Abstract
Objective Interdisciplinary healthcare providers (IHPs) can support effective delivery of optimal rheumatology care. To inform widespread implementation efforts, we assessed rheumatology workforce characteristics and determinants of integrating of IHPs within rheumatology practices in Ontario, Canada.
Methods A convergent mixed methods design included an environmental scan to identify clinically active rheumatologists and a workforce survey guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. Quantitative data were analyzed descriptively and stratified by subgroups. Qualitative responses were analyzed using conventional content analysis. Integration of findings enabled a comprehensive understanding of implementation determinants.
Results Of the 293 Ontario rheumatologists identified by the environmental scan (as of 2025), 26 were nearing retirement, leaving potentially 267 eligible for the survey. One hundred ninety-seven rheumatologists participated in the survey, yielding a response rate of 74% and coverage of > 90% of practice sites. Pediatric rheumatologists and those in hospital-based settings had more structural and collaborative supports than community-based rheumatologists. Overall, 177 (91%) indicated they were interested in adding IHPs, with 126 (65%) preferring an extended role/scope provider. Although inadequate funding was the key deterrent to adoption, motivational readiness was high: 92% perceived an IHP team-based model as an improvement, 86% saw it as a good fit, and 83% considered it a priority to better meet patient needs. Many noted a lack of supportive climate, including that of resources and processes, to enable this practice change.
Conclusion Rheumatologists report high motivation for practice change to integrate IHPs. System- and practice-level implementation strategies are needed to support workforce transformation.
Rheumatology practices globally are facing mounting pressure driven by the rising prevalence of rheumatic and musculoskeletal disorders (RMDs) and a limited workforce.1-3 Rheumatologists are managing increasingly complex patient care needs, heavier workloads, and a growing risk of burnout.4-6 Collectively, these challenges threaten access to timely and high-quality rheumatology services.
Interdisciplinary healthcare professionals (IHPs) are nonphysician clinicians, including physiotherapists, occupational therapists, pharmacists, and nurses, some of whom have advanced practice designations as extended role/scope providers. Integrating IHPs into rheumatology practices, as part of a rheumatology care team, is recognized as a key strategy to enhance service capacity, practice efficiency, quality of care, and patient and provider experience.7-13 Existing team-based models in rheumatology span a continuum from multidisciplinary approaches (where providers work independently and sequentially within their defined roles, like a rapid access clinic with IHP involvement primarily focused on triage) to fully interdisciplinary (where IHPs and rheumatologists collaborate in ongoing shared decision making, and IHPs assume greater responsibilities that extend beyond their traditional scopes of practice).13-18
Within Canada, the extent to which rheumatology practices have integrated IHPs is unclear. Integration of IHPs has been limited, largely due to insufficient funding to support IHPs in rheumatology settings.19 A 2015 national survey found that whereas 80% of Canadian rheumatologists expressed interest in expanding IHP involvement, 98% cited inadequate funding.20 Although funding is essential, effective implementation of incorporating IHPs in rheumatology care also requires an understanding of how rheumatology practices are currently organized to support expansion with IHPs, including practice infrastructure and priority clinical roles needed to support practice needs. Given the variation in patient populations and clinical focus across rheumatology practices, which may influence support needs, these assessments are essential to inform funding policies and implementation strategies. Understanding the willingness and readiness to integrate IHPs as part of a rheumatology team is also critical for scaling up implementation efforts.
To comprehensively assess implementation context for integrating IHPs in rheumatology practices (a type of practice change innovation), we assessed workforce characteristics, practice infrastructure, priorities, determinants, and willingness and readiness for integrating IHPs among rheumatologists in Ontario, Canada. Our findings aim to support future planning, resource allocation, and tailoring implementation efforts to expand team-based models of rheumatology care.
METHODS
Setting. This study is part of a large multiphase initiative aimed to scale team-based models of rheumatology care with IHPs in Ontario, Canada. The broader initiative includes multiple interconnected studies, including evidence syntheses, process evaluations, effectiveness evaluations, environmental scans, readiness assessments, economic and impact analyses, and formulation of implementation strategies. The present report corresponds to the readiness assessment phase, and directly informs subsequent steps, including prioritizing implementation strategies and policy recommendations. In Canada, healthcare delivery and organization are governed at the provincial/territorial levels, leading to regional variations in healthcare infrastructure, funding models, and policy approaches, including those governing team-based care and integration of IHPs. Focusing on Ontario allowed for a comprehensive assessment within a single, coherent healthcare system. As of 2025, Ontario lacks universal funding mechanisms to support IHPs in rheumatology practices. Aside from a few salaried rheumatologists in select hospital-based settings, most rheumatologists are reimbursed by the Ontario Health Insurance Plan (OHIP) via fee-for-service payments for the services they personally deliver. Notably, services provided by IHPs to patients in rheumatology practices are not reimbursed within Ontario’s current rheumatology funding model.
Study design overview. A convergent mixed methods research design was employed, whereby quantitative and qualitative data were collected simultaneously, analyzed separately, and integrated during the interpretation phase to facilitate comprehensive triangulation of findings. The quantitative component consisted of an environmental scan to identify the number and characteristics of clinically active rheumatologists in Ontario, which served as the survey sampling frame. Quantitative metrics and qualitative perspectives were further captured through a cross-sectional survey administered to these rheumatologists, aimed at eliciting detailed information on practice characteristics and contextual factors relevant to implementing IHPs as part of a team-based model of rheumatology care.
To guide this assessment, the Consolidated Framework for Implementation Research (CFIR) 2.0 was applied,21 offering a structured approach to examine multilevel determinants of implementation while considering the integration of IHPs as a type of practice change innovation. The CFIR encompasses 5 domains useful to this context: individual characteristics (rheumatologists involved in implementation), inner setting (practice characteristics, resources, implementation climate, and readiness for implementation), innovation characteristics (preferences for IHP types), outer setting (external influences, financial/cost implications and incentives), and implementation process (rheumatologists’ perceptions and determinants to enact implementation).
Environmental scan. To identify clinically active rheumatologists in Ontario, we employed an environmental scan of publicly available sources. The search commenced with the College of Physicians and Surgeons of Ontario (CPSO; https://www.cpso.on.ca/), which contains a physician register of any individual ever authorized to practice medicine in Ontario, including inactive physicians. Physicians certified in rheumatology identified through the CPSO were cross-referenced with membership directories of the Ontario Rheumatology Association (ORA) and Canadian Rheumatology Association and supplemented by online searches. Where necessary, practices and peers were contacted to confirm status. Physicians were excluded if they were no longer practicing in Ontario or were engaged in a different subspecialty. Data collected included practice location, primary practice setting (community vs hospital-based), gender, subspecialty focus (adult vs pediatric), location of medical school training (Canada vs international), and year of rheumatology certification (with certifications from 1989 or earlier categorized as nearing retirement). This final group of active rheumatologists served as the denominator for determining survey response rates.
Survey development. The survey development was guided by the CFIR to capture both individual- and practice-level determinants relevant to the integration of IHPs in rheumatology practice. The complete questionnaire and a mapping of survey items to CFIR constructs are provided in Supplementary File S1 and Figure S1 (available with the online version of this article). The survey comprised 20 closed questions and was supplemented by free-text fields to allow respondents to elaborate in their own words. The survey captured individual and practice characteristics, interest/willingness to modify future practice with IHPs, and readiness for change using the Readiness Thinking Tool adapted to the context.22 Readiness for change was assessed in 3 domains—motivation, innovation-specific capacity, and general capacity—and was measured only among those willing to consider integrating IHPs. The survey was pilot tested among a diverse group of rheumatologists to ensure usability and was administered electronically via Qualtrics. Although anonymous, respondents provided their postal codes to monitor regional response rates and guide targeted recruitment.
Survey distribution. The survey was distributed electronically by the research team and promoted through the ORA between January 20 and March 30, 2025. Respondents were deemed ineligible for inclusion if they were retired/retiring from clinical practice within a year, primarily saw nonrheumatology patients, or worked exclusively in research or administrative roles.
Analysis. Descriptive statistics were used to characterize rheumatologists identified through the environmental scan and to analyze survey responses. These analyses quantified workforce composition, individual and practice characteristics, interest/willingness to modify future practice with IHPs, and readiness for change. All quantitative analyses were conducted on aggregate data and stratified by select subgroups (adult, pediatric, hospital-based vs community practice, gender). Analyses were performed using R v4.4.1 (R Foundation for Statistical Computing) and Python v3.11.7 (Python Software Foundation).
For qualitative data, conventional content analysis was used to analyze free-text responses from open-ended survey questions relating to (1) key roles rheumatologists felt would best support their practice, and (2) the supports needed for implementation. Two investigators (NSB, MJG) independently reviewed the data and inductively coded responses. Themes were constructed from the codes with input from a larger analytic team with content and methodological expertise. Representative quotations were selected to illustrate key findings and to complement quantitative results. Additional methodological details of the qualitative evaluation are provided in Supplementary File S2 (available with the online version of this article). Integration of quantitative and qualitative data occurred during the interpretation phase, enabling triangulation of findings to provide a comprehensive understanding of factors influencing implementation of team-based rheumatology care.
RESULTS
Overall workforce composition. The environmental scan identified 391 Ontario physicians holding rheumatology certification according to the CPSO registry, of whom 293 were clinically active in Ontario as of January 2025, comprising 263 adult and 30 pediatric rheumatologists. In total, 181 (61.8%) practiced in community settings and 112 (38.2%) in hospital-based settings, including 106 in academic/teaching hospitals and 6 in community hospitals. The workforce comprises 161 (54.9%) women and 132 (45.1%) men, with 197 (67.2%) having graduated from a Canadian medical school. The 293 rheumatologists made up 141 unique practice sites/locations, as 206 (70.3%) rheumatologists shared a practice location with other rheumatologist(s). The geographic distribution of practice sites is presented in Figure 1, and overall workforce characteristics are reported in Table 1. Among the 293 rheumatologists, 26 were nearing retirement, indicating that 267 were potentially eligible but the survey had additional exclusion criteria.
Primary practice locations of 293 rheumatologists in Ontario.
Characteristics of the Ontario rheumatology workforce (environmental scan findings of clinically active rheumatologists).
Survey response rate. Among the 197 rheumatologists who consented to participate, 180 adult rheumatologists and 17 pediatric rheumatologists completed the survey, corresponding to a response rate of 74% (197/267). Respondents represented 45 cities/municipalities, capturing > 90% of practice sites; 6 invalid postal codes prevented precise regional rate calculation).
Survey respondent demographics (CFIR: characteristics of individuals). Supplementary Table S1 (available with the online version of this article) presents the characteristics of survey respondents overall and stratified by practice setting and subspecialty focus. There were more women respondents overall (107; 54%) and within each subgroup, with a similar distribution to the environmental scan. The majority of respondents (155; 79%) were ≤ 55 years old, whereas 36 (18%) indicated they either planned to retire or were uncertain about their retirement plans within 5 years. Additionally, more than one-third self-identified as belonging to a racialized (non-White) group in Canada.
Survey respondent practice characteristics (CFIR: inner setting).
• Structural characteristics. Among adult rheumatologists, 76 (42.2%) were hospital-based, compared with 15 (88.2%) of pediatric rheumatologists. Only 38 (19.3%) respondents were the sole rheumatologist in their setting (Table 2). Hospital-based rheumatologists reported greater shared infrastructure and collaboration than those in community practices. Over half of rheumatologists shared key structural resources (facilities, electronic records, equipment/supplies, administrative support, and expenses). Only one-quarter of community-based rheumatologists shared clinical staff and collaborated on patient care, including providing cross-coverage during colleague absences, compared with 56.6% in hospital settings.
Practice characteristics of survey respondents.
• Available resources/time. Rheumatologists reported a median of 40 hours/week (IQR 30-50) on direct/indirect patient care (Table 2). Community-based rheumatologists reported more time on patient care and reported higher practice overhead costs, averaging 35% of annual remuneration compared to 31% in hospital-based settings.
The types of clinical support across practices were highly variable. Most pediatric rheumatologists (16/17), who are predominately hospital-based, reported receiving support from a diverse team of IHPs, including nurses, physiotherapists, social workers, and Advanced Clinician Practitioner in Arthritis Care (ACPAC)-trained extended role/scope provider (ie, someone with advanced knowledge and clinical skills related to arthritis care, obtained through postlicensure training, who are competent to perform additional activities under medical directives or authorized activities). Overall, 47% of hospital-based rheumatologists reported access to some form of clinical support, compared to 37% of community-based rheumatologists. Among all adult rheumatologists, only 26% reported a nurse supporting their practice, and only 18% had access to an ACPAC. Funding sources to support these IHPs were also highly variable, with the majority of IHPs funded by hospital or external sources (Supplementary Figure S2, available with the online version of this article). Most IHPs supporting adult rheumatologists in hospital settings and nearly all IHPs supporting pediatric rheumatologists were funded by hospital budgets.
• Implementation climate. Overall, 14% of rheumatologists indicated working in a remote model during the past year (traveling to underserviced regions or telerheumatology), 27% in a multidisciplinary model with an IHP, 30% in an interdisciplinary team-based model, and 31% in an interprofessional model with other physician specialists (eg, dermatology-rheumatology clinic; categories not mutually exclusive; Supplementary Table S2, available with the online version of this article). All pediatric rheumatologists indicated ≥ 1 alternative care model, whereas hospital-based rheumatologists were more likely than community-based counterparts to indicate one of these alternative models.
Among the 180 adult rheumatologists, 79% reported increasing work demands due to rising patient care complexity and administrative burden, and 50% reported that work-related stress impaired their ability to deliver high-quality care, with women indicating more demands/stress compared to men. In total, 33 rheumatologists (17%) felt too overwhelmed to consider practice changes and 15 (8%) felt change was not beneficial at this stage of their career (eg, nearing retirement). Additionally, one-third reported that most new patient consults could not be accommodated within 3 months.
Willingness/interest to integrate IHPs and priority IHP roles (CFIR: innovation characteristics). Rheumatologists were asked to identify up to 3 IHP roles they preferred for integration into their practice. Overall, 177 (91%) selected ≥ 1 role, with 126 (65%) preferring an ACPAC-trained extended role/scope provider. This remained the top choice across all subgroups (Figure 2) and across genders. Other commonly selected IHP roles included physician assistants (34%), nurses (32%), and physiotherapists (31%). Rheumatologists’ perceptions on priorities for IHP roles and their rationales are highlighted in Table 3. Rheumatologists identified 3 primary functions as priorities (collaborative physician-extender roles providing full patient assessments and management, discipline-specific care within the usual scope of practice [eg, physiotherapy], and administrative support functions); however, most respondents indicated that combining these functions would be desirable.
Rheumatologists’ willingness/interest to integrate IHPs and the priority IHP roles they selected. Rheumatologists could select up to 3 priority clinical roles for their practice. “Other” included scribe, psychologist, and ultrasound technician. ACPAC: Advanced Clinician Practitioner in Arthritis Care; IHP: interdisciplinary healthcare provider; NP: nurse practitioner; OT: occupational therapist; PA: physician assistant; PT: physiotherapist.
Rheumatologists’ perceptions on priorities for IHP roles.
Only 17 (9%) reported an unwillingness to add additional IHPs, with 10 (5%) indicating they already had a team and were not open to further expansion.
Readiness for change (CFIR: inner setting and process implementation). For 172 (87%) rheumatologists indicating their willingness/interest to consider integrating additional IHPs to implement a team-based model of rheumatology care (the “innovation”), we assessed readiness for this practice change. Rheumatologists indicated high motivational readiness (Figure 3), with findings comparable across subgroups (Supplementary Table S3, available with the online version of this article). Most rheumatologists (92%) indicated this innovation as having clear relative advantage over their current model, and 86% indicated a strong compatibility with their existing practice. Further, 83% viewed the innovation as a high priority relative to others. Conversely, fewer respondents reported having the innovation-specific capacity (what is needed to make this change happen), with 55% indicating a lack of supportive climate such as processes and resources (ie, help) to enable this practice change. Despite this, 123 (72%) still indicated they had sufficient abilities to make the change. In terms of general capacity, most rheumatologists indicated they were open to change in general, whereas just over half (56%) indicated they had the ability to acquire and allocate resources including time, effort, and technology required for implementation. Overall, 149 (87%) reported confidence in their ability to plan, implement, and evaluate implementation efforts.
Readiness for change. Assessed based on responses from 172 rheumatologists (adult and pediatric, hospital-based and community-based practices) who indicated a willingness/interest to consider integrating additional team members to implement a team-based model of rheumatology care (“innovation”). As funding is a key barrier to implementation, rheumatologists were asked to take funding considerations out of the equation in their responses and determine their agreement across each statement. Results stratified by subgroups are reported in the Supplementary Table S3 (available with the online version of this article). EMR: electronic medical record.
Funding considerations/enablers for integrating IHPs (CFIR: outer setting). In the context of limited funding mechanisms for IHPs in Ontario, rheumatologists provided input on financial considerations necessary for integrating an IHP into their practice. Few indicated they were willing to sacrifice earnings to fund IHP costs (Supplementary Table S4, available with the online version of this article). Overall, 53% were satisfied with funding that was sufficient to cover the IHP costs (remain financially neutral). However, 51% of community rheumatologists indicated they need a financial gain (beyond the salary for the IHP) compared to 31% of rheumatologists in hospital-based settings. As one noted, “I do not need financial incentive but do need funding beyond the salary for the IHP as there are additional costs including lease of a larger clinic space, extra equipment such as computer, … [etc.], extra initial time on my part to train them (loss in OHIP billing at onset).” Another noted, “This change in practice model inherently adds a business complexity to my job, so there should be the reasonable expectation of remuneration for the rheumatologist to accommodate this change.”
Barriers to implementation. The predominate concern related to integrating IHPs was sustainable funding (noted by 72%; Supplementary Figure S3, available with the online version of this article). Concerns included if funding were to be provided and then taken away, and then requiring changing their practice back to the way they originally practiced. This disruption in practice operations could create additional burdens. Concerns about physical infrastructure were also prominent, with 43% of respondents identifying clinic space as a constraint. One respondent noted that “the space is also a concern, but if a reliable funding source were obtained, it’d be worth spending the money to expand the space and improve patient care. But again, the biggest fear there is investing all the money and then losing the funding.” Rheumatologists also equally emphasized concerns related to the time and effort to change practice including hiring, training, and implementing change. One respondent noted that “training IHPs…will take a long time/investment of effort and the risk of losing them when they move on in their career is too high.”
Supports/enablers needed for team-based transition (CFIR: implementation process). Rheumatologists underscored 4 foundational supports necessary for implementing a team-based care model. These include (1) infrastructure support (ensuring clinic space and funding for equipment), (2) personnel funding (securing stable funding for IHP salaries), (3) training support (providing initial and ongoing education), and (4) logistical support (covering recruitment, medico-legal guidance, and practice organization). Rheumatologists’ perspectives on the supports needed to transition to a team-based model are summarized in Supplementary Table S5 (available with the online version of article).
DISCUSSION
Implementing practice change in health care is inherently complex, influenced by a range of contextual, structural, and individual factors that can either facilitate or hinder success. A clear understanding of current practice environments is essential to designing implementation strategies that are feasible, scalable, and sustainable. To address important knowledge gaps, our current study employed a CFIR-guided workforce survey of practicing rheumatologists to assess their readiness and contextual factors relevant to scaling up the integration of IHPs in rheumatologists’ practices. The findings highlight a diverse but strained clinical workforce, with limited clinical support structures in place. Despite these challenges, there is strong interest and motivation for change, with most rheumatologists expressing motivation and willingness to integrate IHPs into their practices. Hospital-based rheumatologists reported more collaborative and supportive infrastructure than community-based peers. Despite high perceived advantages, compatibility, and priority of expanding IHP involvement, implementation challenges exist. These findings underscore the need for targeted practice- and system-level implementation strategies that address both inner and outer setting barriers to workforce transformation.
Previous Canadian evidence highlights delayed and suboptimal rheumatology care, rising costs from inadequate disease management, and persistent care disparities, all contributing to poor outcomes and exacerbated by workforce challenges such as high burnout.3,4,6,23-42 Our findings continue to highlight access challenges and unmet patient and provider needs, including work-related stress and challenges in providing timely care, reinforcing the salience and urgency of innovations to alleviate workload and improve practice sustainability. These findings point to significant structural and contextual pressures that hinder current care delivery and motivate consideration of new models of care. Further, a key implementation concern was related to the time and effort to train new team members. Most rheumatologists indicated a strong preference for IHPs who possess additional competency-based training in RMDs. This preference may also point to a practical implementation enabler of selecting IHPs that minimize training burdens. Additionally, IHPs that are most capable of fulfilling the role of a physician extender may also help enhance professional fulfillment, well-being, and practice needs.
Our findings also highlight important differences between hospital-based and community settings, including disparities in access to infrastructure, collaborative supports, and available resources. Hospital-based rheumatologists were more likely to report having access to clinical support and peers, whereas community-based rheumatologists often faced greater overhead costs and higher workloads with fewer structural supports, which likely shaped their differences in preferences for financial considerations. Further, pediatric and hospital-based rheumatologists were more likely to engage with IHPs in their practice, as these rheumatologists have access to additional financial supports through hospital budgets. These variations have important implications for the development of tailored health policy and implementation strategies that account for setting-specific needs.
This study has several strengths, including the use of the CFIR to guide assessment, but also some limitations related to generalizability. Our application of the CFIR complements a growing body of evidence demonstrating its utility in health workforce and service delivery research to comprehensively assess implementation determinants. We intentionally focused on the most relevant subdomains to reduce respondent burden, recognizing that not all CFIR subdomains are applicable in every context. Determining an accurate headcount of rheumatologists is challenging given the dynamic nature of workforces. Although our engagement rate exceeded that of other national physician surveys4,20 (with minimal missing data), some nonparticipation bias is possible; however, most sites were represented, and site-level practice characteristics are expected to be comparable between responders and nonresponders within a given site. Some findings may not be as applicable to other jurisdictions (particularly those outside Canada) with different structural and financial supports. Further, assessing readiness for change is challenging and can only be partially measured quantitatively. More detailed qualitative inquiries are necessary to unpack contextual influences, and subtle dynamics that shape readiness.43,44
This workforce study informs provincial planning in Ontario and offers insights for other jurisdictions facing similar workforce and service delivery challenges. Ontario rheumatologists report high motivation to adopt practice changes that expand IHP involvement as a way to increase service capacity and quality of care. The findings provide evidence to advocate for funding reform by showing rheumatologists’ strong desire and readiness to integrate IHPs, alongside specific practice- and system-level barriers where implementation strategies are needed. These results provide a foundation for scaling up IHP integration by aligning policy reform with identified needs, readiness, contextual factors, and enablers to guide the development of targeted implementation strategies to support workforce transformation.
ACKNOWLEDGMENT
The authors wish to thank study participants, Catherine Hofstetter, and the Ontario Rheumatology Association, particularly Sandy Kennedy, for supporting this research.
Footnotes
CONTRIBUTIONS
JW: study conception and design, data acquisition, data analysis, data interpretation, writing original draft, draft revision. CL, TSHK: study conception and design, data acquisition, data interpretation, draft revision. LO, JCW: study conception and design, data acquisition, data analysis, data interpretation, draft revision. CTA, VA, JCT, JJYL, CEHB, LP: study conception and design, data interpretation, draft revision. NSB, MJG: data interpretation, data analysis, draft revision. LKK: study conception and design, data acquisition, data analysis, data interpretation, draft revision.
FUNDING
This study was funded by the Transforming Health with Integrated Care (THINC) initiative at the Canadian Institutes of Health Research (CIHR), the CIHR - Institute of Musculoskeletal Health and Arthritis (IMHA) and Strategy for Patient-Oriented Research (SPOR); (IT6-188079). LKK is supported by an Arthritis Society Canada Stars Career Development Award (Star-24-0095). JW is supported by the Holland Chair in Musculoskeletal Research at Sunnybrook/University of Toronto.
COMPETING INTERESTS
The authors declare no conflicts of interest relevant to this article.
ETHICS AND PATIENT CONSENT
Participating in this survey was voluntary. Survey respondents were informed that completing the survey implied that they consented to participate. The study was approved by the University of Toronto Research Ethics Board (protocol # 00046878-environmental scan; 00047635-survey).
- Accepted for publication September 23, 2025.
- Copyright © 2026 by the Journal of Rheumatology
This is an Open Access article, which permits use, distribution, and reproduction, without modification, provided the original article is correctly cited and is not used for commercial purposes.
REFERENCES
SUPPLEMENTARY DATA
Supplementary material accompanies the online version of this article.
