Population-based primary care is about effective management of the health of defined groups of people. It ensures all within this group are attached to a regular primary care provider and can access the appropriate care when they need it. The province’s Ministry of Health and Long-Term Care convened an Expert Advisory Committee to recommend how to ensure access to appropriate care for all Ontarians. Their report Patient Care Groups: A new model of population based primary health care for Ontario, was released on October 15, 2015. Two hundred leaders from AFHTO-member organizations convened shortly thereafter to look into the role for primary care teams in a population-based health system. This included examination of the functions that would need to be further developed and strengthened in such a system. The key messages from this session:

• Family Health Teams (FHTs) and Nurse Practitioner-Led Clinics (NPLCs) have the leadership, dedication and a fundamental commitment to the well-being of their patients. They are willing to:
  • Step up to play their part in building a primary care system that understands and meets the needs of our patients and communities.
  • Stand up and be counted – using measurement to demonstrate their value and improve on it.
  • Build on the relationships they have been developing with other teams, other providers, and their LHINs.

• AND there is significant caution about how change is implemented. Most importantly members want:
  • To be heard. Members are cautiously optimistic about closer LHIN alignment; they want thoughtful consideration and adequate consultation with FHTs/NPLCs.
  • To be valued. Primary care is the foundation of a sustainable health system; policy, planning and resourcing need to strengthen this foundation.
  • To be supported to succeed. Above all else, sufficient funding is needed to stabilize the workforce and ensure sufficient capacity to deliver quality care. IT infrastructure and EMR connectivity are also in need of further development.

Click to read AFHTO’s response to the Expert Advisory Committee’s recommendations.

There is a compelling association between comprehensive primary care and system efficiency and effectiveness. The lifelong work of the late Barbara Starfield observed that an investment in primary care was associated with improved system quality, equity and efficiency (reduced cost)^{[i],[ii],[iii] ,[iv]}. In British Columbia this efficiency was quantified by Marcus Hollander. The total cost of care was measured for the sickest patients. Patients without close alignment to primary care had a system cost of $30,000/patients/year. Patients with close alignment to primary care had a system cost of $12,000/patients/year[v]. The value of comprehensive primary care comes from the focus on the whole person, in their family and community context, over their lifetime. It is based on long-term, trusting relationships. This must be reflected when measuring performance in comprehensive primary care. In collaboration with members and research partners, AFHTO has been developing a system of measurement, based on the principles revealed through Dr. Starfield’s work.  Its objective is to enable teams delivering comprehensive primary care to optimize their performance and to evaluate the benefits over time. Using indicators from Health Quality Ontario’s Primary Care Performance Measurement Framework, it measures quality, capacity and total health system cost of care for patients. Click to read more about:

• The Starfield Principles
• Results achieved by a small family health team in implementing this model

  References: [i] Shi L, Starfield B, Kennedy BP, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract. 48 (1999), 275–84. [ii] Starfield B. Family medicine should shape reform, not vice versa. Fam Pract Man. May 28, 2009; Global health, equity, and primary care. J Am Board Fam Med. 20(6) (2007), 511–13; Is US health really the best in the world? JAMA. 284(4) (2000), 483–4; Research in general practice: co-morbidity, referrals, and the roles of general practitioners and specialists. SEMERGEN.  29(Suppl 1) (2003), 7–16, Appendix D. [iii] Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 60 (2002), 201–18. [iv] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 83(3) (2005), 457–502. [v] Increasing Value for Money in the Canadian Healthcare System, Hollander et al. Healthcare Quarterly Vol 12 No. 4 2009

Family Health Teams and Nurse Practitioner-Led Clinics  have matured over the 5 – 9 years that each organization has been in existence. Contracts between MOHLTC and FHTs expire on March 31, 2016, with this comes the opportunity to develop a much more mature and meaningful approach to governing these organizations, from the Ministry and through to the board of each FHT and NPLC, to deliver high-quality primary care and improve the health of people in the communities served.

Principles to guide our way forward

Principles for governance of primary care organizations

Given the strong level of support indicated through the survey of leaders of AFHTO member organizations AFHTO adopts the following governance principles: FHTs and NPLCs are not-for-profit corporations in a health system mandated to provide appropriate, equitable, sustainable care.  Their boards:

• Are accountable to the patients, funders and members of their organization.
• Ensure their organizations are appropriately managed and advocate for appropriate resources so that patients can access high-quality comprehensive care that is sustainably delivered and strives to meet patient and public expectations.
• Ensure the culture of their organization supports development of high-functioning interprofessional teams.
• Provide leadership to harmonize and optimize policies and practices for effective and efficient teamwork within the organization and with other entities contributing to the health and health care of the organization’s patients and community.
• Provide leadership and collaborate with other organizations to spread best practice and encourage growth in capacity so that all Ontarians can have access to high quality interprofessional comprehensive primary care.
• Ensure that patients and community members are engaged in the development of programs and services.

These principles describe the more mature relationship the leaders of AFHTO’s member organizations want to have with their funders, members, staff and other stakeholders. They will guide AFHTO’s work in advocacy and in developing learning opportunities and support for members to succeed in their roles as governors and leaders.

Principles for accountability and reporting to funders

The strength of the survey results also lead AFHTO to adopt the following principles for accountability and reporting to funders. These principles will guide AFHTO’s advocacy with government, on behalf of members, on development of the next set of contract templates:

• Financial and clinical reporting should minimize duplication in data collection and reporting.
• Accountability should be defined in terms of collectively agreed upon measures that reflect value delivered.
• Reporting requirements should place more emphasis on the work of the team to achieve outcomes and less on individual member activities and patient encounters.

Principles for determining accountability measures

While AFHTO members are strongly in favour of accountability and reporting based on meaningful measures, they are also cautious about how these measures will be determined. Leaders who attended the Oct. 15 leadership session provided the following guidance on principles for determining accountability measures that should be followed by AFHTO, the Ministry and any other stakeholders involved in the process:

• MOHLTC must engage in a collaborative process to define outcome measures to be used for reporting.
  • Input from providers/engagement of AFHTO membership is essential.
• MOHTLC must provide adequate support so that FHTs/NPLCs have the capacity (i.e. the people and technology needed) to collect and report their data.
• Measures must be meaningful, measurable, consistent and comparable.
  • More specifically, measures must be evidence-based, clinically important, include process and outcome, be easy-to-track on an on-going basis, clearly defined and standardized for meaningful comparisons, and aligned with other Ministry priorities and reporting requirements.
  • Measures must also incorporate patient experience, and involve patients in what the measures will be.
• The approach to accountability measurement must be sufficiently flexible to account for variation in patient complexity and their social determinants of health, in regional and rural-urban settings, and in size and maturity of teams.