Good Practice: Multiple Roles in the Health-care System
June 30, 2020
Many Alberta physiotherapists are trained or have a background in more than one area of health or wellness. It is not uncommon for physiotherapists to utilize a background in kinesiology to offer personal training sessions or for a physiotherapist who uses yoga in practice to also teach yoga classes in the community. Although less common, physiotherapists may also be registered with more than one health regulatory college. Examples of dually registered practitioners include physiotherapists who are registrants of both Physiotherapy Alberta and the Chiropractic or Acupuncture Colleges as well. While having more than one skill set may expand the services offered to patients, providing several treatment options in one place with one practitioner, it also presents challenges that physiotherapists must address.
What does the Standard say?
The Dual Registration Standard of Practice states that a member “who is also registered as a member of another regulated health profession in Alberta administers each health service as a separate and distinct entity and informs the client of their role when providing each distinct health-care service.”1 Clients can expect that “the physiotherapist clearly identifies the role and service that they are providing at the time of client care delivery.”1 Although this standard specifically relates to physiotherapists registered with more than one regulatory college, the principles can also be applied when physiotherapists offer additional health and wellness services (e.g., personal training, yoga instruction).
The standard also requires physiotherapists to provide the services the patient sought when they requested care. If a service requested is not in the patient’s interest, and the physiotherapist can offer a different one, they need to have a discussion about changing treatment approaches, explaining why an alternate treatment approach is a better option for and in the interests of the patient, and obtain patient consent to change treatment approaches. The physiotherapist must document the decision in the treatment record.
A physiotherapist cannot flip flop between roles depending on what is convenient. All parties (the physiotherapist, client and payer) need to be clear what hat you are wearing, what skills/services you are providing, and when it is or is not physiotherapy.
In the context of COVID-19, it is also important for registrants offering other services in addition to physiotherapy, and those who are dually registered, to be aware of restrictions on their non-physiotherapy practice. For example, although physiotherapists were allowed to resume in-person services without restrictions in advance of Stage 1, acupuncturists were not allowed to resume services until Stage 2 of Alberta’s relaunch on June 12th.
What are the issues?
Physiotherapy Alberta fields many questions related to this topic from members, payers and the public. These boil down to two key issues: what services are considered physiotherapy, and when can the service be billed as physiotherapy? Members planning to provide more than physiotherapy service may also have questions on how to set up their business or practice appropriately to ensure they comply with applicable legislation and the Standards of Practice.
The risk when providing care under multiple roles is that the line between what is or is not physiotherapy can become blurry leading to confusion and misunderstanding by the public about the profession and what we do. For example:
When is an exercise intervention part of a physiotherapy treatment plan and when is it a personal training session or community exercise class?
When is a dually registered clinician using acupuncture as a physiotherapy treatment and when is it acupuncture by an acupuncturist? What makes it physiotherapy?
Each physiotherapist must identify when they are providing physiotherapy services and when they are providing another service. Although physiotherapists can use elements of Pilates, yoga, or acupuncture in their treatment plans, what makes this physiotherapy is the fact that the Standards of Practice have been followed and the physiotherapist has conducted a physiotherapy assessment, identified problems amenable to physiotherapy treatment, provided treatment and documented the services provided. If a physiotherapist is instructing Pilates or yoga classes without completing these steps, they are not providing physiotherapy. They cannot advertise this as physiotherapy, identify themselves as a physiotherapist when delivering these services, or bill the sessions as physiotherapy. Similarly, when a physiotherapist uses acupuncture as part of their physiotherapy treatment plan, this is billed as a physiotherapy service. They cannot bill for acupuncture as a stand-alone intervention or access third-party funding designated for acupuncture. Only registered acupuncturists can do this.
What other standards must be considered?
Advertising: The Advertising Standard relates to the advertising or marketing of physiotherapy services. Members must be aware of what can and cannot be said or implied when advertising or marketing their physiotherapy services. Each regulatory college has different standards and rules related to advertising, while non-regulated health-care or wellness service providers are not subject to Standards of Practice. Know the rules and advertise different services separately and appropriately.
Fees and Billing: Physiotherapists must ensure that fees charged for physiotherapy services are transparent, accurate, and clearly communicated to clients and payers.4 Physiotherapists also have a responsibility to ensure any billing done under his/her registration number is correct. If you are providing services under your title as a physiotherapist, you bill for physiotherapy. Likewise, if you are providing services as a chiropractor or acupuncturist bills and invoices for these services must not be issued under your physiotherapy registration number.
Conflict of Interest: Members are required to “identify and avoid, or manage any real, potential, or perceived conflicts of interest.”2 Services must be delivered in the clients’ best interest and physiotherapists must ensure that their professional judgement is not influenced or compromised by non-clinical factors. Physiotherapists who provide health-care services as different practitioners must be aware of the risk of determining the course of treatment and providing services based on reasons other than the clients’ needs.
Use of Title: Regulated professions are granted the right to use titles protected under the Health Professions Act. If a practitioner is registered with two regulated health professions, they must ensure they use the appropriate title when advertising their services, identifying themselves to patients, or billing for services rendered. If a practitioner is providing services that are not physiotherapy, such as personal training or massage, they must not use the protected title when doing so.
Consider this scenario: A patient has been seeing their physiotherapist and has been doing weight training as part of their physiotherapy treatment for low back pain. The patient is ready for discharge from physiotherapy but wants to continue to work out with their physiotherapist who also provides personal training at the gym in their off-hours. The client wants to access unused extended health benefits for physiotherapy to pay for these services.
Is this physiotherapy? Given that physiotherapists deliver “only services that are clinically indicated for clients” if the physiotherapist has determined that the patient is ready for discharge, continuing to access physiotherapy funding for personal training services, or using professional title while doing so is inappropriate. It may also constitute a conflict of interest if their choice to do so is based on the physiotherapist’s financial interest rather than clinical need.
Performance of restricted activities: The authorization to perform restricted activities identified by the Government Organization Act (GOA) differs across professions. A physiotherapist who is dually registered must ensure that they are aware of the restricted activities they are authorized to provide under each College. For example, a physiotherapist may be authorized to perform spinal manipulations, order diagnostic imaging (DI), or use needles in practice when providing physiotherapy. However, when they are providing interventions as a member of a different regulated health profession, they may not have the same authorizations and, therefore, can’t perform the same activities.
Again, physiotherapists cannot flip flop between professions. If services are being provided as a member of a different College, the dually registered practitioner cannot suddenly decide they are working as a physiotherapist to order diagnostic images and then switch back once the task is complete.
Evidence-informed practice: Each profession is grounded in a specific philosophy of care and body of evidence. Sometimes there is overlap or similarities between professions but sometimes they are in conflict with each other. Physiotherapists are required to provide evidence-informed care. A practitioner must be clear in their own mind about which theories and evidence inform the interventions they are providing. This helps to ensure they are providing their patients with the evidence-informed care that is expected.
Why does this matter?
For the client: Clients need to understand what they are buying and where they can go in the event of a complaint or concern. They need to know when you are providing physiotherapy and when you are not. The therapeutic relationship is central to good practice and is built on transparent, clear communications. How can a client provide informed consent if they are not clear if physiotherapy or other services are being provided?
For third-party payers: The Fees and Billing Standard requires members to “provide clients with clear, transparent, accurate, and comprehensive invoices/receipts in a timely manner.”4 If a practitioner’s invoice fails to accurately and transparently reflect the services provided and the appropriate registration number of the provider, this could constitute billing fraud. Insurance providers have delisted individual physiotherapists or entire clinics if evidence of inappropriate or fraudulent billing is discovered.
For the physiotherapist: Physiotherapists must comply with the Standards of Practice, relevant legislation, and the Code of Ethical Conduct. Although there may be similarities between the Standards and legislation relevant to different Colleges, there are also differences. Members need to be clear which hat they are wearing and what the rules of practice are when delivering services as a dually registered health professional.
How should my dual practice be structured?
Separate your business processes and practices into distinct entities.
Scheduling: Allot distinct appointment days/time dedicated to each practice. Do not provide both in the same appointment. Inform the client when they are or are not receiving physiotherapy.
Maintaining client records: It is recommended that each set of treatment records be kept separately. If using a single record, ensure that documentation identifies which service you are providing, using the relevant protected title to identify yourself when completing your chart notes. If you are registered in two professions that are legislated under different privacy legislation make sure you understand your roles and responsibilities relevant to each.
Maintaining financial records/billing: Ensure your billing and invoices are issued separately and clearly identify the service provided. Do not bill for both services on the same invoice and keep financial records for each practice distinct from each other.
Be transparent. Communicate to all involved parties the differences in the practices, how you plan to manage any potential conflicts of interest and why you must separate the different services you provide. Clients need to provide informed consent when choosing which professional services they receive.
Report practice hours appropriately. Understand when you can record practice hours as a physiotherapist and when you are providing care outside physiotherapy. Ensure you keep accurate records of practice hours for each of your professional roles to allow transparent reporting to regulatory Colleges as required.
The primary role of self-regulated professions is to protect the public. Our clients need to understand what they are buying and where they can go in the event of a complaint or concern. They need to know when you are providing physiotherapy and when you are not. The key message to keep in mind is that, as professionals we must act with transparency and integrity in all professional and business practices.
Physiotherapy Alberta College + Association. Standards of Practice: Dual Registration. Available at https://www.physiotherapyalberta.ca/files/practice_standard_dual_registration.pdf.
Physiotherapy Alberta College + Association. Code of Ethical Conduct. Available at https://www.physiotherapyalberta.ca/files/code_of_ethical_conduct.pdf.
Physiotherapy Alberta College + Association. Standards of Practice: Fees and Billing. Available at https://www.physiotherapyalberta.ca/files/practice_standard_fees_and_billing.pdf.
Patient Safety. Every Person. Every Time.
Regulating Alberta's physiotherapy profession and acting as an association by providing member services.