Priorities for Building an Integrated and Accessible Primary Care System in Ontario

Priorities for Building an Integrated and Accessible Primary Care System in Ontario October 2013

Priorities for Building an Integrated and Accessible Primary Care System in Ontario The Ontario Medical Association (OMA) is committed to ensuring that physicians are at the forefront of building a stronger, higher quality health-care system for patients. To achieve this, Ontario needs to focus its efforts on building a patient-centred primary care system that enables integration between all providers and creates a collaborative network of care around the patient. These integrated relationships will look different in each community, as they will reflect the unique mix of patients, physicians and other health care providers, resources and geography in each area. To be successful family physicians will require supportive structures and financial sustainability as more patient care is shared with other providers. To help provide an orientation and context for the presentation of the practice and health system level factors discussed in this paper, it is important to establish a clear and consistent definition of primary care. While no one universal definition of primary care exists, for the purposes of this paper, we will define primary care as that level of a health service system that provides entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and co-ordinates or integrates care provided elsewhere by others. 1 While it is understood that general and family physicians are practicing in evolving and diverse ways, this paper will not address physicians working in focussed practices, specialists in primary care and other specialized primary care environments such as walk-in and student health clinics. These practice settings face unique challenges that are beyond the scope of this paper. Ontario s Primary Care System In the 1990 s Ontario s primary care system was perceived by many to be disintegrating. General and Family Practice was no longer seen as a desired medical specialty by medical students and the number of students picking family practice fell dramatically. Hard-working physicians were without access to necessary patient supports. Page 1 of 22 October 24, 2013

The OMA worked alongside general and family physicians and with the Ministry of Health and Long-Term Care with a shared vision to regain stability in the primary care system by changing the practice model, starting with redressing funding and payment disincentives. Physician participation in a Patient Enrolment Model (PEM) began on a broad scale when the feefor-service based Family Health Group (FHG) model was introduced as an element in the 2003 Physician Services Framework Agreement between the OMA and the Ministry of Health and Long-Term Care. 2 Participating physicians committed to provide comprehensive care services and to provide after hours and call services. Physicians received a premium for the core GP services provided to patients identified on their roster as well as after hour s premiums, and for some targeted services (e.g. palliative care, mental health care). The FHG model attracted 3,651 physicians between 2003-2009. As of August 2013, that number has declined to 2,818 representing 35 per cent of all physicians that participate in some form of enrolment based primary care payment model. The majority of family physicians in Ontario are now choosing the blended capitation based Family Health Organization (FHO) model. The FHO, established in 2006, offers family physicians the ability to receive an annual age and sex adjusted payment for each enrolled patient while generating additional revenue through a series of fee-for-service and bonus payments. As of August 2013 4,266 physicians or 52 per cent of all physicians in an enrolment model are working within the FHO model. However, new funding models for primary care were never intended to be the solution to all of the system s problems. Issues around access, quality improvement, integration and patient engagement all require attention. The OMA believes these are the next areas for action as we strive towards achieving our vision of a strong, high-quality and patient-centred primary healthcare system. Building on the foundational work of Ontario s family physicians and their commitment to provide comprehensive care to their patients, Ontario has been able to take the next step and develop models of interdisciplinary care that provide a team practice environment. Community Health Centres (CHCs), where physicians are salaried provide primary care services with an emphasis Page 2 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

on health promotion, disease prevention. CHCs also work with local residents to build the capacity of the community to improve its general health. Typical CHC primary care teams include physicians, nurse practitioners, nurses, social workers, health promoters, community health workers and often chiropodists, nutritionists or dieticians. 3 The newest model, the Family Health Team (FHT) has been of particular interest to family physicians. Currently over 2000 family physicians are practicing as part of these collaborative, interdisciplinary teams. Physician remuneration is currently provided through the family health network, family health organization, rural northern physician group agreement and the blended salary model, while non-physician funding is provided by the Ministry of Health and Long-Term Care. As a condition of the funding to support the team infrastructure, FHTs and other interdisciplinary practices are beginning to focus their efforts on providing timely access, measuring quality, and establishing models of care and clinical pathways that support efficiency principles within their practice settings. As Ontario moves forward with its transformation agenda, it is important that all patients, and not just those in funded interdisciplinary practices or those whose physician has joined a capitation based funding model, benefit from the resources being developed that enable collaboration and coordination of care. Additionally, care must be taken to ensure that family physicians are not burdened with excessive administrative roles within these collaborative models at the expense of their ability to provide adequate patient care. Key Drivers Fuelling Further Reform A strong primary care system is a key characteristic of a high-performing health system and effectively addresses primary and secondary prevention, screening and early detection of disease, acute care and chronic care integration and coordination across all health care services. 4 The Ontario government has articulated a transformation agenda for the health care system that it believes will work towards an integrated patient-centred system that supports healthier patients, Page 3 of 22 October 24, 2013

faster access and stronger links to family healthcare and the right care at the right time at the right place. 5 To further reinforce the government s goals of transformation for the health care system, the Ministry of Health and Long-Term Care is leading an Excellent Care for All Strategy through its Action Plan for Health Care which clearly outlines four key commitments to patients: 6 Doctors, nurses and everyone working in health care will put the needs of patients first; The best available evidence will be used to make decisions about the care patients receive; The experience of the patient will be an important part of health care quality; and The patient will have more information and greater choice in the health care they receive. Achieving a stronger, high quality health care system will require organizational support for physicians, patients and all health care workers to meet the new patient focused goals established by the government and supported by Ontario s doctors. Historically, physicians have established autonomous practices, as the demands of patients increase and the capacity of the primary care system expands, special attention must be paid to how providers and services within primary care will be effectively connected to family physicians practices. As small businesses, physician offices have, by necessity, operated very efficiently and economically. However, as new requirements emerge in practice management and system connectivity, we must remember that these offices are neither funded nor resourced for these activities at present. To be successful in transforming the system, we need to agree on what tools are required to support a primary care system that is patient-centred and allows for internal practice based and external system based integration 7. Physicians have a keen desire to always improve the care they provide but limited infrastructure, time and capacity within their practice for change. It is important that change be well considered and includes timely and meaningful input from physicians. This will ensure that it is focussed on achievable, practical and effective Page 4 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

improvements that are focused on better patient outcomes while enhancing both the patient and physicians experience. Primary Care Transformation Research evidence points to several key success factors in improving population health and health outcomes for patients, many of which hinge upon primary care. In order to support transformation in the health system, physicians offices will require support to monitor access, measure quality or to develop formal integration strategies to guide their interactions with the rest of the system. This section of the paper will look at each of these areas in turn and make the case for why they need to be addressed as part of the next wave of primary care reform. Timely Access to Care The 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults indicates that half of all Canadian patients report being able to see a physician or nurse the same or the next day. This contrasts with the twenty three per cent of patients who have to wait six or more days. 8 Providing appropriate and timely access to the family practice setting, and more broadly throughout the entire healthcare system is considered a key measure of a health system s quality. Most physicians typically make time available in their day for patients with urgent health care needs. This kind of scheduling generally includes a combination of unscheduled appointment slots, double bookings or squeezing patient s in-between appointments. For those physicians who have altered their practice scheduling to allow all patients to book an appointment on the same day/next day or on any day of their choosing, the results are often mixed 9, but many indicate over time: Improved physician and office staff satisfaction; Improved patient satisfaction; Reduced delays to accessing physician services; Improved continuity of care; Improved quality of care; and Reduced number of unnecessary visits and no-shows. Page 5 of 22 October 24, 2013

The variability of the family practice setting means that physicians require flexibility in how they adopt scheduling systems that meet the needs of their patients and clinical team. As well, family physicians will require a health care system committed to improving timely access to the community of services and care providers required to support the health care needs of their patients, including laboratory and diagnostic services, hospital and community based specialists, homecare and community supports among other services. Many family physicians have expressed a desire to adapt their practice setting to incorporate alternate visit types including using email, telephone, and group visits to meet patient care needs. These techniques are widely used and validated in the primary care setting and have been demonstrated to improve practice efficiency, and to improve access while meeting patient care needs. 10 11 However, in Ontario many limitations on a full scale adoption of these techniques exist. Family physicians require guidance on how to deploy these alternative service delivery methods in a way that meets appropriate patient privacy and liability concerns. Additionally, many of these types of service delivery techniques are not remunerated sufficiently or are not valid for any OHIP based claim. For services that will advance the access priorities in primary care, sufficient remuneration will need to be established to support an effective change from the delivery of usual care. While no one approach will meet the needs of each family practice or can be imposed upon physicians, it is important that physicians carefully consider how accessible they are and work towards providing patients appropriate and timely access to necessary comprehensive primary care services. Quality Improvement Quality improvement in primary care has been established as a key priority by the government. Through the implementation of Quality Improvement Plans (QIPs), primary care organizations and affiliated groups of physicians are being introduced to an organized approach to improving quality in the practice setting. Quality improvement is meant to focus on improving patient outcomes by Page 6 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

improving patient safety, advocating for evidenced based delivery of care, utilizing clinical practice data to inform decision making and adopting new delivery methods 12. The Ministry of Health and Long-Term Care and Health Quality Ontario has determined that QIPs in primary care practices will initially focus on three priority areas: access, integration and patientcenteredness. QIPs are to build quality improvement measures into the design of the practice and focus on improving patient and provider experience, care effectiveness and value, through improvement continuously over time 13. This includes considering how information technology is utilized, how data is managed, what clinical services are performed, and which measures and targets are set. To be successful, the family practice setting needs to be designed to incorporate quality improvement throughout and physicians need to drive this process. The implementation of QIPs and the selection of quality improvement indicators without physician leadership will have the strong potential to negatively impact physician productivity and satisfaction, and could affect patient care. Quality improvement must focus on the collective work of everyone in the family practice setting; it must be guided by how the physician, staff and other health professionals ensure the strong delivery of patient centred, accessible, continuous and comprehensive care. The collection of a common set of appropriate and measureable targets, patient self-reported measurements and clinical indicators are necessary to measure the quality of care provided. These targets, measurements and indicators take extra time in practice but will help establish goals and benchmarks within the family practice setting that can help to demonstrate improvements in patient care, assist the clinician to focus more quickly on the patient s current health state and improve health outcomes and value 14. Data management support is essential to the common adoption of data elements within the practice and throughout the primary healthcare system. The right indicators and data extractions must be chosen, and that data must be recorded consistently and accurately as this is fundamental to quality improvement. While electronic data is a key element to support a full and robust quality improvement program, it is not a prerequisite to adopting a quality improvement Page 7 of 22 October 24, 2013

process within the practice. As physicians adopt a structured quality improvement program within their practice they should be mindful of ways they can adapt their approach and create high value experiences for patients that focus on solutions that yield better health. Before family physicians can fully adopt quality improvement planning into their practice, it is important that the government commit that all quality improvement programs and data will be used to add positive benefit to the practice setting and will never be used in a punitive way. Additionally, while not within the scope of this paper, issues regarding data ownership, stewardship, appropriate use, privacy and reporting need to be resolved to provide confidence and support to physicians adopting quality improvement planning within their practice setting. Integration An appropriately integrated primary care system ensures that patients move seamlessly between providers and care locations including the home, family practice clinic, community, speciality care and hospital, long-term care or any other institutional setting. Active integration at the community level and between practice sites can result in shared efficiencies, better patient care, improved capacity and greater patient and provider satisfaction. To achieve this goal administrative and system barriers need to be overcome. Integrating the clinical and community care record can remove barriers to collaborative care and network all providers with the patient. 15 Physicians need to adapt to the changing standards of practice through effective integration of practice guidelines, tools and new knowledge from implementation science. Physicians will need to collaborate with other primary care providers to establish clear primary care focussed care pathways. This will require clinical leadership from family physicians, effective knowledge translation and highly functioning clinical integration tools and relationships. 15 Page 8 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

To achieve better transitions for patients, primary care requires investment in infrastructure, relationships, information and communication, team-based care and effective patient engagement. Ontario s Health Links program is based on the belief that a fully integrated health and community care sector improves the ability to provide more appropriate and less costly patient care to Ontario s seniors and those with complex conditions. When combined with the hospital and primary care based approach to quality improvement planning, Ontario is beginning to connect the required elements necessary to establish a patient-centred, collaborative and integrated health system. The OMA has also committed significant resources to the development of Primary Care Councils. These formal networks of physicians, health care providers, and health care institutions within a community are meeting regularly with health system administrators and planners, including hospitals, community care access centres, Local Health Integration Networks, public health and others to discuss and seek solutions to local service issues. As a new initiative, these Councils are active in many areas and currently underdevelopment in many others. Over time it is anticipated that these Councils will provide valuable insight and expertise that improves service integration and delivery at the community level. This section will explore what key elements need to be in place for the broader health system, the primary care sector and the family physicians practice to effectively and efficiently integrate and coordinate care around the patient. Infrastructure: System planning should recognize the need for resources to allow for new infrastructure to support improvements within practices which promotes internal and external integration. Improving existing and developing new infrastructure such as electronic medical records, electronic health records, online patient information and education tools, laboratory results and prescription drugs portals with a multi-disciplinary provider and patient-focussed design can assist physicians in modifying their office practices to enhance team-based provider Page 9 of 22 October 24, 2013

workflow, patient experience and connectivity with the community of providers supporting the patients care needs. Engaging patients and coordinating with system partners are significant undertakings and require administrative and financial supports to do so. Remunerating physicians for their time is an important consideration for local system planners as it ensures that family physicians are able to fully participate in the collaboration necessary to effectively establish a coordinated, community based care environment. This is particularly important when the community of care is built on a virtual team environment as is the case in much of Ontario. Information and communication: Communication is the lynch-pin of high quality practice and includes communication with patients and families in addition to communication among providers. Physicians cannot rely on appropriate, or even necessary, interactions to occur spontaneously. Interactions must be planned for and supported within practice. This will include informal and formal consultations, team meetings, communication with third parties (e.g. schools, workplaces), written reports, etc. It is increasingly evident that ehealth and information technology tools can facilitate practice management and quality improvement by making information about sub-sets of patients and practice flow more readily available. Access to information from the EHR can provide a more robust clinical picture and enable core information to be shared among providers. One component of a comprehensive electronic health strategy yet to be fully appreciated is the use of patient-centred communication technology. Provider and patient communications have been limited to employing conventional tools and techniques. Opportunities exist within the family practice setting to engage patients and for patients to engage with the family practice through electronic means that enhance interaction, satisfaction and improve access and efficiency 15. Common examples include e-mail, practice based websites that include message boards and links to reliable health information, and patient survey tools. Before these tools can be used widely and confidently, family physicians require assurances and confidence that the necessary privacy and information security tools are in place. Page 10 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

Team-based Care: Integrated care is about organizing a collection of fragmented providers and services 16. While co-location or group practice isn t always necessary, physicians and all providers need to find effective ways to integrate care across the primary care spectrum. Establishing a team-based delivery model involves re-examining care from the patients perspective and changing workflows to maximize the efficiency and effectiveness of the team as a whole. Building a formal or virtual interdisciplinary team requires enhanced communication and support within the practice and throughout the primary care system. In leveraging existing information technology infrastructure or adapting new technologies, the focus needs to be on the ability of multiple providers to seamlessly support complex and evolving patient needs. Efficient transitions of care will be achieved only through proactive collaboration and enhanced coordination, information sharing and a commitment to responsiveness and collaboration. As provider services expand as a result of scopes of practice changes, and increased use is made of providers existing skills, the workflow and performance of the interdisciplinary team will need to adapt. Physicians will benefit from a solid understanding of the abilities and capacities of other members of the team and will be better able to accurately support the transitions of care required by their patients. Working collaboratively, all members of the team require education and support to better understand the roles and abilities of those who share in the care of the patient. The involvement and engagement of family physicians and other providers participating in the care of patients is necessary to establish effective and successful clinical care pathways 17. Where possible, the standardization of care paths will improve the coordination of care, creating trust between providers as a higher level of confidence and predictability is established. This does not mean that individualized interventions aren t required, but a more supportive and integrated community of care will be available to help support and deliver a high level of care to the patient. This is of particular interest as Health Links programs are developed to support patients with complex conditions and those who place high demands for care throughout the health care system. Page 11 of 22 October 24, 2013

Engaging the Patient It has become increasingly important that the primary care system engages patients and receives their input and feedback when developing a patient-centred family practice setting. Effective tools like patient surveys and feedback cards can be used to gain insight into how patients view the office practice setting, staff, services, access and wait times. Patient feedback can help set clinical care priorities, assist in the development of preventative and wellness intervention tools and process efficiencies and strategies for better utilizing provider resources within the practice 15. Patients are increasingly looking to participate in a multi-disciplinary care dynamic. They expect, to differing degrees, to engage with providers across the primary care spectrum. However, some also need help navigating through today s complex healthcare system. The sharing of information between providers and the patient will contribute to a more efficient and accessible primary care system. Coordination of care for patients is generally taken by the family physician and may be characterized by clinical leadership of an interprofessional team 18. While physicians generally take the lead in coordinating care, a small sub-set of patients may benefit from the use of formal care coordination. In some practice settings, patient navigation is managed by a team member dedicated to this role. In other teams, each provider is responsible for ensuring patients are properly navigating through the system, while in some practices patients have access to an accessible patient record and health information. This allows the patient to become better informed about the care they have received, the care they require and the self-management techniques and resources they need to apply to better manage their condition or improve their wellness. Through improved access to the patient record, education, test results and health assessments and the providers that treat them, patients can become informed, enabled and more accountable partners in Ontario s primary care system 7. By giving patients a greater voice in the design and delivery of care and treatment in the family practice setting, physicians will be better positioned to Page 12 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

provide higher quality care to reduce the burden of illness, prevent disease, and promote better relationships with their patients 14. A Role for the OMA As a leader in health care and as the representative body of physicians in Ontario, the OMA has both an opportunity and a responsibility to provide leadership, support, advocacy and professional resources to physicians. In primary care, the OMA has represented physicians, actively working with members and physician leaders in the development of practice agreements that introduced the concept of group care, organized after hours and on-call services. These practice agreements have created a stable platform from which the primary care system can expand. The OMA must consider what new roles it needs to play to further engage members to ensure that changes to the practice environment are not only patient centred, but is fulfilling for physicians and reflects the role physicians wish to play in primary care. The OMA is committed to: 1. Work collaboratively with family physicians, the Ministry of Health and Long-Term Care and health system partners to focus efforts on delivering services within a sustainable, high quality, patient-centred primary care system. 2. Enable effective integration and collaboration across the primary care system through tailored investments in incentives, programs, policies, practice tools. 3. Assist physician leadership in decision-making to help focus the development of a high performing, quality primary care system. 4. Identify and pursue meaningful opportunities for effective connections with system stakeholders, the Ministry of Health and Long-Term Care, and the Local Health Integration Networks. 5. Supporting the development of programs like Health Links that work towards fully integrating the health and community care sectors. These programs should engage with family physicians in Page 13 of 22 October 24, 2013

there development and provide a meaningful and active role for family physicians that improves their ability to provide more appropriate and less costly patient care in Ontario. 6. Develop Primary Care Councils as local bodies of physicians engaged with system planners, stewards and leaders and provide planning and priority setting advice at a local and regional level. These Councils are well positioned to provide broad physician engagement, using a physician leadership and peer-to-peer model that will see real changes at the practice level. 7. Negotiate fees, incentives and bonuses that reflect the primary care system physicians want for their patients, their staff and themselves 19. Historically, the OMA has played an essential role in the negotiation of fees and the establishing primary care service priorities through the Physician Services Agreement. This role becomes more critical as the primary care system faces reform. New priorities need to address system goals and gaps while all priorities need to be periodically reviewed to ensure they align to the evolving goals of the system. As payment systems are modernized, the OMA must engage broadly with its membership, stakeholders and partners to ensure that funding is tailored to meet a sustainable, high quality, integrated patient-centred primary care system. 8. Promoting the development and dissemination of best practice tools, resources and supports that will improve physician practices and the delivery of best quality care. These tools such as connected EMRs can support the deployment of a quality improvement program and improve collaboration, integration, patient engagement and communication. 9. Focus on establishing new business lines for its member service portfolio that will help physicians to adapt to the changing dynamic of primary care in Ontario. Moving Ontario s Primary Care System Forward Ontario s family doctors have a key part to play in moving Ontario s primary care system forward. As clinical leaders of health care teams throughout the province, the opportunity for family physicians to deliver change to the health care system is currently before them. This paper has highlighted areas of focus for family physicians that will build a stronger, higher quality health-care system for patients. By focussing on: improving timely access to care; Page 14 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

participating in formal quality improvement programs; working collaboratively to establish strong and effective integration throughout the health care system; and engaging patients Ontario s family physicians can be leaders in transforming the health care system for their patients. Enabling Recommendations and Activities Recommendation 1: The OMA actively promote and advance the concept that development and sustainability of a patient-centred primary care system is a shared responsibility among physicians and other health care providers, patients and their families, and government. Recommendation 2: Establish and support Primary Care Councils throughout Ontario to help facilitate integration in the delivery of primary care service and the development of the capacity for physicians to formally organize communicate and engage with other local system leaders. Physicians need to organize and collaborate locally and regionally as part of the OMA s Primary Care Councils to ensure that the care priorities and service delivery goals meet the local needs of patients, physicians and other primary care providers. Recommendation 3: Family physicians should examine their capacity to provide timely care and to make improvements where appropriate. Timely access to a family doctor means less fragmented care, a reduced need for walk-in clinics and emergency department utilization and a better health status for the patient. Access to an efficient and accessible family practice setting will allow for greater continuity of care, including prevention and wellness interventions, chronic care coordination and re-enablement. Future policy work must clarify clear and effective access criteria to the health system; measureable access benchmarks to track system performance and measurable patient satisfaction with access to all providers, services and institutions. Page 15 of 22 October 24, 2013

Recommendation 4: Modernize the Ontario Health Insurance Plan (OHIP) payment system to reflect current practice realities. The current payment models for primary care are built on principles that generally require the physician and patient to interact face-to-face in a clinical setting to qualify for payment. This limits capacity for physicians to adapt their processes. To meet the needs of a patient-centred system, payment models, incentives, fees and schedules need to offer flexibility in how services can be organized or provided to patients and still qualify for payment. Recommendation 5: Identify and track all primary care providers services to ensure optimal use of resources. Currently, only the services provided by physicians can be tracked by the Ministry of Health and Long-Term Care. The adoption of new service codes in primary care needs to address current and emerging priorities and changes in the delivery of care. With the expansion of services provided by non-physician primary care providers and the expansion of scopes of practice for nurses and pharmacists in the community setting, mechanisms need to be established to record all services performed. Recommendation 6: Improve family physicians understanding of other primary care provider roles and abilities while increasing communication and engagement capacity throughout primary care. With the recent expansion of the scopes of practice for many primary care providers, it is important that physicians be able to access training and educational resources and tools that enable them to better understand when and how to share care with a goal to establish a high quality patient-centred health care system. Recommendation 7: Make sufficient resources available to enable all family practice environments to strengthen their ability to effectively link and collaborate with other providers and practice settings. Page 16 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

The primary care system will require the development of resources that enable the integrated delivery and collaboration of care in a multi-disciplinary and networked environment. Ontario needs to continue to support the adoption of formal patient enrolment practices while ensuring that each practice is equipped to make meaningful connections with primary care providers and practice environments within their communities and throughout the health system 4. Tools and resources that will help identify external and internal practice linkages include E-Health products, clinical care and practice management policies and programs. Implementation of effective tools and resources will require robust training and supports to physicians and their team, including change management support. Recommendation 8: Focus on the quality of care provided for people with chronic conditions as a place to start. Targeting patients with certain chronic conditions will help physicians focus their quality improvement activities. The adoption of shared and common data elements and agreement on best practices and clinical practice guidelines for common conditions will result in more widespread adoption of quality improvement initiatives. References Starfield B. Primary care: balancing health needs services and technology. Rev ed. New York, NY: Oxford University Press; 1998. p. 8-9. Ontario Medical Association; Ontario. Ministry of Health and Long-Term Care. 2012 physician services agreement between: Ontario Medical Association ( OMA ) and Her Majesty the Queen in Right of Ontario, as represented by the Minister of Health and Long-Term Care ( MOHLTC ). Toronto, ON: Ontario Medical Association; Ontario Ministry of Health and Long- Term Care; 2012 Nov 7. Page 17 of 22 October 24, 2013

Ontario. Ministry of Health and Long-Term Care. Community health centres [Internet]. Toronto, ON: Ontario Ministry of Health and Long-Term Care; [Last modified: 2013 Feb 27]. [about 3 screens]. Available at: http://www.health.gov.on.ca/en/common/system/services/chc/default.aspx. Accessed: 2013 Oct 17. Primary Healthcare Planning Working Group (Ontario). Strategic directions for strengthening primary care in Ontario: overview of process and recommendations of the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Dec. Available at: http://www.trilliumresearchday.com/documents/2012_phpg_overview%20of%20process%20and %20Recommendations_Final.pdf. Accessed: 2013 Oct 17. Ontario. Ministry of Health and Long-Term Care. Ontario s action plan for healthcare: better patient care through better value from our health care dollars: let s make healthy change happen. Toronto, ON: Queen s Printer for Ontario; 2012. Available at: http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthychange.pdf. Accessed: 2013 Oct 17. Ontario. Ministry of Health and Long-Term Care. Excellent care for all: Ontario s Excellent Care for All Strategy [Internet]. Toronto, ON: Ontario Ministry of Health and Long-Term Care; [Last Modified: 2012-11-03]. [about 2 screens]. Available at: http://www.health.gov.on.ca/en/public/programs/ecfa/. Accessed: 2013 Oct 17. Porter M, Kellogg M. Kaiser Permanente: an integrated health care experience. RISAI: Journal Of Health Innovation And Integrated Care 2008;1(1):1-8. Available at: http://pub.bsalut.net/cgi/viewcontent.cgi?article=1003&context=risai. Accessed: 2013 Oct 17. Page 18 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

Schoen C, Osborn R. The Commonwealth Fund 2011 international health policy survey of sicker adults in eleven countries [PowerPoint presentation]. New York, NY: The Commonwealth Fund; 2011 Nov. Mehrotra A, Keehl-Markowitz L, Ayanian JZ. Implementing open-access scheduling of visits in primary care practices: a cautionary tale. Ann Intern Med. 2008 Jun 17;148(12):915-22. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2587225/pdf/nihms49162.pdf/. Accessed: 2013 Oct 17. Car J, Sheikh A. Email consultations in health care: 2--acceptability and safe application. BMJ. 2004 Aug 21;329(7463):439-42. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc514210/pdf/bmj32900439.pdf. Accessed: 2013 Oct 17. Car J, Sheikh A. Telephone consultations. BMJ. 2003 May 3;326(7396):966-9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc153854/pdf/966.pdf. Accessed: 2013 Oct 17. Improving Quality in Primary Care Working Group (Ontario). Quality in primary care: final report of the Quality Working Group to the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Aug. Available at: http://www.afhto.ca/wpcontent/uploads/1.-phpg_quality-wg-report_final.pdf. Accessed: 2013 Oct 17. Ontario. Ministry of Health and Long-Term Care; Health Quality Ontario. 2013/14 quality improvement plan: guidance document for primary care organizations in Ontario. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2013 Jan. Available at: http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/qi_pri_guidance.pdf. Accessed: 2013 Oct 17. Nelson EC, Hvitfeldt H, Reid R, et al. Using patient-reported information to improve health outcomes and health care value: case studies from Dartmouth, Karolinska and Group Health. Page 19 of 22 October 24, 2013

Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; 2012 Jun. Available at: http://tdi.dartmouth.edu/images/uploads/tdi_tr_pri_ia_sm.pdf. Accessed: 2013 Oct 17. Ham C. Working together for health: achievements and challenges in the Kaiser NHS Beacon sites programme [Health Services Management Centre policy paper 6]. Birmingham, U.K: University of Birmingham; 2010 Jan. Available at: http://epapers.bham.ac.uk/749/1/kaiser_policy_paper_jan_2010.pdf. Accessed: 2013 Oct 17 Increasing Efficiency in the Family Practice Setting Working Group (Ontario). Increasing efficiency in the family practice setting: report of the working group to the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Aug. Available at: http://www.trilliumresearchday.com/documents/2012_phpg_efficiency-wg-report_final.pdf. Accessed: 2013 Oct 17. Porter ME, Teisberg EO. Redefining health care: creating value based competition on results. Boston, MA: Harvard Business School Press; 2006. Zander K. Integrated care pathways: eleven international trends. Journal of Integrated Care Pathways. 2002 Dec;6(3):101-107. Available at: http://www.cfcm.com/pdf/integrated-care- Pathways.pdf. Accessed: 2013 Oct 17. Ontario Medical Association. Policy on chronic disease management. Toronto, ON: Ontario Medical Association; 2009 Oct. Available at: https://www.oma.org/resources/documents/2009chronicdiseasemanagement.pdf. Accessed: 2013 Oct 17. Technical Report: Using Patient Reported Information to Improve Health Outcomes and Health Care Value: Case Studies from Dartmouth, Karolinska and Group Health, The Dartmouth Institute for Health Policy and Clinical Practice, June 2012 duplicate see #14 Page 20 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989

Improving Accountability in Primary Care Working Group (Ontario). Improving accountability in primary care : report to the Working Group to the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Jun. Available at: http://www.trilliumresearchday.com/documents/2012_phpg_accountability-wg-report_final.pdf. Accessed: 2013 Oct 17. 1 Starfield B. Primary care: balancing health needs services and technology. Rev ed. New York, NY: Oxford University Press; 1998. p. 8-9. 2 Ontario Medical Association ; Ontario. Ministry of Health and Long-Term Care. 2012 physician services agreement between: Ontario Medical Association ( OMA ) and Her Majesty the Queen in Right of Ontario, as represented by the Minister of Health and Long-Term Care ( MOHLTC ). Toronto, ON: Ontario Medical Association ; Ontario Ministry of Health and Long-Term Care; 2012 Nov 7. 3 Ontario. Ministry of Health and Long-Term Care. Community health centres [Internet]. Toronto, ON: Ontario Ministry of Health and Long-Term Care; [Last modified: 2013 Feb 27]. [about 3 screens]. Available at: http://www.health.gov.on.ca/en/common/system/services/chc/default.aspx. Accessed: 2013 Oct 17. 4 Primary Healthcare Planning Working Group (Ontario). Strategic directions for strengthening primary care in Ontario: overview of process and recommendations of the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Dec. Available at: http://www.trilliumresearchday.com/documents/2012_phpg_overview%20of%20process%20and%20reco mmendations_final.pdf. Accessed: 2013 Oct 17. 5 Ontario. Ministry of Health and Long-Term Care. Ontario s action plan for healthcare: better patient care through better value from our health care dollars: let s make healthy change happen. Toronto, ON: Queen s Printer for Ontario; 2012. Available at: http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthychange.pdf. Accessed: 2013 Oct 17. 6 Ontario. Ministry of Health and Long-Term Care. Excellent care for all: Ontario s Excellent Care for All Strategy [Internet]. Toronto, ON: Ontario Ministry of Health and Long-Term Care; [Last Modified: 2012-11- 03]. [about 2 screens]. Available at: http://www.health.gov.on.ca/en/public/programs/ecfa/. Accessed: 2013 Oct 17. 7 Porter M, Kellogg M. Kaiser Permanente: an integrated health care experience. RISAI: Journal Of Health Innovation And Integrated Care 2008;1(1):1-8. Available at: http://pub.bsalut.net/cgi/viewcontent.cgi?article=1003&context=risai. Accessed: 2013 Oct 17. 8 Schoen C, Osborn R. The Commonwealth Fund 2011 international health policy survey of sicker adults in eleven countries [PowerPoint presentation]. New York, NY: The Commonwealth Fund; 2011 Nov. 9 Mehrotra A, Keehl-Markowitz L, Ayanian JZ. Implementing open-access scheduling of visits in primary care practices: a cautionary tale. Ann Intern Med. 2008 Jun 17;148(12):915-22. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2587225/pdf/nihms49162.pdf/. Accessed: 2013 Oct 17. 10 Car J, Sheikh A. Email consultations in health care: 2--acceptability and safe application. BMJ. 2004 Aug 21;329(7463):439-42. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc514210/pdf/bmj32900439.pdf. Accessed: 2013 Oct 17. Page 21 of 22 October 24, 2013

11 Car J, Sheikh A. Telephone consultations. BMJ. 2003 May 3;326(7396):966-9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc153854/pdf/966.pdf. Accessed: 2013 Oct 17. 12 Improving Quality in Primary Care Working Group (Ontario). Quality in primary care: final report of the Quality Working Group to the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Aug. Available at: http://www.afhto.ca/wp-content/uploads/1.- PHPG_Quality-WG-Report_Final.pdf. Accessed: 2013 Oct 17. 13 Ontario. Ministry of Health and Long-Term Care; Health Quality Ontario. 2013/14 quality improvement plan: guidance document for primary care organizations in Ontario. Toronto, ON: Ontario Ministry of Health and Long-Term Care; 2013 Jan. Available at: http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/qi_pri_guidance.pdf. Accessed: 2013 Oct 17. 14 Nelson EC, Hvitfeldt H, Reid R, et al. Using patient-reported information to improve health outcomes and health care value: case studies from Dartmouth, Karolinska and Group Health. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; 2012 Jun. Available at: http://tdi.dartmouth.edu/images/uploads/tdi_tr_pri_ia_sm.pdf. Accessed: 2013 Oct 17. 15 Increasing Efficiency in the Family Practice Setting Working Group (Ontario). Increasing efficiency in the family practice setting: report of the working group to the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Aug. Available at: http://www.trilliumresearchday.com/documents/2012_phpg_efficiency-wg-report_final.pdf. Accessed: 2013 Oct 17. 16 Porter ME, Teisberg EO. Redefining health care: creating value based competition on results. Boston, MA: Harvard Business School Press; 2006. 17 Zander K. Integrated care pathways: eleven international trends. Journal of Integrated Care Pathways. 2002 Dec; 6(3):101-107. Available at: http://www.cfcm.com/pdf/integrated-care-pathways.pdf. Accessed: 2013 Oct 17. 18 Ontario Medical Association. Policy on chronic disease management. Toronto, ON: Ontario Medical Association; 2009 Oct. Available at: https://www.oma.org/resources/documents/2009chronicdiseasemanagement.pdf. Accessed: 2013 Oct 17. 19 Improving Accountability in Primary Care Working Group (Ontario). Improving accountability in primary care: report to the Working Group to the Primary Healthcare Planning Group. Toronto, ON: Primary Healthcare Planning Group (Ontario); 2011 Jun. Available at: http://www.trilliumresearchday.com/documents/2012_phpg_accountability-wg-report_final.pdf. Accessed: 2013 Oct 17. Page 22 of 22 October 18, 2013 For further information, contact Peter Brown at peter.brown@oma.org or via telephone at 416-340-2989