Vancouver Division Q&A In response to your feedback
Thank you for providing your comments about the work of the Vancouver Division. More than likely the thoughts of one physician are similar amongst our membership. We look forward to creating an open dialogue in response to your questions.
Ongoing discussion around primary care in Vancouver and the work of your Division is important to us. We are excited to expand on this Q&A to keep you informed on areas important to members.
We encourage you to continue to share your feedback here.
Vancouver Division Board of Directors & Physician Lead
Our health care system is struggling with too many patients unable to access effective primary care and many family physicians are feeling burned out, overworked and unsupported. The current situation in Vancouver is unsustainable for individual providers and for the system as a whole.
In 2015, the GPSC undertook a province-wide visioning process in which over 2,000 family practitioners participated through in-person sessions and web-based dialogues. The following year, informed by the results of the visioning process found here, as well as national and international evidence regarding the importance of primary care in high-performing health care systems, the GPSC began focussed efforts to support the development of Patient Medical Homes as the foundation of the primary care system in this province, found here.
In 2017, the Ministry of Health released a set of Policy Papers that specifically addressed the primary care system, including the importance of Patient Medical Homes and Primary Care Networks, as well as team-based care.
In 2018 the Vancouver Division ran a membership referendum to confirm, “that family physicians… (believe that they feel they should be) …the driving voice behind designing the future of primary care in Vancouver.” Based on the overwhelmingly positive response, the Vancouver Division has been steadily preparing the organization to influence primary care change in Vancouver.
The primary goals of this work are to improving access to quality primary care for all people and to improving the work experience of family doctors.
Team-based care is not completely new to Vancouver: many of our members already work collaboratively with other healthcare providers to provide care that meets the needs of their patients. However, to optimize the opportunity for primary care system evolution in our city, a more formalized, expanded and well-supported team-based care is necessary. Integral to the successful implementation of Patient Medical Homes (PMHs) and Primary Care Networks (PCNs), team-based care is one of the 12 core attributes of a PMH and is an important vehicle with which to improve provider experience of the system and patient access to quality primary care. Through networking PMHs together to begin to address the needs of patients, practices and communities, we envision integrating allied healthcare providers (AHPs) into practices throughout the city. Through PCNs, physicians and AHPs will access services and other team supports to provide appropriate care for patients at a practice and network level, with easy access and seamless communication.
The Vancouver Division continues to support our partners and members to determine the details of team-based care in Vancouver, including employment contracts, hiring, human resources and team integration. Some of these questions will be answered at a provincial level, some at a regional level and many at a community and practice level. Team-based care will likely take a number of years to be implemented broadly, however, we expect to see some progress in this area over the coming year, in a phased approach. More information will be shared as it becomes available.
The PMH model describes how a medical practice can be optimally designed to meet the needs of the patients, the providers and the community. The ultimate achievement of this goal will provide access to quality primary care. How the attributes are achieved is likely to vary in interpretation throughout the province reflecting the diversity of communities and practices.
The good news is that the vast majority of practices in BC are PMHs of some form. We believe that by supporting practices and providers to explore and develop the PMH attributes we will improve access to quality primary care, and by extension, enhance patient and provider experience of the system.
The attributes of PMHs fall into three broad areas:
More information on the attributes, including definitions and a diagram of the three areas can be found here.
It is generally understood that high-functioning systems that effectively meet the needs of patients and providers are based on a strong foundation of primary care. We believe that well-supported PMHs are essential for both this foundation and for developing effective PCNs that target services to effectively support patients and their needs. The Vancouver Division is focussing much of its efforts on working with members to understand how their current practices fit into the PMH model. We are also exploring ways in which members can be supported to shift or strengthen their practices to meet their personal and practice needs and how they can be prepared for some of the changes they will experience as PCNs are implemented.
This work is built upon the learnings of the Vancouver Division since its inception, including:
Our work in the area of PMH falls into these broad categories, and is summarized here:
As with all of the work of the Division, we are committed to the principles laid out in our Strategic Priorities:
There are different levels of evaluation and measurement for this work.
At a Division level, we evaluate our work through annual strategic planning, committee reporting, work planning and budget tracking (which is linked to work plans). We are currently exploring a more formal evaluation program which will pull together our current work along with our formal evaluation of PCN implementation and provincial level evaluations and tools.
Provincially, the GPSC has developed a number of tools to support practices, community (Division) and provincial level evaluations, including the PMH Self-Assessment Tool and the Patient Experience Tool. The GPSC PMH Evaluation Framework (which is being finalized and will be shared) ties together the work that is going on around the Province, including Vancouver.
The Vancouver Division remains committed to using iteration and improvement science, both formally and informally, to ensure the effectiveness of our work and investments.
This work has individual, community, city, regional and provincial level considerations and opportunities. Different groups are involved at different levels and one of the jobs of the Vancouver Division is to ensure that the voice of our doctors is effectively represented.
For Division-led PMH work, we are coming to you where you work in the community. To support networking of practices, we have identified local Family Physician Champions and hired regional Community Outreach Facilitators (staff leads) to work with doctors and clinics in each Local Health Area (LHA). In the coming months, we will be reaching out to family doctors within each region to bring you together and start the local conversations about what opportunities exist currently, what is likely to come, and most importantly, what is working and not working in your community.
We are currently reaching out to all of the family practice clinics in Vancouver, starting with a connection to office managers or senior MOAs. The goal of our contact is to familiarize your staff with the Vancouver Division and get some feedback from them regarding what works and doesn’t in your neighbourhood. As we grow to understand the primary care neighbourhoods, we will endeavour to involve you, the physician, directly in the process to create the change you would like to see in your community.
Individually, you can become involved on your own or by connecting with the Vancouver Division to better understand the available resources, which include the PMH Self-Assessment Tool, Panel Management incentives, EMR optimization and education.
PCNs are geographically based, formalized networks of practices and primary care services (typically provided by the Health Authority) that work together to meet the healthcare needs of the community. Requiring a strong foundation of PMHs, PCNs are designed to wrap services around patients. Based on the demographics and healthcare needs of geographically defined populations, PCNs create a new system for introducing more integrated team-based care into primary care in the community.
In Vancouver, PCNs are expected to serve approximately 100,000 patients, based on the city’s Local Health Areas (LHAs). There are likely to be six PCNs in the city, which will be developed over time.
Taking our cue from the results of the 2018 Referendum and understanding the importance of ensuring that family physicians are the driving force behind designing the future of primary care change in Vancouver, the Vancouver Division, in partnership with Vancouver Coastal Health, submitted a formal Service Plan to the Ministry of Health to initiate the first two PCNs in Vancouver. These initial PCNs will be located in Local Health Area (LHA) 1 (Downtown and Fairview Slopes) and LHA 6 (South Vancouver and Oakridge). Map of Vancouver LHAs found here.
The Service Plan also contains ongoing support for the First Nations and Aboriginal Health Primary Care Network that has been independently developed to provide care to on and off reserve First Nations and Indigenous Patients through Vancouver, Richmond and North Vancouver.
Finally, the Service Plan begins to explore the role of community owned and operated Community Health Centres (CHC) within the primary care landscape and how they will fit into PCNs. Work will start with REACH CHC and will evolve to explore other CHCs over time.
As per the requirement from the Ministry of Health, the Service Plan was designed to address the current attachment gap in the LHA communities and to develop a PCN Team to support practices to care for higher needs patients.
Leadership and governance of the PCNs is of paramount importance and we are working hard to ensure that family doctors have a strong voice at all levels.
As we continue to explore networking practices and PCN opportunities within the community, the Division is committed to building off the exciting work of the Residential Care Committee, the primary care maternity network, the Cognitive Based Therapy Initiative, and the communities of care that have been developed through the Vancouver Division’s ongoing committee and initiative investments.
In addition to the current ways that work is evaluated at the Vancouver Division, we are expanding our model to include a formal evaluation of PCNs at the community and city levels. The Ministry of Health and Vancouver Coastal Health Authority are actively designing further evaluation processes which will be implemented locally, regionally and provincially.
As with PMH work, local Family Physician Champions and Community Outreach Facilitators (staff leads) are committed to working with you at the practice and community level to better understand what is needed and how to support you in this process. The immediate work around PCNs will occur in Local Health Areas (LHAs) 1 and 6. For the remaining PCNs not identified in the initial Service Plan, the Vancouver Division believes it is important to start the work of networking practices together to ensure everyone gets a fair and equitable opportunity to participate in the process. The good news for all family doctors in Vancouver is that the wait is over – and our journey to PMH and PCN has just begun. We sincerely hope you will join us on this journey.
Most, if not all practices fit into this work. Whether you work in a ‘full-service’ community fee-for-service practice, a focussed practice, a walk-in practice, a Community Health Centre, or any type of practice, you play a role in providing primary care to patients in the community. You are a part of this work and an important part of the system change. Ideally, all types of practices and providers will work together to form a network of primary care providers to care for patients throughout their lifespan.
We are committed to designing a fair and equitable process that will ensure appropriate distribution of resources as they come available. The resources that appear to be forthcoming are fairly limited and primarily focussed on addressing the attachment gap (number of patients living in a geographic area who do not have a family doctor). We are starting to work with physicians in the Local Health Areas (LHAs) 1 and 6 to determine how best to deploy these resources and we look forward to working with physicians across the rest of Vancouver to determine what will work in their community.
No one is required to participate in this work, although we hope our members will be interested in participating to whatever degree they feel comfortable.
As part of the 2019 Strategic Priorities, the Vancouver Division Board committed to creating opportunities for members to learn about and provide input on topics such as remuneration. We are currently exploring ways to achieve this goal and more information will be forthcoming.
In the meantime, we invite you to visit the following resources on physician payment models:
Current work around primary care system change incorporates existing physician funding models and begins to explore the role of alternate models. Given the need to start this work in the present environment and the desire of many members to continue in a fee-for-service (FFS) model, much of the initial work is designed to be implemented within FFS. As the work continues, Vancouver Division plans to create opportunities for members to explore the structures, principles, pros and cons of various models of remuneration.
In the current plans for Primary Care Networks, a limited number of Ministry of Health developed, Health Authority administered, non-FFS contracts will be available for new physicians who are interested in starting a practice and building a panel of new patients. Details for these contracts will be released as they become public.
As negotiated in the 2019 Physician Master Agreement (PMA), Doctors of BC has started the process to create an ad hoc committee, composed of representatives of BC Government and of Doctors of BC, for each specific compensation model, so as to provide an avenue for the BC Government and Doctors of BC to develop a new, mutually agreeable compensation contract for physician services under the new model over a relatively short period of time.
In BC, physician remuneration (mainly FFS and hourly-based Service, Salary and Sessional rates for clinical care) is negotiated primarily through the PMA, between the BC Government and the Doctors of BC. The PMA also contains template Service/Salary/Sessional contracts that Health Authorities and physicians that provide a basis for hourly paid clinical services. Health Authorities may also enter into other contracts with physicians for clinical services through other arrangements that are not included in the PMA, but don’t conflict with its provisions (eg. Population Based Funding Contracts). Doctors of BC Negotiations Department staff may be involved in such contracts in a formal or supportive capacity. The Vancouver Division plays no role in negotiating contracts or payment models for physician services. The Doctors of BC (Negotiating Committee) and the Society of General Practitioners are the formal advocacy bodies for primary care remuneration models in the Province.
We are optimistic about expanded access to different payment models and the identification of a clear pathway and process for such a transition. We look forward to further consultation with our members, Doctors of BC, the Health Authority and the Ministry to ensure the voice of our members is considered and supported as part of the Patient Medical Home/ Primary Care Network implementation process within Vancouver.
In addition to Vancouver Division level evaluation, our work will be evaluated provincially through the GPSC Patient Medical Home (PMH) Evaluation Framework and the Ministry of Health Primary Care Network (PCN) Evaluation Framework (yet to be published). At a local level, we are developing an evaluation plan that will align with the provincial frameworks while ensuring it captures measures that speak to our local work. We intend to use a number of provincially developed tools to support this work, including the PMH Self-Assessment Tool and the Patient Experience Tool, as well as other sources to meet our needs. Specifically related to the PCN work, we will identify indicators to support the 8 core PCN attributes, ensuring they align with the provincial metrics, which are still under development. Some of the local indicator considerations at this time include attachment, access to service, same day access to urgent services and integration of team-based care.
We remain committed to using iteration and improvement science, both formally and informally, to ensure the effectiveness of our work and investments. As such, we are examining and incorporating our evaluation learnings over the past years.
Our implementation team is led by a number of individuals with graduate level education and peer reviewed publications. They have experience with designing evaluation plans for both qualitative and quantitative variables. Additionally, we plan to consult with an external evaluator as well as a consulting statistician, as appropriate.
Our evaluation will be continuous for as long as this work is underway. We are committed to an iterative process to ensure we adapt our work appropriately. With respect to the formal Service Plan for the Primary Care Network, our efforts will be formally evaluated as per guidelines set by Ministry of Health, at the end of each fiscal year and then as a fulsome report for the three-year Service Plan.
We are designing a communication strategy to ensure all members have access to regular updates about the progress of the work, as well as the successes and challenges we encounter. A comprehensive evaluation report of the work will also be communicated to our members and made available for other interested stakeholders. While the initial Service Plan commits to three years, this work is intended to be ongoing. The evaluation and the communications strategy will continue over time.
Building on the 2017 policy documents on an Integrated Health System for Primary and Community Care, which introduce the models of Patient Medical Homes and Primary Care Networks, the Government of BC announced an expanded strategy (available here) in 2018, introducing the concepts of Urgent and Primary Care Centres (UPCCs) and Community Health Centres (CHCs) to support access to quality primary care.
An Urgent and Primary Care Centre (UPCC) is simply a place where patients can access care which is not appropriate for, or not available through, the Patient Medical Home (PMH), and does not require the specialized services of the Emergency Department. Diagnostics such as labs and imaging, as well as acute care services such as IV antibiotics and casting are available on an urgent basis 7-days a week.
UPCCs are ultimately designed to be part of the Primary Care Network (PCN) and are directly linked to PMHs, serving as a tool to facilitate appropriate access to primary care and support physicians to provide the care their patients need.
With one UPCC in Vancouver (as of May 2019), the design of how this model can be expanded to support physicians and patients locally and throughout the city is actively underway. Over time, there may be a UPCC in each of Vancouver’s six PCNs and it is essential that each one adds value to patients and practices within the community. The Vancouver Division is working with the local communities, the Health Authority and the Province to achieve this goal.
The City Centre Urgent and Primary Care Centre (UPCC) opened November 2018 as the first UPCC in Vancouver. Seymour Health Center operates the Centre through a service agreement with Vancouver Coastal Health. Its mandate is to care for non-life-threatening illnesses or injuries when patients are unable to see their family physician or care provider. Patients are currently being seen on a walk-in basis with the most urgent seen and cared for first. The UPCC provides care requiring medical attention within 12-24 hours such as sprains and strains; cuts, wounds or skin conditions; high fever; infections, including chest, ear and urinary tract; asthma attacks; new or worsening pain; dehydration/constipation; and less serious child illness and injury; as well as support from a team of inter-professional health providers such Mental Health and Substance Use (MHSU) and Pharmacist services.
The UPCC is not intended to replace family physicians or nurse practitioners as a person’s first point of contact for health concerns, nor will it replace Emergency Departments for life-threatening illnesses or injuries. Rather, it is intended to be an additional service in the community, working in concert with all touch points for care to provide appropriate urgent services to patients, when and where they need it.
Support services and community partnerships- The City Centre UPCC provides access to on-site lab, diagnostic imaging and pharmacy services. The UPCC works with the St. Paul’s Hospital Emergency Department (SPH ED) to refer identified patients whose condition is best cared for at an ED.
Team-based staffing complement- The City Centre UPCC provides the above services via a team of care providers including family physicians, nurse practitioners and emergency doctors working together with registered nurses, a MHSU clinician, care coordinators, medical office assistants and pharmacists.
Patient attachment- Patients who present to the City Centre UPCC unattached to a family physician in the community are supported to become attached through 3 mechanisms:
Evaluation- Seymour Health Centre has an independent evaluator to ensure the services are addressing the Ministry policy expectations, the VCH service agreement requirements and system objectives as outlined here:
A Community Health Centre (CHC) is a primary care clinic that operates under a different model of care provision than a typical, community-based, family practice clinic. At its core, a CHC is a non-profit primary care organization that provides integrated health care and social services, with a focus on addressing the social determinants of health.
Vancouver has both Health Authority-owned and operated, and community-governed and operated CHCs. Health Authority owned CHCs are managed and governed by the Health Authority and have a mandate to provide service to the most marginalized members of our community if they are unable to access care in the more typical settings (eg. community-based, fee-for-service family practice clinic).
Team-based care is a fundamental component of CHCs and often includes nurses, nurse practitioners, physicians, social workers, dieticians, pharmacists, First Nations Elders and Healers, in addition to other team members. To support this model of care, physician remuneration in a CHC is often non-fee-for-service (FFS).
Building on their 2017 campaign platform the Government of BC developed a strategy and supportive policy for community governed CHCs in 2018. The strategy envisions that CHCs will bring together health and broader social services to improve access to health promotion, preventive care and ongoing services. Each of these centres will be designed and developed uniquely in line with the needs of their communities and fully integrated into local primary care networks.
The Ministry’s vision for CHCs is presented in this Canadian Centre for Policy Alternatives paper: The Importance of Community Health Centres in BC’s primary care reforms, found here.