Organizing Care for Complex Patients in the Patient-Centered Medical Home

Dear Colleagues:

It should be reassuring to both our jurisdictions that we in British Columbia, Canada, are moving inexorably towards similar goals, using similar principles and values, and with relatively similar strategies (payment schema notwithstanding) as expressed in your paper.

In British Columbia, the General Practice Services Committee (GPSC) has been instrumental in promoting integrated, comprehensive and continuous primary care built around "connected and supported" family doctors to better serve complex patients. Family doctors, with connections to others (often virtually) are the de facto medical homes. Local collectives of family doctors are encouraged to organize into "Divisions" of Family Practice, where infrastructure support is provided to assist with quality, develop linkages with relevant Health Authorities (created and mandated by the Ministry of Health to ensure their respective populations receive appropriate health services), and to engage in organic change to the health system, informed by community partners and patient voices. The GPSC is a collaboration of the Ministry of Health and the British Columbia Medical Association.

Physician payment in British Columbia is typically fee for service, through the Ministry of Health (and not the Health Authorities), which historically has regarded community physician practices as independent businesses, but are now committed to collaboration. Interest in blended funding is beginning to appear in both physicians and the Ministry. Perhaps more interestingly, "targeted" fee for service, purposefully designed to support comprehensive, complex, and continuous care has led to demonstrably improved outcomes, as well as improved provider satisfaction.

New fees have encouraged "non-face-to-face" care, via various communication modalities, group visits, and richer dialogue between family physicians and specialists. Other fees (notably obstetrics and inpatient) have been designed to encourage and support "networking" and sustainable call groups. All such new fees are reviewed regularly, and modified or even eliminated as warranted. All physicians know and generally accept this..

Relationships between acute and primary care are being deconstructed and redesigned to improve transitions of care, communications, and clarity of care plans for patients and providers alike. The group "Patients as Partners" has become part of the organizational culture, and most clinical redesign initiatives have patient voices at the table. The "patient voice" is formalized through the "Patient Voices Network", which trains interested patients to better represent this broad constituency in an objective and effective fashion.

The "triple aim", as described by IHI, is the lens through which all changes are considered.

Additionally, the past few years have seen the creation of a "Practice Support Program" to help family doctors engage in office and practice redesign such as advanced access, group visits, and chronic disease management, as well as "Regional Support Teams" that can identify relevant Health Authority resources for physicians, provide regional population data, and themselves also serve as resources to help sustain practice change. Health Authorities are at present working to "wrap community services" around family doctors.

This strategy may, for us, serve to minimize the problems you identify of converting "small" practices into "medical homes", and serving certain marginalized populations.

Still evolving are stronger working linkages with allied health, nurse practitioners, RNs, pharmacists and others.

Case Management, IT, quality measurement, and care for specialized populations are other topics of ongoing interest, implementation, or evaluation.

Liberating for everyone, I believe, have been: * a change culture that ensures no "pilot" project will come to an abrupt end, but rather is evaluated and modified as needed; * a costing principle that any implemented change must be scalable to the entire province; * the Ministry's stated endorsement of the value of primary care, and of the family doctor in the provision of that care, and * the willingness and commitments of both the Ministry of Health and the British Columbia Medical Association to problem-solve together.

One might speculate that you (i.e. the USA) are better positioned to initiate change, given your funding model, and the multiple players. However, now that change has been recognized as being imperative in BC by all players, and by society at large, it is happening rapidly, substantively and across the entire province. To greater or lesser extent, other provinces are following suit, albeit with modified strategies.

Of course, there are frustrations and gaps. However, we now have an infrastructure to ensure a validated primary care voice, the tables at which to engage in meaningful discourse, and the commitment of parties to move forward.

Your destination is the same as ours, your route is similar, and the signposts articulated in the paper that you hope to see, we also hope to see. Many are now in clear view in British Columbia. The vehicles we drive are somewhat different, as are the rules of the road and the price of fuel. However, moving in (more or less) the same direction as we are, I conclude by stating that I think you are going in the right direction. We will undoubtedly continue to watch and learn from each other.

Congratulations on this paper, which I believe provides a reasoned and accurate glimpse of our respective and largely congruent futures.

G Mazowita Clinical Professor, University of British Columbia Faculty of Medicine Member, General Practice Services Committee Head, Department of Family and Community Medicine, Providence Health Care

Competing interests:   None declared