harnessing an innovation agenda for primary care ... · respect to emerging primary care...

Harnessing an Innovation Agenda for Primary Care Transformation

Primary Care Innovations across Canada and Future Directions for British Columbia

Monica Aggarwal, PHD Thomas G. O’Shaughnessy, MSc

kpmg.ca

http://www.kpmg.ca

Foreword 1

Foreword from KPMG International 2

Introduction 3

Current State of British Columbia’s Primary Care System 6

Primary Care Innovations in Canada 8

Conclusion 22

Appendix A: Canada’s Primary Care Performance 24

Appendix B: British Columbia’s Primary Care Performance 36

Appendix C: Characteristics of Emerging Primary Care Models in Canada 39

Sources 40

Contents

© 2014 KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.

Health care in Canada has faced, and continues to face, calls for reform, innovation and transformation. A fundamental question on the minds of every Health Minister, policy maker, provider, and health care organization is how to deliver better patient outcomes at a lower cost.

Much is made of reforms that seek to shift services and resources from the acute system to the community and to primary care settings, in response to a growing recognition that a wide range of services can be appropriately and effectively delivered outside of expensive hospital settings, not to mention patients’ own preferences to receive care closer to home and in their own communities.

In order for this to happen our primary care systems require strengthening. There are lots of reasons why Canada has seen substantial federal investment in primary care renewal over the past several decades, and why some provincial governments have made strengthening primary care their raison d’êtres.

For many jurisdictions, this quest for improvement continues. It continues because improving people’s “health,” keeping people well and out of hospital, helping people better manage chronic diseases, are all fundamental to achieving better health outcomes, lower mortality, a more equitable system and ultimately lower overall costs.

To make this point, our paper provides a systematic overview of pan-Canadian evidence, and offers, I think, some interesting reflections on which Canadian provinces are leading the way in strengthening primary care, with a particular focus on British Columbia.

I am privileged to have been able to collaborate with Dr. Monica Aggarwal, as well as a number of my KPMG colleagues, who have been advising leading provinces in successfully implementing primary care innovations for several years now, to bring this research and these observations forward for some fresh discussion and dialogue.

The evidence is more than clear around the benefits of a strong primary care system. That’s evidence not only worth paying attention to, it is evidence that we must act upon as a key driver to improve the whole of health care.

Thomas G. O’ShaughnessyHealth Sector Advisory Lead (BC)Associate Principal, KPMG

Foreword


Harnessing an Innovation Agenda for Primary Care Transformation | 1

Primary care is a vital building block of many successful health systems. It is however coming under strain as health systems look to this sector to deliver a wider range of preventative, diagnostic and treatment services 24/7, typically as part of plans to reduce reliance on inpatient hospital care and enable better co-ordination of care for groups such as the frail elderly, those living with mental health problems, and vulnerable families.

The model traditionally used to deliver primary care in many countries has not changed significantly for many years. Very often primary care:

• is delivered by small independent practices with limited access to a wider multidisciplinary team;

• is based on a model of inflexible and short appointment slots only available from Monday to Friday within normal working hours;

• is unable to offer telephone, email, Skype or other modern access to medical and nursing advice;

• has inadequate diagnostic support; and

• is insufficiently connected to specialists, community based services (e.g. pharmacy) and other resources that could help it function more effectively.

Changes in the patterns of disease, expectations, workforce and across the whole of health care means that primary care needs to change.

Our report, The Primary Care Paradox – New Designs and Models, presents the results of discussions with primary care experts from Europe, brought together in Brussels by the Nuffield Trust and KPMG.

This report provides a unique global perspective on these issues and explores a range of innovative primary care models being implemented across Europe in particular.

We hope that the report’s findings, taken together with Harnessing an Innovation Agenda for Primary Care Transformation, will be able to contribute to the ongoing efforts of Canadian policymakers and health care providers in driving innovation in their primary care systems.

Nigel EdwardsDirector, Global Health ReformGlobal Strategy, KPMG in the UK

Foreword from KPMG International


2 | Harnessing an Innovation Agenda for Primary Care Transformation

IntroductionHealth systems with a high-performing primary care1 sector achieve

better health outcomes, better equity, lower mortality rates, and lower overall costs of health care.i,ii,iii,iv There is consensus in Canada and

internationally that the transformation of health care systems must be built on a foundation of high-performing primary care. A high performance

system is one that is accessible, person-centred, safe, effective, efficient, and equitable. It is also one that is driven by evidence that is coordinated and

oriented toward population health.i

The purpose of this paper is to identify and synthesize the evidence with respect to emerging primary care innovations across Canada, as well as to offer

insight on potential strategies to further strengthen the primary care system in British Columbia.2

Over the past decade, primary care renewal has been on the agenda across Canada. Several provinces and territories have initiated a range of new strategies,

including:

• group practices and networks

• multidisciplinary team-based care

• diverse funding and payment arrangements

• patient enrolment

• electronic medical record implementation

• mechanisms to promote patient engagement

• quality improvement programs.v,vi

This activity has been precipitated for the most part by federal investment in primary care renewal efforts; as well as changes in patterns relating to diseases, expectations, workforce,

and other factors across the health care spectrum. These have served to catalyze the need for significant changes in primary care systems. As such, greater innovation in primary care is fast

becoming a burning priority for health systems around the globe in their effort to ensure that it can serve the needs of modern users.

Canada’s primary care system performance faces certain challenges when compared to other high-income countries (United States, United Kingdom, Australia, Netherlands, New Zealand,

Germany).vii Specifically, Canada is behind best-performing countries on timely access to care; communication across health care settings; development of inter-professional teams; adoption of

1 The terms primary care and primary health care have been debated, analyzed, and defined in a variety of ways. This paper will use Aggarwal and Hutchison’s definition of primary care as the “spectrum of first-contact health care models from those whose

focus is comprehensive, person-centred care, sustained over time, to those that also incorporate health promotion, community development and intersectoral action to address the social determinants of health”. Aggarwal, M. and B. Hutchison (2012).

Towards a Primary Care Strategy for Canada. Ottawa: Canadian Foundation for Healthcare Improvement.2 This paper draws on a draft report prepared for the Health Council of Canada by Dr. Monica Aggarwal and Dr. Brian Hutchison on

behalf of the Canadian Working Group for Primary Healthcare Improvement. This material is used with the permission of the Health Council of Canada.



electronic medical records; systematic feedback on performance; and addressing health and health care inequities (Refer to Appendix A for detailed information).viii,ix,x,xi,xii,xiii,xiv

Over the past several decades, there has been ample evidence and experience in terms of the features and impacts of high-functioning primary care. According to the research, high-functioning primary care systems have these attributesi:

• Explicit policy direction and objectives for primary care are based on public needs, values and preferences.

• Governance mechanisms are implemented at the local, regional, and provincial levels to foster an orientation to population health, system integration and joint accountability.



Figure 1

• Inter-professional teams of primary care providers work collaboratively to provide comprehensive, person-centred, accessible, continuous and responsive care to patients.

• Financial incentives are aligned with health system goals.

• Patients and providers have access to well-designed information technology that supports evidence-based clinical care and decision-making; enhanced communications among providers and between providers and patients; population health management; performance measurement and management; quality improvement; and coordination of care.

• All participants are provided with appropriate evidence-informed quality improvement resources to assist in their delivery of high-quality care.

• Patients, families, and their caregivers are engaged in decision-making at the organizational and system level and are partners in their care.

• The primary care system is coordinated and well integrated with other health and social services in the community.

• Systematic evaluation of innovation, primary care research is undertaken as well as ongoing measurement of the performance of the primary care system.

With this knowledge, jurisdictions have unique opportunities to assess and implement their own primary care innovation. As such, we envision a primary care system for British Columbia that is centred on people, their families and caregivers and which is built on a foundation of high-performing primary care. Such a system is portrayed in Figure 1.

Community Resources & Social Services

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Adapted from Charles Kilo’s “Primary Care Oriented Health System” model by the Health Quality Ontario Primary Care Quality Improvement Team



During the 1990s, the federal government established the $800 million Primary Health Care Transition Fund (PHCTF) to support provinces and territories in their efforts to develop and implement primary care renewal initiatives.i British Columbia used this funding to develop an inter-professional model of care through 14 primary health care organizations (PHCOs).xv

Over the past decade, British Columbia has invested significant resources into the revitalization of the primary care sector.3,xvii In 2002, the province established the General Practice Services Committee (GPSC), a joint committee of the Ministry of Health, the British Columbia Medical Association (BCMA), and the Society of General Practitioners of British Columbia.

The mandate was to recommend solutions to support and sustain full-service family practice in British Columbia.xviii

In 2006, the Ministry and BCMA established the Shared Care Committee, which has equal representation from the Specialist Services Committee4 and the GPSC.xix, xx The Shared Care Committee has introduced a variety of initiatives to meet its mandate including a Partners in Care Referral Program; financial incentives for telephone consultations; and various pilot shared care programs.xx Together these committees have played an important role in introducing new initiatives, evaluating their impact and spreading innovation across the province. In the past decade, the majority of new investments for primary care renewal in British Columbia have been provided to the GPSC.xxi

In 2007, British Columbia published the Primary Health Care Charter, founded on the philosophy of “Patients are Partners”. This Charter establishes a vision of what

will be accomplished in the primary care sector by 2017.xxii In the same year, British Columbia was the first and only province to establish the First Nations Health Authority, whose mandate is to transform health services for First Nations and Aboriginal people in the province.xxiii

The recent results of the 2012 Commonwealth Fund International Health Policy Survey of nine Canadian provinces (excluding Prince Edward Island) indicated that British Columbia’s investments have resulted in high performance with respect to access to same-day or next-day appointments and home visits, as well as the enablers of quality improvement (i.e. investment in financial incentives and the adoption of electronic medical records). However, there are opportunities for improvement with respect to access to after-hours care (Figure 25), and coordination with hospitals (Figure 3) and specialists (Figure 4) (Refer to Appendix B for detailed information).

Current State of British Columbia’s Primary Care System

3 An assessment of PHCOs indicated that the potential benefits of the model were not “fully realized.”xvi,xxi To date, the original model has not been significantly expanded throughout the province and provides services only to a portion of British Columbians.

4 The mandate of the Specialist Service Committee is to support the delivery of specialist physicians in British Columbia by facilitating collaboration between the Government of British Columbia, the British Columbia Medical Association, and Health Authorities.

5 Figures 2–4 have been adapted from Health Council of Canada (2013). How do Canadian primary care physicians rate the health system? Survey results from the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Doctors.xi The results are based on responses from 2,124 Canadian primary care physicians who participated in the 2012 Commonwealth Fund International Health Policy Survey.



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Physicians who say they always recieve a report back from specialists withall relevant health information

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Physicians who say they are always notified when their patients go to the emergency department

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Figure 3

Figure 2

Figure 4



Primary Care Innovations in Canada

Primary Care Governance Mechanisms In order to transform the system, achieve better alignment of care and ultimately deliver the care people need, provinces require a clear vision and policy roadmap that articulates goals for the primary care system and strategies to achieve them.i

Effective governance, administration, and managerial structures between health ministries, health authorities and primary care at the local/regional level is critical to the establishment of mutual accountabilities which drive change, adoption of best practices, and system integration.i To date, there have been various efforts in Canada in this direction.

In 2008, British Columbia established local organizations of family physicians (called the Divisions of Family Practice) that participate in joint health-service decision making with their regional health authority.v This innovative practice allows for groups of local family physicians to work together to improve clinical practice and offer comprehensive services to patients, as well as identify gaps in service delivery in the community.ci,xiv,xxv The Divisions work with their Health Authority,

the GPSC and the Ministry through Collaborative Service Committees (CSCs), which is co-chaired between the local Division and Health Authority.

A case study of one Division of Family Practice showed the following results:

• Greater interaction among family physicians

• More ownership and accountability by family physicians for the implementation of projects

• Increased engagement by physicians in decisions about service delivery

• Greater implementation of initiatives to address community issues.xxvi

In 2005, Alberta established Primary Care Networks (PCNs). PCNs are not-for-profit corporations consisting of a group of family physicians that work with multidisciplinary health care providers to provide a comprehensive array of primary care services to patients.xli,l The not-for-profit corporation and Alberta Health Services (AHS) sign joint venture agreements.xxvii The PCN is governed by a joint Governance Committee, which consists of two representatives from the physicians’ organization and two representatives from AHS. This

committee is responsible for the PCN, oversight of the business plan and budget and its implementation.xxvii

Québec, however, is the only jurisdiction to implement governance structures that enable the oversight of primary care services at the regional and/or local levelsi,v though Alberta is undertaking some emerging work in this area as well. The Regional Departments of General Medicine (DRMG) were established in 1991. These operate under the authority of regional health authorities and consist of all general practitioners practicing in the region. The purpose of DRMGs is to engage physicians in providing recommendations to the health authority on human resources planning.v

Québec introduced significant transformation by developing Centres de la santé et des services sociaux (CSSSs)xxviii with the goal of moving from service-based to population-based responsibility in order to improve the health of geographically defined populations.xxix,xxx This entity was created by merging various health organizations – i.e. Centres locaux de services communautaires (CLSCs), residential and long-term care



centres and hospitals – under a single governance structure in the same local health region. The practice has been launched in 95 local areas covering the entire province. In this model, CSSSs enter into service agreements with partners in their local services networks, including physician-run practices and some CLSCs. Initial evidence indicates that this governance structure has facilitated greater integration between health and social care sectorsxxix,xxxi among other benefits.xxix

Inter-Professional TeamsThere is growing evidence that collaborative primary care teams improve patient health and quality of life, especially for those with chronic conditions.i In Canada, evidence is emerging on the positive impact of integrating a range of professionals.

To date, all jurisdictions in Canada have implemented multidisciplinary teams of inter-professional primary care.i Several provinces and territories have expanded the number and/or types of primary care providers (e.g., registered nurses, nurse practitioners, pharmacists, midwives, physician assistants) through the creation of employment opportunities, licensing requirement and regulation changes, and incentives for family physicians.v

Despite these efforts, there is significant variability on the degree to which these teams have been implemented on a system-wide level. Some initiatives have focused on targeting specific patient populations (Québec); others are focused on geographic needs (Saskatchewan and Nova Scotia); and others on pilot and local initiatives (Manitoba and Prince Edward Island).

In summary:

• Québec launched the Integrated Network Clinics (clinique-réseau intégrée or CRI) in Montreal, which focus on providing services to vulnerable populations.xxxii

• Saskatchewan’s Primary Health Bus innovation services low-income neighbourhoods in Saskatoon.xxxiii The Health Bus is a mobile clinic staffed by nurse practitioners and paramedics that provides daily primary care services to patients at various locations that are convenient to residents.xxxiv Early evidence suggests mobile clinics improve screening for chronic conditions (diabetes and hypertension) and coordination of care.xxxiv The province has also announced the implementation of inter-professional teams at eight primary health care innovation sites.xxxiv

• Recently, Manitoba adopted a similar practice with the implementation of three nurse-led mobile clinics.xxxv The province has also established Physician Integrated Networks (PINs), a physician-led pilot initiative focused on quality-based incentive funding and integration of the electronic medical record for charting, indicator management and use of clinical practice guidelines.xxxvi Some PIN clinics have hired inter-professional health care providers.xxxvi Manitoba is also developing inter-professional teams through Primary Care Networks (PCNs).xxxvii

• Nova Scotia has implemented Collaborative Emergency Centres (CECs) in rural areas of the province. These Centres were established in response to frequent closures of emergency rooms and long wait times for appointments with primary

care providers, as well as to reduce pressure on rural family physicians who service emergency departments overnight.xxxviii

• Prince Edward Island has established Primary Care Networks in five geographical areas, which are comprised of five health centres of family physicians, nurse practitioners and advanced practice nurses and in some communities the team also consists of inter-professional providers.xxxvii

Alberta, Ontario and Québec stand out as the leaders in the country for the widespread implementation of multi-disciplinary teams. For example:

• Ontario introduced Family Health Teams (FHTs) and Nurse Practitioner Led Clinics (NPLCs). FHTs and NPLCs consist of a team of inter-professional primary care providers. The NPLC is led by a mixed model of nurse practitioners and community representatives.

• Québec has supported the development of physician-led organizational models through Family Medicine Groups (FMGs) (also called Groupe Médecins de Famille or GMF). FMGs commonly include nurses and administrative staff with the option to include other inter-professional health care professionals. This differs from FHTs and NPLCs whose premise is the integration of a variety of inter-professional health care providers.

• Alberta has taken a similar approach as Québec through the implementation of Primary Care Networks (PCNs). They have also recently begun to implement Family Care Clinics (FCCs).



CASE STUDY Family Health Teams

The implementation Family Health Team model across Ontario is a unique example of the diffusion of primary innovation across Canada’s most populous province.

In business plans prepared for the Ministry, the first FHTs were asked to identify the number of patients they expected to sign-up over the coming years and how the resources provided by the Ministry would support this goal. The Ministry also asked FHTs to implement an EMR, develop patient-centred care programs and create linkages with community partners.

With these broad guidelines, each FHT was able to define the team size, composition, governance model, partnerships and program mix, as well as develop an implementation timeline that would best suit its community.

Between 2006 and 2011, the Ontario government established 200 FHTs in which there are 185 entities (due to amalgamations of FHTs). As of September 2013 there are 2,716 family physicians and 2,022 other primary health care professionals working at a FHT. These providers include 739 nurses, 355 social workers, 496 nurse practitioners, 161 dietitians, 95 pharmacists, 95 registered practical nurses, and 936 administrative support staff. Almost 3 million Ontarians (22% of the provincial population) are currently enrolled with a FHT physician.xxxix

Preliminary evaluations of these primary care innovations suggest that primary care teams have the potential to improve access, effectivenessxl,xli,xlii,xliii health promotion and disease preventionxli,xliv,xlv and patient-centred care.xl,xli On the other hand, there is room for improvement in the following areas:

• Development of collaborative teams;liv,xlvi

• Design of compensation models;lxviii

• Building partnerships in the community;xlvi

• Coordination of care between family physicians and specialists;xlvii and• Implementation of organizational accountability mechanisms.xlviii

Several studies have indicated that the success of these models is contingent on:

• The type of governance model;l • Effective leadership;xlix,l,li,lii • Development of strong connections and relationships between team providers;l • Standardized measurement of outcomes;l • Ongoing research and evaluation;l • Group and developmental culture;lii,xlii • Definition of roles and scopes of practice;xlvi,l,liii

• Providing a framework for understanding inter-professional interventions to support inter-professional collaboration;xlix

• Adequate space;xlix and • Use of electronic medical record functionality.li



Patient Enrolment and AttachmentFormal patient enrolment (‘rostering’) with a primary care provider establishes accountability for a defined population and fosters a proactive, population-based approach to preventive care and chronic disease management.i It also allows for performance measurement and quality improvement.i In Canada, evidence suggests attachment of high users to a primary care practice increases continuity and lowers cost of care.liv,lv There is also a proven association between having a family doctor and fewer unmet needsxxxii as well as better coverage of clinical preventive services.lvi

Across Canada, jurisdictions have implemented various innovations to improve patient access to primary care providers. For example:

• To facilitate attachment of patients to family physicians, Ontario and Québec have implemented mechanisms for formal patient enrolment.v An Ontario study shows that the acute length of stay in hospitals declined by 2.1% for patients enrolled with family physicians – equivalent to $85 million in hospital expenditures.lvii

• British Columbia has introduced “A GP for Me” program (also known as the Attachment Initiative), which offers financial incentives to family

doctors who provide longitudinal care to patients.lviii These fees are for telephone consultations with patients, additional time for patients with chronic complex conditions, and acceptance of high needs patients. The Divisions of Family Practice are receiving funding over three years to develop a community plan for improving local primary care capacity and determining the mechanisms for facilitating patient attachment to a family physician.

• To address the concern of unattached (or “orphaned”) patients without a primary care provider, Ontario, Québec and Prince Edward Island



implemented Health Care Connect,lix Access Registries,lx and Patient Registry Programlxi respectively. These initiatives directly coordinate the connection of unattached patients with accepting primary care providers. All of these initiatives require unattached patients to register by telephone with the provincial service (Ontario, PEI) or local network (Québec). In Ontario and Québec, financial incentives are provided to family physicians for accepting complex-vulnerable patients from the registry.lxii

Funding and Provider Payment Arrangements Aligned with Health System GoalsOver the last decade, there has been increasing focus on payment models for primary care physicians. The general conclusion of this work is that jurisdictions should consider designing blended payment models that focus on results and outcomes, optimizing incentives associated with fee-for-service,6 salary, capitation and pay for performance models.i

In most jurisdictions in Canada, fee-for-service (FFS) arrangements continue to prevail as the dominant form of payment to family physicians and general practitioners.lxiii Ontario and the Northwest Territories are the only jurisdictions that have significantly shifted away from FFS models and moved towards blended payment or salary arrangements.i,v

British Columbia, Ontario, Alberta Québec and Manitoba have all explored pay-for-performance (P4P) financial incentives. British Columbia launched the Full Service Family Practice Incentive Program (FSFPIP), which provides a comprehensive array of FFS incentive payments to all general practitioners for providing services to chronic patients, delivering babies and sharing care between specialists and inter-professional health care providers.7,lxiv,lxv

Physician Reimbursement ModelsTo date, Ontario is the only province that has experimented with a variety of the payment models for primary care physicians. This has created a rich environment for assessing their impact. Over time, the province has introduced five primary care models: Community Health Centres (CHCs, a salaried model); Family Health Groups (FHGs, a blended fee-for-service model); Family Health Networks (FHNs, a blended capitation8 model); Family Health Organizations (FHOs, a blended capitation model); and Family Health Teams (FHTs, an inter-professional team model that enhances FHNs and FHOs).lxviii Currently capitation payments in blended capitation models are adjusted based only on age and sex. However, efforts are underway to adopt more sophisticated risk adjusted approaches that incorporate acuity and other factors.

Early evidence comparing the outcomes of these models indicates that no

reimbursement model stands out in improving the health of the population, enhancing the patient experience of care, and/or reducing – or at least controlling – the per capita cost of health care. This is because these payment systems remain input based; physicians are compensated for treating a certain condition, not necessarily for the outcomes or results it achieved.

With respect to the evidence, blended fee-for-service models were found to serve patients that resemble the profile of the provincial population.lxviii These models have also been found to increase physician productivity (as measured by the number of services, patient visits, and distinct patients seen); result in lower referral rates; and treat slightly more complex patients than traditional FFS physician practices.lxvi The evidence is mixed however on their impact with respect to patient use of emergency departments.lxvii,lxviii

Blended capitation models were found to serve higher income populations,lxviii lower number of newcomers;lxviii,lxix and serve patients with lower patterns of chronic disease, morbidity and comorbidity.lxviii,lxix Patients in this model were more likely to visit emergency departments.lxviii To prevent unintended outcomes, the design of capitation payments must take into consideration expected health care needs, patient complexity and/or socioeconomic disparitieslxxvi and ultimately desired results.

6 Fee-for-service is a payment model in which primary care providers are paid per service delivered.7 Payments are provided for: providing care to patients with diabetes mellitus; congestive heart failure; chronic obstructive pulmonary

disease and hypertension according to clinical guidelines; delivering babies; training for maternity care skills; developing clinic-actions plans and discharge plans for frail elderly palliative care patients; patients with mental illness or with co-morbidities; developing plans for high-risk patients with two or more chronic illnesses; health risk assessments of patients in targeted populations; providing cognitive behavioural therapy and ongoing management services to mental health patients; and promotion of shared care with specialists and inter-professional health care providers.xvii, lxiv

8 Capitation is a payment model in which primary care organizations/primary care providers are paid per patient for an established period of time.



Pay For Performance (P4P)Emerging evidence indicates that the impact of P4P financial incentives in Canada is mixed or modest.

• British Columbia’s evaluation of the Full Service Family Practice program found that more patients were seen for congestive heart failure, diabetes, hypertension, complex care and mental health.lxx General practitioners who actively used these incentive payments also increased attachment of the proportion of patients (defined by majority source of care (MSOC)).lxxi

• In Ontario, P4P incentives increased uptake of preventive procedures including seniors’ influenza vaccinations, pap smears, mammography, and colorectal cancer screening.lxxii Over time, there were significant changes for colorectal cancer screening but the impact was minimal for cervical cancer screening and breast screening.lxxii There was no significant change in vaccinations for toddlers,lxxii diabetes carelxxiii and for special payments for priority services (obstetrical services, hospital services, palliative care, office procedures, prenatal care, or home visits).lxxii

• In Manitoba, P4P incentives improved testing for identified patients in accordance with clinical practice guidelines.lxxiv More patients were screened for colon cancer, dyslipidemia, nephropathy screening for diabetic patients, full fast lipid profile screening and obesity screening for hypertensive patients.lxxiv Less significant changes were observed for blood pressure testing in diabetes patients, and blood pressure measurement for hypertensive and coronary artery disease patients. A feasibility study found increasing breast and colorectal cancer screening avoided cost to the health care system while cervical cancer screening increased costs.lxxv

The British Columbia, Ontario and Manitoba experience with P4P financial incentives indicates mixed impacts: some have resulted in significant uptake by physicians while others have resulted in only modest impacts on care.

Health Information TechnologyInvestment of information technology in primary care practices is essential for supporting evidence-informed clinical care and decision-making; identification of patients’ care needs; performance measurement; quality improvement; patient engagement; and care planning, and coordination across the continuum of care.i Systematic integration of information allows for health care planning and evaluation, as well as informing resource allocation at the local, regional, provincial and national levels.i

British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, and the Northwest Territories have invested significant resources to encourage the adoption of electronic medical records (EMRs) by family physicians. The highest proportion of family physicians reporting they are adopting an electronic medical record is in Alberta, Ontario, Nova Scotia, British Columbia and Saskatchewan.xi



Other significant milestones of note include the following:

• Saskatchewan and Nova Scotia introduced financial incentives for use of the EMR system.lxxvii Physicians receive monthly payments for booking, billing and documenting patient visits in Saskatchewan. A utilization grant (for using functionality based on eligibility thresholds) is also provided to physicians in Nova Scotia.

• Alberta recently announced plans to eliminate the Physician Office System Program (POSP) since the aim of adoption – 80% of GPs have an EMR – has been achieved. The next phase of EMR implementation will focus on meaningful use of data and integration outside the physician’s practice.

• An innovative practice that is emerging in Alberta is the integration of patient health records on the wireless devices of health care providers.lxxviii This technology offered by a private company provides mobile access to patient data from old or new EMRs, electronic health records and imaging results from the Picture Archiving and Communication System (PACS). Physicians throughout Alberta are adopting the technology.

• In Ontario, a pilot project entitled the “Mental Health Engagement Framework” is focused on providing access to personalized health records on smartphones/tablets to mental health patients and their mental health care professionals. The goal is to provide mental health patients with better access to the health care system; empower them to actively manage their health; and reduce the number of emergency room visits and

hospital admissions.lxxix The province is also developing an e-referral project through the Ontario Telemedicine Network.

• Manitoba initiated a unique electronic practice to improve coordination between family physicians and specialists. This Bridging General & Specialist Care (BGSC) initiative is an information technology system that facilitates referrals between family physicians and specialists.lxxx Based on agreed-upon referral guidelines established by family physicians, specialists and allied providers, it allows primary care providers to submit patient information to the system for a specialist consult, as well as monitors patient wait times. Declined referrals can be automatically re-directed to alternative specialists.lxxx In 2011, the province also announced the creation of the eReferral initiative, which will integrate this technology as part of the electronic medical record.lxxxi

British Columbia is also in the process of developing the Physician Data Collaborative (PDC), a unique initiative that enables doctors to collaboratively use EMR-generated clinical data to improve patient care. The initiative is driven by front-line physicians and owned and controlled by the Divisions of Family Practice.lxxxii PDC’s distributed data network will collect patient-level information from participating practices (e.g. number of patients with a diagnosis of diabetes). This information will be summarized across practices and physicians to generate reports that will allow for comparisons amongst practices within a community or region.

Ongoing Performance Measurement/ManagementSystematic, ongoing performance measurement at the practice, organizational, local, regional, provincial and national level is essential for assessing the impact of health services planning, management and quality improvement activities; and to enable accountability.i

In Ontario, CHCs are the only primary care model that has accountability agreements with regional entities relating to the development, collection and reporting of information on key quality indicators of health equity, value, affordability and quality of care.lxxxiii The province recently required FHTs, NPLCs, Aboriginal Health Access Centres (AHACs) and CHCs to submit quality improvement plans (key priorities include access, integration and patient-centred care).

In Alberta, PCNs are required to produce evaluation plans. In Ontario, there are no requirements to report on specific quality indicators. However, both provinces are in the process of developing/implementing a performance measurement framework for primary care.

Overall, there has been minimal progress across the country in systematically measuring primary care performance and reporting back to providers, payers, and patients.

Quality Improvement Training and SupportContinuous quality improvement is crucial to primary care transformation and improving quality of care, health outcomes and efficiency.i



To that end, British Columbia, Alberta, Saskatchewan, Ontario and New Brunswick have implemented quality councils, each with the responsibility to build capacity and expertise for quality improvement.lxxxiv In Saskatchewan, Ontario and New Brunswick, these councils are also mandated to publicly report on the health care system. In Québec, the Health and Welfare Commissioner (Commissaire a la santé et au bien-etre) is responsible for the continuous assessment of the health and social services system and providing recommendations to the Minister on the changes that are needed to enhance the performance of the health and social system.lxxxv

There is also a growing recognition across the country of the need to support quality improvement training of primary care providers. Several provinces have embarked on implementing initiatives to improve access to training and support for primary care providers. For example:

• New Brunswick and Nova Scotia have created online communities that allow providers to communicate and collaborate with each other to improve patient care.

• Manitoba and Nova Scotia, New Brunswick, Newfoundland and Yukon are providing training support to providers on specific topics including advanced access, mental health, diabetes and obesity respectively.lxxxvi,lxxxvii,lxxxviii,lxxxix

• Alberta, British Columbia, Saskatchewan, Manitoba and Ontario have the most comprehensive system-wide implementation of quality improvement training for primary care providers.



• British Columbia, Alberta and Ontario have all launched programs based on the Institute for Healthcare Improvement (IHI) Breakthrough Learning Series approach.

• British Columbia has established the Practice Support Program (PSP), which provides physicians and their medical office assistants (MOAs) with peer-to-peer training by coaches on a variety of topics.9,xvii Evaluation of the program over three years shows consistently high satisfaction ratings and perceived impact on GP practices and patients.xc

• Access Improvement Measures (AIM) is an Alberta initiative that supports family physicians, specialists, Alberta Health Services programs and their teams to reduce or eliminate wait times and improve office efficiency.xci Early evaluation of the program suggests that many primary care teams reduced delays for next available appointments to less than five days; improved cycle time for short and long appointments; and lowered the number of no-shows.xci

• Ontario also launched the Quality Improvement and Innovation Partnership (QIIP) (now Health Quality Ontario) whose mandate is to support quality improvement training for primary care providers. Initially the training was available to FHTs and CHCs. Over time, the province has expanded the service to all primary care providers. An evaluation of the initiative indicates that participation in the collaboratives: increased participants’ knowledge of quality improvement methods; improved their

understanding of inter-professional roles; and enhanced the performance of participating and control practices over time.xcii

• Saskatchewan launched the Chronic Disease Management (CDM) Collaborative under the Saskatchewan Health Quality Council to facilitate quality improvement for the care of diabetes, coronary artery disease, depression, and chronic obstructive pulmonary disease.xciii

• Manitoba has implemented Manitoba IMPRxOVETM, a unique initiative designed to improve safety and health outcomes for patients receiving medication for mental health conditions.xciv

Patient EngagementA high-functioning primary care system must be premised on a patient-centred approach. Mechanisms need to be in place to support patient engagement in their own health care; in the care delivered to them at the practice level; and in the design and planning of health care services.i

British Columbia, Ontario, New Brunswick, Prince Edward Island and Newfoundland and Labrador have each implemented programs to support self-management for patients with chronic conditions.xcv,xcvi,xcvii,xcviii

To date, British Columbia is the only province that has invested in the engagement of patients at the individual, organizational and system level. The province supports several self-management programs including the innovative Bounce Back Program,

9 Learning modules include: advanced access and office efficiency, chronic disease management, group medical visits, patient self-management, adult mental health, end-of-life module, chronic obstructive pulmonary disorder/heart failure, child and mental health, musculoskeletal care. Participants are remunerated for their involvement in the program.xvii



which addresses mild to moderate depression for referred patients by providing self-help materials (DVD) and telephone health coaching in the patient’s home.xcix This service is available to patients through physician referral.

British Columbia’s Patients as Partners program was driven from the embedded philosophy of the provincial government to create a patient-centred system in which patients, families and caregivers work in partnership with health system decision makers.c Impact BC has instigated the Patient Voices Network (PVN), an innovative practice that recruits, trains and supports patients, families and their caregivers to facilitate a dialogue with patients on how to make changes to primary and community care.ci In addition, ThinkHealthBC.ca is an interactive website that engages the public in an open dialogue about innovations in health care and how to improve the health care system.cii

British Columbia has also implemented a pilot project, www.howsyourhealth.org, an on-line survey that allows patients to provide physicians with feedback about their health care needs and perception of care.ci The results of pilot study showed that in some practices, this initiative improved office wait time, information for patients and physicians’ recognition of the impact of a patient’s financial situation on health.

Manitoba created a Self-Advocacy For Everyone (SAFE) patient safety toolkit which provides information, tips, and resources to help people learn to be more involved in their health care

(e.g., patient rights, patient advocates, prevention of falls, health care plan, access medical records).ciii

They have also implemented a unique telephone-based or video conferencing program (TeleCARE Manitoba) that permits Manitobans with heart failure or Type 2 diabetes with limited access to services to obtain specialized advice on how to manage their condition.civ Patients are offered education and tools to assist them with the management of their health.

Coordination, Integration and Partnerships with other Health and Social ServicesThe coordination and integration of services between the primary care sector and other parts of the health and social system is not taking place at a system-wide level in any province except for Québec (Refer to Section on Primary Care Governance). British Columbia, Alberta and Ontario have invested in promoting collaboration between family physicians and specialists. British Columbia, Ontario and Newfoundland and Labrador are supporting initiatives to integrate primary care with hospital care. Recently Ontario initiated a pilot project which focuses on creating direct linkages between the primary care sector and other organizations within the local community. British Columbia launched the Integrated Primary and Community Care (IPCC) initiative, which is a province-wide effort to coordinate general practitioners and community care providers.



http://www.www.howsyourhealth.org

The following are some additional initiatives of note:

• British Columbia created the Shared Care Committee (SCC). An early initiative of this Committee is the Partners in Care Referral Program, which provides interested local family physicians and specialists with knowledge, funding, and infrastructure support for developing locally-appropriate solutions to challenges with respect to access to and delivery of comprehensive care.xx Rapid Access to Consultative Expertise (RACE) was introduced as part of this initiative in the Vancouver Coastal Health Authority. Other SCC initiatives include tele-dermatology; poly-pharmacy (focus on medication regimens for patients), youth transition initiative (for complex paediatric patients moving to adult care for youth and young adults), transitions in care initiative (patients in and out of acute care), and system redesign funding for participating physicians.xix,xx

• British Columbia has also introduced the “In-Patient Care” initiative which promotes and coordinates care of patients in transition between hospitals and primary care practices. Incentives are provided to all family physicians who are providing care to their own patients in the hospital; patients admitted in hospital without a family physician or who have a family physician without hospital privileges or who have a family physician from out of town; and patients who are in a hospital or other facility.cv

• British Columbia transitioned the Integrated Health Network (IHN) initiative to the Integrated Primary and Community Care (IPCC) initiative. The initiative focuses on integrating care for frail seniors, patients with complex chronic conditions, and those with mental health and substance use challenges.cvi In some circumstances, efforts are being made at the local level to co-design integrated primary and community care services for people with complex needs or high risk of admission through the joint Collaborative Service Committee of the Divisions of Family Practice and Regional Health Authorities.cvii

• In Newfoundland and Labrador, a regional ER Pilot project is underway in which case management services are provided to patients over the age of 50 who have presented to the emergency department five or more times in a 12 month period for at least one chronic condition and have a CTAS score of 3, 4 or 5.cviii Primary care nurses lead the program and are responsible for contacting identified patients and preparing an intensive chronic disease case management plan for consenting patients. Early evaluation indicates that the practice has decreased the number of visits to the emergency department by 27%.cvi

• Alberta and Ontario support PCNs and FHTs with funding for specialist integration. As a result, unique shared care initiatives have emerged in both provinces at the local level. In Alberta, a visiting cardiologist is on a PCN

team. In Ontario, the Inter-professional Model of Practice for Aging and Complex Treatment (Plus) has been introduced in a few FHTs. This program targets patients with three or more chronic conditions who are on five medications with a minimum of one activity of daily limitation and are not home bound or institutionalized.cix Patients are assessed in a two-hour clinic by an inter-professional team that is comprised of a family physician, community nurse, pharmacist, occupational therapist, dietician, social worker, psychiatrist, general internist, and Community Care Access Centre (CCAC) coordinator.cix

In Ontario, the provincial government also recently introduced a pilot project entitled “Health Links”. This initiative brings together local health care providers to support collaboration among primary care providers, specialist physicians, hospitals, home care and community supports, and long-term care in 19 communities to improve care for high-needs patients. All Health Links have a coordinating partner such as an FHT, CHC, CCAC or hospital.lxxvi This collaboration provides unique opportunities for organizations to identify high needs populations and build connections with each other in order to attach complex patients, share resources, develop care plans, implement strategies to reduce emergency department visits, integrate electronic information, and better utilize existing services.



Conclusion

An assessment of primary care innovations across the country indicates that significant efforts have been made to improve primary care in all provinces and territories at the provincial, regional, and local levels. While British Columbia, Alberta, Ontario, and Québec appear to have made the greatest progress toward primary care transformation, each jurisdiction has distinct opportunities to advance primary care to the level of best-performing countries.

Compared with other provinces, there is no doubt that British Columbia stands out as a leader in the establishment of primary care governance mechanisms that allow for collaboration between groups of local family physicians and regional health authorities, as well as the investment in patient engagement

initiatives at the patient, organizational, and system levels.

In addition, British Columbia has made progress with respect to the adoption of information technology, investment in quality improvement training, and support for coordination between family physicians and specialists.

Like other provinces, there are some key steps or actions that British Columbia might consider to further strengthen its primary care system. Opportunities include:

Primary Care Governance and System Coordination and Integration • Continuing to develop the Divisions of

Family Practice across the province.

• Supporting Divisions of Family Practice to build formal partnerships and accountabilities with local health and social service organizations in response to the community needs.

• Continuing the development and expansion of existing shared care initiatives across the province under the Shared Care Committee.

Inter-professional Teams and Payment Model• Exploring design of an inter-professional

team model of care that includes the appropriate structures, governance, processes, and incentives to allow for full collaboration between team members.

• Delivering services that are comprehensive, accessible, effective, and patient-centred and allow for coordination and integration with other sectors by:

– Incrementally introducing the designed inter-professional model of care to providers on a voluntary basis through an application process

– Completing a comprehensive evaluation of the inter-professional model before its expansion

• Exploring a model of remuneration that supports collaborative inter-professional teams and enables the adoption of care for vulnerable populations. This should consider the role of incentives for team-based care



and the integration between primary care and other sectors.

• Considering the development and implementation of innovative models of primary care delivery (Health Bus, NPLCs, CECs) in regions in which provider capacity is low and patient need is high.

Mechanisms That Promote Access • Continuing to explore the opportunities

for physicians to join a group practice; and for group practices to provide 24/7 access to care.

• Realizing the benefits of formal enrolment of patients with primary care providers and groups.

• Implementing local patient registries to allow for the connection of unattached patients with accepting primary care providers.

Information Technology• Continuing investments for EMR

adoption in primary care practices.

• Creating common data standards, the capacity for data sharing, and appropriate training and support for providers to ensure the meaningful use of EMRs.

• As part of the Shared Care Committee, supporting an initiative for the implementation of an e-consultation system that allows for timely referrals between family physicians and specialists.

Ongoing Performance Measurement• Developing and communicating a

clear and measurable statement of goals and objectives for which the primary care system should be held

accountable. This should be done in consultation with governments, professional and provider associations, regulatory colleges, patient groups, and other stakeholders in primary care.

• Designing a performance measurement framework with indicators and targets to examine how the primary care system is performing against its goals and objectives at practice, local, regional, and provincial levels. This should be performed in consultation with a broad range of stakeholders, including the public.

• Supporting and establishing a mechanism for proactive public reporting on performance against local, regional, and provincial goals and targets, taking into account variations in population demographics.

• Supporting providers in developing and implementing quality improvement plans, and providing support to primary care practices.

Quality Improvement Training and Support• Supporting initiatives for effective

development of inter-professional teams and implementation of quality improvement.

• Expanding the Practice Support Program to include: training for the meaningful use of EMRs; expanded roles of inter-professional health care providers in primary care practices; board governance; leadership; and organizational development (i.e. establishing legal agreements, and implementing operational processes and effective governance mechanisms).

Patient Engagement• Continuing to support the Patients as

Partners program.

• Enabling province-wide access to initiatives such as the How’s Your Health program (http://www.howsyourhealth.org/) to allow for the continual assessment and improvement of patient experiences in primary care practices.

The key steps outlined above could enhance British Columbia’s potential to improve performance, while continuing to strengthen health outcomes, patient experience and value for money at the nation’s best levels.

Like all governments facing similar burning platforms in driving primary care innovation, the challenge for payers and governments is how to create a set of incentives and a policy framework that supports the diffusion of innovation across the system. They must also hold providers and the system firmly to account without unintended adverse consequences and bureaucracy.

These suggested actions may entail many different practical solutions, but they will need to be very precise in terms of outcomes and value for British Columbians. As we have seen before, walking that fine line between difficult choices and compromises will be the key to success in achieving a primary care system that is fit for British Columbia’s future.



http://www.http://www.howsyourhealth.org/

http://www.http://www.howsyourhealth.org/

Accessibility

Indicator Sample% of Respondents(Canada)

Best Performing Country

% of Respondents from Best Performing Country

Canada’s Ranking among Countriescx

Data Source

Report having a regular doctor Adults 77% Netherlands 94% 7.5 (tied with Germany)

Commonwealth Fund, 2010

Report having a regular doctor or place of care Adults 86% Netherlands 99% 8 Commonwealth

Fund, 2010

Report having a regular doctor Sicker Adults 88% Netherlands 99% 9 Commonwealth Fund, 2011

Report having a regular doctor or place of care Sicker Adults 96% Netherlands 100% 9 Commonwealth

Fund, 2011

Report waiting 6 or more days, or were never able to get an appointment when sick

Adults 32% Switzerland 2% 11 Commonwealth Fund, 2010

Sicker Adults 23% New Zealand 5% 11 Commonwealth Fund, 2011

Report that their practice had an after-hours arrangement to see a doctor or nurse

Primary Care Physicians 43% Netherlands 97% 9 Schoen et al,

2009

Report that their practice had an after-hours arrangement to see a doctor or nurse

Primary Care Physicians 45% United Kingdom 95% 9 Commonwealth

Fund, 2012

Report almost all patients can get same- or next-day appointment

Primary Care Physicians 22% France 86% 11 Commonwealth

Fund, 2012

Report accessing medical care in the evenings, on weekends and on holidays was somewhat or very difficult

Adults 57% Netherlands 20% 11 Commonwealth Fund, 2010

Sicker Adults 51% Switzerland and United States 18% 11 Commonwealth

Fund, 2011

Appendix ACanada’s Primary Care Performance10

10 These charts have been adapted from Aggarwal and Hutchisoni and updated with information from the 2012 Commonwealth Fund.xiv,xi



Person-Centredness

Indicator Sample% of Respondents (Canada)



Canada’s Ranking among 11 Countries

Data Source

Provider-Patient Communication

Report somewhat/very easy to contact doctor by phone during regular hours


Report that when they call their regular doctor`s office with a medical question or concern during regular practice hours, they always or often get an answer the same day

Sicker Adults 50% Netherlands 79% 11 Commonwealth

Fund, 2011

Report receiving clear instructions about symptoms to watch

Sicker Adults 66% Switzerland 84% 4.5 (tied with

Australia)Commonwealth Fund, 2011

Report that someone from regular place of care explained the potential side effects of a medication

Adults with chronic conditions

73% Australia 78% 3 Commonwealth Fund, 2010

Continuity and Performance Feedback

With same doctor for 5 years or more Adults 64% Netherlands 78% 6 Commonwealth

Fund, 2010

With same doctor for 5 years or more Sicker Adults 64% France and

Netherlands 80% 7.5 (tied Australia)


Report that their practice routinely received and reviewed data on clinical outcomes of patient care

Primary care Physicians 17% United Kingdom 89% 10 Schoen et al,

2009

Report routinely received and reviewed data on patient satisfaction/ experience

Primary care Physicians 15% United Kingdom 96% 8 Schoen et al,

2009







Data Source

Patient Engagement and Preferences

Report that their regular doctor always or often spends enough time with them

Adults 80%

Germany, Netherlands, New Zealand, Switzerland

90% 8 Commonwealth Fund, 2010

Sicker Adults 77% Switzerland 96% 9 Commonwealth Fund, 2011

Report always or often having the opportunity to ask questions about recommended treatment

Adults 85% New Zealand 92% 8 Commonwealth Fund, 2010

Report they were always or often involved in decisions about their care

Adults 86% New Zealand and Switzerland 92% 7.5 (tied with

U.S.)Commonwealth Fund, 2010

Report that in the last year, a health care professional discussed main goals in caring for their condition

Sicker Adults with at least one chronic condition

67% Switzerland 81% 4.5 (tied with Netherlands)


Report their health care professional helped them make a treatment plan

Sicker Adults with one or more chronic conditions

63% United Kingdom 80% 4 Commonwealth Fund, 2011

Report that their practices routinely gave chronically ill patients written instructions on managing care at home

Primary Care Physicians 16% Italy 63% 7 Schoen et al,

2009



Safety





Data Source

Report that someone from regular place of care explained the potential side effects of a medication



Report that someone from regular place of care reviewed all medications including those prescribed by other doctors

Adults with chronic conditions taking at least one prescription medication


Report that their practice has a process for identifying adverse events and taking follow-up action

Primary Care Physicians 10% United Kingdom 56% 9 Schoen et al,

2009

Report an experience with wrong medication, medical mistake or incorrect lab test result outside of the hospital

Adults with chronic conditions that experienced wrong medication, medical mistake or incorrect lab test

86% Switzerland 68%8.5 (tied with New Zealand and United States)


Sicker Adults that experienced wrong medication, medical mistake or incorrect lab test

79% Germany 46%

6.5 (tied with Netherlands, Sweden and United States)


Report that someone from regular place of care gave them a written list of all prescribed medications


47% United States 53% 8 Commonwealth Fund, 2010

Report that practices routinely give patients a written list of medications


2009



Effectiveness




Canada’s Ranking Among 11 countries

Data Source

Prevention

Women (aged 20-64) reporting that a Pap smear was performed in the last two years

Adults 70%Canada, Switzerland and United States

70%1.5 (tied with Switzerland and United States)


Women (aged 25-64) reporting that a Pap smear was performed in the last three years


Women (aged 50-64) reporting that they received a mammogram within the past 2 years

Adults 76% New Zealand 80% 3 Commonwealth Fund, 2010

Women (aged 50-64) reporting that they received a mammogram within the past 3 years

Adults 84% Netherlands 93% 6 Commonwealth Fund, 2010

Report receiving a flu shot in the past year

Adult Seniors (≥ age 65) 68% Netherlands 83% 3.5 (tied with

U.S.)Commonwealth Fund, 2010

Report having blood pressure checked by a doctor or nurse in past year

Adults 82% France 95% 5 Commonwealth Fund, 2010

Report receiving reminders for preventive care Adults 39% Netherlands 59% 8 Commonwealth

Fund, 2010

Chronic Illness Care

Report their blood pressure had been checked in the past year

Sicker Adults with hypertension, heart disease or diabetes

97% Australia and New Zealand 100% 5.5 (tied with UK

and US)Commonwealth Fund, 2011

Report having their blood pressure measured in the last year Adults with

diabetes 94% New Zealand and France 99% 6 Commonwealth

Fund, 2010

Report having their cholesterol tested in the last year

Adults with diabetes 88% Australia 89% 2.5 (tied with U.S) Commonwealth

Fund, 2010

Report their eyes were examined within the past year Sicker Adults

with diabetes 77% United Kingdom 81% 4.5 (tied with Netherlands)


Report their feet were checked for sores or irritations

Sicker Adults with diabetes 50% United Kingdom 86% 7 Commonwealth

Fund, 2011



Efficiency





Data Source

Report using the emergency department in the past two years

Adults 44% Switzerland and Germany 22% 11

Commonwealth Fund, 2010; Health Council of Canada, November 2010

Sicker Adults 58% Germany 31% 11 Commonwealth Fund, 2011

Report they could have been treated at their usual place of care if it had been available

Adults that used an emergency room in the last two years and have a regular place of care

45% France 22% 10

Commonwealth Fund, 2010; Health Council of Canada, November 2010

Sicker Adults that used an emergency room in the last two years and have a regular place of care


Report their time was wasted due to poorly organized and poorly coordinated care


Report medical records or test results were not available at the time of an appointment

Adults 11% Switzerland 7% 9.5 (tied with Australia)


Report experiencing situations where test results or medical records were not available or reasons for referral were not available at the time of their scheduled doctor’s appointment

Sicker Adults 19% Switzerland 7% 10.5 (tied with Norway)




Equity

Indicator Sample% of Below Average Income Canadian Respondents

% of Above Average Income Canadian Respondents

Data Source

Population Health

Report their health as fair or poor Sicker Adults 45% 24% Commonwealth Fund, 2011

Report having two or more chronic conditions Sicker Adults 52% 27% Commonwealth Fund, 2011

Report hypertension Sicker Adults 33% 19% Commonwealth Fund, 2011

Report heart disease including angina or heart attack Sicker Adults 14% 6% Commonwealth Fund, 2011

Report diabetes Sicker Adults 16% 9% Commonwealth Fund 2011

Report joint pain and arthritis Sicker Adults 50% 31% Commonwealth Fund 2011

Report asthma, COPD and other chronic lung problems Sicker Adults 21% 11% Commonwealth Fund 2011

Report depression, anxiety and other mental health problems Sicker Adults 24% 16% Commonwealth Fund 2011

Report chronic back pain Sicker Adults 35% 19% Commonwealth Fund 2011

Report problems walking Sicker Adults 37% 15% Commonwealth Fund 2011

Report problems walking or dressing Sicker Adults 8% 4% Commonwealth Fund 2011

Report problems performing daily activities Sicker Adults 37% 20% Commonwealth Fund 2011

Report moderate or extreme pain or discomfort Sicker Adults 67% 50% Commonwealth Fund 2011

Report being moderately or extremely anxious or depressed Sicker Adults 31% 20% Commonwealth Fund 2011



Indicator Sample% of Below Average Income Canadian Respondents

% of Above Average Income Canadian Respondents

Data Source

Accessibility

Report waiting 6 or more days, or were never able to get an appointment when sick

Sicker Adults 28% 21% Commonwealth Fund 2011

Report having private health insurance Sicker Adults 46% 82% Commonwealth Fund 2011

Report not filling a prescription or skipping doses in the past year because of cost


Report serious problems paying medical bills in past 12 months Sicker Adults 12% 3% Commonwealth Fund 2011

Person-Centredness

Report regular doctor or someone in doctor’s practice spends enough time always or often

Sicker Adults with regular doctor or place of care 73% 79% Commonwealth Fund 2011

Report regular doctor or someone in doctor’s practice explains things in a way that is easy to understand


Report health professional has discussed main goals in caring for condition during the past year

Sicker Adults with at least one chronic condition 63% 74% Commonwealth Fund 2011

Safety

Report pharmacist or doctor reviewed and discussed all medicines in past year

Sicker Adults taking prescription medications 68% 76% Commonwealth Fund 2011

Report having a written list of medications

Sicker Adults taking prescription medications 74% 65% Commonwealth Fund 2011

Effectiveness

Report having cholesterol checked in past year

Sicker Adults with hypertension, heart disease or diabetes

81% 91% Commonwealth Fund 2011

Fair or poor rating of quality of medical care received in the past 12 months




Coordination/Integration




Canada’s Ranking amongst 11 Countries

Data Source

Report doctor always/often coordinates or arranges care Adults 68% New Zealand and

United States 69% 3.5 (tied with United Kingdom)


Report someone in doctor’s/GP’s practice always/often helps coordinate or arrange the care received from other doctors or places, such as appointments

Sicker Adults with regular doctor


Report that their specialist had information about their medical history

Sicker Adults with regular doctor and needed to see a specialist in the past two years


Report their regular GP seemed informed about the care they received from specialist

Sicker Adults 72% United Kingdom 88% 8 Commonwealth Fund, 2011

Report information from a patient discharged from hospital was available between 5-14 days of discharge

Primary Care Physicians 40% Norway 60% 7 Commonwealth

Fund, 2009

Report always receiving report with relevant health information after patient visit with specialist

Primary Care Physicians 26% Switzerland 59% 6.5(tied with

Norway)Commonwealth Fund, 2012

Report the information received from specialists is always timely and available when needed

Primary Care Physicians 11% Switzerland 27% 5.5 (tied with

United States) Commonwealth Fund, 2012

Report receiving needed information within 48 hours after patient is discharged from hospital

Primary Care Physicians 15% Germany 67% 9 Commonwealth

Fund, 2012

Report always being notified from emergency department when their patients go to visit

Primary Care Physicians 30% Netherlands 60% 6 Commonwealth

Fund, 2012

Report managing and coordinating patient care after discharge from hospital


Fund, 2012

Report coordinating care with social services and other community providers

Primary Care Physicians 88% Switzerland 97% 7 Commonwealth

Fund, 2012



Enablers of Quality





Data Source

Inter-professional primary care health care teams

Report working with non-physician staff (such as nurses) to provide primary care

Primary Care Physicians 52% Sweden 98% 10 Schoen et al,

2009

Report using nurse case managers or navigators for patients with serious chronic conditions


Fund, 2012

Report receiving financial support or incentives for adding non-physician clinicians to the practice


2009

Report being offered financial incentives to add non-physician providers to their practice team

Primary Care Physicians 33% Netherlands 60% 3.5 (tied with

Sweden)Commonwealth Fund, 2012

Performance management, clinical guidelines and incentives

Report that their clinical performance was routinely compared with other practices


2009

Report that their clinical performance was routinely compared with other practices


Fund, 2012

Report routinely receiving and reviewing data on clinical outcomes


Fund, 2012

Reports reviewing clinical performance against targets annually


Fund, 2012

Report the routine use of written guidelines to treat asthma or chronic obstructive lung disease


2009

Report the routine use of written guidelines to treat diabetes


United States)Schoen et al, 2009

Report the routine use of written guidelines to treat depression


2009

Report the routine use of written guidelines to treat hypertension

Primary Care Physicians 81% United Kingdom 96% 6.5 (tied with

Norway)Schoen et al, 2009

Report being offered financial support or incentives


2009







Data Source

Report being offered financial incentives based on high patient satisfaction ratings

Primary Care Physicians 1% United Kingdom 41% 11 (tied with

Norway)Schoen et al, 2009

Report routinely receiving and reviewing data on patient satisfaction

Primary Care Physicians 15% Sweden 90% 8 Commonwealth

Fund, 2012

Report being offered financial incentives based on non-face-to-face interactions with patients


2009

Report being offered financial incentives based on clinical care targets


2009

Report being offered financial incentives to add non-physician providers to their practice team


2009

Report being offered financial incentives to manage patients with chronic disease or complex needs


2009

Report being offered financial incentives for preventive care

Primary Care Physicians 26% New Zealand 38% 5 Schoen et al,

2009


Primary Care Physicians 70% New Zealand 83% 4 Commonwealth

Fund, 2012

Report being offered financial incentives for enhanced preventive care

Primary Care Physicians 42% Sweden 55% 2.5 (tied with

Australia)Commonwealth Fund, 2012

Report being offered financial incentives for home visits

Primary Care Physicians 54% Australia 57% 2 Commonwealth

Fund, 2012

Information Technology

Report using electronic medical records


2009



Fund, 2012

Report using electronic medical records and multifunctional Health IT Capacity (at least two electronic functions)11


Fund, 2012

Report using electronic test ordering

Primary Care Physicians 18% Italy 91% 10 Schoen et al,

2009

11 Electronic functions include: order entry management, generating patient information, generating panel information, and routine clinical decisions support







Data Source

Report using electronic prescribing


2009

Report using computerized drug alerts


2009

Report using computerized patient reminders


2009

Report using computerized physician reminders

Primary Care Physicians 9% Australia 67% 8.5 (tied with

Netherlands)Schoen et al, 2009

Report using computerized list of patients by diagnosis


2009

Report using computerized list of patients by lab result

Primary Care Physicians 23% Australia 88% 10 Schoen et al,

2009

Report electronic exchange of patient summaries and test results with doctors outside of their practice

Primary Care Physicians 14% New Zealand 55% 11 Commonwealth

Fund, 2012

Report routinely receiving electronic prompts about potential problems with Rx Dose or Interaction


Fund, 2012


Report routinely use of electronic prescribing of medications


France)Commonwealth Fund, 2012

Report easily generating a list of patients by diagnosis


Fund, 2012

Report easily generating a list of patients by lab results


Fund, 2012

Report easily generating a list of patients for tests or preventive care


Fund, 2012

Report generating a list of an individual patient’s medications


Fund, 2012

Report providing patients with a clinical summary at each visit


Fund, 2012



Accessibility

Indicator Sample

% of Respondents(British Columbia)

Best Performing Province

% of Respondents from Best Performing Province

British Columbia’s Ranking among Provinces

Data Source

Report that patients can see physician or nurse when the practice is closed, other than at a hospital emergency department

Primary Care Physicians 41% Ontario 67% 3 Health Council of

Canada, 2013

Report their practice shares after-hours services with other practices or groups


Canada, 2013

Report most or almost all patients can get same- or next-day appointment

Primary Care Physicians 62% British Columba 62% 1 Health Council of

Canada, 2013

Report making home visits Primary Care Physicians 70% British Columbia 70% 1 Health Council of

Canada, 2013

Appendix BBritish Columbia’s Primary Care Performance



Coordination/Integration

Indicator Sample





Data Source

Report information from a patient discharged from hospital within 48 hours of discharge

Primary Care Physicians 18% Nova Scotia 22% 3.5 (tied with

New Brunswick)Health Council of Canada, 2013

Report always receiving notification when patient goes to emergency department

Primary Care Physicians 45% New Brunswick 69% 3 Health Council of

Canada, 2013

Report receiving a report from specialists with relevant health information

Primary Care Physicians 32% Nova Scotia 39% 5 Health Council of

Canada, 2013

Report always receiving information from specialists in timely fashion

Primary Care Physicians 14% Saskatchewan 17%

2.3 (tied with Alberta and Nova Scotia)

Health Council of Canada, 2013

Report managing and coordinating patients’ care after discharge from hospital

Primary Care Physicians 91% Nova Scotia 93% 2 Health Council of

Canada, 2013

Report coordinating care with social services or other community providers

Primary Care Physicians 95% British Columbia 95% 1 Health Council of

Canada, 2013



Enablers of Quality

Indicator Sample





Data Source

Performance management, clinical guidelines and incentives

Reports reviewing clinical performance against targets annually


Canada, 2013



Canada, 2013

Report being offered financial incentives for preventive care


Canada, 2013

Report being offered financial incentives for home visits


Canada, 2013



Primary Care Physicians 70% Alberta 74% 2 Health Council of

Canada, 2013

Report routinely using electronic prescribing of medications

Primary Care Physicians 50% Alberta 58% 2 Health Council of

Canada, 2013

Report easily generating a list of patients by diagnosis


Canada, 2013

Report easily generating a list of patients by lab tests


Canada, 2013

Report easily generating a list of patients due for tests of preventive care


Canada, 2013

Report easily generating a list of patient’s medication


Canada, 2013

Report easily providing patients with a clinical summary at each visit

Primary Care Physicians 54% British Columbia 54% 1.5 (tied with

Alberta)Health Council of Canada, 2013



Appendix CCharacteristics of Emerging Primary Care Models in Canada

Model JurisdictionTarget Population Governance

Physician Reimbursement Model

Formal Enrolment Inter-Professional Teams

Provide Extended after hours

PCN Alberta All Residents Physician-Led

FFS and targeted incentive payments

No

Physicians, nurses, social workers, pharmacists, mental health workers, kinesiologist, exercise specialists, medical office assistants, dietitians

Yes

FHT Ontario All Residents

Physician, mixed provider or community led

Blended capitation/FFS or Blended salary and targeted incentive payment

Yes

Physicians, nurse practitioners, nurses, pharmacists, dietitians, mental health workers, social workers, chriopodists or poditarists, health educators, occupational therapist, respiratory therapists. and information technology staff

Yes

NPLC Ontario All Residents Nurse Led Salaried No Physicians, nurses, social workers

and dietitian No

FMG Québec All Residents Physician Led

FFS and targeted incentive payments

Yes Physicians and nurses Yes

CRI Québec Vulnerable Patients Physician-led Blended capitation

and FFS Yes

Physicians, social workers, nutritionists, psychologists, physiotherapists, kinesiologist, occupational therapists, respiratory therapists and pharmacists

Yes



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civ Manitoba Health. (2013). Telecare Manitoba. Retrieved October 25, 2013 from http://www.gov.mb.ca/health/primarycare/telecare.html

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cvi Government of British Columbia. (2013). BC continues to expand primary and community care. Retrieved November 22, 2013 from http://www.newsroom.gov.bc.ca/2013/03/bc-continues-to-expand-primary-and-community-care.html

cvii Thompson Region Division of Family Practice. (2013). Integrated Primary and Community Care. Retrieved November 22, 2013 from https://www.divisionsbc.ca/thompson/IPCC

cviii Health Council of Canada. (forthcoming). Health Innovation Portal: Eastern Health Chronic Disease Prevention and Management Emergency Room Pilot Project.

cix Health Council of Canada. (2013). Health Innovation Portal: Inter-professional Model of Practice for Again and Complex Treatment (Plus). http://innovation.healthcouncilcanada.ca/innovation-practice/interprofessional-model-practice-aging-and-complex-treatment-impact-plus



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