Clinical Practice Settings and Healthcare Systems in Canadian Physiotherapy

Overview of Physiotherapy Practice and Care Settings in Canada

• Professional Scope and Skills     * Physiotherapists in Canada possess skills and competencies to support individuals and populations across the full continuum of care.     * Practitioners are encouraged to reflect on similarities and differences between Canadian practice and their countries of origin, including specific advanced practice roles.

Objectives and Modes of Care Delivery

• Module Objectives     * Describe key aspects of healthcare across the continuum, including institutional-based and community-based healthcare.     * Discuss funding structures, specifically comparing publicly funded versus privately funded models across different care settings.
• Virtual Care and Telerehabilitation     * Physiotherapists effectively provide care through virtual platforms or telerehabilitation.     * Hybrid Model of Care: Many health providers offer a combination of in-person and virtual care options.

Healthcare Funding and National Expenditures

• Governmental Roles     * The Ministry of Health and Ministry of Long Term Care fund and regulate hospitals, long-term care homes, and public health laboratories.     * They coordinate emergency health services and operate mental health facilities.     * Public services are provided through programs including:         * Health insurance (e.g., OHIP in Ontario).         * Drug benefits.         * Assistive devices.         * Care for the mentally ill.         * Home and community care support services.         * Public health, health promotion, and disease prevention.
• Spending Statistics (2024 Projections)     * Total health expenditures are expected to reach $372,000,000,000$, which equates to approximately $9,054$ per Canadian.     * Expenditure Growth Rates:         * $2024$: Expected increase of $5.7\%$.         * $2023$: Increase of $5.4\%$.         * $2022$: Increase of $1.7\%$.     * Sector Allocation: Hospitals, prescription drugs, and physician services consume the largest share of health dollars.
• Growth Drivers     * Rapid population increase.     * Impact of the overall economy on health sector prices during provider agreement negotiations.     * Policy changes such as the Canadian Dental Care Plan (CDCP) and Bill C-64 (an act respecting Pharmacare), which may increase utilization by patients who previously avoided these services due to cost.     * Expansion of publicly funded but privately delivered healthcare (e.g., funding for surgeries at private clinics).
• Private Sector Spending     * Private sector expenditures were projected to increase by $6.2\%$ in $2023$ and $6.1\%$ in $2024$.

Pandemic Impacts on the Healthcare System

• Service Declines (March 2020 – June 2021)     * Emergency Department Visits: Approximately $9,300$ fewer visits per day on average compared and pre-pandemic levels.     * Surgical Backlog: Approximately $560,000$ fewer surgeries were performed during this period.     * Physician Care: Currently returned to pre-pandemic levels after a substantial drop during the first wave.
• Funding Split     * Public Sector: Pays for approximately $71\%$ of health expenditures.     * Private Sector: Pays for approximately $29\%$, categorized into out-of-pocket expenses, private insurance, and other funding.     * Physiotherapy Categorization: Physiotherapy is included in the "Other Health Professionals" category, which accounts for $10.3\%$ of spending.

Hospital Systems and Organizational Structure

• Hospital Statistics in Ontario     * There are $141$ public hospital corporations and a total of $228$ public hospital sites.
• Key Functions of Hospitals     * Client care.     * Education and training.     * Research.
• Hospital Services     * Emergency services and ambulatory care (outpatient programs).     * Inpatient care and diagnostics.     * Operating rooms and surgical services.     * Allied health services, including rehabilitation (PT, OT, and SLP).
• Care Levels     * Secondary Care: General hospitals or home care. Requires a referral from a primary care provider (e.g., family doctor) to see a specialist.     * Tertiary Care: Specialty hospitals, often university-affiliated.
• Hospital Funding     * Funds flow from the Ministry of Health through Ontario Health (formerly through Local Health Integration Networks or LHINs).     * Global Funding: A small amount supports general operating costs.     * Activity-Based Funding: The majority is earned based on patient needs per diagnostic category and specific treatment pathways.     * Revenue Split: Provincial payment provides approximately $85\%$ of funding; the remaining $15\%$ comes from semi-private/private accommodations, parking, co-payments for non-acute beds, and the Workplace Safety and Insurance Board (WSIB).     * Accountability: Hospitals must balance their budgets according to accountability agreements with Ontario Health. Hospitals accounted for $25.8\%$ of total public health spending in $2024$.     * Cost Drivers: Health human resource salaries account for more than $60\%$ of hospital budgets.
• Governance and Management     * Hospitals are incorporated under provincial legislation and governed by the Public Hospital Act.     * A Board of Governors or Board of Directors provides oversight.     * The Chief Executive Officer (CEO) reports to the board and the community.     * Management Approaches:         * Program Management: PTs are part of a multidisciplinary team (e.g., stroke or cardiac) and report to a program leader.         * Discipline-Specific Departments: PTs report to a leader from their own discipline and provide services across various program areas.
• Types of Hospitals and Units     * Classifications: Community hospitals, teaching hospitals (e.g., University Health Network affiliated with the University of Toronto), mental health facilities, and rehabilitation hospitals.     * Bed Types/Units: Critical care, Step-down, Acute care, Alternate Level of Care (ALC), Transitional care, Rehabilitation, and Complex Continuing Care (CCC).

Alternate Level of Care (ALC) and Discharge Processes

• Defining ALC     * A designation for clients occupying a hospital bed who no longer require the intensity of hospital resources or services.
• ALC Designation Criteria     * Care goals have been met or progress has plateaued.     * The client has reached their potential in the current program level.     * Social Admission: Admission for supportive care because community services are inaccessible.
• Impact of ALC     * Occupies limited beds and staff resources.     * Causes delays for emergency department patients and postponement of surgeries.
• Discharge Planning     * Determined by a physician (or delegate) and an interprofessional team.     * Physiotherapists assess patient status to help determine destination.     * Destinations: Home (with/without services), rehab, CCC, transitional beds, long-term care, convalescent care, palliative care, retirement homes, shelters, or supportive housing.

Rehabilitation Continuum

• Inpatient Rehabilitation     * Occurs in acute hospitals, specialized rehab hospitals, or community convalescent care.     * Models include mixed rehab units, dedicated specialized units, and short-stay (low tolerance) or long-duration rehab.     * Toronto Rehab Institute (UHN): Canada's largest rehab hospital; a teaching facility affiliated with the University of Toronto. Global leader in physical and cognitive rehab with five sites.     * Programs at Toronto Rehab: Brain rehab, cardiac rehab, CCC, geriatric rehab, multisystem/musculoskeletal rehab, and spinal cord rehab.
• Community Rehabilitation     * Outpatient Rehab: Within hospitals for mobile clients.     * Clinic-Based Care: Community clinics providing PT services.     * Home Care: Rehabilitation professionals visiting the client's place of residence.

Primary Health Care (PHC) and Reform

• PHC Philosophy     * Focuses on the Social Determinants of Health (housing, education, income).     * Aims for integrated, coordinated services responding to population needs, including illness prevention and health promotion.
• Family Health Teams (FHTs)     * Introduced in $2005$ as part of Ontario's health renewal plan.     * Goal: Keep Ontarians healthy, reduce wait times, and provide access to multidisciplinary teams.     * Includes doctors, nurse practitioners, dietitians, pharmacists, social workers, and OTs.     * Physiotherapy in FHTs: PTs were added as a funded role following an announcement in April $2013$.
• Community Health Centres (CHCs)     * Not-for-profit organizations governed by community-elected boards.     * Focus on primary health and health promotion for diverse populations.     * Multidisciplinary teams now include physiotherapists alongside health promoters and community health workers.
• Outpatient Physiotherapy Trends     * There has been a $15$ to $20$-year decline in publicly funded community and hospital outpatient PT.     * Increased reliance on self-pay or private insurance.     * Title Protection: There is no protection for the title "physiotherapy clinic"; protection only applies to the titles "physiotherapist" or "physical therapist."

Government-Funded Home Care in Ontario

• Organizational Evolution     * 1972: Home visiting became an insured service.     * 1980s: Home care became a substitute for institutional care during the recession.     * 2006: Community Care Access Centers (CCACs) aligned with the $14$ LHINs.     * 2017: Under the Patients First Act, LHINs assumed CCAC responsibilities.     * 2021: Home and community care support services moved under Ontario Health.     * Current Status: Ontario Health at Home is the business name for these organizations.
• Accessing Home Care     * Care Coordinators: Assess suitability and eligibility.     * Referrals: Anyone can refer (client, family, physician). Nursing is the only service requiring a physician's signature for orders.     * Eligibility Criteria: Must have a valid Ontario Health Card, needs that cannot be met on an outpatient basis, a condition treatable at home, and a need for at least one professional or personal support service.
• Service Types     * Professional Services: Nursing, PT, OT, SLP, Social Work, Nutritional Counseling (generally short-stay/time-limited).     * Non-Professional Services: Case management, personal support workers (can be longer-term).

Residential and Long-Term Care (LTC)

• Care Options     * Supportive housing, retirement homes, LTC, and complex continuing care.     * Aging at Home: The preferred option for most Canadians.
• Long-Term Care Characteristics     * Regulated by the Fixing Long Term Care Act.     * Provides $24$-hour nursing care and supervision for those unable to live independently.     * Funding is overseen by the Ministry of Long Term Care.     * Facilities: Over $600$ homes in Ontario.
• Policies and Inspections     * Homes must prepare a Plan of Care for each resident, reviewed every $3$ months.     * Annual inspections are mandatory, and reports are published online.
• Short-Stay Bed Programs     * Respite Program: Caregiver relief; stays up to $60$ days.     * Convalescent Program: Recovery of strength/function; stays up to $90$ days.
• Costs and Co-payments     * Resident payments are called co-payments.     * Rates vary (effective July $1$, $2025$) based on accommodation type: Long-stay basic, Semi-private, or Private.     * Rate Reduction Program: Subsidies available for those unable to afford the basic room rate.

Physiotherapy Funding Summary

• Publicly Funded Settings     * Acute care general hospitals.     * Rehabilitation centers.     * Hospital-based outpatient departments.     * Community Health Centers.     * Home and community care (via contracts).     * Long-term care (via contracts).     * Specific publicly funded outpatient clinics.
• Third-Party or Self-Pay Settings     * WSIB (Workplace injuries).     * Private practice.     * Motor vehicle collision/auto insurance.     * Armed forces.     * Unfunded services at public organizations.
• Bundled Care Model     * A single payment covers the full spectrum of care for a specific health issue (e.g., a joint replacement) to promote integration and efficiency.

Advanced Practice and Specialization

• Advanced Practice Physiotherapy (APP)     * Domains: Expert clinical practice (extended scope), program evaluation/research, leadership/consultancy, and professional development.     * Training depends on the facility and role.
• Clinical Specialist Certification     * Obtained through the Canadian Physiotherapy Association (CPA).     * Certifies advanced clinical competence, leadership, and research involvement in specific practice areas.     * Does not typically include an extended scope of practice unless the individual also holds an APP role.