Integration of Primary Health Care and Public Health During a Public Health Emergency

Abstract

We have provided a detailed evaluation of how collaboration between an Ontario public health unit and its primary care providers facilitated an optimal response to the 2009 H1N1 influenza pandemic.

Family health teams (integrated, interdisciplinary teams that provide a range of care options) provided flu assessment centers, with public health as a partner providing infection control advice, funding, coordination, antiviral medication, clinical care guidelines, supplemental nurse staffing, and arrangement of communication strategies with the public.

The family health team structure offers a new capacity for timely, coordinated, and comprehensive response to public health emergencies, in partnership with public health, and provides a promising new direction for healthcare organization.

The H1N1 pandemic of 2009 killed nearly 13 000 people worldwide by year’s end.¹ More specifically, H1N1 had a substantial impact on Canada’s health care system, resulting in 8596 hospitalizations, 1446 intensive care unit admissions, and 426 deaths.² In just nine months in the province of Ontario, emergency departments (EDs) received roughly 140 000 more patients with flu-like symptoms than they had in previous years, and the national cost of responding to H1N1 has been estimated at more than $2 billion.³ In southeastern Ontario’s Kingston, Frontenac, and Lennox & Addington (KFLA) Health Unit, the new primary care provider (PCP) structure facilitated a partnership between PCPs and public health and an optimal response to the 2009 pandemic. The improved PCP structure allowed a timely and comprehensive response to pandemic H1N1 by providing enhanced coordination, communication, and collaboration among PCPs and with public health and offered a new capacity for ongoing partnerships between PCPs and public health.

FAMILY HEALTH TEAMS

Family health teams (FHTs), the government of Ontario’s homegrown version of the patient-centered medical home, offer a new way to structure primary care. Introduced in 2004, FHTs are composed of an integrated, interdisciplinary team that can include physicians, nurse practitioners, social workers, pharmacists, and dieticians, and therefore provides a range of care options for their communities.⁴ Each FHT varies in composition on the basis of the clinical care needs in each community to provide optimal service to those in its patient population. The KFLA health unit has a population of approximately 190 000 and contains six FHTs (see the box on the next page).

Examples of Public Health and Primary Care Collaboration Practices

Role of Public Health	Role of Primary Care: Coordinated Through Family Health Teams
Funding of FACs and treatment clinics	Provision of location, service, and staffing for FACs
Infection control and inspection	Adherence to occupational health and labor code standards
Surveillance using real-time electronic acute care systems: both emergency department and admissions to hospital, occupational health, mortality, and laboratory	Report to public health on daily total number of patients seen in FACs
Generation of biweekly surveillance reports sent via e-mail (three times per week once second wave declared)	FACs open on the basis of surveillance information and surge capacity being reached
Business continuity planning, including communication with stakeholders	FHTs prepared for business continuity planning by public health on the basis of Canadian College of Family Physician recommendations
Clinical guideline preparation (per Ministry of Health and long-term care guidelines)	Dissemination of guidelines to primary care providers
Antiviral medication provision and coordination from government stockpile	Public health coordinates local provision of antiviral medication through FHTs

Note. FAC = Flu Assessment Center; FHT = Family Health Team.

FHT implementation has resulted in high patient and physician satisfaction.⁴ Patients are matched with the health professional best suited to their care needs and are ensured access to care seven days per week, and the complementary nature of the FHT design reduces patient load on individual doctors.⁴

Planning and Coordination

The World Health Organization calls for planning and coordination before pandemic onset.⁵ The first H1N1 wave—an increase in pandemic activity followed by a decrease²—reached North America in April 2009,³ but vaccine prophylaxis to prevent pandemic came too late.⁶ Instead, public health focused efforts on preparedness strategies in anticipation of a second wave. Public health in Ontario is structured into 36 geographic units that are responsible for health promotion, protection, and disease prevention. Accomplished through avenues such as population-based communication strategies, epidemiology, and surveillance, public health is not generally included in direct patient care except through specialized clinics such as sexual health, immunization, and travel clinics.

KFLA Public Health worked directly with FHT management and lead physicians, meeting monthly for six months to develop specific strategies to minimize the second wave’s effect on its citizens. Collaboration between public health and FHT leadership led to the introduction of flu assessment centers (FACs). Advertised as an alternative to the ED for patients presenting with H1N1-like symptoms, FACs were offered at sites separate from EDs, either in hospitals or at alternative community locations. Patients were assessed, treated, and provided with antiviral medication as needed and offered advice on follow-up. Early analysis of disease spread in comparable health care systems such as Australia’s revealed that a small proportion of H1N1 cases required hospitalization, an even smaller proportion resulted in death, and presentations to the ED increased.⁷ Therefore, given the low morbidity and mortality of H1N1, FACs would provide the public with safe avenues for care and would potentially decrease pandemic impact on the acute care sector. Furthermore, FACs allowed patients presenting with serious symptoms to receive direct hospital admission, thus alleviating the need to visit the ED. Sites were provided by FHTs, with KFLA Public Health as a partner providing infection control advice, funding, coordination, antiviral medication, clinical care guidelines, supplemental nurse staffing, and arrangement of communication strategies with the public such as radio and print advertisements. A detailed account of the coordination between public health and primary care is provided in Box 1.

Surveillance

An additional pandemic preparedness requirement is the surveillance and assessment of disease activity.⁵ KFLA Public Health has a complex, real-time surveillance system that monitors its acute care sector through syndromic surveillance of EDs; all admissions to hospital and sentinel laboratory results are also monitored. Additional data include daily occupational health, mortality, and school absenteeism surveillance. Data are integrated into a biweekly report shared with primary and acute care through an e-mail distribution system. During the pandemic, reporting was increased to three times each week. This system was used to establish FACs at a predetermined level of increased ED visit volume decided by KFLA Public Health and its partners. On October 21, 2009, this threshold was exceeded, and FACs were opened for a three-week period from October 24 to November 15, 2009. Ongoing surveillance by public health ensured that FACs were open in time to meet the immediate health care needs of the community, maximize efficiency, and minimize the disease impact on the acute care sector. FACs were operated by physicians and support staff who had to leave their practices to do so. Real-time surveillance ensured that health care workers’ time away from regular practice was kept to a minimum.

Reducing Disease Spread

A third goal of pandemic preparedness is reduction of disease spread.⁵ FACs were located throughout the jurisdiction to ensure easy access to care for all citizens, and non-FHT physicians could advise their patients to obtain medical care from FACs as well. FACs were therefore accessible to all citizens without limitation. Oseltamivir antiviral medication was made available at these clinics. FHTs and public health also collaborated to design and implement population health measures, including cough etiquette, education, and quarantine. Reduction of disease spread to at-risk patients was addressed through placement of FAC sites separate from the ED.

Continuity of Care

Pandemic preparedness guidelines maintain that in the midst of disease outbreak, continuity of care is critical.⁵ Historically during public health emergencies, PCPs were responsible for coordinating direct public care; however, high demand combined with shortages in frontline providers hindered the health care system’s ability to respond optimally.⁸ Poor coordination of the health care system and an overwhelming workload has led to frustration and exhaustion among family physicians.⁸ FACs provided an alternate avenue for patients with flu-like symptoms to seek medical care, allowing continuity in traditional health care settings. Encouragingly, on the basis of a previously described linear regression model, FAC establishment successfully reduced the burden on EDs in KFLA.⁹ Before FAC establishment, actual ED visits during fall 2009 exceeded expected patient volume, likely owing to patients seeking H1N1 care; following FAC establishment, actual visit volume dropped below what was expected.⁹

Enhanced Communication

Finally, and importantly, pandemic planning emphasizes communication and collaboration among health care sectors as well as with the public during a public health emergency.⁵ The FHT structure in Ontario enabled efficient and timely coordination of primary care. FHT managers act as the primary contacts for communication between PCPs and public health. These leads can then disseminate relevant information to PCPs that are a part of their respective teams. For instance, information communicated by public health to KFLA physicians during pandemic influenza involved correspondence with just six FHT managers and six lead physicians. This coordinated strategy enabled timely communication of relevant health care information to 94 physicians responsible for more than 113 000 patients, or 57% of KFLA physicians, representing 55% of patients in the region (Table 1). All FHTs in KFLA participated in FAC planning and establishment; therefore, KFLA patients were well represented during the six-month planning phase with public health.

TABLE 1—

Family Health Team Composition and Patient Coverage in KFLA Health Unit: H1N1 Response Evaluation; Ontario, Canada; September–December 2009

FHT	No. Family Physicians	No. Patients	KFLA Population, %
North Kingston CHC	4	7000	3.67
Sharbot Lake FHT	2	2720	1.43
Maple FHT	24	38 000	19.95
Kingston FHT	21	33 000	17.33
Queen’s Student Health	22	12 590	6.61
Queen’s Family Medicine Centre	22	12 000	6.30
Total	95a	105 310	55.29

Note. CHC = Community Health Center; FHT = Family Health Team; KFLA = Kingston, Frontenac, and Lennox & Addington.

^aThis represents 57.2% of 166 family physicians in KFLA.

A NEW DIRECTION FOR PRIMARY HEALTH CARE AND PUBLIC HEALTH

Improving the health of a population means first understanding the health needs of that population. PCPs are on the medical frontline, witnessing daily the issues most relevant to citizens in their communities. If we are to improve the health of a population, it is fitting that PCPs have the opportunity to advocate for their patients and communicate these needs. Communication and collaboration between PCPs and public health policymakers enables public health informed decision-making, whereby programs can be implemented that will address patient needs for care and can be delivered in a manner that will reach our most vulnerable populations. Ongoing partnerships also enable evaluation of health care programs. This partnership allows PCPs to make direct measurement of health outcomes coordinated with epidemiological support and a population health approach.

The new primary care structure in Ontario is built to optimally foster this relationship, as physicians are no longer working independently of one another. H1N1 represents just the first public health emergency in which public health and primary care interacted using the FHT structure in Ontario, and in doing so displayed the potential for its application to other public health emergencies. FHT structure makes communication between physicians and public health leadership rapid, timely, and efficient. Public health provided anticipatory infection control guidance, preestablished e-mail communication strategies, facilitated funding, and provided real-time surveillance of the disease outbreak. Using these strategies could mitigate the health effects of public health emergencies such as natural disaster or other disease outbreaks.

We must not assume that Canada’s universal health care system ensures equal health outcomes. Disparities in health are preventable; such inequalities are unjust and unfair, and represent inequity in society. Especially during a public health emergency, the health care system must show sensitivity to socioeconomic circumstance and use an understanding of the determinants of health when developing emergency mitigation strategies. Therefore, it is important to highlight how the FHT structure helps promote equitable access to care. During H1N1, PCPs were able to communicate patient needs to public health, and together they developed a strategy to provide treatment to all citizens, without exception. First, FACs were made available not only to citizens with family doctors but to every citizen who sought care. Treatment at FACs, including provision of oseltamivir, was available free of charge, thus minimizing cost as a barrier. Furthermore, public health collaborated with FHTs to identify its most socioeconomically deprived communities and ensure that they had adequate geographic access to FACs. This was accomplished through partnership with community centers that work closely with KFLA’s most vulnerable populations and that agreed to host FAC locations. Advertising campaigns launched by public health in print, television, radio, and through KFLA’s Infection Watch Live Web site (http://www.infectionwatchlive.com) ensured that the most vulnerable populations, who may have reduced access to personal health messaging, were made aware of this service.

Examination of FHTs’ role in emergency preparedness sheds light on a new capacity for improving the health of our communities. Continued partnership between FHT leadership and public health can provide a network of communication that enables codevelopment of strategies in other areas of health, most notably chronic disease. PCPs can efficiently collaborate to identify the needs of their patients at a community level, develop strategies to address these needs on a population basis, and communicate with public health to implement and evaluate these strategies. Public health can act as a partner, providing leadership, advice, surveillance tools, evaluation, population approaches, and channels for information dissemination to the public.

CONCLUSIONS

On the basis of international pandemic planning recommendations, Ontario’s PCPs and public health contributed to a successful response to the 2009 H1N1 pandemic in southeastern Ontario. The FHT structure can facilitate timely, coordinated, and comprehensive response during public health emergencies, in partnership with public health, and provides a promising new direction for health care organization. In Ontario, the integration of PCPs and public health in response to pandemic disease activity is a promising model for future population-based approaches to disease control.