Daniel’s primary care experience

Daniel is a 65-year-old, retired engineer, who attends his annual diabetes check-up with his nurse practitioner (NP). The NP notices Daniel struggling to understand her at times and repeating himself or searching for words during their conversation. The NP asks him if he is experiencing problems with his memory, where Daniel reveals that he sometimes has difficulty remembering his day-to-day whereabouts and activities, prompting her to conduct a mental status screening and make a general neurology referral, with a 6-month wait (Creavin et al., Reference Creavin, Wisniewski, Noel-Storr, Trevelyan, Hampton, Rayment, Thom, Nash, Elhamoui, Milligan, Patel, Tsivos, Wing, Phillips, Kellman, Shackleton, Singleton, Neale, Watton and Cullum2016). In the meantime, she suggests Daniel meet with the team’s S-LP who has expertise in conducting cognitive-communication tests for early detection of cognition and memory problems, to which Daniel agrees. The NP also notices Daniel has no record of a hearing test. She informs Daniel about the current recommendations for hearing screening (see Figure 1, level 5), which should be conducted regularly starting at 50 years of age, as hearing impairments can contribute to poor cognitive assessment performance (Littlejohn et al., Reference Littlejohn, Bowen, Constantinidou, Dawes, Dickinson, Heyn, Hooper, Hopper, Hubbard, Langenbahn, Nieman, Rajagopal, Thodi, Weinstein, Wittich and Leroi2022). The NP uploads her report to the shared EMR for the team to access (level 4). The medical administrator schedules an appointment with the team’s S-LP and affiliated audiologist through the team’s shared EMR, sends the referral to neurology, and gives Daniel a written reminder of his hearing test for the following week.

During his appointment at the local audiology clinic, the audiologist conducts a comprehensive hearing assessment, finding that Daniel has permanent, moderate binaural hearing loss and is a candidate for bilateral hearing aids. The audiologist discusses Daniel’s results, hearing device options, and at-home communication strategies for Daniel and Rosa, his wife (level 3). Daniel selects a hearing aid model and accessories that fit his lifestyle and the audiologist schedules appointments for the hearing aid fitting and review. During the appointment, the audiologist observes Daniel having difficulty rising from the chair. Given Daniel’s symptoms (level 2), the audiologist conducts a mobility screen and determines that Daniel would benefit from a falls risk assessment and programme (level 5), with Daniel’s consent. This information is recorded in the EMR report.

Prior to Daniel’s speech and language assessment, the S-LP reviews the team’s EMR notes to determine the best standardized tests to identify Daniel’s challenges with communication and cognition, including following commands, verbal repetition, and description of objects. The S-LP interviews Daniel and Rosa to determine their leisure activities, physical activity habits, social connections, sleep patterns, and any other communication-related concerns that they might have. The findings indicate that Daniel is experiencing difficulties with attention, short-term memory, and information processing, consistent with a mild cognitive impairment (MCI; level 2). The S-LP shares with the team via the EMR her concerns regarding the possible presence of MCI. The S-LP, Daniel, and Rosa co-create a plan to leverage Daniel’s cognitive-communication strengths, address his challenges, and support his participation in his preferred activities (level 3). Daniel is scheduled for bi-weekly cognitive-communicative group therapy (level 5), offered through the team.

Within days of wearing his hearing aids, Rosa notices an improvement in Daniel’s attention; however, his memory and word-finding difficulties persist. She also notices that Daniel appears slightly steadier on his feet. At his follow-up appointment, the audiologist confirms that the hearing aids have improved Daniel’s speech-understanding abilities and balance, and educates Daniel and Rosa on the relationships among hearing, balance, diabetes, and cognitive health (Baydan-Aran et al., Reference Baydan-Aran, Aksoy, Şahin, Caliskan, Kırdı and Doğu2023; Koh et al., Reference Koh, Lee and Lee2015; Samocha-Bonet et al., Reference Samocha-Bonet, Wu and Ryugo2021; Sarant et al., Reference Sarant, Busby, Schembri, Fowler and Harris2024). The audiologist also reviews effective communication strategies and basic hearing aid care with Daniel and Rosa. She recommends Daniel attend annual check-ups and obtain further testing if he is experiencing changes to his hearing or balance symptoms. Additionally, the audiologist sends a recommendation through the shared EMR used by Daniel’s team for the team to attend an educational session on communication strategies and devices, led by the audiologist and S-LP. This session aims to equip team members with communication techniques and strategies that benefit Daniel and other patients experiencing communication difficulties and enhance their care experience (Glista et al., Reference Glista, Moodie, O’Hagan, Gavarkovs, Pichora-Fuller, Cooke, Cameron-Turley, Carey, Cooper, Bataineh, Alaniz, Pfingstgraef and Wilson2024a).

Following the team’s educational session, the EMR sends a prompt to the NP to review the team members’ notes and Daniel’s recent bloodwork. The nurse practitioner requests the medical administrator to call and book an appointment for Daniel and Rosa to review his progress in his therapies and to discuss his bloodwork results. In preparation, the nurse practitioner reviews the EMR, noting each team members’ recommendations regarding Daniel’s hearing, cognition, and mobility.

During the appointment, the NP discusses the team’s recommendations and progress. She emphasizes the importance of utilizing hearing assistive devices to improve communication ability, and in maintaining a routine around physical activity, cognitive-communication therapy, and a balanced diet as key strategies to mitigate some of the risk factors associated with MCI that could, in turn, progress to dementia. The nurse practitioner recommends Daniel meet with the team’s dietitian (level 4) to review his diet, as his bloodwork indicates elevated blood glucose levels. She also suggests seeing the occupational therapist (OT; level 4) for the falls risk prevention programme (level 5). Daniel agrees to book both appointments.

Prior to Daniel’s appointments, the EMR prompts the OT and dietitian to review communication recommendations (e.g., hearing aid check) from the S-LP and audiologist prior to Daniel’s appointments. Using the recommended strategies, the OT assesses Daniel’s balance and determines he has a mild falls risk. The OT recommends a 6-week group balance and strengthening programme to minimize his risk of falls. The dietitian reviews Daniel and Rosa’s current diet, meal preparation, and cooking routines and provides education and strategies to improve Daniel’s blood glucose levels. Together, they create a feasible plan that works for both Daniel and Rosa since they both cook in their household. They also decide on monthly follow-up appointments to review their progress.

Next, Daniel and Rosa attend his neurology appointment. Based on team members’ reports, Daniel’s laboratory results, and the neurologist’s clinical examination, the neurologist confirms that Daniel does show MCI and ongoing monitoring for dementia will be needed. Neuroimaging is recommended and a requisition is issued for an MRI. In the meantime, the neurologist prescribes Daniel medication to improve his memory and judgement and advises him to continue with the team’s recommendations as much as possible. The neurologist’s office schedules a 6-month follow-up appointment and enters the report into the EMR.

Throughout the next 6 months, Daniel attends his follow-up appointments with his primary care team and follows their recommendations. Daniel and Rosa recognize that attending to hearing, physical activity, diet, social connections, communication, and/or cognitive health can potentially modify the trajectory of Daniel’s MCI diagnosis (Xiao et al., Reference Xiao, Xue, Li, Li, Wu and Zhang2006; Hughes et al., Reference Hughes, Flatt, Fu, Chang and Ganguli2013; McGrattan et al., Reference McGrattan, McEvoy, McGuinness, McKinley and Woodside2018; Bucholc et al., Reference Bucholc, Bauermeister, Kaur, McClean and Todd2022; Zhu et al., Reference Zhu, Al Mahmud and Liu2023). The team also recognizes that many providers are involved in Daniel’s care and work closely with Daniel and Rosa to ensure the frequency of appointments is feasible. If, and when, Daniel and Rosa feel there are too many appointments, the team will work to accommodate them by booking appointments back-to-back when possible, offering virtual care options, and providing home visits when appropriate.

The role of audiologists

Daniel’s case highlights two important aspects of the roles and expertise of audiologists in primary care including their abilities to identify and to treat hearing loss, and to triage common risk factors for hearing loss and balance (i.e., diabetes; Pichora-Fuller et al., Reference Pichora-Fuller, Mick and Reed2015). Research has demonstrated that cognitive test accuracy can be limited when mild hearing impairment is present, due to the standard verbal administration of these tests (Dupuis et al., Reference Dupuis, Pichora-Fuller, Chasteen, Marchuk, Singh and Smith2015; Kolberg et al., Reference Kolberg, Morales, Thallmayer, Arnold, Burgard, Chisolm, Coresh, Couper, Hayden, Huang, Lin, Mitchell, Mosley, Gravens-Mueller, Owens, Pankow, Pike, Reed, Sanchez, Schrack, Deal and Goman2024). For Daniel, it was necessary to address his hearing loss before proceeding with additional neurocognitive testing to ensure accurate screening. Additionally, hearing loss has been associated with reduced static balance, increasing the risk of falls (Jiam et al., Reference Jiam, Li and Agrawal2016; Negahban et al., Reference Negahban, Bavarsad Cheshmeh Ali and Nassadj2017). Audiologists’ training in vestibular and balance disorders provide the opportunity to identify factors that contribute to balance and falls risk, benefitting musculoskeletal intervention, and assists in a comprehensive care process, in collaboration with other health care team professionals, such as the OT in Daniel’s case. For older adult patients, audiologists can provide intervention for hearing, vestibular, and balance disorders, including counselling, treatment, management, and rehabilitation, integral components in cognitive care and falls prevention (SAC, 2016).

The role of S-LPs

Daniel’s case illustrates S-LPs’ expertise in conducting cognitive-communication screenings, assessments, and implementing therapeutic interventions. Research shows that cognitive-communication therapies can significantly improve memory function and prevent further decline (Bosco et al., Reference Bosco, Parola, Angeleri, Galetto, Zettin and Gabbatore2018). Given that older adult patients can experience a worsening of symptoms while awaiting specialist appointments, S-LPs provide essential, timely care that supports ongoing management of communication needs, including when access to specialist services is delayed. Additionally, swallowing difficulties can emerge with the progression of MCI to specific types of dementia, where the management of dysphagia falls directly within the scope of practice of S-LPs, further emphasizing their important role in managing a broad range of symptoms associated with cognitive decline (Pichora-Fuller et al., Reference Pichora-Fuller, Mick and Reed2015).

First point of contact

Within team-based primary care, family physicians (also known as general practitioners outside of Canada) and NPs can operationalize Starfield’s first contact/accessibility principle by enabling audiologists and S‑LPs to serve as first-contact providers for concerns within their regulated scopes of practice. This approach, which has been implemented for other professions (e.g., physiotherapists and midwives) in select Canadian primary care teams, can improve access by reducing unnecessary steps to care and by ensuring patients reach the most appropriate provider earlier (Vader et al., Reference Vader, Donnelly, French, Grady, Hill, Tripp, Williams and Miller2022; Darling et al., Reference Darling, Graybrook, Jameel, Dion, Ku-Carbonell, Begun and Mattison2025). Shifting initial screening for hearing and communication-related concerns directly to audiologists and S‑LPs means CIPC teams can optimize each team member’s expertise, reduce unnecessary demand on physicians and NPs, and streamline care pathways so patients receive timely, appropriate support, while reserving physician/NP visits for needs requiring medical assessment or broader diagnostic workup (Kiran, Reference Kiran2022; Glazier, Reference Glazier2023). In the scenario, Daniel required an initial NP visit to determine his appropriate care pathways. However, in future, he could directly access these providers for new or recurring hearing and communication-related concerns, as long as his primary care team enables audiologists and S‑LPs as first-contact providers.

Service delegation

The current climate of primary care has required innovative ways to engage in care provision. Service delegation improves access to care by leveraging health providers overlapping skills and expertise (CIHC, 2024; Brown et al., Reference Brown, Mulder, Clark, Belsito and Thorpe2021). This delegation allows various providers to deliver care, rather than depending on just one provider, and enables patients to access care from a range of available and appropriate providers. However, successful service delegation relies upon role clarification and negotiation, both of which are key competencies in the CIHC Interprofessional Competency Framework (CIHC, 2024). Role clarification refers to a thorough understanding of each team member’s role and scopes of practice, whereas role negotiation refers to a collaborative decision-making process that engages providers in roles that benefit the team and patient. In Daniel’s case, the audiologist identified and screened his balance symptoms, and the S-LP provided Daniel cognitive-communicative therapy, which can overlap with the OT’s scope of practice. However, given Daniel’s symptoms and his OT’s clinical focus on falls prevention, the audiologist and S-LP were the most suitable professionals to attend to him, given their expertise in communication disorders. This allowed Daniel to receive ongoing care tailored to his cognitive-communication needs. Thus, diverse primary care teams that adopt collaborative, interprofessional care approaches can provide high-quality care, while relieving the strain on the primary care system, particularly in the current climate of rapidly increasing physician burnout (Dennis et al., Reference Dennis, Ball, Harris and Refshauge2021).

EMR as a collaborative communication tool

Healthcare systems globally are seeing increased technological advancements, such as EMR systems (O’Malley et al., Reference O’Malley, Draper, Gourevitch, Cross and Scholle2015; Kosteniuk et al., Reference Kosteniuk, Morgan, Elliot, Bayly, Froehlich Chow, Boden and O’Connell2024). EMR systems can effectively serve as information sharing platforms, facilitating service delegation as well as enhancing communication and collaboration within interprofessional primary care teams (O’Malley et al., Reference O’Malley, Draper, Gourevitch, Cross and Scholle2015; Kosteniuk et al., Reference Kosteniuk, Morgan, Elliot, Bayly, Froehlich Chow, Boden and O’Connell2024). More specifically, the information sharing capacities of EMR systems allow for easier access to other providers’ findings and recommendations, facilitating cohesive, integrated care provision for patients (Kosteniuk et al., Reference Kosteniuk, Morgan, Elliot, Bayly, Froehlich Chow, Boden and O’Connell2024). These benefits of EMR systems apply whether teams are co-located or working remotely (O’Malley et al., Reference O’Malley, Draper, Gourevitch, Cross and Scholle2015; Kosteniuk et al., Reference Kosteniuk, Morgan, Elliot, Bayly, Froehlich Chow, Boden and O’Connell2024). This flexibility is increasingly important in healthcare, where providing remote care and maintaining seamless communication between healthcare professionals is crucial (O’Malley et al., Reference O’Malley, Draper, Gourevitch, Cross and Scholle2015; Kosteniuk et al., Reference Kosteniuk, Morgan, Elliot, Bayly, Froehlich Chow, Boden and O’Connell2024). Furthermore, we highlight this well-documented utility of EMR to emphasize that while co-location is advantageous, it is not necessary to encourage collaborative relationships. Collaborative relationships can be fostered with existing community providers through collaborative communication tools, such as EMR, as illustrated by the audiologist in Daniel’s case. Lastly, although not illustrated in the scenario, EMR systems are increasingly incorporating patient-facing communication functionalities (e.g., secure messaging, appointment reminders, and access to care plans and results), aligning with primary care goals related to timely access and comprehensiveness (Gorfinkel and Lexchin, Reference Gorfinkel and Lexchin2018; Tapuria et al., Reference Tapuria, Porat, Kalra, Dsouza, Xiaohui and Curcin2021).

Trust in team expertise

The transition from a siloed health care delivery model to an integrated primary care model can pose challenges to collaborative efforts. The introduction of new professions into an existing care model can lead to issues of trust related to professional service boundaries, and uncertainty regarding the knowledge and competence of these new roles (Brown et al., Reference Brown, Mulder, Clark, Belsito and Thorpe2021). Within the context of Canadian primary care, audiologists and S-LPs have been overlooked (Bataineh et al., Reference Bataineh, Glista, O’Hagan, Pichora-Fuller, Alaniz, Pfingstgraef, Carey, Cooke, Marson, Springer, Orange, Cameron-Turley and Moodie2024). The lack of inclusion of audiologists and S-LPs in primary care can perpetuate misconceptions regarding their knowledge and expertise among primary care professions, limiting audiologists and S-LPs potential contribution to patient management within a CIPC team. Trust, a crucial component of teamwork, relies on respect and communication across individual, team, and organizational levels (Hamilton et al., Reference Hamilton, Layden, Storrar, Skinner, Harden and Wood2024). In an effort to improve health providers’ trust and understanding of audiologists’ and S-LPs’ roles within CIPC, educational modules have been developed by the authors of this paper (Glista et al., Reference Glista, Moodie, O’Hagan, Pichora-Fuller, Carey, Cooke, Cooper, Sindrey, Orange, Cameron-Turley, Bataineh, Alaniz, Pfingstgraef and Wilson2024b; Moodie et al., Reference Moodie, Glista, O’Hagan, Gavarkovs, Pichora-Fuller, Carey, Cooper, Cameron-Turley, Cooke, Orange, Sindrey, Alaniz, Bataineh, Pfingstgraef and Wilson2024). These modules focus on the roles and scopes of practice for audiologists and S-LPs, and how they can support the goals of primary care. Such educational tools can pave the way for the provision of collaborative care, and the enhancement of care for patients with complex communication disorders. As primary care responds to current pressures, it becomes crucial for organizations, teams, and providers to willingly collaborate with new team members to fully leverage the advantages of CIPC teams.