Primary Health Care Integration Network

KEY POINTS

• In Canada and Alberta, there is a long-standing history of tension between primary health care and the acute care system.

• The Primary Health Care Integration Network is a shared space for traditionally divergent groups, such as specialists and family physicians, to integrate shared-care models and collaboratively work toward more feasible and efficient approaches to care for Albertans.

• Overcoming the pull toward keeping to the status quo of health care delivery is critical to foster integration of services across primary and other health care settings.

• Strong leadership and creating shared visions of a desired future state, to help partners understand the price of not engaging with one another, can help overcome barriers to changing the existing state of health-system delivery of care.

Canadian health care needs reform,¹ as evidenced by its poorer rankings than other nations with respect to access, safety, quality and health outcomes, as well as particularly poor performance on timely communication between hospitals and family physicians.² Furthermore, aging populations and increasing patient complexity threaten to overwhelm services and increase the costs of providing care.² Primary health care, which covers a spectrum of activities from first-contact episodic care to person-centred and comprehensive care sustained over time, is a critical piece of the overall health system.³ Accumulating evidence suggests good primary health care can lower health care costs overall, improve population health through access to more appropriate services and reduce inequities.⁴ Mechanisms that may account for the beneficial effects of primary health care on population health include greater access to needed services, greater focus on prevention and early management of health problems, and reduced unnecessary specialist care.⁴

In 2005, the first Primary Care Network was established in Alberta. Family physicians set out to provide a comprehensive range of services targeted to the local needs of a defined population. This fostered networked practices, facilitated change and served as a vehicle for the spread and scale of innovation across the health system.⁵ As of September 2019 in Alberta, there are 3700 physicians working in 41 Primary Care Networks to provide primary care to most Albertans (about 3.7 million people).⁶ The perspective of this field has changed, with the increasing prominence of the Patient’s Medical Home model.⁶ The model is defined by patients as the place they feel most comfortable seeking care (i.e., a family doctor or clinic they have a long-standing relationship with) and focuses on chronic disease management, health maintenance and prevention.^5,6 Under this model, many provinces are shifting toward integration of health services, offering care to Canadians in homes or community venues to improve the quality of care⁶ and efficiency across the health system.⁶

In 2017, the Primary Health Care Integration Network (PHCIN; www.ahs.ca/phcin), was launched as a member of the Strategic Clinical Network (SCN) family with a goal to improve health outcomes and patient experience in Alberta by fostering innovative integration solutions for primary health care. Enhanced access to multidisciplinary health care teams and working collaboratively across care settings has increased Alberta’s capacity to deliver care for patients’ outside of hospitals.⁵ The PHCIN works to link disconnected health care services to ensure patients and families have a safe and seamless journey as they transition across the system. A key understanding of the network is that every Albertan deserves care that helps them thrive in their own community, on their terms. Therefore, the PHCIN focusses on 3 clinical priority areas: Keeping Care in the Community, Linking to Specialists and Back and Home to Hospital to Home Transitions (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190595/-/DC1). To foster improvement in these clinical areas, it is necessary to create ideal conditions for an effective health system to function, which led to an additional area of focus — System Foundations for Integration.

Priority areas were chosen following an environmental scan, in-depth interviews, multiple focus groups and various learning collaboratives with key stakeholder partners to identify where gaps existed and where the network could best position supports for change. Detailed impact assessments, logic models for evaluating each priority area, and key performance indicators to measure whether the network is achieving its intended outcomes, are currently in development. Within each SCN, a Scientific Office embeds scientific rigor into each of the networks’ areas of focus and facilitates research connections with academic communities. The Scientific Office drives innovation, embeds evidence and integrates findings into clinical operations and front-line practice.

The PHCIN is a common platform for other specialty-driven networks to integrate priority initiatives and innovative health solutions into primary health care. It is a shared space for traditionally divergent groups, such as specialists and family physicians, to integrate shared-care models and work collaboratively toward more feasible and efficient approaches to patient care, especially for those with chronic, comorbid conditions. Unfortunately, a long-standing history, both nationally and provincially, of tension between primary health care and the acute care system has challenged health care reform in Alberta.³ Cutbacks in primary health care, lack of diversity in funding arrangements for providers, and separation of hospital and primary health care services in the early 1970s all contributed to this problem.³ Overcoming these tensions among divided groups and systems is not an easy or comfortable process.

In Alberta, Primary Care Networks and other key partners are developing their own core structures and functions. Each have differing needs, and clear goals and objectives for each organization need to be solidified before any alignment between them can be realized. Bold leadership from both primary health care and the broader health system have been essential to bridge the gaps and break down the barriers that have entrenched the status quo. However, it has taken time to learn how to realize common pressure points, co-design shared solutions and identify collective areas of focus. The journey has been filled with ups and downs and many lessons learned. To navigate these challenges, the PHCIN is embedded both within AHS and broader provincial primary health care. Building relationships and trust to bridge the divide between clinical operations in the acute care system and primary health care partners is a key activity for the network. Acknowledging the differences in partnering clinical communities and recognizing the uniqueness of their approaches are integral to maintaining the overall foundation of trust that the network has built over the past several years. Engagement strategies (i.e., creating a shared vision) that help network partners understand the price of not engaging with each other, and creating a picture of a desired future state that is attractive enough to overcome the pull toward the status quo, are key.

Alberta has the advantage of a single health authority collaborating with partners on delivery of both primary and acute health care. However, integration is difficult to tackle.^7,8 Provincial efforts targeted at integration do not go far enough to address or rationalize systemic resources or align provincial work to address key barriers such as strategies for delivering primary health care to vulnerable populations such as First Nation communities. ⁹ These are gaps that the network aims to address. With the network officially launched and driving forward, all partners are moving toward a shared understanding of what integration truly means, and the need to shift behaviour and practice patterns to achieve effective and meaningful integration.