Achieving care goals for people with chronic health conditions

Care models to achieve these goals

Health care approaches for chronic conditions include primary and secondary prevention, acute episodic interventions, and expansion of the care circle to recognize the role of caregivers and family. The Canadian health care system is oriented toward the provision of acute care; it functions well for single disease–focused health issues, but is ill-suited to the management of multimorbidity and chronic conditions.

People with chronic conditions require care that is as seamless as possible as they move between primary, acute, specialty, and community care. From the patient perspective, there is no such thing as primary care, acute care, specialty care, or community care—there is simply health care. A functioning health care system needs to operate just as seamlessly.

In a call to action, the Canadian Academy of Health Sciences identified the following overarching recommendation to transform care for Canadians living with chronic health conditions³: Enable all people with chronic conditions to have access to a system of care with assigned clinicians or teams of clinicians who are responsible for providing their primary care and for coordinating care with acute, specialty, and community services throughout their lifespans.

The report recommends that each primary care practice be responsible for a defined population captured in a roster or registry; have appropriate infrastructure and staffing to support the management of individuals with multiple chronic conditions; and coordinate with other aspects of the health system. Thus, primary health care providers and teams act as the critical hub for the comprehensive approach required for person-centred, integrated care that can improve health care system efficiency, patient outcomes and satisfaction, and quality of care.^4,5 This model of care requires a shift from the traditional solo family physician to team-based, interprofessional care that can provide the comprehensive services needed.

While providing a locus for continuity of patient relationships and knowledge, effective primary care also plays an important role in ensuring that people have access to the right care, including acting as a navigation point for an increasingly complex system and providing the site for patients to take on a context-appropriate role in their own health maintenance and decision making.^6,7

The Canadian Academy of Health Sciences report³ suggested a number of enabling recommendations to support the development of this model. While all are important, 3 stand out as critical for success. They are appropriate funding models, creating a culture of continuous quality improvement, and supporting patient self-management.

Summary of recommendations

The expert panel made specific enabling recommendations that addressed funding models, quality improvement, and self-management.

• Shift funding models away from exclusively fee-for-service remuneration of physicians to allow greater regional flexibility, incentives to pursue excellence in chronic condition management, accountability for population-based outcomes, and dedicated budgets for primary care practice infrastructure.

• Develop and strengthen health region quality improvement structures and processes to better support other specialty physician and primary care practices in examining their performance and their population-based health outcomes.

• Assure that all primary care practices have the appropriate infrastructure and staffing to provide effective self-management support, including empowering people to easily access and manage their own health information.

Gaps in knowledge

The challenge in achieving the care goals for people with chronic conditions is not so much determining what do to, but being clear about the priorities and how to provide leadership for the bold steps that are necessary to make it happen. This analysis identifies 3 priority areas (funding models, quality improvement, and self-management) that would have a great effect and would serve as catalysts for further changes.

Key physician stakeholder groups have signaled readiness for change.^15,16 The Patient's Medical Home¹⁶ offers a timely opportunity for the College of Family Physicians of Canada (CFPC) to work with other medical organizations such as the Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada to advance specific elements of the model. The Canadian Academy of Health Sciences report³ recognized the need for government leadership to ensure a pan-Canadian implementation approach and recommended the following.

• Federal, provincial, and territorial ministers of health should review these recommendations with a view to making them part of the 2014 renewal of the federal-provincial-territorial accord on health care.

• Each province and territory has embarked on primary care renewal initiatives. The CFPC should work with the provincial chapters to influence and “push” their ministries to support the Patient's Medical Home model and with academic departments of family medicine to ensure that graduates have the skills needed to work in this environment.

• The CFPC and its research community need to be proactive in providing strong evaluation data on the effectiveness of this model.

There is a collective responsibility to acknowledge the urgency of the current situation and, more important, to take sustained action to improve care for Canadians living with chronic health conditions.