Impact of Team-Based Care on Emergency Department Use

February 11, 2022

Dear Dr. Kiran, Dr. Moineddin, Mr. Kopp and Dr. Glazier,

On behalf of the Association of Family Health Teams of Ontario (AFHTO), I would like to thank you for this research and further demonstrating the need for strong team based primary care in Ontario. Over the years, AFHTO has heard many stories from primary care teams on the impact they are having within their community and this research helps bring that narrative to life through data. As primary care teams have matured over the years, there has been an increase in collaboration between team members and we are continuing to see the improvements happening in patient care. Your research highlights that there is indeed a difference between teams and non-teams with respect to adjusted Emergency Department (ED) visit rate and that there are lower ED visits in teams compared to non-teams as physicians transitioned into team-based care. Since this study included data up to March 31, 2017 it will be important to explore the data further, especially given new primary care teams were announced in 2017 and we have seen tremendous innovations happen in primary care to keep patients from visiting hospital EDs during the COVID-19 pandemic.

Primary care is the entry point and foundation of the healthcare system as it manages chronic diseases, provides mental health support, preventative care and focuses on health promotion initiatives. To support this foundation of the healthcare system, primary care teams offer interprofessional care including physicians, nurse practitioners, nurses, dietitians, social workers, pharmacists and much more. Consistently the literature has demonstrated that primary care teams improve patient care, health outcomes, access and decrease costs (Somé, Devlin, Mehta, Zaric, & Sarma, 2020; Gocan, Laplante, & Woodend, 2014; Goldman, Meuser, Rogers, Lawrie, & Reeves, 2010; Riverin, Li, Naimi, & Strumpf, 2017). An all-encompassing vision for team-based primary care is providing “the most appropriate care, by the most appropriate providers, in the most appropriate settings”(Canadian Intergovernmental Conference Secretariat, 2000). It is with that vision that we have seen primary care teams support emergency department diversion programs through a variety of initiatives. Teams have been supported with data on ED visits with comparisons of their team to the province through the Ontario Health Quality MyPractice Primary Care Report which has helped inform initiatives by teams to create ED diversion programs. This has translated to meeting the elements of the Institute for Healthcare Improvement (IHI) quadruple aim of providing better patient care and access while also seeing cost savings to the system.

Through collaboration and trusting relationships, primary care teams are well positioned to collaborate with community partners to also support ED diversion. As an example, Couchiching FHT
has participated in the Community Home Visit program which provides in-home visits to rostered patients with COPD, CHF and/or Diabetes. Through this program, Community Paramedics work
collaboratively with team family physicians and Nurse Practitioners (NPs) to provide regularly scheduled home visits and to respond rapidly to patient and caregiver calls when they see an exacerbation of symptoms that could otherwise lead to an ED visit. Analyzing a sample of patients prior to starting these proactive home visits and after has seen an 18% reduction in ED visits.

Quality improvement is a core component of primary care teams which is usually directed by the Quality Improvement Plan (QIP) indicators created by Ontario Health. Over the years, this has shaped the impact primary care teams have on emergency department use. Through the 7-day post hospital discharge follow up indicator, teams have been following up with patients and their caregivers within the 7-day post discharge period to ensure they are following their treatment plan and recovering from hospitalization, and this can prevent patients from presenting back to the ED and being readmitted. In addition, with the unique interprofessional component of primary care teams, there is an opportunity for teams to refer patients internally for appropriate care by other health care professionals like social work for mental health issues or the pharmacist for medication reconciliations. This allows the teams to create a one-record narrative for the patient that all team members have access to, minimizing fragmentation of care and reducing the risk of re-hospitalization.

Currently, with the tracking of the “ED first point of contact for Mental Health and Addiction care” within Ontario Health Teams through the Collaborative QIPs, primary care teams are working closely with their partners to create initiatives to decrease reliance on the ED as the first point of contact. Mental health is a common issue in primary care and during the pandemic there has been an increase in mental health visits to primary care teams (Donnelly, et al., 2021; Das, Naylor, & Majeed, 2016; Ashcroft, et al., 2021). Throughout the pandemic, teams provided check-in calls to their patients especially to those in isolation. Haldimand FHT mental health staff reached out to not only to patients in active counseling prior to the pandemic, but also to patients who may have received mental health support in the past. Through collaboration with other primary care clinics, counselling services have been extended to non-FHT patients like at the Centre for Family Medicine FHT, which has launched an initiative to provide mental health services to patients of three Family Health Organizations (FHOs) in Kitchener-Waterloo. This program makes counselling services available to 52 additional family-physicians, serving approximately 65,000 patients.

This study was completed on a data set prior to the COVID-19 pandemic; therefore, it will be important to see the impact increased collaboration had amongst primary care teams and community partners during and after the pandemic. Through a survey of interprofessional primary care providers
within primary care teams at the start of the pandemic, teams were quick to adapt virtual care through which they were then able to decrease wait times (Donnelly, et al., 2021). Over the years, teams have adapted once again to provide a balanced mixture of both virtual and in-person visits as it aligns with primary care’s commitment to deliver equitable and accessible care. During the pandemic, we also saw primary care teams step up to support their communities to ensure that hospital capacity was protected. Queen Square FHT in Brampton established a clinical assessment clinic for the entire community that was staffed by physicians, NPs, and other team members to support individuals with COVID, cold and flu symptoms. This was just one clinic that was developed in the province to divert mild to moderate symptomatic patients away from the local hospital’s emergency department to a community clinic where the individual would be clinically assessed for their symptoms, tested for COVID-19, and supported with treatment options. Many primary care teams also protected hospital capacity through the COVID@Home remote monitoring programs where teams monitored COVID positive patients’ health and wellness remotely while they are recovering at home. This allowed for safe, effective care to be provided to patients who did not require immediate hospital attention but could be at risk of developing more serious symptoms without monitoring. McMaster FHT initiated this program, which was adopted by Ontario Health, and then spread throughout the province, rebranded as the COVID@Home primary care program. Since January 2021, more than 600 McMaster patients have had care through this program, with a satisfaction rate above 90%.

Primary care teams have served patients within their rosters and beyond for many years. Primary care teams closely resemble the Patient Medical Home (PMH) concept and include many of the pillars needed for a high functioning health care system. 20-30% of Ontarians have access to primary care teams and with the growing literature supporting the impact that they can have on patient care, it is time for the under-funded primary care system of Ontario to be further strengthened. As we head into post-pandemic recovery it is crucial we start with a strong foundation based in primary care with a focus on equity and integrated, comprehensive team-based care for all those who need it. We strongly support the call to action by the authors to extend team based primary care.

Yours Sincerely,

Kavita Mehta, Chief Executive Officer, Association of Family Health Teams of Ontario
Dr. Allan Grill, Past-President, Association of Family Health Teams of Ontario

References
Ashcroft, R., Donnelly, C., Dancey, M., Gill, S., Lam, S., Kourgiantakis, T., . . . Brown, J. B. (2021). Primary care teams’ experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study. BMC Primary Care.
Canadian Intergovernmental Conference Secretariat. (2000). First Ministers’ meeting communique on health. Ottawa.
Das, P., Naylor, C., & Majeed, A. (2016). Bringing together physical and mental health within primary care: a new frontier for integrated care. Journal of the Royal Society of Medicine.
Donnelly, C., Ashcroft, R., Bobbette, N., Mills, C., Mofina, A., Tran, T., . . . Miller, J. (2021). Interprofessional primary care during COVID-19: a survey of the provider perspective. BMC Primary Care.
Gocan, S., Laplante, M. A., & Woodend, K. (2014). Interprofessional Collaboration in Ontario’s Family Health Teams: A Review of the Literature. Journal of Research in Interprofessional Practice and Education.
Goldman, J., Meuser, J., Rogers, J., Lawrie, L., & Reeves, S. (2010). Interprofessional collaboration in family health teams, An Ontario-based study. Canadian Family Physician.
Riverin, B. D., Li, P., Naimi, A. I., & Strumpf, E. (2017). Team-based versus traditional primary care models and short-term outcomes after hospital discharge. Canadian Medical Association Journal.
Somé, N., Devlin, R., Mehta, N., Zaric, G., & Sarma, S. (2020). Team-based primary care practice and physician's services: Evidence from Family Health Teams in Ontario, Canada. Social Science & Medicine.