunately, there’s alternatives.

Manual therapy: a medication-free alternative for low back pain

Over the past 10 years, research has demonstrated that treatments chiropractors provide, such as spinal manipulation and therapeutic exercise programs, can relieve low back, neck, shoulder or other MSK pain. Also, the type of care chiropractors provide is now globally recognized as an evidence-based first and second-line approach for low back pain.[7]

In fact, the 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain recommends therapies without medication, such as spinal or joint manipulation and therapeutic exercise, for treating back and neck pain, as well as knee osteoarthritis, fibromyalgia and severe headaches/migraines. Similarly, Health Quality Ontario suggests that making better use of non-medical treatments to manage acute and chronic pain will reduce the number of people who end up using opioids for the long-term.

This means Ontario’s health care system now has a recognized option for treating low back and other spine, muscle and joint pain, aside from opioids. But this option hasn’t been utilized to its full capacity. This shortfall is due in part to the complexity in the public and private pay components it requires to help all patients, including those most vulnerable.

Success of Ontario’s Primary Care Low Back Pain program

For an extended period, Ontario has monitored utilization of the health system with a goal to appropriately move care from acute care settings and emergency departments into the community. So, successive governments focused on strengthening primary care and interprofessional teams as a way of bringing leading practice and efficient health care models to Ontario.

With the knowledge that MSK conditions could be managed in the community, our association advocated with the provincial government to include chiropractic care in the primary care models it was developing at the time.

These efforts led to it funding seven Primary Care Low Back Pain (PCLBP) pilot sites across the province in 2015. Under this model, interprofessional primary care teams were formed to deliver efficient, co-ordinated and integrated care to vulnerable patients with low back pain via MSK experts, such as chiropractors.

Successful outcomes followed and 83 per cent of patients surveyed after receiving MSK care at one PCLBP pilot site said they now rely less on medication, including opioids, to help manage their low back pain.[8] And the PCLBP program continues today.

However, evolution of the community-based model of care has generally seen primary care models focus on disciplines funded by the public health care system – limiting chiropractors’ potential to bring relief to more patients.

OCA’s Opioid and Pain Reduction Collaborative

With the growing awareness of the opioid crisis, there is a desire for all levels of health care professionals, as well as governments to decrease the burden it creates and research what’s causing it. That research reveals significant links to MSK pain and that, for example, these conditions presenting in emergency departments contribute to patients’ initial access to opioids.

So our Board of Directors had the foresight to prioritize the opportunity for chiropractors to help solve the opioid crisis.

Subsequently, we partnered with the Centre for Effective Practice (CEP) to create the evidence-based Opioid and Pain Reduction Collaborative (‘Collaborative’). It’s designed to help chiropractors, or other manual therapists, co-ordinate a plan of care with patients and their prescribing health care professionals toward the end goal of them successfully reducing their opioid use.

Our solution includes the CEP-developed Manual Therapy as an Evidence-Based Referral for Musculoskeletal Pain clinical tool. It’s designed to inform physicians and nurse practitioners with the best available evidence.

Another key part of this solution is a script to help chiropractors start a conversation with a patient about reducing their opioid dependency. Most importantly, this script enables chiropractors to do so while staying within their professional scope of practice. We also offer fillable forms to help chiropractors share care plans with prescribing health care professionals.

Why interprofessional collaboration is imperative

But chiropractors can’t do this on their own. Interprofessional collaboration is imperative because MSK disability that’s related to opioid dependency involves much more than the pain of sitting or standing for long periods of time. It affects all aspects of a patient’s life, including their work, social interactions, family life, mental health and finances.

Spine, muscle and joint experts, such as chiropractors, can target the cause of the MSK pain and connect to affected areas of the patient’s life. Patients, primary care providers, as well as often social workers and other health care professionals, are also essential for the depth and expertise they bring to the complexity of a patient’s situation.

And to achieve the best outcomes, all care team members who the patient wants connected to their care plan should be aware of what’s happening at each stage.

So, as the patient’s mobility improves, it’s important for their care team to understand what the chiropractor’s next steps are in their plan of care. This understanding helps ensure the physician or nurse practitioner reduce their medication at an aligned pace or closely monitors the patient’s medication, if they are taking on a greater amount of exercise.

This close connection among the care team is needed to ensure the patient’s overall goals, such as reducing dependence on opioids, strengthening their mobility or improving their ability to stay at work, are met.

I believe patients also recognize the value of collaboration, as our research has found many are frustrated with the lack of communication and coordination among health professionals who care for them.[9] 

Key challenge: communicating across public and private care disciplines

One of the challenges we face is communicating across disciplines and at the right points in time. As we move into post-pandemic recovery, we know the publicly funded system will be under tremendous pressure to catch up and with enhanced interprofessional communication, chiropractors can help.

So, for example, when a physician refers a patient to a chiropractor or a chiropractor reaches out to them to discuss a patient’s plan of care, it’s important for them to agree on:

  • What the early weeks of care look will look like
  • When they’ll circle back with each other

This is a watershed moment for all of us to come together to change the outcomes for Ontarians who depend on opioids to relieve their MSK pain.

Health care community’s response to OCA’s Collaborative

This urgency coincides with a growing interest among family health team providers to know what’s going on with their patients’ care – whether it’s from a chiropractor or another health care professional outside the publicly funded system.

There’s a recognition that an increasing number of patients choose to see chiropractors or health care professionals who are not within the public pay system.

We’ve heard about an increasing number of family physicians and nurse practitioners asking about chiropractic care and providing information about the kind of care practitioners can deliver outside the bundled care systems. And again, with a focus on interprofessional care, they want to be engaged in these conversations.

Not surprisingly, the CEP clinical tool has been accessed more than 2,500 times since the Collaborative launched in June 2020 and some of our members have cited favourable feedback from physicians they’ve shared it with.

How the Collaborative will help Ontarians and Ontario

This collaborative approach empowers public and private health care professionals to achieve better patient outcomes for many Ontarians.

Once we reach a critical level of adoption, we expect to see more Ontarians moving, healthy and able to be a committed part of our workforce.

If we can provide the best MSK care at the right place, which is often outside hospitals, we’ll also help enable our health system to efficiently address the pandemic’s backlog of patient needs. Then our publicly funded system can devote its resources to priorities, such as cardiac and cancer care, that can’t be delivered elsewhere.

Finally, I think there’s an opportunity to further explore the co-ordination of care between the public and private pay system for evidence-based, well-established pathways of care. And low back pain would be one of those.

We know more than 70 per cent of Ontarians have extended health care benefit coverage through their workplace and the impact MSK conditions indirectly have on employers.[10] I think there’s an opportunity to leverage these benefits for the greater good, in terms of how they’re covered.

How can you help?

We launched the evidence-based Collaborative’s tools to our members in 2020 and are providing additional supports, such as this podcast series, to advance their implementation.

You can help by encouraging prescribing physicians and nurse practitioners to use this CEP tool and apply this approach to collaboratively help solve this opioid crisis.

I welcome your thoughts and feedback.

(Please note, this blog will be taking a break in August so you can enjoy your summer but it will be back in September with a focus on extended health care insights.)

[1] Kassam, A. (2021, July 4). Doctors’ focus on ‘missing patients’ is just first step in leading the pandemic recovery. Toronto Star.

[2] Vos, T., Lim S.S., Abbafati C., et al. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. The Lancet, 396:1204–22.

[3] Gomes, T., Murray, R., Kolla, G., Leece, P., Bansal, S., Besharah, J., Cahill, T., Campbell, T., Fritz, A., Munro, C., Toner, L., Watford, J. for Ontario Drug Policy Research Network. (2021) Changing Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic.

[4] Deyo, R.A., Von Korff, M., Duhrkoop, D. (2015). Opioids for low back pain. Thebmj. (350):g6380

[5] Borgundvaag, B., McLeod, S., Khuu, W., Varner, C., Tadrous, M. and Gomes, T. (2018). Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open. 6(1): E110-E117

[6] Shaheed, C.A., Maher, C.G., Williams, K.A., Day, R., McLachlan, A.J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 176(7):958-968

[7] Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 391(10137): 2368–2383.

[8] Primary Care Low Back Pain Pilot Evaluation: Final Report.

[9] Partnership4BetterHealth, OCA Patient and Family Advisory council.

[10] Environics Research, as commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractic Care. 13

Chiropractic Care During COVID-19

The role of chiropractic care in this pandemic

Chiropractor Dr. Amy Brown treating frontline nurse during COVID-19.
Chiropractor Dr. Amy Brown treats one of many frontline nurses during the COVID-19 pandemic, as explained in our Better Health in Any Space feature.

This is my first blog post since joining the Ontario Chiropractic Association (OCA) as CEO. I’m proud to lead an organization that represents 80 per cent of chiropractors in Ontario. This is an outstanding profession of regulated health care professionals, who are respected and valued by their patients.

This appreciation is even more evident as we continue to navigate the challenges of a global pandemic.

Pre-COVID-19, patients value their chiropractors

Long before COVID-19, we commissioned an Environics study on Attitudes of Ontarians Toward Chiropractors in June 2019. We learned that 26 per cent of Ontarians received chiropractic care, up from 20 per cent in 2016 – across regions, age, gender, education and income levels.

This study also told us Ontarians see chiropractors as trusted, competent and ethical health care professionals. In fact, more than seven in ten patients rated their chiropractic care experience as good or great.

COVID-19 has reinforced these findings, demonstrating the multi-pronged value of chiropractic care, while prompting the evolution of virtual care delivery.

Supporting frontline essential workers during COVID-19

During this pandemic, frontline health care and other essential workers have emerged as the heroes. At the best of times, spine, muscle and joint (musculoskeletal) injuries have been cited as the leading category of occupational injuries among health care workers.1 And sprains and strains account for 44 per cent of all lost-time claims across occupations in Ontario.2

The demand for essential workers to sustain COVID-19 efforts imposed longer shifts, increased stress and made redeployment to unfamiliar sites a frequent reality. Those extra pressures increased the risk of injury among frontline workers and the need for spine, muscle, joint and related nervous system (neuromusculoskeletal) care to help treat or avoid them.

Many of our members, such as Dr. Amy Brown, a chiropractor who practises at Coronation Chiropractic, Massage & Physiotherapy in Cambridge, experienced a spike in nurses seeking chiropractic care during the pandemic. Fortunately, chiropractic care was approved to deliver essential services for emergency, acute and urgent care during Ontario’s first lockdown period and could meet this increased need.

And chiropractors continue to provide care to help those on the frontline – from truck drivers to bakery workers – to keep working during the pandemic.

More than a year into COVID-19, it’s been a gruelling marathon for frontline workers. And Ontario chiropractors continue to treat essential workers’ neuromusculoskeletal issues and support the province’s COVID-19 efforts. They also continue to treat Ontarians working from home, who never thought their sofa or dining table would serve as their office for months on end.

Alleviating Stress on Emergency Departments

While hospital emergency departments (EDs) strain to care for patients with COVID-19, the system needs other options for people with back pain.

Data tells us that in a given year, more than 400,000 patients visited EDs in Ontario with musculoskeletal disorders, including arthritis, bone and spine conditions, among others.3 But as many as 97 per cent of emergency patients with back pain are not admitted and are sent home.4

Chiropractors are experts in assessing, diagnosing and treating many of these types of musculoskeletal conditions in the community. They also provide the type of care recommended as first and second-line approaches for low back pain.5

In delivering this direct benefit to patients during the pandemic, chiropractors continue to help reduce unnecessary visits to hospital EDs that are urgently needed for patients suffering from COVID-19.

Growth of Virtual Care Delivery

During this pandemic, patients continue to seek treatments for chronic care. So, with guidance from our regulator, the College of Chiropractors of Ontario (CCO), many chiropractors began offering virtual care.

Patients responded favourably to this treatment option. It enabled those with ongoing needs to continue their care plan, while minimizing the risk of spreading or contracting COVID-19.

Fortunately, insurance providers also adapted and included virtual care in extended health care benefit plans. Four out of five patients rely on their employer’s plans for chiropractic care.

To help our members safely deliver permitted services during the initial 2020 shutdown and beyond, we provided them with the ongoing information and resources they required. We also formed a return to practice working group and collaborated to provide them with a toolkit to support their safe return to patient care.

Recently, we were honoured to receive an Ovation Award of Excellence for COVID-19 Response & Recovery Management and Communications from the International Association of Business Communicators’ Toronto chapter, recognizing this work.

Some of my colleagues in other health care fields asked: “How can chiropractors deliver care without hands-on, manual therapy?”

The answer is that chiropractors develop a comprehensive treatment plan. Hands-on therapy, such as manipulation of vertebrae or other joints, is one type of treatment provided. Chiropractic care also includes customized, therapeutic exercises, patient education and self-management strategies, such as positions of relief.

Ongoing Value of Virtual Care

Even with most clinics open, virtual care continues to prove advantageous to many patients, such as those with compromised immune systems or other health concerns. It’s also valuable for those who have mobility issues or transportation challenges that may be worse during the pandemic.

Chiropractors are also combining virtual and in-person care to provide patient-centred solutions. Medical history, discussing patient expectations, education and coaching are completed virtually while in-person visits for treatments foster optimal patient experience and outcomes.

The Future of Chiropractic Care in the post-pandemic world

In my next post, I’ll talk about another crisis affecting Ontarians before, during and after COVID-19 – the opioid crisis and our strategy to help address it.

I look forward to our collective future in Ontario during and long after this pandemic.

1. Ngan, K., Drebit, S., Siow, S., Yu, S., Keen, D., and Alamgir, H., (2010). Risks and causes of musculoskeletal injuries among health care workers. Occupational Medicine. Volume 60 (Issue, 5). 389 – 394.

2. WSIB (2019), Schedule 1 – By the Numbers, 2019 WSIB Statistical Report. Common Characteristics of allowed lost time claims in 2019 (infographic).

3. MacKay C., Canizares M., Davis A.M., Badley E.M. (2010) Health care utilization for musculoskeletal disorders. Arthritis Care & Research. 62(2). 163-169.

4. CIHI (2017-2018) NACRS Emergency Department Visits and Length of Stay.

5. Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 391(10137). 2368–2383.

How CEOs and Boards Can Leverage 3 Keys to Soar in Unison

Leading Board of Directors meeting - with strong CEO as insight from Caroline BreretonIn my previous post, I identified 3 keys to enable successful leadership, outlining the leadership challenges Boards of Directors and CEOs, Presidents or Executive Directors face. Having served on and chaired Boards of Directors, as well as been accountable to one in my CEO role, I’ve lived the challenges and rewards.

Like ballroom dancers, boards and CEOs must find ways to cooperatively lead together and deliver on their accountabilities, without stepping on each other’s toes. Boards should only delve into operations when necessary and CEOs must appear to welcome detailed questions, even when they don’t.

Each party must develop a trusting, productive relationship with the other and clear accountabilities for the organization to flourish. If the relationship is not optimal, the entire organization flounders, as the CEO and management team struggle to meet new or unclear expectations from the board.

In the public and not-for-profit sectors, boards complete the accountability cycle back to funders and residents. And if you work in these sectors, you know how complex they are.

Patience runs thin for slower progress on strategies, when either the board or CEO changes. Boards organically change when their membership changes. Each cycle brings a renewed need to focus on the relationship and accountabilities as new board members offer their unique contributions. Yet sometimes boards and CEOs forget to put the necessary supports in place to ramp up quickly to a productive working relationship.

To successfully choreograph this dance, here are traditional and new approaches that have helped me leverage 3 keys: Listening, Learning and Leading, from both sides. I invite other CEOs and boards to retrace these steps as they forge their own paths to success.

Listening – From Meaningful Conversations to Generative Dialogue

An essential part of listening is having meaningful conversations so that we can uncover what’s really important.

Boards of Directors govern, while the CEO manages the organization. Yet both provide leadership to enable success, must meet specific accountabilities and make tough decisions.

Board decisions relate primarily to fiduciary and strategic issues. Understanding the context is essential for good decision-making and sometimes requires insight into operations. Structured reports and information can help but can only go so far. Meaningful conversation on issues fosters greater understanding. Coined by William Isaacs, as ‘Generative Dialogue,’ this kind of conversation is gaining more traction with some boards but is not yet common practice.

Generative dialogue mode enables the board and CEO, with their senior leadership, to delve deeper into an issue without overstepping each other’s accountabilities. Each party understands that the time spent on a topic must focus on listening to issues from all perspectives around the table.  The goal of the process is to reach a shared understanding of the context, before the decision is made.

One way I’ve found to achieve this goal is through scheduling educational sessions on topics of strategic or fiduciary importance prior to the board meeting and ideally a month or so before the decision must be made. This process allows board members to digest the information and complement their understanding with other reading/information before the decision-making meeting. In the limited time boards have together, we need to ensure they have what they need to effectively fulfill their role.

Learning – Using 360 Dynamic Feedback to Adapt, Grow and Thrive

Adapting what we know to the context of each scenario we land in is critical. Board members bring diverse skills from their professional and personal experiences and this diversity gives the board strength. However, applying these skills to board governance is different. For example, the way performance indicators are presented in one organization may not apply in another but they may work perfectly for a particular board and CEO. If you have an experienced information management professional on your board, they will apply the ‘nose in’ and ‘finger out’ concept, by asking questions to understand meaning and action plans without telling the CEO how to do their role.

Giving directors formal opportunities to learn about governance helps them adapt their knowledge to your board’s specific context. It is also important for the CEO to have a strong foundation in governance. Even better is learning together to create a shared understanding of best practices in governance.

Either way, learning through dynamic feedback is crucial. Good governance practices include the annual board survey, meeting evaluations and in-camera debriefs without the CEO to discuss board performance. These tactics may generate improvements to board process and even change the CEO and the management team’s expectations in a way that better supports the board or its priorities.

I think there’s another performance enhancing feedback process we usually miss:  Capturing how the CEO and senior management experience the board’s impact and effectiveness. CEOs change less frequently than boards but new board members change the context of the board/CEO relationship.

In welcoming feedback from the CEO and management team, boards role model the principles of continuous learning, which help us all grow.  To be effective, both parties should probe for tough feedback and follow through to make sustainable improvements. I believe we need to optimize the board/CEO relationship so that both can co-create the best future for the organization they serve. Then, at the centre of a successful public or not-for-profit sector organization, you’ll find a Board Chair focused on improvements and learning, as they adeptly share the CEOs feedback with their board

Leading – Uniting Leaders through Clear Expectations and a Solid Workplan

The Board Chair’s leadership makes or breaks the board’s effectiveness. While not always recognized as leaders, the Board Chair’s role determines the success of the board/CEO relationship. Their leadership must start with authentic intention and a genuine desire to serve the organization through their role. Of course meeting management, relationship building, communications and conflict management expertise make the Chair’s contributions even more effective.

Through its succession planning process, the board should define these skills as imperative and support aspiring chair candidates’ efforts to enhance these skills, during their tenure as members.

On the other hand, the Chair holds the CEO accountable for access to effective staff support to deliver on the board’s responsibilities. In setting expectations that the board will have good practices for doing its work, the Chair signals respect for the CEO.

Sounds wonderful but how do you achieve this balanced leadership? One tool I’ve found indispensable for making the CEO and board relationship most effective is having a comprehensive, annual workplan that:

  • Aligns with the organization’s strategic priorities
  • Fulfills its fiduciary responsibilities
  • Builds in generative dialogue time
  • Addresses the responsibilities of the board’s one employee: the CEO, President or Executive Director (through performance assessment, compensation and succession planning)
  • Accommodates its own governance processes (policies and procedures, board succession planning and board development)
  • Supports stakeholder engagement

Once developed, this workplan should serve as a central blueprint for the board’s work and the support needed from the CEO.

Boards play a central role in accountability. I’ve had the invaluable experience of seeing a community-based board step up to an enormous challenge and ensure that the organization it served flourished, even under extreme external forces.  This is how I’ve worked to master the dance between the CEO and board.

What works for you? I welcome your thoughts on these approaches to strengthen governance and the board/CEO relationship.

3 Keys to Make You a Successful Leader

Keys to effective leadership: listening, learning and leadingLeadership has been fundamental to our accomplishments for as long as we have shared stories of our successes and failures. Coordinating work or rather making the best use of an organization’s assets and the skills of its people, along with engaging everyone to advance a better future, drives us as human beings.

So why is effective leadership for positive change so challenging?

Frequently we hear people express their dissatisfaction with leadership. It’s hard to recall anyone writing about the thousands of exceptional leaders we have in the public or private sector. We tend to focus on the few outlier examples, positive or negative.

Different stakeholders express their expectations of leadership from their varied vantage points.

  • Clients/Patients/Customers no longer tolerate organizations that do not engage effectively with them, understand their needs and make a difference to their lives. We need to identify which principles guide our interaction with these priority stakeholders, particularly as this is our reason for being in health care or a service industry.
  • Employees are seeking a different work experience. The workplace is filled with different generations but it’s time to stop labelling them. Yes, we need to understand trends but each employee brings a unique contribution and their own expectations within a multigenerational team. In her “Body of Work,” Pamela Slim describes a workforce who sees their work and personal lives aligned with their drive, passion and values. How will we learn to lead in this environment? My experience in public service and complex environments, such as health care, suggests that it’s crucial for leadership to enable this alignment. This alignment creates a culture that retains talent, which is essential to success in any service or care industry.
  • Boards of Directors are challenged to understand a dynamic environment where they are expected to have their “nose in” but “fingers out” of the business. Can boards deliver on their accountabilities without duplicating the management function? Stakeholders are quick to lay blame if the organization fails to deliver on its mandate, as we have seen time and again. Balancing the governance accountability with the management/CEO role requires leadership in itself.
  • Funders expect their constituents to be satisfied. However, we have just begun to scratch the surface of understanding, through dialogue and big data, what constituents expect. How will we rapidly gain a better understanding so that we can be strategic and thoughtful about the changes we implement?

In previous posts, I have shared my teams’ successes, from working in a complex health care environment. These learnings also apply to other settings.

In upcoming posts, I am going to focus on what I believe are the important considerations for leaders to succeed in their roles. As Ontario’s employee demographic shifts during the next 10 to 15 years, leaders will need to get much better at rapidly learning how to effectively lead others and employees will need to ramp up their ability to collaborate.

I believe the following three attributes are keys to success, which I will focus on in upcoming posts

  1. Listening to gain insight – In my last post, I shared my perspective on how important listening is to our work with patients and families. A key part of listening is having meaningful conversations so that we can uncover what’s really important to our patients, so that we are in a better position to meet their needs. These listening strategies and approaches can effectively guide engagement with other stakeholders. I will explore how these strategies and approaches can improve interactions with boards, funders, residents and employees.
  2. Learning to adapt what we know to the context – Learning is a skill that must be mastered by individuals and organizations. In his book “Getting Everything You Can Out of all You’ve Got,” Jay Abraham addresses the issue of how to avoid the costly learning curve. He recommends we master the ability to borrow success practices from other industries and then apply them to ours. We need to understand that there are well established, proven ways to work with people to deliver what they as individuals need. The methods can be transferred. It’s coordinating the intervention or support and its outcomes that are unique to each individual. “Agile” is a term used frequently these days to describe how organizations learn and improve. It also describes the culture and leadership practices of successful organizations.
  3. Leading with authentic intention – In any business/sector/enterprise, leadership is essential to deliver on the mission or mandate its stakeholders set. In a guest Leadership Lab column I wrote for the Globe and Mail earlier this year, I described ways a leader can engage with their stakeholders to steer their organization through complex change.

Leaders will be successful if they listen and learn and apply that learning with their skills to lead an organization.

Recently Andre Picard wrote in the Globe and Mail about Dr. Philpott’s move from the health file to Minister of Indigenous Services. He listed the strengths she brings to her new, even more complex role. Among those strengths are many that all leaders need today. Most significantly for me he noted that: “her unofficial title will certainly be Minister of Social Determinants of Health.” Given our success locally incorporating this perspective into our strategies, I am excited to observe how this will impact outcomes for our Indigenous People and other areas of our health services. She will continue to “Listen, Learn and Lead.”

Please watch for upcoming posts where I will explore these three critical attributes.

What do you think about these three attributes? I’m particularly interested in hearing how, as leaders, we can more effectively lead multigenerational teams. What challenges do you face?

5 Ways to Engage Patients and Uncover Invisible Insights

Patient and care coordinator engagingIn my first post, I outlined five features of a patient-focused integrated health care system that I envisioned. The third was a system that: stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and social, economic and cultural (SEC) tools, among others.

There is a real opportunity for our health care system leaders to understand what our communities, patients and families consider to be the best quality care they can receive.  Some believe we have this answer in the depth of knowledge, research and clinical evidence that we have and use to guide decision-making. Clearly, patients tell us: we don’t. Clinical data only gives us partial answers.

We need to effectively engage patients, caregivers and families, actively listening to their voices to uncover invisible insights for the rest of the answers. Only then can we fully understand what’s needed to shape a patient-focused system.

In a guest Leadership Lab column I wrote for the Globe and Mail earlier this year, I described ways a leader can engage with their stakeholders to steer their organization through complex change and mitigate risks. We may not have all the answers but when we engage, we bring our team, partners, clients or patients and other stakeholders’ questions, concerns and fears to the surface.

Of all our stakeholders in health care, patients are our priority and it’s important for leaders to continuously engage them, not just during times of change.

Here are five approaches that I found invaluable in my work leading a home and community care organization (Mississauga Halton CCAC):

1. Having meaningful conversations with patients –

If you directly ask a patient what their goals are, they might find them hard to articulate. However, they may enthusiastically express their joy in watching their grandson fine-tune his hockey skills or playing cards with their friends.

A skilled care coordinator starts the patient assessment process by gently having a meaningful conversation with their patient to learn what’s important to them and through this process, subtly uncovers their goals. This conversation also elicits feedback on how the patient wants their care delivered. With this insight, we can form pledges to patients on how they will ‘receive’ care, not just how we deliver it.

In 2015, the Mississauga Halton CCAC launched the award-winning Care Coordination Program of Work to drive consistent quality in our care coordinators’ varied competencies, while providing this essential service.  One competency is communications and we set specific standards and training to help each care coordinator guide these meaningful conversations and effectively engage each patient.

2. Partnering with each patient, their caregiver and family members –

Next to patients themselves, their caregivers and families are in the best position to help care coordinators, service providers and other funded resources understand their specific goals. Actively listening to our patients and partnering with their families helps us deliver on their expectations. And meeting or exceeding a patient’s expectations makes their health care experience that much better.

Patients, caregivers and families want to work with us to make sure their needs or those of their loved ones are met. And when they talk about how care is delivered, their requests are practical. They want to be treated with respect, participate in the conversation and have the opportunity to influence care decisions. To meet these requests, care coordinators work with the patient and often their caregiver or family to co-create a care plan they all agree on.

Based on input from patients and caregivers, our CCAC developed a personalized patient information package called ‘My Story’ to support this process and help patients be confident with their care.

3. Facilitating formal patient engagement forums to inform programs & services –

In 2014, our CCAC established Share Care Council – a structured patient engagement forum of 15 patients, substitute decision-makers and family members. Council members volunteered their time quarterly to provide input into new programs and services, on behalf of our region’s residents.

What I found most interesting is when we asked specific questions about program planning for the future, we didn’t hear “We need more PSWs or more nursing care,” even though we were at the lower end of the funding per capita, per senior resident in our region. Our patients and families understood the constraints of the system. Instead, they told us about their care experience, how it made them feel and how our system design can do better with the resources we do have.

For example, we asked what respite care or caregiver relief means to them. They told us it is temporary care that substitutes for the care provided by their loved ones or family members. It enables their loved one/family member to recharge, so they can continue to provide support. More importantly, they explained how this respite needs to consider how the loved one provided care, by understanding what matters to the patient, such as the way a chair is placed, the specific supports they need for reading or the companionship they seek. Essentially, they want support beyond the clinical care requirements.

Council members showed us the health system is not fractured in their mind. That’s why they find it frustrating when the care they experience falls short. It doesn’t matter whether they are a primary care patient, a hospital patient or a home and community care patient, they are simply a patient – in need, stress or crisis.

Feedback from our council informed many successful initiatives, such as My Story, our Health Links Patient Partnership (HeLPP) program and our award-winning Seamless Transitions, a new approach to help patients transition from hospital to home.

I’m pleased that the Patients First Act requires each expanded LHIN to have a Patient and Family Advisory Committee, like our Share Care Council, to support community engagement. This requirement offers the potential to put patients first by actively using their voice to inform day-to-day planning.

4. Establishing an Ombudsperson office for managing formal complaints –

Complaints are tough and call for intense, specialized interactions. We created an Ombudsperson role and dispute resolution process to address patient complaints that were complex and escalated beyond the care coordinator and their manager.  In a true service culture, point of care teams are supported to resolve issues as soon as possible and as close as possible to the patient and family. However, in the “complexity” of our health system design, “complex” complaints often involve multiple stakeholders across the system. Point of care teams need additional support. This office receives complaints via varied sources – from the patient or caregiver to the Long-Term Care ACTION Line.  The team uses specialized negotiation techniques to focus on the needs of each party with the end goal of achieving the best solution for everyone.

Time and again, we discovered a communications breakdown at the root of an issue. To address it, we needed to ask questions and create opportunities to hear the assumptions behind it. In our information overload world, we can’t assume all input is based on the best or most up-to-date information. We found engaging, even in challenging circumstances, often leads to clarity, prompts dialogue and helps forge solutions.

5. Encouraging broad feedback through formal measurement tools –

Each year, a third-party research firm conducted a Client and Caregiver Experience Evaluation (CCEE) survey of our patients, as well as those at CCACs across Ontario.

This standardized tool invited patients to anonymously answer a series of standard questions about the quality of care they received and how they felt about it.

These provincial comparisons of our local performance gave us a consistent way to assess how well we met patient expectations and opportunities for improvement. For example, through a deep analysis of this information we were able to uncover the need for greater consistency in our communication with patients. As described earlier, this finding led to our investment in the Care Coordination Program of Work and a turning point in satisfaction results with our services.

Through sharing what’s important to them, patients and families will help us as leaders evolve our organizations, make the system adaptable and responsive to their needs, as well as those of the next generation to come.

“It’s far more important to know what person the disease has than the disease the person has” – Hippocrates

What do you think? Can you think of other ways to engage patients and their families?  Can you share an example of how engaging patients helped shape a successful decision or initiative?

Why Care Coordination is an Essential Health Service

Benefits to the Patient and the Health System

In just over a decade, Ontario is expected to see its number of seniors, 85 years and older, quadruple. As Ontarians age, they also develop more comorbidities, with 70 per cent of seniors expected to live with two or more chronic conditions by 2030. For these frail patients requiring services from multiple providers, accessing the right level of care at the right time is bound to be tricky.

That’s where care coordination comes in. It’s a fundamental health service that assesses and coordinates the most appropriate services for a person’s health needs. Through this process, care coordination facilitates smooth transitions between varying levels of care. Care coordinators are regulated health professionals with backgrounds in nursing, social work, occupational therapy, physiotherapy or speech therapy. They work directly with patients receiving care either in hospitals, doctors’ offices, community clinics, schools, or in their own homes.

Care coordinators take a holistic view of the person’s clinical and social status to identify the most appropriate services for the patient, such as nursing care, personal supports for daily living, occupational or physiotherapy, adult day programs, or help finding a primary care provider.

Reducing health risks

At the patient level, care coordination reduces health risks by ensuring that every patient receives health services to match their needs. Seniors with multiple chronic conditions rarely require the same level of care over a consistent period of time. Their health fluctuates. Sometimes they require intensive care, while at other times they may be able to live more independently, needing less care.

Care coordinators are crucial in helping patients and families weave through these different types and levels of care by assessing patients’ clinical statuses, monitoring their outcomes and adjusting the plan of care with all health care providers. They also focus on patient’s social determinants of health, such as income, housing status and social supports, which might affect their wellbeing.

As I mentioned in a recent post, “3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes,” patients with socioeconomic barriers can’t afford to follow health care directions if they don’t have the necessary social supports. Care coordinators have the means to link with other organizations and share information with partners in the patient’s circle of care to address socioeconomic issues through non-clinical supports. These supports could be help related to lifestyle changes or assistance in accessing social support services and volunteer programs.

Providing effective care coordination that addresses clinical and social determinants of health enables patients to live safely in their home. This health service spares patients the social impact of leaving the comfort of their home. It also saves the financial costs of hospitalization or a premature move to long-term care.

Optimizing Resources

An unnecessarily early move to long-term care isn’t just costly for the patient – it’s taxing on the entire health system, with long-term care costing $126 per day, compared to $42 per day for home care. Beds are also limited – the Mississauga Halton LHIN for example, has 25 per cent fewer beds per senior than the provincial average.

Yet we still see some patients moving prematurely to long-term care homes without first receiving Supports for Daily Living, Adult Day Programs, assisted living or home care – services that could help patients retain their independence for as long as possible, while easing the demand for beds in hospital or long-term care homes.

Without having a care coordinator involved in their care, patients might skip these crucial levels of care when they experience health crises and go to the hospital emergency department or seek a physician’s care. During crises, patients and their families may also rush to obtain care in a long-term home believing it’s the only solution. Many have difficulty understanding that with the proper supports, they may improve at home or in their community.

To optimize our province’s resources, we have to ensure that long-term care beds are reserved for patients with the highest needs. Care coordinators can help patients who don’t require services in long-term care by empowering them to remain at home and independent. They can also arrange for home and informal care services to help discharge seniors admitted to long-term care following an acute episode.

Evolving Care Coordination to Meet Patient Needs

To best serve our patients, care coordination must be consistent in its service delivery – something we learned after surveying the Mississauga Halton Community Care Access Centre’s (CCAC’s) patients and caregivers. Feedback from this survey showed that patients value consistency above all. Regardless of where they live, patients want to receive the same approach to care coordination and the same quality of care, as any other individual in the region.

Based on this survey’s findings and results from the Community Capacity Plan, the Mississauga Halton CCAC saw an opportunity to redefine and enhance the role of care coordinators.

We found care coordinators to be most effective when they’re connected to every part of the health system, serving as the single point of contact for patients to obtain services and information in their neighbourhoods. To facilitate this, our CCAC implemented the Care Coordination Program of Work, through three key phases:

1. Care Coordination Enhancement

To ensure patients receive consistent care, we trained care coordinators on the following eight core competencies, which serve as the foundation for delivering a patient-centred, holistic approach to care:

  • Assessment
  • Communication
  • Navigation
  • Quality and patient safety
  • Collaboration
  • Sustainability
  • Care transitions
  • Care planning

These core competencies modernized the way we deliver care by establishing consistent care practices for coordinated care planning.  They also leveraged technology and proactively engaged all those in a patient’s circle of care.

2. Neighbourhood Realignment

Because Socioeconomic and Cultural (SEC) statuses vary significantly across neighbourhoods, it’s important to have a strong understanding of the social, cultural and economic factors that impact the ability of people in those neighbourhoods to access care.

Our CCAC also realigned care coordination teams and caseloads to specific neighbourhoods within the Mississauga Halton region. This helped care coordinators hone expertise in the specific resources available in the dedicated neighbourhood where they work. With this knowledge, they can remove barriers to care, tailor services to patients and arrange for support from local resources.

3. Connecting to Primary Care

Finally, to deliver quality care, we must establish strong connected teams that wrap care around patients and in collaboration with their family physician or other primary care provider. To help achieve this, Mississauga Halton CCAC created the Primary Care Advisor (PCA) role. PCAs serve as the point of contact for primary care physicians in Health Links boundaries.

Through this relationship, they’re able to increase awareness of LHIN programs and services among primary care physicians and also gather feedback to improve patient outcomes and experiences.

Expanding the Role of Care Coordination

I’ve seen efforts to reimagine the role of care coordinators to become coordinators for the entire health system move forward, largely due to the eight core competencies that now guide and standardize care coordination in our region. Looking ahead, we need to understand that care coordination offers value among the broader circle of care, and that sometimes, there might be minimal involvement from partnered service providers.

Care coordination could be expanded to include other partners funded through community and social services, such as Development Services Ontario and Correctional Services for specific patient populations, rather than just through the health system. It could also involve coordinating care to include pharmacy, laboratory, imaging and physician services, which are beyond the LHINs’ current mandate.

What do you think? In what other ways do you see care coordination evolving?

3 Ways Collaboration Expands Health Care Capacity

We know that to help our patients achieve what’s most important to their wellbeing, we need to bring clinical care and social determinants of health together. But to realize a patient-focused, collaborative and integrated health care system, we must focus on fostering strong relationships with everyone in a patient’s circle of care.

As I mentioned in my first post, collaboration is a key feature of a sustainable, integrated health care system. It’s also at the root of home and community care. Care coordinators are connected throughout the health care system. They work with patients and families, hand-in-hand, to co-create tailored care plans that may involve nursing care, Adult Day Programs, personal support care, occupational or physical therapy, mental health and addictions or other services.

In fact, results from the CCAC’s Community Capacity Plan highlight the importance of care coordinators, patients and caregivers working together at multiple levels. The plan also cites the value of collaboration between multidisciplinary partners, such as health care professionals in acute, primary, long-term care, mental health, addictions and community services.

1. Collaboration Leads to Innovative Programs

Primary Care Advisors

While care coordinators collaborate with patients and caregivers at a clinical level, Primary Care Advisors (PCAs), who are currently unique to the Mississauga Halton LHIN, work as trusted points of contact for primary care physicians and gather feedback to improve patient outcomes and experiences. They also meet regularly one-on-one with primary care providers to keep them informed about LHIN-wide programs, services and initiatives.

Before meeting with PCAs last year for example, many physicians weren’t aware of the support and scope of expertise CCAC palliative nurse practitioners can provide to help them care for their patients and families.

Through the PCA-physician collaboration, which began in 2015, we’ve learned two important lessons:

  • We need to effectively coordinate services to address the socioeconomic and cultural (SEC) impacts on patients
  • Care conferencing, where multidisciplinary partners meet to discuss how patients’ needs are or can be met, is vital for the success of patients’ care plans

Health Links

Meanwhile, through the province’s Health Links initiative, we’ve seen multidisciplinary partners, including: primary care providers; specialists; care coordinators; other allied health professionals; community service providers; hospital clinicians; social workers; and those working in long-term care homes, engaging with each other to coordinate care for the top five per cent of our province’s patients with the most complex needs.

When it comes to health care, turf and structure don’t matter to patients. Patients don’t care where their care is coming from, or who developed the approach to their care. What matters to them is having maximum opportunity to achieve their health goals. That’s why Health Links, which has seen care coordinators going beyond their traditional roles, has succeeded.

And as this network expands, Health Links can evolve from a program approach to a philosophy of collaborative care where patients receive the level of care coordination they require to support their health. The term “Health Link patient” would then become obsolete, as patients with complex needs will simply receive timely and quality care to match their needs.

2. Collaborative Information Exchange Increases Knowledge

To evolve collaborative, innovative initiatives, health care providers need to share knowledge about the best ways to help patients and families succeed in their care plans.

As Ontario’s CCACs integrate with their corresponding LHINs through the Patients First legislation, one of the most valuable assets they can bring is their capacity to ethically share valuable knowledge and information about their patients. As I outlined in “4 Ways Big Data Informs and Manages Health Care Performance,” accessing patient data from experts across the continuum of care enables us to obtain a complete picture of each patient. We can also use it to learn about the broader population’s needs and identify opportunities to improve each patient’s experience.

As the CCACs and LHINs integrate, I also see a significant opportunity for LHINs to build stronger connections between primary care providers and community resources. Within this new structure, LHINs can become true collaborators, forging connections with various health care providers and creating new knowledge to share across the continuum of care.

To do this, we need to move beyond our walls and not let current management structures constrain our capability to exchange insights that help our patients. My philosophy has always been that structure exists to manage an organization, but to deliver on an organization’s mission and vision, we need to operate in teams across the continuum.

That means we need to share information, which has traditionally been one of the most protected assets in health care. Since their inception, CCACs have been working to integrate information from their Client Health Related Information System (CHRIS) or electronic patient health record system, in as many ways as possible. This integration includes connecting with hospitals and enabling health care partners to document patient updates online in CHRIS records. And as CCACs integrate with the LHINs, CHRIS will become a provincial asset, with information more readily accessible to those in each patient’s circle of care.

But sharing data isn’t enough. We also need to also collaborate on projects and share approaches that work. Ontario is known for its numerous pilot projects. We regularly see exciting new, innovative programs developed throughout the province. Unfortunately, we continuously fail to spread knowledge and increase awareness of approaches that work. We seem to be constantly reinventing the wheel. Why is that? One reason is that as a provider-driven system, individual providers are motivated to deliver innovative solutions that earn recognition, which may lead to increased funding. But our patients and families see the health care system as disjointed, bouncing them from one heath care silo to the next. We have to turn our thinking on its head and see success through our patients’ lens.

3. Working Together to Wrap Care around our Patients

For a long time, hospitals have been the hub of knowledge and care – but as I mentioned in my first post, clinical care alone can’t meet all patient needs. Those patients with complex and chronic needs often require health care services from multiple partners at the community level. The challenge so far is we have not deliberately designed a community care system that meets the needs of aging patients with complex needs. Our system is not set up to connect clinical care with other necessary supports to address socioeconomic issues and ultimately improve patient outcomes.

One way forward is to create “health care hubs.” Health care leaders can use existing assets in certain LHINs to develop these hubs, which would serve as physical spaces within communities that vary between neighbourhoods. These hubs could be attached to primary care practices, seniors’ centres, home and community care clinics, hospital urgent care centres or community health centres.

This holistic approach to care aims to bring the right care to the neighbourhood in which our patients live. In these community hubs, we’d see various health professionals – including care coordinators, geriatricians, professionals from Adult Day Programs and Falls Prevention Programs, neighbourhood-based nurses and personal support workers – working together to closely monitor their patients’ conditions.

Over time, this capacity to collaborate and wrap care around patients in their communities would be virtually everywhere.

As we continue to revamp the health care sector and develop new approaches to care, we have to rely on the experiences of our patients and their family members. To do this well, we need to learn more. We need to engage our patients to uncover invisible insights about their challenges and goals, which I’ll address in a future post.

What do you think? What other ways do you think collaboration can expand health care capacity?

3 Steps to Addressing Socioeconomic Barriers to Achieve Better Outcomes

Meet Sonia: she’s an 86-year-old woman born in Poland, who has outlived her husband, suffers from depression and diabetes and has just been discharged from hospital following surgery. She’s unable to afford the medication prescribed to her and has few family members or friends around to help her safely travel to a neighbourhood clinic and receive the proper follow-up care.

Sonia represents the dilemma many Ontario seniors will face in the coming years. We know that by 2030, 70 per cent of Ontario seniors will be living with two or more chronic conditions, similar to Sonia. What we don’t know is how many seniors like Sonia are being disadvantaged because of their socioeconomic living conditions. The fact that she has trouble communicating in English, that she has a small support network, and that she lives on a small income means she’s more likely to experience poorer health outcomes than individuals without these types of variables.

Addressing Socioeconomic Barriers

I believe that too few health organizations consider the added dimension of socioeconomic living conditions. Under tremendous pressures, teams work diligently to treat episodes of illness but often neglect important socioeconomic factors. When we are blind to these issues, we negatively affect the plan of care and the health outcomes patients strive to achieve.

1. Know your patients’ complete story and the neighborhood in which they live

Providing quality health care is no longer about simply shortening patients’ length of stay in hospital and getting them home as quickly as possible. Nor is it simply about caring for patients’ clinical needs. Only by tailoring care models in all care settings to specific populations, can we really meet the needs of individuals like Sonia.

The CCAC’s Community Capacity Plan, developed in collaboration with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC, revealed that the care coordination we provide should be tailored to individuals based on: their diagnosis, the neighbourhood in which they live and other social determinants of health – those social and economic factors, including education level, income, race, gender, sexual orientation and place of residence, which influence health and wellbeing.

If we don’t address social determinants of health and the contributing factors in each patient’s situation, we’re putting people like Sonia at higher risk of health complications, poorer quality of life, hospital admissions and readmissions and avoidable emergency department visits.

The evidence supports this. Data from the Mississauga Halton Community Capacity Plan found that seniors from the highest-risk Socio-Economic and Cultural (SEC) group were more likely to move to institutional care, or long-term care, than those from low SEC groups. They were also 40 per cent more likely to visit hospital emergency departments than individuals with low SEC status.

These at-risk patients can’t afford to follow health care direction without the necessary resources. If their income is used to support five family members, or if they live at home with a small support network like Sonia, priorities are more likely to focus on paying rent and purchasing food than on filling prescriptions or paying for transportation to a health clinic, for example.

In fact, a Health Quality Ontario report found that one in 12 Ontarians surveyed, aged 55 years and older, didn’t fill their prescriptions or skipped a dose because of cost, while another study found that one in eight Canadians between 55 and 64 years old will occasionally skip prescription medications for the same reasons. If we know patients can’t afford their medications, we should certainly be approaching their care differently.

As I mentioned in my first post, “5 Features of a Sustainable, Integrated Health Care System,” bringing care out of institutions and closer to patients’ homes lets us tackle socioeconomic obstacles. By asking the right questions in all care settings, we can move beyond clinical diagnoses, to having meaningful conversations with patients, engaging their families, and providing more comprehensive support services at home, in the community and in hospital.

2. Identify individual and systemic barriers that create inequities

After implementing the CCAC’s Care Coordination Program of Work a recommendation from the Community Capacity Plan – we saw the realignment of care coordination teams and service providers within the Mississauga Halton region. We identified 26 neighbourhoods of roughly 10 square kilometres each, as relevant for organizing care delivery in the community setting.

We now have teams who will really know the gaps that exist, which will allow them to better provide comprehensive care in neighbourhoods in which their patients live. For example, high utilization of certain services in a region helps us uncover the specific challenges the population in the area faces. Teams can proactively consider not only the clinical care needs but the supports required to address the SEC issues that impact a patient’s care plan.

The questions now are, how can we overcome the challenges of involving family physicians, pharmacists, nurses, hospital physicians, and others in the continuum of care, so that we can collectively wrap care around individuals more effectively and efficiently? How do we create high-performing care teams across the diversity of the independent programs and services that are available in the community?

Dr. Kwame McKenzie, Medical Director of Underserved Populations at the Centre for Addictions and Mental Health (CAMH), led an initiative to identify ways in which we can improve health equity in the country. He helped develop the following eight questions that health care professionals can ask their patients during the assessment process, which would then be shared with other health professionals:

  1. What language would you feel most comfortable speaking in with your health care provider?
  2. Were you born in Canada? (If no, what year did you arrive?)
  3. Which of the following best describes your racial or ethnic group? (list provided)
  4. Do you have any of the following disabilities? (list provided)
  5. What is your gender?
  6. What is your sexual orientation?
  7. What was your total family income before taxes last year?
  8. How many people does this income support?

These are questions that we don’t traditionally think about asking. They can be asked once by any health care professional conducting a patient’s initial assessment – either a family doctor, hospital discharge planner, nurse or care coordinator. The value of asking these questions is that health care professionals are able to have patients’ socioeconomic information at their fingertips. When they meet with patients for the first time, they will have a deeper understanding of their needs and the kinds of individualized questions to ask, to build an effective care plan that will enable patients achieve their health goals.

By acting on this data, we’re better equipped to reduce unnecessary hospital and emergency department visits and entry to long-term care. We’re also able to identify trends with patients over time, to understand risks to certain populations in the region, and to connect patients with the appropriate services in their neighbourhood.

Some organizations have begun collecting data on patients’ socioeconomic situations using these eight questions. Now we need to find a way to consolidate and share this information with everyone involved in a person’s care. As of today, we don’t have the means to share SEC scores at a patient level. Even though care providers may understand the importance of SEC status, when information isn’t shared, we see ourselves entering into the familiar cycle of asking patients to repeat their story over and over again.

The CCAC will continue using equity data collection to inform the delivery of quality care through its Care Coordination Program of Work, to ensure that care is wrapped around the patient at the neighbourhood level. Through our Client Health and Related Information System (CHRIS), we have the means to link with other systems and to share this information with those in the patient’s circle of care. Being able to share information effectively is one of the characteristics of high performing, patient-driven health systems, and leads to my third step to addressing socioeconomic barriers: effective collaboration

3. Bringing together clinical and social determinants of health through collaboration

Hospital physicians, clinicians, nurses, family physicians, care coordinators and others in the continuum of care must collaborate to help patients achieve what is most important to their wellbeing. Frankly, our patients expect this of their care team. We need to bring clinical and social determinants of health together.

By asking Sonia questions related to her socioeconomic status, we would know she feels more comfortable speaking Polish, that she is still mourning the loss of her husband, which led to her depression, that poor eating habits contributed to her type 2 diabetes and that she has a very small support system at home – issues that cannot be addressed through medication alone, but also through lifestyle changes, volunteer programs and other non-clinical supports.

Creating effective, accountable inter-professional teams through strong relationships with everybody in a patients’ circle of care is a must. As I mentioned in my previous post, “4 Ways Big Data Informs and Manages Health Care Performance,” we need an integrated system focused on system planning and patient-driven care delivery operations to ensure that individuals with the greatest needs receive comprehensive, individualized care. This includes supporting care coordination, monitoring quality, patient outcomes and their experiences and service providers’ resource use.

Standardizing clinical care pathways – management plans that display goals for patients – are a great move forward to improving clinical care outcomes for Ontario residents. Knowing SEC information, which allows us to wrap necessary supports around patients to help them achieve expected outcomes, is necessary for the individualization of care plans.

In my next post, I’ll delve a little deeper into the importance of collaboration and the ways in which it can expand health care capacity.

What do you think? Are you collecting SEC data? How is it helping you provide more effective care?