Moving Ahead in Ontario
Part 1 of a series on the state of chiropractic in some of the most influential Canadian provinces.
By Brenda Duran
In east-central Canada, chiropractic is thriving in the most populous province – Ontario. Today, there are approximately 4,000 practitioners in Ontario, with many taking an active role in the advancement of the profession by raising awareness of the value of chiropractic. Because of their strong alliances with provincial government decision-makers, chiropractors in Ontario are increasingly becoming key players in family health care teams – a major accomplishment for the profession.
"I think having chiropractors as a part of these teams is a fantastic positive development for the profession. I feel that the profession will benefit from more exposure in hospital settings and I hope that we see more integration that way in the near future," said Stacy Irvine, BSc, MSc, DC, CSCS, who currently maintains four practices in Toronto.
Dr. Irvine, like many of her colleagues, is a member of the Ontario Chiropractic Association, which represents more than 3,000 chiropractors. The OCA has been a key player in moving the profession forward in the province, and in recent months has helped put chiropractic at the forefront of the profession in Canada.
The organization continually encourages its members to get involved by setting the example. Recently, the OCA designed a low back pain strategy which includes new, innovative care models for thousands of Canadians.
Advances & Hurdles
Miguel Pacheco, manager of external relations for the OCA, said the advocacy many chiropractors in Ontario are currently working toward includes participating in new, innovative, team-based-care, non-fee-for-service models.
So far, recent successes indicate Ontario chiropractors are moving in the right direction in this area. Pacheco noted that recently, the profession gained a huge advantage when the Ministry of Health and Long-Term Care made two announcements that are unique in the history of Ontario chiropractic and represent a significant shift in government policy.
Ontario Health Minister Deb Matthews recently announced an evolution of the OCA's Consulting Chiropractor Role in Primary Care Demonstration Project, which commenced in 2011. As part of the Provincial Low Back Pain Strategy, primary care teams will be funded by the Ministry of Health and Long-Term Care to design, plan and implement a lower back pain program.
An RFP will be issued to Family Health Teams (FHTs), Community Health Centres (CHCs), Nurse Practitioner-Led Clinics (NPLCs) and Aboriginal Health Access Centres (AHACs) to develop these programs and help improve lower back pain management in primary care settings. This is intended to eventually inform the implementation of one or more provincial models.
Matthews also announced that chiropractors will be added to the list of health professionals eligible to work in Family Health Teams and Nurse Practitioner-Led Clinics. According to Pacheco,"The announcements together signify that chiropractors are viewed by the Ministry as an important component of the health care system, and further paths for our inclusion are being explored."
Although Ontario chiropractors are headed toward more inclusion, issues regarding patient access, funding and integration still persist.
"The healthcare system is undergoing a transformation towards integrated, patient-centered models of care, which changes patients expectations and provides opportunities and challenges for the profession," said Pacheco.
Dr. Moez Rajwani, who practices in Toronto, said he hopes to see more chiropractors integrate into the public health care system as MSK specialists.
"Many other health care providers now have manipulation in their scope of practice (Medicine, Physios, Naturopaths). This is leading to a very competitive marketplace where patients have many choices," said Dr. Rajwani. "Chiropractors need to establish themselves as experts in MSK care and competency in manual care."
Dr. Rajwani added that many chiropractors in Ontario are also still not seeing enough of the population. At this time, chiropractors in the province are seeing between 10-15 percent of the population, but would like that percentage to grow to at least 20 percent.
There are also issues that limit scope of care, such as the ability to order tests being limited to plain-film X-rays. Chiropractors in Ontario also do not have direct access to MRI, CT and ultrasound, and legislation still limits the ability of chiropractors to order blood tests or directly refer patient to a medical specialist.
Dr. Rajwani said these are all issues chiropractors in the province are working hard to change.
When it comes to financial issues, there is both public funding for chiropractic services and private funding through extended health care insurance plans, which DCs in Ontario are concerned with.
Chiropractic in Ontario was funded on a fee-for-service basis from 1971 to 2004. The health care systems have been moving away from fee for service since the early '90s, and the profession was de-listed from fee-for-service in 2004, according to Pacheco. But there is hope that things will change for the better.
"The Minister of Health has just announced the inclusion of chiropractors in a number of publicly-funded primary care models. Integration means chiropractic being part of the care pathways a patient embarks on when they have a condition," said Pacheco.
A Day in the Life
So far, chiropractors in Ontario have enjoyed a steady influx of patients and have built practices that reflect the growth of the profession.
Dr. Irvine said there has been an increase in the number of lower back pain issues among the patients chiropractors see these days. This is due to the fact that the population is now more sedentary than in the past, he noted.
Efforts to get more patients to move have been widely popular in many areas of Canada, highlighted recently in DC Canada's front-page article, "Motivating Patients to Embrace the Power of Exercise" (December 2013 issue), which focused on the "Exercise is Medicine" initiative backed by the Royal College of Chiropractic Sports Sciences (RCCSS).
For Ontario chiropractors working in interdisciplinary teams, there is also the growing trend of seeing their role as a critical one when it comes to overall patient health.
Dr. Irvine said she normally spends 30 minutes per treatment with each of her patients. Some of that time would normally be out in the gym working on functional strengthening or range-of-motion activities, with the remainder in the treatment room using hands-on techniques.
For chiropractors like Dr. Rajwani, who teaches part-time at CMCC , involvement in a array of organizations is vital to his growth in the profession.
Like many Ontario chiropractors, Dr. Rajwani has his hands in many areas. He is the director of clinical services for North York Rehab, coordinates the Workplace Safety and Insurance Board (WSIB) Regional Evaluation Centre for the Toronto East General Hospital, and assists the OCA part-time with health policy in the area of auto insurance.
"Each day is intense; full but very satisfying," he said. "I pride myself on hard work and a collaborative approach. I have great teams of staff and chiropractors who assist me in achieving our daily, weekly and monthly goals. My focus is on quality and a set of core values of integrity, compassion and helping other reach their potential."
When it comes to the future of chiropractic in Ontario, optimism seems to be the overriding theme.
"I think very positive. We are starting to emerge into some exciting partnerships with the government and are heading down a path where we can see in the near future [that] chiropractors [will be] known as the 'go-to provider' for lower back pain," said Dr. Rajwani.
He noted that chiropractors in Ontario have some exciting partnerships with different universities and collaborative research in areas of interest, as well as strong academic institutions (CMCC, UQTR) that are graduating many new practitioners and working closely with other universities to improve the quality of research and integration.
Dr. Rajwani said he would like to see chiropractors tightly integrated into health care models in Canada and play an active role as experts in MSK care, while becoming strong contributors in the system, with at least 20 percent of population seeing a chiropractor.
Dr. Irvine agreed: "I am excited about the current developments in research in all areas of treatment and care. I have felt that our current health care system is under strain related to the volume of patients needing treatment in a traditional hospital setting, and I feel that chiropractors can play a very positive role to help alleviate this strain," she said.
Dr. Irvine added that she hopes in the future, chiropractors will have the ability to provide direction to patients and other health care practitioners in preventative medicine, as well as in the treatment of their acute and chronic injuries.
Pacheco said Ontario is already headed in that direction and as long as the advocacy work continues, the government will focus on the usage of chiropractic for musculoskeletal expertise; and at the same time, will gain a greater understanding and recognition by both governments and health care stakeholders that more resources and attention needs to be paid to disease prevention and health promotion programs.
"Chiropractic is known for both treatment of acute conditions [and] for an educational, prevention-based approach to managing conditions. There is work to be done from within the profession and the health care system so that chiropractors are seen as both MSK experts and experts in health promotion and disease prevention," said Pacheco.
Editor's note: Look for a similar article highlighting the status of chiropractic in another province in an upcoming issue.