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