The Role of Physiotherapists on Family Health Teams: Understanding Active Interprofessional Team Members’ Perspectives 

 

Proposed submission to: Physiotherapy Canada 

Instructions for Authors: https://utpjournals.press/journals/ptc/journal/authors 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACKNOWLEDGEMENTS  

This research was completed in partial fulfillment of the requirements for a Master of Science in Physical Therapy degree at the University of Toronto. The authors would like to acknowledge the participants and the Department of Physical Therapy for their time and insight. 

ABSTRACT  

Purpose: The Ontario government created Family Health Teams (FHTs) in 2005 to increase access to healthcare and optimize patient-centered care and collaborative decision making. It remains unclear how effective this care model is for larger, socioeconomically and culturally diverse areas like Scarborough, Ontario. This study aimed to 1) understand administrators’ and practitioners’ perspectives on how FHTs are operating in this region, and 2) illuminate the current and potential roles of physiotherapists (PTs) within FHTs to address the diverse health needs of the Scarborough community.  

Methods: Participants were recruited by snowball and purposive sampling and completed semi-structured interviews. Qualitative data analysis involved dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analysis, and a knowledge translation and exchange plan.   

Results: Ten active members of Scarborough FHTs took part in this study, including both administrators and practitioners such as physicians, a nurse practitioner, a dietician and a PT. All participants noted that PTs would be beneficial to FHTs. Three overarching themes emerged from the data: 1) Ongoing challenges with FHT model Model of care Care2) Community-specific barriers to resource allocationResource Allocation, and 3) Competing Pperspectives on Ccollaboration, including both benefits and challenges.  

Conclusion: FHTs in underserved areas may benefit from greater awareness and integration of PTs to maximize the potential of this model of care. There also needs to be ongoing communication with governing bodies and frontline workers about the changing health needs of the community to improve resource allocation and funding. Additionally, increasing diversity within FHTs could better represent the cultural diversity of Scarborough residents. 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION 

Access to primary healthcare remains a significant challenge for Canadians, particularly in communities with diverse populations and complex health needs. Despite ongoing reforms, timely access to healthcare is often inadequate. In response, new models of care, such as Family Health Teams (FHTs) in Ontario, have emerged. FHTs are interdisciplinary teams aimed at increasing access to healthcare, optimizing care delivery, prioritizing patient-centered approaches, and enhancing collaborative decision-making among healthcare professionals, including physiotherapists (PTs).1 This team-based approach aims to better serve communities, especially those that have historically lacked resources.2  Understanding how team members may contribute is crucial to maximizing the potential of FHTs in meeting the evolving healthcare needs of all communities, and identifying the specific role(s) of PTs within FHTs remains unclear.  

The introduction of FHTs in 2005 by the Ontario Ministry of Health marked a significant shift in the Canadian healthcare landscape, which had been struggling with system backlogs, difficulties in managing caseloads, and widespread burnout among family physicians since the 1980s.1 These challenges led many family physicians to narrow their scope of practice and increasingly refer patients to specialists, making family medicine less attractive to new medical school graduates in Ontario. The FHT model, which operates on a capitation funding basis where clinicians are paid a fixed salary based on the number of patients they manage, contrasts with the traditional fee-for-service model that bills each patient interaction individually.3 This model was adapted in 2015 to include PTs, in an effort to further fostering expand patient-centered interdisciplinary care and allowing allied healthcare professionals to work to their full potential in a team environment with a focus on person-centered care.1  

This interdisciplinary model includes a wide range of healthcare professionals working collaboratively.1,2 FHT team members include a diverse array of clinicians and allied health workers, such as family physicians, nurse practitioners, dietitians, social workers, and pharmacists, as well as administrators. This includes executveexecutive directors, and board members at in community- goverened FHT’s. These administrators play crucial roles in ensuring the smooth operation and strategic direction of the teams.4 They manage non-clinical aspects of the organization, provide governance and oversight, ensure the FHT aligns with its mission, and maintain financial health. By securing funding, managing budgets, and allocating resources, they enable cohesive and effective service delivery that supports comprehensive care that is both accessible and adjustable to meet different population needs.4 

Compared to other primary care models in Ontario, such as Community Health Centres (CHCs), FHTs tend to serve a limited demographic. The geographic location of FHTs, which are predominantly located in suburban and wealthier urban neighborhoods, combined with capitation-based funding models, may inadvertently restrict the reach of their services to more socioeconomically disadvantaged populations. For instance, a 2022 review by the Association of Family Health Teams of Ontario (AFHTO) found that Scarborough had the highest percentage of patients unattached to FHTs than any other region in the Greater Toronto area. Also, a descriptive study of Ontario primary care models by McLeod et al. revealed variations in group size, payment details, and service provisions across different models. Physicians in capitation models tend to have smaller patient rosters than those in fee-for-service models, meaning proportionate FHT access in a fast-growing community like Scarborough may be inadequate. Additionally, a study exploring the influence of Ontario primary care models on patient selection and physician behavior highlighted the tendency of physicians in capitation models to roster a greater proportion of patients who are younger, healthier, and require fewer regular visits compared to fee-for-service models. In contrast, CHCs are mandated to provide care to populations facing barriers to healthcare access, including seniors, refugees, new immigrants, and members of lower-income households. Their programs are funded by various ministries and levels of government, and they do not require rostering, positioning them to address the specific needs of vulnerable communities through these programs. It is therefore evident that CHCs, which utilize salaried funding models that do not rely on patient enrolment numbers, are better equipped to serve marginalized populations in contrast to capitation models which indirectly incentivize care in healthier and wealthier geographic areas where patients are more likely to enrol and maintain straightforward continuity. 

However, compared to other primary care models in Ontario, FHTs tend to serve wealthier and healthier populations, with the majority located outside large urban areas and serving communities with a small proportion of recent immigrants.5 To date, the function of FHTs in communities with different socioeconomic statuses and diverse cultures has yet to be explored. Understanding how FHTs may address the health care needs of such communities is important for leveraging their full potential to enhance primary care for all. For instance, in immigrant-dense communities such as Scarborough, Ontario,6 where 74% are visible minorities and English is not the primary language for 50% of the community, social determinants of health such a diet and physical activity opportunities significantly impact health outcomes, leading to higher rates of community-specific health issues like diabetes.6-8 This is especially problematic when considering that over half of the residents in Scarborough earn less than $40,000 per household annually.6 It is also important to consider that Scarborough is a continuously growing community; there were approximately 8,000 new immigrants to the community from 2016 to 2021 alone.6  While FHTs are well-positioned to address such chronic diseases,5 it remains unclear how effectively this interdisciplinary approach is in meeting the unique health concerns of communities like Scarborough with different socioeconomic and cultural characteristics.  

These challenges highlight the need for interprofessional collaboration in primary care. Transitioning from a physician-centric model to a more collaborative approach within FHTs allows for parallel access and better utilization of allied healthcare professionals to meet the diverse needs of the healthcare system.8,9 This model is designed as an attempt to reduce the load on physicians by letting them focus on serious and life-threatening conditions, while allied health professionals such as PTs manage non-life-threatening and chronic conditions.10,11 Research also supports the integration of PTs into primary care settings, indicating it can enhance access to care, improve chronic disease management, and promote preventive healthcare.11,12 

This qualitative study seeks to gain a deeper understanding of the perspectives of health care practitioners and administers on how FHTs are functioning in less privileged communities such as Scarborough. We specifically sought: 1) to explore the perspectives of active members working within FHTs in Scarborough on how FHTs are currently addressing the most pressing healthcare needs in Scarborough; and 2) to identify potential roles of PTs in addressing Scarborough-specific healthcare needs and the factors (facilitators and barriers) influencing their integration into FHTs. 

METHODS 

Study Design  

This study employed a qualitative descriptive design, using individual semi-structured interviews to encourage elaborate descriptions of participants’ experiences and perceptions of primary care practitioners working within Scarborough FHTs (S-FHTs). This approach afforded us a deeper understanding of Scarborough’s unique sociocultural milieu and healthcare challenges. Ethics approval #00045346 was obtained by the Research Ethics Board at the University of Toronto. 

Recruitment  

Participant recruitment occurred between November 2023 and June 2024 and incorporated both purposive and snowball sampling.13 Given the study’s objectives, the inclusion criteria necessitated that participants were active members of a S-FHT and had access to the internet and a device compatible with Zoom teleconferencing software. We used the Toronto Service Directory to find FHTs within a 10-kilometre radius in Scarborough, and found six FHTs, We were able to successfully contact invited the executive directors of three S-FHTs, who then to forwarded  recruitment details to eligible participants via email and delivered recruitment posters to FHT sites. Interested candidates contacted the research team via email to schedule interviews.  

 

Data collection 

Interview Design: The research team developed and piloted an interview guide for the one-on-one semi-structured interviews. Interview questions were created based on a review of the current literature on FHTs and consisted of open-ended questions with probing questions as necessary. Questions were designed to generate data about participants’ experience in a FHT, the health needs in the community of Scarborough, and the current and potential role of PTs within a FHT. The interview guide was piloted with two participants who were familiar with FHTs but did not meet the inclusion criteria and were not part of the final sample. Feedback from the pilot included refining the phrasing of certain questions and adding probes to explore insights and personal experiences related to our research objectives more deeply. 
  
Interview Procedure: Participants were individually interviewed virtually via Zoom software by two designated student researchers. To maintain consistency,a single designated the same student researcher interviewed all participants, while another student researcher (in rotation) observed the interview, took field notes, and prompted the interviewer as necessary. Each interview lasted approximately 45 minutes on average. Additionally, all interviews were audio-recorded to subsequently allow for accurate transcription and analysis. After each interview, the interviewers wrote additional field notes to summarize key observations that were then shared with other team members. 

Data Analysis 

The interviews were automatically transcribed using Zoom software and reviewed by the research team for accuracy. Following the transcription process, we followed the DEPICT model for qualitative data analysis. This model allows for collaboration between research team members and equitable distribution of workload, thereby enhancing efficiency and incorporating diverse insights from all members of the research team.14 DEPICT involves six key steps including: dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analysis, and a knowledge translation and exchange plan to share the results.14 

The initial phase involved two team members being randomly assigned to each transcript, and their task was to engage in dynamic reading and develop field notes to identify and interpret patterns in participant responses. These insights formed the basis of developing an engaged draft codebook, where all team members shared ideas for categorizing data. This underwent further refinement through participatory coding, inclusive reviewing, and summarization of categories by the entire team. Participatory coding refers to assigning initial codes by team consensus, while inclusive reviewing in this context encompasses an iterative process of thoroughly refining and validating these codes to ensure they capture the richness and complexity of participants’ unique perspectives. Collaborative analysis then ensued to ensure the relevance of codes to our research objectives, culminating in a final codebook. Finally, an inductive thematic data analysis was applied iteratively to allow themes to emerge organically and ensure the transformed data closely aligned with participants’ experiences., resulting As a result, in the generation of three overarching themes, and each with their respective subthemes, were generated, after which the team discussed knowledge translation and an exchange plan to effectively disseminate the study’s findings. 

Reflexivity 

Reflexivity is essential for our study as it acknowledges our own beliefs, assumptions and preconceptions, and how they inform the research process. Our research team, composed of six PT students and two PT faculty advisors, inherently brought a specific perspective on the role of PTs in FHT settings. This professional lens, influenced by education and experience in healthcare, inevitably shaped our interpretations of the data. 

The diversity within the team further enriched the research process. Most members have lived in suburban areas, with one student researcher having spent their entire life in Scarborough and the suburbs, and another who has always lived in an urban environment. Both faculty advisors are from Toronto, with one specifically from Scarborough. These varied backgrounds and experiences provided a broad spectrum of insights but also introduced distinct biases and assumptions. 

To enhance reflexivity, we engaged in regular discussions during the data analysis phase focused on critically examining how our professional and personal backgrounds might influence their interpretation of the data, particularly in relation to advocating for the role of PTs in healthcare. By systematically reflecting on our own perspectives, we aimed to provide a more nuanced and comprehensive analysis, ensuring that their conclusions were well-rounded and credible. 

RESULTS 

Participant Demographics 

This study involved a cohort of 10 primary care practitioners and administrators currently working within the three S-FHTs, with a stratification of 2 board members recruited by the community, 3 executive directors, 2 physicians, 1 nurse practitioner, 1 dietician, and 1 PT. The participant pool reflects roughly 10% of the total workforce at each represented S-FHT location. Table 1 describes their roles and years on their respective FHTs. 

 

Overarching Themes 

Three overarching themes emerged from our analysis of interview data: 1) FHT Model of Care, 2) Resource Allocation, and 3) Competing Perspectives on Collaboration, with subthemes that elaborate on each of the themes.  

Theme 1: FHT Model of Care 

The FHT model in Ontario follows a salaried system rather than a fee-for-service model, offering both benefits and challenges as noted by study participants. Policies set at the provincial level often contend with the practical operations of FHTs, especially in diverse communities like Scarborough. This model ideally allows for more personalized care tailored to the demographic, although some practitioners see room for improvement. Four subthemes relating to the FHT model have been generated from participants’ opinions. 

 

1.1: Challenges in Aligning Ministry Goals with Community-Based Care Implementation  

As mentioned earlier, the goals of the Ontario Ministry of Health as part of their vision for FHT implementation include improving access to care, fostering interprofessional collaboration, and addressing community-specific health needs. The goal of a FHT is to provide interdisciplinary care to meet the specific health needs of the community, which includes parallel access to allied health services. Participants in this study identify the lack of collaborative care to be a disconnect between the Ministry’s goals and implementation of the S-FHT. One primary issue is the lack of standardized interprofessional collaboration. As one participant – an executive director (P2) – noted, "we have team meetings... we could establish patient rounds" to support better patient care, but there is no strategic plan mandated by the Ministry, leading to inconsistent models across different FHTs. This participant added, “in my executive director meetings, there are 14 FHTs coming to this meeting, and we all operate on a different model.” Additionally, funding constraints limit the ability to enhance collaborative efforts, with directives to "find it in your budget" despite already tight financial conditions (P2). Effective teamwork is crucial, as illustrated by successful collaborations with outside organizations like the Scarborough Centre for Healthy Communities, which have improved palliative care access through strong interprofessional relationships. However, within the FHT itself, the lack of resources, such as dedicated caseworkers, often places additional burdens on medical staff, highlighting the need for more comprehensive interprofessional teams to fully meet patient needs. Participants also identified a key issue in the stringent financial oversight by the Ministry of Health, which necessitates returning unused funds; for instance, funds allocated for the hiring of needed allied healthcare professionals. This is further complicated by uncertainty regarding the ideal composition of healthcare professionals to best meet Scarborough-specific needs, with a community board member expressing concern that “we haven’t seen evidence supporting the current mix of healthcare professionals in FHTs” (P5). Therefore, while there are pockets of success, broader structural support and adequate funding from the Ministry are essential for achieving the intended goals of community-based care through FHTs.  

  

1.2: Policy Focus 

Participants noted the hierarchical structure of FHTs and recommended a more streamlined and patient-centered funding approach to enhance care delivery. For instance, a board member expressed the need to reduce administrative burdens that detract from patient care. Another hurdle mentioned is the lack of Canadian data showing the impact of services such as physiotherapy on patient outcomes and healthcare costs. While there is international literature on the role of PT in primary care teams, the Ontarian healthcare system and landscape is unique. Without FHT-specific data justifying allocating resources for these services becomes difficult. As an example of this, an executive director stated, "To even create a [PT] position, I think Ontario Health would have to identify how many patients would benefit from physio, and right now our statistics aren't that great" (P9). This lack of data creates a challenge – FHTs need resources to collect data, but securing those resources requires data in the first place. According to a physician, a potential solution could involve the Ministry of Health allocating funding for pilot programs in high-risk areas. This participant suggested “let's try with one FHT or a couple of selected FHTs, where there is a high-risk population to give physical therapy and see whether that will change outcomes” (P10). These pilot programs could demonstrate the effectiveness of specific services like physiotherapy, providing the data needed for broader implementation.  

 

the recommendation here should be better collaboration across different models of primary care - at the Ministry level - to develop a formula for team composition, based on number of patients and their need 

  

1.3: Physician-Centric Model 

The current structure of Ontario's FHTs prioritizes physicians, centering care around them and their rostered patients. As one board member pointed out, "There’s a very common misconception in Ontario that family medicine and family physicians equals primary care. I'm a firm believer that that is just not true" (P5). This highlights the need to broaden the understanding of primary care to include various health professionals. Despite the potential of non-physician practitioners like PTs to reduce physicians' workloads and enhance patient care, they remain underutilized. A PT working in an S-FHT, for instance, shared that they feel they are working in a silo, despite their ability to carry a portion of a physician’s caseload pertaining to patients with mobility deficits. Moreover, an executive director remarked, "We have a lot of disciplines, and sometimes patients see one or two of those disciplines, but there's not a connection between the disciplines. It's like everybody is practicing in silos" (P8). This further emphasizes the necessity for better integration and collaboration among healthcare professionals. 

1.4: Perceived Effectiveness of the Current Model 

Many participants advocated for the FHT model, particularly the salaried structure, which allows healthcare practitioners to focus on delivering personalized care without the pressure of high patient turnover. One board member emphasized, "FHTs are better than the traditional [fee-for-service] model" due to faster patient access and the ability to address multiple health issues in one visit, which is crucial for chronic and vulnerable patients (P9). A PT added, "I can concentrate on my work because my payment isn't affected. You have a certain autonomy" (P6). There are important benefits to patients since they would not need to take extended leave from work to address different health concerns. From an allied health perspective, role autonomy and flexibility have notable influences on the current model's perceived effectiveness. A nurse practitioner echoed this sentiment, saying, "I don't feel limited in my FHT. I don't think I would change anything" (P1). 

  

Theme 2: Population Impact on Resources and Availability 

A goal of FHTs is to offer services that address the specific needs of their corresponding populations. However, high demand and diverse demographics place significant pressure on the limited resources available, affecting both the types of services provided and the quality of care. In S-FHTs, certain health issues are especially prevalent, leading to high demand for specific programs. According to one participant, an executive director, the primary areas of demand are "... mental health, seniors and the third one is diabetes and obesity" (P4). This focus is reflected in the tailored programs offered by FHTs. For example, another participant, a dietician, states, "We offer group programs and inpatient programs, gathering information on how many people come in with certain conditions and their discharge status" (P3). This approach aims to meet the community’s needs effectively, yet it highlights the challenge of catering to multiple high-demand areas simultaneously. Participants identified certain resource-related and community-related challenges that form the basis of two subthemes.  

2.1: Challenges with Resource Allocation 

FHTs strive to offer services addressing the specific needs of their population. However, high demand for community-specific services and diverse demographics put pressure on resources, affecting both the types of services provided and the quality of care delivered. Therefore, some services may be prioritized at the expense of others. An executive director discussed the difficulties in allocating the necessary resources to hire other allied health positions needed within their FHT while working within the funding allocation model of the Ministry, noting, "You can convert [an allied health] position into, say, a PT, but that's just like swapping one issue for another. How could I pull mental health workers out to fund a PT?" (P2). This highlights that due to limitations in funding, decisions about resource allocation often require difficult trade-offs, potentially compromising the availability and funding of other essential allied health services to meet specific needs. The challenge of balancing diverse population needs without neglecting critical areas is also highlighted by participants. Another executive director pointed out the strain on existing resources, stating, "There's such a high need, and some collaborative programs would benefit from a physiotherapist. We run diabetes education and weight management programs, but she's just stretched too thin" (P8). Even when the need for specific healthcare professionals is recognized, limited funding and high demand prevent optimal integration and utilization. Additionally, there is a noticeable pay discrepancy between FHTs and hospitals or private clinics. As an executive director mentioned, "It’s actually insulting what clinicians are making versus their counterparts in hospitals" (P2). This disparity can lead to staff retention issues and difficulties in recruiting new practitioners. 

  

2.2: Scarborough-Specific Barriers 

Meeting the diverse needs of a multicultural community like Scarborough remains challenging. A family physician highlighted these unique health challenges: "Scarborough residents... the biggest issue is with a new immigrant population, unemployment, poor socioeconomic background. Their health needs are much different—obesity, high blood pressure, diabetes, smoking" (P10). Integrating physiotherapy services into Scarborough FHTs is hindered by reliance on private funding challenges related to securing funding for these positions, and sometimes due to the reliance on private funding. , The as noted by the same family physician notes: "The challenge is that it's privately funded. You must have private insurance, which not every patient has" (P10). Language barriers further complicate care delivery, as this participant mentioned, "When it comes to staffing, there's a big language barrier. Most of our staff are fluent in English but not in other languages" (P10). The lack of funding for translation services exacerbates this issue. A board member remarked, "There's no money from the Ministry of Ontario Health to pay translators, so the language barrier is an issue" (P9). These barriers hinder effective communication and care delivery in a unique community with a high proportion of immigrants. 

Theme 3: Competing Perspectives on Interprofessional Collaboration in FHTs 

Interprofessional collaboration within FHTs is vital for comprehensive patient care and comes with unique opportunities. This collaborative approach involves diverse health professionals working together, drawing on each other’s expertise to address the multifaceted needs of patients. However, collaboration within FHTs is associated with its own set of challenges, and the dynamics of teamwork are influenced by structural, organizational, and interpersonal factors that can both facilitate and hinder effective collaboration. Two subthemes related to the complexities of interprofessional collaboration were identified, offering a nuanced perspective based on participant responses.  

 

3.1: Perceived Benefits of Interprofessional Collaboration 

Several key factors were identified as facilitators of effective interprofessional collaboration within FHTs. A critical element is the physical and organizational structure that promotes frequent and open communication. For instance, a nurse practitioner highlighted the importance of continuous interprofessional dialogue among healthcare professionals to ensure that complex patient issues are addressed using multiple insights and collective expertise. This ongoing exchange of knowledge facilitates tailored care delivery. 

 

Building a team culture based on mutual respect and open communication emerged as another crucial factor. An executive director emphasized, "For us, it's about open communication and transparency... and really building the team culture so that people feel comfortable" (P8). Creating an environment where team members feel valued and respected enhances collaboration and team cohesion. Similarly, some participants suggested that the proximity of diverse health professionals within the same physical space greatly influences collaboration, though this varied across different FHTs. A PT remarked, "This team I'm currently working with has everybody on site, and the convenience of communication and the regular meeting of every patient... it's very effective" (P6). The co-location of team members fosters a more integrated approach to patient care, ensuring that all aspects of a patient's health are considered. 

 

The shared Electronic Medical Record (EMR) system in some S-FHTs was also cited as a significant facilitator, enhancing transparency and continuity of care. As a family physician explained, these systems enable quick access to patient information and support coordinated decision-making, therefore improving efficiency and continuity in healthcare delivery.  

 

3.2: Perceived Challenges of Interprofessional Collaboration 

Alongside these facilitators, participants identified several barriers that impede optimal interprofessional collaboration. One significant barrier is the lack of physical co-location for all team members within the FHT, which can hinder effective communication and team building. A nurse practitioner pointed out, "In terms of team building, it would be nice to be in one place... rather than being so scattered. So that’s a bit challenging. You know, someone new might join the organization. You might not see them for a while before you first meet them" (P1). Despite working in the same FHT, team members are often dispersed when treating their patients, and maintaining cohesive communication becomes challenging. 

 

Despite their potential to facilitate seamless collaboration in patient care, the lack of a centralized EMR server in some FHTs also poses a barrier to efficient collaboration. A family physician noted, "Though they [allied healthcare professionals] use the same EMR, they are on a different server. That server is not talking to my server. So, I don't know what was told. Then, by the time the patient comes to see me, I have no clue what has been discussed. So that's the biggest challenge that we have" (P10). This discrepancy can lead to fragmented information flow and delays in patient care coordination, highlighting the need for a standardized system that enables access to necessary EMR data for all team members. 

 

Another barrier highlighted by participants is resource inefficiency due to overlapping scopes of practice among healthcare professionals within FHTs. When roles overlap, there is a risk of duplicated services and inefficient resource utilization. For instance, a dietician commented, “I don't know if it's the nurse or the nurse practitioners that often do diabetes care, and so they'll do like 3-month check-ins with patient... and we've chatted about this with our executive director as well, because I was just feeling like there's a little bit of overlap, and not the best use of resources that way. Because sometimes, someone has just been in for their 3-month check, and then I have an appointment with them, and it's kind of like doubling up on information” (P3). Clear role delineation is essential to optimize resource allocation and streamline patient care processes, minimizing redundancy and enhancing overall efficiency. 

 

A significant challenge identified is the varying levels of teamwork experience among physicians. An executive director believed that compared to other professions, physicians may lack the necessary skills for effective teamwork, which can hinder collaborative efforts and compromise patient care outcomes. Moreover, the prevalent culture of working independently among healthcare professionals poses another barrier to achieving true interdisciplinary collaboration. Shifting towards more integrated practices requires fostering a collaborative mindset across all disciplines within FHTs. 

DISCUSSION 

This study sought to understand the perspectives of health care practitioners and administers administrators on how FHTs are functioning in more diverse and less privileged communities such as Scarborough. Additionally, it explored the most pressing health needs of this population and the potential role of PTs in FHTs. Although FHTs were initially designed to enhance collaboration, interprofessionalism, and efficiency in primary care,2 our study participants expressed frustration with how this model of care may be falling short. Our findings suggest that professional hierarchies persist within S-FHTs, with opportunities for improving collaboration between governing bodies and interprofessional team members to better align decision-making with frontline realities. 

Implemented in 2005, FHTs were originally designed by the provincial government to ease the workload of family physicians using a specified formula to recruit primary care professionals.1,2 However, this formula does not initially did not include PTs, despite growing evidence that supports their value on interdisciplinary primary care teams..1,15 OngoingR research has highlighted the importance of PTs in managing individuals with chronic disease, providing comprehensive patient-centered care, improving patient outcomes, and enhancing the efficiency of care delivery.15 However, our study reveals that limited governmental support affects not only family physicians but also allied healthcare professionals. The persistence of unrealistic caseloads noted by members of S-FHTs in our study questions the effectiveness of FHTs in easing workload. In recent years, the formula for FHTs has been updated to include allied healthcare professionals, including PTs, yet there continues to be a disconnect between the integration of these roles and the necessary funding and resources to support their contributions effectively.15,21 

Despite the intentions to foster interdisciplinary collaboration within FHTs, our study shows that these teams remain very physician-centric, which impedes the potential benefits of a truly integrated healthcare model. Our results reveal a disproportionate reliance on physicians, with care often revolving around them. When physicians remain the primary gatekeepers for referrals to other healthcare professionals who can treat specific conditions, the efficiency of the FHT is negatively impacted, reducing access to essential services.10 In contrast, several global primary care models have successfully enhanced efficiency through innovative approaches. For example, Finland offers a viable model of interdisciplinary teamwork, where the initial patient assessment is often conducted over the phone by a nurse. The nurse then provides guidance on at-home care or schedules an appointment with the appropriate healthcare professional, such as a PT for musculoskeletal issues.16 With a similar goal of enhancing access to care, England introduced the concept of first-contact PTs. This system enables patients to access PT services directly without needing a physician referral.22 Implementing a similar approaches in Ontario's FHTs could alleviate the burden on physicians and optimize the utilization of allied health professionals like PTs who play a critical role in preventative care, particularly in managing chronic conditions prevalent in Scarborough's diverse community.6,15 By providing tailored exercise prescriptions and education, PTs can promote healthier lifestyles, reduce the risks of chronic conditions, and lessen the long-term burden on the healthcare system.15 This aligns with the goals of Ontario’s Ministry of Health, aiming to decrease physician workloads and enable more efficient, patient-centered care.1 

Our study findings also reveal divergent opinions among participants regarding the collaborative nature of S-FHTs. While some participants felt that the interdisciplinary approach improved care quality, many reported working in silos with physicians often at the centre, which led to scope of practice overlaps and inefficient use of clinician time and resources. For instance, when asked about potential FHT roles for PTs, few participants acknowledged their role in primary care, though many recognized their value in providing home-based care. This indicates a lack of awareness regarding the full scope of physiotherapy and its role in primary care, including the management of chronic conditions. This may be influenced by the diverse years of experience and different care settings among healthcare professionals. Those who have worked longer within a single FHT might perceive the collaborative efforts differently compared to those with varied experiences across multiple settings. This raises an important question: why is there a gap between the intended goals and the actual operations of FHTs? Future research could explore this discrepancy further, examining how professional hierarchies, communication barriers, and varying levels of experience impact the effectiveness of interdisciplinary collaboration within FHTs. Understanding these factors is crucial to bridging this gap and realizing the full potential of FHTs in providing comprehensive and efficient primary care.  

Participants frequently expressed concerns about insufficient funding for S-FHTs. Our study found that PTs on S-FHTs can have extremely long waitlists, indicating limited access to physiotherapy services and a need for more PTs in a primary care role. However, the significant pay disparity between FHTs and hospitals or private practices may hinder PT recruitment.17 In addition, all FHT decisions require government approval, and participants believed the inflexible funding model may impede reallocating funds even if roles become redundant. For instance, participants revealed that in their experience funds allocated for specific employee positions may not be reallocated for other positions even when different needs of the FHT emerge or change. This rigidity poses barriers to integrating PTs in FHTs. To address these issues, continuous communication between public health administration and frontline workers is essential for developing a more dynamic funding model that better meets the evolving and diverse needs of communities such as Scarborough. One solution could be adopting Alberta’s Primary Care Networks (PCNs) model, which allows flexible fund reallocation based on evolving needs and provides performance-based incentives to attract and retain healthcare professionals like PTs.18 

The need for robust evaluations to improve Ontario FHTs has been noted. Our study highlights the importance of metrics specifically designed to assess collaborative care, including the contributions of PTs.19 Embedding these metrics into EMRs can help track patient outcomes and gauge the effectiveness of interdisciplinary teams. However, participants in our study pointed out that some S-FHTs lack a centralized EMR system and do not regularly collect patient outcome data. This is particularly challenging in diverse communities like Scarborough, where varying health needs and cultural factors complicate data collection. We recommend implementing a unified EMR system across all S-FHTs to standardize data collection and enhance the tracking of clinical practices and outcomes. Working closely with the government and the Ministry of Health is essential for developing these systems and ensuring they capture the complexities of diverse communities. This collaboration will facilitate better data-driven decision-making, enhance communication, and ensure consistent quality improvement across all FHTs. Systematically collecting and analyzing this data will demonstrate the value of other allied health professionals such as PTs, optimizing their roles within FHTs and ultimately improving patient care.19 

Our study participants described the population in Scarborough as one with multiple and significant health needs, noting a high incidence of diabetes, heart disease, mental illness, homelessness, and an aging demographic. This is particularly relevant because these chronic diseases and social challenges require comprehensive, continuous, and accessible primary care services, which the current FHT model in Scarborough struggles to provide effectively. The high prevalence of these health issues underscores the necessity for an interdisciplinary approach to healthcare, which includes the integration of PTs to manage chronic conditions and promote preventative care.11,15 

Scarborough is notably home to many new Canadians, a significant portion of whom face marginalization and barriers to healthcare due to language difficulties and challenges navigating the Canadian healthcare system.7 These barriers highlight the importance of culturally competent care and the need for a diverse healthcare workforce that can address the unique needs of this community, which again necessitates a top-down restructuring of the current resource allocation policies upheld by the Ministry. The provincial government's recent announcement of a $3.1 billion agreement to improve healthcare in Ontario is significant because it presents an opportunity to address some of the structural and funding issues identified in our study.20 The agreement aims to enhance access to family physicians, reduce wait times, hire more primary care providers, and streamline quality care.20 Additionally, by supporting internationally trained healthcare providers to continue their practice in Canada, the plan could help mitigate the workforce shortages and enhance the diversity of healthcare professionals, which is particularly beneficial for multicultural populations like Scarborough's. 

Our findings contribute to the literature by providing empirical evidence on the specific health needs and systemic challenges faced by FHTs in a diverse and underserved community. They emphasize the need for integrated, multidisciplinary teams that include PTs to address chronic disease management and preventative care effectively. Furthermore, our study highlights the potential impact of targeted government funding and policy changes on improving the functionality and effectiveness of FHTs. These insights can inform future policies and practices aimed at optimizing primary care delivery in similar multicultural and high-need communities. 

Limitations 

We used a sample of 10 participants to gain insights into the perspectives of various FHT employees. However, we did not analyze power differentials among FHT members, which may have affected participants' openness. Future research should examine the views of team members from a broader range of FHTs to see if there are differences in opinions about roles and needs. Our findings may not be transferable to other primary care models and other FHTs across the province, as we focused on FHTs in a specific region of Ontario, which may differ in demographics, organizational structures, and healthcare policies. Future studies should replicate this research in diverse healthcare settings, including rural and urban areas with different funding and delivery systems, to assess the broader applicability of our findings. 

CONCLUSION 

PTs would be invaluable assets to any FHT. However, due to a lack of resources, specifically funding, and limited awareness of the role and value of PTs, significant barriers to their integration persist. While the FHT model of care is ideally suited to meet the needs of communities like Scarborough, their implementation has not been optimal. Improving healthcare delivery and outcomes may be best achieved by addressing the gap between policy and practice, optimizing resource allocation, fostering interprofessional collaboration, and incorporating PTs within FHTs. Future research should explore a wider variety of participants in FHTs across Ontario to explore how they function and leverage the potential role of PTs. 

 

 

 

 

 

 

 

REFERENCES 

Rosser WW, Colwill JM, Kasperski J, et al. Progress of Ontario’s Family Health Team model: a patient-centered medical home. Ann Fam Med. 2011;9:165-71. 

Family Health Teams. Ontario Ministry of Health. (2014, September 4). https://www.ontario.ca/page/family-health-teams 

Berenson RA, Rich EC. US approaches to physician payment: the deconstruction of primary care. J Gen Intern Med. 2010 Jun;25(6):613-8. doi: 10.1007/s11606-010-1295-z. PMID: 20467910; PMCID: PMC2869428. 

Association of Family Health Teams of Ontario. Executive Director Resource Toolkit. 2015. 

Glazier RH, Hutchison B, Kopp A. Comparison of Family Health Teams to Other Ontario Primary Care Models, 2004/05 to 2011/12. Toronto: Institute for Clinical Evaluative Sciences; 2015. 

Government of Canada, S. C. (2023, February 1). Census profile, 2021 Census of Population Profile Table. Profile table, Census Profile, 2021 Census of Population - Scarborough-Guildwood [Federal electoral district (2013 Representation Order)], Ontario.  

Annual Report 2022-23: We’re Just Getting Started. (2023). Scarborough Health Network. 

Toronto Public Health. Health Surveillance Indicators: Diabetes. 2017. 

Morley, L., & Cashell, A. (2017). Collaboration in Health Care. Journal of Medical Imaging and Radiation Sciences, 48(2), 207–216. https://doi.org/10.1016/j.jmir.2017.02.071 

Wasan KM, Berry L, Kalra J. Physician centric healthcare: is it time for a paradigm shift? J R Soc Med. 2017 Jul;110(7):295-296. doi: 10.1177/0141076817707337. Epub 2017 May 2. PMID: 28463065; PMCID: PMC5524259. 

Dufour, S. P., Brown, J., & Deborah Lucy, S. (2014). Integrating physiotherapists within primary health care teams: perspectives of family physicians and nurse practitioners. Journal of interprofessional care, 28(5), 460–465. https://doi.org/10.3109/13561820.2014.915210 

HealthStats. Evaluation of Physiotherapy Primary Healthcare Model in TCLHIN Community Health Centres. June 20, 2016. 

Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015 Sep;42(5):533-44. doi: 10.1007/s10488-013-0528-y. PMID: 24193818; PMCID: PMC4012002 

Flicker S, Nixon SA. The DEPICT model for participatory qualitative health promotion research analysis piloted in Canada, Zambia and South Africa. Health Promot Int. 2015;30:616-24. 

Maharaj S, Chung C, Dhugge I, Gayevski M, Muradyan A, McLeod KE, Smart A, Cott CA. Integrating Physiotherapists into Primary Health Care Organizations: The Physiotherapists' Perspective. Physiother Can. 2018;70(2):188-195. doi: 10.3138/ptc.2016-107.pc. PMID: 29755175; PMCID: PMC5938073. 

Shahaed, H., Glazier, R. H., Anderson, M., Barbazza, E., Bos, V. L. L. C., Saunes, I. S., Auvinen, J., Daneshvarfard, M., & Kiran, T. (2023). Primary care for all: Lessons for Canada from peer countries with high primary care attachment. CMAJ, 195(47), E1628–E1636. https://doi.org/10.1503/cmaj.221824 

Ontario Physiotherapy Association. (2018). Executive summary compensation report. https://opa.on.ca/wp-content/uploads/2019/03/2018-Executive-Summary-Compensation-Report-OPA.pdf 

Alberta Medical Association. (2014). Home. Alberta Medical Association. Retrieved from https://www.albertadoctors.org/ 

Sibbald, S., Selkirk, K., Cherla, A., & Misra, V. (2019). An opportunity for quality: The need for better evaluation of family health teams in Ontario. Healthcare Quarterly, 21(1), 28-31. https://doi.org/10.12927/hcq.2019.25744 

Government of Ontario. (Feb 2024). Cutting wait times, delivering better health care in Ontario. Retrieved from https://news.ontario.ca/en/release/1004174/cutting-wait-times-delivering-better-health-care-in-ontario 

Guide for Interprofessional Primary Care Teams: Interprofessional Health Care Providers Roles, Responsibilities, and Scopes of Practice 2023. (n.d.) 

NHS England. First contact physiotherapists. https://www.england.nhs.uk/gp/expanding-our-workforce/first-contact-physiotherapists/. (n.d.) 

  
Theme 3: There is an important overlap between the information covered in the barriers and facilitators. For
example, the proximity of the practitioners and the electronic medical record are mentioned as both barriers
and facilitators. The subthemes could be presented as broad categories of elements that may act as barriers
or facilitators, and under each sub-theme, the differing opinions of participants could be highlighted,
allowing for a clear presentation of the contrasting viewpoints.

Rewrite theme 3 to address the comments regarding overlap of information.