Models for Integrating Rehabilitation and Primary Care: A Scoping Study

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Models for Integrating Rehabilitation and Primary Care: A Scoping Study Mary Ann McColl, PhD, MTS, Samuel Shortt, MD, PhD, Marshall Godwin, MD, MSc, Karen Smith, MD, Kirby Rowe, BSc, Patti O’Brien, MSc, Catherine Donnelly, MSc ABSTRACT. McColl MA, Shortt S, Godwin M, Smith K, Rowe K, O’Brien P, Donnelly C. Models for integrating rehabilitation and primary care: a scoping study. Arch Phys Med Rehabil 2009;90:1523-31. Objective: To describe the scope and breadth of knowledge currently available regarding the integration of rehabilitation and primary care services. Data Sources: Peer-reviewed journals were searched using CINAHL, MEDLINE, and EBM Reviews for the years 1995 through 2007. This process identified 172 items. Study Selection: To be considered for the subsequent review, the article had to describe a service delivery program that offered primary care and rehabilitation, or services specifically designed for people with chronic conditions/disabilities. Further, it had to be available in English or French. No methodological limitations were applied to screen for levels of evidence. Data Extraction: Based on these criteria, 38 articles remained that pertained to both primary care and rehabilitation. These were reviewed, sorted, and categorized to discover commonalities and differences among the approaches used to integrating rehabilitation into primary care. Data Synthesis: In consultation with the team of investigators, it was determined that there were 6 different models for providing primary health care and rehabilitation services in an integrated approach: clinic, outreach, self-management, community-based rehabilitation, shared care, and case management. In addition, a number of themes were identified across models that may act as either supports or impediments to the integration of rehabilitation services into primary care settings: team approach, interprofessional trust, leadership, communication, compensation, accountability, referrals, and populationbased approach. Conclusions: Rehabilitation providers interested in working in the primary care sector may be assisted in conceptualizing the benefits that they bring to the setting by considering these models and issues. Key Words: Patient care team; Primary health care; Rehabilitation; Review (publication type). © 2009 by the American Congress of Rehabilitation Medicine

From Queen’s University, Kingston, Ontario, Canada (McColl, Smith, O’Brien, Donnelly), Memorial University of Newfoundland, St. John’s, Newfoundland, Canada (Godwin), Canadian Paraplegic Association-Ontario, Toronto, Ontario, Canada (Rowe), and Canadian Medical Association, Ottawa, Ontario, Canada (Shortt). Supported by the Ontario Ministry of Health and Long-Term Care, Ontario Rehabilitation Research and Advisory Network, and Ontario Neurotrauma Foundation. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Mary Ann McColl, PhD, MTS, Centre for Health Services and Policy Research, Queen’s University, Abramsky Hall, 3rd Fl, Kingston, ON, Canada, e-mail: [email protected]. 0003-9993/09/9009-00805$36.00/0 doi:10.1016/j.apmr.2009.03.017

ESPITE THE RECENT POLICY focus on chronic disease D management in primary care, research continues to show that people with chronic conditions and disabilities are system-

atically disadvantaged when seeking to obtain primary care.1-4 They are shown to be among the highest users of health care,5 and yet they experience the highest number of unmet needs.6 They report a lack of coordinated primary health care, as well as difficulties accessing specialty services and obtaining required assistive equipment.7-9 People with chronic conditions and disabilities make up a small percentage of the typical primary care caseload; however, they consume an inordinate proportion of primary care resources.10,11 They differ from the average primary care patient in that the balance of their health is more easily disturbed; the functional consequences of illness are greater; treatment may be prolonged or complicated because of the disability; and multiple providers and agencies are often involved in their care. Furthermore, disabled patients often do not have the same opportunities for health maintenance and preventive health behavior as their nondisabled counterparts.12 They require intensive management, including a high degree of coordination among multiple providers and agencies, in addition to frequent contact, coaching, and support.11,13 Family physicians recognize the challenges associated with providing good quality primary care to their patients with chronic and disabling conditions: they require more time and more coordination, they tend to have more complex problems, and they often have needs that are beyond the usual scope of primary care.12 The purpose of this article is to explore models of primary care for people with disabilities and chronic conditions that offer some of these benefits. Reform in the primary care sector has been a subject of media discussion, research, and political imperative for almost a decade. A number of authors observe that the primary health care sector is performing considerably below expectations,11 and that providers are overstressed and dispirited.14 Family medicine has become an increasingly difficult specialty to which to attract residents, and high attrition and low participation rates combine to create a crisis in primary health care access and quality.14-16 A review of some of the difficulties encountered in providing primary care to patients with chronic and disabling conditions has led to a recommendation for the integration of rehabilitation services in the primary health care setting.13 Leutz17 suggests that the need for integration of rehabilitation services with primary health care depends on the severity and instability of the patient’s condition, the duration of the condition, the urgency of intervention, the number and complexity of services involved or needed, and the patient’s capacity for self-direction. The more compromised the person on each of these 5 dimensions, the greater the need for fully integrated care. Fully

List of Abbreviation CBR

community-based rehabilitation

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integrated care refers to a case where information, decisionmaking, and service delivery responsibilities are shared among medical and allied health professionals.17,18 Someone with a severe condition, needing multiple specialized services, would benefit from an integrated situation where service providers make decisions jointly and function as a team. Bodenheimer11 proposes as a solution to the difficulties experienced by both patients and physicians in the primary care sector its reorganization as a team-based enterprise. In his view, physician-led teams could undertake effective chronic disease management if payment methods were structured to create incentives for team building, rather than for individual performance. For those patients with complex continuing problems, another proposal of interest is the notion of a “patientcentered medical home,” meaning a physician-directed environment where integrated, coherent, cross-disciplinary care was available to patients.19 The medical home provides lifelong continuity of care, where personal medical services are available, as well as coordinated access to specialty and allied health services. Common to both is the assumption that care of complex patients requires a team, made up of an appropriate mix of primary health care and allied health professionals. The objective of the present study was to describe the scope and breadth of knowledge currently available regarding the integration of rehabilitation and primary care services. To achieve this objective, a scoping study was conducted to assess the state of knowledge and the need for enhanced research capacity in this area. METHODS The scoping study is an emerging methodology for literature synthesis,20 defined as a way of mapping key concepts within a research area by assembling multiple sources and types of evidence available. The emphasis of a scoping study is on comprehensive coverage, rather than on a particular standard of evidence. This approach permits identification of strengths and weaknesses in a body of literature, as well as high-level conceptual observations. Concepts that emerge from the review may either be identified a priori, or they may arise from the data itself. The scoping study typically unfolds in 5 steps: (1) identify the research question; (2) identify all pertinent studies; (3) select the studies for detailed analysis; (4) chart the data according to key concepts; and (5) collate and summarize the findings of the selected studies. Identify the Research Question The study was guided by the question, “What is known from the existing literature regarding the best ways to integrate rehabilitation services into primary care?” Identify All Pertinent Studies The literature review was conducted to identify a comprehensive set of articles detailing approaches to integrating rehabilitation services with primary care. Inclusion criteria for the scoping review were as follows: Keywords. The process began with a traditional keyworddriven electronic search, guided by the following terms: chronic disease; disability; primary health care (including primary care, rural health services, community health services, home care services); rehabilitation (including occupational therapy, physical therapy, physiatry); integrated care; collaborative care. Databases. Peer-reviewed journals were searched using the following electronic search engines: CINAHL, MEDLINE, and EBM Reviews. Arch Phys Med Rehabil Vol 90, September 2009

Years. The electronic search of peer-reviewed literature spanned the interval between 1995 and 2007. Next, hand searches were conducted of references from key articles. In this way, it was possible to follow-up on promising literature that might not have been captured by the databases used. To capture the most recent literature, content searches were conducted of e-journals and web-based journals available. Finally, searches were conducted for gray literature on the websites of governments, research institutes, and professional associations. This process identified 172 items. Select the Studies for Detailed Analysis To be considered for the subsequent review, the full set of articles was focused by applying the following exclusion criteria: (1) the article had to describe a service delivery program that offered primary care and rehabilitation, or services specifically designed for people with chronic conditions/disabilities; (2) articles had to be available in English or French; and (3) no methodological limitations were applied to screen for levels of evidence. It was thought that an inclusive approach would provide a better understanding of the current practices integrating rehabilitation into primary care, rather than adopting a stringent definition of methodological parameters. Based on these criteria, 134 articles were excluded, and 38 articles remained that pertained to both primary care and rehabilitation. The final subset of 38 articles dealt with the integrated delivery of rehabilitation and primary care. This tended to happen in 1 of 3 ways: (1) by introducing rehabilitation personnel into the primary care setting, (2) by including primary care providers into existing community rehabilitation teams, or (3) by creating new entities for the integrated provision of rehabilitation and primary care. Chart the Data According to Key Concepts The final 38 articles were reviewed in detail and repeatedly sorted and categorized in an attempt to discover commonalities and differences among the approaches used to integrating rehabilitation and disability services into primary care. In consultation with the team of investigators, it was determined that there were 6 different models for providing primary health care and rehabilitation services in an integrated approach (table 1). The team of investigators included rehabilitation specialists, allied health professionals, primary care providers, and disability consumer representatives. As such, they constituted an expert group made up of all pertinent stakeholders, providing advice to the study from a variety of perspectives. Collate and Summarize the Findings of the Selected Studies The results are presented to correspond with the definitions and features of the 6 models of integrated primary care and rehabilitation that emerged from the scoping review. RESULTS Clinic The most common model for integrating rehabilitation services and primary care is the clinic approach. The typical configuration of this type of practice is for a rehabilitation professional, such as an occupational or physical therapist, to work out of an examining room in a family practice. The key to this model is that family physicians and rehabilitation professionals are colocated, resulting in a geographically defined team. The role of professionals is to exercise their usual scope of practice in a concentrated and often condition-specific manner.

SCOPING REVIEW REHABILITATION AND PRIMARY CARE, McColl

The scoping review produced 16 articles discussing the clinic approach. These articles described a range of programs typically designed for special populations, such as elderly and disabled patients. The main advantage of the clinic approach is that it is familiar for both medical and rehabilitation providers, each of whom work exclusively within their usual scope of practice, seeing patients singly and sequentially. The clinic model is efficient from the professional’s perspective and affords the opportunity for joint appointments if necessary. The clinic model has a benefit of colocation, and the possibility of developing interprofessional trust and coordination by virtue of both formal and informal communication. From the patient’s perspective, the clinic model is familiar, and allows patients to consolidate their care from various providers at a single location, thus potentially minimizing their transportation and associated costs. This model is often found in multiple-provider primary health care organizations, such as community health centers, family health teams, and other shared or group practices. Some commentators argue that the clinic approach remains too firmly embedded in institutional practice patterns and culture. It has been criticized for failing to exploit its location in the community by extricating patients from their social context in the same way that institutional practice does. It has also been criticized as inefficient because patients tend to be seen individually, leading to lengthy wait lists and treatment delays. The clinic model perpetuates a “siloed” approach to care provision unless specific communication structures between disciplines are in place. The resources needed to operate an integrated rehabilitation clinic within a primary health care organization include therapists, clerical staff, office space, treatment space, and therapy equipment. Outreach Outreach services, as the term suggests, emanate from an institutional base and concentrate on providing professional services to people who could not access them in their usual institutional location. Specific approaches to outreach include mobile teams and satellite units. Outreach models often target remote or resource-poor locations, and attempt to simulate institutional service offerings without the infrastructure provided by the institution. Specialized outreach approaches in collaboration with primary care have been shown to improve health outcomes, provide more consistent care, and decrease the use of inpatient services. Our review identified 9 articles that evaluated the outreach model of integrated rehabilitation and primary care. The main advantage of the outreach approach is the availability of specific clinical expertise from the tertiary care setting and the subsequent potential for skill development in the primary care setting. The outreach therapist is perceived as an expert who contributes in a specific way to the care of a particular patient or group of patients. The disadvantage, however, is that this expertise is transient, and the opportunity for sustained development of skills and aptitudes for treating disabled patients may not exist. In other words, the care team may be integrated in how they provide care, but the team itself may not be integrated in the community. Another disadvantage is the complexity of institutional arrangements required to cover costs and potential liabilities associated with this arrangement. It is also, of course, dependent on the availability of tertiary care experts in the community. The resources needed to offer an outreach approach within a primary health care organization include expert therapists in the institutional setting, administrative arrangements between primary and tertiary care orga-

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nizations, office space, meeting space, therapy equipment, and transportation. Self-Management Self-management programs involve the systematic provision of education and support by health care staff to increase patients’ skill and confidence in managing their health problems. Self-management has been applied to a diverse range of chronic diseases including asthma, diabetes, stroke, congestive heart failure, and depression. Health promotion models are classified as self-management because of their emphasis on the centrality of the patient in the network of health decisionmaking, as are independent living models, because of the focus on the patient as consumer and coordinator of his/her own services. The scoping review identified 5 articles that dealt with a self-management perspective. They all identified a specific population to whom their services were targeted. Many involved self-referral, and all involved a self-directed approach to care. They also all involved linkages within a given geographic community between different levels of services, such as family physicians, home-based services, and community agencies. The primary advantage of the self-management approach is the extent to which it empowers patients to monitor and care for their own health. It also imparts new skills and information to patients, making them not only more confident but also more effective managers of their health. Therapists working from a self-management perspective may be colocated, or they may have a contractual relationship with the primary care setting to provide self-management education and support. In either case, formal communication mechanisms are essential to the success of this model. The self-management approach is entirely compatible with the rehabilitation philosophy of optimizing independence. The main disadvantage of this approach is that it is not acceptable to those who prefer to place their confidence in professional service providers—that is, patients who do not wish to or are not capable to take responsibility for their health, but rather prefer to operate within a model where providers assume responsibility. Another disadvantage is the front-end costs of producing educational materials that permit patients to be self-managers. The development of educational materials about primary care in general, and about specific conditions requires a significant up-front commitment of resources. The resources needed to offer a self-management approach within a primary health care organization include therapists, clerical staff, office space, meeting space, educational materials, and follow-up strategies. Community-Based Rehabilitation CBR was designed to deliver rehabilitation services in the developing world, where both material and human resources are scarce. It is based on a community development philosophy, whereby the role of rehabilitation professionals is to advocate for the issues of people with chronic diseases and disabilities and to assist in the mobilization of community resources and supports. CBR typically operates through nongovernmental community organizations, and professionals function as community development workers and are considered one of the resources available within the community to assist in problem solving. Our review identified 4 articles associated with CBR and primary health care. The chief advantage of the CBR approach is that it typically results in broader, more far-reaching effects Arch Phys Med Rehabil Vol 90, September 2009

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SCOPING REVIEW REHABILITATION AND PRIMARY CARE, McColl Table 1: Summary of Programs and Literature for Each Model Authors

Year

Clinic (16) Gans et al38

1993

Journal

Skargren and Oberg39 Roebroeck et al40 Rijken and Dekker41 Sicotte et al42

1998

Archives of Physical Medicine and Rehabilitation Pain

1998 1998 2002

Physical Therapy Clinical Rehabilitation Social Science and Medicine

Brown et al43

2003

Health & Social Care in the Community

Druss et al44

2003

New England Journal of Medicine

Pattinson45

2003

Health Service Journal

Beck et al46

1997

Gross et al47 Hansson et al48

2004 2004

Journal of the American Geriatrics Society Milbank Quarterly Clinical Rehabilitation

Stock et al49

2004

Asenlof et al50

2005

Journal of the American Geriatrics Society Physical Therapy

Von Korff et al51

2005

Pain

Nordeman et al52

2006

Clinical Journal of Pain

Luijsterburg et al53

2008

European Spine Journal

1996 1999

Outreach (9) Allen54 Lapierre55 Boult et al56

2001

Rothschild et al34

2003

Australian Journal of Rural Health Canadian Journal of Nursing Leadership Journal of the American Geriatrics Society Journal of Medical Systems

Hultberg et al26

2003

Health Policy

Lang et al57

2003

Spine

Hendriks et al58

2003

Physical Therapy

Pinnington et al59

2004

Family Practice

Gruen et al60

2004

Cochrane Library

Self-management (5) Worsfold et al61

1996

British Journal of General Practice

Wells-Federman62

2000

Glazier et al63

1996

Soegaard et al64

2006

Clinical Excellence for Nurse Practitioners Canadian Medical Association Journal (CMAJ) European Spine Journal

Moffett et al65

2006

Rheumatology

2000

Disability and Rehabilitation

CBR (4) Eldar66

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Program

Country

Model program in managed care setting

USA

Chiropractic and physiotherapy for back and neck pain in primary care Therapeutic ultrasound in soft tissue injury Physiotherapists work in primary care settings Interprofessional collaboration in community health centers Integrated, colocated health and social services including rehab Substitution of occupational therapy, physical therapy for medical services in primary care Call center in primary care setting for booking community physiotherapy Monthly contact with interdisciplinary team for high-utilization patients Program of All-Inclusive Care for the Elderly Balance training and vestibular rehab program in primary care Chronic Care Model—geriatric clinics including primary care Individually tailored programs for musculoskeletal pain in primary care Individualized physiotherapy and psychology program for chronic back pain Early access to physiotherapy in primary care setting General practitioner and physiotherapist for treatment of sciatica

Sweden Netherlands Netherlands Canada UK USA UK USA USA Sweden USA Sweden USA Sweden Netherlands

Mobile teams of allied health professionals Primary care nurse practitioner outreach to rehabilitation facility Geriatric Evaluation and Management interprofessional Communications technology links rehab specialists with primary care Rehab personnel from specialized units offered at community health centers Multidisciplinary rehab program associated with local primary care Single physiotherapy consultation before referral for rehab by primary care Physiotherapy back pain programs associated with health authority Review of specialist outreach models to primary care in remote settings

Australia Canada

Primary care physiotherapy for education and advice Self-management interventions in primary care for chronic pain Educational intervention for family physicians and patients with arthritis Videotaped exercise program with support group for spinal fusion Physiotherapy using cognitive-behavioral pain management

UK

Integration of regional rehabilitation services into primary care settings

Israel

USA USA Sweden UK Netherlands UK International

USA Canada Denmark UK

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SCOPING REVIEW REHABILITATION AND PRIMARY CARE, McColl Table 1 (Cont’d): Summary of Programs and Literature for Each Model Authors

Year

Journal

Program

Country

67

Kendall et al

2000

Disability and Rehabilitation

Kuipers et al68

2001

Australian Journal of Rural Health

2003

Asia-Pacific Journal of Public Health

2003

Health coaching for prevention of disability among seniors in community Occupational therapist as care coordinator in Older People’s Support Service

USA

2004

Journal of the American Geriatrics Society Nursing Standard

Shared Care (2) Gallagher70

1999

Clinical Journal of Pain

USA

Savard et al71

2003

NeuroRehabilitation

Support and consultation by pain specialists to network of family practices Tele-rehabilitation for specialty consultation to remote family practices

Lee14 Case Management (2) Holland et al10 Hudgell et al69

than could be achieved on a 1-to-1 basis. It results in the development of skills and capacities in the practice, in the disability community, and in the broader community. It raises the profile of disability issues and increases attention to the need to enhance accessibility and inclusiveness. However, these structural and attitudinal changes do not happen overnight—typically community development is a process that requires a commitment of time and energy over a sustained period. The resources needed to offer a CBR approach within a primary health care organization include therapists with community development skill and experience, information technology, office space, meeting space, liaison with community resources, and transportation. Case Management Another model for providing integrated primary health care and rehabilitation is case management. According to this model, a case manager, on the basis of a referral and intake assessment, marshals and coordinates the necessary services, including family medicine and rehabilitation services, either in the patient’s home or other community location. Case managers are usually specialized health professionals who act not within their usual scope of practice, but rather as coordinators, brokers, or liaisons. The scoping review identified 2 articles with a rehabilitation/primary care case management perspective. The focus was on complex, high-needs groups, such as those with severe disabilities, the frail elderly, or injured workers. It was observed that these are populations with special needs beyond standard primary care that required an advanced coordinating function. Case management has the advantage of tracking and coordinating multiple service providers and organizations. The effective use of case management reduces the number of visits to the primary care physician and instead links the patient with more appropriate service providers who can meet many of the social and functional needs of patients with complex conditions. It is efficient from the patient’s perspective because all services and communications are coordinated through one portal, and there is some assurance that information is being efficiently shared among those who need it. The disadvantage of the case management approach arises if various involved professionals do not acknowledge the case management role and do not cooperate by furnishing information in an accurate and timely fashion. The resources needed to offer a case management approach within a primary health care

CBR as a model for integrating rehab in primary care Engaging community in meeting health needs of rural disabled CBR programs coordinated with primary care

Australia Australia China

UK

USA

organization include therapists, clerical staff and information technology, office space, meeting space, liaison with community resources, and transportation. Both self-management and case management are components of a more general model of primary care termed chronic disease management, usually represented by the Wagner Chronic Care Model.4,21 Shared Care The final model for integrating rehabilitation with primary care is the “shared care” model. It originated in mental health, where a psychiatrist was paired with a family physician, either on a case-specific or a practice-wide basis.22 This model has also been implemented with chronic physical conditions such as diabetes and chronic obstructive pulmonary disease.23 Shared care typically refers to 2 providers with the same professional background, one a specialist and one a generalist. While the family physician plays the essential role of coordinating care, providing continuity and bringing a health promotion perspective, the specialist (in this case, a physiatrist) provides condition-specific expertise. One method for implementing a shared care approach is by the use of technology for teleconferencing, especially where family physicians collaborate with condition-specific experts at a distance.24 This approach is dependent on the availability of a suitable conferencing suite and a willingness of providers to adopt this technology, but also can be perceived by some as impersonal. There were 2 articles on shared care contained in the scoping review. These articles recognized the need for rehabilitation specialists to deal with disability-specific issues, while primary care physicians dealt with general health issues. It was suggested that a general shift in thinking was required from illness and diagnosis to function and dysfunction if optimal service was to be provided to people with chronic diseases and disabilities. The main advantage of the shared care model is the assurances it provides to the patient of communication and coordination between family physicians and specialists. Not only do clinicians involved in shared care gain information about a specific patient, but they also gain experience and knowledge that can be transferred to future patients with similar problems. Further, the shared care model promotes networking of physicians within a community, and a decreased sense of isolation for the family physician. Like all models of collaborative practice, however, it requires a commitment of time and reArch Phys Med Rehabil Vol 90, September 2009

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sources in excess of that required for the more autonomous style of practice. Often, this additional time is not directly compensable. The main disadvantage of this model is that it tends to be restricted to medical inputs. There was no analogous model found of specialist-generalist collaboration between therapists in the primary care and tertiary care settings. The resources required for shared care include tertiary care specialists willing to collaborate, communication mechanisms compatible to the style of practice of both physicians, space for joint clinics if applicable, and office space for the visiting specialist. DISCUSSION In summary, we undertook an extensive review of rehabilitation and primary care literature covering a 13-year period. Six models were identified for integrating rehabilitation and primary care services, to better serve the health needs of people with chronic diseases and disabilities. The most common models were clinic and outreach. Less common, but worthy of consideration were case management, self-management, shared care, and CBR. A number of themes were identified across models that may act as either supports or impediments to the integration of rehabilitation services into primary care settings.14,25 The key issue in successful integration appears to be the development of relationships between rehabilitation and primary care providers, 2 groups that seldom come into contact otherwise. For the most part, family physicians practice in a highly independent fashion, corresponding with other providers through written notes or reports as necessary.26 Rehabilitation, on the other hand, is by definition a team enterprise.27 Not only is the team approach unfamiliar in family medicine, the literature suggests it may be anathema to the culture of family medicine.28-30 The team approach has a number of advantages, including offering different types and degrees of expertise to patients, and generally offering more service and more perspectives on the problems patients face. However, teamwork tends to be perceived by medical practitioners as an inefficient deployment of their human resource.17,31 The time required to communicate and coordinate with other members of the team is time not spent in patient care, and time not compensated in many reimbursement models. Thus, to be successful, the integration of rehabilitation with primary care must be thought through from the perspective of efficiency, and justified as a means of enhancing rather than diminishing the efficiency of the medical workforce. The literature also states that interprofessional trust is essential to the success of collaborative relationships. Trust is particularly an issue among professionals who do not have a history of working together, and that issue is amplified by the burden of liability. While all health professionals expect to be trusted on the basis of their credentials, a personal relationship appears to be needed, whereby both parties come to know the professional needs, strengths, and limitations of the other and work toward a partnership. The development of this type of relationship takes time and patience, as well as faith in the notion that the potential payoff is real and worthwhile. Another factor underlying trust in interprofessional relationships appears to be a thorough knowledge of the role of the other, and some participation in the negotiation of roles. It is probably safe to say that neither rehabilitation professionals nor family physicians adequately understand the role and scope of the other. Thus, a process is needed during which expectations and assumptions are explored, and mutually satisfactory roles are arrived at. This requires that both professionals act as effective advocates for their own role, effective listeners for the Arch Phys Med Rehabil Vol 90, September 2009

other’s role, and reasonable partners in terms of accepting limitations and exploring options. Another issue related to integration that must be confronted if it is to be successfully addressed is the issue of leadership. To the extent that primary care is typically the host organization of these integrated models (because that is where patients go to seek care at the first point of contact), it stands to reason that there will be an expectation on the part of family physicians that they will be in a leadership role in any team that emerges in their setting.11,32 This may be a difficult issue for rehabilitation professionals to accept because they expect to function as equals with other members of the team; however, we suggest that there will be little progress on integration of rehabilitation into primary care unless this issue is resolved. One of the key elements to successful integration appears to be structured communication, whether through regular meetings or electronic media.14,27 Structured formal mechanisms of communication are essential for effective collaboration between rehabilitation and primary care professionals. Whether electronic or paper media are involved, a shared record containing all pertinent information is required.33 Another important issue in communication was associated with colocation of rehabilitation and primary care professionals, and the opportunity this afforded for informal communication and the subsequent development of interprofessional understanding and trust. Rothschild and Lapidos34 observed that in the absence of colocation of service providers, it was possible to construct a “virtual” team with electronic means, so that communication and shared decision-making could happen in a cost-efficient fashion. A number of articles referred to the importance of regularly scheduled meeting times, with a clear and explicit expectation that all providers would attend. Regular staff meetings provided a forum for airing and resolving issues, and reinforced the shared nature of decision-making in the organization. They also reinforced the administrative structure of the organization and the fact that administrative issues were the business of all, with authority for them typically vested in designated administrative staff rather than in the medical staff. Again, commitment of time to communication with other team members, with staff, or with administration must be seen to enhance the efficiency of the primary care enterprise.19 If physicians perceive that the additional burden of communication detracts from their ability to care for patients or to generate revenue for the practice, it will be resisted either actively or passively. It is clear from our deliberations that some methods of remuneration in primary care are more amenable to integrating rehabilitation services than others.35 For example, in both feefor-service and capitation models of physician compensation, revenues for the practice are generated on the basis of the volume of medical services rendered.36 Thus, for other providers to be included in the practice, resources have to literally come out of the physician’s pocket to compensate the rehabilitation professional. Under such circumstances, integration is a much more difficult case to make than it would be in a payment model where a global budget flowed to the primary care organization, and all providers and staff were compensated out of that budget.14,33 The exception to this is the shared care model, which has its own complexities associated with 2 physicians sharing authority and compensation for a single patient. The scoping review was limited by a number of constraints. Most importantly, the body of literature on integration of rehabilitation and primary care was decidedly small, despite covering 13 years of published and unpublished literature and an international scope of sources. Only 38 articles were found that met both the inclusion and exclusion criteria outlined above. Therefore, this must be considered an exploratory at-

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tempt to delineate models and a stimulus for further discussion of models of integration, rather than as a definitive and final exposé on the subject. Furthermore, very little was available within this body of literature on evaluation of the models. Another issue that cannot be resolved satisfactorily for all practices is the issue of accountability and control. Traditionally, physicians are accustomed to self-regulation and independence from administrative control, while rehabilitation professionals are used to working within an organizational structure where they report to an administrative head, who subsequently reports to a community board of governors. The integration of rehabilitation in primary care is best served by an administrative and governance structure that can be seen by all to make decisions in an impartial fashion, acting in the best interests of the organization as a whole and the population it is designed to serve. The final challenge to the integration of rehabilitation services into primary care is the necessity for rehabilitation professionals to plan and offer services on a population basis.14,37 Rehabilitation professionals are unaccustomed to managing a caseload of thousands of patients. To do so effectively, they will have to move beyond clinics and home visits where they see patients one at a time, to population-based programs and groups. Rehabilitation professionals are ill-prepared to think in terms of serving a caseload of 10,000, distributed among perhaps 5 family physicians, and yet this is the challenge that is before them if they wish to practice in primary care. To prepare rehabilitation professionals for the realities of the practice opportunities that exist for them in the primary care sector, educational programs must take seriously the challenge of training professionals to assess the needs of a population, to set priorities among competing needs, to analyze policy for indications of willingness to pay for specific services, to undertake case finding and care planning with other health professionals and assistants, to advocate and liaise with community resources for populations as well as patients, and to evaluate the effectiveness of interventions at a population level.27 CONCLUSIONS Despite the enumerated challenges, this review offers 6 ways in which those committed to the service of people with disabilities might relate to one another in a community primary health care setting. The default approach, and by far the most common, is the clinic approach. Although this approach is familiar to virtually all types of health professionals, it is only one way to promote the collaborative care that is so clearly advocated as the means to not only enhance the provision of primary care, but also to ensure that the most complex patients receive the services they need. Alternative models such as outreach, case management, self-management, and shared care also bring considerable benefits to patients, providers, and payers. Finally, CBR based on community development principles, advocacy, and consumer participation should also be considered as an alternative to professionally dominated models of integrated rehabilitation in primary care. References 1. Safran DG, Wilson IB, Rogers WH, Montgomery JE, Chang H. Primary care quality in the Medicare program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service Medicare. Arch Intern Med 2002; 162:757-65. 2. Iezzoni LI, Davis RB, Soukup J, O’Day B. Satisfaction with quality and access to health care among people with disabling conditions. Int J Qual Health Care 2002;14:369-81. 3. Beatty PW, Hagglund K, Neri MT, Dhont KR, Clark MJ, Hilton SA. Access to health care services among people with chronic or

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