On Dec. 8, the CMA hosted the second event in our Health Summit Series: Bold Choices in Health Care, a national conversation with physicians and other key stakeholders on urgent system reform. The focus for this session: how we deliver effective and efficient care. Below are some of the issues informing new models of care.
CMA EXPLAINS
How many times will a patient have to tell their story?
The answer is a good indicator of how well health services are organized – for those who need them, and those who provide them.
And in Canada, the answer is too often “again and again” for every step of a patient’s care.
Care is being offered in a wider range of settings, by a broader range of health care professionals, but in many cases teams, individuals and organizations operate independently of one another, with little support or accountability for continuity of care.
Patients and their families – especially those who have complex, chronic or multi-morbid conditions – can be left behind as they transition between care providers, or are forced to navigate the health system on their own.
“Fragmentation - patient journeys fractured into smaller pieces managed by isolated, uncoordinated, autonomous entities - makes for terrible patient experiences. It's also one of several reasons why it's so hard to manage our current health systems.”
- Dr. Alika Lafontaine MD on Twitter
Silos of care are no better for health providers. They can lead to bottlenecks, increasing pressure across the continuum of care. There are multiple, frustratingly incompatible, electronic record systems to contend with. And they fundamentally fracture relationships with patients – the cornerstone of medicine, and, for many health workers, professional fulfillment.
But a more integrated, collaborative model of care delivery is possible. Here are some key considerations for a better organization of health resources:
The best use of health professionals
There have been calls for integrated, multidisciplinary health teams – particularly in primary care – for more than a decade.
Optimal scope of practice
Team-based care allows health professionals to perform at their optimal scope of practice. Adding a medical scribe to a family practice, for example, would give doctors more time with patients and alleviate administrative burdens – one of the top contributors to burnout among physicians. Working together, physicians, nurses, pharmacists and social workers (among others) can complement each other’s skills and expertise.
Health care teams in integrated settings can also provide a consistent touch point for patients across interactions with different providers, and help patients, families and caregivers navigate social services, housing and other social determinants of health.
Extending primary care
Although their scopes of practice vary across the country, nurse practitioners could help alleviate gaps in care resulting from shortages of family physicians. Advanced care paramedics can also be an extension of primary care. In Renfrew County, outside of Ottawa, they are conducting patient assessments and providing treatment in the community – referring patients back to physicians as necessary.
Virtual care, which was quickly ramped up at the onset of the pandemic, can be a better use of both provider and patient time. As part of an integrated health care system, it has the potential to improve access to care as well.
A single pan-Canadian licensing system would give physicians the ability to practice both virtual and in-person care where it’s needed most.
“Working together, we can build – for the first time since the dawn of Medicare – a health care system that is integrated, co-ordinated and collaborative.”
Dr. Alika Lafontaine/Globe and Mail
New approaches to specialty and surgical care
The COVID-19 pandemic sparked a vicious cycle of postponed procedures and staffing shortages that contributed to a massive backlog for specialty and surgical care. Improving staffing – especially the supply of nurses – is a vital step. But a number of provinces are also experimenting with alternative models for patient referrals and treatments.
Centralized intake
A pilot project in Alberta shows how a centralized system for elective surgeries like hip and knee replacements can streamline and shorten wait times. Referrals for procedures and diagnostic tests are routed to a central clinic where patients can book appointments with a specific physician, or with the provider with the shortest wait time.
Dedicated surgical centres
New approaches to lower-complexity surgeries are keeping patients out of overwhelmed hospitals and lowering costs. One program in London, Ont., is taking select orthopedic surgeries to ambulatory operating rooms.
New Brunswick’s premier is proposing inter-provincial collaboration on dedicated surgical centres. These could reduce wait times for common hip and knee procedures, or work like the New Brunswick Heart Centre in Saint John, which accepts cardiac patients from across Atlantic Canada.
New payment models
More than 70% of physicians in Canada are remunerated through fee-for-service.
But many members of the Canadian Medical Association (CMA) have expressed dissatisfaction with this model for valuing quantity over quality at the expense of team-based care, mental health services and chronic disease management.
“In recent years, family doctors have reported that fee-for-service payments are falling behind the growth of expenses in their small business practices. They also face pressure from the growing complexity of their patients’ medical needs.”
- Globe and Mail
In primary care, alternative funding models including capitation and salary can incentivize team-based practices and improve patient outcomes. In July, Nova Scotia announced a new pilot program to encourage team-based care through a “blended capitation” payment model.
In October, British Columbia announced it is overhauling pay for family physicians with a new model based on the number and complexity of patients they see, the services they provide, as well as the time they spend with their patients.
Bundled payments tie remuneration to all of the care required to treat a specific condition or medical event – such as surgery and the subsequent transition back into the community – and provides incentives to deliver efficient, high-quality care.
Learn how the CMA is advocating for integrated, team-based care at a national level.