Team-based care can improve patient access and alleviate pressure on family physicians.
But in a survey of over 9,000 people in Canada, only 15% of respondents said they had access to health professionals in their primary care clinic beyond a doctor, nurse or nurse practitioner.
The research is part of OurCare, a national project to engage the public on the future of primary care in Canada. It’s led by Dr. Tara Kiran, who is the Fidani Chair in Improvement and Innovation at the University of Toronto and a family physician with the St. Michael’s Hospital Academic Family Health Team.
The CMA spoke to Dr. Kiran about why Canada needs more team-based care— and what it will take to make it the norm.
We’re in the middle of a massive primary care crisis— six million Canadians have no family doctor. Why talk about team-based care?
It is indeed a crisis. Primary care is the front door to the health system— and when you look at demographic trends, both for physicians and the population, you can see that there won’t be enough family doctors to go around for years to come.
That’s where team-based care comes in. We need to build a system that expands the capacity of our existing family doctors and other primary care clinicians so they can serve more patients.
How would team-based care improve capacity in primary care?
Not every problem needs to be seen by a family doctor. People with diabetes who have stable blood sugar levels can often be seen by a nurse. Physiotherapists have incredible skill when it comes to assessing musculoskeletal conditions. Social workers can connect seniors to meal supports or other programs in the community.
We really have to rethink the structure of primary care so we maximize the value of both physicians and other health professionals.
Watch Dr. Tara Kiran's presentation on OurCare at CMA's 2023 Health Summit
What about actually increasing the number of family physicians?
Even after a residency in family medicine, family physicians aren't necessarily setting up comprehensive cradle-to-grave practices. Many young doctors are choosing instead to go into emergency medicine, hospitalist work, or palliative care, rather than traditional office practice. Why is this? They don’t want the hassles of running a small business. They want to work in a supportive environment and not take work home with them. They want to be able to take parental leave or vacation — something that’s sometimes hard to do in office-based practice.
With a team, you no longer feel like everything is on your shoulders. You can talk about a difficult case with colleagues who can help support patients in different ways. You can take a vacation and others will be there to look after your patients.
Team-based care can improve clinician joy in work.
What would ideal team-based care look like in Canada?
Team-based care can take many forms. In primary care, a lot of the research is about interprofessional teams — where two or more clinicians from different health professional backgrounds work together on an ongoing basis to take care of a shared group of patients. Ideally, they share the same medical records, work under the same roof and cover for one another if someone is away.
In Canada, it’s common for interprofessional teams to include physicians and nurse practitioners working together with health professionals like social workers, dietitians and pharmacists. I work in a very large family health team in Ontario and we even have psychologists, physiotherapists, chiropodists and income security health promoters.
That’s incredible, but not the norm. Is team-based care gaining momentum in Canada?
Team-based care models have slowly expanded, with Ontario and Quebec leading implementation. In Ontario, about 25% of people have access to a primary care team, usually a family health team or community health centre. In Quebec, 65% of people access a family medicine group.
Learn more about why Canada needs (a lot) more team-based care
Physicians have greater job satisfaction when they see patients get better. Can you talk about the evidence on team-based care and patient outcomes?
I’ve led some research evaluating team-based care in Ontario. We found patients in a team-based model were more likely to get recommended diabetes testing and cancer screenings. In addition, while emergency department visits have been increasing for all patients in Ontario, we found patients who were part of a team had a lower increase in emergency department visits over time.
Let’s talk about what patients want. What have you heard in the course of your work on OurCare?
Despite the fact that so few Canadians have access to team-based care, when people were asked if they would be willing to see a non-physician health professional if their family doctor recommended it, 90% of our survey respondents said yes. Over 90% said they would be willing to see a nurse practitioner for most of their care needs. These findings are a real endorsement of team-based care.
We’ve now done deep citizen dialogues in five provinces and, in each one, members of the public are strongly supportive of team-based care. People are particularly taken with the community health centre model that includes many other health professionals working with physicians, where physicians are employees on salary, where there is community governance and where teams have connections to local social service agencies to address the social determinants of health.
Perhaps the boldest recommendation coming out of our dialogues was moving to a system that’s more akin to public schools, where everyone would be automatically registered with a health care team in their community. Members of the public did say, however, that they would still want some degree of choice, such as choosing a clinician within a community team.
The CMA has called for an increase in team-based care to serve 50% of the population within five years and 80% within 10. What stands in the way?
I think the main barrier is financial. Paying for more team members costs money and then there’s the added cost of related infrastructure like shared medical records and managerial oversight.
But another is that physicians can feel threatened by the idea of other people taking on our roles. But I don’t think we need to worry about that. One in five Canadians don’t have a family doctor and we aren’t going to train enough doctors to meet the need in the coming years — so we have to look at different ways of working to solve this crisis.
We also need more evidence on which professionals should be included in teams, at which ratios, to improve health outcomes and expand the capacity of clinicians to care for more people.
Read the CMA’s call for expanded health indicators and targets across Canada
How will team-based care change the way physicians work?
Team-based care requires a culture shift. It can mean structuring a clinic to serve the larger community rather than individual patients. It requires agreeing on the clinic’s programing and policies as a group. And it means setting up protocols so that patients can see other health professionals without always going through a physician.
Ultimately, team-based care requires us to trade off some of our autonomy as physicians in exchange for more supports.
I personally think the trade-offs are worth it. One demoralizing part of family practice right now is how hard it can be to get your patients the care they need— particularly when it comes to mental health and addictions. The workload can be overwhelming and it’s hard to even take a vacation. Teams can help with all of that.
This interview has been edited and condensed for clarity.