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One in four Ontarians may be without a family doctor by 2026, analysis says

KELLY GRANT  – HEALTH REPORTER

The Globe and Mail – PUBLISHED Oct 26, 2023

More than 4.4 million Ontarians could be without a primary-care physician by 2026, according to a new analysis that predicts a substantial increase in orphaned patients as older doctors retire and younger ones turn away from traditional family practice.

New figures released Wednesday by the Ontario College of Family Physicians show an estimated 26 per cent of residents in Canada’s most populous province may not have a regular primary-care provider three years from now, up from an estimated 18 per cent at the end of this year.

“We know that we’ve been facing a crisis in family medicine, and I think what we’re seeing with this new data is that the crisis is worsening,” said Mekalai Kumanan, president of the OCFP and a family doctor in Cambridge. “It really is incredibly worrisome to see our forecast showing one in four people in Ontario may be without a family doctor by 2026.”

The new forecast is the latest alarm bell rung by the OCFP, which advocates for family doctors in a province that generally boasts better primary-care access than most other parts of the country, according to Statistics Canada.

The national statistical agency’s most recent data from 2021 suggest that 14.4 per cent of Canadians don’t have a regular health care provider, while in Ontario that figure is just over 10 per cent.

However, the OCFP’s analysis goes deeper than the surveys that underpin Statscan’s estimates. The college’s model draws on the work of Inspire Primary Health Care, a network of family medicine researchers who use health administrative data, including Ontario Health Insurance Plan records, to forecast how looming retirements will affect supply.

The OCFP analysis also takes into account the anticipated growth in Ontario’s population – driven mostly by immigration – and the number of new family doctors this year and each of the next three years, but assumes they will be less likely to practise comprehensive, cradle-to-grave family medicine than their predecessors.

Those who do are expected to enroll fewer patients and be more inclined to split their time between traditional family practice and other types of medicine, according to Kamila Premji, an Ottawa family physician whose research has found that the proportion of Ontario doctors practising comprehensive family medicine fell to just more than 65 per cent in 2022 from 77.2 per cent in 2008.

After considering those factors, the OCFP developed a model that predicted the number of Ontarians without a family doctor will rise from an estimated three million by the end of this year to estimates of 3.5 million next year, 3.9 million in 2025 and 4.4 million by the end of 2026. In September, 2022, there were 2.2 million Ontarians without a family doctor, up from 1.8 million in March, 2020, when the COVID-19 pandemic hit.

Nick Cristoveanu is hoping more young doctors will embrace the joys of family medicine, a profession he found deeply meaningful, despite its challenges. He was one of six doctors from a practice in Kingston who retired in May after years of fruitlessly searching for a replacement.

“Without me getting too tearful here,” Dr. Cristoveanu, 69, said, “after 42 years in practice you’re so connected to people. I looked after four generations of families at the same time. … It’s hard to leave people like that in a lurch.”

Hannah Jensen, a spokeswoman for Ontario Health Minister Sylvia Jones, said in a statement the government is working to increase the supply of doctors by opening more medical school seats, removing barriers for internationally educated doctors, and letting health workers registered in other provinces start working in Ontario right away.

The province is also expected to announced this fall the winning proposals for a $30- million fund for the creation or expansion of new inter-professional primary-care teams.

Marilyn Crabtree, the clinical lead of the Great River Ontario Health Team, which helps to co-ordinate care for about 125,000 people in Cornwall and the surrounding area, is waiting to hear whether the province will endorse her group’s $9.3-million proposal.

Dr. Crabtree’s hope is that more options for team-based practice will reduce burnout, enticing more trained family doctors to actually offer cradle-to-grave care. “The biggest thing we have to get our heads around,” she said, “is that no matter what we do, we can’t create hundreds or thousands more family doctors and nurse practitioners in the short term.”

The Globe and Mail

 

 

in Need Posted by Developer

What Are Primary Health Care Teams?

Ontario Primary Health Care Teams: Better Care. Healthier Families. Best Value.

Around the world, cost-effective and high-performing health systems share a common characteristic: they are based on a foundation of comprehensive primary care.

Primary health care teams are teams of inter-professional health providers that provide comprehensive primary care. Although team composition may differ, they typically include family physicians or nurse practitioners who work in concert with other healthcare providers, such as nurses, dietitians, social workers, and pharmacists.
AFHTO members have as many as 15 different health care providers that work in team-based care. These providers work together to care for the whole patient in delivering comprehensive primary care.

Defining Comprehensive Primary Care

Comprehensive primary care is the foundation of a high quality, sustainable and integrated health care system. Evidence demonstrates that investments in a robust primary health care system lead to a higher performing health system with better patient outcomes and less costs. And it will keep people out of the hospital hallways by giving them the care they need closer to home.

Jurisdictions that are high performing place primary care at the center of health care delivery and are supportive of the pillars of the Patient’s Medical Home and Patient Medical Neighbourhood for readily accessible care, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated with other services in the health care system and the community. The health of people refers not just to the physical well-being of an individual but to the social, emotional, cultural, and spiritual well-being of the whole community in which everyone is able to achieve well-being of their community.

The concept of comprehensive primary care is congruent with that of the Patient Medical Home. The US National Committee for Quality Assurance–Patient Centered Medical Home  identified the key elements as follows:

  • Enhance Access/Continuity
  • Identify/Manage Patient Populations
  • Plan/Manage Care
  • Provide Self-Care Support/Community Resources
  • Track/Coordinate Care
  • Measure/Improve Performance

AFHTO supports support Dr. Barbara Starfield’s observation that comprehensive, relationship-based, patient-centered care is the foundation of a sustainable healthcare system. And that relationship is strong in primary care.
You can read more about AFHTO’s approach to measuring comprehensive primary care through the Starfield Model here.

Most of our members are Family Health Teams (FHTs), and we also represent some Nurse Practitioner Led Clinics (NPLCs), Community Health Centres (CHCs), and other interprofessional models of primary care.
We represent primary care teams.

What is a Family Health Team?

  • Family Health Teams (FHT) are not for profit primary health care organizations that include health care providers, such as nurses, social workers, dietitians, pharmacists and many others, who work with affiliated/associated physicians and other community providers to provide comprehensive primary care to patients, their families and their communities.. Each Family Health Team has programs and services that are designed to help meet local health and community needs, including Indigenous family health teams whose care focuses on the health and social needs of local Indigenous peoples.

What is a Nurse Practitioner led Clinic?

  • Nurse Practitioner-Led Clinics (NPLCs) are not for profit primary health care organizations that provide comprehensive, accessible, person-centred and coordinated primary care services to people of all ages and stages in over twenty communities across Ontario. NPLCs improve the quality of care through enhanced health promotion, disease prevention, primary mental health care and chronic disease management, as well as improve care coordination and navigation of the health care system. Engaging patients as full partners in their care plan is an important aspect of the underlying philosophy of NPLCs.

What is a Community Health Centre?

  • Community Health Centres (CHCs) are non-profit organizations that provide primary health and health promotion programs for individuals, families and communities. A health centre is established and governed by a community-elected board of directors.

CHCs work with individuals, families and communities to strengthen their capacity to take more responsibility for their health and wellbeing. They provide education and advice on helping families access the resources they need from other community agencies. CHCs work together with others on health promotion initiatives within schools, in housing developments, and in the workplace. They link families with support and self-help groups that offer peer education, support in coping, or are working to address conditions that affect health. As such, the Community Health Centre Program contributes to the development of healthy communities.

You can find a primary care team near you here.

AFHTO

in Need Posted by Developer

The Value Of Team-Based Care

Providing Value

Primary care teams provide value for health dollars by speeding up access to care, and offering a wider range of programs and services to promote health and manage chronic disease. They bring together the variety of skills needed to help people stay as healthy as possible.

Evidence from British Columbia suggests that a very sick patient without access to high quality primary care can cost the province’s system $30,000 a year. The same patient, when aligned with a care model providing comprehensive primary care, can cost just $12,000.

Making Progress

Ontario has made significant progress building a more coordinated and comprehensive primary care system to meet the needs of patients and governments. The building blocks of this new system are inter-professional primary care teams who combine the expertise of a range of health professionals to provide comprehensive primary care.

Primary care teams are participating across the province in new programs to identify our sickest patients and develop new ways to better manage their care. It is work that will help the system manage costs and ensure providers are working with better information and with the same objectives.

MEETING LOCAL CHALLENGES WITH LOCAL SOLUTIONS:

  • In Prince Edward County, the local FHT created a cardiac rehab program for residents to easily access a physiotherapist,registered nurse, dietitian, social worker and physician specialist.
  • In Kitchener, the local FHT created a dementia clinic for patients to access family physicians, pharmacists, nurses and social workers with geriatric mental health experience.
  • In Lambton County, the FHT there created a mental health care team to deliver more cost effective and collaborative care. Its success led to developing a teen suicide prevention program and an early detection program for dementia.

At present, about 25-30% of Ontarians can access team-based primary care. The logical question is – how do we expand access to primary care teams and get the best value from this investment?

AFHTO has combed the research literature to find the answer. From this we assembled the evidence, presented a set of principles for optimizing the value of teams and offered an initial set of recommendations to get started.

Evidence Of Added Value:
TEAMS IMPROVE TIMELY ACCESS TO PRIMARY CARE

Patients in primary care teams report higher levels of access to care, compared to Ontario residents in general. Key drivers for enhancing patient access include after-hours clinical services, reduced wait times, and inter-professional services. Patients are able to see the right provider, at the right time.

  • AFHTO Data to Decisions (D2D) report shows that AFHTO members are performing better than the provincial average on same day/next day access (40% better).
  • Interprofessional Collaboration in Ontario’s Family Health Teams: A Review of the Literature (2014)
  • External evaluation report on family health teams (2014) shows that almost 80% of patients reported that they are able to get an appointment with their family doctor or primary care provider on the same day they need one.

PATIENTS EXPERIENCE BETTER CARE COORDINATION IN PRIMARY CARE TEAMS

Effective care coordination leads to more seamless transitions for patients and families, reduces duplication, increases quality of care, facilitates access, and contributes to better value by reducing costs. Primary care is an anchor for patients and families to navigate through the healthcare system.

The primary care team model improves care coordination by increasing communication between healthcare providers through the use of a common electronic medical record (EMR). Ensuring a level of systems integration that is currently lacking across different models of primary care in Ontario. This kind of seamless integration improves communication among providers, results in less conflicting advice from care providers, and facilitates the transfer of data between providers.

  • Patient Experiences of Care Coordination and Communication
  • Interprofessional Collaboration in Ontario’s Family Health Teams: A Review of the Literature (2014) found coordination and collaboration to be an outcome of the team approach to care.
  • External evaluation report on family health teams (2014) showed that less than 10% of patients receiving care in teams felt they had received conflict advice from different providers.

TEAM-BASED PRIMARY CARE SUPPORTS IMPROVED MANAGEMENT OF CHRONIC DISEASE

About one in three Ontarians live with a chronic condition. For those over age 65, close to 80% have a chronic condition; of these, 70% live with two or more conditions. The bulk of chronic disease management is provided through primary care but most physicians simply do not have enough time to address all chronic disease needs in a standard visit.

The team model gives ready access to interprofessional health providers that deliver diverse professional expertise and access to the resources and skills required to manage the “whole patient”, and the knowledge of and connections to external services and supports in the community.

  • Interprofessional Collaboration in Ontario’s Family Health Teams: A Review of the Literature (2014)

AFHTO

in Need Posted by Developer

ONTARIO COVID-19 SCIENCE ADVISORY TABLE BRIEFS ON PRIMARY CARE

OCTOBER 03, 2022

Brief on Primary Care part 1

Health systems with strong primary care achieve better health outcomes and improved health equity at lower cost.1–3 Primary care offers a critical entry point into both COVID-19- and non-COVID-19-related care by providing people with the “Four C’s” of first contact, continuity, comprehensiveness, and coordination.4 The international community has therefore repeatedly called for a focus on strengthening primary health care both in general, and in particular to support COVID-19 pandemic response and recovery.5–8

In Canada9 and internationally,10–15 primary care clinicians (PCCs) have played an integral and varied role in the pandemic response. The term “primary care clinicians” in this context refers to family physicians/general practitioners, primary care nurse practitioners, and other inter-professional health providers working in community health centres, primary care clinics, and teams in Ontario, including nurses, pharmacists, social workers, and others. Additional providers supporting primary care teams for First Nations, Inuit, and Métis (FNIM) communities may include Indigenous Cultural Service Providers such as Traditional Healers, Knowledge Keepers, Medicine People, Language Holders, and others.

Primary care spans the life-course, supporting preventive, prenatal, well-child, chronic disease, mental health and addiction, and elder care in an environment that must consider the specific circumstances, needs, values, and preferences of the person and family for whom they are caring. PCCs are central to the healthcare system, supporting patients to navigate and access specialized care and community-based interventions and supports. PCCs work in urban and rural communities as well as in long-term care, correctional facilities, homeless shelters, and academic settings.

Ontario, with its population of over 14.8 million people and projected growth of 5.6 million people over the next 25 years,17 has a large and growing demand for primary care. On any given day, many more Ontarians need to access a primary care clinician than hospital or specialist services (Figure 1).18,19 Indeed, Ontario faces a significant challenge in keeping up with demand for primary care at baseline, but also in potential pandemic waves to come and throughout health system recovery.

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Primary care is a critical entry point into both COVID-19- and non-COVID-19-related care in Ontario. Primary care clinicians (PCCs) played an integral and multi-faceted role in Ontario’s pandemic response. This included a rapid transition to virtual care; participating in testing, treatment, and wraparound services for COVID-19; providing education and support to local communities to increase vaccine uptake; and more recently, catching up with non-COVID care despite fixed resources. COVID-19 care is increasingly being integrated into primary care practices but without added resources or supports. At the same time, PCCs are supporting patients who experienced missed or delayed care through the pandemic. Practices funded to include interprofessional teams have inherently had more flexibility to support both the pandemic response and catch-up of non-COVID-19 care.

…
As the pandemic has continued, COVID-19-related work has increasingly been integrated into PCPs without additional supports or resources. PCCs with direct funding for inter-professional teams have inherently had more resources to support both COVID-19 and non-COVID-19-related care. In the current phase of the pandemic and beyond, the role of PCCs will be especially important given high levels of deferred care; long waits for specialty care and diagnostics; a rise in mental health and addictions issues; persistent gaps in health equity; and the need for clear communication to the public about how best to access the system and what to expect on the road to health system recovery.

Brief on Primary Care part 2

Primary care is a crucial component of pandemic and health emergency preparedness, response, and recovery. It is also essential to continued health system improvement, person-centred care in communities, and optimal population health for Ontarians. A capacity crisis in primary care has deepened during the COVID-19 pandemic. Urgent efforts are needed to address the factors that limit primary care provision. This will include ensuring an

infrastructure that supports coordinated and integrated primary care. It will also include ensuring the training, support, and retention of interdisciplinary health human resources (HHR) that comprise teams providing care associated with patient enrolment models (PEMs), so they are equitable and accessible for all Ontarians before, during, and after public health emergencies.

…
A lack of PCCs across the health professions that work in primary care threatens the success of Family Health Teams (FHTs), which have proven to be an important model of primary care in Ontario.
…

Primary care is crucial to ongoing pandemic preparedness, response, and recovery. As the capacity crisis in primary care deepens and demand continues to increase, there is a pressing need to address the factors that limit primary care provision before, during, and after pandemics. This requires training, supporting, and retaining the interdisciplinary HHR that comprises team-based models of care.

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Ontario’s growing, multi-morbid, and aging population needs increased access to primary care, but this demand cannot be met by current numbers of PCCs.11,12 Shifting physician demographics, impending retirements, shifts away from comprehensive family practice, limited service provision by some PCCs during the pandemic, and burnout across PCCs pose an accelerating threat to the provision of primary care in Ontario.

…
Ontario’s family physician workforce is aging, with an increasing proportion of Ontario family physicians nearing retirement.
In addition, an increasing proportion of Ontario family physicians in every age group and at every career stage is shifting away from comprehensive practice and into focused scopes of practice…
Further exacerbating these challenges is the declining proportion of graduating medical students ranking family medicine as their first choice of specialty when applying to residency.

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The reasons for shifts away from comprehensive primary care… include …

  • Lack of the inter-professional team-based supports necessary to respond to trends in older patient age, increasing patient complexity independent of age, and increasing complexity in managing chronic diseases.
  • Lack of administrative and operational supports, with the costs and time commitments of running a business seen as drawbacks by many new physicians who would prefer to focus on patient care.
  • Difficulty accessing predictable forms of compensation… This is especially a consideration given that45% of new graduates carry over $100,000 in medical school debt in addition to their undergraduate

    education debt, which is, on average, $28,000.

  • Additionally, the pandemic appears to have exacerbated burnout rates across all physician groups,including family physicians …

    Also of concern is that 21.9% of Ontario nurses in primary care report an intention to retire within four years.31,32 Based on the unfilled positions in Family Health Teams (FHTs) for nursing and other inter-professional health care providers, the declining interest in comprehensive primary care likely extends beyond the physician workforce, signaling a need for a comprehensive approach to address shortages in all areas of HHR in the primary care sector.

    …
    Health systems with stronger primary care have better population health outcomes, and evidence indicates this

is likely facilitated by a core set of mechanisms commonly termed “the Four C’s”: first contact, continuity, comprehensiveness, and coordination. Models of care, or the way in which health services are organized and delivered, are important for realizing these “Four C’s”. …patient enrolment models (PEMs) that formally attach patients to a regular source of primary care, patient attachment to team-based models of care, and inter- physician practice variations, have been important determinants of access, continuity, and outcomes…

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In Ontario, there are many practice models. These range from solo, fee-for-service physicians to team-based, capitated FHTs, community-governed Community Health Centers (CHCs) Nurse Practitioner-led clinics (NPLCs), and various other models. There is no easily accessible central registry of PCCs or clinics in Ontario, which impairs communications to and between PCCs. There are also no clear governance structures at the regional level, although this may be addressed by the emerging structure of Ontario Health Teams (OHTs), where groups of clinicians and organizations aim to become clinically and fiscally accountable for delivering care to a defined geographic population. Ontario’s current fragmented primary care landscape stands in contrast to greater coordination across the sector in other Canadian jurisdictions, such as Alberta, and in many international comparators, such as the UK, the Netherlands, and Australia.

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Continuity of care with a primary care professional or team is associated with improved access, better preventive care, decreased utilization, decreased health care costs, improved health, decreased mortality, and improved patient satisfaction. Continuity of care can also foster more person-centred care, including greater trust and confidence in a person’s medical care, as well as joy and meaning in a clinician’s work.45 In the Ontario context, a PEM is a model in which there is a formal relationship attaching the patient to a PCC (“rostering”). In most PEMs, primary care physicians work in groups which have some accountability for after-hours access. Overall, evidence indicates physicians participating in group practices such as PEMs are more likely to offer after- hours appointments, use an electronic medical record (EMR), and participate in quality improvement initiatives

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Team-based care builds on the concept of the PEM. In a team, as with a PEM, the patient is formally attached to a regular source of primary care. In addition, primary care teams include inter-professional health care providers (e.g. nurse practitioners, nurses, physician assistants, social workers, dieticians, pharmacists, occupational therapists, etc.) who collaborate with primary care physicians to serve patients’ health and social needs. Evidence indicates that health care teams, aligned to the needs of the population (the “medical home”) and networked / integrated within the health system, support the best health outcomes. The mechanism is likely the enhancement of the “comprehensiveness” described in the “four Cs”.

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Prior to the pandemic, these benefits were contested in some Ontario models. While an early evaluation of team-based care (the FHT model) suggested few benefits,54 a more recent review conducted by a third party for the Ministry of Health found that FHTs improved patient and clinician experience and improved quality of care (better after-hours access, better quality, and cost neutral).

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The benefits associated with team-based care have been prominent throughout the pandemic. As described in detail in part 1 of this Ontario Science Table Brief,57 throughout COVID-19, teams have inherently had the flexibility and inter-professional resources to meet their patients’ and communities’ needs to a greater extent than have non-team-based primary care practices.

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In view of the evidence to date on the benefits of teams, the increasingly complex needs of Ontario’s aging patient population, and rising concerns around the added strain of the possible long-term, disabling effects of COVID-19,59 it seems clear that teams will play a key role in pandemic recovery, future preparedness, and ongoing health system functioning. Despite this, the availability of teams in Ontario remains persistently low. In

general, Canadian primary care physicians are less likely than physicians in other countries to work in inter-professional models. Ontario is on the low end of Canadian jurisdictions for the proportion of primary care physicians who use personnel, such as nurses or case managers, to monitor and manage care of patients with chronic conditions that need regular follow-up care (Figure 2).43 Across Canada, the proportion of physicians in solo practice varies from 9% to 25%; at 17%, Ontario is in line with the average.

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Within the context of the general trend towards teams, team composition in Ontario has been variable in terms of team size, membership, funding models and structure, and allocation to populations who will benefit the most. Ontario currently has 101 CHCs, 25 NPLCs, 184 FHTs (72 rural and 44 Northern) and 10 Aboriginal Health Access Centres.60–63 The vast majority of team-based care in Ontario is delivered by FHTs, who serve approximately 3.4 million Ontarians,61 or less than 25% of the population. As is the case for attachment in general, access to teams is inequitably distributed in Ontario and does not align with needs. Patients living in urban areas, new immigrants, and sicker patients are less likely to be in an FHT.47,51,64 Figure 3, which depicts patient attachment to a FHT based on their local OHT catchment area, demonstrates that access to team-based care is highly dependent upon where one lives.

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Ontario’s ability to meet its primary care HHR needs during the recovery phase of the pandemic will depend, to some extent, on PCCs’ ability to work in team-based models of care. Access to teams is likely to be a determining factor in medical students’ decision to enter the specialty of family medicine, practicing physicians’ decision to provide comprehensive primary care, and the ability to retain PCCs in the coming decade. Longitudinal data indicates an increasing preference among family physicians of all age groups to practice in team-based models of care.15 Capitation models provide income security and better align payment with the principles of continuity and comprehensiveness compared to fee-for-service models.
FHT-based models also support inter-professional PCCs to help physicians manage increasingly complex patient care.53 These models also represent the practice environment in which medical students and residents learn the required competency of collaborative, team-based care as part of their family medicine training. Newer primary care models (capitation models with or without team-based care, i.e., not fee-for-service) are associated with lower total health care costs for patients compared to the traditional fee-for-service model, despite higher primary care costs in some models.67 This adds to national and international literature supporting investment in primary care as a means to reduce overall health system spending.1,68 Recent Ontario data also suggests that primary care teams have led to reductions in ED use…
Work satisfaction, examined separately from financial satisfaction, has also been found to be higher among family physicians working in non-fee-for-service settings, a finding that is highly relevant to HHR recruitment and retention.71 Further work is needed to determine the optimal model (roles, composition, and teamwork) that best aligns with the Quadruple Aim in Ontario Health’s Vision for Health Care in Ontario; that is, improving the patient and caregiver experience, improving the health of populations, reducing the per capita cost of health care, and improving the work life of clinicians.72 All of these factors will have important effects on primary care capacity.

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In early 2015, limitations were introduced that reduced eligibility for physicians to enter capitation models.73 Although Ontario recently loosened these restrictions,74 there remain logistical requirements, such as group co- location, that may impede entry in some communities, particularly for physicians where operational considerations (e.g., existing building leases) affect their mobility. Further, insufficient team-based care remains unaddressed, with no significant expansion of FHT numbers since fiscal year 2011/12.

…

Brief 2 Interpretation (summary)

The practice and capacity of primary care in Ontario have changed since the start of the COVID-19 pandemic. Primary care is facing an accelerating capacity crisis driven by trends in HHR, varying models of care, and gaps in integration and coordination. These complex factors, when coupled with longstanding health system challenges, pose an ongoing threat not only to coordinated pandemic response and future pandemic preparedness, but also to routine health system functioning.

Changing physician demographics, impending retirements, shifts away from comprehensive family practice, and burnout across the professions that comprise PCCs are important trends undermining primary care HHR capacity. A lack of team-based supports, administrative and operational challenges for those starting their own practice, and unpredictability of fee-for-service compensation models, may all be contributing to the HHR crisis. These affect not only physicians but all PCCs. A lack of PCCs across the health professions that work in primary care threatens the success of FHTs, which have proven to be an important model of effective primary care in Ontario.

Primary care is crucial to ongoing pandemic preparedness, response, and recovery, continued health system improvement, person-centred care in communities, and population health. As the capacity crisis in primary care deepens and demand continues to increase, efforts are needed to address the factors that limit equitable primary care provision. These include training, supporting, and retaining the interdisciplinary HHR that comprise team-based models of care, and upporting PEMs that are equitably accessible to all Ontarians and aligned with the Quadruple Aim outlined in Ontario Health’s Vision for Health Care in Ontario; that is, improving the patient and caregiver experience, improving the health of populations, reducing the per capita cost of health care, and improving the work life of clinicians.

…

Brief on Primary Care part 3

We summarized five lessons learned to date during the pandemic:
Lesson 1: Care provided in formal attachment relationships and through team-based models provides superior support for COVID-19- and non-COVID-19-health issues in the community.
…

Investments are needed to increase the number of Ontarians formally attached to a primary care clinician supported by a primary care team.

During the COVID-19 pandemic, patients who had a formal and continuous relationship with a PCC had better access to virtual and in-person care. … Specifically, formal attachment to a PCC was a key determinant of being able to continue to access care, and team-based PCCs were more fully able to participate in a wide range of pandemic-response activities. The ability to adapt to the emerging pandemic response needs while continuing to deliver regular primary care was demonstrated as teams rapidly shifted, redeployed, and innovated in their roles. The value of primary care teams in responding to the pandemic was described by the Organisation for Economic Co-operation and Development (OECD) as the capacity of teams to re-organize tasks and services to respond to community needs, often through leveraging digital tools and/or linking with community services. In contrast with solo PCCs, multidisciplinary, team-based primary care practices (e.g., with multiple family physicians and/or nurse practitioners working along with inter-professional colleagues in nursing, pharmacy, social work, community health and other disciplines within primary care) were better able to support integration with other parts of the health system as well as community organizations.

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Ontario needs more PCCs, including family physicians, nurse practitioners, physician assistants, primary care nurses, pharmacists, and other primary care clinicians.

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COVID-19 response and recovery will be aided by an increase in the number of Ontarians formally attached to primary care and this must be pursued even as the traditional workforce contracts. This will only be possible through advancing team-based primary care, which should take place in the context of clear expectations and accountability for access, equity, and continuity at the team and individual level.
A plan must be developed to expand team-based resources with a view to improving access to primary care teams for more Ontarians. Investments should be accompanied by clear expectations for impact on access and equity as measured through ongoing evaluations. This should start with teams and clinicians who are prepared to serve historically and/or currently under-served and under-resourced populations.

…
Hospitals, clinics, and PCCs should continue to build stronger links in their regions, either directly, or through the local OHT, or both.

Science Table

in Need Posted by Developer

Primary Care in Ontario is in Crisis.

Family physicians providing primary care are the backbone of our health care system. People without access to primary care are forced to utilize walk-in clinic or hospital emergency rooms. Neither of these options are designed to provide ongoing comprehensive care to Ontario residents. Hospital Emergency Departments are overrun with non-urgent issues and wait times have grown well beyond capacity.

Small rural hospitals normally staffed by the local family physicians. This typically means these physicians have somewhat lower rosters of patients resulting in more unattached patients in their communities. Such is the case in the town of Carleton Place, Mississippi Mills, and the bordering township of Beckwith.

The health care system has, to date, focussed much of its efforts on long term solutions such as increasing opportunities for medical school education or supporting foreign trained doctors. While these are important initiatives, neither adequately address the province’s immediate crisis.  

Family physicians are leaving their practices in record numbers due to burnout, unmanageable workloads, administrative burdens etc. All of these challenges can be addressed with very simple solutions. Providing our family physicians with the appropriate level of qualified support will enable our doctors to perform the work they were trained to do. 

Physician Burden

The average family doctor is forced to run his or her practice as a small business. Administrative duties such as staff management, financial management, bookkeeping, clinic maintenance, managing IT systems such as their EMR, phone systems and internet all fall under the doctor’s responsibility.

Additionally, each family doctor will be required to work an average of extra two to three hours per day managing patient needs like, phone calls to patients, ordering diagnostic test, referrals to specialists, completing insurance, legal, employment and government required forms. It should be noted, that much of this work is not compensated for.

A family doctor usually employs an administrative staff member. This person would be responsible for answering phones, booking patient appointments, greeting patients, sending consultation requests to specialist physicians, managing incoming documents, billing non-insured and government funded through OHIP services, and office and medical supply inventory control.

The family doctors in Carleton Place as well as many other small communities do not have appropriate clinical support. For the average doctor, this means on average 45 to 60 minutes of work each day providing clinical services that could easily be provided by qualified nursing staff.  

Below are some examples of efficiencies that can be realized when a family doctor is properly supported.

Nursing Support 

Many family doctors are not able to afford hiring and paying nursing staff to support their practices. The cost of this comes directly from the revenue they receive billing OHIP. Nursing salaries can be cost prohibitive.

RPN Triage

The nurse triage program in Almonte is served by a Registered Practical Nurse. This staff member answers calls from patients who may have an acute issue that requires attention. 

  • Average calls triaged per month – 35.
  • Number of calls that resulted in an appointment – 19.
    • The nurse was able to record the presenting complaint in the EMR for the doctor to read, making the patient visit much more efficient. 
  • Number of calls where no appointment was necessary – 16.
    • The nurse providing medical advice on symptom management without the need to see their family doctor.

This resulted in an average of 46% of triaged calls not requiring the physicians time or 3 appointments per day.

RPN Clinic Nursing Support

The family doctors in Almonte are supported by clinic nursing for many routine services such as: childhood and adult immunizations, allergy serum injections, wound dressing, stiches, or staple removal post-surgery, etc. 

  • Our clinic nurses see on average 4 patients per day supporting a family doctor. This results in a time savings of 45 minutes for each physician.

Registered Nurses

Registered nurses can be utilized to care for simple medical conditions. Utilizing Medical Directives, (a written directive from a physician to a nurse that provides instruction on how to deal with specific medical conditions), RNs are able to treat patients without physician intervention. Some examples of these conditions are, uncomplicated urinary tract infections, wart treatments, blood pressure checks, ear infections, etc.

Nurse Practitioner, (NP) Support

Nurse Practitioners are able to see patients for the majority of routine medical issues. The average NP salary is $120,000 per annum which far exceeds the average primary care doctor’s ability to afford. The NP provides primary care as well as acute, episodic care. 

  • The NP can see an average of 25 patients per day. 
  • On average 15 would be seen for primary care. 
  • Ten patients would be seen for same day/next day acute care.
  • The goal of the NP Program is to provide patients alternatives to seeking care at the local Hospital Emergency Department. At the inception of this program, there was a marked reduction of patients visiting the ED for lower acuity visits.

The Solution

It’s clear to see why family doctors are choosing to leave their medical practices.  They simply can’t keep up with the demands of providing comprehensive care to their patients. Doctors need to be provided with both administrative and clinical support as well as lessen the financial stressors that comes with providing care.

If you consider the numbers illustrated above, you can see that patients would be much better served if family doctors were appropriately supported.

  • A simple nurse triage service with direct access to a patient’s family doctor can free up 45% of unnecessary patient visits.
  • Clinic nursing support frees up at least three to four patient appointments per day.
  • Utilizing Medical Directives for Registered Nurses allows doctors to focus on providing better care to more patients.
  • Nurse Practitioners can utilize their skills to deliver both primary care as well as episodic care that can result in an additional 10 to 20 patients seen each day.
  • Additional administrative support can alleviate the physician’s burden currently required to manage his or her practice. 

These solutions require a financial investment 

 

 

 

in Need Posted by Developer

Lessons from a city that solved the family doctor shortage

ANDRÉ PICARD  – HEALTH COLUMNIST

The Globe and Mail  – PUBLISHED OCTOBER 23, 2023

Psst: Don’t tell anyone, but there’s a city in Canada where everyone who wants a family doctor has one. There are also several clinics accepting new patients.

“This didn’t happen by accident,” says John Crosby, a family doctor in Cambridge, Ont., who just retired after 50 years of practice. “We had a problem and we worked hard to fix it.”

With 6.5 million orphan patients nationwide, the lack of access to primary care is arguably the number-one problem in Canadian health care today.

Cambridge offers up some lessons on how to fix it.

A picturesque city along the banks of the Grand and Speed Rivers, Cambridge was one of the first relatively urban places in the country to experience a doctor shortage.

Back in the year 2000, the city in the tech triangle was booming, and local business leaders worried that poor access to health care would scare workers away.

They created a task force of community leaders to find solutions. Their first move was hiring a full-time physician recruiter. Local doctors also worked together to ensure Cambridge was a good place to practice medicine, especially family medicine.

Today, the city of 150,000 – a number that’s gone up sharply over the past two decades – has 88 family doctors, including seven taking new patients.

Almost all of them work in group practices, a combination of family health organizations, family health teams, a community health centre, and a nurse practitioner-led clinic. (As in every province, Ontario has experimented with various models for delivering primary care, but the common trait is teamwork, and payment models other than fee-for-service.)

Doctors in Cambridge co-operate in ways rarely seen in other communities. They share on-call shifts across practices, making themselves available to patients after hours in such a way that each physician is on-call only once a month. There is also one doctor in town who does almost all the house calls. The fees collected for home visits are very small, but a doctor with no overhead from a brick-and-mortar practice can make a go of it in terms of revenue.

But back to recruitment.

The role of Donna Gravelle, the sole employee of Doctors4Cambridge, is to help fill every position that comes up, whether it is a doctor retiring or a clinic expanding.

She recruited seven family doctors last year and has at least seven more positions to fill in the coming year.

Ms. Gravelle casts her net at medical schools and job fairs for interns, and personally fields calls from those looking for work.

“Having someone knowledgeable answer the phone makes a big difference,” she says. Too often, this task falls to a beleaguered secretary, even in towns and cities desperate for workers.

Ms. Gravelle says her main job is making sure potential recruits see what their future could be. What matters most these days is work-life balance: a good job, but also a nice lifestyle.

“To be honest, Cambridge sells itself,” she says. “But I’m the tour guide.” The recruiter works to learn what interests potential recruits and takes them to visit schools, sporting facilities, places of worship, or wherever. She can also help spouses find work – often a key factor for couples.

For medical students and residents, there is a week-long tour that includes everything from shadowing local doctors to canoeing local rivers with active seniors, and everything in between.

Locums – where doctors (typically younger ones) fill in for those who are off on holidays, maternity leave, or sick leave – are also a key source of recruitment because they provide a taste of practising and living in the community.

“You have to get them early before they’ve decided where to settle,” Ms. Gravelle says.

Increasingly, communities are offering financial incentives to woo doctors, everything from cash signing bonuses, to free rent on clinic space, to subsidized housing. But Doctors4Cambridge has never done so. Ms. Gravelle says incentives may attract doctors temporarily but they won’t necessarily stay. “Retention matters. We want people to stay in our community long-term,” she says.

Recruitment is getting tougher because there is a lot more competition. But as someone who has been doing this for a long time, Ms. Gravelle has advice for policy- makers: “You have to change the way family medicine is run. More teamwork, but also more attention to work-life balance.”

In other words, we know how to fix this problem. Instead of provinces and cities competing for the scarce number of family doctors available, we need to recruit more potential family docs to the profession and keep them working by creating a decent workplace.

It’s not rocket science; it’s common sense.

The Globe and Mail

in Need Posted by Developer