Interprofessional Care

Transcription

1 FEATURE OMA Policy Paper Interprofessional Care by Aura Hanna, PhD OMA Health Policy Department The following OMA policy paper deals with interprofessional care and outlines the necessary features for successful integrated care from the physician perspective. It is important to note, however, that while improvements in interprofessional care are welcomed, they will not solve all of the problems in our health-care system. It is important that government and others not lose sight of the necessary, profession-specific changes that are needed. Continued attention must be given to matters such as physician human resource shortages, fair and equitable treatment across payment models for similar work, reducing the administrative burden upon physicians and ensuring that the health-care infrastructure supports, rather than impedes, good medical practice. Interprofessional care is a multidisciplinary, team-based approach to practice, with health-care professionals interacting to solve common issues. Successful interprofessional care provides mechanisms for ongoing communication among caregivers, optimizes participation in clinical decision-making within and across disciplines, and fosters respect for the contributions of all professionals within the group. 1 The movement toward collaborative interdisciplinary care has been ongoing for several decades. In 1987, in its report known as the Alma-Ata Declaration, the World Health Organization urged that health workers, including physicians, nurses, midwives, auxiliaries, and community workers, work as health teams to respond to the health needs of their communities. 2 Similarly, in Canada, the Romanow final report on the future of health care in Canada 3 suggests that with the growing emphasis on collaborative teams and networks, traditional scopes of practice and education programs will need to change. Although it is envied around the world, Ontario s health-care system faces challenges, particularly with regard to system capacity. Health professionals, politicians, and the public are now attending to the system, often critically. The shortfall in capacity is largely the result of government decisions made that reduced the number of medical school admissions 4 and reduced the number of hospital beds and hospitals a. 5 Ontario is also losing physicians to other jurisdictions. It is estimated that about 9,000 Canadian-trained physicians are working in the United States. 6 In Ontario, as nationwide, there is a shortage of primary care physicians, and waiting times for specialty care are lengthy. The College of Physicians and Surgeons of Ontario 2005 survey indicates that only 11.4 per cent of family physicians/general practitioners were accepting new patients b. Reported experiences of Canadians confirm this shortage. A 2004 cross-country survey that included 1,400 Canadians indicated that 18 per cent of Canadian respondents had been to an emergency room within the last two years for a condition that could have been treated by a physician or other source of care if it were available. 7 Wait times from time of specialist consultation to treatment average 97 days for cataract surgery, 35 days for cancer surgery, and 167 days for knee replacements. 8 As Ontario s population ages, responding to population health needs will become even more challenging. Ontario population projections indicate that the population aged 65 and over is expected to double in the period from 2004 to 2031 from 1.6 million to 3.6 million. This represents a percentage increase from 12.8 per cent to 22.2 per cent of the population. 9 Thus, as well as numerical increases, the shape of the population distribution will change. New approaches will be needed to provide successful interventions to this group. Although it is unlikely that any single strategy will provide a panacea to the health-care system problems, Ontario is moving toward interprofessional care models as one way to address the system problems and as a way to provide better patient care. This paper is designed to outline the principles that will form the basis for further OMA work. Ontario Medical Review September

2 Interprofessional Care in Canada Canadian Government One of the outcomes of the Romanow Report, cited above, was Health Canada s Primary Health Care Transition Fund. Ontario was allocated $213M from the Fund to ensure the sustainability and affordability of Ontario s primary healthcare system. Use of these funds in Ontario focuses on the integration of interdisciplinary providers. 10 Ontario Interprofessional Care Initiatives Many hospital-based practices have been multidisciplinary for years and have provided a practice environment that supports collaborative care. Although there have been Community Health Centres for several decades, and Assertive Community Treatment (ACT) teams have provided team-based specialty care for persons with serious mental illness for many years, the Family Health Team model represents the province s first broad implementation of multidisciplinary care in the community. Another approach to collaborative care that has been promoted actively in Ontario is the shared care model of disease management. In Hamilton, two programs have been implemented mental health and nutrition. During , the program included 79 family physicians, 39 mental health counsellors, 17 psychiatrists and eight registered dieticians working part-time or fulltime in 38 primary care practices. An evaluation determined that practitioners were very satisfied with the team approach. 11 The shared care model is important in that it expressly brings generalist and specialist physicians together in a formalized relationship. The government of Ontario has recently taken an active interest in interprofessional care through its HealthForceOntario initiative. The HealthForceOntario initiative was announced in 2006 and has three components. It provides for the introduction of four new roles: physician assistants, nurse sigmoidoscopists, surgical first assistants, and clinical specialist radiation therapists. It provides a website c that will provide qualification information for internationally trained health professionals. The same website includes a comprehensive job portal. Ontario Legislation Recent legislative changes and proposals represent major changes to the healthcare system. Revisions proposed to the Regulated Health Professions Act by the Health Systems Improvement Act (Bill 171) d propose three new Ontario Colleges: Kinesiology, Naturopaths & Homeopaths, and Psychotherapists. It also provides for the regulation of pharmacy technicians under The Pharmacy Act, and expands the scope of practice for nursing and optometrists. Bill 171 also adds the objective of promoting interprofessional collaboration with other health profession colleges to the procedural code of each health profession act. Bill 50, enacted in 2006, provides for the College of Traditional Chinese Medicine Practitioners and Acupuncturists and specifies their scope of practice. The OMA believes that the collaboration that occurs in interprofessional team care could improve patient care in Ontario. Key Success Factors for Collaboration Resources The current differential fee structure and unequal access to system resources for physicians represents an issue of contention among Ontario physicians. Although there are a variety of funding and remuneration models in Ontario, they generally involve variations on fee-for-service and capitation. e Fee-for-service payments permit physicians to be paid for the patient care that they deliver. However, there is usually no allocation for supervisory, consultative, or administrative activities, all of which are time-consuming in interprofessional care models. Capitation payments are on a per-patient basis, rather than a perservice basis, so that payment encompasses all activities the physician performs. Capitation payments permit better fiscal planning by government, but may underpay those physicians who treat patients who require many complex services. Capitation has had widespread adoption by US insurers and the British National Health Service for primary care physicians. Some specialists may also be paid by salary. 12 The problems with either pure fee-for-service or capitation methods of payment can be attenuated by combining aspects of both such as capitation with fee-for-service for some procedures, fee-for-service within a capitated department budget, or case rates for episodes of care. Different combinations may be needed for primary care physicians and specialists. Other payment mechanisms such as base salaries, commissions, bonuses, may be mixed with blends of fee-for-service and capitation to create the best payment structure. 13 In some jurisdictions, additional incentives have been implemented that are tied to either financial or health outcomes. Although they may limit expenditures, payment mechanisms that include ties to financial outcomes, such as reduced hospital admissions, create conflicts of interest and may compromise the quality of patient care. Probably for those reasons, incentives tied to health-care outcomes are more widespread. For example, both the UK and some US insurers pay premiums for attaining prevention objectives. In the UK, those objectives are increasing immunizations for children and cervical cancer screening. In the US examples, the targets are increased immunization rates for the elderly. 14 These modifications reflect attempts to address the shortcomings of strict capitation models. A change to an interprofessional 2 Ontario Medical Review September 2007

3 care model will change the daily work of the physician in other ways that require compensation. If the physician assumes responsibility for only more complex and time-consuming patient care, the basis of remuneration should be increased. The roles of clinical lead and consultant decrease time available for patient care and should be compensated. Non-clinical activities that are critical to effective interdisciplinary care, such as team co-ordination meetings, strategic planning, team evaluations, and educational activities, should also be compensated. The OMA is in the process of establishing a Working Group on Interprofessional Health Care Teams that will report to the Physicians Services Committee on issues related to compensation. The OMA believes that appropriate resources should be available to support all physicians who wish to work with other health professionals, regardless of their remuneration method. Liability of the Interprofessional Care Team Members Physician discussions around collaborative care invariably touch upon liability and the potential for increased physician exposure to medico-legal risk as a result of the actions of team members. The Canadian Medical Protective Association (CMPA) has done extensive work in this area over the past several years and has recently advanced the opinion that, Provided every member of the collaborative team has adequate liability protection, the current liability system will effectively support the emerging practice trends. In an information sheet directed to clinics and facilities f, the CMPA includes the following principle regarding the provision of assistance in legal actions: 4. Assistance will be extended to employees of a physician member, or of a clinic or facility that meets all of the above conditions, provided that those employees do not have the ability to see and treat patients independently. (p.3) The CMPA asserts that, for regulated health-care workers, adequate liability protection should be a condition of licensure and employment; for unregulated health-care workers, mandatory adequate liability protection should be an obligatory clause in their contract. 15 Effective interprofessional care teams have differing organizational structures. Some teams have a hierarchical organizational structure; some have a flat structure. The determination of the type of structure to be used in an IPC team may affect physician liability, depending upon the extent to which the physician controls the care delivered by other members of the team. One of the practices now evident is for physicians to provide consultation to a collaborative team on a part-time basis. In the absence of the physician, other team members may perform procedures that are either within their scope of practice or that are delegated to them. Physician liability and liability protection is uncertain in scenarios where events occur when they are not present. s All members of the health-care team must have adequate liability protection. Before becoming part of an interprofessional care team, physicians must be assured that other team members have adequate liability protection. Physician leaders of interprofessional care teams should require evidence of liability protection as a condition of employment or affiliation for other team members. A formalized procedure should be established to ensure evidence of liability protection. Physicians Roles in Interprofessional Teams Physicians clinical and leadership roles must be examined in the context of interprofessional care teams. Although physicians are especially skilled at handling complex patient problems and removing the relatively simple tasks from the physician may provide some workload relief, there are potential disadvantages. The balance of simple and more complex tasks in day-to-day practice is lost. Some physicians may not want to lose that balance for a variety of reasons the episodic relief provided by randomly interspersed simpler cases during the usual workday provides relief physically and intellectually to many physicians. In other jurisdictions, the physician generally assumes the roles of clinical lead and consultant. Assumption of these roles decreases the amount of time available for direct patient care. This must be recognized and physician remuneration needs to reflect both the higher acuity of care provided and the time required for such services. Unless there are hired administrative staff members, the physician may also undertake many of the administrative tasks of a larger practice and a larger physical site than there would be in a single-practitioner model. These roles must be accounted for as they also decrease the amount of time available for patient care and they have the potential to increase physician workload. In Ontario, the question of team leadership is not clearly settled. Nursing, in particular, does not accept the assumption that physicians must supervise other members of the team. It is important to distinguish leadership from supervision experience from other jurisdictions supports physician clinical leadership, but does not necessarily imply a direct supervisory role over all the clinical services provided within the team context. The distinction between governance and clinical leadership is an important one. With an organizational chart and clearly delineated roles, potential confusion and conflict can be avoided. s The OMA believes that the physician, having greater breadth of training and larger scope of practice, should be the clinical lead in interprofessional teams. 3

4 Physicians should be compensated for their leadership and the indirect services they provide in interprofessional team settings. Rostering In interprofessional care teams that involve patient enrolled models of care, the OMA believes that patients must be rostered with a physician or group of physicians in order to ensure appropriate accountability for the services delivered to the rostered patients. The physician or group of physicians should be the only health-care providers to whom patients roster. Physician Review All new patients should be reviewed by a physician. The physician may then decide, as part of the treatment plan, to have the patient seen by other health-care providers, or to refer the patient to other members of the health-care team. Patients who are in ongoing care may be seen by the appropriate non-physician providers and triaged according to need. Patients who require episodic care may be seen by their physician or by the appropriate non- physician provider, depending on need, with the understanding that physician review, consultation or transfer will occur if necessary. All new patients should be reviewed by a physician and physician consultation must be available as required on an ongoing basis. On-Call Traditionally, physicians have provided on-call services. When nurse practitioners and some other healthcare professionals are on-call, they require that physicians be available for consultation. This is an additional factor that adds to physician workload and which should be duly compensated. It may require new compensation models. The OMA believes that physicians should be compensated appropriately for their on-call services and for the time that they are required to be available when other health-care professionals are on-call. Communication, Consultation, and Referrals to Specialists Communication within the healthcare team has been recognized as a key success factor for interprofessional care. Communication strategies will need to provide for both formal and informal opportunities to promote dialogue. Interprofessional care teams must meet, preferably faceto-face, on a regular basis. Ideally, a formal process for conflict resolution will be in place so that issues regarding scopes of practice, roles, and patient safety can be addressed in a timely fashion. The physician, as clinical leader, must be available to support other members of the team. There are various levels of consultation that have been delineated for collaboration between physicians and other team members. The corridor model takes minutes for each contact and there is no consultation fee charged. This is an informal contact within the team, but should be documented. Formal consultation can occur when the physician and another provider see the patient jointly but the other provider maintains care of the patient or when another provider asks the collaborating physician to see the patient for an assessment. All require the physician s time, thus, the physician role in these types of consultation should be recognized and compensated. Consultation within some teams, such as Assertive Community Treatment teams, will include direct communication between specialists and non-physician providers; however, referrals to physician specialists outside of the team should be arranged through a physician. s Effective communication within interprofessional care teams is critical for success and, therefore, the planning, funding, and training for such teams must include measures to support it. A formal process for conflict resolution should be in place so that issues regarding scopes of practice, roles, and patient safety can be addressed in a timely fashion. Consultation within the team may be either informal or formal; each must be remunerated appropriately. Formal requests for consultation outside of the team, such as referrals to medical/surgical specialists, should be made by a physician. Physicians may choose to delegate referrals to specialists in some specific circumstances; however, this assumes that the non-physician provider is acting of behalf of the physician. Scope of Practice The expansion of scopes of practice is related only peripherally to interprofessional care. Collaborative care is not dependent on members of a team expanding their independent scopes of practice and, indeed, may be antithethical to the team concept. More important than scope is the need for clear delineation of roles from the outset and mutual confidence in the competence of team members in the provision of care within their respective roles. This confidence comes from the knowledge that health-care providers share a fundamental educational base through training in the medical model and is supported by personal experience. Over time, as competencies become evident, the responsibilities of various team members may expand. The notion of working to full scope may sound appealing; however, the reality is that scope of practice statements are written to accommodate the activities of a profession as a whole, not to reflect the practice of any particular provider. The important thing for team-based care is that every provider is trained and capable of performing the activities associated with his or her role. The advantage of having non- 4

5 physician providers working under their own scope of practice is that it may make any complaints or litigation more straightforward from the physician perspective. If the provider is acting within his or her own scope of practice (versus delegation), there is adequate documentation about processes of care within the team and the process has been followed, the physician should be protected from liability. s Health-care professionals have differing scopes of practice which may change over time. The OMA believes that the success of interprofessional care is not dependent upon the expansion of scopes of practice. The OMA supports the Health Professions Regulatory Advisory Council as the appropriate body to review and recommend changes to scopes of practice. Delegation The Federation of Regulatory Colleges of Ontario has recently published a document entitled, An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario. 17 In this Guide, the Federation describes the process of delegation and specifies the circumstances and process by which a medical directive may be given. Medical directives are approved only when all affected professionals and relevant administrators participate in their development. They have the integrity of a direct order and permit various regulated and unregulated providers to undertake acts outside of their customary scope of practice. One option for interprofessional care models is for physicians to bill for delegated services provided by other health-care professionals, as if the physician provided the service. However, for a physician to bill OHIP for delegated services, the Schedule of Benefits to the Health Insurance Act g requires that the allied health professional be an employee, that the physician be present and available at all times, and that the service be listed in the table. The OMA believes that delegation and the use of directives are important supports for team-based care and encourages physicians to review the Federation of Regulatory Colleges of Ontario guide, An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario. Prescribing Several professions have the legal right to prescribe, but most of them are limited to the treatment of certain conditions, the use of certain drugs, or both. It will be incumbent upon the regulated colleges to ensure that members prescribe within the regulations of their colleges. As patient risk increases with multiple health-care providers prescribing for a patient, collaboration in prescribing will be critical when more than one team member has responsibility for a patient. Shared access to patient prescription information will be important for patient safety. s The OMA believes that it is the responsibility of individual colleges to ensure that members prescribe within their regulations. The OMA believes that communication among providers around prescribing is an important element of care and that a centralized repository of information about all medications prescribed for a patient is an essential element of good health care. Admission to Hospitals The complexity of care delivered in the community has increased to the point where hospital admission is reserved only for patients whose medical condition is sufficiently serious or unstable to require inpatient care. Consequently, it is important for patient safety and resource utilization that every inpatient admission is overseen by a physician. All inpatient admissions must be under the authority of a physician. Record-Keeping Record-keeping in a team-based environment is important for quality of care, patient safety, and medico-legal purposes. It will be necessary to document such things as who has responsibility for various aspects of care and decision-making processes, such as team conferences. It is important that there be only one chart per patient. Although it is possible to undertake collaborative care in the absence of an electronic health record (EHR), the EHR is generally agreed to be a fundamental tool for team-based care. The EHR not only facilitates communication within the team, it provides important linkages to other providers, such as laboratories and pharmacies. Maintaining patient privacy in a team environment can present challenges, as can the electronic patient record. Generally, access should be on a need to know basis and consideration should be given when selecting computer systems about the need for and capacity to provide variable levels of access. s There must be one patient chart. The OMA believes that appropriate documentation is important for quality of care and risk management; that documentation should include the identity and credentials of the recorder. The Ministry of Health and Long- Term Care should fund electronic health records. Summary Interprofessional care has the potential to increase the capacity of the Ontario health care system, improve patient care, and increase patient satisfaction. However, the process of moving from a single-practitioner or group-physician model to an interprofessional care model is difficult, time-consuming, and expensive for 5

6 the physician and the government. To be successful, physicians must be in favour of the change. Roles and responsibilities of team members must be clearly delineated and designed for all health care professionals within the team. There must be effective systems in place that include provision for patient safety. At their best, interprofessional care teams can increase the capacity of the health care system and, through collaborative working relationships, improve patient care. Alternative fee structures may be necessary to provide the opportunity for Ontario physicians to move toward a collaborative interprofessional care model over time. For established physicians, the change from working as an independent practitioner to working as a team member may be better achieved if it is perceived as a process that occurs over time, rather than a singular event. A commitment by the Ontario government that funding for interprofessional care teams will be sustained over the coming years would increase the willingness of physicians to move toward this model of care. A systematic cross-site evaluation of existing Ontario models, including cost-benefit analyses, would be useful. Such an evaluation would provide information to improve existing practice and the potential for improved models. Results of the evaluations of existing pilot projects will be of interest to assist in planning new interprofessional care projects and models. Who to Contact Carol Jacobson, Director OMA Health Policy Department carol_jacobson@oma.org Tel. (416) or , ext Endnotes a. When Mike Harris became Premier, he immediately imposed a $1.3 billion cut on hospitals. The two previous provincial governments had closed 10,000 hospital beds without closing any hospitals. b. Interpretation of these percentages must be qualified as the response rate for the provision of clinical practice information on the survey was 45 per cent. c. d. Bill 171 passed first reading on December 12, Bill 50 received royal assent on December 20, The bills are available online at e. Family Health Groups and Comprehensive Care Models are fee-forservice models; Family Health Networks and Family Health Organizations are capitated models. f. Canadian Medical Protective Association (2005). CMPA Assistance to Clinics and Facilities: General Principles (Revisions Effective January 1, 2006). g. Ontario. Ministry of Health and Long-Term Care. Schedule of benefits: physician services under the Health Insurance Act (January 1, 2007). Toronto, ON: Ontario Ministry of Health and Long-Term Care. p. GP42. Online: health.gov.on. ca/english/providers/program/ohip/ sob/physserv/genpre.pdf h. The Public Hospitals Act permits midwives to admit women for lowrisk deliveries. References 1. Herbert CP. Changing the culture: interprofessional education for collaborative patient-centred practice in Canada. J Interprof Care 2005 May;19 Suppl 1: World Health Organization; United Nations Children s Fund (UNICEF). Primary health care: report of the International Conference on Primary Health Care, Alma-Alta, USSR, 6-12 September Geneva, Switzerland: World Health Organization; Available from: w h q l i b d o c. w h o. i n t / p u b l i c a tions/ pdf. Accessed: 2007 Aug Commission of the Future of Health Care in Canada. Building on values: the future of health care in Canada: final report. [Chair: R.J. Romanow]. Saskatoon, SK: Commission on the Future of Health Care in Canada; 2002 November. p Available from: HCC_Final_Report.pdf. Accessed: 2007 Aug Barer ML, Stoddart GL. Toward integrated medical resource policies for Canada: background document [HPRU 91:6D]. Vancouver, BC: Health Policy Research Unit, Centre for Health Services and Policy Research, University of British Columbia; 1991 June. p Available from: ubc.ca/files/publications/1991/hpr u91-06d.pdf. Accessed: 2007 Aug Gray C. Will hospital closures mean physician unemployment in Ontario? CMAJ 1997 Jun 1;156 (11): Available from: pdf. Accessed: 2007 Aug Mullan F. The metrics of the physician brain drain. N Engl J Med 2005 Oct 27; 353( 17): Available from: nejm.org/cgi/reprint/353/17/1810. pdf. Accessed: 2007 Aug Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, Peugh J. Primary care and health system performance: adults experiences in five countries. Health Aff (Millwood) 2004 Jul-Dec;Suppl Web Exclusives: W Available from: content.healthaffairs.org/cgi/reprin/ hlthaff.w4.487v1.pdf. Accessed: 2007 Aug Ontario. Ministry of Health and Long-Term Care. Wait times in Ontario. Hospitals reporting wait times for key services completed in October/November Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2007 March. Available from: gov.on.ca/transformation/wait_time/ providers/wt_pro_mn.html#. Accessed: 2007 Aug Ontario. Ministry of Finance. Ontario population projections: : Ontario and its 49 census divisions: based on the 2001 Census. Toronto, ON: Ontario Ministry of Finance; 2005 February. Available from: english/economy/demographics/ projections/2005/demog05e.pdf. 6

7 Summary of s on Interprofessional Care Patient Care and Satisfaction The OMA believes that the collaboration that occurs in interprofessional team care could improve patient care in Ontario. Resources The OMA believes that appropriate resources should be available to support all physicians who wish to work with other health professionals, regardless of their remuneration method. Liability of the IPC Care Team Members All members of the health-care team must have adequate liability protection. Before becoming part of an interprofessional care team, physicians must be assured that other team members have adequate liability protection. Physician leaders of interprofessional care teams should require evidence of liability protection as a condition of employment or affiliation for other team members. A formalized procedure should be established to ensure evidence of liability protection. Physicians Roles in Interprofessional Teams The OMA believes that the physician, having greater breadth of training and larger scope of practice, should be the clinical lead in interprofessional teams. Physicians should be compensated for their leadership and the indirect services they provide in interprofessional team settings. Rostering The physician or group of physicians should be the only health-care providers to whom patients roster. Physician Review All new patients should be reviewed by a physician and physician consultation must be available as required on an ongoing basis. On-Call The OMA believes that physicians should be compensated appropriately for their on-call services and for the time that they are required to be available when other health-care professionals are on-call. Communication, Consultation, and Referrals to Specialists Effective communication within interprofessional care teams is critical for success and, therefore, the planning, funding, and training for such teams must include measures to support it. A formal process for conflict resolution should be in place so that issues regarding scopes of practice, roles, and patient safety can be addressed in a timely fashion. Consultation within the team may be either informal or formal; each must be remunerated appropriately. Formal requests for consultation outside of the team, such as referrals to medical/surgical specialists, should be made by a physician. Physicians may choose to delegate referrals to specialists in some specific circumstances; however, this assumes that the professional is acting on behalf of the physician. Scope of Practice Health-care professionals have differing scopes of practice which may change over time. The OMA believes that the success of interprofessional care is not dependent upon the expansion of scopes of practice. The OMA supports the Health Professions Regulatory Advisory Council as the appropriate body to review and recommend changes to scopes of practice. Delegation The OMA believes that delegation and the use of directives are important supports for team-based care and encourages physicians to review the Federation of Regulatory Colleges of Ontario guide, An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals in Ontario. Prescribing The OMA believes that it is the responsibility of individual colleges to ensure that members prescribe within their regulations. The OMA believes that communication among providers around prescribing is an important element of care and that a centralized repository of information about all medications prescribed for a patient is an essential element of good health care. Admission to Hospitals All inpatient admissions must be under the authority of a physician. Record-Keeping There must be one patient chart. The OMA believes that appropriate documentation is important for quality of care and risk management; that documentation should include the identity and credentials of the recorder. The Ministry of Health and Long-Term Care should fund electronic health records. 7

8 Accessed: 2007 Aug Canada. Health Canada. Primary Health Care Transition Fund: summary of initiatives. Final edition. Ottawa, ON: Health Canada; 2007 March. Available from: hc-sc.gc.ca/hcs-sss/alt_formats/ hpb-dgps/pdf/phctf-fassp-initia tives_e.pdf. Accessed: 2007 Aug Paquette-Warren J, Vingilis E, Greenslade J, Newnam S. What do practitioners think? A qualitative study of a shared care mental health and nutrition primary care program. Int J Integr Care 2006 O c t 9 ; 6 : e 1 8. A v a i l a b l e f r o m : v/picrender.fcgi?artid= &bl obtype=pdf. Accessed: 2007 Aug Robinson JC. Theory and practice in the design of physician payment incentives. Milbank Q 2001; 79(2): Available from: w w w. m i l b a n k. o r g / q u a r t e r l y / 7902feat.html. Accessed: 2007 Aug Ibid. 14. Grignon M, Paris V, Polton D, Commission of the Future of Health Care in Canada. Influence of physician payment methods on the efficiency of the health care system [Discussion paper No. 35]. Saskatoon, SK: Commission on the Future of Health Care in Canada; 2002 November. Available from: romanow/pdfs/35_grignon_e.pdf. Accessed: 2007 Aug Gray JE. (Executive Director/ CEO, Canadian Medical Protective Association, Ottawa, ON). Letter to: Barbara LeBlanc (Executive Director, Health Policy Department, Ontario Medical Association, Toronto, ON) Dec 4. 2 leaves. 16. Ontario Medical Association, Task Force on the Working Relationship between Physicians and Registered Nurses (Extended Class). The working relationship between physicians and registered nurses (extended class): OMA discussion paper. Ont Med Rev 2002 Nov;69(10): Available from: org/pcomm/omr/nov/02rnec.htm. Accessed: 2007 Aug Federation of Health Regulatory Colleges of Ontario website. Available from: Accessed: 2007 Aug 7. 8