Primary Care Reform

February 5, 2018

CANADIAN FOUNDATION for HEALTHCARE IMPROVEMENT (CFHI)

To read the full report, please visit http://www.cfhi-fcass.ca/Libraries/Reports/Primary-Care-Strategy-EN.sflb.ashx

‘Toward a Primary Care Strategy for Canada’

From the summary:

PRINCIPLES OF PRIMARY CARE TRANSFORMATION

Aims and vision, however clear and compelling, are not sufficient by themselves to bring about system transformation. A thoughtful approach to the change process is also crucial. As primary care transformation proceeds at the provincial, regional and local levels – with appropriate federal support – what principles should guide the change process? We suggest the following:

◥ Strict adherence to the principles of universality and access to care based on need.

◥ An unwavering focus on public benefit, as opposed to professional or private interest

◥ Meaningful engagement of patients and citizens in system design (person-centred system design).

◥ Application of an equity lens to health services planning and measurement.

◥ Attention to the health and healthcare needs of communities and populations as well as individuals — in particular socially disadvantaged and high-needs communities and populations.

◥ A multi-faceted change strategy based on a long-term perspective.

◥ Responsiveness to local needs and context.

◥ Engagement of a full range of key stakeholders.

◥ Pluralism of primary care models.

◥ Patient choice of “regular” primary care provider.

◥ Fostering a culture of innovation

◥ Systematic, relevant and rigorous monitoring and evaluation of the impact of transformation.

FEATURES OF HIGH-PERFORMING PRIMARY CARE

This section addresses the question: What do primary care organizations, providers and the people they serve need to achieve breakthroughs in health outcomes, the experience of care and control of healthcare costs?

Based on Canadian and international evidence and experience, we consider the following features to be the fundamental elements of a high-performing primary care system. These features underpin the primary care functions of  first contact, person-focused care over time, comprehensiveness and coordination, and support the achievement of the aims identified above. None is sufficient by itself; the full array is necessary to generate major improvements.

EXPLICIT POLICY DIRECTION ANCHORED IN PUBLIC VALUES, NEEDS AND PREFERENCES

Although primary care reform has been initiated in each province, most provinces have no clearly articulated vision for the future of primary care or a transformation strategy for moving toward that vision. In our federal system, responsibility for health policy rests primarily with the provinces and territories. However, progress in primary care reform is most likely to advance rapidly and effectively if provincial/territorial efforts are informed and supported by a shared sense of direction among the federal and provincial/territorial governments.  This has been recognized by the Council of the Federation through their creation of the Health Care Innovation Working Group. Addressing areas of common interest to the provinces and territories, such as the pan-Canadian deployment of team- based models of care and clinical practice guidelines, may contribute to driving innovation, system transformation and quality improvement in primary care and other sectors of the healthcare system.

To transform the system, achieve better alignment of care and deliver the care the population needs, a clear vision and a coherent set of strategies are required. Policy roadmaps that articulate specific improvement goals for the primary care system and its role in the overall health system, together with a menu of strategies for achieving these ambitions, need to be developed.

A clearly articulated policy direction helps public servants, healthcare managers and professional leaders to maintain a focus on key health system objectives and reduce ambiguity. It also sends a clear message to the public about what it can or should expect from a high performing primary care system. A policy roadmap is most likely to command support if it is anchored in the values, needs and preferences of those who use primary care, informed by relevant evidence and experience and based on a high degree of consensus (or at least an accommodation) among key stakeholders.

PRIMARY CARE GOVERNANCE MECHANISM AT THE COMMUNITY, REGIONAL AND PROVINCIAL/TERRITORIAL LEVELS.

Given the predominance of independent, solo or small group physician-managed family practices, the primary care sector has often been likened to a cottage industry. Inclusive primary care organizations are mostly absent at the regional and local levels. As a result, primary care providers in most Canadian communities and health regions lack a collective voice and the capacity to assume shared responsibility and accountability for addressing their patients’ and populations’ needs. Effective governance, administration, and managerial structures at the local/regional level are needed to improve system integration and to support the adoption of best practices. Having an appropriate management structure between health ministries and primary care at the regional/community level ensures that an organizational body has both the accountability and the authority to drive and support change.

Australia, New Zealand and the United Kingdom have established primary care governance mechanisms to integrate primary care delivery with other health services “that seek to increase the influence of primary care organizations, and in particular general practitioners, in health planning and

resource allocation”. Although the objectives of these organizations vary, their fundamental purpose is to establish links “between activities at the micro level of care delivery (clinical care delivered by individual practitioners) and the macro level of care delivery (systems responsible for policy, funding, and infrastructure)”.

New Zealand established Primary Health Organizations (PHOs) to coordinate and deliver primary care services to a local population.  These organizations are administered as part of the activities of District Health Boards and have an explicit requirement to include a broad range of providers in the decision-making process and to focus on access, population health and care of disadvantaged groups.  These organizations have been successful in facilitating provider engagement.

Australia has implemented Medical Locals (formerly Divisions of General Practice (DGP)) to provide professional support for general practitioners (GPs), promote the involvement of GPs in local health planning, and encourage integration between general practice and other health services. These organizations have been essential to quality improvement initiatives, expansion of multidisciplinary teams, regional integration, information technology adoption and improved access to care.

The United Kingdom implemented Primary Care Trusts (PCTs) which are responsible for: assessing local needs; developing a local health system strategy; commissioning a range of preventive, primary, secondary and tertiary services; integrating health and social services; monitoring service delivery; and delivering services to their local population.

Currently, England is planning to implement consortia of general practices (Clinical Commissioning Consortia) which will give GPs control over two-thirds of the National Health Service budget for specialists and hospital care. According to Russell and colleagues, these organizations have been shown to improve access to after hours care, increase the use of electronic medical records and facilitate quality assurance activities associated with prevention and management of chronic disease.

In Canada, British Columbia and Quebec have addressed regional primary care governance, albeit through distinctly different approaches (see section on ‘Progress to Date’).

Local primary care provider organizations can respond collectively to community needs, participate with others in healthcare planning, negotiate with other sectors (e.g., hospitals and specialists) on behalf of primary care, support performance measurement and reporting, sponsor and coordinate quality improvement initiatives, and facilitate the pooling and sharing of expertise and resources among primary care practices and organizations. Ideally, primary care governance arrangements, whether at the local, regional or provincial/territorial level, need to include a broad range of primary care providers and stakeholders to promote collaboration and to provide a forum in which competing interests can be identified, explored and resolved.

PATIENT ENROLMENT

Patient enrolment is a process in which patients are formally registered with a primary care organization, team or provider. Patient enrolment facilitates accountability by defining the population for which the primary care organization or provider is responsible and facilitates a longitudinal relationship between the patient and provider.

Patient enrolment has been adopted in the United Kingdom, Netherlands, Denmark and New Zealand.

Formal patient enrolment with a primary care provider lays the foundation for a pro-active, population-based approach to preventive care and chronic disease management and for systematic practice-level performance measurement and quality improvement.94 It clarifies accountabilities and clearly establishes primary care providers as health stewards for a defined population rather than providers of services to those who present themselves for care.

INTER-PROFESSIONAL TEAMS

There is growing evidence that collaborative primary care teams can improve patient health and quality of life, especially for those with chronic conditions. Team-based care has resulted in: improvements in blood chemistry, physical and social functioning, energy, and bodily pain in patients with diabetes; fewer days per year of symptoms in children with asthma; fewer psychological and behavioural symptoms in patients with Alzheimer disease and improvements in distress and depression in their caregivers; improvements in emotional role function, social function, bodily pain, mental health, vitality, and general health in terminally ill patients; and weight reduction by obese patients.

Primary care teams can reduce emergency department use, improve access to care and enhance patient satisfaction. An examination of systematic reviews and meta-analyses by Dahrouge and colleagues found that multidisciplinary teams are associated with improvements in mental health and preventive care.

Primary care teams can achieve efficiencies by allowing each team member to function at the top of their skill set. Inter-professional teams can facilitate the provision of comprehensive, continuous and person-centred care, mobilization of healthcare resources and patient navigation of the healthcare system. Improvements in quality, patient satisfaction, access and equity, appropriately valued, should offset the additional resources required to implement inter-professional teams.

PATIENT ENGAGEMENT

A patient-centred approach is fundamental to high-performing primary care. Patients need to be supported to participate actively in their own healthcare, and patients and citizens need the means to participate in the design and planning of health services.

At the clinical level, patients are more likely to feel engaged when they have easy access to their providers, understand the information that is provided, receive guidance and support that assists them in understanding the choices available for their treatment, have their medications reviewed for risks and benefits, and receive care that is coordinated, and when relevant information is communicated among various providers, institutions and with them.

Patients who are engaged in their primary care are more likely to recall information, have knowledge and confidence to manage their conditions, report the chosen treatment path was appropriate for them, report satisfaction with their care, participate in monitoring and prevention, and show improvements in health outcomes for diabetes, depression, eating disorders, asthma, hypertension and behavioural change. Patients who share in decision-making about treatment choose less interventionist (and less costly) treatments than their clinicians might have done.

“A truly patient-centred healthcare system must be designed to incorporate features that matter to patients—including “whole person” care, comprehensiveness, communication and coordination, patient support and empowerment, and ready access. Without these features, and without consumer input into the design, ongoing practice, and evaluation of new models, patients may reject new approaches”.

FUNDING AND PROVIDER PAYMENT ARRANGEMENTS ALIGNED WITH HELATH SYSTEM GOALS

Over the past decade, there has been a growth of blended payment models for primary care physicians that include capitation, fee-for-service, salary, infrastructure funding and targeted payments for particular services or performance levels.  This broad range of payment models has allowed the alignment of targeted payment with specific healthcare objectives and the balancing of the desirable and perverse incentives inherent in different payment methods.

A vast amount of research related to reimbursement mechanisms has been published, all with similar conclusions—no single reimbursement mechanism provides all the necessary incentives to achieve health policy goals.There is ambiguity about the benefits of pay-for-performance (P4P) and its potential for perverse effects in primary care. To date, there are only a few rigorous studies of P4P models, and the evidence of a significant effect is weak.

Financial incentives targeting individual healthcare professionals appear to be effective in the short run for simple, distinct, well-defined behavioural goals.  There is less evidence that  financial incentives can sustain long-term changes.

Current evidence supports the thoughtful design of blended payment and funding models which mitigate the perverse incentives associated with fee-for-service, salary, capitation and pay for performance. Ongoing evaluation and adjustment are needed to ensure that incentive structures are achieving their objectives.

HEALTH INFORMATION TECHNOLOGY THAT EFFECTIVELY SUPPORTS PATIENTS AND PROVIDERS

Sophisticated information technology to support clinical practice is essential to the provision of high quality, efficient primary care. Well-designed information management systems support evidence- informed clinical care and decision-making, identification of patients’ care needs, performance measurement, quality improvement, patient engagement and care planning, and coordination and integration across the continuum of care.\

The use of information technology for clinical decision-support and for generating patient reminders supports both operational efficiency and quality of patient care. Potential benefits include: improved preventive care and disease management; increased prescribing of generic drugs; improved management of medication; reduced medical errors; reduced unnecessary tests; and cost reductions.

A recent literature review found a potential for substantial savings to the healthcare system through the implementation of electronic medical records. However, none of the studies included in that review focused on primary care.

Electronic health records and electronic medical records are valuable tools for generating performance measures for monitoring patient care, healthcare planning, evaluating innovations, and determining resource allocation. Investment in and implementation of information technology are critical to improving outcomes, achieving greater e ciencies, and improving the integration of care.

ONGOING PERFORMANCE MEASUREMENT

Systematic, ongoing performance measurement is required at multiple levels (practice, organization, community, regional, provincial/territorial and national) to inform and assess the impact of health services planning, management and improvement activities and as a basis for accountability processes.

Performance measurement is fundamental to continuous quality improvement since it allows for the identification of opportunities for improvement, tracking progress against organizational goals, and comparison of performance against both internal and external standards.

TRAINING AND SUPPORT FOR QUALTITY IMPROVEVEMENT

Continuous quality improvement initiatives linked to ongoing performance measurement are crucial to primary care transformation and improvements in quality of care, health outcomes and effciency.

Quality improvement training and ongoing support of primary care providers are needed to ensure the success of quality improvement efforts.

A review of three successful system-redesign initiatives using quality improvement methods in primary care found that a common theme in all three initiatives was investment in building knowledge and skills of the team to support quality improvement. Each organization set clear expectations that staff  would work on improving patient care to provide the organizational capacity for continued improvement.

A recent systematic review by O’Beirne and colleagues that examined the impact of quality improvement (defined as “sustained effort to improve healthcare quality that incorporates repeated performance measurements and feedback to healthcare providers”) in primary care, found “strong” to “high or moderate” evidence that quality improvement increases colorectal cancer screening and foot examination for diabetes.

The evidence was “weak to moderate” for a positive impact on increasing tobacco cessation activities, improving HbA1c, LDL and HDL levels and blood pressure in patients with diabetes and cardiovascular disease, increasing treatment for depression, decreasing prescribing by providers for patients with a variety of conditions and associated drugs, and the adoption of clinical guidelines.

Two widely applied approaches for providing quality improvement training and support are quality improvement collaboratives and practice facilitation (coaching), which are often used in combination.

Learning collaboratives focused on chronic diseases have been shown to: improve health outcomes for patients, improve patient education, increase preventive procedures, reduce hospitalization, improve quality of life indicators and improve access to primary care.

The Institute for Healthcare Improvement’s Breakthrough Series model is designed to enable participants to share experiences, accelerate learning and spread best practices. Learning collaboratives based on this model have resulted in: reduced wait times for appointments; reduced wait times while at the physician’s office; improved continuity of care; and increased patient and provider satisfaction.

Practice facilitation has a positive effect on the application of evidence-based practice guidelines and helps staff  apply quality improvement techniques.

Quality improvement coaches have been shown to increase office efficiency and improve care for patients with diabetes or asthma; improve communication, trust, sense of team, leadership and create a culture of self-directed change and result in cost-savings.

Providing hands-on training and support to healthcare practitioners and the inclusion of improvement science in curricula for health professional students can facilitate the adoption and use of quality improvement methods and tools.

LEADERSHIP DEVELOPMENT

High-performing primary care requires effective leadership. Leadership at all levels (government, executive and clinical) has been shown to be instrumental in the implementation of quality improvement initiatives and electronic medical records.

In complex healthcare systems that face a variety of internal and external pressures, a distributed leadership approach—in which responsibility for leadership is dispersed and shared among a variety of actors throughout an organization or system—is gaining support.

A common theme in a cross-comparative case study of five international high performing healthcare systems (as identified by international experts in quality improvement and health system monitoring) was that the leadership approach was distributive, embraced common goals and aligned activities throughout organizations.

A Canadian study showed that the implementation of integrated multidisciplinary primary care teams was successful when internal and external leaders pooled their resources to bring about change.

Successful leadership requires: a compelling vision for quality; performance targets and timelines that incorporate a vision; a strategy that includes evidence-based practices and establishes clear accountabilities and expectations at the organizational and individual level; a culture of quality improvement that emphasizes learning, innovation and quality measurement; engagement of frontline staff  and champions; celebration of successes; and sharing of best practices.

A systemic approach to leadership development that is focused on both providers and managers, is required for system transformation and quality improvement. Leadership development interventions should focus on organizations as a whole and teach trainees the unique attributes of leadership which stimulate transformative change, with a focus on collaborative approaches and continuous assessment.

COORDINATION, INTEGRATION AND PARTNERSHIPS WITH OTHER HEALTH AND SOCIAL SERVICES.

Primary care providers assume responsibility for facilitating their patients’ trajectory through the healthcare system and for the appropriate use of health and social services. To ensure access to a comprehensive range of appropriate services for the population they serve, primary care providers need to assist patients with healthcare decision-making and serve as mediators between patients and the other levels of the healthcare system, community resources and social services.

Coordination and integration strategies include informal relationships, formal agreements and partnerships, and integrated governance.

All such arrangements require clear articulation of the roles and responsibilities of each participant.

Integrated delivery of primary care services improves service delivery and results in: more efficient use of physicians, hospital and laboratory services; healthier lifestyles; lower health service utilization; and improved patient satisfaction.

Systems designed to improve coordination between primary care physicians and specialists have been shown to lower hospitalization rates and resource use. Integrated models focused on chronic disease have demonstrated improvements in prescribing.

Integrated models for mental healthcare have shown greater patient retention rates in treatment programs, patient satisfaction, more rational use of resources and diagnostic tests, improved clinical skills, more frequent use of appropriate treatment strategies, and more frequent clinical behaviours designed to detect disease complications.

SYSTEMIC EVALUATION OF INNOVATION

In addition to ongoing performance measurement and monitoring, effective primary care system planning and management require focused evaluations of the implementation and impact of key policy and system management innovations. Such evaluations allow shortcomings to be identified and addressed and successes to be reinforced and spread.  The effective dissemination of learning from these innovations is critical to system transformation.

RESEARCH CAPACITY AND PRODUCTIVITY

Canada lags behind on investment in primary care research and the translation of knowledge into practice and policy.According to Starfield, Canada has invested poorly in primary care research and evaluation and is at least 10 years behind other countries.

A recent study of six countries that examined the productivity of primary care research based on the volume of publications (2001-2007) found that researchers from the United Kingdom (followed by the Dutch and Americans) were the most productive while Canada and Australia showed slow signs of growth.

Significant progress is being made on this front through the Community-Based Primary Health Care “signature initiative” of the Canadian Institutes of Health Research.

A constant  flow of research evidence to inform primary care policy and practice is an essential underpinning of a high-performing and continually evolving primary care system. Adequate funding of both research and research training are needed to create and sustain a vibrant and productive primary care research enterprise.

DECISION SUPPORT

Evidence-informed decision-making by patients, healthcare providers, organizational and health system decision-makers, policy makers and legislators requires that relevant evidence be available in a useful form at the point of decision-making – an enormous challenge, but one that needs to be creatively and doggedly addressed. All health decision-makers need access to user-friendly evidence summaries tailored to their needs. To meet this challenge, substantial investment in the development, testing and implementation of alternative approaches is needed.

PRINCIPLES OF PRIMARY CARE TRANSFORMATION

Aims and vision, however clear and compelling, are not sufficient by themselves to bring about system transformation. A thoughtful approach to the change process is also crucial. As primary care transformation proceeds at the provincial, regional and local levels – with appropriate federal support – what principles should guide the change process? We suggest the following:

◥ Strict adherence to the principles of universality and access to care based on need.

◥ An unwavering focus on public benefit, as opposed to professional or private interest

◥ Meaningful engagement of patients and citizens in system design (person-centred system design).

◥ Application of an equity lens to health services planning and measurement.

◥ Attention to the health and healthcare needs of communities and populations as well as individuals — in particular socially disadvantaged and high-needs communities and populations.

◥ A multi-faceted change strategy based on a long-term perspective.

◥ Responsiveness to local needs and context.

◥ Engagement of a full range of key stakeholders.

◥ Pluralism of primary care models.

◥ Patient choice of “regular” primary care provider.

◥ Fostering a culture of innovation

◥ Systematic, relevant and rigorous monitoring and evaluation of the impact of transformation.

WHAT REMAINS TO BE DONE?

Primary care, along with public health and community care, has long been the poor cousin of hospital and specialist care in Canada’s health systems. Overcoming our mediocre—or worse—performance relative to most other high income countries will require redirecting investment toward those sectors—not by denying access to needed specialist and hospital care, but by reducing the need for it. This demands a transformed system that is: centred on patients, their families and informal caregivers; responsive to community needs; and built on a foundation of high-performing primary care supported by and integrated with specialist and hospital care, community care, public health services, long-term care, and community support and social services.

Such a system is depicted in Figure 2. In this transformed system, patients, their families and informal caregivers are partners in care; the primary care team provides the majority of healthcare, serves as integrator/coordinator with other system providers and services and works in partnership with others to address the social determinants of health; all other sectors interact with each other and with the primary care team to form an integrated system; all participants are committed to continuous improvement of health outcomes (better health) and patient experience (better care) while controlling health costs (better value); and all stakeholders take responsibility for ensuring the system is effective and accountable.This vision of a healthcare system centred on patients supported by a primary care team is consonant with the concept of the patient-centred medical home that has galvanized primary care reform in the U.S. and has been adapted to the Canadian context by the College of Family Physicians of Canada and with primary care models that feature a leading role for nurses in chronic disease management.

To read the full report, please visit http://www.cfhi-fcass.ca/Libraries/Reports/Primary-Care-Strategy-EN.sflb.ashx

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