Using Systems Thinking to Bridge the Gap between Family Medicine & Allied Healthcare
One of the challenges with our Canadian healthcare system is how disjointed it can be at certain points in a patient’s care journey. Within the hospital system, roles exist to examine and resolve these handoff points, but one area I’ve grappled with throughout my career as a leader of health centres is the disconnection between Family Practice and allied health practitioners. When patients are referred for services such as physiotherapy, chiropractic, or pedorthics, they often leave the clinic with a prescription or referral and must then navigate insurance coverage, find an appropriate provider, and hope their GP receives feedback to close the loop and support better chance for healing.
This disjointed patient experience creates several challenges: patients end up coordinating their own care, communication gaps emerge between providers and patients, and the overall patient experience suffers. This challenge has been near and dear to my heart: how to ensure patient compliance once they “exit” the universal system, close the communication loop with external providers, support follow-up despite service costs, and measure outcomes? Finding answers to these questions is central to delivering effective, patient-centered care. Improving the connection between GPs and allied health practitioners not only enhances patient outcomes but also strengthens the healthcare system overall.
At first glance, this may seem like a simple referral problem. Yet when we apply systems thinking, it becomes clear that the issue is far more complex—a structural gap affecting patient outcomes, clinic efficiency, the effectiveness of GP-allied provider relationships, and ultimately a missed opportunity for improving patient care and experience.
Systems thinking allows us to look beyond surface-level symptoms and examine interconnections, feedback loops, and leverage points contributing to the problem. In this scenario, the system includes:
The Family Practice clinic – the public-care hub, coordinating care and capturing patient outcomes.
Allied healthcare providers – physiotherapists, chiropractors, pedorthists, and massage therapists operating largely in private streams.
The patient – navigating insurance, scheduling, and essentially forced to be the hub of their own continuity of care.
Feedback loops are critical: delayed or missed physiotherapy can lead to repeat GP visits, additional strain on the public system, and frustration for patients. Small changes in the system can produce outsized benefits—but only if we address underlying structures rather than isolated symptoms.
So, what’s the solution? While fully shared EMRs can help, the reality is that fully integrating EMR systems across all private and public providers in the province is unlikely in the near term. Instead, here are some practical alternatives:
Referral Tracking Dashboards – Internal trackers combined with patient follow-up can measure the percentage of referrals successfully booked within a set timeframe.
Patient Navigators – Clinic staff can help patients navigate insurance, recommend vetted physiotherapists, or pre-book appointments. Measurement: completion rates and patient-reported ease.
Relationships with Allied Health Providers - Relationships with trusted providers streamline scheduling and feedback. Measurement: time-to-first-appointment.
Feedback Loops from Allied Providers – Short progress notes returned to the GP allow clinics to close the loop and track patient outcomes. AI can help highlight relevant notes for physicians during the next patient visit.
These interventions are measurable, implementable, and strengthen the GP’s role as the hub of patient care. Of course, physicians’ EMRs must be configured to properly track these activities.
For allied healthcare providers: it pays to get to know the Family Medicine physicians in your catchment area. In a previous post on LinkedIN, I discussed marketing tips for physiotherapists and other allied health providers; this one is a winner. Improving these systems doesn’t just help GPs and patients—allied healthcare providers also benefit:
Reduced lost patients/no-shows, improving revenue predictability.
Clearer communication, minimizing duplicated assessments and aligning care plans.
Enhanced reputation and patient experience, generating referrals and trust.
My suggestion: start small, with 5–6 Family Medicine Clinics. After years of developing relationships with Family Medicine physicians to support better referral pathways, I can attest that this approach works.
Things are progressing; we have seen some pockets of innovation in Canada. Certain Health Authorities, Divisons of Family Practice (Primary Care Networks), and Collaborative Service Committees are exploring ways to better integrate the patient journey between Family Medicine and allied health providers. However, much of this work remains localized, leaving many clinics fragmented.
The GP-to-allied health referral gap illustrates a broader principle: systems thinking is not just an abstract concept—it is a practical tool for improving outcomes, efficiency, and patient-centered care. By mapping interconnections, identifying leverage points, and implementing feasible, measurable solutions, clinics can strengthen both public and private care streams, creating a healthcare ecosystem that truly serves patients, providers, and communities alike.
If you are an allied health or family medicine clinic looking to improve referral pathways, enhance communication, and strengthen patient outcomes, Afya Consulting can help. Or, if you’re also super passionate about this topic - I would love to chat more. Let’s work together to transform how your clinic coordinates care across the patient journey.