Prepared By:Kate Rexe, Canadian Physiotherapy Association

BRIEFING NOTE

Subject:Access and barriers to Physiotherapy under the federal Non-Insured Health Benefits (NIHB) Program

Prepared by:Kate Rexe, Canadian Physiotherapy Association

Date: October 7, 2014 – UPDATED OCTOBER 24, 2016

Submitted to:Erin Tomkins, Assembly of First Nations

Marie Frawley-Henry, Assembly of First Nations

Summary:

The Health Action Lobby (HEAL) formed a Non-Insured Health Benefits (NIHB) Working Group in the Spring of 2014 as an opportunity to further discuss opportunities to advance issues and concerns related to the health of Canada’s Aboriginal peoples. This group met for the first time in May 2014 and quickly realized the goals of the working group should be closely aligned with the work of the Assembly of First Nations and future activities related to the NIHB joint-review.

Background:

In the summer of 2014 the Canadian Physiotherapy Association (CPA) issued a call out to members to gather their feedback on experiences with the NIHB Program. The purpose of gathering this information is three-fold:

1)To support CPA members through the improvement of communications and administration of health programs that incorporate their services;

2)To improve access to essential rehabilitation services which will improve the health and wellbeing of First Nations and Inuit peoples; and,

3)To support the NIHB review process with information related to the experiences of health providers, challenges and barriers to providing care, differences in standards of care, and recommendations for improvement.

It is the hope of CPA that this information will support a collaborative process that leads to a more efficient program which meets the needs of First Nations and Inuit individuals and communities.

Current Context and Key Issues:

Thirteen physiotherapists from seven regions responded to CPA’s request for member feedback on the NIHB program. The following is a chart and regional summaries of the current issues or challenges experienced by physiotherapists working with the NIHB Program in seven provinces/territories in Canada.

Issues/Challenges / AB / SK / MB / ON / YK / NWT / NU
Access / X / X / X / X / X / X
Transportation / X / X / X / X
Consistency in Process/Policy / X / X / X / X / X / X / X
Fiscal Sustainability / X / X / X
Communications / X / X / X / X / X / X
Gap in Essential Services / X / X / X / X / X
Equipment / X / X / X / X / X / X / X
Difference in Standard of Care / X / X / X / X / X / X

Alberta

NIHB requires a physician or nurse practitioner to sign off on medical equipment and supplies, as well as general work that has been done, but in fly-in communities in the Athabasca region communities don’t have access to physicians or Nurse Practitioner’s to sign off
Physicians and nurses are referring to physiotherapists to prescribe equipment that only the physician or nurse have the authority to sign off on – this is an inefficient system

Orthopedic surgeons are required to approve braces – this is inefficient and costly to the provincial health system when a physiotherapist is more than qualified to prescribe a brace
NIHB needs to recognize that it is within the physiotherapists scope of practice to prescribe medical equipment

In the Athabasca region the provincial government cost shares physiotherapists going into fly-in communities to provide rehabilitation to patients on reserve – i.e. the Athabasca Health region funded a physiotherapist position for 1 week/month, NIHB paid for transport of the therapist but only if there were enough people in the community to warrant a flight to one location. This means patients would go without care until there was a critical mass in the community to warrant the visit of the therapist

Working in fly-in communities forces therapists to triage and prioritize the patients seen in a visit because of the limited amount of time available. This leaves many patients without access to care they need and the value of the care provided suffers. This also forces the therapist to explain to patients she wasn’t wanting to neglect patients, but that she needed to see other clients too.
Patients will fly south to get treatment because they would get more care if they needed it. But, down south the system tries to refer patients back to their community because there is a physiotherapist that can visit. Unfortunately, the access is limited because of limited time and number of visits to communities in the region (as mentioned above)
Chronic disease management and care is not seen as important – only acute care needs
Equipment prescriptions – in the north and in remote communities there is more wear and tear on equipment, but this is not reflected in NIHB policies. Patients are only allowed to order equipment every five years, even though the equipment (e.g. walker, wheelchair) wear out faster in communities without paved roads or sidewalks
It is challenging to fill in NIHB paperwork, which nurses will help to coach therapists to do, but there is no clear understanding of process or policies
Communications and communications infrastructure needs significant improvement. E.g. technical issues occur and a fax doesn’t go through but the therapists would leave community and only find out six months later when she returned to the community that the requisition didn’t make it to NIHB
No consistency in the approval process – e.g. equipment prescription is rejected because the “right” person wasn’t reviewing the file or signing off on approval
Therapists often leave rehabilitation to homecare nurses for continuation because the therapists has limited time in the community to deliver care
Health professionals working with NIHB have to educate themselves and others on the system, which is complex, inconsistent and incompatible with other provincial health policies
Need NIHB policies to reflect the value of physiotherapy in the rehabilitation process – rehabilitation is as valuable as acute care. If this change was made, some of the costs and transportation issues could be resolved (e.g. flying patients south for care when it could be provided in the community)
NIHB needs to see that physiotherapy is not a “nice to have”, mobility is necessary to health

Saskatchewan

The “physician as gatekeeper” model requiring physician prescriptions for medical equipment and supplies is inefficient, often goes beyond the physicians expertise or knowledge of the patient’s need, and doesn’t recognize the regulated professional scope of practice for direct access to services in the province (and every jurisdiction in Canada)
The NIHB program is not compatible with patient-centred care
Physician sign-off on equipment and supplies creates inefficiency and delays in the system for all patients. E.g. patient discharge from hospital may be delayed because equipment requisitions are not signed, surgeries may be cancelled because patients have not been discharged in timely manner (waiting on NIHB approvals and physician-signed requisitions)
“If the NIHB policy could be changed whereby the people who know the patient’s needs (ie: therapists, or nurses who are eligible to order equipment) could be the responsible person for signing of the requisition, then significant amounts of healthcare dollars, could be saved (decreased hospital bed costs because discharge delays would be reduced, clinicians have more time to spend with other patients which improves their outcomes leading to a faster recovery, those patients who are not in hospital get their equipment faster which may reduce falls risks because therapists are not waiting for GP’s to return the requisition or send in a specific referral equipment for equipment that they do not have any idea of what is needed).”
Physiotherapists recognize system improvement under NIHB now that therapists can send equipment requisitions directly to vendors who then do the legwork to get approval. This has decreased the amount of time that clinical staff have to spend on non-clinical care work allowing them to spend more time with their patients.
Please see additional briefing note on NIHB concerns in Saskatchewan for detailed information on communication, differences in standard of care, differences in health outcomes based on access, travel and access to outpatient physiotherapy services

Manitoba

Physiotherapists provide limited service to some northern First Nations; the majority of care/prescription and fitting of medical equipment and supplies is accessed under NIHB
There are significant gaps in access to rehabilitation and health care in rural and remote areas of Manitoba
Many patients with complex and acute care needs are forced to go to Winnipeg to access services. For patients with mobility issues, they are required to travel without support when they leave the community
Poor communication has led to delays in discharge from hospitals, not getting access to necessary equipment and appropriate referral to outpatient rehabilitation provided under the provincial system
Physiotherapy is not accessible under NIHB or available in most First Nations communities unless it relates to equipment

Physician sign-off for medical equipment and supplies creates administrative barriers and delays for patients accessing necessary equipment - NIHB needs to recognize that it is within the physiotherapists scope of practice to prescribe medical equipment

Policies for equipment coverage don’t reflect the needs of patients or the wear and tear on equipment in northern communities, which have gravel roads, inclement weather and poor infrastructure
Jordan’s Principle was the result of jurisdictional challenges that prevented Jordan Anderson getting access to the health care he needed in his home community of Norway House Cree Nation.
In July, 2016, the federal government committed additional funding to support First Nations Children with complex needs access the care they need on-reserve
Needs to be better communication between health care providers, health system and patients because patients end up suffering when the bureaucracy isn’t working

Ontario

Access to rehabilitation and differences in standards of care in Northwestern Ontario are striking due to the fact that the North West Local Health Integration Network (NW LHIN) has chosen to fund hospital out-patient rehabilitation through a global hospital budget, rather than directly though OHIP/Ontario Ministry of Long Term Care
The funding model for out-patient rehabilitation in Northwestern Ontario provides the rationale for ineligibility for NIHB medical transportation benefits; travel claims also denied if not for a physician appointment
There is no access to specialized rehabilitation services for arthritis in some Communities
Poor communication has led to delays in rehabilitation as well as discharge from hospitals
There are inconsistencies in the application of policies for fly-in vs. road access communities e.g. Clients from fly-in First Nations denied travel and accommodations for a block period (2-3 weeks) for rehab associated with stroke or brain injury, while those from road access communities have been approved.
Denial of medical transportation under NIHB can lead to acute conditions becoming chronic, continued pain and disability, greater chance of hospital re-admission and increased costs to NIHB

Yukon

Yukon funds therapy for a variety of clients, e.g. children with special needs – this is not available under NIHB
Home Care Program Community Liaison Coordinators are either PT or OT and bring their rehab skills to benefit First Nation clients – not covered under NIHB unless it is related to medical equipment and supplies
The Home Care program also provides an itinerant therapy program to smaller outlying communities – some communities (e.g. Dawson City) co-funds therapy program, not covered under NIHB
NIHB is seen as a “payer of last resort” in Yukon and often will not cover anything unless all other options have been exhausted
There are consistent challenges with approvals under NIHB, communications, access to care, appropriate coverage, etc.
The territorial government offers ongoing support of First Nation Home and Community Care workers to increase their knowledge and skills through education and training in a variety of areas eg. fall prevention, exercise and diabetes
Council of Yukon First Nation has an NIHB navigator to help patients access care. However, there continues to be significant challenges with communications and access

Northwest Territories

Equipment not designed/suitable for use in the North and NIHB polies don’t allow for more suitable terms for replacement
Communities don’t have access to professionals (e.g. specialists, physicians) that are recognized by NIHB for prescription of equipment
Inconsistency in the application of policies (depends on the NIHB program officer, not the policy)
Poor communication when policies change (e.g. prescription/coverage for equipment changes)
Differences in standards of care – Under a physio’s scope of practice to prescribe equipment, but NIHB policies make it complicated and time consuming, requiring a physician/specialist’s approval (Chronic Disability Program and Seniors Health Benefits don’t require physician prescription)
Clients don’t have timely access to care because the process for prescriptions takes so long
Appeal process unreasonable – six levels of appeal, which may take more than a year to resolve. The result is daily challenges of limited mobility, disability, isolation and declining health
Grab bars that are attached to the wall in on-reserve homes are not covered under NIHB – this is a low cost solution that improves safety and reduces the risk of injury
Suggestions:
Allow physiotherapists to prescribe equipment under $150 to streamline process and save costs of requiring Dr.’s approval
Change equipment replacement policy to every 2-years
Include permanent grab bars on the list of funded equipment in on-reserve homes

Nunavut

Equipment is ordered even though it is not appropriate
System isn’t always cost effective – order most expensive equipment, rather than most cost-effective e.g. Orthotics – Over-the-counter shoe inserts are not available in most communities, so expensive custom orthotics are ordered
Communication of NIHB policies and training/educating of staff working in the North – not easy to find up-to-date information and sometimes information is conflicting
Communication to clients - NIHB should educate clients on what types of equipment can be ordered/covered
NIHB requires specialist referral and only certain specialist are available in NU
NIHB fills a huge gap in need- Rankin Inlet/Nunavut offers the best access to physios out of all the territories – they offer 4-5 visits a year)
Need to streamline things and find ways to deliver care in the most cost-effective way
Should promote/educate clients on access to equipment/care via extended health benefits – this is underutilized in the territory. Clients go to NIHB without trying to access through employer benefits
Suggestions
Give physios the ability to prescribe equipment
Hold annual teleconference/webinar for staff in Rankin Inlet to be educated on NIHB policies and how to understand the system. This would help coordinate practice among health professionals; currently practitioners are trying to learn the system on the job

SETTING / Ontario / Québec / N&L / PEI / Nova Scotia / New Brunswick
Hospital / Inpatient / Covered by public insurance / Covered by public insurance / Covered by public insurance / Covered by public insurance / Covered by public insurance / Covered by public insurance
Outpatient / Covered by public insurance where available (department closures, significant regional variation, strict eligibility criteria) / Covered by public insurance (strict eligibility criteria) / Covered by public insurance (strict eligibility criteria) / Covered by public insurance / Covered by public insurance; regional variability in out-patient wait times and patients encouraged to use private insurance first, with public coverage for treatment when private funding runs out. / Covered by public insurance. Cannot refuse anyone; however, there are lengthy waitlists, and patients are encouraged to use private coverage first (this cannot be enforced)
Community* / Community
(Clinic-Based) / 259 Community Physiotherapy Clinic contracts – now located in all regions of the province (up from 94 in 2011) Eligibility restrictions remain as previous (19 and younger, 65 and older, social programs, after overnight hospital stay) / No physiotherapy services available through non-hospital clinics, public insurance coverage for those over 65 / No physiotherapy services available through non-hospital clinics / No physiotherapy services available through non-hospital clinics / Central Zone (formerly Capital Health District) has physiotherapists working in community health teams with a strong chronic disease self-management model. Regional variation in access to physiotherapy in a primary health care team outside of Central Zone. / There are a few local health centres, but not all have physiotherapy in place. These cut down on travel for those who live in rural communities.
Primary Health
Care (PHC) / 32 Community Health Clinics (CHC)
2 Aboriginal Health Access Centres (AHACS)
17 Family Health teams (FHT) and 2 Nurse Practitioner Led Clinics (NPLC) for a total of 53 PHC settings up from 8 in 2011.
Home Care / Community Care Access Centres provide home care physiotherapy (strict eligibility criteria) / Coverage for services based on needs and income / Limited coverage through health regions (co-payments based on income, regional variation) / Home care physiotherapy sparsely available (significant rural/urban variation) / Coverage through Home Care Service (free for low income beneficiaries) / Coverage through Hospital Extra-Mural Program is part of provincial health coverage and available to those who are homebound or those whose treatment is better provided in a natural environment (e.g. in school for pediatric clients)
Major Gaps / Lack of community care options, restricted out-patient criteria, lack of out-patient departments, (Physiotherapy now funded in PHC settings since reform see above) / Reliance on private insurance, restricted out-patient criteria, lack of physiotherapists / Lack of specialized services, lack of home care options, poor long-term care options, geographic variation in care / Lack of physiotherapists, low pay of physiotherapists, geographic variations in care, lack of community care options / HR challenges consistent across province. Rural hospitals face recruitment challenges; Outpatient clinics have long wait lists and lack human resources to achieve desired intensity of rehabilitation; focus on in-home safety assessments and caregiver education in the home care sector; and, major gaps in access in long term care. / Lack of chronic care focus, lack of physiotherapists, geographic variations in care. Long term care facilities provide a “consultation” service by an extra-mural physiotherapist. Physiotherapists are clustered in urban areas; it is more difficult to provide/access service in rural and remote areas. Physiotherapists are not included in primary health care teams, emergency departments or to prevention/wellness
*"Community Care" defined as publicly-funded clinic and home-based care
SETTING / Manitoba / Saskatchewan / Alberta / BC / Nunavut/NWT / Yukon
Hospital / Inpatient / Covered by public insurance / Covered by public insurance / Covered by public insurance / Covered by public insurance / Covered by public insurance
Outpatient / Covered by public insurance / Covered by public insurance (strict eligibility criteria) / Covered by public insurance (strict eligibility criteria) / Covered by public insurance (department closures, regional variations) / Covered by public insurance (strict eligibility criteria)
Community* / Community / (Clinic-Based) / No publicly funded physiotherapy clinics in the community. Limited coverage through Community Therapy Services (CTS) with strict eligibility criteria, regional variation. / 3 community clinics and 5 out of 12 health regions provide contracted community services / Contracted community services (significant regional variation) / Premium Assistance MSP (10 visits/year, $23/visit) / Regional Rehabilitation Teams funded through Regional Health Authorities provide community and home care through hospitals (acute care facilities, and regional community outreach clinics)
Home Care / CTS only provides community service in the Winnipeg Regional Health Authority. Other health authorities have limited home care physiotherapy. OTs do home visits in rural areas. / Limited coverage (significant regional variation) / Provincial Home Care Program, often requires co-payments based on income ($300/month maximum co-payment) / Offered through health regions (eligibility criteria, wait lists, monthly co-payments based on income)
Major Gaps / Lack of chronic care focus, geographic variations. Patients fund their own equipment if it is not covered by Home Care or EIA. Physiotherapists provide limited service to some northern First Nations communities. / Reliance on private insurance, lack of out-patient departments, lack of prevention focus, geographic variations / Lack of primary care options, lack of prevention focus, lack of long-term care options / Lack of community care options, reliance on private insurance, lack of out-patient departments / Lack of chronic care focus, lack of community care options, lack of physiotherapists, geographic variations
*"Community Care" defined as publicly-funded clinic and home-based care