Accountability by Design: Moving Primary Care Reform Ahead in Alberta

Abstract

Health-care reform is perennially popular in Alberta, but reality doesn't match the rhetoric. Government has invested more than $700 million in Primary Care Networks-with little beyond anecdotal evidence of the value achieved with this investment. As the province redirects primary care to Family Care Clinics, the authors assert that simply tinkering with one part of the system is not the answer: health care must change on a system-wide basis. Drawing on the experiences of frontline staff and a rich body of literature, the authors present their vision for integrated team-based primary care, designed to be accountable to meet the needs of populations. This will require governance that makes primary care the hub of the system, and brings together government and health-services leadership to support the integration of primary and specialty care. There are shared accountabilities for achieving primary care that exhibits the attributes of high performing primary care systems, and these exist at multiple levels, from individuals seeking primary care, up to and including government. The authors make these accountabilities explicit, and outline strategies to secure their achievement that include system redesign, service delivery redesign and payment reform. All of this demands whole-system reform focused on primary care, and it won't be easy. There are plenty of vested interests at stake, and a truly transformative vision requires buy-in at every level. However, Alberta's rapidly growing and aging population makes it more urgent than ever to realize such a vision. This paper offers guidelines to spark the fresh thinking required. † We declare that two of our six authors are physicians currently practicing in PCN clinics in southern Alberta; both of these physicians are faculty of Alberta AIM. One of these physicians, Dr. Wedel, also co-chairs Alberta AIM. We also felt it important to declare from the outset that the authors come from a particular shared history: involvement in primary care reform in the former Chinook Health Region. This former health region has received numerous acknowledgments for its record of leading-edge reform around integrated primary care-we believe the lessons we have learned are still relevant, and applicable anywhere in the province. We also wish to state that despite this shared history, we come from different professional backgrounds and bring different perspectives. We have done our best to acknowledge and balance our biases as a team, and challenged one another to rise above any entrenched position. We fully acknowledge and accept, however, that as much as we believe that our experiences might be useful sources of practical wisdom, those same experiences could be legitimately criticized as sources of bias ACCOUNTABILITY BY DESIGN: MOVING PRIMARY CARE REFORM AHEAD IN ALBERTA The American writer Adam Hochschild tells us that, "Work is hard. Distractions are plentiful. And time is short." For us, this quote sums up where we are in relation to actually reforming (not just restructuring) the hea...

An Implementation History of Primary Health Care Transformation: Alberta’s Primary Care Networks and the People, Time and Culture of change

“…However, between 2008 and 2011, the MoH became pre-eminent and began exerting, in concert with AHS, greater central control over the PCNs. (33,38,39) Alberta's PCNs are positioned between the MoH and front line family physicians. More often than not, they operate at the supra-clinic level, joining together practices with one or more physicians.…”

Indicators and measurement tools for health system integration: a knowledge synthesis protocol

“…Comprehensive services across the care continuum • Cooperation between health and social care organizations • Access to care continuum with multiple points of access • Emphasis on wellness, health promotion, and primary care • Coordinated transitions in care across services [ 23 ] • Shared programs across sectors/services [ 24 ] • Third next available appointment [ 25 ] • Emergency department average LOS registration to discharge; registration to admission (QPSD 23) [ 26 ] • Measure wait time for referral to treatment by provider type (QPSD 20) [ 26 ] • Proportion of patients with health outcomes which are avoidable given the current state of medical knowledge and access to appropriate care [ 27 ] • Tobacco screening [ 28 ] 2. Patient focus • Patient-centred philosophy; focusing on patients’ needs • Patient engagement and participation • Population-based needs for assessment; focus on defined population • Involvement in care planning for chronic disease/complex care [ 29 ] • Evidence of a population-based needs assessment [ 30 , 31 ] 3. Geographic coverage and rostering • Maximize patient accessibility and minimize duplication of services • Roster: responsibility for identified population; right of patient to choose and exit • Existence of primary care network structures (e.g.…”

“…Geographic coverage and rostering • Maximize patient accessibility and minimize duplication of services • Roster: responsibility for identified population; right of patient to choose and exit • Existence of primary care network structures (e.g. family health teams, primary care networks, GP Divisions, inner city primary health care clinics) [ 30 ] 4. Standardized care delivery through interprofessional teams • Interprofessional teams across the continuum of care • Provider-developed, evidence-based care guidelines and protocols to enforce one standard of care, regardless of where patients are treated • Team effectiveness [ 32 ] • Using a shared clinical pathway across care sectors (e.g.…”

“…Physician integration • Physicians are the gateway to integrated health care delivery systems • Pivotal in the creation and maintenance of a single-point-of-entry or universal electronic patient record • Engage physicians in leading role, participation on Board to promote buy-in • Physician integration within care teams and across care sectors [ 10 , 36 , 38 ] • Practitioner payment models that support integration [ 37 ] 9. Governance structure • Strong, focused, diverse governance represented by a comprehensive membership from all stakeholder groups • Organizational structure that promotes coordination across settings and levels of care • Existence of interagency agreements, service delivery team coalitions [ 39 ] • Governance model that includes representation of communities served [ 30 ] • Evidence of governance in monitoring and evaluation of health system [ 40 ] 10. Financial management • Aligning service funding to ensure equitable funding distribution for different services or levels of services • Funding mechanisms must promote interprofessional teamwork and health promotion • Sufficient funding to ensure adequate resources for sustainable change • Extent to which financial management is coordinated across care units and sectors [ 36 ] 11.…”

An Implementation History of Primary Health Care Transformation: Alberta’s Primary Care Networks and the People, Time and Culture of change

“…As elsewhere in the federation the province of Alberta, aligning itself with the Canada Health Act, seeks "to facilitate reasonable access to health services without nancial or other barriers" (27) to Albertans, and is responsible for the delivery of care. Alberta's particular policy approaches to delivering care have, arguably, been subject to one of the most radical administrative shifts in Canada: in 2008, nine regional health authorities were centralized into the province's largest single employer, Alberta Health Services (AHS) (39). With 110,000 staff, but a very limited role in the delivery of primary care, AHS' central focus is the province's acute care system.…”