The future is promising for allied health practitioners (AHPs) already in rheumatology and for those seeking to be part of the fraternity. In an age of healthcare where care will be increasingly more multidisciplinary and integrated, AHPs should play a growing role in the management of chronic rheumatic conditions. The biopsychosocial nature of chronic disease […]
The future is promising for allied health practitioners (AHPs) already in rheumatology and for those seeking to be part of the fraternity.
In an age of healthcare where care will be increasingly more multidisciplinary and integrated, AHPs should play a growing role in the management of chronic rheumatic conditions.
The biopsychosocial nature of chronic disease management too lends itself to a multidisciplinary approach. It is important to define the term “rheumatic” in this instance, as reference is made not just to inflammatory diseases but also osteoarthritis, osteoporosis and the plethora of degenerative musculoskeletal conditions.
Much has been said and written about our aging population and Australia’s increasing disease prevalence. A 2016 McKinsey report on health megatrends in Australia showed that chronic disease is the leading cause of illness and disability in Australia and its prevalence is the highest amongst OECD countries with musculoskeletal issues accounting for a significant proportion of health expenditure.
Despite these statistics, there are only 350 rheumatologists in the entire country.
Yes, 350! A shortage to say the least, but what’s worse is that there are even fewer AHPs who identify as having a special interest in rheumatology.
Professor Andrew Briggs, physiotherapist and NHMRC TRIP fellow, believes that health services “must look at alternative and cost effective workforce models”.
An example would be to consider changes in primary contact, triage and advance practice roles. He feels that allied health can play a leadership role. “AHPs are ideally placed to provide high-value care for many MSK conditions (with respect to) education, lifestyle, self-management, pain literacy, physical activity (and) behaviour change support, et cetera,” Professor Briggs says.
If you consider the landscape as described above, the opportunities for AHPs interested, and already in, rheumatology are immense.
WHY SO FEW AHPs IN RHEUMATOLOGY?
Firstly, education (or lack there of) of AHPs in the field of rheumatology is an obvious hurdle.
Professor Andrew Briggs, again, best sums it up:
“I think training in rheumatology (i.e. specific diseases like inflammatory arthritis, osteoporosis) is inadequately addressed in the undergraduate curriculum. We have data to show that trainees (and indeed clinicians) are not confident to manage these diseases and need more support in doing so when entering the workforce.
“In terms of other musculoskeletal pain conditions (non-specific low back pain, shoulder pain, and perhaps osteoarthritis), the training tends to be more comprehensive, but the problem is transition from ‘What care to provide (the knowledge) to the actual delivery of the right care in practice (the how).
“Many students, for example, have never developed a chronic disease management plan, and relying on guidelines alone does not adequately prepare them to effectively deal with the complexities of real world service delivery, like dealing with co- or multi-morbidity.
“Clinicians and students struggle particularly with the biospsychosocial model and understanding of pain neurobiology. For many, it contradicts what they were taught (and believe) whilst others understand the model but struggle to implement it in practice.
“Clinicians and students also struggle with value-based care in musculoskeletal health; (reflected in the difficulty) when determining for a given individual, what a high-value package of care would be and how to implement it.”
Secondly, poor funding models tend not to drive AHPs towards proper chronic disease management in primary care. At a maximum of five sessions per calendar year under Medicare’s chronic disease initiative, it would be difficult for any one specialty group to achieve decent patient outcomes, let alone sharing fivesessions amongst the range of eligible AHPs.
At the same time, the Medicare rebate for one of these sessions is just above $50 with patients regularly needing to pay a considerable gap. AHPs do really need to spend time with patients suffering with chronic diseases and often spend at least 30 minutes, or much longer, to have an effect, especially in the initial phases of management. Many patients too expect to be bulk billed, making allied health services less viable.
Rheumatologists are obvious leaders in their field. Imagine if more rheumatologists were passionate and advocated for a team of AHPs to help manage their patients, the result would be more interested rheumatology AHPs.
Stronger and contrasting relationships already exist in healthcare. The most obvious being between orthopaedic surgeons and physiotherapists, a relationship most likely cultivated in the hospital setting and then further fostered in primary care. There is no reason why this same bond can’t exist in rheumatology if the will is there.
To the credit of the Australian Rheumatology Association (ARA), they have pledged their support for non-medical rheumatology practitioners to be part of the ARA. The Rheumatology Health Professional Association (RHPA) membership in recent years has been dwindling and its existing members have renewed hope that one day all interested rheumatology practitioners can co-exist equally under the ARA with no particular medical and non-medical divide.
The ARA should be congratulated in taking this first step to making the above a reality.
HOW CAN THE FUTURE BE MORE THAN JUST PROMISING?
There is no magic bullet, but the following may just create the momentum needed:
• Greater advocacy to include more rheumatology training in AHP curriculum is essential at undergraduate and post graduate levels. This should create practitioners with greater confidence thus giving them more satisfaction when managing rheumatic patients. An initiative such as the “Rheumatoid Arthritis for Physiotherapists e-Learning” website (rap-el.com.au) is one step in the right direction. Another is the Australian Physiotherapy Association agreeing to include a rheumatology module in their post graduate spinal course.
• There is a bigger push for funding models to change. “Better value care” seems to be all the buzz at the moment and conservative allied healthcare is an important cog in providing such value. There seems a will to pilot more programs and trial more innovative models of care. If at the same time, public-private partnerships can rise above the bureaucracy, and the digital health revolution brings about the changes it promises, our rheumatic patients will be better off and allied health will definitely be part of the mix.
• The NDIS too gives some hope. Preventing further disability and improving the quality of life is why the NDIS was created. There is no mention of rheumatic disease in the guidelines but it doesn’t mean some of our patients can’t access funding for necessary allied health services. As our rheumatology patients learn to navigate the system and we share their stories amongst the community, increasing awareness of NDIS should lead to new opportunities for AHPs.
• Lastly, the opportunity is there for the existing rheumatology community to accept that AHPs belong in their family. Australian rheumatologists can take the lead and embrace the fact that their non-medical colleagues need their support, time and effort. In doing so, this greater acceptance will equate to better care and satisfaction for the entire rheumatology community.
Errol Lim is a sports physiotherapist with an interest in rheumatic disease. He sits on state and national committees at the Australian Physiotherapy Association and
is a director of the RHPA
