Over forty AFHTO members from around the province – the combination of AFHTO’s Physician Leadership Council (PLC) and ED Advisory Council (EDAC) – came together last Thursday to dialogue with the Ministry to gain further clarity on what is known (and not known) as it plans for primary care.  One of the messages is that work to develop policy and strategy is underway and that there will be further discussion and consultation as this progresses. Following this dialogue, members concluded the priorities for action they identified over July/August are on the right track, and then developed further advice on each topic.

Meeting summary

For the full meeting report click here. So what do we know and where do we go from here?  EDAC and PLC members concluded that:

• Members should expect a closer relationship between LHINs and primary care, but we don’t know yet what that will look like and whether or not this will include any form of funding and accountability. We need to further develop these relationships right away. AFHTO is facilitating meetings and preparing education materials to help members do this.
• Government’s priority on access and equity signals that interprofessional teams must continue (or begin) to look more broadly at their communities to find ways to broaden access to team-based care to those who need it most.
  • More equitable funding is needed to attract and retain the staff needed to do all this work. We have no formal commitment from government as of yet; this remains the top priority for AFHTO’s advocacy.
  • As demand grows to broaden access to teams, AFHTO members’ collective work in defining how we measure and track health human resource capacity is critical to reduce the risk of compromising patient care and teamwork. The goal is to introduce an initial indicator of this capacity in the next cycle of Data to Decisions – D2D 3.0.
• Government is considering a common set of publicly reported, primary care performance indicators. The collective work of AFHTO members to advance measurement is absolutely critical to lead the way to ensure these measures are meaningful to clinicians and manageable for reporting.
• At the strategy and planning level, we remind the Ministry and LHINs of the need for thoughtful ways to include primary care leaders in its development.
• As teams, we also need to look internally at how we can improve the value we deliver to our patients and communities.
• Transparency is critical – at all levels, from the Ministry, from LHINs, from AFHTO, from all of the stakeholders. Information is needed from the Ministry since the voids are being filled by misinformation.

In light of AFHTO’s growing impact on the provincial stage, EDAC and PLC members applauded as the AFHTO President announced the board’s decision to confer the title of Chief Executive Officer to Angie Heydon, following their recent leadership review. For further details from this meeting please see the full report [PDF].

Discussion at the May 19 quarterly meeting of AFHTO and MOHLTC Primary Health Care Branch covered:

1. Parameters and next steps for developing new contract templates, given the ministry’s intent to:
   1. Conduct a review of all interprofessional primary care models
   2. Move toward “comprehensive regionally governed, population-based primary health services for Ontarians”
   3. Implement policy directions emerging from sources such as the Expert Panel on Primary Care (Price Report)
2. Next steps regarding performance reporting and the schedules in the contract
3. Commitment to improve Schedule A as a tool for meaningful program planning and reporting
4. Re-purposing funds (e.g. for telemedicine programs)

1.  Developing new contract templates amidst the “many moving parts”

AFHTO has been keeping members informed on what is emerging about the province’s policy direction for primary care. (Click here and here for past reports.) The ministry’s desire to move toward a “comprehensive regionally governed, population-based primary health services for Ontarians” is given – implementation questions include how this will affect the organization of primary care, how it is resourced, and what will be the reporting relationships. The review of interprofessional teams can be expected to inform these decisions; however AFHTO anticipates it will be well over a year before there are any results since the details of this review are under development. We understand this review will look at performance and accountability, funding, and use of interprofessional teams (recruitment and retention, ratios of team members, opportunity to leverage these resources). Meanwhile, the current 5-year FHT contracts expire at the end of this fiscal and to that end work to redevelop the contract templates will proceed. Because of these “many moving parts”, the contracts could potentially need further updates going forward. Members may feel unsettled by this uncertainty – understandably so.  Keep in mind the province is well aware that:

• Quality patient care must continue.
• Ontario needs AFHTO members – the innovators and leaders in improving comprehensive primary care – in order to succeed in whatever direction the ministry may want to take with primary care.
• AFHTO members have a very strong voice – through their collective work in this association – and must be engaged in finding the workable solutions for moving forward.

Next steps:

• AFHTO has pressed the need for the leaders of our member organizations to receive more information about the direction the province is taking. We have been told the Expert Panel report will be shared, possibly in a few weeks’ time.
• As reported in the ED Advisory Council news, a work group of AFHTO members will begin the process of reviewing the contract, guided by the principles identified by FHT and NPLC leaders last fall, to identify issues that need to be addressed and begin strategizing.

2.   Performance reporting and the schedules in the contract

As reported in the most recent ED Advisory Council news, PHC Branch has agreed to recommendations from AFHTO to:

• Retain Schedule A – program planning and reporting. (Improvements are required – see the next section below.)
• Eliminate reporting that is not meaningful, i.e. activity reporting found in Schedule E. (The current contract states Schedule E is required. Contract needs to be changed, but given this direction, AFHTO anticipates compliance is unlikely to be pursued.)
• In place of Schedule E, leverage work of D2D and to select 6-10 meaningful measures to be included in the next contract agreement.  Ministry priorities would also add:
  • One or two chronic disease measures (AFHTO thinks this is doable in the next iteration of D2D)
  • 7-day follow up (Adopted in the D2D 2.0 list as developmental, since AFHTO Indicators Working Group identified a number of current limitations in this measure that need further refinement)
  • Avoidable ED use (AFHTO Indicators Working Group had concluded this is not a good measure as it is right now. This needs further investigation.)

3.   Commitment to improve Schedule A as a tool for meaningful program planning and reporting

All agree that Schedule A has the potential to promote stronger program planning, coordination and evaluation; however many FHT/NPLC EDs have called for improvements to the Schedule A template, instructions and education. Next steps: PHC Branch and AFHTO will put together a joint working group to:

• Improve Schedule A as a useful tool for program planning and reporting.
• Do a joint presentation at the AFHTO conference on how to do effective program planning and evaluation, ministry needs for reporting, and how to use Schedule A effectively.

4.   Re-purposing funds

AFHTO followed up on a question from our previous meeting with PHC Branch regarding funding to replace telemedicine equipment. The response was that, for everyone who had asked, the ministry was able to help the FHT/NPLC identify existing funds to re-purpose to purchase replacement equipment. PHC Branch reps said this was also true for those who asked to re-purpose funds to cover sessional costs for these telemedicine consults. We were told that, for the past fiscal year, there are still some FHTs and NPLCs returning unspent funds to the Province. Next steps:

• As reported from the Nov. 21 AFHTO-PHC Branch meeting, FHTs and NPLCs are encouraged to request reallocation of approved budgets to meet needs.
• When it comes to telemedicine programs, AFHTO has reminded PHC Branch of the need to address the policy question as to how this need can be supported in a sustainable fashion.

Participants in the May 19, 2015 meeting AFHTO was represented by:

• Randy Belair (AFHTO President and ED, Sunset Country FHT, Kenora)
• Sean Blaine (AFHTO Vice President and Lead MD, STAR FHT, Stratford)
• Ross Kirkconnell (Secretary + QIDS Steering Committee Chair and ED, Guelph FHT)
• Kavita Mehta (ED Advisory Council Chair and ED, South East Toronto FHT)
• Angie Heydon (AFHTO Executive Director)

MOHLTC’s PHC Branch representatives were:

• Nadia Surani (Senior Manager, Interprofessional Programs Unit, PHC Branch)
• Fernando Tavares (Program Manager, Interprofessional Programs)
• Debbie Lora (Senior Program Consultant)

Topics discussed at AFHTO’s March 5, 2015 quarterly meeting with PHC Branch are listed below. Key points made by Deputy Minister in a March 9 speech are added.  Scroll down for details on each.

1. What’s ahead for FHTs + NPLCs, in light of ministry’s plans for health system reform?
   1. “Comprehensive regionally governed, population-based primary health services for Ontarians.”
   2. Process for determining “high needs” areas / replacement of FHO+FHN physicians
   3. Review of primary care team models
   4. Development of new contract templates for FHTs
2. More immediately, what can FHTs and NPLCs expect from this year’s operating plan and funding process?
   1. Outlook for funding approvals
   2. Data support for FHTs and NPLCs
   3. Premises costs
   4. Performance measures in the 2015-16 Service Plan (“Schedule A” or “Part B)
   5. Governance and Compliance Attestation
   6. Accountability Reform Initiative
   7. Reallocation and some inconsistency in decisions
   8. Telemedicine equipment
   9. Getting meaningful feedback from your consultant

1. What’s ahead for FHTs + NPLCs?

AFHTO members received an email summarizing Associate Deputy Minister Susan Fitzpatrick’s meeting with the AFHTO board on March 3.  AFHTO’s representatives met with PHC Branch on   March 5 to learn more about what’s ahead for primary care in Ontario and advocate for our members. On March 9 Deputy Minister Bob Bell delivered a speech which added further specificity to ministry priorities.

“Comprehensive regionally governed, population-based primary health services for Ontarians.”

This statement has appeared on slides used by both the Deputy and the Associate Deputy Ministers – the intent is clear, but not much more is known at this time.  In his March 9 speech, the Deputy emphasized the critical need for a strong foundation of primary care, and went further to speak of a “possible move to Accountable Care Organizations as our primary care system strengthens.”

Process for determining “high needs” areas / replacement of FHO+FHN physicians

This topic is clearly linked to the statement above.  The ministry has communicated changes to primary health care physician payments, such that, “effective June 1, 2015 and onwards, monthly registration into these models will be limited to 20 physicians per month in areas of high need.” By end of March, the ministry is aiming to have the criteria and process in place for determining “areas of high need”. LHINs will be playing a key role. The ministry’s new policy regarding entry into FHO and FHN models does allow for replacement of positions vacated by an existing member of that FHO or FHN, outside of the “managed entry” process. The PHC Branch reps confirmed this is on a one-to-one basis – it does not allow for two physicians to divide the roster. Key points for FHTs and NPLCs:

• Future relationship between LHINs and primary care: Much is not yet known, but this clearly signals much greater involvement with LHINs going forward. This is already happening with Health Links. Many AFHTO members have already developed good relationships with their LHINs; it would be prudent to strengthen these, and keep the leadership in your LHIN aware of the needs and opportunities in your community.
• FHT and NPLC leadership: AFHTO members have already developed the capacity to lead, govern and build strong collaborations with other partners. Of the 69 Health Links to date, 20 are led by AFHTO members. You are well-positioned to play important leadership roles within your region and more broadly across the province, to shape what “Comprehensive regionally governed, population-based primary health services” will look like.

Review of primary care team models

AFHTO’s March 3 email also reported the ministry will be reviewing the team-based models from the perspectives of performance and accountability, funding, and use of interprofessional teams (recruitment and retention, ratios of team members, opportunity to leverage these resources). The ministry is developing terms of reference for this review, and is considering the range of team-based models to be included. One of the ministry’s drivers is to ensure that Ontarians who could benefit most from team-based care have access to this. The review is still in early development but the PHC Branch confirmed that AFHTO and related associations will be involved to inform the review process. Key points for FHTs and NPLCs

• “Programs” and “comprehensive team-based primary care”: AFHTO has been challenging PHC Branch to look beyond their focus on “programs” if the ministry is truly interested in reaping the full value of comprehensive team-based primary care. PHC Branch has acknowledged this need – see below regarding “Schedule A” of the FHT annual operating plans.
• Value comes from team collaboration, not referral: AFHTO has been taking every opportunity, including this meeting, to stress this point. The pressure to broaden access to teams has led some in the ministry and elsewhere to look to enabling physicians outside of teams to refer patients to IHPs within teams. Research evidence to date in Ontario, including the FHT evaluation report, points to the value of team collaboration, with all providers, including family physicians, as active members of that team.  The question is how to strengthen teams and broaden their reach.
• What does it mean to be a team? Following from this, we will all be thinking about the further evolution of these team-based models and how the various providers are connected to them.
• Measuring the value of team-based care: AFHTO continually reminds the ministry that the cost of team-based care is NOT the question – it is the value delivered for system sustainability. Data to Decisions (D2D) 2.0 will include further refinements to the measure of “total cost of care”. Your participation is critical to making the case that the investment in team-based care pays off by, among other things, optimizing total health system costs for patients. Stay informed – sign up for the bi-weekly D2D ebulletin.

Development of new contract templates for FHTs  

Contracts between MOHLTC and FHTs expire on March 31, 2016. AFHTO is ready with clear direction from the leaders of our member-organizations on the necessary principles – for the governance of primary care organizations; for accountability and reporting to funders; for determining accountability measures; for funding allocation; and for the support teams need to deliver timely, high-quality, comprehensive team-based care. In his March 9 speech the Deputy emphasized several times over the need to improve performance measurement and performance management in primary and community care, as has been done in hospitals. No doubt this will be reflected in future contracts. AFHTO and PHC Branch will meet again in a few weeks for further discussion of the specific question of measurement and reporting. Key points for FHTs and NPLCs

• AFHTO continues to work with and on behalf of members to advance manageable and meaningful measurement. Through the Quality Improvement Decision Support program AFHTO members are strengthening capacity to measure and leading the way to identify appropriate and meaningful measures.
• Likewise, AFHTO members are guiding development of contract templates. The ED and Physician Leadership Councils will play key roles in advising the AFHTO board as these discussions move forward.

2. What to expect in 2015/16 operating plan and funding process

AFHTO probed into a number of issues and questions members have been asking. Following from this meeting with PHC Branch, we offer the following advice to members;

Outlook for funding approvals

In simple words – don’t expect new money. Government has not yet presented its 2015/16 Budget, so the size of the “pies” to be divided among FHTs and among NPLCs is not yet known. These “pies” have been fully stretched in the past year, and as is happening in the rest of government, they could shrink. FHTs/NPLCs that are seeking additional funds can expect the approval process will take at least 4 months. Those who are only requesting reallocations of their base funding can expect fairly quick turnarounds.

Data support for FHTs and NPLCs

All AFHTO members – NPLCs and FHTs — are welcome to take full advantage of AFHTO’s QIDS Provincial Program. Unfortunately about 25 FHTs and all 25 NPLCs have no access to direct support from a QIDSS Specialist. The ministry is considering a proposal from NPAO for the NPLCs, and will consider any others from FHTs, however the funding situation described above means additional positions may not be possible.

Premises costs

Following the same theme as above – the ministry will consider increases where premise costs have gone up, but will insist that you first look at funding from within your existing budget.

Performance measures in the 2015-16 Service Plan (“Schedule A” or “Part B)

The Annual Operating Plan for FHTs includes “Schedule A – FHT Service Plan”.  NPLCs report their Service Plan in “Part B: 2015-2016 Strategic Priorities and Vision”, which includes strategic priorities, program and service commitments. The “Schedule A Guidance Document” in the FHT AOP package also gives specific instructions to list each of the FHTs programs, target population, objectives and performance measures. Key points for FHTs and NPLCs:

• Following from the “programs” versus “comprehensive team-based primary care” discussion above, the ministry welcomes seeing “comprehensive team-based primary care” listed as a program, with objectives and measures.
• The examples in the FHT Guidance Document are “counts” rather than actual performance measures with numerators and denominators. PHC Branch confirmed performance measures are welcome. The need is to demonstrate the return on the public investment.
• For FHTs, the three topics at the top of the Schedule A submission sheet are required – enrollment, same day/next day and house calls.
• For all other measures your FHT or NPLC can choose what you believe is most appropriate for your organization.

Governance and Compliance Attestation

All FHTs and NPLCs must submit the Governance and Compliance Attestation. This form sets out the ministry’s expectations for appropriate governance practices. If a FHT or NPLC is lacking in any areas, the PHC Branch has said they will work with the entity to improve in these areas. It will also send the aggregate results to AFHTO to share with the membership and focus our Governance and Leadership programming. A number of EDs asked about the requirement that “FHT has a current Performance Measures document monitored by the Board on an ongoing basis”. In the Attestation the ministry is looking for a simple “yes/no” response, although the PHC Branch will do occasional audits. The Quality and Safety section of AFHTO’s Fundamentals of Governance guidebook and toolkit provides guidance for boards on their fiduciary duties for performance and how performance measures are used to fulfill this duty. Suggestions include using AFHTO’s Data to Decisions 1.0  measures. (For more information about the upcoming D2D 2.0 indicators, click here.)

Accountability Reform Initiative (ARI)

Once again FHTs have the option to apply for ARI, which would give the team greater flexibility in how it uses its budget. It will be granted to those who meet all the governance and compliance requirements. Those who come close but don’t quite make it can be reconsidered later in the year if they’ve taken all the necessary steps to comply. NPLCs may be able to apply for ARI in the 2016-17 Annual Operating Plan process. Since they are newer entities, the ministry is waiting another year before potentially extending ARI to them.

Reallocation and some inconsistency in decisions

Following from the ministry’s recent call for reallocation requests, member EDs had reported to AFHTO some situations where consultants had not allowed a budget reallocation. The common element in the issues in question appeared to be regarding what physicians should cover.  PHC Branch reported they received over 100 submissions and are working to improve the response process. There are budget guidelines regarding what should be covered by the physician group, and decisions can be reviewed to ensure they’re applied consistently.

Telemedicine equipment

Members have been faced with vendors declaring ‘end of service’ for their telemedicine equipment and financial challenges to replace equipment. Some have been able to find funds within their budgets to address this; others have made arrangements through their local hospitals.  AFHTO members have offered assistance to help the ministry develop a more sustainable and unified strategy for ongoing OTN support. Recognizing this issue involves OTN, its funder (eHealth Ontario), the Northern Health Travel Grant program and the Nursing Secretariat, PHC Branch has agreed to take the first step. Starting with FHTs and NPLCs in the NE/NW, they will look at the most valuable uses of OTN equipment, how much of OTN use falls into this category, and whether a sustainability policy can be developed.

Getting meaningful feedback from your consultant

The short answer is – phone your consultant. AFHTO members periodically send us examples of feedback letters from ministry that offers no insight into why a decision was made. FHTs and NPLCs want to improve – and need specific, constructive feedback to help them do so. PHC Branch reported that each letter must be reviewed and approved before going out, so content is limited.

3.    Participants in the March 5, 2015 meeting

AFHTO was represented by:

• Randy Belair (AFHTO President and ED, Sunset Country FHT, Kenora)
• Ross Kirkconnell (Secretary + QIDS Steering Committee Chair and ED, Guelph FHT)
• Kavita Mehta (ED Advisory Council Chair and ED, South East Toronto FHT)
• Angie Heydon (AFHTO Executive Director)
• Carol Mulder ( AFHTO QIDS Provincial Lead)

MOHLTC’s PHC Branch representatives were:

• Phil Graham (Acting Director, PHC Branch and Manager, Interprofessional Programs Unit)
• Fernando Tavares (Program Manager, Interprofessional Programs)
• Alexa Pagel (Senior Program Consultant)