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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.

Despite the increasing number of doctors in Alberta, many Albertans – especially in rural areas – still do not have a primary care provider.

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.

Looking forward

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.

Should Alberta continue to expand Family Care Centres?

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  1. NPs on the move

    You report:
    Gelber says, “..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”
    This most erroneous quote shows that many physicians still do not know/understand the legal authority, education and regulation of NPs: NPs not only know how to diagnose acute and chronic conditions but are perfectly capable of doing so. This is rhetoric as a cover for turf protection, loss of control of the monopoly physicians have had over health care in Canada, potential loss of status, and the fear of potential competition which translates into competition for $.
    FCCs are the perfect vehicle to open the door for other providers can provide safe and effective care, and that physicians may be best used as team members rather than private, for profit business owners. Albertans deserve the opportunity to try another model of care – the FCC model.

    • We need more NPs and more collaboration!

      Completely agree “NPs on the move” – another example of a medical turf battle which seems to be happening whenever any other profession tries to serve patients using their full set of training.

      Some physicians don’t understand (and frankly, are often unwilling to accept) what nurse practitioners, dieticians, pharmacists, physios, etc. learn in their training, are experts on, and are capable of doing. The mindset is that only a physician can do everything, and is largely motivated by for-profit medical clinics and fee for service payment. I would gladly visit an NP any day who practices to his/her full scope and is open to collaboration with other health professionals when their expertise is needed, then a physician who refuses to collaborate with other health professionals because they don’t want to lose the billing opportunity or control, and threaten to stop caring for patients if they seek collaborative care from other health professionals. I’ve been in that position before, and it feels like you’re being taken hostage when you’re supposed to be receiving care that’s in your best interest as a patient. If a patient needs additional assessment that is beyond an NPs (or any other health professional’s) scope, I have all confidence they would be referred. No true, caring health professional will risk their patients’ health or their license to simply protect their ego. Physicians just express concern over misdiagnosis, etc. because it instills fear, but I don’t believe is based on any real evidence. We all know there are also many physicians who don’t refer patients when further assessment is needed because they don’t want to admit they don’t know what’s going on. Perhaps a look in the mirror is warranted before other professionals are shot down and fear mongering is practiced.

      Don’t get me wrong, not all physicians are like this and some are very open to collaboration, but there is definitely a culture of bullying in healthcare by some physicians who are unwilling to give up complete unquestioning control, and I think this is largely due to the fact that they are running businesses where the number of patient visits directly impacts their bottom line. I empathize with that – we all have bills to pay and need to make a fair living, and running a medical practice isn’t cheap or easy – but I fully agree that the fee for service system only worsens this pressure. Pay physicians (and all health professionals) by salary, make that payment fair for their level of training and responsibility, and take away the financial incentive that currently exists to not practice collaboratively because of the fear of losing billable visits.

      Fully in support of NPs and FCCs, and salary-based payment.

    • Dr. Brian Graham

      I would never opt to choose a nurse practitioner over a physician.

      Nurse practitioners receive far less relevant medical training than even a third-year medical student! Their early training in no way overlaps with that of medicine. They are experts at nursing, not medicine, so they should not be practicing the latter. To allow them to do so would be to harm patients.

      This is clearly a grab at power by the nursing lobby. Nurse practitioners will present themselves as the cheap solution to our primary care woes, until their numbers swell and they demand pay parity. Imagine that: paying just as much for an inferior product.

      If a nurse wishes to practice medicine, they are more than free to apply to medical school.

      • C Hebert

        A vehement disagreement with Dr. Brian Graham. Health Canada commissioned a report on nurse practitioners in primary care. Dr. Margo Rowan led the literature review process (in case you want to try to track down a report). They found quite the opposite of what Dr. Graham suggests: substantial NPs competency overlap with family physicians; produce equivalent or better outcomes when compared to physicians; patients of NPs report higher satisfaction with care; and were cost-effective – saw fewer patients per day, but remunerated much lower as well.

        The notion that these skills belong to medicine and medicine alone is part of the problem that got us into the mess we are in in the first place.

  2. Dr. Merrilee Fullerton

    I’m just wondering how much funding Alberta will have for FCCs when thousands of people have lost their homes and need support and compensation…When it comes to social determinants of health a fairly major one is is having a home to live in.

  3. Dianne Dyer President College and Association of Regsitered Nurses of Alberta and Member of the Minister's Advisory Committee on Primary Health Care

    The College and Association of Registered Nurses of Alberta (CARNA) recognizes the family care clinic model as an important new initiative which will expand Albertans’ access to primary health care services in their communities.

    When evaluating whether the government should continue to establish more clinics, I would like to point out three things:
    1. The FCCs are not a duplication of the Primary Care Networks (PCNs).
    The primary differences are that the work of the FCC is based on the principles of primary health care and is specifically designed to address the complex needs of the community, to fill the gaps, not duplicate existing services. Primary health care reflects the fundamental values and principles that have always guided registered nurses (RNs) in their practice: promoting health, preventing disease and injury, and restoring health through rehabilitation and recovery. It is not setting-specific and occurs across the continuum of care from community to acute care to continuing care settings.
    FCCs will fill needs that are not met by PCNs. FCCs will target underserved communities and support delivery of services under one roof or ensure effective timely linkages to services within the local community.
    The primary goal of the FCC is to provide each individual and their family with attachment to a health home with direct access to a variety of providers and services in order to address their often complex and unmet health, social and educational needs.
    In addition, the governance of the FCC involves a community-led board working in partnership with the various professionals and the community.

    2. The FCC and the CHC model are not mutually exclusive
    The comparison with the Community Health Centre (CHC) model is valuable and important as CHC effectiveness is well-grounded in research over an extended period of time. As the writer said the CHC studies have identified that there is a need for upfront investment in primary health care which ultimately saves money down the road by addressing complex social and health needs of a specific community or “buying good value”. Moving forward there is no evidence that the FCCs will not offer similar or the same services as the successful CHCs.

    3. Rather than being physician-led, staffing will be determined by the community needs.
    The FCC is a pivotal access point to primary health care and will be staffed by an interdisciplinary team of providers from various sectors (e.g. health, social services, environment, and interpretative services). The numbers and professions included in the work of the FCC will be determined by the community needs. Each profession will work in equal partnership with each other and the community, and the client(s) will directly access the most appropriate provider to address their needs (e.g. registered nurse, social worker, housing expert, nurse practitioner and/or physician).
    The services provided will be determined by community needs and if dental care, for example, is a need and a gap then dental care may be provided or links to local dental care services will be established. RNs and nurse practitioners (NPs) will play a pivotal role in FCCs as they will provide direct expert care and services combined with coordination of services across a wide spectrum of existing community agencies, community experts and timely links to acute care services and programs when necessary. Physicians will also play an important role through direct involvement in the FCC as a salary-based provider (compensation model is under review) or through timely response to referrals as required.

    It is inaccurate to suggest that the NP cannot work independently in an FCC. They are highly educated and well aware of their scope of practice and expertise and work with physicians in partnership or refer clients to a physician whenever it is necessary.

    Primary health care and the important work of the FCC will extend beyond the traditional health system to include the individuals, families and the community in decisions about their care and services where they live, work and play.

    • Jeneen Vennings

      If these FCC models are supposed to be better and they ARE NOT, why are we in Slave Lake waiting hours weeks and months to get an appointment. Why are pregnant women being turned away from our FCC at 36 weeks gestation with reasoning that they do not need to see a Dr. Why is a first time mother in the hospital in Edmonton with a tubal pregnancy that threatened her life because of inadequete or should I say absolutely no prenatal care. Receptionists or Nurses should have no say in who we as patients are able to see or when we are able to see them

      • Dr. Harnsby

        I agree Jeneen.

        Patients want to see doctors. Patients should be able to see doctors. Doctors want to see patients.

        Having a nurse gatekeeper is ridiculous, for a nurse lacks the knowledge base to determine whether a patient needs medical care and what level of care is needed.

  4. Shelley Leishman

    Not working. I live in Slave Lake and it is a farce. Many many duplications. I will not vote PC again. This has to fixed and we need our Dr.s back. Our situation has been ignored and dr.s have resigned in protest over this system. Let’s listen to them. I think they would know the best. Take the gag order off and if you really care, then listen

  5. Nicola Ramsey

    Like many models, the FCC looks good in theory but in practice it has been nothing short of a disaster.

    Problems with the model include:

    • Inability to attract and retain doctors. Over the past several years, Slave Lake has had about a dozen doctors serving over 11,000 people, When the Family Care Clinic opened in the spring of 2012, there were two clinics. The Associate Medical Clinic, that now houses the FCC, had 6 practicing doctors and the Slave Lake Family Clinic had one. Since the establishment of the FCC, the one private clinic has closed and the FCC is currently staffed with 4 doctors and 7 nurse practitioners. Two doctors are generally available for a portion of the time the clinic is open. 4 family doctors resigned from the clinic, citing patient advocacy issues. These doctors still live in our community and commute to work in neighbouring towns. No new doctors have been recruited.
    • Quality of care concerns AHS states that “FCCs provide patients access to the most appropriate member of a health care team.” In reality it is a receptionist decides who sees a doctor, who sees a nurse practitioner, what order they get in, and who gets to wait for another day. Last Friday there were 20 people waiting to see a health care provider on a walk-in basis. Those near the end of the queue waited 5 hours to see someone.
    • An end to the physician patient relationship People are no longer patients of one particular doctor. They are patients of the clinic. The physician-patient relationship that allows doctors to understand the whole person, their history and their circumstances all of which are essential aspects of appropriate medical care, is not part of the model..
    • Lack of continuity of care In the absence of a personal physician, it is unclear who provides follow-through or advocates for patients. Seniors no longer have family doctors. Expectant mothers and their babies no longer have one family doctor to look after their needs. Patients are falling through the cracks.
    • No community input. The model was implemented with no input from the community. There is no local advisory committee as mandated by AHS.
    • No alternative Unlike people in larger centres, the people of Slave Lake have no alternatives for their care unless they drive 50 kilometres to the nearest town, or 200 kilometres to the nearest city. Many people are doing just that.

    Slave Lake has been the guinea pig for a failed experiment that was imposed while the community was still reeling from the after-effects of a horrific wildfire. While AHS claims this model is highly effective, the Slave Lake experience clearly shows the opposite to be true.

    • Dr. Harnsby

      This is clearly an attempt by AHS to contain costs. Doctors are expensive, nurses are cheaper, and to get doctors to migrate to small isolated communities requires retention bonuses etc. Unfortunately, the old adage that “you get what you pay for” still rings true.

      The unfortunate truth is that doctors are the leaders of medical care and are the ones best able to diagnose, treat, and most importantly advocate for their patients. Unfortunately AHS wants to save money, and a few militant nurses are getting a bit too big for their britches, and this means that your health care suffers all in the name of saving a few bucks.

  6. Ellen Criss

    In Slave Lake this experiment was unsuccessful. It seems that the person deciding what treatment is allowed is a receptionist. This can have disastrous results. In addition, the doctor-patient relationship is non-existent. A person who is struggling with an illness or long-term condition needs more than a prescription; he or she needs the support and compassion that is provided by a consistent care-giver who knows his or her condition. A doctor is more than a machine that delivers a diagnosis or treatment plan: a doctor is also involved with the well-being of the whole person. One of my family members saw at least four different doctors during a two week period, as she continued to seek care for cramps she experienced early in her pregnancy. Each time, she was given blood tests and sent home. Ultimately, it was discovered that she had an ectopic pregnancy. Unfortunately the pregnancy was so far advanced by that time that she required an emergency ambulance ride to Edmonton, and surgery. It is somewhat miraculous that nothing ruptured. I cannot help but think that the continuous care of one physician could have alleviated the multiple trips to emergency, the pain and suffering of the surgery and the frustration of knowing that she was a number, not a person. The FCC model does NOT work. I believe that it is part of the reason that we are going backwards here in Slave Lake and losing services.

  7. ShawnaLee Jessiman

    The question of whether the FCC is filling the gap or a costly duplication is irrelevant.

    The FCC model has been a failure in the community that wasn’t a large centre, therefore, how will it improve access to health care for communities needing services. It may work in a large centre where there are other options for patients besides the FCC, but in the smaller communities it could have the same effect it had in Slave Lake. That community has seen it’s health care access deteriorate to less than acceptable standards.

    Stop the FCC before it totally decimates our health care system.

  8. Sheri Smears

    This description of the FCC experiment is very accurate. We have gone from a community with choices of whom we wish to see concerning our healthcare to a community who has no guarantee if we can see anybody. The frustration, anger and fear that this experiment has caused the residents of this community is unbelievable. We no longer feel that we have any say in our own healthcare, we have no options, we are being treated as if we do not deserve to be a part of our own healthcare. Decisions are made for us, not with us, we are not part of the whole process.

  9. Mary Kupsch

    AHS has stated that the numbers are down at the emergency therefore this experiment is a success but people are sitting for four and five hours as a walk in patient at the FCC, so you tell me where the difference is. When asked for the name of my family doctor , what do I answer? The FCC.

  10. Darlene Brownlee

    The FCC in Slave lake is NOT working even tho Fred Horne can’t see
    people that are following through the cracks. If we have an emergency we will be on our way to St.Albert even tho it is a Two & a half hour drive. Can not take a chance on Slave Lake. My husband & I are over seventy years old and we do not have a Family Doctor. How Sad is that. You can be sure we are not the only people in this Boat.
    GET RID OF THE FCC NOW!!!!!!! we also have a MLA who does not support her consituents.

  11. Arlene Travnik

    I am not convinced that the decision to go ahead with this model is in the best interest of Albertans. Where is the proof?? Why have the evaluations not been made public? Why is Horne insisting that this model is going ahead regardless of the results shown in the evaluation? This does not make sense. The people in communities where it has been implemented (like Slave Lake) are NOT happy with it, and it has caused many of the Dr’s there to leave the community. What possible reason does the PC government have to push these through without listening to the concerns and criticisms of the people effected by the changes??
    You can be sure this is going to be a HUGE issue in the coming election! PC’s are too heavy handed!!

  12. Jim

    The FCC is not the only clinic in town, but it is the most successful one. All the doctors also seem to think so, and the last doctor at the private clinic recently moved across to the FCC. Adding nurse practitioners has allowed extended hours of service that Slave Lake has never had before. Many northern communities are competing for doctors, and the doctor shortage is not the fault of the FCC; in fact potential recruits for Slave Lake seem very interested in joining the FCC. I think if the FCC was privately owned, it would not be such an easy target.

  13. Jim

    I have been thinking some more about the comments on this page. How is the doctor shortage the fault of the government? Did the FCC stop recruiting doctors just because they hired nurse practitioners? Can the government force doctors to come to Slave Lake? If I was a doctor and read some of these complaints, I would wonder if Slave Lake residents really supported their clinics and physicians. Thankfully, I know that many in our community still do.

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