Our Call in a Broken Health System

We need funded team-based care

[ April 2023, Get Well Clinic]

We thank all of you who have been with us on our journey to building a better family medicine clinic for you. For those of you who trusted our providers with your health, we extend our gratitude. Your kind words of encouragement have been particularly uplifting during the darkest times of the pandemic. This article attempts to put in perspective the progress we have made, and explain the path we are on, and what we are looking forward to. Our health system needs your support, our community, to build a better world for us to live in.

The pandemic has shown the cracks in our once prized health care system. Health commentators have lamented that our health system was on the breaking-point even before the pandemic arrived. The frustrations you have experienced with your interactions with the health system are signs that things are not right, and that things need to change for the better. Health providers have long experienced this sense of frustration growing for several years, and have culminated to the rising burnout among doctors, nurses and their subsequent departure from the workforce (early retirement, mental health break, shift to private-pay opportunities) which contribute to the growing problems of the lack of family doctors, crowded emergency departments, long wait times for access to care, and declining patient satisfaction.

There are no simple answers to a problem that has many interacting parts. A systemic problem requires a systems approach. We all play a role in the system: the health provider, the patient, the community, the clinics, the government. We started Get Well Clinic to be a team-based primary care clinic that would find it's place amongst the complexities, limitations, and opportunities of the healthcare field. We would work towards the greater vision for better health for our community. We designed our clinic with the anticipation that one day, the government would provide sustainable funding to expand our team-based model of care. We are calling on the provincial government to fund team-based primary care at Get Well Clinic.

This is our journey in finding innovative approaches to team-based care with our limited resources. It is a story of hope against great odds, perseverance in times of challenge, sorrow at loss or disappointment, and the joys of achievement. The story is not yet finished, for the next chapter requires bold committments from funding sources. We are calling on the Ministry of Health and provincial government to fund a Family Health Team for "Spring Health and Friends".

The primary care problem in context

Although Canada reports 80-90% of people have someone or someplace that they receive regular primary care (lower than many OECD countries such as France, German, UK, Denmark, Norway), Canada has fewer doctors per capita population. Although Canada has similar number of general practitioners (GP) per capita compared to other OECD countries (about 12 MD per 10,000 people), the reality is that many (about 30%) family medicine doctors practice in specialized areas (ie. emergency medicine, sports medicine, hospitalist, psychotherapy, cosmetics) or provide only walk-in care. This means there could be less doctors actually providing comprehensive family medicine, compared to other OECD countries like France, Germany, UK, Denmark etc. It has been reported that even in Toronto, at least 415,000 residents lack a family doctor as of March 2022. Up to 20% of Toronto doctors are considering closing their practice in the next five years. There are fewer medical students choosing family medicine as their specialty (30% medical students ranked family medicine as their first choice in 2023, compared to 38% in 2015), with the largest vacancy for first-round family medicine residency spots during the 2023 Canadian medical residency match (268 empty spots, which was 76% of all vacant residency spots). This will not be enough to keep up with the growing population, nor maintain the 50:50 ratio of family doctors to specialists that currently make up our health system.

In the beginning...

In 2016, we started Get Well Clinic with a vision to provide timely access to primary care. We started with three University of Toronto trained family doctors who provided family medicine care and walk-in episodic clinic care. Our intent was to provide a family doctor for patients who did not have one, and provide family medicine care at walk-in accessibility to those who could not access their own doctor or who chose not to have one. Initially, this meant that anyone could be seen same-day at Get Well Clinic, Monday to Saturday. In order to augment the care provided by our family doctors, we attracted some like-minded allied health providers (chiropractor, dietitian, psychotherapist, physiotherapist, child youth behaviour analyst etc) who offered their private insurance-covered services at Get Well Clinic while documenting and communicating on our common team-based EMR. Since the 1990's, OHIP has steadily delisted services from the medically neccessary list in order to achieve cost constainment: from dental care to optometry eye care to physiotherapy. After a brief rennaissance in primary care reform (the formation of physician-led primary care groups such as FHG's, FHO's, FHT's) in the mid-2000's, the provincial government stopped funding new Family Health Teams in 2012 (and closed off adding new physicians to these FHT's). Therefore, at Get Well Clinic, we sought to provide team-based care funded through any other means available (such as with private insurance through employee extended health benefits). However, this meant that those without insurance or limited insurance coverage would have to pay out-of-pocket, alternatively, some chose to forego care. There was an idea that if we could attract more family doctors to practice in a team-based supportive model of care, that we could reach some economies of scale that would allow us to provide charity to those who could not afford allied healthcare services.

In addition to providing family medicine, we also used this team-based approach for providing a program-based care for two areas of chronic disease management: obesity and mental health. Our Weight Management program followed Obesity Canada's guidelines and brought together a doctor, dietitian, psychotherapist to provide an evidence-based approach to help clients reach and maintain their "Best Weight". Our approach combines medications, coaching, medical nutrition, and various psychotherapeutic techniques to motivate patients to build a sustainable value-based weight management behavioural change. This approach has been used effectively in obesity, as well as overeating conditions such as binge eating. Our mental health program also brings together a medical doctor working in conjunction with in-house psychotherapists to provide evidence-based medications and psychotherapy (CBT, MBCT, ACT, DBT-informed, and EFT) for treatment and maintenance of mental health disorders and conditions. However, the use of allied health providers are not universally and provincially funded, and are out-of-pocket expense. Some may be reimbursed by private extended health insurance plans.

Calamity strikes

The unthinkable pandemic hit our clinic hard in early 2020, and started a snowball effect that reverberates to this day. One of our doctors left to return to their home country for safety. Some cut back their workload and took a break from burnout. Many eventually retired. We even had to drastically reduce our walk-in clinic availability. There was a point in the early days of the pandemic lockdown, that it felt that all was lost. Only a sole family doctor was left to man the clinic; wondering how he would sustain the staff payroll and their livelihood.

The hope and innovations

In spite of the crisis, there was also opportunity, so we at Get Well Clinic rose to the challenge. We have been blessed by providence, serendipity, and some supporters in the provincial health bureacracy. With vision and faith, we managed to wade against the pandemic currents and achieved some notable progress.

We pivoted to virtual care rapidly in March 2020 so we could continue providing care to our patients during the lockdowns. We recruited volunteers to help with our e-Platform, providing training, technical support to patients, and administrative support to our staff. Whereas the most virtual encounters were by telephone (70%-90%), Get Well Clinic was able to achieve 75-90% video-enabled virtual care for several months. We pioneered a hybrid in-person/virtual care approach for primary care that saw a 3x increase in doctor-patient encounters at Get Well Clinic, in spite of the pandemic.

From 2020 to 2023 (during the pandemic), Get Well Clinic has attracted five more family doctors to practice family medicine with us and have rostered 7000 patients. Our physicians have formed a Family Health Organization (FHO) in a previously designated underserviced-area and have provided same-day after-hours care to rostered patients. By 2023, we have over 18,000 patient records in our EMR (many are episodic care patients or allied health clients). We even opened a secondary satellite clinic in anticipation of onboarding more family doctors, and a vision of being a multi-site team. We plan to attract 10 more family doctors to start a family practice and accept more unattached or orphaned patients.

Get Well Clinic was also a leading pilot site for the primary care vaccination efforts in Toronto led by Public Health and Ontario Health, in 2021. We organized our own mini-mass vaccination clinic and provided over 3000 COVID-19 vaccinations at Get Well Clinic, from March to July 2021. Dr Jeffrey Poon presented our approach at one of the online Community of Practice sessions to teach other family doctors how they could also do their own vaccine drive in their own community.

Get Well Clinic also project managed a provincially funded Online Booking Project for 19 clinics (over 100 providers). This allowed over 200,000 patients who receive care at these clinics to be able to book, reschedule, or cancel a medical appointment with their family doctor (or allied health provider) online, without needing to call and wait on the phone. The $100k funding for this project ended on March 31, 2023.

Get Well Clinic is also active in supporting the open source community in building an OSCAR-based EMR that is responsive to end-user feedback, continually updated with improvements, and collectively stewarded by the community for patient care benefit, not profitization.

Get Well Clinic is also actively involved in the North York Toronto Health Partners, Ontario Health Team, with Dr. Kevin Lai serving as digital health lead on the Primary Care Network Council.

The strain on our resources

Throughout the pandemic, the issues of increased clinic-costs, increased administrative burden, increased patient expectations, increased labour shortage, increased labour costs compounded to the feeling of provider burnout. Labour wages had to be increased by 20% to compete with other larger employers who poached staff. The same-day Amazon-effect put undue pressures on virtual care. Doctors reported 25-30% of their time buried with administrative paperwork instead of clinical time seeing patients. There is no wonder why fewer medical students choose to be family doctors in this environment.

It was unreasonable to sustain a primary care health system with volunteers, charity, and goodwill. Although we were blessed by volunteers at our clinic (many who have been inspired and have eventually been accepted in to medical schools across Canada and the US), it became increasing apparent that we could not maintain the level of work required to operate both virtual care and in-person care to the level of our expectations. Operating a virtual care clinic meant duplicating the amount of staff required, which also meant increased labour costs. The increased channels of communication, although more convenient for patients, meant increased workload and demands for our front staff. This led to burnout for even our front staff operating the virtual care platform, whom we had to give a mental health break, otherwise she would have quit. Even one of our family doctors who provided primarily virtual care, retired his family medicine practice during this time period. With the lessening pandemic restrictions, there was a return to in-person care and a shift of virtual care towards primarily telephone. Various guidelines were also developed that favoured in-person care as optimal, with virtual-care options as an augmeent to in-person care. We made a decision to drastically ramp down our services through our e-Platform by implementing an optional paid subscription; the alternative was to shut it down completely due to the unsustainable workload and staff resignations.

New graduating family doctors mostly train in academic team-based models of primary care where they have access to funded resources of nurse practitioners, nurses, dietitians, physiotherapists, psychotherapists, social workers and more. We find it difficult to attract new family doctors to join our clinic and start accepting patients if we do no have the funds to provide these allied health team members, such as a nurse. Our clinic operating expenses are funded by a portion of the family doctors own salaries. This situation systematically underfunds team-based care. This is in sharp contrast to other situations where heathcare workers do not have to use a portion of their salaries to pay for their organization's expenses or hospital personel.

There is still hope

In 2023, a panel of 35 member of the Ontario public were brought together by MASS LBP to have a collaborative discussion and present some key recommendations about our primary health care system. Amongst some of it's recommendations was a call for the provincial government to fund team-based care in Family Health Teams, in order to reduce provider burnout and provide more access to comprehensive care. They recommend that all Ontarians have a primary care home, close to the community in which they live in. They recommend addressing the hinderances to family doctor supply by calling for better administrative support and technology infrastructure for family health teams and primary care providers so they can devote their time to delivering primary care. We, at Get Well Clinic, resonate with this report and have structured our approach to providing care in our community for such a time as this. In March 2023, the Trudeau government and Ford's Ontario government reached a deal to inject more funding for the health care system, which includes $30 million allocated to create 18 new primary care teams, allowing 1,200 family physicians to join a team-based model of care in the next 2 years.

We are calling on the provincial government and the Ministry of Health to fund "Spring Health and Friends" to form a Family Health Team. We want to continue providing excellent care to our patients and community. We are delivering in desperate time, and we need your help.

If you are supportive of our efforts to form a Family Health Team (FHT) for you, please send us a written letter of support (with attention: to the Ministry of Health) and/or fill out this petition form. We may also reach out to you to join in feedback / engagement sessions to co-design the FHT with you.

~ Get Well Clinic Management

References

Kiran, Tara, "What can Ontario learn from other countries when it comes to primary care?", OurCare, 10-Dec-2022.
https://static1.squarespace.com/static/6262cccb57de734a6952e846/t/63975cbf059a0c245d37fdd1/1670864066347/OurCare+-+DrKiranPresentation_Dec10.pdf

Ogilvie, Megan, "Toronto residents increasingly don't have a family doctor. Here's why", Toronto Star, 6-Apr-2023.
https://www.thestar.com/news/canada/2023/04/06/more-and-more-toronto-residents-dont-have-a-family-doctor-heres-whos-being-affected-the-most.html

Grant, Kelly, "Almost 20 per cent of Toronto doctors are considering closing their practice in the next five years", Toronto Star, 15-Nov-2022.
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Joschko, Justin, "Exploring the factors that influence the ratio of generalists to other specilists in Canada", Canadian Family Physician, 2016-Mar; 62(3): 3122-e128.
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Ministry of Health, "Family Health Teams".
https://www.health.gov.on.ca/en/pro/programs/fht/

Leung, Wency, "Doctors spending millions of hours a year on paperwork, report says", The Globe and Mail, 30-Jan-2023.
https://www.theglobeandmail.com/canada/article-doctors-paperwork-hours-burnout/

OurCare Infographic, "Virtual Care with your Family Doctor", OurCare.ca
https://static1.squarespace.com/static/6262cccb57de734a6952e846/t/641db57476cf3509813b2ea7/1679668596776/OurCare-1Pager-HD-VirtualCarepdf.pdf

Lai, Kevin. Abdul Nabi, Mura, "Innovative Expansion of Virtual Care Family Medicine Services During the COVID-19 Pandemic". Poster presentation, NAPCRG Conference 2021.

Crawley, Mike, "How Ontario's new health-care deal could change the way your family doctor works", CBC News, 20-Mar-2023.
https://www.cbc.ca/news/canada/toronto/ontario-canada-doctors-family-health-teams-1.6764329

OurCare.ca, "Ontario Priorities Panel on Primary Care: New perspectives and possibilties for primary care in Canada", Members Report, March 2023.
https://static1.squarespace.com/static/6262cccb57de734a6952e846/t/642de2fb8a801044e28ed7cd/1680728832209/OurCare+-+Ontario+Members%27+Report+-+ENWEB.pdf