Family Care Clinics – filling a gap or costly duplication?
During her campaign for reelection in 2012, Alberta premier Alison Redford promised to create 140 Family Care Clinics (FCCs) over three years. She articulated a vision of primary care that would be one-stop, with many different health care providers under one roof. These clinics would have expanded hours to improve patient access, and would focus on prevention.
More than a year later, only three Family Care Clinics have opened, though 24 more communities have been identified as possible sites for future clinics.
While Alberta has slowly begun to move forward with this newest form of primary care reform, some remain skeptical about the value of these clinics, and whether they will simply duplicate the work already being done by Primary Care Networks (PCNs).
Will Family Care Clinics fill a crucial gap in Alberta’s primary care system, or are they just a costly duplication of services?
FCCs to provide integrated primary care to underserved communities
“The main thing we want to accomplish with FCCs is to provide primary health care coverage to Albertans that don’t currently have it,” explains Fred Horne, Alberta’s Minister of Health, in an interview with Healthy Debate.
FCCs are meant to alleviate this shortage by providing an interdisciplinary model of care, with family doctors, nurse practitioners, registered nurses, dietitians, pharmacists and others all working to their full scope of practice. Under this model, not every health issue – such as diet advice or vaccinations – would have to be dealt with by a family doctor. Instead, patients will have each issue addressed by the most appropriate practitioner at their FCC.
Horne emphasizes that the FCCs will be located in areas where the need for primary care is high. However, many rural Albertans hoping for better access to primary care will continue to wait for relief: two of the three existing FCCs are located in Calgary & Edmonton and the same is true of seven of the 24 communities identified for the next phase of the roll-out.
Richard Lewanczuk, Senior Medical Director of Primary and Community Care at Alberta Health Services, explains that the 24 communities identified for FCC sites were chosen based not just on need, but also “readiness and capacity to implement a FCC.”
While it makes sense to pilot new initiatives where there are existing resources to build upon, it is likely that communities with “readiness and capacity” already have substantially more primary care resources than those that do not, meaning FCCs – at least at this phase – will probably not be established in the communities that need them most.
FCCs to emphasize prevention by addressing social determinants of health
While FCCs will not immediately repair the gaps in primary care coverage in Alberta, they could lay the foundation for a healthier population.
Many factors contribute to a person’s health, including genetics, lifestyle, and environment. Scientific evidence has demonstrated that some of the most powerful contributors to health are social: income and social status, employment and working conditions, housing, and early childhood education and development. These are known in health care circles as the social determinants of health.
Addressing social determinants of health is believed by many experts to be the most powerful form of preventative health care, and the World Health Organization officially committed to tackling them worldwide at its congress in 2011.
Lewanczuk says FCCs will address these social determinants by integrating primary health care (family doctors, nurse practitioners, etc.) with other social services, such as health promoters, social workers and specialists in early childhood development. This way, patients will have both their current and future health needs met under the same roof.
A similar model of care is already in place in Canada’s Community Health Centres (CHCs). There are 73 CHCs in Ontario, and Alberta has three CHCs of its own, including one in Calgary and one in Edmonton. CHCs provide targeted care to vulnerable populations, often in neighborhoods that are home to many newcomers to Canada or that are of lower socioeconomic status. CHCs provide many services beyond traditional health care, including a major focus on childhood and youth development.
And there is some evidence that the approach works. A recent comparison of primary care models in Ontario found that CHCs produce very good outcomes in the form of significantly lower-than-expected Emergency Department use.
Cost vs. value in primary health care
A major concern raised over FCCs is their potential price tag. While Premier Redford promised during the election campaign that FCCs would not require additional funding from government, it now appears that some additional funding will be allocated.
“The expansion of FCCs will involve both reallocating existing funding for primary care, as well as some new funding,” says Horne. According to Lewanczuk, about $50 million of new funding has been allocated this year to set up the new 24 FCCs. Horne sees this new investment as complementing the $181 million the government invested last year into Primary Care Networks.
It is perhaps not surprising that FCCs will require new investment. Interdisciplinary models of primary health care tend to cost more per patient than traditional primary care provided by a solo family doctor. However, if Ontario’s experience with CHCs is any indication, this increased cost may buy good value.
Rick Glazier, a research scientist at the Institute for Clinical Evaluative Sciences, explains in an email that “in Ontario, CHC providers look after fewer patients with more health and social needs than in other primary care models, so they appear to be more expensive, but they also appear to be providing highly appropriate care for the high needs people they serve.”
Adrianna Tetley, executive director of the Association of Ontario Health Centres agrees that this model of primary health care requires upfront investment, but argues that “it saves money down the road.”
Glazier notes that the overall cost-effectiveness of CHC-style care is an “ongoing debate” in Ontario. “Cost-effectiveness is challenging to determine under these circumstances, because CHCs embody the philosophy of primary health care, not just primary care,” he writes. However his research does indicate that patients of CHCs have lower-than-expected Emergency Department visits, which may well save the system money in the long run.
It should be noted, however, that FCCs will not necessarily offer the same scope of services as many of Ontario’s CHCs, which receive funding from multiple government ministries and whose services can include dental care, street outreach, English as a second language classes, and seniors programs.
The relationship between Family Care Clinics and Primary Care Networks
Another concern about FCCs is that they could create needless duplication of services already offered by Alberta’s Primary Care Networks. “It would be a disaster if FCCs and PCNs wind up doing the same work for the same patients,” says Tobias Gelber, chair of the Primary Care Alliance, an Alberta Medical Association body representing Alberta’s primary care doctors.
Primary care networks are led by family doctors, who work with other health professionals (such as nurses, dieticians and pharmacists). These practitioners may work together under the same roof or may be spread across a geographic region. PCNs were established with a great deal of flexibility, so there is no single model of care delivery. More than 2500 family doctors currently work within Alberta’s 40 PCNs. (Readers in Ontario will recognize PCNs as close relatives of Family Health Teams.)
The chief differences between FCCs and PCNs appear to be that FCCs are specifically targeted at underserved communities, have a more defined mandate to focus on social determinants of health, and are expected to deliver all of their services under one roof, rather than be spread across a region.
Another difference – and a likely source of some of the criticism directed at FCCs from doctors – is governance: according to Horne, most FCCs will be governed by community boards, while PCNs are governed by the family doctors who work in them in partnership with their regional health authority. Doctors at FCCs will also be paid a salary, whereas doctors at PCNs are paid through a blend of fee for service and capitation (payment per patient).
Lewanczuk agrees with Gelber that FCCs and PCNs should not double-up services, and explains that new FCCs are being located in areas that are currently underserved, so the risk of duplication is minimal. “These clinics are targeted. While some identified areas already have a PCN in the region, there’s still a lot of unmet need in those communities,” he explains.
Lawanczuk also notes that risk of duplication will be further reduced by allowing PCNs to operate FCCs. “FCCs are going to be community led,” he says, “so PCNs are welcome to put forward proposals to open and operate FCCs in underserved areas. This will allow PCNs and FCCs to coordinate and get the right care to the right patients.”
If the Ontario experience is any indication, concerns about duplication may be overblown, as researchers have found that CHCs provide services to quite different populations than other models of interdisciplinary primary care.
Gelber remains concerned, however, that many details about the relationship between FCCs and PCNs are still unclear, and believes coordinating care and funding for patient services between these two very different models of primary care will prove challenging.
Unanswered questions remain
Many details of how FCCs will be structured are still unsettled. This is partly because Horne wants communities to be able to customize FCCs to meet their needs. Communities where substance abuse is a major concern might design their FCC with an addictions and mental health focus, for example. Another community where obesity is prevalent might instead invest in programming that focuses on activity and food security, in addition to core primary care services.
One detail that has been settled is that FCCs must have either a family doctor or a nurse practitioner on staff, explains Joan Berezanski, Assistant Deputy Minister of Primary Care at Alberta Health.
This is proving a point of contention with doctors. Gelber complains that “Alberta Health has not sought a lot of input from doctors on the development of FCCs… we don’t think that it is a good idea that they will be physician optional.”
Gelber believes FCCs will be most effective if they all have family doctors in-house. “If a patient’s condition is already differentiated – if we know they have congestive heart failure – then it makes good sense for them to go straight to a nurse practitioner to have their condition managed, but if a patient comes through the door with an undifferentiated condition – where we don’t know what’s wrong with them – that’s where we need a family doctor in-house to make a diagnosis,” he says.
The other major question that hangs over FCCs is how effective the model will ultimately prove. While CHCs in Ontario appear to have been quite successful at providing quality care to high risk populations, FCCs – at least initially – will not offer the same scope of services (such as subsidized dental care), so it is unknown whether they will prove as effective as their Ontario cousins.
An evaluation of the three pilot FCCs is underway, but the results have not yet been made public. However, “the decision to move forward with FCCs has been made,” says Horne, “expanding them is not contingent on the results of that evaluation.” Instead, Horne envisions an ongoing evaluation process, which will be used for quality improvement purposes and to guide the next phase of the FCC expansion.
While unanswered questions remain, the government is clearly committed to Family Care Clinics as the next step in the evolution of primary care in Alberta.
With only three sites currently in operation and 24 more still at the proposal stage, it seems unlikely Redford’s campaign promise of 140 FCCs in three years will be realized, and rural Albertans hoping for better primary care coverage will likely be waiting a good deal longer before they see an FCC in their community.
However, there is some reason for optimism. The model of care embodied by FCCs has been successful elsewhere, so while these clinics will not cure all that ails primary care in Alberta, they may ultimately close some gaps in coverage, and by providing integrated primary health care, contribute to a healthier province.