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MUMJ Allied 49

ALLIED HEALTH

Allied Professionals and Care: When Should Refer?

Jessica Hunter-Orange, BKin, BHSc Usha Ramanathan L. Kate McLachlin-McDermid, BHSc

ABSTRACT Since the advent of the Regulated Health Professions Act, RHPA (1991), 22 health care disciplines outside of have been regulated in the province of Ontario. Though it is important to recognize the valu- able contribution made by these disciplines to patient care, there are some that are encountered more often than others by physicians in both outpatient and inpatient settings. This article serves to explore the scope of practice, settings, educational requirements and responsibilities of four of these routinely consulted RHPA professions: physiotherapy, , speech-language and dietetics. Although does not fall under the RHPA, it is an invaluable and frequently encountered profession in allied health care, and thus has been included in this paper. The purpose of this article is to discuss the utility of these professionals within health care, provide a brief review of their roles, and to indicate when it is appropriate for primary healthcare physicians to refer.

INTRODUCTION Unfortunately, no current comparable literature exists. edical students, residents and licensed physicians are However, in April 2000, the Ontario Chairs of constantly striving to do what is best for by and the Council of Ontario University Programs in Mproviding optimal care in a timely, caring and evi- issued a statement that “some programs have tried to bring dence-based fashion. In many instances, the is limit- together students in their first year of professional training, but ed in what he or she can provide to patients and must rely on the difference between student profiles can prevent effective the , training and experiences of a wide variety of integration.”3 They also concluded that “the current practice allied health care professionals who make up the interdiscipli- system fragments the education of health care professionals and nary health care team (see Table 1).1 In order for physicians to does little to engender collaboration when students progress make appropriate allied health care referrals, they must have a into the working environment...students have never experi- solid understanding of the roles, responsibilities and scopes of enced the benefits of collaborative care.”3 practice of the various health care professionals available to With the increase in patient care complexity, the aging pop- their patients. ulation and lack of time and resources, physicians must become However, there is growing concern that cur- familiar with the various health professionals available to assist ricula lack appropriate education regarding the roles, responsi- them, but there has been much controversy as to when interdis- bilities and expertise of other health care professionals. In fact, ciplinary education should be introduced to the health profes- evidence from research done in the last 20 years has suggested sional. Hall and Weaver Ð researchers from the University of that interdisciplinary education within medical curricula is Ottawa with an interest in inter-professional education Ð sug- either weak or absent altogether.2,3 In 1982, a survey examin- gest there is no optimal time for interdisciplinary education to ing the incorporation of ‘inter-professional education’ in begin.4 Conversely, the Ontario Chairs of Family Medicine and Canadian and American medical curricula found that fewer the Council of Ontario University Programs in Nursing suggest than 30% of the 105 responding schools had incorporated for- that, “interdisciplinary education should be mandatory for all mal interdisciplinary training into their programs. Furthermore, professional education programs before practice.”3 In accor- only 15% of those training programs were mandatory.2 50 Allied Health Volume 2 No. 1, 2004

Table 1. The Professions in Ontario under the Regulated Health Professions Act (1991)

Health Profession Act Health Profession

Audiology and Speech-Language Pathology Act, 1991 Audiology and Speech-Language Pathology Chiropody Act, 1991 Chiropody and Act, 1991 Chiropractic Dental Hygiene Act, 1991 Dental Hygiene Dental Technology Act, 1991 Dental Technology Act, 1991 Dentistry Denturism Act, 1991 Denturism Dietetics Act, 1991 Dietetics Therapy Act, 1991 Massage Therapy Medical Laboratory Technology Act, 1991 Medical Laboratory Technology Medical Technology Act, 1991 Medical Radiation Technology Medicine Act, 1991 Medicine Midwifery Act, 1991 Midwifery Nursing Act, 1991 Nursing Occupational Therapy Act, 1991 Occupational Therapy Opticianry Act, 1991 Opticianry Act, 1991 Pharmacy Physiotherapy Act, 1991 Physiotherapy Psychology Act, 1991 Psychology Respiratory Therapy Act, 1991 Respiratory Therapy

Government of Ontario. (1991). RHPA Schedule 1: Self Governing Health Professions 1991. http://192.75.156.68/DBLaws/Statutes/English/91r18_e.htm#P459_36229 1 dance with this statement, one can assume that education early Canada was a Master’s level degree. By 2010, the Advisory on in a physician’s training will enhance that physician’s famil- Group predicts that Canadian universities will only offer phys- iarity with the allied health professions. Regardless of timing, iotherapy education at the Master’s level, and that this will knowledge and familiarity on the part of physicians of how become the required level of education for entry to practice.7 these professionals contribute to patient care are essential. This Once a degree has been obtained, the therapist must pass a set article will discuss the utility of five of the most commonly of national certification exams and register with the profes- encountered allied healthcare professionals; physiotherapy, sion’s provincial regulatory board, the College of occupational therapy, speech-language pathology, dietetics and Physiotherapists. Further, many physiotherapists participate in social work. It will also provide a brief review of their roles, as specialty-specific continuing education programs, once they are well as general guidelines suggesting when it may be appropri- registered, to improve their practice skills. ate for medical students, residents and practicing physicians to Physiotherapists may choose to practice in a variety of set- refer for consultation. tings, including clinical practice, academic research and profes- sional leadership. In reality, most physiotherapists practice in a OVERVIEW OF SELECTED ALLIED HEALTH clinical, patient-care setting often focusing on a specialty disci- PROFESSIONALS pline.6 The determine not only the setting, but also the demographics of the patient population as well. For Physiotherapists example, a physiotherapist working in respiratory therapy may Physiotherapists are registered health care professionals who work with children who have undergone lung transplant or are experts in movement and rehabilitation. The Physiotherapy older patients with chronic obstructive pulmonary Act (1991) states that physiotherapy practice is “the assessment (COPD). As such, a physiotherapist often works with patients of physical function and the treatment, rehabilitation and pre- of all ages and a variety of different .6 vention of physical dysfunction, injury or pain; to develop, Regardless of the specialty in which the physiotherapist maintain, rehabilitate or augment function; or to relieve pain.”5 chooses to work, the accompanying responsibilities are fairly Physiotherapy practice is generally focused on treating dys- standard. The therapist takes an appropriate history and performs function in three main body systems: the musculoskeletal sys- a physical examination. Following this, an assessment of the tem, the nervous system and the cardio-respiratory system. patient’s condition is made based on the physical examination More specifically, sub-disciplines in physiotherapy include and relevant laboratory tests. Finally, a plan and appropriate , burns, , , orthopedics, ergonom- treatment is initiated. Treatment options usually include electri- ics, and amputee rehabilitation.6 cal modalities, , manual therapies and education. By In order to practice physiotherapy in Canada, the therapist using these treatments, the physiotherapist’s role is to “improve must hold a university level Bachelor’s degree.7 However, quality of life through maximizing a patient’s movement and existing regulations regarding the required entry-level educa- functional ability.”6 Whether it is a child with cystic fibrosis tion are changing. In June 2001, the National Physiotherapy needing respiratory conditioning or a geriatric patient living with Advisory Group issued a statement expressing that the pre- arthritis, the physiotherapist facilitates independence and confi- ferred entry-level education for physiotherapy practice in dence in a patient’s ambulatory and functional abilities. MUMJ Allied Health 51

Physiotherapy is an autonomous profession, meaning that a "the treatment of physical and psychiatric conditions through patient usually does not require a physician’s referral in order to specific activities to help people reach their maximum level of be treated by a physiotherapist. However, there are some cases function and independence in all aspects of daily life."13 when a physician’s referral is necessary; for instance, if the In order to practice as an OT in Canada, one must have patient is in or is being treated in an OHIP-funded out- graduated from either an occupational therapy educational pro- patient .6 Regardless of how a referral should take place, gram accredited by the Canadian Association of Occupational physicians should be encouraged to consult a physiotherapist Therapists (CAOT), or a non-Canadian occupational therapy when they believe a patient may benefit from their services (see educational program recognized by the World Federation of Table 2). Occupational Therapists. Candidates must also successfully Due to the diverse nature of physiotherapy practice, it is pass the CAOT Certification Examination upon graduation. impractical and beyond the scope of this paper to summarize Most university programs across Canada are now at a Master's the effectiveness of each area of physiotherapy practice. The level, requiring an honours undergraduate degree from any dis- Cochrane Collaboration has published a number of meta-analy- cipline with some prerequisites, prior to commencing a Master ses clearly outlining the effectiveness of physiotherapy as a of in Occupational Therapy. As of 2008, CAOT has beneficial adjunct to in a wide variety of patient mandated Masters level entry for all new graduates.14 populations such as those with cystic fibrosis, cerebral vascular Occupational therapists work in a wide variety of settings, accidents, stress incontinence as well as a variety of muscu- with patients of all ages and abilities. In , schools, out- loskeletal disorders.8,9,10 Physiotherapy has been shown to be patient and treatment centres, private practices, long- effective in clearing lung secretions, improving independence term care facilities, community-based settings and industry, in activities of daily living, as well as reducing stress inconti- OTs use a “variety of assessment and treatment techniques to nence in the aforementioned populations. Although physiother- address goals developed with the client.”11 OTs are concerned apy as a profession is grounded in evidence-based practice, with the ‘occupation of all individuals in society’ and use the more methodologically sound data is required to demonstrate term ‘occupation’ to refer to the activities one does on a daily the unequivocal value of the various physiotherapy specialties. basis,12 whether that involves a premature, 30 week-old neonate in the NICU with feeding difficulties, a 76 year-old Table 2. When do I refer to a Physiotherapist (PT)? gentleman with Parkinson’s Disease who lives in a , or a 42 year-old administrative assistant with Carpal ¥ Restoration of muscle strength and joint mobility after injury, or neurological disease Tunnel Syndrome who is struggling to meet her deadlines. ¥ Education regarding pre-natal and post-natal care and activity ‘Occupation’ is what clearly guides occupational therapy prac- ¥ Pelvic floor strengthening for incontinence tice. Ultimately, the goals of assessment and treatment involve ¥ Mobilizing patients after periods of inactivity or de-conditioning maximizing occupation, overall function and improvement of ¥ Manual chest therapy to aid in secretion clearance in patients with lung 12 pathology such as pneumonia. quality of life of both individual and groups. Over the past ¥ Respiratory therapy to increase strength of respiratory muscles and several decades, the scope of practice of the OT has greatly increase ability to breathe in patients with chronic lung . expanded to provide a more valuable contribution to overall ¥ Education and exercise training for patients following cardiac diseases patient care (see Table 3). such as myocardial infarction in order to increase functional capacity. ¥ Movement and motor control re-education after , spinal cord injury or stroke. Table 3. When do I refer to an Occupational Therapist (OT)? ¥ Education regarding the use of mobility devices such as walkers, canes, ¥ Assessment and training regarding activities of daily living (ADLs) crutches and wheelchairs. (i.e., bathing, dressing, feeding) or instrumental activities of daily living ¥ Assessment of physical readiness for work or sports (IADLs) (ie. banking, groceries, driving) ¥ Osteoporosis prevention via exercise training ¥ Prescription of assistive devices to assist with ADL’s, IADL’s, walkers, ¥ Pain relief via modalities, exercise and mobilizations. wheelchairs Table adapted from the Ontario Physiotherapy Association (2004), ¥ Discharge planning for transition from hospital or care facility to home http://www.opa.on.ca 6 ¥ Prescription of mobility devices, such as walkers & wheelchairs ¥ Evaluation and modification to physical environments such as a client’s home, work or school ¥ Counseling regarding work and return to work issues and ergonomic Occupational Therapists assessments Occupational therapists (OTs) are registered health care pro- ¥ Design and fabrication of hand splints/foot orthoses fessionals who assist their patients in "developing or maintain- ¥ Issues regarding chronic medical conditions, which may have an impact on day-to-day function ing life roles and activities at home and in the community, when ¥ Psychosocial integration & life skills teaching in those with mental ill- one's ability to function independently has been challenged by ness or developmental delay accident, handicap, emotional problems, developmental diffi- ¥ Issues regarding positioning, feeding in infants and children culties or disease."11 Typically, the main areas of focus for OTs ¥ Assessment and treatment of children with school-related issues &/or developmental delay and their patients are self-care, productivity and leisure, with ¥ Cognitive and perceptual rehabilitation in acquired brain injuries emphasis on the interaction between the person, their environ- ment and their occupation.12 The World Federation of Occupational Therapy (WFOT) defines occupational therapy as 52 Allied Health Volume 2 No. 1, 2004

Occupational therapists worldwide are responding to the new approaches in the treatment of communication and need for evidence-based literature to evaluate outcomes of swallowing disorders.21 SLPs also play an important role in interventions they provide. The Cochrane Collaboration has the lives of those who are non-verbal through the develop- published numerous meta-analyses which have demonstrated ment and prescription of communication methods and the value, contribution and of occupational therapy devices. Due to the diverse nature of their clientele, from services to a variety of diverse populations ranging from those infants to the elderly, SLPs work in a variety of different set- with a condition, to those living with physical tings such as hospitals, child development centres, rehabili- and/or cognitive disabilities.15,16,17,18 There is a continuous tation centres, as well as home care and governmental agen- call for further methodologically sound research involving ran- cies.19,21,22 domized controlled trials in order to continue to evaluate spe- As evidenced by the speech-language pathologist’s scope cific occupational therapy interventions. of practice, there are many opportunities for physicians and physicians-in-training to integrate the services of SLPs into Speech-Language Pathologists the care of a patient (see Table 4). Children who are slow to The ability to convey thoughts and emotions is a crucial speak or patients with declining communicative abilities due aspect of human culture. A lack of proper attention to com- to a progressive neurological disease, for instance, can ben- munication as well as swallowing disorders can lead to seri- efit from the services of a speech-language pathologist. ous long-term consequences with respect to socialization, Additionally, patients with receptive (comprehension) or literacy, academic achievement, and overall development.19 expressive language difficulties can be referred to Speech-language pathologists (SLPs) work to alleviate these SLPs.19,21,22 SLPs can also provide care to address the problems in patients and comprise an integral part of the specific concerns of the individuals who are deaf or have allied healthcare team. The Audiology and Speech- developmental disabilities. By closely working with the Language Pathology Act (ASLPA) (1991) describes the patient’s school teacher(s), SLPs can help create appropriate scope of practice for speech-language pathology as the classroom programs. SLPs can also initiate voice restoration “assessment of speech and language functions; the treatment procedures, or introduce alternative forms of communica- and prevention of speech and language dysfunctions or dis- tion for the patient who has undergone a laryngectomy due orders; and the development, maintenance, rehabilitation or to .21 augmentation of oral motor or communicative functions.”20 In order to practice, speech-language pathologists must Table 4. When do I refer to a Speech-Language complete professional training at the Master’s or Doctoral Pathologist (SLP)? level. Following this, provincial certification requirements must be met. The College of Audiologists and Speech- ¥ Child with delayed language skills Language Pathologists of Ontario (CASLPO) has developed ¥ Child/adult with expressive or receptive communication difficulties ¥ Adult who has expressive and/or receptive disorders following a stroke a Quality Assurance Program ensuring that SLPs are regu- or other brain injury lated professionals who are held accountable to CASLPO. ¥ Child/adult who is hard-of-hearing or who may be deaf Further, it is mandated under the Regulated Health ¥ Persons with developmental or learning disabilities Professions Act (1991) and the Audiology and Speech- ¥ Persons requiring augmentative and alternative communication ¥ Child/adult who has a chronically , or who loses his/her Language Pathology Act (1991) that SLPs are required to voice for periods of time deliver safe, competent and ethical services.20 ¥ Child/adult with swallowing difficulties In general, a speech-language pathologist diagnoses and ¥ Persons/community groups etc. needing education on coping with com- treats ‘communication disorders’, a term encompassing munication and swallowing disorders speech, language, voice, fluency, hearing, and cognitive- Table adapted from Canadian Association of Speech-Language Pathologists and communicative disorders.19 SLPs assess language disorders Audiologists (2004). http://www.caslpa.ca22 with the goal of improving the individual’s ability to under- stand as well as convey messages, both oral and written. It is evident that SLPs can contribute greatly to the scope With other professionals such as OTs, speech-language of care offered by the allied health care team. To further pathologists assess and treat cognitive-communication dis- establish the necessity for including SLPs in the care and orders. This involves helping patients improve reasoning, management of patient, there are ongoing evidence-based problem solving, memory and organizational skills so that evaluations of speech and language therapy interventions. the individual is able to interact in social situations. SLPs Recently, a study by Law et al (2003) examined the efficacy can also improve articulation and fluency in those who stut- of speech-language interventions for children with primary ter, and with respect to dysphagia, the SLP assesses whether speech language delays and disorders.23 This meta-analysis a person is at risk for choking or aspiration.19,21 Overall, revealed that the interventions resulted in a positive effect SLPs are responsible for providing counseling to patients for those with expressive language difficulties. Other about their condition, as well as how to best cope with it. researchers are currently investigating the efficacy of direct From a research standpoint, speech-language pathologists speech and language interventions aimed at improving com- have the opportunity to participate in the development of munication skills of children with cerebral palsy.24 Thus, MUMJ Allied Health 53 the results of these and other studies should encourage fession to patient care. In 1998, the ADA formed a Health physicians to include SLPs in the care of patients who have Services Research Task Force to examine both the effective- language and communication issues. ness and outcomes of medical nutrition therapy provided by registered dietitians. Much literature has been published, Registered Dieticians however “inadequate specification of the nutrition care Registered dietitians are allied health care professionals process and the lack of common definitions for nutrition who are “highly educated in the related to care and its outcomes” have been major barriers.29 In the and human nutrition and are trained to apply their knowl- Journal of the American Dietetics Association, Ron Smith a edge in a variety of settings.”25 More specifically, the registered dietitian, states that “anecdotal summaries of Dietetics Act (1991) clearly defines the scope of practice of patients' responses to medical nutrition therapy are no longer the registered dietician as, "the assessment of nutrition and sufficient to justify the benefit. Everyone understands that a nutritional conditions and the treatment and prevention of proper diet is critical to good health.”27 The development of nutrition-related disorders by nutritional means."26 The a model for effective nutrition care has been put forth with American Dietetics Association (ADA) refers to the servic- the aim of “linking nutrition care to positive outcomes”.29 es provided by a registered dietician as medical nutrition Currently, the profession is working on demonstrating and therapy.27 justifying that registered dietitians are the best providers of In order to practice as a registered dietitian (RD), one medical nutrition, that services provided by RDs improve needs to successfully complete an undergraduate university the quality of life of patients, and that RD services are cost program in and nutrition followed by an accredited efficient.27 internship of at least 35 weeks in duration.25 Following for- mal education and internship, RDs must pass a competency Table 5. When do I refer to a Registered Dietician (RD)? exam in order to practice in Canada. As with other regulat- ¥ Assessment and treatment of nutrition and nutrition-related conditions ed healthcare professions, only those who are registered ¥ Ideal body weight recommendations with the College of Dietitians of Ontario can use the titles ¥ Caloric and dietary needs advice Dietitian, Registered Dietitian, or other abbreviations. The ¥ Recommendations of foods that facilitate swallowing title ‘Nutritionist’ is not a protected title by Ontario law; ¥ Need for special diets (i.e. renal, cardiac and diabetic patients) ¥ Specific dietary modifications that need to be made as a result of a dis- therefore only those who use the designation ‘Registered ability or general medical condition Dietitian’ are regulated and have achieved standards set ¥ Total Parenteral Nutrition (TPN) formulas and schedules for patients forth by the College of Dietitians of Ontario.25 who are unable to eat by mouth

Registered dietitians work in a wide variety of settings, Table adapted from the College of Dieticians of Ontario (2004), http://www.cdo.on.ca similar to other allied health care professionals. Registered & from the Dieticians of Canada (2004), http://www.dieticians.ca25,28 dietitians and physicians work closely together in the neona- tal intensive care units, nurseries, pediatrics, and both med- ical and surgical wards. RDs can commonly be found in hos- Social Workers pital wards, where their responsibilities center around the While it is difficult to define social work, the concepts ongoing assessment of an individual’s nutritional and meta- underlying social work are easier to explain. A key component bolic status through the monitoring of fluids, electrolytes of social work is the “person-in-environment” perspective, and overall health status. Premature neonates, individuals which highlights the need for the care of a person in the context with eating disorders, the elderly, and those with both acute and of environmental influences such as support networks, person- chronic diseases are a few of the patient groups who can bene- al beliefs, social customs and societal laws.30 The idea of a bi- fit from the services of a registered dietician (see Table 5). directional relationship existing between a person and society is and disease prevention are also a large part of termed ‘social functioning’. Social work is a framework that is dietetic practice. Registered Dietitians are commonly consulted concerned with the social well-being and functioning of indi- for primary prevention regarding healthier dietary choices in viduals at the individual, family, community, national and inter- order to decrease the risk of heart disease, cancer and . national levels.30 Dietitians can also be found in the community through The education required to become a social worker is strictly Community Care Access Centres (CCACs) and regulated. The 4-year Bachelor of Social Work (BSW) degree units in Ontario. They offer healthy eating information and at a university accredited by the Canadian Association of resources, run various nutritional programs for both groups and Schools of Social Work is required for generalists. However to individuals, and devise public health protocols regarding health practice in different sub-specialties, a Master of Social Work and nutrition. Industry and businesses employ dietitians to (MSW) is usually required. Those interested in teaching, assist with the development of food products and to manage research, or social policy administration can pursue post-grad- food preparation and distribution.28 uate study leading to a Doctorate degree. There are regulations Over the past several years, there has been an increased and a code of ethics, guiding the conduct and practice of social call for evidence-based practice within the dietetics commu- work, and these principles are an important aspect of the social nity in order to justify the value and contribution of the pro- worker’s education.30,31 54 Allied Health Volume 2 No. 1, 2004

Understanding the components of social work helps one er acting as a link between them Ð the individual Ð and commu- appreciate the specific roles and responsibilities of the practi- nity resources, often as a transition from hospital to home or to tioners in this field. Though social workers are commonly a long-term care facility. This allows the individual to become viewed as those who work with the homeless, the unemployed integrated into the social structure of his or her community, and and street youth, this perception is only partly true. For example, ensures that the individual has access to necessary healthcare social workers can influence community and social planning, resources.31 such as unemployment insurance, old age pension, and other There have been studies investigating the benefits of social large scale programs.31 Moreover, social workers are capable of work practice methods. For example, researchers have evaluat- working in a wide variety of settings such as family services ed the positive effects of case management for people with agencies, psychiatric hospitals, school boards, welfare adminis- severe mental disorders,32 have compared the benefits of coun- tration agencies, federal departments, and even private prac- seling therapy over therapy of patients in a primary tice.31 In essence, social workers empower individuals, via cer- care setting,33 and have assessed the increased effectiveness of tain practice methods, to identify and use problem-solving skills group-based teenage parenting programs in improving psy- to improve their social situation (see Table 6). chosocial outcomes of the parents and their children.34 Since physicians also strive to educate and empower their However there is a serious need for methodologically sound patients, there are many opportunities for collaboration between projects to firmly establish the need for including social workers the two professions (see Table 7). As a physician, if one suspects in the allied health care team. child abuse or neglect, a social worker employed by a child wel- fare agency can be called in to investigate the case. In such a sit- CONCLUSION uation, the social worker has the ability to take immediate, pro- Due to the aging population, and the concomitant problems tective action, such as recruiting foster parents or placing the arising from this Ð namely that of increasingly complex patient child in protective care.31 As a physician, one may also presentations, together with the rising incidence and prevalence encounter, for instance, an aggressive and truant student. In this of chronic illnesses Ð the focus of health care is shifting. case, social workers, with their expertise in mediation and man- Physicians are now required to look beyond pharmacological agement, may add much-needed skills to the healthcare team. solutions and emphasize overall functioning and quality of life Though it may sometimes seem as though social workers are for their patients.4 More emphasis is being placed on the need only consulted in dire cases such as abuse, this is certainly not for health care to be comprehensive and holistic, thus requiring true. Social workers can be enlisted when there is a need for the expertise of allied healthcare professionals in order to ade- interventions such as parent-child counseling or marriage coun- quately address the needs of current patient populations. In fact, seling. Older adult patients, as well as individuals with physical in his November 2002 report entitled “Commission on the or mental illnesses, may also benefit from having a social work- Future of Health Care in Canada”, Roy Romanow highlighted

Table 6. Common practice methods used by Social Workers

Case management Psychosocial therapy Community resource co-ordination

Child protection assessments* * Developmental social welfare Client-centered therapy Social casework Grassroots mobilization Clinical social work* Social group-work Neighborhood and community organizing Crisis management Client advocacy Political and social action Discharge planning Network skills training Social planning Family and marital therapy* Class action social work Social policy analysis and development

*Restricted practice activities Ð practice methods that are exclusive to social workers who have received specialty training, and who are regulated by provincial statutes Adapted from original table published in the National Scope of Practice Statement, Canadian Association of Social Workers, http://www.casw-acts.ca30

Table 7. When do I refer to a Social Worker (SW)?

Situation Which social worker do I refer to?

¥ Possibility of domestic violence, child abuse, or child neglect Social worker associated with a child welfare agency ¥ Adoption issues Social worker associated with a child welfare agency ¥ Young or adult offenders Social worker specializing in the correctional field; Classification officers; Probation officers; Parole officers ¥ Marital problems; parenting problems Social worker in private practice, or, social worker in health and community service centers ¥ Social-welfare problems Social worker in private practice, or, social worker in health and community service centers ¥ Rehabilitation of the elderly, or those with physical or mental disabilities Social worker associated with a general or psychiatric hospital

Adapted from Canadian Association of Social Workers (2002). http://www.casw-acts.ca 30,31 MUMJ Allied Health 55 this by emphasizing the importance of “getting the right mix of January 22, 2004 from the World Wide Web: http://www.physiotherapy.ca. 8. van der Schans C, Prasad A, Main E. (2003). Chest physiotherapy compared to skills from an integrated team of healthcare providers to deliver no chest physiotherapy for cystic fibrosis (Cochrane Methodology Review). In: the comprehensive approaches to health care that Canadians The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd. 9. Outpatient Service Trialists. (2003). Therapy-based rehabilitation services for expect.”35 Unfortunately, many medical schools fail to ade- stroke patients at home (Cochrane Methodology Review). In: The Cochrane quately educate future physicians on the various roles and Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd. 10. Hay-Smith EJC, B.K, Berghmans LCM, Hendriks HJM et al. (2003). Pelvic responsibilities of other health care professionals, and how they floor muscle training for urinary incontinence in women (Cochrane can serve as adjuncts to contemporary medical practice.2,3 Methodology Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd. Recognizing this, the preceding discussion has served to high- 11. College of Occupational Therapists of Ontario (2004). Members of the the value, contribution and scope of practice of five key Public/General Information. Retrieved January 17, 2004 from the World Wide Web: http://www.coto.org. health care professions which are commonly involved in the 12. Canadian Association of Occupational Therapists (1997). Enabling Occupation: management of patients in both hospital and community set- An Occupational Perspective. CAOT Publications, ACE. 13. World Federation of Occupational Therapists (2004). Occupational Therapy. tings. The professions of physiotherapy, occupational therapy, Retrieved January 20, 2004 from the World Wide Web: http://www.wfot.org/. speech-language pathology, dietetics and social work have been 14. Canadian Association of Occupational Therapists (2004). Occupational Therapy. Retrieved January 20, 2004 from the World Wide Web: described and general guidelines for physician referral have http://www.caot.ca. been outlined. Ultimately, it falls to physicians to familiarize 15. Cochrane Stroke Group. (2003). Therapy-Based Rehabilitation Services for Stroke Patients at Home. [Systematic Review]. Cochrane Database of themselves with the wide variety of professionals who are Systematic Reviews. 3. available to them, in order to ensure that their patients are 16. Cochrane Stroke Group. (2003). Services for Reducing Duration of Hospital Care for Acute Stroke Patients. [Systematic Review] Cochrane Database of receiving holistic and comprehensive health care. Clearly, the Systematic Reviews. 3. trend is now moving towards inter-professional teamwork and 17. Spector A, Orrell M, Davies S, Wood B. (2003). Reality orientation for demen- tia. [Systematic Review] Cochrane Dementia and Cognitive Improvement collaborative practice in order to optimize outcomes and Group. Cochrane Database of Systematic Reviews. 3. improve the quality of life of current and future patients. 18. Bowen A, Lincoln NB, Dewey M. (2003).Cognitive Rehabilitation for Spatial Neglect Following Stroke. [Systematic Review]. Cochrane Stroke Group. Cochrane Database of Systematic Reviews. 3. 19. Gray J. (1991). About Speech-Language Pathology. Ontario Association of ACKNOWLEDGEMENTS Speech-Language Pathologists and Audiologists. Retrieved January 15, 2004 The authors would like to thank our Faculty Editor, from the World Wide Web: http://www.osla.on.ca. Professor Penny Salvatori, as well as Derek Orange, Troy 20. Government of Ontario. (1991). Audiology and Speech-Language Pathology Act, 1991. Retrieved January 15, 2004 from the World Wide Web: http://www.e- Grennan and Sarah McMullen for their valuable editorial con- laws.gov.on.ca/DBLaws/Statutes/English/91a19_e.htm tributions. 21. College of Audiologists and Speech-Language Pathologists of Ontario. (2004). Speech-Language Pathologists and Speech-Language Problems. Retrieved All three authors contributed equally to the writing and January 15, 2004 from the World Wide Web: http://www.caslpo.com. development of this article. 22. Canadian Association of Speech-Language Pathologists and Audiologists. (2002). Speech-Language Pathology. Retrieved January 15, 2004 from the World Wide Web: http://www.caslpa.ca. 23. Law J, Garrett Z, Nye C. (2003). Speech and language therapy interventions for AUTHOR BIOGRAPHIES children with primary speech and language delay or disorder (Cochrane Jessica Hunter-Orange is a final-year medical student at Review). In: The Cochrane Library, Issue 4. 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