This message presents what the Deputy and Associate Deputy Ministers of Health and Long-Term Care said recently about the ministry’s key priorities for health system transformation, the role of primary care in this transformation, and some of the key steps ahead. While the media have asked if government “has pressed the pause button on team-based primary care” (Globe and Mail, TVOntario), the information below indicates significant movement ahead. The content of this email comes from Associate Deputy Minister Susan Fitzpatrick’s meeting with the AFHTO board on Feb. 25 (click here to access her slide presentation). Many of the same points were reiterated the next day in addresses made by Deputy Minister Bob Bell and by Susan Fitzpatrick at the Feb. 26 HealthLinks conference. Highlights:

• “Primary care must be the strong foundation for our health system.” Both DM Bob Bell and Associate DM Susan Fitzpatrick clearly stated this view. The key question – what does this look like and how will we get there?

• “Comprehensive regionally governed, population-based primary health services for Ontarians.” Slide 10 is a specific look at how the ministry sees primary care teams in advancing transformation, from 2005 and into the future. On several occasions the Deputy has called for movement toward “population-based risk-adjusted primary care”; this slide confirms the intent.

• Ministry’s key priorities for primary care teams. Slide 12 lists them as follows:
  • Population health based programs and services with focus on access, integration and patient experience
  • Collect community-specific data to improve performance and quality of primary care for its population
  • Continue progress in expanding availability of same day/next day appointments and after-hours
  • Continue to provide access to integrated health care teams for Ontarians who need it
  • Establish policies to improve Quality Improvement indicators ( e.g. post-hospital discharge visits, readmission rates, ED visits)
  • Participation in HealthLinks and other local initiatives (e.g. Physiotherapy reform)
  • Leveraging full scope of practice and improving team functioning
  • Strengthening and expanding local partnerships and care coordination

• “Sector Leadership and Excellence are Critical.” Slide 6 depicts the adoption curve; AFHTO members are clearly identified in the “Early Adopter” group. Our individual and collective work to engage patients, advance measurement, spread best practice and improve quality is recognized by the ministry, and in the results of the recent Conference Board of Canada FHT evaluation report. Team-based primary care is rich with strong leaders and champions to lead the way for this sector as the ministry and stakeholders work to transform the health system.

• Review of interprofessional primary care models. On both occasions Susan Fitzpatrick stated it was time to review 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). FHTs and CHCs will be included in the review. The ministry is developing terms of reference for this review, and is considering the range of team-based models to be included.

• Physician Services Agreement. Susan Fitzpatrick summarized the current status – click here for the ministry update.

AFHTO continues to work with and on behalf of members to show the way forward. We are 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. Collectively we continue to advance measurement capacity to give solid evidence of the value of team-based care, and develop governance and leadership capacity to lead the way. We will ensure our members’ successes are seen and voices heard by the ministry and stakeholders. We look forward to showcasing and further invigorating this work at the AFHTO 2015 Conference in October — Team-Based Primary Care: The Foundation of a Sustainable Health System.

On February 2, 2015 the Honourable Minister Dr. Eric Hoskins presented his plan for health care — Patients First: Action Plan for Health Care – on four themes: access, connecting patients to the services they need in their community, informing and educating patients on health care options, and protecting the quality, value and sustainability of health care services. There is one specific mention of primary care in the Action Plan. It reads – Quality Primary Care We know that access to quality primary care varies across the province. Some Ontarians have timely access to a family doctor, nurse practitioner and integrated health care teams and some do not. Together with our partners, we will bring forward a plan to ensure our primary care providers are organized around the needs of our population, such as those in northern, rural and fast-growing communities, focussing on greater accountability and access for these individuals and families. The plan does not go into any detail. The Minister did note in his speech the need to ensure access to “team-based, integrated, coordinated primary care,” and stated the report of the Expert Advisory Committee on Strengthening Primary Health, co-chaired by David Price and Elizabeth Baker would point the way. The Home & Community Care Expert Panel, chaired by Gail Donner, will also speak to the role of primary care. The Minister has received reports from both of these expert groups and we anticipate they will be released in the next month. The action plan does not mention recruitment and retention in primary care. Immediately after the speech, AFHTO’s Executive Director had the opportunity for a brief chat with the Minister. Before she said anything, the Minister’s first words were, “Recruitment and retention in primary care … we have to act on this.” A follow-up meeting with staff in the Premier’s Office and Minister’s Office is being organized. Additional items for AFHTO members to note are the province’s commitment to:

• Increase access to primary care providers and same day/next day appointments.
• Expand Health Links in more communities across Ontario.
• Integrate physiotherapists and other types of health care providers into the family health practice.
• Allow nurse practitioners to prescribe assistive devices.
• Explore ways to improve dementia supports, including new memory clinics.
• Increase transparent reporting on the quality and value of care to ensure the sustainability of the health system.

There are many details that are not yet known. AFHTO will continue to work with and on behalf of members to monitor, consult, advocate, inform and support you as events unfold. Links:

• Press release: Patients First: Action Plan for Health Care
• Patients First: Action Plan for Health Care, 2015 [PDF]

Yesterday afternoon the Ontario Medical Association held a press conference announcing that they will not accept the government’s offer reached through the current negotiation and conciliation process. This was followed by the Minister’s press conference about 1 1/2 hours later. The parties have reached the point where government is now in a position to impose a contract. Click here to read:

• OMA’s press release
• Minister’s press release
• Ministry’s “Physician Services: Ten-Point Plan For Saving And Improving Service”
• Former Chief Justice Warren Winkler’s written report on the conciliation process

What does this mean for interprofessional primary care in Ontario? The OMA’s release states: The government’s offer will cover less than half of the funding required for new doctors who are needed to treat current patients already struggling to access the care they need, for new patients coming into the health care system, as well as the more complex care required for our aging population. The following points in the ministry’s Ten-Point Plan  will affect primary care physicians:

• The fee for a walk-in visit on weekends or holidays will be reduced to become comparable to the fee for a visit to a patient’s own family doctor.
• Elimination of funding for doctors to attend courses and events that are considered part of their continuing medical education.
• Income stabilization payments for doctors who work in underserviced areas will continue, while doctors who work in over-serviced areas will no longer benefit from the payments.
• Only areas with a high need for physician services will get new Family Health Organisations and Family Health Teams.
• Additional funding to support the care for complex patients is to be restructured to directly target their care.  Until a new funding model is developed that more accurately reflects patient care complexity, this additional funding will not be applied.
• The ministry will apply a 2.65 per cent discount to all fee for service physician payments, effective February 1, 2015 and apply the reduction to non-fee-for-service payment contracts after the respective requirements for providing notice are met. The ministry will work with the OMA on a savings methodology that results in a higher proportion of savings from higher paid specialties.

AFHTO is following up on the items that could impact the organization and delivery of comprehensive interprofessional primary care, and will keep the membership informed.

This afternoon the Premier publicly released the mandate letters sent to each of her Ministers.  These letters outline the specific priorities that each member of cabinet and their ministry will focus on. The mandate letter addressed to the Minister of Health and Long-Term Care begins by pointing out government’s overall priorities, i.e. growing the economy, creating jobs, fiscal prudence. The Health Minister is specifically mandated to “lead the shift toward a sustainable, accountable system that provides co-ordinated quality care to people, when and where they need it.” The priorities named in the Health Minister’s letter include: “Bringing forward a plan to ensure that every Ontarian who wants one has a primary care provider.” The Liberal election platform articulated that one of the steps needed to make this a reality is to “Improve the recruitment and retention of community-based primary care teams.”  AFHTO continues to press this commitment, working in an environment where the Treasury Board President’s mandate letter says, “You will help ensure that any modest wage increases negotiated are absorbed by employers within Ontario’s existing fiscal plan through efficiency and productivity gains, or other trade-offs, so that service levels continue to meet the public’s needs.”

The Health Minister’s mandate letter provides the possibility for the role of primary care to be strengthened. Statements include:

• You will foster collaboration across the system and make the necessary trade-offs to shift spending to where Ontario will get the best value for our health care dollars — which must be shared between our health system partners.
• Ensuring that patients receive timely access to the most appropriate care in the most appropriate place — and that the needs of Ontario’s patients are at the centre of the system.
• Championing the delivery of quality co-ordinated care to patients by making the best use of the skills and capacity of all our health care providers, hospitals, community clinics and organizations, long-term care homes and others. You will take the lead in ensuring that changes are informed by evidence — and that Ontario’s precious health care dollars improve quality of care and health outcomes for patients and families.
• Continuing to ensure that our system has the health human resources it requires to deliver quality and efficient care. This includes exploring appropriate expanded scope of practice for providers and more models for collaborative care.

While primary care is not specifically named in these statements, AFHTO believes the strength of evidence that investment in a strong primary care system leads to better health and lower costs, combined with the evidence we anticipate will emerge as we progress with our “Data to Decisions: Advancing Primary Care” initiative, give us ample opportunity to build the strength of our sector. “Accountability and transparency” is a strong theme throughout the letter. One of the many references states:

• You will now work with them (health care administrators, institutions and providers), as outlined below, to continue to drive accountability, transparency and quality throughout the system, while limiting expenditure growth.
•  One of the outlined specifics is “Exploring options to further strengthen the framework for ensuring that the community sector and LHIN-funded health service providers are accountable for delivering quality patient care, including expanding the Excellent Care for All Act.”

AFHTO is well-positioned to address these issues with and on behalf of members.  We have already begun to work with the leaders of our member FHTs and NPLCs to develop a common statement of principles and priorities for governance and accountability. This will guide our continuing work to advocate for our members and be a resource to support you. We look forward to receiving responses to our leadership survey from board chairs, lead MDs/NPs and executive directors, and building from the results at our Toward the Next Ministry Contract session immediately before the AFHTO conference.

• To access the mandate letter to the Minister of Health and Long-Term Care, go to http://www.afhto.ca/wp-content/uploads/2014-09-25-Health-Minister-mandate-letter.pdf
• To access all of the mandate letters, go to  http://www.ontario.ca/government/mandate-letters

As promised, we are sharing with you the response we received from each of the three main political parties to the questions we had posed (see below). Click on the links to see responses (listed in the order they were received) from the:

• PC party
• Liberal party
• NDP party
• Plus a follow-up letter from Deb Matthews

Please make sure to vote! Angie Heydon Executive Director, AFHTO

1. For a summary of where each of the three main parties stands on health issues see below.
2. By June 10, AFHTO will share responses received from the parties on 5 questions about interprofessional primary care. Scroll down to see the questions.
3. Thank you to AFHTO members for raising awareness among candidates of the value interprofessional primary care delivers to patients and the health system and the need to support recruitment and retention of staff to deliver this care. Scroll down for more information.

1. PARTY PLATFORMS:

Lib – http://ontarioliberalplan.ca/#plan;

Liberals have pledged to “Guarantee that every Ontarian has access to a primary care provider.” Details on this pledge were released this morning; it includes the statement – “Improve the recruitment and retention of community-based primary care teams.”  Read more at http://kathleenwynne.ca/guaranteeing-primary-care-ontarians/ Other details about their health platform is found at – http://ontarioliberalplan.ca/wp-content/uploads/2014/05/Access-to-the-Right-Health-Care-at-the-Right-Time-in-the-Right-Place.pdf .

• Reduce wait times for referrals to specialists
• Advocate for national drug insurance
• Increase funding to our Mental Health and Addictions Strategy
• Provide access to free vaccinations and newborn screening
• Develop Community Hubs for community-driven programs that focus on health and wellness
• Create 36 more Health Links to help those with multiple, complex conditions
• Provide culturally appropriate care
• Provide Ontarians with better information about chemicals linked with cancer
• Increase funding for the seniors activity and community grants program

PC – http://ontariopc.com/millionjobsplan/plan.pdf

The plan largely builds on the vision advanced through the earlier PC party white papers on health care. The major health care commitments in the plan are as follows:

• Local Health Integrated Networks (LHINs) will be eliminated and replaced by Health Hubs (which would bring together hospitals and community providers). These hubs will be run by front-line local health experts.
• To help manage chronic conditions, the PCs would increase home care and create Chronic Care Centres. Doctors and nurses would work together to develop comprehensive care plans. Patients with the highest needs would be assigned a dedicated care navigator to ensure care is received right when they need it. This person will be a frontline caregiver such as a nurse, not a bureaucrat.
• Home care and long-term care would be expanded.
• The scope of practice would be updated for pharmacists, nurse practitioners and other professionals, to allow treatment where it is most convenient and beneficial for patients, particularly seniors.
• Introduce a self-directed model of home care that would allow patients to select their services.
• Encourage more competitive contracts for companies that provide health care services.
• The role of modern, specialty clinics to provide more services such as dialysis and routine surgeries would be expanded.
• Mental health services would be integrated to address the fragmented service delivery experienced by most patients today.
• Children’s physical activity would be increased to 45 minutes per day, through school-based activities and after-school sports.
• A secure health care database that will allow doctors and nurses to study real-world feedback on what treatments work best to help them determine the best care path for future patients would be created.

NDP — http://ourplan.ontariondp.ca/?source=homepage

The major health care commitments outlined in the plan are as follows: YEAR 1:

• Open 50 new 24-hour Family Health Clinics with the capacity to serve 250,000 people, reducing the number of Ontarians without primary care access by 25 per cent.
• Hire 250 more nurse practitioners in the Emergency Room in an effort to cut wait times in half.
• Create 1,400 new Long-Term care beds with the goal of eliminating the waitlists for acute long-term.
• Eliminate home care wait times for seniors with a Five Day Home Care guarantee. Clients would receive approximately two nursing visits and 7.5 hours of personal support per month.

YEAR 2:

• A Caregiver Tax Credit of $1, 275 per year to families caring for the ill or elderly.
• Student debt forgiveness for doctors who choose to practice in rural, underserviced areas. The plan targets participation by 250 physicians, forgiving $20, 000 of debt per service.

2. AFHTO’S QUESTIONS FOR PARTIES:

Answers to the following questions have been requested by June 6. Response received will be sent to AFHTO members no later than June 10:

1. Evidence shows that a very sick patient without high quality care can cost the province $30,000/year but the same patient with access to interprofessional family care only costs the province $12,000/year. Will your party support strengthening our family care teams and enhancing our capacity to care for more patients?
2. Despite having family care teams in 206 communities across Ontario, 3 out of 4 Ontarians still do not have access to the benefits of interprofessional family care. If elected, what will you do to expand this care model to ALL Ontarians?
3. Interprofessional family care teams are committed to optimizing health outcomes for patients and populations, meeting patient and public expectations, and supporting a sustainable health system.  What will your party do to advance the capacity of family care teams to capture and track the information they need to achieve these goals?
4. Interprofessional care teams struggle to retain health professionals due to higher salaries being paid in hospitals, community care access centres, public health units and other settings. How will your party help interprofessional care teams recruit and retain more health care professionals in order to expand better care to more Ontarians?
5. Final question is specific to each party’s platform:
   1. Lib: In your 2014 campaign platform you state that part of your 10-year plan is to support family health by guaranteeing everyone in Ontario has access to a primary care provider. How do you plan to use interprofessional family care teams to fulfill this promise?
   2. NDP: In your 2014 campaign platform, you state that you will add 50 new 24-hour Family Health Clinics. How will this commitment affect the current care model we have in place? Will it have a positive or negative effect on interprofessional family care teams
   3. PC: In your 2014 campaign platform, you state that you will help manage chronic care by increasing home care and creating Chronic Care Centres where doctors and nurses will collaborate to develop comprehensive care plans. Will this commitment compliment the current care model we have in place or have a negative effect on interprofessional family care teams?

3. AFHTO MEMBERS RAISING AWARENESS:

While AFHTO’s President and ED have been working at the provincial leadership level, AFHTO members have been active in their ridings and on social media.  Among those attending a recent meeting of the ED Advisory Council, about one-quarter had met with their MPPs and about one-third intended to contact candidates. Materials to help you spread the word on the value of continuing investment in team-based primary care are posted on the AFHTO members-only website:

• Advocacy Tools & Resources

Just before the AFHTO 2013 Conference, the OMA Negotiations Committee requested input from AFHTO “to identify potential topics or areas of focus that might warrant consideration during Ministry negotiations.” Their deadline for response was November 1, 2013. While the turnaround period was tight, the timing was ideal – two valuable opportunities to solicit membership input were taking place immediately before the AFHTO conference: the FHT Physician Networking Session and the Executive Director Advisory Committee. AFHTO’s response is based on the input received from these groups and approved by the AFHTO board. We are sharing AFHTO’s letter to the OMA’s Negotiations Committee with the board chairs, lead physicians and EDs of our member organizations, as well as about 50 physicians who had signed up for the pre-conference FHT Physician Networking Session. Click here to see AFHTO’s letter to the OMA Negotiations Committee.

A new session opened in the Ontario Legislature today. The Hon. David Onley, Lt. Governor of Ontario, set out the new premier’s agenda for the upcoming legislative session in the Speech From the Throne.  The components of the Government’s plan are:  a Steady Hand and a Bold Vision focusing on economic growth and increased employment; A New Sense of Community focusing on prosperous communities; A Fair Society that ensures all Ontarians have the same footing; and The Way Forward focusing on working collaboratively with all MPPs in the legislature. There are a number of healthcare and seniors initiatives included in the speech such as Community Health Links, home care, mental health and addictions, research and innovation, seniors and health promotion.   You can find the speech online at http://www.premier.gov.on.ca/en/news/24955.

AFHTO congratulates the Ministry of Health and Long-Term Care and Ontario Medical Association on reaching a Tentative 2012 Physician Services Agreement.  AFHTO’s Executive Committee has reviewed the agreement to assess what it may mean for family health teams. Overall, the tentative agreement contains a number of provisions that are aligned with the vision for FHTs to deliver accessible, comprehensive, high-quality, patient-centred primary care. These include measures to improve care for vulnerable populations, support evidence-based care, incorporate technology into the process of care, ease the ability of FHTs to bring in new doctors, and include FHT physicians in FHT quality improvement plans. The Tentative Agreement also contains a number of fee reductions and revisions. The amounts are varied, and in the OMA’s words, “… have been negotiated to be as fair and reasonable as possible, reflecting a balance of the government’s fiscal priorities, and the proposed evidence-based changes and program revisions set out in the Tentative Agreement.” There are a number of details to be worked through. The tentative agreement includes establishment of a Primary Care Policy Committee to imple­ment primary care initiatives and address policy issues identified in this agreement.  AFHTO will monitor the issue of staffing pressures on FHTs related to the increase in after hours requirements and the expansion of access to interdisciplinary services to non-FHT physicians, to ensure that FHTs are supported to improve and deliver optimal care. Further details on these topics are presented below for information. AFHTO encourages all FHT physicians to review the documents available to them through the OMA website (www.oma.org) and vote in the OMA referendum – November 28 to December 5.  Informed by the referendum results, OMA Council will meet on December 9 to vote on ratification. …………………………………………………………………………………………………………………………………………………………… Provisions in the Tentative 2012 Physician Services Agreement that could affect Family Health Teams Supporting care for vulnerable populations:

• Existing bonuses for house calls will be enhanced.
• A one-time acuity modifier is proposed and will be developed by the Primary Care Policy Committee (see below), until an acuity-adjusted capitation model is developed and implemented.  Forty million dollars is set aside for this initiative and the funding will come from other cuts.
• To develop proposals for medically complex patients, both post-discharge and ongoing, demonstration projects will be established to measure results, which will be evaluated after one year.
• Fee codes for group appointments will be introduced for chronic diseases and some mental health issues. These diseases include diabetes, congestive heart failure, asthma, chronic obstructive pulmonary disease (COPD), hypercholesterolemia, and fibromyalgia.

Supporting evidence-based care:

• Annual health exam will be replaced by personalized health review for ages 18 to 64.
• The lab requisition will be modified to remove ferritin, TSH, Chloride, CK and B12 but these tests may still be ordered.
• Only ALT (but not AST) may be ordered by non-specialists in community labs.
• Only red cell folate may be ordered by non-specialists.
• Thyroid scans should only be ordered for hyperthyroidism, congenital hypothyroidism, and masses in neck or mediastinum.
• Follow up colonoscopies will be at intervals of 5 or 10 years based on indicators.
• Paps will be every three years from age 21 to 70.
• The following tests will no longer be billable to OHIP:  annual stress tests for asymptomatic patients at low risk for CAD; preoperative cardiac testing for low/moderate risk patients; routine chest films.
• A working group will be established to review evidence to minimize overuse, misuse and underuse of best practice.

Incorporating technology in patient care:

• The Northern Health Travel Grant will be modified to encourage virtual visits where appropriate.
• A working group will evaluate existing pilots and use the data to recommend a model for better communication between hospitals and primary care.
• An evaluation will be developed to examine patient-initiated to provider eConsultations.
• eReferral fee codes will be developed for specialist referral with dermatology and ophthalmology as the initial trial specialties.
• An OTN Working Group will evaluate Personal Video Conferencing (PVC) deployment progress, utili­zation, volume and workflow trends to reduce the need for full telemedicine premiums and a new premium for northern and non-northern telemedicine consultations will be developed.

Increasing the opportunity for physicians to enter FHO and FHN models:

• Current stream of 25 entries into FHNs and FHOs will be expanded to 40 physicians per month beginning April 1 2013— 20 in a prioritized stream based on local need; and the remainder on a first come, first serve basis. Unfilled spots can be shifted to either stream or into subsequent months.  (There will be unrestricted entry to FHGs for all physicians.)

After hours requirements:

• New enhanced after hours requirements will apply to groups with 10 or more physicians:
  • 10-19 physicians – 7 blocks (2 additional)
  • 20-29 physicians – 8 blocks (3 additional)
  • 30-74 physicians – 10 blocks (5 additional)
  • 75-100 physicians – 15 blocks (10 additional)
  • 100-199 physicians – 20 blocks (15 additional)
  • 200+ physicians – 25 blocks (20 additional)
• Existing exemptions continue for ED coverage and obstetrics. If the FHN/FHO contract requires that 50% of FPs are required to have hospital privileges, then the group is exempt from the additional requirement.
• Some FHTs may be challenged to support additional after hours clinics with the necessary administrative and IHP staff.  AFHTO will monitor staffing pressures and advocate for the resources needed to meet requirements.

Annual quality improvement plans:

• Following from the Excellent Care for All Act, all interprofessional models of primary care (FHTs, CHCs, AHACs, and NPLCs) will be required to submit annual qual­ity improvement plans to Health Quality Ontario as of April 1, 2013. The tentative agreement expands participation to include phy­sicians practicing in these models.

Fee reductions and revisions:

• Diabetes management fee will be reduced from $75 to $60.
• Preventive care management fees ($6.86) will be discontinued but the annual preventive care bonuses will continue.
• Access Bonus rebate will be discontinued.  The Access Bonus itself is not changed.
• Two special bonuses that had been rarely accessed (In Office Service and Out of Office Care) will be discontinued.
• Physician payments for Telephone Health Advisory Service will be discontinued. Physicians will not be required to provide on call to THAS, however physician groups may continue to do so on a voluntary basis. Physician groups will still be required to report after hours clinic schedules. PEM groups will continue to receive a report when enrolled patients use Telehealth Ontario.
• Individual PEM physicians with more than 2,400 patients will receive the full value of the CCM fee for the first 2,400 rostered patients. For each subsequent patient, the fee will be reduced by 50%.
• Global payment discount of 0.5% will apply to all physician payments regardless of model.

Access to interdisciplinary services:

• Patient access to interdisciplinary primary health-care services will be expanded by allocating IHP resources to non-FHT affiliated phy­sician groups of three physicians or more, including Family Health Groups, Family Health Networks, Family Health Organizations and RNPGAs.  An implementation plan will need to be developed. What this could mean for the future direction of interdisciplinary primary care and the role FHTs could potentially play in implementation is unknown.

Once again, AFHTO encourages all FHT physicians to review the information available to them through the OMA and vote in the referendum.