Health Committee on March 10th, 2015

[Dr. Paulette Guitard, Professor and Former President, Canadian Association of Occupational Therapists]

Thank you.

My name is Paulette Guitard and I am an occupational therapist. I am an associate professor at the University of Ottawa and also the director of the occupational therapy program there. I've just finished my term as president of the Canadian Association of Occupational Therapists that I am representing today, and we thank you all for your invitation.

Before I delve into the subject, I would like to give you a brief overview of our profession and our association.

Occupational therapy came into existence around 1915, just after the First World War when the soldiers were coming back with their injuries and trying to transition to their daily lives. Occupational therapists helped them restore, through meaningful occupation, their physical issues, mental health issues, and their social capabilities.

Today our CAOT, which was founded in 1926, has about 9,000 members, and we represent 15,000 occupational therapists within the country with a master's level entry to practice. We also have post-graduate degrees in areas of specialization.

As occupational therapists we help people do the occupations that are meaningful to them in their everyday lives, and by occupation I mean everything the person does from the time they get up in the morning to the time they go to bed at night, whether it is paid work, going to the bank, driving to the bank, playing with your child, or watching a hockey game with friends.

As occupational therapists we ensure that the person has the skills to meet their occupation and we also look at the environment in which the occupation is being done to ensure there is a perfect fit between all of them.

Just to let you know, we work with people of all ages and we work mostly in hospitals, schools, homes, everywhere where people have occupations.

Coming back to the subject, there are four things we would like to talk to you about, where in the federal arena, the occupational therapist scope of practice could be better used: better representation in first nations and Inuit communities; veterans communities; correctional services; and also general health and community care, especially for the aging population.

Starting with the first nations and Inuit communities, the first problem is access. There is very limited occupational therapy service able to serve that population. In B.C., for example, less than 5% of the occupational therapists are employed in remote first nations communities, so access for those people is very limited.

There are several things we can do to increase that. One of the things we've noticed in education is that when people are trained, they go back to where they came from. If we can get youth from the first nations and Inuit communities into specific programs, they could go back to serve their communities, and that would be helpful.

We might also look at foreign trained professionals. More and more there are demands for foreign trained people to come to Canada. It's my understanding that occupational therapy is no longer a part of the national occupational classification, so that foreign-trained occupational therapists can take advantage of the express entry system under the federal skilled worker program.

That would be something we could look at because there are roughly 175 foreign-trained occupational therapists who take the national certification examination every year. As of May 2015 it will cost a foreign-trained OT about $4,000 to qualify to practise in Canada, so if there could be some funding available, that would be helpful. Maybe in return, they could have a period of time that they could devote to this community, which would also help.

The second thing is that the non-insured health benefits program is causing a lot of frustration. When you have an occupational therapist who is meeting with a client who needs a wheelchair, for example, the occupational therapist completes his or her assessment, talks to the supplier, the supplier might even be in another territory or another province, and then that person needs to go back to the program. Then the program comes back to the supplier, who then goes back to the OT, and it takes months before the person actually gets the wheelchair, so they are limited within their occupation during all that time. If there were a clearer process, we believe these people would be better served by our skilled people.

I mentioned that occupational therapy started after World War I. It's very interesting to see that today there is very limited occupational therapy within veterans' services.

We've tried over the last few years to make some headway. We have, but there's still very limited occupational therapy involvement for these people who are coming back from outside of the country. Occupational therapists are employed as policy analysts and case managers, which is not necessarily a bad thing, but it prevents the client from having direct access to an occupational therapist who will be able to help them return to the occupation that is meaningful to them.

Where OTs are employed, it's often on a contractual basis. They're relegated to the periphery and not included in the decision-making for their client. This also limits our scope of practice. Privately contracted OTs are sometimes also used to review reports, and this is not an effective use of OT scopes of practice, education, training, or competency and skill sets. We can also help not only with the injuries but with the transition from military to civilian life.

The other sector is correctional services. This is another federal arena where there are very few OTs who are involved, and as we all know, this population has a lot of mental health issues. This is one of the arenas where occupational therapists can have an impact. These people are going back to their communities without having developed any better coping skills than they had before they went into prison. It's a perpetual circle. We would be hoping to make headway into the correctional services to have better service for that population.

With regard to health care in community and the aging population, we would like to talk briefly about some of the initiatives our association has done to help older adults live more independently and as actively as possible.

We've worked a lot on the older driver blueprint. The goal is to help older adults maintain their licences for as long as possible, but to be safe because we're all sharing the road. We believe there are a lot of things that we can do. As part of that, we are hosting the CarFit educational program. That's another initiative where we have partnered with CAA. We've noticed, and there are statistics from Transport Canada, that a lot of older adults or seniors are driving and there are a lot of fatalities. We also know that a lot of times these happen because the cars are not properly adapted to the person. There are a lot of adjustments that can be done, but older adults do not know about these and don't know how to do them. For about $500, we can host an event where we can show people how to be better suited in their own cars and make sure that the car is best suited to them.

Another project would be elder abuse. This project came into effect because a lot of our members were working in homes and asking us what to do when they suspect elder abuse. We got some funding to look at this issue, and now we're hosting train the trainer programs to train people to prevent, detect, and intervene appropriately when elder abuse is taking place. This is not just for occupational therapists, but we're broadening this to physiotherapists, speech language pathologists, nurses, social workers, anybody who's working with the elderly population.

I would like to conclude by saying that one of the things that would be helpful would be to look at OT as a return on investment. When you look at costs, a day in a hospital is about $1,000 very minimally, and it's $130 for a long-term care facility. One day at a supportive housing or home in community care costs about $55. Occupational therapists are looking at helping people to stay in their homes longer and safer, so we're keeping people out of the hospitals and saving the system a lot of money.

Lastly, one of the things we would like is that occupational therapy be included in the extended health benefits for federal workers; that is not always the case. There's a limited amount of money, so people who require our services are not able to get them.

I would stop there, if you would have any questions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is the Canadian Physiotherapy Association.

Ms. O'Connor, go ahead.

[Kate O'Connor, Director, Policy and Research, Canadian Physiotherapy Association]

Thank you very much. It's a pleasure to be here this afternoon.

On behalf of the Canadian Physiotherapy Association, I'd like to thank you for this opportunity to speak to best practices and federal barriers related to the scope of practice of Canadian health care professionals. I think this is an extremely important topic, as there are many different health professionals looking to work through interprofessional collaboration, and it's not always possible. There are a lot of local innovations that aren't necessarily spread throughout the system.

One of the most important changes to improve efficiency in health care today is the integration of this interprofessional collaboration in a variety of different primary health care settings. The benefits of interdisciplinary team-based care have been clearly demonstrated in research, with very positive outcomes, including better access to services, shorter wait times, better coordination of care, and more comprehensive care than from a single health care provider alone.

Physiotherapists are among health professionals who have the qualifications and skills to share responsibility for the provision of care with the family physician and with other health care providers. They have advanced knowledge in the assessment and diagnosis of conditions and injuries, and it's all within their scope of practice.

Today I'd like to focus my comments on three specific areas where the federal government can play more of a leadership role: first, to align federal health programs and permit health professionals to work to their maximum scope of practice; second, to support best practice through collaboration and communication with health professionals in areas of federal health programs; and third, to support skills training for physiotherapists and other health professionals who are working in rural and remote areas.

To begin, aligning federal health programs with recognized scope of practice is a bit of a challenge, and we do recognize this, because many health professionals are regulated by provincial bodies. It's a bit of a patchwork quilt to be able to match the provincial regulatory bodies and regulations and the scope of practice with what is happening federally. However, we do see that there's an opportunity where there can be better alignment with provinces and regions, particularly because within federal programs there are a lot of regional offices that do oversee the health provisions under the programs.

I'll use the NIHB program, the non-insured health benefits program, as an example of where there are barriers to working to full scope of practice. I'd like to reiterate Dr. Guitard's comments around the challenges of access to care. Really, the barriers to appropriate care in this program do include these gaps in access to the right professionals, who can deliver the right care at the right time to improve health outcomes and quality of life. Evidence shows that there are significant opportunities for cost savings when there is a focus on prevention and promotion of health, but more important, there's an immediate need to curb epidemics of obesity, diabetes, and asthma, and to focus on injury prevention and ending addictions.

When Minister Ambrose announced the review of the non-insured health benefits program in 2014, we took that opportunity to reach out to our members to find out what their challenges are with the NIHB program. We really wanted to better understand what physiotherapists are doing and how they're working within the program and to possibly help inform a better direction for the future.

What we learned is that while there are regional variations in the program and the regulation of physiotherapy, the federal program is not consistent and does not recognize or support current scopes of practice of physiotherapists. One of the biggest challenges we see as physiotherapists is not just that they're not quite aligned with the scope of practice, but that their scope within the federal program is actually quite minimal, where they're only allowed to prescribe or order assisted devices and supports for individuals, for example, rather than actually working to fully use their knowledge and competencies to improve the health and well-being of the individual.

In practice, what this really means is that physiotherapists are regulated, so if you're working in northern Alberta, you're regulated within the Province of Alberta to work to your full scope of practice, but as soon as you step onto a reserve to provide care or services, that scope is no longer recognized. There's a great variation in the ability—and the inability—to really work to full capacity under the NIHB program.

The recommendation for this is really to look at the evidence. There's strong evidence in favour of positive patient outcomes at a lower price if governments are willing to invest in interdisciplinary models of care to maximize health outcomes.

We call on the federal government to actually look at how to maximize scopes of practice within federal programs, such as the NIHB program, and invest in interdisciplinary models of care that truly reflect these models.

To go back to one of Dr. Guitard's points, if a physiotherapist, for example, were to work under the NIHB program, they would not only have to look at suppliers but call the doctor to ask for the doctor to sign off on what they would be prescribing as an appropriate device, when the doctor has never seen this patient. The physiotherapist actually does have the scope to order it on their own, but under the program, they aren't able to actually follow through with their full scope of competencies.

The second point I'll make is around supporting best practice through collaboration and communication with health professionals. Evidence has shown that direct access to physiotherapy services decreases total health care costs. This is because patients require fewer visits with their general practitioners and they require fewer prescriptions. Patients require less referrals for radiographs, less referrals for secondary care, and a decreased need for invasive treatments. An example of cost treatment per episode is with patients with musculoskeletal conditions. It is much less when patients are treated by physiotherapists, making additional health care dollars available for other more critical medical services.

To fully achieve these interprofessional models of care within the federal health programs, we have to look at examples of communication and collaboration at the systems level rather than looking at the local level for how to improve care. Without this change, we'll continue to have local-level efficiencies but with very little system-wide change. If we reverse it so that there's better communication at the systems level, we can actually improve the efficiency at all levels under the larger umbrella.

Our second recommendation is to reinstate the federal health care partnership program. The federal health care partnership program, if you're not aware, was created to achieve economies of scale while enhancing the provision of care. Under the program, federal departments responsible for the delivery of health services would meet regularly with health professional groups to identify gaps and concerns and provide strategic leadership. While there are still some ongoing agreements between various departments and associations, the program on the whole has been disbanded. CPA would like to see this program reinstated, as we see it as a best practice model. We believe if it were to be reinstated, it could facilitate strategic partnerships with key stakeholders in support of better programs, interdisciplinary care, and evidence-based policy development.

The third area I'll focus on is federal support for skills training. Physiotherapists are health care professionals who have demonstrated advanced knowledge and scope of practice and a unique value to solve problems within Canada's health systems. However, there's a disconnect between physiotherapy education programs that provide this advanced skills education and training for health professionals and the recruitment and retention of physiotherapists in rural and remote areas. I know that physiotherapists aren't alone in this challenge. It's across the board. Rural and remote areas struggle to recruit and retain the best of the best, because they're often going to urban areas. However, of significant concern to CPA is the challenge of filling vacancies or getting access to physiotherapy in many regions across Canada.

For example, in 2014 the Physiotherapy Association of British Columbia reported that vacancies across B.C. reached 267 positions, which was last audited at the end of 2013. These 267 vacancies represented a substantial gap between the nearly 3,000 practising physiotherapists in the province and the need for a least 10% more physical therapists to fill the immediate need, not to mention the need in the future. At this time the physical therapy community of B.C. has urged the Ministry of Advanced Education to immediately expand the UBC physical therapy department to 132 seats through a distributive model that would better address challenges for Fraser Health in northern B.C.

Now, I understand that this a provincial issue, but it does reflect on federal responsibility as well, because we do see evidence to suggest that models of distributive education across the country actually do enhance recruitment and retention in rural areas. We would like to see this opportunity extended to physiotherapy programs and other programs that would allow for a more stable health care workforce that will meet the urgent need in various regions.

B.C. is not alone in its challenge in filling vacancies in rural and remote regions. We also see, through the Manitoba Physiotherapy Association, that there's a top priority to improve access to physiotherapy in rural and remote parts of the province because there's only a handful of publicly funded physiotherapists outside of the Winnipeg region. Nova Scotia is also fearful of the impact of vacancies. because what happens in Nova Scotia is that if a vacancy is left open for too long, the vacancy disappears rather than having it filled.

We see that the solution is more about health human resource planning as opposed to provincial jurisdiction over education.

So the third recommendation is about expanding the—

[The Chair, Conservative, Ben Lobb]

We are over time, so I wonder if you'd be able to sum it up in the next 30 seconds or so.

[Kate O'Connor]

Yes.

So, the third recommendation is about expanding the CanLearn program to rehabilitation professionals working in rural and remote areas.

In conclusion, I'll just say that I don't think it's news that many Canadians don't have access to the right care or the right professional. We would like to see better coordination of care and services through different levers from the federal government.

Thank you.

[The Chair, Conservative, Ben Lobb]

Okay. Thank you very much.

From the Paramedic Association of Canada, Mr. Poirier. Go ahead, sir.

[Pierre Poirier, Executive Director, Paramedic Association of Canada]

Thank you, Mr. Chair.

My name is Pierre Poirier, and I am the executive director for the Paramedic Association of Canada.

Thank you for the opportunity to speak today.

I have a few notes, and hopefully I'll be brief, in recognizing the time of day.

In some ways the short answer to the question regarding the best practices and the federal barriers is that the federal government continue to be engaged in the development of professional scopes of practice. The paramedic best practice probably already does exist in many locations within Canada, and that's also international recognition, and the federal government should continue to support curriculum development in alignment with those scopes of practice.

Just a bit of history, there are about 40,000 paramedics in the country. We're arguably the third-largest health care group in the country, following nurses and physicians. Our nomenclature is related to three classes of paramedics: primary care, advanced care, and critical care. The education related to that is at the diploma level. It's two years to be at primary care, probably a third year to be at advanced care, and subsequent training to that for critical care.

We're throughout the country. A bit of our history includes the contemporary history, probably transitioning in the 1970s in Calgary away from ambulance drivers, where enhanced training started to be provided. In Toronto there were advanced care paramedics starting in the 1980s. In the 1990s you saw many other provinces come on board with recognition of education. The key element to the transition for paramedics in this country, and our contribution to health care delivery, was the support in 1997 from Human Resources and Skills Development Canada—I'm not sure what the title was at that time—of the development of a national profile for paramedics. That was a key contribution from the federal government that helped create a national view of what a paramedic was. There were over 50-odd different titles for what we did at the time. Right now we recognize that there are essentially three for the profession. Different jurisdictions across the country have different titles, but essentially they are all trained to be three specific titles.

Our scope of practice is varied across the country, and that's a result of our health care framework in recognition of the province's authority over health care to a large degree. Paramedics, in terms of their scope, do incredible things in terms of the ability to save a life. All of the interventions are about that. What we're seeing today is the development of a community paramedic and our ability to, I wouldn't say intervene, but contribute to health care in many different ways that are not necessarily in the critical or the emergency situations.

I was thinking about this in a broader context, and my apologies for that. In some respects the Canada Health Act doesn't recognize paramedics. It doesn't recognize us in terms of our environment. When you talk about ensured health services, that limits us to hospitals and physician services and doesn't include what we do outside of that. I think there's an opportunity there to look at the broader scope of how we view the health act and how the federal government could be engaged in what paramedics do.

I think we're at a transition time where, when we look at health care delivery models, another dollar added isn't necessarily of equal value in terms of what it was previously. To look at it in a different sense, I think there should be a recognition of interprofessional collaboration and unexclusive scopes of practice, particularly opening up scopes of practice and reducing the ability to have exclusivity in areas of treatment. A good example of that recently is in Alberta with the Health Professions Act, where it was recognized that colleges would apply for the ability to make use of restricted activities. Everything that wasn't a restricted activity was open to the health care system and for different colleges to provide that service. Colleges could, by themselves, build the argument to access these restricted activities. That's really opened up the realm of how health care can be delivered. That's an important piece for us to look at. I think there's an opportunity for national leadership from the federal government on this issue of looking at scopes of practice in a much more open way.

Recently there was documentation with respect to the “Optimizing Scopes of Practice” document, which talks specifically about not having exclusive scopes and not having siloed regulation or siloed concepts at how we look at health care.

Another area where the federal government could take a leadership role would be looking at how we combine what is current practice or how professions practise, how paramedics practise, and how we can integrate that into the system and recognize those as different skills, and all those skills and abilities are attributed to a specific area, and that there's a way of accrediting that outside of the college realm in terms of delivery of service. I think Dr. Turnbull in that document “Optimizing Scopes of Practice” has a very good point about how we should look at health care in a very different way.

I mentioned that in many respects Canada has demonstrated a leadership role with respect to alternate service delivery. The development of community care paramedicine over the last five to 10 years or so has really contributed to a positive delivery and access for patients. I can list a few of those initiatives.

I think this committee may have heard previously about the aging at home strategy in Deep River, Ontario, whereby paramedics are providing blood glucose checks; teaching prevention education with respect to slips, trips, and falls; and doing blood pressures. These are not restrictive activities in terms of medically delegated acts. It's basically helping or assisting people to age at home and keeping them healthy in that environment. That's one of the areas.

Paramedics were also very much engaged in H1N1, providing vaccines. There's a long-term case study that's been going on in Brier Island in Nova Scotia with respect to paramedics providing service to the local community. It's not always emergency care. It's oftentimes the more basic levels of care and I think those are very important.

Recently, the Ontario government provided $6 million to community paramedicine, which is a great investment. I think what we're starting to see is the return on investment for the communities and also for different levels of government on how this is a very positive thing.

Another important note, and I come back to the Canada Health Act, was in terms of cost being restrictive or preventing access. Recently, CBC's Marketplace talked about the cost of—and I hate to say it—an ambulance ride in terms of the care that a paramedic provides as being, I would say, outrageous, but also preventing or restricting access. Across this country you'll pay around $50 in Ontario, $140 in New Brunswick, and upwards of $250 to $300 easily in Saskatchewan or Manitoba for an ambulance, and this is a problem. I think there should be some leadership that could be demonstrated from the federal government in assisting with the concept of it being something that restricts access for patients.

In all, I'd like to thank the group for your time and for the ability to present before you today.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

For the members, first up is Ms. Moore.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Mr. Poirier, I would like to ask you a few questions about current disparities between the provinces.

In Quebec, there has been a longstanding fight to recognize certain medical acts. Ontario paramedics are allowed to perform certain medical procedures, while those in Quebec are not entitled to do so. There is a rather significant difference between the provinces in terms of the medical procedures that may be performed by paramedics.

I would also like you to talk about that kind of independence regarding assessment. I am a nurse and I was still working until January, before my pregnancy. Paramedics would regularly arrive at the hospital with patients and say that although these people did not need to go to emergency, they had no choice but to take them there.

Is there a way for you to assess patients and provide guidance by telling them that they do not need to go to the hospital's emergency department as their condition does not warrant it, while providing some advice? Would it be possible to make this part of your practice?

I have a technical question. Medical assistants in the Regular Force take the same study program at Collège Ahuntsic as civilian paramedics do, but not medical assistants in the Reserves. Would it be a good idea to find a way to incorporate them into your profession after they have completed their military careers?

Those are all the questions I have for you, Mr. Poirier.

I will now turn to Ms. Guitard.

I would like to talk about access to occupational therapy. Often in the health system, a medical referral is required for access to occupational therapy services. We need to have something happen and then go to a doctor, who will give us a referral. We are then put on a waiting list and eventually see an occupational therapist.

Would not it make more sense to make it possible for a person to directly ask to be assessed by an occupational therapist or other health care professional, such as a nurse, and enable these professionals to give a referral and determine whether it would be appropriate for this person to be assessed by an occupational therapist, thus preventing injury?

[Pierre Poirier]

Thank you.

I will start by answering the first question about non-emergency care, outpatient care.

It's important to note that there have been a number of initiatives. Probably the most recent one—it's been going on for several years in Toronto—is called the community referrals by emergency medical services.

That is exactly what they do. Instead of sending people to the hospital, they put them in touch with the social services available. I wish this could be done across the country, in every city.

It's really an important piece of the care, and it's not in terms of acute care. It's not even health care in many respects. It's a referral service to the appropriate social service that may be available in the community. Toronto is a good example. It's being done in other communities across the country, but they're the first ones to have done that.

For some time now, Collège Ahuntsic has offered a program related to the national profile. It works quite well. There are also ways for health professionals leaving the Canadian Forces to be recognized as civilian professionals.

I would compliment the federal government. Over the last 10 years, actually, they've taken the initiative on that, with respect to integrating military, post-service, into the profession of paramedics. There's been a link. They've adopted the terminology from the national profile.

Merci.

[Dr. Paulette Guitard]

A medical referral is not required for access to occupational therapy services. Some occupational therapists see clients without requiring them to submit a medical referral. The problem is that insurance companies ask their customers for a medical referral before they reimburse them for the services received. If people want to be reimbursed for their expenses by their insurance company, then they must provide a medical reference. We then get caught in a vicious circle where a referral from a physician is required to obtain a refund from the insurance company. That aside, the referral is not necessary.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Seeing an occupational therapist who works in a health centre absolutely requires a referral. You cannot just show up at the hospital and say you want an appointment with an occupational therapist.

[Dr. Paulette Guitard]

It is true, and that is becoming increasingly the case. I, for one, am from the old school. I have been an occupational therapist for a long time. When I started practising this profession, many of the occupational therapists available worked with outpatients. We rarely see that today. Occupational therapists who work in hospitals are strictly assigned to in-hospital patients.

Indirectly, a medical referral is necessary in a hospital. However, things are different in such settings as schools, where occupational therapists have a private practice. Only hospitals, internally, require a medical referral.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Ms. O'Connor, do physiotherapists have the same problem in terms of the requirement for medical referrals?

[Kate O'Connor]

Yes, in every province and territory in Canada there is direct access to physiotherapists. You do not need a physician's referral. It comes down to a question of insurance coverage.

We recently conducted a study of access to extended health benefits. A couple of the things that we learned are that insurance companies use that doctor's note, the referral or the prescription for physiotherapy, occupational therapy, and other services as a cost containment measure. It's simply to try to defer patients from seeking other treatment, but what it does in essence is double bill the system.

One of the reasons why we would be in support of the federal health partnerships program is to look at how to streamline the system for direct access under federal health programs, including Sun Life for coverage of public servants through their extended health benefits. There are a lot of things within the program that actually don't make sense because they are delaying the access to treatment and access to professionals who are within the scope of practice of the professionals.

[The Chair, Conservative, Ben Lobb]

Thank you very much. We're over time.

Mr. Wilks.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thanks to those who came here today.

I have three questions for you, Mr. Poirier, and one for Madam Guitard. If I have any time, left Dr. Lunney has a question and I have no idea how to say it, so I'll let him do it.

Pierre, first, what role could paramedics play beyond emergencies if they were to maximize their scope of practice? Second, could you provide more information on community paramedicine and examples of their scope of practice? Third, how would inclusion in the federal health workforce strategy benefit paramedics and Canadians?

Ms. Guitard, you brought up quite an interesting topic that intrigues me, and that is with regard to Corrections Canada and the release through federal penitentiary—not provincial jail but federal penitentiary—and the need for better coping skills for those who are being released. I think it's something that is sorely missed because they have things that trigger them very quickly when they're released, and I wanted to hear your thoughts on that part of it.

Mr. Poirier is first and Madam Guitard second.

[Pierre Poirier]

Thank you.

With respect to paramedics and their role, and expanding that, I think there's very much an opportunity with respect to rural and remote areas. You've probably heard from different professions that the rural and remote communities are oftentimes the least served by our health care system. I'll use Alberta as an example. Right now, many of the rural hospitals don't have physicians overnight or in specific periods of time. Paramedics provide those services, and paramedics oftentimes provide the emergency care service in the overnight period. That's one place where I think there is opportunity.

I think it's a good use of resources from a value perspective as well. I'm not saying that paramedics are underutilized or that they have great capacity. I just think it makes sense, in terms of their skills and ability, to be able to provide that service. It's a good use, and it works for the community. I heard Kate or Paulette mention before that if you can train individuals from a community, they are more likely to stay in that community. I think there is great opportunity with respect to that.

I'll go to the third question and then come back, because that leads into the whole concept of health workforce planning, which is an important piece, and I think this could be a good opportunity for the federal government. Paramedics are not listed in that plan of where we're going. If you look at pharmacists—and I've reviewed the pharmacy—there is information about their number, age, education, and career prospects. There is a whole understanding of who they are, so you can plan in the future.

When I said there are approximately 40,000 paramedics, I absolutely don't know the exact number. We could go to all provincial regulators, and we still wouldn't know the number. I think there is a real disconnect, and there is a missed opportunity in terms of planning. I think that's a very important linkage, so thank you for that question.

The last part is with respect to scope of practice. Hopefully this is not too abstract, but the Royal College of Physicians and Surgeons has adopted the CanMEDS model of looking at how they define the profession. We've adopted that model as well, because it takes your knowledge, skills, and abilities or competencies and takes it up one step to look at what your role is. I've always been fascinated by their presentation on it. They went to the community and said, “What do you want physicians to be?” Physicians themselves thought they wanted to be clinicians, and that's how they viewed the world. When they asked the community, the community wanted physicians to be collaborators, educators, leaders, all these other things.

That's how they started to develop their new competency profile. That's what we are choosing to do with respect to the paramedics. We are engaged in that exact process, to look at all the roles that we can undertake. How does the community view the way we should be engaged? What are those roles? That will then lead to what the knowledge, skills, and abilities or competencies are that support that.

Again, I think there is a role for the federal government to support that kind of thinking about how we look at health care. Hopefully I've answered your question.

[Dr. Paulette Guitard]

I'll go back to your question about people who are in these settings who have mental health issues. You were talking about triggers. As occupational therapists, we can help these people recognize what their trigger points are to help them know the signs, and then get them to express their emotions in a socially acceptable manner. That's one of the coping skills that we can give to people: helping them learn to say “I'm upset“ when they are upset, rather than take a punch at somebody.

Those are the types of things in day-to-day life that we can work on, having a routine and a sense of purpose and meaning through occupations. These people usually don't have skills. I'm talking about job-readiness skills. We can help them with that. Then we can help them look at having a meaningful occupation. We can work toward that, helping them build some of the coping strategies that they need to deal with the everyday stressors that they are going to be facing.

[The Chair, Conservative, Ben Lobb]

Mr. Lunney, sir.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thanks very much.

That's three underutilized professionals here, and I appreciate your contributions, all of you.

I have a quick question for the physiotherapist. In British Columbia, we had 12 visits when I was practising. I did a lot of things with overlap, obviously. In my office, I had a lot of adjunctive therapy, lasers, microcurrent, interferential current, and so on. Twelve visit is what they allowed. For low-income people, often you can't fix them or adequately rehabilitate them in 12 visits, so I would refer them to a physiotherapist, and he'd follow up. He had the same issues I did with low-income people; he'd refer them over my way to follow up.

I just wanted to ask you to contribute. What is the coverage for physiotherapy across the country? Have you been more or less defunded, as chiropractors have across the country in order to feed the monster overall, the health budgets? Where are you at?

[Kate O'Connor]

Physiotherapists across the country have largely been delisted from provincial health insurance programs. There are exceptions. For example, in Ontario, if you're under the age of 18 or over the age of 65, often there are exceptions if there's an overnight stay in hospital that requires rehabilitation. Unfortunately, the circumstances are such that low-income people often don't have access. Even if there is the potential for coverage under provincial programs, the wait-lists are so long for the publicly funded physiotherapist that it is inaccessible, because if you have a fractured ankle and have to wait six to eight months for a physiotherapist, you will have chronic pain and problems that often cannot be resolved at that point.

The balance, for the profession, is to look at the opportunities to try to promote better access to care, to look at the competency issues and how we can overlap in areas where there is access to care with the public system, and then also to look at the private system and opportunities to help support access.

[The Chair, Conservative, Ben Lobb]

Okay, thanks very much.

Ms. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much.

Actually, I think that segues into something that is.... We're talking about scope of practice here. The point is that there is a lot of overlap in scope, so the big question is as you look at appropriate HHR strategies, how do you fit...? I know what occupational therapists do. I think it's really a crying shame that occupational therapists are no longer involved in veterans' care and diagnosis, because occupational therapists were the actual advocates for veterans. I think that's why they're no longer involved in veterans' care.

I want to suggest that if we were to look at integrated models of care, community care—let's just leave aside the hospital and acute care model, which is part of that new integrated model—where does a physiotherapist, an occupational therapist, or a chiropractor fit in the scope of practice in that model? If you look at the paramedic, the nurse practitioner, the home care nurse, the family physician, how do those four people fit into the scope of practice when you have overlapping?

How do we build effective scopes of practice that are necessary and needed? How do we integrate them into a system without duplication, overlap, and turf wars? How do we ensure that the most effective care is given to the patient in the most cost-effective manner, so that we can see the savings and the quality of life and all those other indicators for measuring a system that are working well? How do we do that when there are so many people that overlap? That for me is the beginning of how we have to start looking at scope of practice when some people are doing the same things in so many ways. I just wonder how we do that. That is something that I am struggling with. I think integrative, comprehensive care, etc., is important. But how do we decide who is the best person, let us say, in rehabilitative care?

That's what I'm struggling with. How do we decide?

[Dr. Paulette Guitard]

Well, when Ms. O'Connor was talking about interprofessional models, that is exactly what interprofessional models are trying to do, and that's what we're trying to teach our students as well. So there's no need to be in a turf setting, saying, “This is needed, and this needs to be done by this person and this person”. If you really have a truly interprofessional concept, then the person will come in, will be evaluated, and then it will be identified who is the best person to meet that person's need. The assessment might not be from an occupational therapist but a physiotherapist knows exactly what an OT can do, and in a particular setting, the physiotherapist might say, “This is the problem with this person and I believe that she needs OT, and she needs speech language pathology”.

I think there's a lot of duplication going around because we're set in our ways, and we also have rules and regulations from our colleges. But there's nothing preventing us from being truly interprofessional and doing one assessment, instead of doing an assessment in OT, one in physiotherapy, one nursing, etc. We could have somebody there who does one assessment. We'd work as a team, and then would decide on the best professional to meet this person's needs. There are some models like this working really well right now, but it's a shift. So you're constantly debating with a model like that and trying to fit it into a model that it's not. It's difficult.