Chiropractic + Naturopathic Doctor • May 2016 • Health Care For Everyone

It started as a simple idea during contract negotiations between a chiropractic association and a provincial government. After many years of meetings to review feasibility issues, the Manitoba Chiropractors Association, the Manitoba Provincial Government (Family Services Department) and Mount Carmel Clinic (MCC) in inner-city Winnipeg eventually came to an agreement. They agreed that the inclusion of chiropractic services at MCC would be a welcome addition to the current health services provided there.

The Point Douglas area in Winnipeg, where MCC is located, includes 65 to 75 per cent of the Employment and Income Assistance (EIA) recipients in Manitoba. The EIA Program provides financial help to Manitobans who are unable to support themselves or their families.

The goal was to improve access and coverage of chiropractic services for low-income Manitobans living in inner- city Winnipeg. This included people who receive income assistance benefits, homeless people who move from shelter to shelter, those who were in the “Rewarding Work Program” of the EIA, new immigrants to Canada, or those reintegrating into society after an incarceration or lengthy hospitalization. The mandate of the project was to ensure that the low-income population had equitable health-care benefits and services. The clinic is designed to reduce financial barriers allowing a sizable population of low-income Manitobans to have access to chiropractic care in their community.

Dr. Audrey Toth is the clinic chiropractor at MCC and has been a member of the Manitoba Chiropractors Association for 25 years. As the MCC chiropractor, she provides clinical services to the Point Douglas community. This includes clinical work within MCC alongside allied health providers including medical physicians, registered nurses, nurse practitioners, midwives, psychiatric nurses, dentists, x-ray techs, pharmacists, as well as nutritionists and social workers. The MCC is a not-for-profit community health centre with a purpose to create and promote a healthy inner-city community. Services are provided primarily to the residents of the North End and Point Douglas communities.

The MCC recognizes that health and well-being are achieved only in part by the provision of health care services. Health is determined by a combination of many factors such as: income level, employment status, type of employment, level of education and training, environmental conditions, social supports and contacts, healthy child development, and access to health-care services at all stages of life.

The MCC strives to focus on the needs of people who are living with the effects of poverty, while working toward improvements in the health of the community through community development, early childhood development and care, primary health for the economically disadvantaged and integrated programming. It provides quality services to meet professional standards, while maintaining strong external relationships with communities, associations, businesses and government agencies.

An example of this cooperative spirit is in the Manito Ikwe Kagiikwe/Mothering Project, which has been established in the MCC, but will eventually be housed in a new building that is still under construction. The program specifically serves any woman who is pregnant or who is early parenting a child under the age of three and who has a substance use problem. The outreach program provides one-on-one support, access to prenatal care, advocacy, cultural ceremonies and teaching, as well as health care referrals. Since the chiropractic clinic opened at MCC, Toth has received referrals from the Mothering Project.

Mackenzie Kein, a registered nurse, is the primary health services manager at Mount Carmel Clinic and has been working with Toth for several years now. “The collaboration and cross referrals between our programs and available services bring a unique dynamic health approach for our clientele,” she comments. “We love that we have a chiropractor under our roof to offer assistance to patients who are also challenged by addiction.

“Some of our physicians have commented that patients who were taking opioid medications have required reduced dosages after seeing the chiropractor here.”

The province of Manitoba, via the department of family services, has fully funded the chiropractic clinic at MCC for six years, including the initial clinic set-up, capital costs and continued operations. The clinic’s chiropractor receives hourly wages regardless of the number of patients she cares for. The hourly wage is set at the same rate of entry-level physicians. Toth is contracted to work two five-hour shifts per week.

During the initial funding contract, the project was considered to be a pilot project for the first three years. In the second funding contract – years four through six – the clinic shed the “pilot” title, and became a recognized clinic by the provincial government. Manitoba Family Services just recently approved an additional three-year contract beginning April 1, 2016 running through March 31, 2019.

During hours of operation of the Chiropractic Care Program, Toth is on site at the MCC. She provides services, which include conducting an initial intake, case history, physical examination, providing a diagnosis, treatment – including supportive modalities when appropriate – and recording her findings and patient progress on the clinic’s electronic medical record program (EMR). The clinic uses the Accuro EMR system, developed by QHR Technologies Inc. in Kelowna, B.C. The same EMR system is utilized throughout the Winnipeg Regional Health Authority.Training on the EMR was lengthy but well worth it.

“Our providers in the clinic share access to the entire patient file. Dr. Toth can see the treatment provided by the medical staff and she has access to lab work and special studies,” says Jay Bodner, director of primary health. “Our physicians have access to her intake history and narratives,as well as her treatment and progress notes. This communication is very helpful between disciplines and that is good for our clients.”

Where radiographs or other diagnostic services are deemed necessary, the chiropractor has the ability to refer within the MCC. Toth also has access to the results of diagnostic tests and other electronically available information including, but not limited to, the EMR documentation of all health conditions, medications (current and past), surgical history, radiology reports, CT reports, MRI reports, lab studies, nerve conduction studies, pathology reports, assessment reports from other providers, history of services used, and clinical notes of all other providers – which are always readily available to the chiropractor, even those relating to co-morbidities.

“Over the years, there have been several examples when the chiropractor caught something that was referred to triage and got the patient to their physician faster. We have clients with serious challenges in health. We had a client recently who was experiencing a serious reaction to a prescribed medication. The chiropractor caught that reaction and the patient was referred to triage and sitting with his physician within a half hour. We also know that there have been other instances where this has happened for wound care or severe infections,” Bodner says.

Reciprocally, Toth is often called upon to assess and treat patients that have been identified by other providers, within the duration of the patient’s visit at Mount Carmel.

“For those patients, it is a huge deal because so few of them drive,” Kein notes.

Hallway consultations between the chiropractor and physicians, nurse practitioners and nurses, and many other on-site providers are happening daily, which facilitate appropriate patient management and referral in an interprofessional setting. Such valuable interactions only happen when the chiropractor is on-site and is a truly integrated member of the health-care team.

Some patients who are obtaining chiropractic care at the MCC may find themselves in the unfortunate circumstance of a car accident or work injury. Since the clinic only operates for five hours per day, two days per week, the needs for those patients change beyond what the MCC chiropractor can provide. “Many patients who have had previous success with the chiropractic program here at Mount Carmel return and reactivate their files to see the chiropractor again,” says Kein. “This speaks to the success of the integration of chiropractic services within our clinic.”

Patients who have open case files with Manitoba Public Insurance or the Workers Compensation Board must see chiropractors outside of the MCC in order to preserve the treatment times for those who do not: 1) have access to; or 2) coverage for chiropractic care.

Through the administrative structure, and in collaboration with the faculty of kinesiology and recreation management at the University of Manitoba, quality assurance data collection has been set up to collect and summarize chiropractic utilization, clinic operation and patient outcomes. The quality assurance data has been useful internally at the clinic, for government stakeholders, and even for a retrospective research study. The first research paper utilizing the collected clinic data, entitled “Initial integration of chiropractic services into a provincially funded inner city community health centre: a program description,” was published in the December 2015 issue of the Journal of the Canadian Chiropractic Association (Passmore et al, 2015).

According to this recent study, during the MCC’s first year of operations, the clinic’s medical doctors were the number one referral source to the chiropractic clinic. It also highlighted a statistically significant improvement (that also exceeded a minimally clinically important difference) demonstrated by patients with chiropractic treatment. Only four per cent of the patients required referral back to their medical physicians at the facility at the conclusion of their course of chiropractic care.

Now in its sixth year of operation, the MCC Chiropractic Care program has provided care to more than 700 individuals, and over 10,000 treatment visits. Patients who would have otherwise “slipped through the cracks” in the health-care system are now being seen in a provincially funded clinic with positive outcomes.

Through the efforts of the Manitoba Chiropractors Association, Mount Carmel Clinic, their chiropractic staff, and the investment by the Manitoba government, chiropractic care within a multidisciplinary setting is not just surviving – it is thriving and providing tremendous benefits to an otherwise underprivileged portion of the population.

DR. AUDREY TOTH, DC, is the attending chiropractor at Mount Carmel Clinic. DR. GERALD OLIN, DC, is the Manitoba Chiropractors Association liaison for the Mount Carmel Chiropractic Clinic and a consultant to Manitoba Public Insurance Health Care Services department.

DR. STEVEN PASSMORE, DC, PHD, is an assistant professor in the faculty of kinesiology and recreation management at the University of Manitoba.