Questions & Answers

Primary Care System Change

Our health care system is struggling with too many patients unable to access effective primary care and many family physicians are feeling burned out, overworked and unsupported. The current situation in Vancouver is unsustainable for individual providers and for the system as a whole.

In 2015, the GPSC undertook a province-wide visioning process in which over 2,000 family practitioners participated through in-person sessions and web-based dialogues. The following year, informed by the results of the visioning process found here, as well as national and international evidence regarding the importance of primary care in high-performing health care systems, the GPSC began focussed efforts to support the development of Patient Medical Homes as the foundation of the primary care system in this province, found here.

In 2017, the Ministry of Health released a set of Policy Papers that specifically addressed the primary care system, including the importance of Patient Medical Homes and Primary Care Networks, as well as team-based care.

In 2018 the Vancouver Division ran a membership referendum to confirm, “that family physicians… (believe that they feel they should be) …the driving voice behind designing the future of primary care in Vancouver.” Based on the overwhelmingly positive response, the Vancouver Division has been steadily preparing the organization to influence primary care change in Vancouver.

The primary goals of this work are to improving access to quality primary care for all people and to improving the work experience of family doctors.

Patient Medical Home (PMH)

The PMH model describes how a medical practice can be optimally designed to meet the needs of the patients, the providers and the community. The ultimate achievement of this goal will provide access to quality primary care. How the attributes are achieved is likely to vary in interpretation throughout the province reflecting the diversity of communities and practices.

The good news is that the vast majority of practices in BC are PMHs of some form. We believe that by supporting practices and providers to explore and develop the PMH attributes we will improve access to quality primary care, and by extension, enhance patient and provider experience of the system.

The attributes of PMHs fall into three broad areas:

  • Service Attributes (practice/clinician level)
  • Relational Enablers of Care (networks of practices and team-based care)
  • Structural Enablers of Care

More information on the attributes, including definitions and a diagram of the three areas can be found here.

This work has individual, community, city, regional and provincial level considerations and opportunities. Different groups are involved at different levels and one of the jobs of the Vancouver Division is to ensure that the voice of our doctors is effectively represented.

For Division-led PMH work, we are coming to you where you work in the community. To support networking of practices, we have identified local Family Physician Champions and hired regional Community Outreach Facilitators (staff leads) to work with doctors and clinics in each Local Health Area (LHA). In the coming months, we will be reaching out to family doctors within each region to bring you together and start the local conversations about what opportunities exist currently, what is likely to come, and most importantly, what is working and not working in your community.

We are currently reaching out to all of the family practice clinics in Vancouver, starting with a connection to office managers or senior MOAs. The goal of our contact is to familiarize your staff with the Vancouver Division and get some feedback from them regarding what works and doesn’t in your neighbourhood. As we grow to understand the primary care neighbourhoods, we will endeavour to involve you, the physician, directly in the process to create the change you would like to see in your community.

Individually, you can become involved on your own or by connecting with the Vancouver Division to better understand the available resources, which include the PMH Self-Assessment Tool, Panel Management incentives, EMR optimization and education.

There are different levels of evaluation and measurement for this work.

At a Division level, we evaluate our work through annual strategic planning, committee reporting, work planning and budget tracking (which is linked to work plans). We are currently exploring a more formal evaluation program which will pull together our current work along with our formal evaluation of PCN implementation and provincial level evaluations and tools.

Provincially, the GPSC has developed a number of tools to support practices, community (Division) and provincial level evaluations, including the PMH Self-Assessment Tool and the Patient Experience Tool. The GPSC PMH Evaluation Framework (which is being finalized and will be shared) ties together the work that is going on around the Province, including Vancouver.

The Vancouver Division remains committed to using iteration and improvement science, both formally and informally, to ensure the effectiveness of our work and investments.

It is generally understood that high-functioning systems that effectively meet the needs of patients and providers are based on a strong foundation of primary care. We believe that well-supported PMHs are essential for both this foundation and for developing effective PCNs that target services to effectively support patients and their needs. The Vancouver Division is focussing much of its efforts on working with members to understand how their current practices fit into the PMH model. We are also exploring ways in which members can be supported to shift or strengthen their practices to meet their personal and practice needs and how they can be prepared for some of the changes they will experience as PCNs are implemented.

This work is built upon the learnings of the Vancouver Division since its inception, including:

Our work in the area of PMH falls into these broad categories, and is summarized here:

  1. Engagement
  2. Physician Wellness and Resilience
  3. Practice/Clinical Support
  4. PMH Networking
  5. Recruitment and Retention
  6. Patient Attachment Initiative

As with all of the work of the Division, we are committed to the principles laid out in our Strategic Priorities:

  • Patients are at the centre of the healthcare system.
  • Doctors are supported to provide quality patient care.
  • Autonomy and self-determination of individual family doctors is respected.
  • Access to opportunities is fair and equitable for all members.
  • System changes are spreadable and scalable across our city.
  • Physician wellness and personal capacity is paramount.
  • Changes are evidence based; built on previous investments and experience where appropriate; and incorporate an iterative process.
Primary Care Network (PCN)

PCNs are geographically based, formalized networks of practices and primary care services (typically provided by the Health Authority) that work together to meet the healthcare needs of the community. Requiring a strong foundation of PMHs, PCNs are designed to wrap services around patients. Based on the demographics and healthcare needs of geographically defined populations, PCNs create a new system for introducing more integrated team-based care into primary care in the community.

In Vancouver there are six PCNs, each appropriately supported to address the needs of their unique patient populations.

Informed by the past 10 years, 2019/2020 has brought an overarching focus to our work in the development of Primary Care Networks (PCNs) and the redesign of healthcare service delivery to increase access to quality primary care for all patients. As a collaborative community effort, the development and implementation of our work is presented in Vancouver’s PCN Service Plan.

Click here for an overview of the Service Plan and our work to date.

The Service Plan also contains ongoing support for the First Nations and Aboriginal Health Primary Care Network that has been independently developed to provide care to on and off reserve First Nations and Indigenous Patients through Vancouver, Richmond and North Vancouver.

The Service Plan begins to explore the role of community owned and operated Community Health Centres (CHC) within the primary care landscape and how they will fit into PCNs. Work started with REACH and RISE CHCs and will evolve to explore other CHCs over time.

As per the requirement from the Ministry of Health, the Service Plan was designed to address the current attachment gap in the Vancouver’s Communities and to develop a PCN Team to support practices to care for higher needs patients.

As we continue to implement the networking practices and develop PCN opportunities within the community, the Division is committed to building off the exciting work of the Residential Care Committee, the primary care maternity network, the Cognitive Based Therapy Initiative, and the communities of care that have been developed through the Vancouver Division’s ongoing committee and initiative investments.

As with PMH work, local Family Physician Champions and Community Outreach Facilitators (staff leads) are committed to working with you at the practice and community level to better understand what is needed and how to support you in this process. The immediate work around PCNs will occur in Local Health Areas (LHAs) 1 and 6. For the remaining PCNs not identified in the initial Service Plan, the Vancouver Division believes it is important to start the work of networking practices together to ensure everyone gets a fair and equitable opportunity to participate in the process. The good news for all family doctors in Vancouver is that the wait is over – and our journey to PMH and PCN has just begun. We sincerely hope you will join us on this journey.

In addition to the current ways that work is evaluated at the Vancouver Division, we are expanding our model to include a formal evaluation of PCNs at the community and city levels. The Ministry of Health and Vancouver Coastal Health Authority are actively designing further evaluation processes which will be implemented locally, regionally and provincially.

Team-Based Care

Team-Based Care (TBC) refers to multiple health care providers (ie. physicians, nurses, social workers, dieticians, etc) working together to care for the needs of patients and specific populations. Providers are often co-located or geographically close to one another, however, this is not required and, in some instances, virtual teams are more appropriate.

In Vancouver, the majority of community-based practices are limited to family physicians and MOAs working as a team. Barriers such as remuneration models, cost of space, and lack of experience with models of TBC are some of the reasons for the low number of family practices that include allied health care providers.

TBC is an important component of the Patient Medical Home and introducing teams to primary care in the community is one of the main goals of the Ministry of Health. TBC is intended to improve health outcomes, patient and provider experience, and capacity within the system. To learn more about TBC, click here.

While the majority of community practices in Vancouver do not include allied health care providers (AHP), we do have a number of practices throughout the city that have already integrated team members, beyond FPs and MOAs. We have engaged a number of these practices and are trying to learn as much as we can from their experience.

Through PCNs, the Ministry of Health (MOH) is providing funding for a limited number of Nurse Practitioners (NP) and Registered Nurses (RN) in each CHA (Community Health Area) to help address the attachment gap (the number of patients not attached to a primary care provider). As funding is released, we are working with practices in each area to explore their interest in incorporating an NP or RN into the group. Both positions are funded directly by the MOH, through Vancouver Coastal Health contracts.

In addition to the NP and RN positions described above, PCNs will also include a PCN Team, designed to support practices to care for residents of each CHA. These teams are likely to include RNs, Licenced Practical Nurses (LPN), Clinical Counsellors, Physio Therapists (PT), Occupational Therapists (OT) and Social Workers (SW). We are working with VCH to determine how to optimally use these teams within each PCN.

Moving forward, we will continue to work with VCH and the MOH to expand access to allied health care providers for integration in family practices in the community. By developing formal PCNs, we hope to use data and evidence to show the need for, and potential impact of, integrated AHPs in community practices.

I have team members already working in my office: 

If you already have team members working in your office, you are unlikely to see any immediate change. We encourage you to participate in the local networking events and explore becoming part of the PCN, so you can help us demonstrate the impact and importance of allied health care providers within primary care practices.

 

I have no team members beyond family physicians and MOAs: 

If you are interested in working with a Nurse Practitioner or Registered Nurse in your clinic, understanding that there are patient attachment targets that accompany the positions, we encourage you to read more about it here and email or speak with our team. If you are interested in helping us understand the need for, and potential impact, of integrated team-based care, please participate in the local networking events and explore becoming part of the PCN as it is implemented in your community.

While the problems we face are immediate and increasing, sustainable system change takes time. We have been working with our partners to lay the foundation for meaningful system change that will shift the way primary care is supported in the community. By demonstrating the importance of physician-led change and exploring the challenges and opportunities around team-based care in the Vancouver environment, we hope to create the conditions for allied health care resources to be effectively integrated in the community to better support practice-based family physicians.

Meaningful system change will not be successful without your input, participation and leadership. We appreciate that the pressures on your time and energy are already high and that it can be difficult to see the value in engaging in activities that take you away from your personal and professional lives and may not appear to lead to an immediate improvement in your life. We believe that networking with other providers at a community level to support each other and play a central role in the leading formal Primary Care Networks will have positive impacts on your practice life and the system as a whole.

Currently, Ministry and Health Authority funding for FPs, NPs and RNs are limited to those provided in the PCN Service Plan and are primarily directed at addressing the attachment gap within a community (the number of patients unattached to a primary health care provider). By showing the impact of integrating NPs and RNs into practices, through the Service Plan implementation, we hope to influence future resource deployment to bring more and different team members into the community.

There are practices in Vancouver that have successfully integrated other healthcare practitioners, including RNs and LPNs under the fee-for-service model, without external funding. Our team is happy to discuss business models for such integration with you.

There are currently no plans to explore funding supports such as physician assistants, scribes, health coaches, etc. In this early stage of system change, we have been asked to optimize the roles of already regulated care providers such as NPs, RNs, LPNs, Social Workers, etc. As the work of the PCN progresses, we hope to make the case to support the integration of AHPs into the community.

  1. General Practice Services Committee incentive fees:

Since 2010, the GPSC has introduced a number of fee codes that are intended to acknowledge the time and energy involved with providing longitudinal care to a defined panel of patients. These include fee codes for chronic disease management (Hypertension, CHF, COPD and Diabetes), complex care management (for patients with certain combinations of chronic diseases, as well as patients with significant frailty), mental health management fees and conferencing fees. Fee codes were also introduced to support maternity networking, in-hospital care networking and residential care networking. More recently, the GPSC has introduced a panel management fee to acknowledge the importance of, and time required for, maintaining an up to date panel that includes accurate data around numbers of patients, status of patients and appropriate disease codes. One of the goals of this fee code is to create the conditions to better understand what resources are required in the system to support primary care in the community.

 

  1. Division and PSP practice support:

Over the past 4 years, the Vancouver Division has created and sustained programs to support community-based family doctors through business supports, locum matching, retirement supports and patient matching. Over 300 of our members have taken advantage of these resources and the work of this team (Vancouver Division’s Physician Support Team) will continue.

Since its inception in 2010, the Division has strived to give a voice to all of our members and support the ongoing provision of longitudinal primary care in the community. Our core committees are member-populated and over 180 members have participated in these committees and other committee-based sub-projects.

In 2018, the Division committed to supporting the model of the Patient Medical Home as the overarching goal of the organization. Understanding that a health care system based on a strong foundation in primary care leads to better health outcomes, improved provider and patient experience and lower per capita health care costs, and  appreciating that most, if not all, community practices in Vancouver are some form of PMH, the Division has worked to align its work and committees to support this goal, while still supporting members’ right to choose how they want to practice. As we embark on the system change occurring around the province, we feel confident that this foundational work will support the importance of longitudinal primary care in the community. (see more under networking)

Hearing a number of our members’ desire to access alternate funding models (non-fee-for-service), the Board of the Division struck a working group in 2019 to explore how best to meet the needs of our members. This work is currently underway.

 

  1. Supporting networking for influence:

In Fall 2019, the Division is launched Element 2 of our PMH/PCN Implementation Plan, found here. We will support local family practitioners to come together to understand who is in their medical community and to identify characteristics of their patients and community. Through these sessions, we hope to learn how physicians can be supported to start working together to meet their personal and professional needs, as well as influence the allocation of health care resources within their community. By working with local doctors to update and maintain their patient panels and support doctors to provide local leadership to the Primary Care Networks, we hope to create the conditions necessary to effectively shift primary care resources into the community.

How It Will Work

Most, if not all practices fit into this work. Whether you work in a ‘full-service’ community fee-for-service practice, a focussed practice, a walk-in practice, a Community Health Centre, or any type of practice, you play a role in providing primary care to patients in the community. You are a part of this work and an important part of the system change. Ideally, all types of practices and providers will work together to form a network of primary care providers to care for patients throughout their lifespan.

No one is required to participate in this work, although we hope our members will be interested in participating to whatever degree they feel comfortable.

We are committed to designing a fair and equitable process that will ensure appropriate distribution of resources as they come available. The resources that appear to be forthcoming are fairly limited and primarily focussed on addressing the attachment gap (number of patients living in a geographic area who do not have a family doctor). We are starting to work with physicians in the Local Health Areas (LHAs) 1 and 6 to determine how best to deploy these resources and we look forward to working with physicians across the rest of Vancouver to determine what will work in their community.

This work is currently being designed to be independent of specific funding models. We know that many family physicians are interested in learning more about non-fee-for-service (FFS) models and a large number of our members work in more than one model; however, we also know that many physicians are not interested in changing their current payment model. While aspects of the PMH and PCN models are likely better supported by alternate forms of funding and the Ministry of Health has expressed interest in supporting physicians to transition to non-FFS models, a clear pathway and process for such a transition does not currently exist.

The Vancouver Division intends to support members’ desire to learn more about models of payment through a variety of venues in the coming year.

Resources:

Vancouver Division- Exploring Value Based Payment for Family Physicians in Vancouver, view here

Doctors of BC- Physician Compensation Models, view here

College of Family Physicians of Canada- Physician Remuneration in a Patient’s Medical Home, view here

The Ministry of Health (MOH) is working with Doctors of BC to develop contracts for practicing family physicians (with a panel) who are interested in shifting from fee-for-service to an alternate funding model. More information on this is expected in the Fall of 2019.

As part of the introduction of PCNs, the Ministry of Health (MOH) is offering a limited number of Alternate Payment (non-fee-for-service) contracts for family physicians interested in opening a practice and developing a panel of new patients, within a PCN. These positions are funded by the MOH and administered through Vancouver Coastal Health contracts. The number of contracts available is based on the attachment gap within a Community Health Area (CHA) and new family physicians are expected to develop a panel of approximately 1250 patients over three years.

The Vancouver Division was not involved in negotiating these contracts. Our involvement is limited to exploring them with interested members and ensuring participating physicians are connected with the local PCN  in their community. More information on this opportunity and the contract can be found here and here. The Doctors of BC website has further information and we encourage interested physicians to visit the website (login required) and engage with the negotiations department.

For information on other types of payment models in BC, click here for Vancouver Division’s Exploring Value Based Payment for Family Physicians in Vancouver, or Doctors of BC- Physician Compensation Models, view here.

Currently, the process to access different models of payment is somewhat unclear. As negotiated in the 2019 Physician Master Agreement, the Doctors of BC has struck a committee to explore the issue and develop a fair and transparent process for access, in collaboration with the Ministry of Health.

Hearing a number of our members’ desire to access alternate funding models (non-fee-for-service), the Board of the Division struck a working group in 2019 to explore how best to meet the needs of our members. This work is currently underway.

Urgent and Primary Care Centre (UPCC)

An UPCC is simply a place where patients can access care which is not appropriate for, or not available through, the PMH, and does not require the specialized services of the Emergency Department. Diagnostics such as labs and imaging, as well as acute care services such as IV antibiotics and casting are available on an urgent basis 7 days a week.

UPCCs are ultimately designed to be part of the PCN and are directly linked to PMHs, serving as a tool to facilitate appropriate access to primary care and support physicians to provide the care their patients need.

With two formal UPCCs in Vancouver (as of January 2021), the design of how this model can be expanded to support physicians and patients locally and throughout the city is actively underway. Over time, there is likely to be a UPCC in each of Vancouver’s six PCNs and it is essential that each one adds value to patients and practices within the community. We are working with the local communities, the Health Authority and the Province to achieve this goal.

UPCCs are an initiative of the Government of BC (Ministry of Health) and the Health Authority which are intended to support local practices to provide urgent primary care within a geographically defined PCN.

The primary role of the Division is to work with local family physicians, VCH and UPCC managers and providers to ensure that the UPCC is integrated with local practices, ideally as a part of the PCN. The Division is not involved with negotiating contracts or positions for the UPCC; however, we assist interested members in obtaining information on opportunities that arise through the UPCC, as we do for other physician positions in the city.

As of January 2021, there are two UPCCs open in Vancouver (City Centre and REACH), and three (North Shore) within VCH region.  More information, including locations, can be found here.