Patient, Rheumatologist and Therapist Perspectives on the Implementation of an Allied Health Rheumatology Triage (AHRT) Initiative in Ontario Rheumatology Clinics

Figures & data

Table 1 Participant Characteristics

Participant			Total
Rheumatologists (n=6)	Clinical site	Community	4
		Hospital	2
	Sex/Gender	Male	3
		Female	3
Extended Role Practitioners (n=5)*	Clinical site*	Community	4
		Hospital	3
	Sex/Gender	Male	0
		Female	5
	Professional designation	Physiotherapist	3
		Occupational therapist	2
Patients (n=10)	Clinical site	Community	6
		Hospital	4
	Sex/Gender	Male	0
		Female	10
	Urgency of referral	Expedited	6
		Non-expedited	4
	Age	20–30 years	1
		31–40 years	1
		41–50 years	2
		51–60 years	3
		61–70 years	2
Unknown		1

Notes: *Two of the five ERPs worked within a triage role at more than one clinical site. Each site is presented individually to reflect seven separate ERP placements.

Table 2 Thematic Categories and Emerging Themes with Exemplar Quotes

Themes	Patients	Rheumatologists	Extended Role Practitioners (ERPs)
1) Motivation for Participation
Accessing earlier medical care	“Seeing somebody sooner meant if there was something serious that needed to be addressed, that it would get me into the doctor quicker” (Expedited 3).	N/A	N/A
Learning about condition and obtaining information	It gave me a little more information about my condition … it gives us some coping techniques until we see the rheumatologist” (Not Expedited 7).	N/A	N/A
Health system improvement	N/A	“We do have a very long wait time … if we can have a model of care that can help to reduce the wait times by whatever means, I think that will help to serve that patient population better” (Rheum 7).	“I wanted to be able to show that there are different ways to increase the efficacy of the system” (ERP 5).
Altruism	It helps if people take part in studies. I enjoy helping” (Expedited 2).	“I really wanted to help the patient, identify the patients with early inflammatory disease, because there’s a heavy burden trying to identify these patients and bring them in” (Rheum 1).	“One of the end goals for me was to work in a different role that serves clients with arthritis … frequently, people that end up on a wait list should have been assessed earlier, particularly with inflammatory arthritis” (ERP 3).
2) Perceived Impact and Value of Intervention
Reduced wait times to rheumatology care and treatment for those with IA	“The speed to get to the rheumatologist and getting my condition dealt with was the primary benefit, because otherwise I know I wouldn’t have gotten in to see the rheumatologist for a good 4–5 months” (Expedited 3).	“The therapist did a really great job of identifying early inflammatory arthritis, so those patients got seen much more quickly in an appropriate way. They weren’t languishing at home waiting to be seen, they were seen, worked up, and I could sail forward and get them started on their DMARDs early” (Rheum 3).	“People were seen within 2 weeks, where his previous wait time was 3 months, so I think it really reduced that period of time for people who were appropriate” (ERP 5).
Reduced wait times to care for those with non-IA	“She gave me some advice about stretching, and this and that, and some non-medical things to do to alleviate the pain, which was helpful” (Not Expedited 7).	“If they had non-inflammatory disease, there were more referrals to other arthritis stakeholders like occupational therapy, physiotherapy, sometimes social work, or education. It was fantastic. It was much better for the patient” (Rheum 1).	“They were getting treatment before the rheumatologist. The time to treatment was less than the time to rheumatologist for the non-urgent because they were being treated in some way, shape, or form” (ERP 5).
Improved clinical efficiency	“Blood work and x-rays were done in advance of seeing the doctor, which was a bonus because that cuts down the time. If you get in to see the doctor first and then they send you off for blood work and x-rays, then you have to wait again” (Not Expedited 8).	“I would normally see them and order investigations … everything was in order so I was able to initiate full treatment” (Rheum 6).	“If I do the triage, if I put everything in place, then the rheumatologist just needs a 15–20-minute appointment that we can squeeze in somewhere, rather than the normal 45-minute appointment” (ERP 6).
Improved quality of care	“Sometimes with a doctor or someone who’s a specialist, you feel like they’re on a time limit and they’ve got someone waiting. Whereas with her, she took the time to just go over things and didn’t leave anything not asked.” (Expedited 2).	“They have more time so there is more education and a real plan, a real sense of a plan. I see so many patients; I could give them a plan in 30 seconds or a minute, but [with the ERP] there’s a good 10-15-minute discussion about planning. Especially if it’s chronic pain … it was much different” (Rheum 1).	“Giving them a few helpful hints and some things to work on, even for the few weeks before they saw a doctor was helpful … it contributes to a higher quality of care” (ERP 5).
Earlier coping/management strategies	“She gave me some pointers like using different kinds of keyboards … she also provided me with sheets of exercises to do at work and at home to give more flexibility and strength” (Expedited 5).	N/A	“I was also able to provide them with some education about their condition … I was able to send them away with a few strategies. Sometimes I recommended various other interventions, whether it was referral … or just self-management techniques that they could use at home” (ERP 3).
Feeling listened to/heard	“I felt cared for. I walked out of there feeling heard and validated. I came out of there feeling like I mattered in the story” (Not Expedited 7).	“People are very pleased to be seen by somebody, and to have their concerns listened to and moved through the system” (Rheum 2).	“The patient feels that, ‘you know what, I am getting good care here. They do listen to me and I’m not just another number’” (ERP 4).
Reassurance	“She put my mind to rest” (Expedited 4).	“It bothers me that we have all these patients that end up waiting for months to see someone, and no one really knows how urgent they are or not. It makes me feel a lot more safe in terms of the quality of care we provide” (Rheum 5).	“By assessing them and knowing whether or not there was IA … I think it was reassuring to people” (ERP 5).
Professional satisfaction	N/A	“I was happier because I was able to see people who needed to be seen earlier, rather than seeing them in 6 months and thinking ‘oh my god, why didn’t I see this patient earlier?’ So that was a huge professional satisfaction” (Rheum 6).	N/A
Added value provided by ERP	“It gave me additional information, because I find sometimes in our medical world, the patient actually doesn’t get as much information as we think they get. I think there’s a lot of assumptions by our medical people that when they say something, we understand what they’re saying, and we don’t” (Not Expedited 7).	“I don’t see things through an OT perspective, so I think it’s also sort of like having a second opinion. She can provide advice that I’m not qualified to give that is more OT related … she can provide a lot of stuff that I can’t” (Rheum 5).	“Explaining the diagnosis or the differentials of what was suspected, explaining the purpose of the medication, sometimes explaining how certain symptoms were connected … Having the discussion about exercises, having the discussion about what’s safe for them to do or not do, resources, mentioning the Arthritis Society if it was appropriate” (ERP 2).
3) Facilitators/Barriers of Successful Implementation
Facilitators
Trust in the knowledge, skill, and judgement of ERP	“I felt confident to be in their hands. I knew I was in good hands, so it was a relief” (Expedited 5).	“You need to know your therapist and you need to have seen them in action a little bit so you have trust … so you know when they’ve seen them, you trust what they see” (Rheum 4).	“We had a comfort level with our inter-examiner reliability” (ERP 5).
Administrative support	N/A	N/A	“Without administrative support, it would have been a lot more stressful and disorganized. I think they are vital in keeping the clinic flowing” (ERP 2).
Regular communication/collaboration with clinical team	N/A	“I like working with other professionals … there is some co-learning that takes place.” (Rheum 3).	“There was actually time for dialogue at the end of clinics just to quickly touch base about anything interesting that came up … it helped to break some of the potential barriers because there was ongoing communication” (ERP 6).
Buy-in from clinical staff	N/A	“We gathered my colleagues as well as the secretaries up front, not just my secretary up front, and talked about the study and why it was important and introduced the therapist to everybody in the atmosphere. And then they all knew what was happening”(Rheum 3).	“It’s so important that you have support staff on board because they’re the gatekeepers really. If they don’t really understand what’s going on or appreciate it, you’re gonna run into problems” (ERP 4) “The group I don’t think were buying into this. I feel that maybe the group was not as keen having me there as a help because I was just in the way almost … I was not really working with the group and that’s why it didn’t work as well” (ERP 1).
Barriers
Unsupportive administrative staff	N/A	N/A	“The secretary was less than helpful with expediting the appointment. When I said, I needed an appointment in 2 weeks, she laughed … I’m not sure that there was good communication, perhaps, from the rheumatologist to his staff that this [intervention] is important” (ERP 5).
Insufficient clinical space for ERP	N/A	“We did have an awkwardness around space … if we had more space it would have been great, but we didn’t … if the therapist needed this clinic room to do the physical examination, I would go for a few minutes, she would do her thing, and then I would come back” (Rheum 3).	“Hospitals are very busy. Trying to get a separate room for me to do my assessments was a challenge, so what we chose to do was book it at a time, a Friday afternoon, that typically, the clinics weren’t as busy” (ERP 3).
4) Recommendations for Program Improvement and Future Implementation
Modification/expansion of therapist role for stable patient follow-up	N/A	“These therapists are trained to do history and physical and think about labs and x-rays, and they could see new patients and go over them with me as a resident does, in my practice. They could also see the stable IA patients with me, see them in the next room and report back on how they’re doing. That would improve efficiencies and would open up time in our clinic for new patients … They could advise to the rehabilitation program the patient needs” (Rheum 3).	“We could be seeing follow-ups independently. So, the rheumatologist wouldn’t necessarily have to see their follow-ups so frequently … it opens up time, it increases their capacity to see more people” (ERP 5).
Long-term placement of ERP in rheumatology care	“I think it would be a good program to institute … let people that really need it see somebody first” (Expedited 6).	“It’s much faster for me to go forward. I just think we would deliver the right care to the right person at the right time if we had this as a permanent part of our practice … Instead of therapists running around the community, this group of highly-trained therapists would be used better where there is a concentration of patients”(Rheum 3).	“In the rheumatologist office, I had medical directives, I had access to the system, so I saw the person, I made it happen and it was complete within an hour … being in the office with the rheumatologists is for me, much more efficient” (ERP 6).
Placement of ERP in primary care rather than specialty care	N/A	“Rather than make the referral to the rheumatologist, they [GPs] could make the referral to the therapist [ERP] who screens the person, and then have the referral come to the rheumatologist if they think it’s appropriate, which might weed out some of the people who don’t actually need to be seen” (Rheum 4).	“the ideal place for ACPAC would be in a family health team in GP offices, where we could do exactly the same, and then expedite the referral to rheumatology with all the findings” (ERP 7).
Communicate purpose of intervention to secretary/clinical team	N/A	“We gathered my colleagues as well as the secretaries up front, not just my secretary up front, and talked about the study and why it was important and introduced the therapist to everybody in the atmosphere. And then they all knew what was happening” (Rheum 3).	“Pull in the secretary, pull in the rheumatologist, and have a conversation so the rheumatologist can express to the receptionist how important it is” (ERP 5).
Ability to see/contact therapist after assessment and/or between routine rheumatology appointments	“It would be nice if we could have, in between those six months, maybe another visit with the physiotherapist, or the possibility of asking questions over the phone” (Expedited 2).	N/A	“We may see someone and we’re just not sure … until I see some initial blood work, I can’t even really triage them … So, having some flexibility with how many appointments a therapist can book with a patient before they see a specialist” (ERP 4).

Abbreviations: ACPAC, Advanced Clinician Practitioners in Arthritis Care; DMARD, Disease-Modifying Anti-Rheumatic Drug; ERP, Extended Role Practitioner; GP, General Practitioner; IA, Inflammatory Arthritis; OT, Occupational Therapist; Rheum, Rheumatologist.