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.

3 Hurdles to Dodge in the Patients First Marathon

Patients First Hurdles

Runners' hurdle with Patients First report cover on top.In my last post, I discussed three goals Ontario’s Patients First legislation can potentially realize, if health care leaders effectively leverage Community Care Access Centre (CCAC) assets (people, processes and technology), as well as other organizations’ assets.

On the flipside, I believe health care leaders need to dodge the following risks when implementing Patients First:

1. Working in Silos without a Shared Understanding of Vital Design Principles

We need to work collaboratively, with a shared understanding of the design principles that are essential to a high-functioning, sustainable system.

As I outlined in my last post, we have an opportunity to build stronger connections between primary care providers and community resources. This means designing a system that enables everyone in the circle of care to easily engage with each other in the course of patient care.  For this to succeed, all parts of the system must optimize resources and work collaboratively.  It is contemplated that the LHIN sub-regions will enable this collaboration and integration.

Implementing Health Link helped many patients with complex needs but it also put us precariously close to creating parallel systems to care for those patients. Once this challenge was recognized, changes were made to streamline care and use resources in a more sustainable manner.

This time, as we think about LHIN sub-regions we have an opportunity to step back and identify the shared system design principles that need to be in place, before we move forward.

2. Paying Scant Attention to CCACs’ Proven Culture and Leadership

There’s a risk that in integrating CCACs into the LHINs, health care leaders may pay insufficient attention to proven aspects of the existing home and community care’s culture and leadership. While not perfect, we know that to deliver care in the community, enter people’s homes, work with a diverse, virtually connected workforce and their supports, a unique culture is required. This culture is led by a dual focus on system planning and care delivery operations, which include supporting care coordination, monitoring quality, patient outcomes and service providers’ resource use to ensure those with the greatest need, receive care.

Conversely, LHINs currently require a different type of culture and leadership to meet different mandates, which exclude patient care.

Effectively integrating each organization’s culture and leadership is a huge challenge. CCAC assets (people, process and technology) will be under-leveraged if this part of the expanded LHIN’s mandate receives minimal attention. Focusing on system planning at the expense of leading care delivery, could also mean that one or thousands of patients stay in hospital longer than needed, due to oversight shortfalls. This is far from ideal when systems are constrained.

Understanding the magnitude of the responsibility they are taking on, LHIN board members raised early concerns about potential conflicts for new boards as they communicate their focus after integration. Boards will need support to pay significant attention to their care delivery operations to ensure they set high standards for care quality and oversight.

3. Assuming an Easy, One-Day Transition and Disrupting Vital Processes

Some people may assume integrating two distinct organizations is an easy process with an immediate transformation point, where teams cross over to a new governance structure with new projects. In doing so, they could put the opportunity to leverage existing CCAC assets and progress in peril.

Patients First impacts the expert implementation skills and other strengths within the current CCAC system. These skills include a solid understanding of the current home and community care system and service providers’ performance, plus the leadership to ensure patients/caregivers have quality experiences. It also has the potential to disrupt the support systems developed to manage care in homes and a virtual workforce.  These systems must be adeptly integrated as part of a long-term marathon, not a sprint. This work currently underway in the CCACs includes many strategies that are planned or in motion to continuously improve home care delivery.

There is a significant risk that through integration we will disrupt current culture, process, teams and technology without understanding their value in effectively reorganizing around the LHIN sub-regions. Current initiatives need to be recognized and supported post-integration day to maintain positive traction. It’s critical how attention to that work is prioritized, pre and post-integration.

Fortunately, the MOHLTC has enabled LHIN boards to expand from nine to twelve and has been explicit in requiring directors from CCAC boards to be given consideration. Having this voice of CCAC governance engaged in LHIN planning will help mitigate this risk to patient care disruption but there is an urgency to expand these boards sooner than later.

As with a marathon, we are in the warm up phase. If LHIN boards are expected to plan now for the post-integration transformation agenda, the voice of CCAC governance and leadership at the local level should be reflected in that planning. Ideally, LHINs and CCACs should share and have a continuity plan in place for moving the collective agenda forward post-integration, with ongoing support for strategic home care work in progress.

Patients First is a marathon with a long-term agenda. Ahead of the starting line, it needs CEOs and governance to establish the culture necessary to succeed. This culture requires full engagement of primary care, home and community care, hospitals, LHINs, public health and others to propel it.

My team is ready to move forward toward the long-term goal of a more sustainable, integrated health care system that puts patients at the forefront. Are you?

What do you think? Are there points you’d like to add?  Please share your comments at the bottom of this post.

3 Aspirational Milestones in the Patients First Marathon

Patients First Marathon

Baton with Patients First written on it being passed from one runner's hand to anothers.Change is necessary for sustained and progressive success but it is rarely simple or easy. Such is the case with Patients First, new legislation that the Ontario government’s Ministry of Health and Long-Term Care (MOHLTC) first proposed on December 17, 2015 to improve the accessibility, integration and consistency of patient care across the province. This proposal has since progressed to Bill 41, the Patients First Act, which passed second reading on October 27, 2016. A key part of this legislation calls for integrating Ontario’s 14 Community Care Access Centres (CCACs) into their corresponding Local Health Integration Networks (LHINs).

Since its introduction, Patients First’s proposed design has and continues to evolve. The due diligence to advance this change is also shaping it by shining a light on high performing parts of the current system.

A noteworthy shift is the new context the MOHLTC placed around reintroduction of the legislation. Essentially, the narrative about CCACs has changed to be one about building on the strength of the current home and community care sector. Minister Eric Hoskins has said on numerous occasions: “This is not about fixing a broken system but leveraging the assets within the CCACs for the broader good.”

These assets include people, processes and technology. On the people side, initial integration talks cited the need to have CCAC care coordinators in hospitals and physicians’ offices as a key goal. Digging deeper, many learned that care coordinators have been working in hospitals and connected to physicians’ offices for years. In fact, this practice made it possible for care coordinators to help 210,000 Ontarians transition from hospital to home with a warm hand-off in 2015/16. We all know now this practice is working.

Instead, we need to focus on how to effectively optimize the relationships between care coordinators and so many parts of the system, such as primary care, acute care, working with home care providers, community resources and in patients’ homes. In my first post, Sam’s story demonstrates how our care coordinators use these relationships to help patients, even those with complex health and socioeconomic needs, to stay out of hospital.

The new system can also leverage process and technology assets. The MOHLTC is seeking a dashboard with readily accessible information to help it assess how the home and community care system is functioning, both pre and post-integration. There is now clear recognition that all CCACs use a dashboard, of various levels of sophistication, to provide oversight and inform decisions. Our care coordinators use Insights, an interactive dashboard, for multiple purposes, from planning patient visits to measuring their outcomes. The Ministry can adopt and adapt an existing CCAC dashboard.

This expanded understanding of the capacity to apply CCAC’s, as well as other’s assets, to the system’s greater transformation, opens opportunities for us to achieve several aspirational milestones or goals that put patients first. Here are three goals Patients First can realize, if health care leaders effectively leverage these assets:

Aspirational Milestones or Goals

1. More Engaged Primary Care Providers to Help Patients Achieve their Goals

A great benefit we can realize is having a system that makes it easier for primary care providers (including physicians, nurse practitioners and physician assistants) to interact with the broader community of support services that help patients achieve their goals.  This includes creating stronger connections between primary care and community resources that address a patient’s socioeconomic or cultural needs, as well as publicly funded services.

Through our care coordinators’ experiences, we know how crucially important primary care involvement is to ensure our patients have the best outcomes but it’s not easy for these providers to interact with our current, intricate community care system with its multiple access points.

Patients First legislation contemplates better understanding, planning and support for primary care and a future with expanded roles to complement their practice. These roles will involve primary care providers more closely in the planning for home and community care at the regional, neighborhood and patient level.  For example, this means that a family doctor will know that patients like Yasmin, a single, Urdu-speaking senior, who suffers from depression and diabetes, are connected with a local cultural or faith-based group, as well as home and community services.

2. Inserting the Voice of the Patient and Caregiver in Planning

The new Act sets a requirement for each LHIN to have a Patient and Family Advisory Committee to support community engagement. This offers the potential for LHINs to have and use a greater line of sight about what’s important to patients and families in their day-to-day planning.

All CCACs have experience with patient engagement strategies, and can bring that knowledge of how to involve patients and families into the LHIN’s planning work.

In 2014, we established Share Care Council – a highly structured and successful patient and caregiver advisory forum. It includes 15 patients, substitute decision-makers and family members, who volunteer their time to provide input into new programs and services. Share Care Council applies a carefully defined approach that authentically engages patients and caregivers to elicit their valuable input.

What’s eye opening is Share Care Council members’ responses to questions about how our programs can best meet their needs. We don’t hear “We need more personal support workers (PSWs) or more nursing care.” Instead, they tell us about their care experience, how it made them feel and how our system design can do better. It is less about the technical elements of care and more about the soft touches, social interaction and how these services are delivered that make the difference. For patients like Hilda, it’s having a PSW who knows how to braid her hair and set her up in the chair by the window when she leaves.

Through this requirement, the expanded LHINs can discover that when you carefully engage with patients and families on your journey of continuous quality improvement, their experience can drive development of meaningful programs and changes to care.

3. Organizing Home and Community Care around LHIN Sub-regions

A third advantage is the legislation’s shift to organizing delivery of home and community care around a LHIN sub-region, with consistent, service providers.

Our capacity plan research told us that people’s social, cultural and economic status often varies significantly between our neighbourhoods. So having care providers who are familiar with their patients’ neighborhood and its existing support resources (provincially funded and others) helps ensure successful home and community care delivery.

We also know that having a minimum number of consistent service providers who interact with our teams and patients/families builds strong relationships. Furthermore, this approach helps create high performing teams, whether virtual or in-person, in each patient’s circle of care.

With a goal of being able to identify local resources, numerous CCACs have begun reorganizing their care coordination and service provider teams around these LHIN sub-regions.

In our region, we’ve reorganized patient care around neighborhoods, so that patients, like Betty and Patty, can receive the services they need from consistent providers, who know their community and are located near their home. Organizing services around LHIN sub-regions or neighbourhoods gives service providers a greater connection with the communities where they deliver care.

I believe there’s much to be gained through LHIN sub-region planning but it’s complex work and should be viewed as part of a long-term vision or marathon.

On the flipside, implementing Patients First also poses risks, which I believe health care leaders need to dodge. I will outline three of these risks in my next post.

What do you think? Are there opportunities I’ve missed or points you’d like to add? Please share your comments at the bottom of this post.