Primary Care Networks in Alberta

National Healthcare Leadership ConferenceSaskatoon, Saskatchewan

June 2, 2008

Presentation

1. Overview of Primary Care InitiativeBetty Jeffers

2. Alberta Health & Wellness PerspectiveBetty Jeffers

3. Regional Health Authority PerspectiveMarion Relf

4. Alberta Medical Association PerspectiveDr. Gerry Prince

5. Common ViewpointsDr. Gerry Prince

6. Question and Answer

What is Alberta’s Primary Care Initiative?

� Strategic agreement under the 8 year tripartite Master Agreement between Alberta Health and Wellness (AHW), Regional Health Authorities (RHAs), and the Alberta Medical Association (AMA)

� Provincial framework to improve access to and effectiveness of primary care services

� Collaborative, comprehensive, and cooperative approach

Master Committee

Secretariat

Physician Services

Agreement

Physician OfficeSystem Program

Agreement

Primary CareInitiative

Agreement

Physician On-CallPrograms Agreement

PS Committee POSP Committee PCI Committee POCP Committee

Agreement Structure

Primary Care Initiative Committee

� One of a number of Strategic Physician Advisory Committees

� Mandate is to provide oversight for implementation of the Primary Care Initiative

� Broad responsibilities include all aspects of implementation, provincial policy direction, recommendations on funding, monitoring and evaluation

� Equal representation from the partners (AHW, AMA and RHAs) and consensus decision-making model

� AHW retains funding responsibilities

Primary Care Networks (PCN)

� New way to deliver primary care

� Local initiatives within provincial framework

� Formal arrangements between an RHA and a group of physicians

� Defined roles and responsibilities

� RHA and physicians in PCN jointly:

– Make decisions

– Provide service responsibilities

– Receive payments

PCN Funding

� Mixed funding environment� Physicians bring existing payment arrangements into the

partnership – either fee for service or alternate compensation plans

� Networks receive funding of $50 per capita for each enrollee –only informal enrollment is currently being used

� Informal enrollees are identified through historic encounters with participating physicians

� New method to define these enrollees through assignment to patient panels is being implemented

� Funding may be used to implement programs as per approved business plans – including administrative and overhead costs, staffing costs and so forth

PCN Governance

� PCN partnership is formed through a joint venture agreement between the RHA and a not for profit corporation (NPC) formed by the physicians

� Physicians sign this agreement and related letters of participation; RHA signs the agreement

� Partnership forms a governance committee to provide oversight for the network

� Day to day operations are typically managed by the NPC but many arrangements in place

Primary Care Initiative: Provincial Objectives

� Increase the number of Albertans with ready access to primary care

� Manage 24/7 access to appropriate care� Increase emphasis on:

– Health promotion and disease and injury prevention– Care for patients with chronic diseases, complex problems

� Better coordination and integration between components of the health system

� Greater use of multi-disciplinary teams

Alberta Health and Wellness Perspective

Betty Jeffers

Director Primary Care Unit

Alberta Health and Wellness

Government Role

Alberta Health and Wellness Roles:

1) One of three partners to the agreement

2) Provide funding and manage related accountabilities

3) Overall health system policy direction

4) Integration with other government policy directions

5) Dissemination of best practice

“Partnership” Role

Provincial Partnership

– Equal representation on tripartite committees

– PCIC oversight and provincial policy framework

– Consensus model (not traditional government role)

Local Partnership

– RHA/Physician based

– More traditional perspective on government role at this level

Funding and Accountability

Ensuring that accountability framework meets AHW requirements as funder

� AHW accountable to public for funding and related service delivery

� Establishing internal controls related to this

� Negotiating appropriate reporting and monitoring –consistent with government reporting requirements

� Developing operational interface with other operational support structures

Health System Policy

� Ensuring that implementation of the initiative is consistent with overall health system policy directions

� Coordinating implementation with other government initiatives and major activities (examples – access strategies, public health strategy, continuing care)

� Developing policy positions for AHW participation in PCIC policy development process

Dissemination

Best Practice

� Dissemination of other related activities, for example, Primary Health Care Transition Fund

Supporting Success

� Provision of additional resources (ranging from funding for resource development such as team training manuals, to support for access to practice improvement resources)

Benefits of Governance Approach

� Local Flexibility leads to true innovation

� Responsiveness

� Consensus model creates a new type of partnership (not an “in the box” approach)

� Participatory Approach leads to better “buy-in”

� Enables joint design and implementation (not imposed)

� Promotes better integration of publicly funded health services

Challenges

� Balancing local flexibility with provincial policy requirements (provincial policy issues such as universality and access <> local responsiveness)

� Recognition of unique roles (“equal but different”)

� Pursuing the common interest without prejudice

Regional Health Authority Perspective

Marion Relf, RN, MHSA

Director Primary Care Initiatives

Capital Health – Edmonton

Interim Director

Program Management Office

Primary Care Initiative

The Contribution of Alberta’s RHAs

Three roles for Regional Health Authorities (RHAs) in supporting Alberta’s Primary Care Initiative

1) One of the three signatories to the agreement; responsible for the oversight of the Initiative through representation on PCIC

2) Contribute to leadership in implementation of the agreement across and through all communities

3) At a local level, the RHA is a “partner” with a group of family physicians to form a Primary Care Network (PCN) through a legal agreement and joint business plan; varying models –governance/management responsibilities

RHA Role in a PCN

The Physician group (NPC) and the Region

agree to work together:

� Prepare “Letter of Intent” (LOI)

� Upon LOI approval, by the Provincial Committee, jointly develop a “Business Plan”

� Complete legal documentation

� Upon approval, by the Provincial Committee, implement a PCN

� Joint governance of the PCN; some management roles depending on legal model

RHA Role in a PCN (continued)

Why did the Initiative set a structure in place that includes the Region and Physician?

� Same patients access services of both;

� Primary Care’s strengths and weaknesses impact the system as a whole and general health of the current population;

� Identifies and fills legitimate gaps, not duplicating services already provided;

� Primary care is the gateway to an integrated health system.

Benefits to the Region

� Improvements to the health of the population;

� Ability to match the region’s services more effectively to patient and physician needs (and vice versa), example – Home Care;

� Mechanism to consider and address unmet primary care needs identified by the Region, for example – Unattached patients;

� Re-establishing relationships with family physicians often leads to new ideas and opportunities.

Governance Strengths of the PCI Model

Local PCN Governance

� Region and Physicians have equal say and decisions are made by consensus;

� Builds the relationship between physicians and region.

PCI Committee Governance

� All three parties are represented and decisions are made by consensus;

� Tripartite structure allows for resolution at more senior levelswhen required.

Governance Challenges

Local PCN Governance

� When relationships are strong and positive, it works well; when they are not the governance model may not provide options.

PCI Committee Governance

� Always three parties and their interests to balance;

� Challenge to set aside the individual parties’ interest for the program’s best interest.

Alberta Medical Association Perspective

G.D. Prince, BMSc,

MD, FCCFP, FAAFP

Alberta Medical Association

Co-Chair on Primary Care

Initiative Committee

The Role of the Alberta Medical Association

1) One of the three signatories to the 2003 agreement.

2) Provide Logistical support to physician and physician groups wishing to develop a Primary Care Network (PCN) through the Practice Management Program

The Role of the Alberta Medical Association (cont’d)

3) Fund Holder for Program Management funds

4) Contribute Leadership to all levels of the Tripartite agreement

The Role of the Alberta Medical Association

Practice Management Program � Assist physicians in managing practice risks

associated with entering PCNs.

� Support physicians as they work through the process to develop PCNs.

� Support physicians in making informed decisions.

� Assist physicians to realize the full benefits of PCNs.

� Increase PCN implementation success.

� Integrate PMP with the broader Primary Care Initiative (PCI) framework

Individual Physician Role

Individuals and groups of Physicians form an entity (usually a Not for Profit Corporation) to enter an agreement with the Region to form a Primary Care Network.

Identify community and physician needs and help build a program to address them.

Take an active role in Joint governance of the PCN.

Individual Physician Role

Participate in PCN activities

� Office Programs

� Regional Programs

� Specialty Linkages

Individual Physician Role

Why Bother?

� Altruism - Desire to improve patient care

� Supports enhanced office-based delivery of care

� Physician remains core member of team

� Part of the design, not a “victim” of the design

Benefits for Physicians

� Closer, more cooperative relationship with Region.

� Expanded Capacity to provide care without losing touch with patients

� Financial incentive to provide needed services not traditionallyfunded

� Improved linkage and communication between community physicians

Why a Partnership?

Local Primary Care Network level

� Neither Region nor Physicians can coerce the other party to participate.

� For either to receive benefit, both must agree on process.

� Local solutions developed by local innovation.

Why a Partnership?

Tripartite PCI Committee Governance

� All three parties are interested in success;

� Demands of the program foster cooperative development of solutions;

� No time to stand on positions

� PCIC (and other SPACs) expected to model cooperative behavior! (How to play nice and get things done)

Challenges

� Demand has often outstripped support� LOI Application process

� Business planning

� Program review

� Total funding

� Impossible to develop policies as fast as Local Networks propose new ideas!

� Have developed a “common law” approach. Use principles to guide practical solutions

� Universality

� Recognition that to meet local needs, everyone will not be the same

Conclusions

Strengths as Viewed by All

� Relationships Improved

– AHW, AMA, RHA

– local level

� Between physicians

� Between physicians and region

� Buy In has been outstanding and enthusiasm is high

� Integration of primary care within whole health system is progressing

� Value realized

– For system

– For each party

– For the providers and patients

Challenges as Viewed by All

� Balancing interest of party with interests of the initiative

(i.e., patient care, health of population)

� Balancing innovation with provincial objectives and direction

(i.e., local versus provincial)

Where are we at?

� Program is well established

� Physician/RHA relationships firm and improving

� Innovative service delivery happening

� Widespread enthusiasm, collaboration and buy-in as PCN partners and physicians establish PCNs

� Canada-wide interest

� Growth of teamwork and collaboration

� Positive feedback from operating PCNs