Team-based care has long been hailed as key to fixing Ontario’s primary care crisis.
Over the past 20 years, models such as Family Health Teams have demonstrated success in improving patient access to allied health professionals and quality of care. Substantial investments in developing and expanding these teams are being made by the Primary Care Action Team (PCAT) led by Jane Philpott, which has a mandate to attach all Ontarians to a family doctor, nurse practitioner or primary care team by 2029.
But interestingly, physicians’ roster sizes are slightly lower when working with these government-funded team models. Why? Because Family Health Teams were not designed with the objective to increase patient attachment to comprehensive, longitudinal care. Instead, most Family Health Teams focus on improving patient access to specific aspects of care through dedicated programs and services such as diabetes education. While access to better quality of care is a fundamental element of care, it is not directed to the goal of attachment.
But if the goal is to increase patient attachment, then the underlying problem must be tackled: it is essential to enhance the capacity of those who attach, such as family physicians. To free up capacity to attach more patients, physicians need to be able to offload and share tasks with other team members.
This can be achieved through building and funding patient core teams.
A patient core team comprises a physician and other health-care professionals who work to their optimal scope to provide comprehensive, longitudinal primary care to the patient. The entire team is focused on the objective of attaching patients with timely access to care. This includes providing routine and acute care visits, chronic and preventive services, and coordinating care with outside services.
Physicians, who are responsible for attachment, direct and share clinical and administrative tasks with their patient core team members. This frees up their capacity to attach more patients and focus on care decisions with the patient.
Registered Nurses (RNs), Registered Practical Nurses (RPNs), Physician Assistants (PAs) and practice support staff (e.g., patient navigators, Medical Office Assistants) are highly effective in expanding physician capacity to attach.
Clinical team members can support a broad range of primary care tasks, including triaging new issues, managing care plans for chronic diseases, performing routine and preventive screenings, conducting patient follow-up calls and providing patient education.
Practice support staff play a vital role in alleviating much of the administrative burden for physicians that takes time away from seeing patients. Patient navigators can help connect patients with the health system and community resources. Medical Office Assistants can handle patient appointment bookings and check-in patients, manage office administration tasks such as ordering equipment and completing basic sections of forms.
Each patient core team composition would depend on the unique practice needs and goals for patient attachment in different communities.
Patient core teams have proven effective in helping family physicians see more patients. In the Netherlands, where more than 95 per cent of people have a family doctor, practice assistants play a key role. They handle tasks like wound care, immunizations and pap tests, along with triaging patients and managing administrative work, which increases physician capacity.
In the United States, clinics using patient core teams with nurses or medical assistants have increased capacity for physicians to see more patients while also improving access to care, quality of care and satisfaction for patients, physicians and staff.
With patient core teams, more people can be seen and attached to comprehensive, longitudinal primary care and help achieve PCAT’s goal of ensuring all Ontarians have a family doctor.
To fully implement patient core teams in Ontario, essential system changes are needed:
- Funding and resources to build patient core teams made available to all family physicians through the PCAT investments
- Training for family physicians and other professionals on how to effectively become a patient core team to increase capacity to attach
- Investments to increase the workforce needed to fill these patient core team roles
Investing in patient core teams is also part of the strategy to recruit and retain more family physicians. A host of systemic issues has made family medicine a less desirable and sustainable specialty, including the overwhelming administrative burden and updating family medicine compensation models. Progress on the latter is imminent with the new FHO+ model culminating from negotiations between the Ontario Medical Association and Ministry of Health. The Arbitration Board has a few issues to decide on. This updated compensation model will address many long-standing issues identified by family physicians, including administrative burden, increasing complexity, the gender pay gap and lagging compensation.
As the province works toward attaching all Ontarians to primary care, it’s time to re-imagine how we build teams to support this new objective. Let’s start at the core.
Starting at the core of building primary care teams means starting with patients. Different patients have different needs, and the kinds of services that are needed and how many of these services are required vary from patient to patient. Identifying patient needs and matching them with services and providers who can deliver these services will be key to identifying the “patient core teams” that actually meet the needs of communities. But how do we know what is needed? Family physicians need information about who is in their community, their characteristics and service needs, and the resources available to help, including the full range of interprofessional health practitioners. Right now, we don’t really know who receives what primary care service from whom, where, when, how and why, and we also don’t have a good idea of the services – and the workforce – that will be needed in the future. Investment in data and data infrastructure, paired with rigorous workforce modelling, is urgently needed so that we can build and fund primary care “patient core teams” properly, starting with patients.
As a newly graduated Nurse Practitioner program student, I find it disheartening to read articles that address the crisis of access to primary healthcare that completely omit any mention of NPs, as if they do not exist. Nurse Practitioners are highly educated and competent healthcare professionals who can be immediately utilized to help improve access to primary care.
Ignoring the capabilities of NPs, which have been shown to enhance patient care and health outcomes safely and effectively, only fuels unnecessary divisiveness among healthcare professions. Instead of fostering teamwork and collaboration, this omission highlights a growing animosity towards NPs by medical associations, which for me is a canary in the coalmine, suggesting there is a perceived power struggle that is contributing to barriers for NP entry into primary care. This dynamic is detrimental to our communities, preventing a group of qualified healthcare professionals from delivering much-needed primary care.
I am not asserting that NPs are the sole solution to the issue of access, however their inclusion in the primary care team is an essential and obvious step toward addressing this crisis, that this article has ignored. The exclusion of including NPs from such discussions about possible solutions, has to reflect political motivations, rather than a practical commitment to comprehensive healthcare.
I feel that it is crucial for health policy leaders to acknowledge and address this negative interdisciplinary dynamic that is developing (and seemingly expanding), and implement policies that will alleviate tensions among healthcare professionals. By ensuring that all healthcare providers feel secure in their professional identities and are providing care within the team at their full scopes of practice, we can foster a patient-centered approach to care that prioritizes access for all.
First, full disclosure I have been involved with family health teams most recently as the senior executive of two teams and 20+ years ago as a Director at the Ministry. I was involved in implementing the model and prior to that negotiating physician compensation agreements. There was a crisis in family medicine and creating a roster based payment model for doctors supported by a new primary care team model virtually eliminated this crisis and connected millions of Ontarians to a family physician.
Patient core teams and family health teams do not have to be mutually exclusive. Significant funding investments in physician practices are critical to making the opening of a comprehensive family practice appealing. Family physicians trying to maintain a practice in the face of runaway inflation is to my mind the root problem. Their revenue has not come close to keeping up with the cost of rent, supplies and staffing – I strongly support investments directly into physician practices.
A major reason that patient attachment to physicians has suffered is that these out of control costs have driven physicians to a mixed practice – as one family physician told me, they work half-time as a hospitalist just to keep the lights on at their family practice. With competitive compensation and well funded family health team supports many would choose a full time family practice with the subsequent outcomes we all seek.
It is hard to make a fair assessment of family health teams today when base budgets have not increased in 10 years and staff wages in six years.
Investments in both physician practices and in family health teams will drive both quantity and quality and will dramatically decrease the pressure on hospitals and improve the lives of our citizens with cost effective and compassionate measures.