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Recommendations for Canada’s long-term recovery plan - open letter

https://policybase.cma.ca/en/permalink/policy14262
Date
2020-08-27
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-27
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Re: Recommendations for Canada’s long-term recovery plan Dear Prime Minister Trudeau, We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering. We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the upcoming Speech from the Throne on September 23rd. The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and access to education. These social determinants of health contribute to and perpetuate inequality, which we see the pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery. To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are recommending below are critical and should be part of your government’s long-term recovery plan: 1. Ensure pandemic emergency preparedness 2. Invest in virtual care to support vulnerable groups 3. Improve supports for Canada’s aging population 4. Strengthen Canada’s National Anti-Racism Strategy 5. Improve access to primary care 6. Implement a universal single-payer pharmacare program 7. Increase mental health funding for health-care professionals We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our health-care system and create a safer and more equitable society. 1. Ensure pandemic emergency preparedness We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale capacity to conduct viral testing and contact tracing. 2.Invest in virtual care to support vulnerable groups The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported being satisfied.ii We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be given to deploying technology and ensuring health human resources receive appropriate training in culturally competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and Indigenous communities. 3.Improve supports for Canada’s aging population Develop pan-Canadian standards for the long-term care sector The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care, there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings, with proper accountability measures. Meet the health-care needs of our aging population Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures are necessary.v That is why we are calling on the federal government to address the rising costs of population aging by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community and home care. 4.Strengthen Canada’s National Anti-Racism Strategy Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural determinants of health have created and continue to reinforce serious health and social inequities for racialized communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s National Anti-Racism Strategy to address identified health disparities and combat racism via community-led projects. 5. Improve access to primary care Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi, almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased, interprofessional approach is integral to improving the health of all people living in Canada and the effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to Page 3 of 4 expand the establishment of primary care teams in each province and territory, with a special focus in remote and underserved communities, based on the Patient’s Medical Home visionvii. 6. Implement a universal single-payer pharmacare program People across Canada, especially those who are vulnerable, require affordable access to prescription medications that are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life. Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system offering affordable medication coverage that ensures access based on need, not the ability to pay. 7.Increase mental health funding for health-care professionals During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID- 19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports for health-care professionals is needed. We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in Canada and the health system. Sincerely, Tim Guest, M.B.A., B.Sc.N., RN President Canadian Nurses Association (CNA) president@cna-aiic.ca Tracy Thiele, RPN, BScPN, MN, PhD(c) President Canadian Federation of Mental Health Nurses (CFMHN) tthiele@wrha.mb.ca Lori Schindel Martin, RN, PhD, GNC(C) President Canadian Gerontological Nursing Association (CGNA) lori.schindelmartin@ryerson.ca E. Ann Collins, BSc, MD President Canadian Medical Association (CMA) Ann.collins@cma.ca Miranda Ferrier President Canadian Support Workers Association (CANSWA) mferrier@opswa.com Dr. Cheryl L. Cusack RN, PhD President Community Health Nurses of Canada (CHNC) president@chnc.ca Lenora Brace, MN, NP President Nurse Practitioner Association of Canada (NPAC) president@npac-aiipc.org ~ r. Cheryl Cusack, RN PhD CC.: Hon. Chrystia Freeland, Minister of Finance Hon. Patty Hajdu, Minister of Health Hon. Deb Schulte, Minister of Seniors Hon. Navdeep Bains, Minister of Innovation, Science and Industry Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet Dr. Stephen Lucas, Deputy Minister of Health Dr. Theresa Tam, Chief Public Health Officer of Canada
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Submission in Response to the Consultation on the Canada Emergency Wage Subsidy: Keeping Medical Clinic Employees on the Payroll

https://policybase.cma.ca/en/permalink/policy14258
Date
2020-06-05
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-06-05
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
Submission in Response to the Consultation on the Canada Emergency Wage Subsidy: Keeping Medical Clinic Employees on the Payroll June 5, 2020 Since the outset of the COVID-19 pandemic, the CMA has been actively engaged as part of Canada’s domestic response. In addition to our engagement on key public health issues such as the supply and distribution of personal protective equipment, the CMA has addressed physician practice needs, including releasing a Virtual Care Playbook to support the rapid conversion of medical practices to virtual care delivery. In the context of physician practices operating as small businesses, the CMA strongly supports the federal government’s emergency economic relief programs. Access to these programs is critical to the viability of many physician practices — and the ability of medical clinics across Canada to retain vital front-line health care workers (FLHCWs) and keep their doors open to continue serving the needs of their patient population. However, despite the dire need for these programs by medical professionals — who constitute a strategic resource and sector at the best of times, but particularly in a pandemic — presently, the CMA is concerned that many physicians are experiencing administrative barriers to accessing these critical federal support programs for their employees. This submission provides a briefing on physician practices and the need to access the CEWS, an overview of the technical and administrative factors impeding access, as well as proposed remedies to enable a rapid federal response. Physician Practices and Access to the CEWS While health care in Canada is predominantly publicly funded, it is primarily privately delivered. In Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Physician-owned and -run medical practices ensure that Canadians are able to access the health care they need, in communities across all jurisdictions. In doing so, Canadian physicians are directly responsible for 167,000 jobs across the country, contributing over $39 billion to Canada’s GDP. Including the expenses and overhead associated with running physician practices, nearly 289,000 jobs indirectly relate to physician practices. However, as much as physician practices resemble small businesses on the basis of key criteria like employing staff and paying rent, it is imperative to recognize that they are in fact core stewards of a substantial portion of Canada’s health care system and critical health system infrastructure. It is a national imperative to ensure the viability of such a core component of Canada’s health care system as our medical clinics and the staff they employ. To this end, both federal and provincial/territorial governments have a role in ensuring Canada’s medical clinics are there to serve the health care needs of Canadians, through the pandemic and beyond. Physician practices have experienced significant impacts related to changing volumes of patient care and delivery models of care in light of public health restrictions since the pandemic was declared on Mar. 11, 2020. The CMA commissioned an economic impact analysis to better understand the impacts across various practice settings. This analysis reveals that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario. Despite meeting the revenue reduction and employer eligibility factors, the CMA is concerned that many physicians are ineligible for the CEWS because of technical and administrative factors that are inconsistent with other existing federal legislative frameworks. The CMA conducted a survey of its membership between May 22 and June 1 to better understand physicians’ experiences accessing the federal economic relief programs; 3,730 physicians participated in this survey. Overall, about a third (32%) of physicians polled had attempted to apply to at least one of the federal programs available and 15% of all physicians who responded applied for the CEWS, making it the second most applied-to program. Of those physicians who applied to the CEWS, 60% were successful, 7% were denied and the remaining 33% were still awaiting response at the time of the survey. Of those who applied but were denied the CEWS, a third (33%) indicated it was because of their cost-sharing structure, 3% responded it was because they worked in a hospital-based setting and a further 22% simply didn’t know. Finally, as part of the survey, physicians shared comments that speak to the issues outlined in this brief. A few excerpts are below:
“We are a group of 4 surgeons and have a cost sharing agreement to pay our office expenses. Our office is outside of the hospital. We tried to apply for the CEWS but have recently received accounting advice supported by legal advice that cost sharing agreements will not be candidates for the CEWS. We are therefore presently exploring other options such as a work share situation or temporary/permanent layoffs.” CMA member, survey respondent
“I work in a group with 11 other OBGYNs. We are still unsure to this point about whether the CEWS applies to our situation. Our revenue is certainly down by ~30% or more. The issue is that our structure doesn't fall into one of the neat categories for CEWS … We are awaiting clarification from our accountant on our status but it seems that the way the rules are currently written, we will not benefit from CEWS, and unfortunately, we are reducing staff hours to cope with our reduction in revenue.” CMA member, survey respondent
“My main frustration is that I can't find a clear answer on whether a clinic made up of multiple doctors with a cost sharing agreement is eligible for CEWS for our employees. I imagine many family practice clinics are set up this way … So as it stands we have not been able to access any financial programs in order to help pay our overhead/staff despite 50% reduction in patient volume.” CMA member, survey respondent A. Cost-Sharing Arrangements — Front-Line Health Care Workers Employed in Physician Clinics One of the main types of practices that are unable to access the CEWS because of technical administrative barriers, despite meeting the key eligibility criteria, are physicians operating independently within a cost-sharing business structure. Like many other independent professionals, physicians operate in group settings. In fact, according to the Canadian Institute for Health Information, in 2019, 65% of family practices operated in a group setting. However, unlike other independent professionals, physicians have been encouraged to operate in a group setting, both by accreditation bodies as well as by provincial health authorities, to meet system delivery goals. Appendix A provides a case study based on Sudbury Medical Associates (SMA), an illustrative example of three doctors (Dr. Brown, Dr. Lee and Dr. Assadi) who coordinated the operations of their medical practices together to open an integrated health care clinic. While they provide care to their own respective patient rosters, these three physicians share in the clinic space rent and employ 10 employees together. Because of the way SMA is structured, these physicians are unable to access the CEWS for their proportionate share of their employees’ salaries. Each physician has met all the CEWS criteria except for the fact that SMA administers the payroll for their 10 employees under its own payroll number. SMA illustrates a typical family medicine clinic representative of the many medical practices in Canada who employ numerous FLHCWs. B. Cost-Sharing Arrangements — Front-Line Health Care Workers Employed by Specialist Physicians Practising in a Hospital-Based Environment Another type of physician structure unable to access the CEWS because of the use of cost-share arrangements are specialist physicians practising in a hospital-based environment or academic health science centre (an “AHSC”). The purpose of an AHSC is to provide specialized health care services, carry out medical research and train the next generation of Canada’s health care professionals. Provincial funding agreements are designed to align the interest of all parties in an AHSC (clinical care, teaching, research and innovation) and often contain governance and accountability requirements. In order to discharge responsibilities under provincial funding agreements and to run a practice that can meet certain metrics, physicians are required to hire their own staff. Consequently, cost-sharing arrangements are utilized by these physicians to efficiently hire staff while meeting their other responsibilities. In response to the COVID-19 pandemic, hospitals have implemented strategies designed to protect the health care system from collapsing or being overwhelmed. For example, many hospitals have cancelled elective surgeries; coupled with the fear many patients have of going to the hospital, this has resulted in a decline in patient care volume as hospitals and physician practices adhere with public health guidelines. This has led to a significant decline in revenue, requiring physicians to access the CEWS program in order to continue to employ their staff. Like all physicians in Canada, specialist physicians practising in a hospital-based health care setting are responsible for significant levels of fixed overhead expenses related to a medical practice. This includes medical insurance, licensing fees, maintaining an office and other professional fees. As a standard practice, employees of physicians who practise in AHSCs are often paid by a third party. In many instances, physicians have established an agency relationship pursuant to which they delegate authority to the hospital to act as their agent with respect to withholding taxes, source deductions and filing T4 returns. The main reason for this agency is to ensure that the physician focuses on teaching, researching and patient care. For clarity, the administrator (hospital) has no legal authority to conclude on any employment matter such as the determination of a bonus or a wage increase or the payout of any severance. All these matters would be the responsibility of the physician in his/her capacity as employer. Anticipating a second wave of COVID-19, many physicians are concerned about maintaining their staff during a future work stoppage given their current inability to apply for the CEWS. As employers, physicians can appreciate that the hospital’s payroll number is creating additional administrative complexity for the Canada Revenue Agency (CRA). However, as an employer and small business, their ability to access the CEWS program is an integral part of their strategy to retain and maintain their staff. C. Technical Analysis — CEWS Legislation and the Principal-Agent Relationship i) CEWS Legislation — Qualifying Entity Pursuant to the COVID-19 Emergency Response Act, an entity will qualify for CEWS to the extent that it is a Qualifying Entity under ss. 125.7(1) of the Income Tax Act (ITA). One of the criteria to be a qualifying entity is that the entity had, on Mar. 15, 2020, a business number in respect of which it is registered with the Minister to make remittances required under ITA s. 153. By virtue of how cost-sharing arrangements are structured, the administrator (agent) handles the payroll filings using their own payroll number, which can be different from the employing physician (principal). On the basis of the uniqueness of cost-sharing structures and the definition in the legislation, physicians who employ individuals under these arrangements need to rely on principal-agent concepts in order to qualify for the CEWS provided all other criteria are met. Presently, the CEWS application portal does not recognize principal-agent arrangements, which are common among physician practices as they employ FLHCWs. It is recognized that each participant or physician in a cost-sharing arrangement is in fact its own business and that physicians share the costs of certain overhead expenses, which include wage-related costs for FLHCWs. In these structures, the payroll number for the employee(s) may be associated with one of the independently operating physicians or it may be associated with a separate entity. As such, these physicians are not likely to have a distinct payroll number associated with their eligible employee under the CEWS. The case law and the administrative position of the CRA demonstrate the following: 1. The principals in a cost-sharing arrangement are the employers; and 2. The agent’s payroll number should be considered the payroll number for the principal for the purposes of making a CEWS application. ii) Case Law Subsection 9(1) of the ITA provides for the basic rules as they relate to computing the income or loss from business or property. In both Avotus Corporation v The Queen and Fourney v The Queen , the Tax Court of Canada determined that where a person carries on business as agent for another, it is the principal that is carrying on the business and not the agent. The Fourney case provides for several concepts that extend to the unique nature of cost-sharing arrangements. These concepts should provide clarity about a principal’s ability to make a CEWS claim if it had a payroll agent that had a business number to make remittances before Mar. 15, 2020. The concepts are summarized as follows: 1. Corporations can act as Agent In Fourney, at paragraphs 41 and 42, it was concluded that a corporation can act as its shareholder’s agent: It is established, then, that corporations can act as agents, and this concept is not repugnant to the rule that corporations have separate legal personality a matter addressed in the oft-cited Salomon case. 2. Business Activities belong to the Principal At paragraphs 60 and 65 of Fourney, the Tax Court examined the following activities and ultimately concluded that the activities were in fact the activities of the principal and not the agent. The following conclusions can be drawn from the case:
Payments made to the corporate agent were found to be revenues of the principal.
Contracts entered into by the corporate agent were contracts entered into by the principal.
T4s issued under the corporate agent’s name were deductible expenses to the principal. Lastly, at paragraph 65, the Tax Court characterized the corporate agent as a mere conduit for the appellant. iii) Administrative Policy For GST/HST purposes, the CRA accepts the concept of an agency relationship typically utilized by physicians in cost-sharing practices. In RITS 142436 “Implementation of Cost Sharing Arrangement,” the CRA concluded that GST/HST does not apply to payments made to “Company A” because it was an agent in relation to remuneration paid to the employees of Company B and Company C. In this ruling, Companies A, B and C were all employers with Company A administrating the payroll as agent. The CRA’s conclusions appear to take the follow matters into account:
Employees are jointly employed by the principals in the cost-sharing arrangement.
Principals have legal responsibility for the employees.
The principals would delegate responsibility or authority to an agent, which could be a corporation or another physician.
That agent would be given discretion to pay the employees, withhold and remit the appropriate amount of taxes, file T4 slips, hire and terminate at the determination of the principals.
Each principal would pay the agent for their proportionate share of payroll and report such payroll on their respective financial statements and tax returns. The CRA also concluded that the “employment status of a person for GST/HST purposes is the same for income tax purposes.” The Department of Finance provides that the CEWS helps businesses keep employees on the payroll, encourages employers to rehire workers previously laid off, and better positions businesses to bounce back following the crisis. In keeping with this objective, a payroll number for an agent should extend itself to the principals for the purposes of applying for the CEWS because it is supported by case law and the administrative practices of the CRA. Application of any federally legislated program should be conceptually consistent with historical frameworks already established. Recommendations: The CMA holds that the legislation as written can remain as currently drafted as it provides for the majority of applicants looking to access the CEWS. However, to address the unintended exclusion of cost-sharing arrangements, the CMA recommends that the CRA provide administrative guidance consistent with and based on existing case law and administrative positions. The CMA recommends that the Federal Government and the CRA enable physicians to claim their proportionate share of eligible remuneration paid through a cost-sharing arrangement provided all other program eligibility criteria are met. Administratively, this may be achieved by the following:
a “check-box” on the application denoting the applicant is a participant in a cost sharing arrangement
identification of the cost-sharing arrangement payroll number
a joint election between the agent and employer allowing the employer to utilize the agent’s payroll number and denoting the percentage allocation of salary costs to the particular employer If this recommendation is not feasible, the CMA recommends that the Federal Government and the CRA implement an alternate approach whereby a cost-share administrator is permitted to make a CEWS claim in their capacity as agent on behalf of each eligible entity (principal). Since period 3 is almost complete, there could be less administration regarding these claims as agents have not made application. Similar to the preferred remedy above, this may be achieved by the following:
a “check box” on the application indicating that an “agent” is filing the claim on behalf of eligible employers
the applicant could also provide (either initially or upon desk audit) the business numbers to CRA for each employer
a joint election among the agent and the employers allowing the agent to act on behalf of the employers for purposes of the CEWS This would provide ease of audit for the CRA as the claim can be verified against the T4 and payroll remittances. The election and disclosure requirements would also alleviate any concerns the CRA or Department of Finance may have regarding potential abuse of the program. In Appendix B we also outline supporting documentation to be retained for a CEWS Claim by a Cost-Sharing Entity, which will ensure cost-sharing entities have the appropriate documentation to submit a claim and also assist the CRA in conducting pre-assessment audits. The CMA would be pleased to provide further detail on this issue or consider other alternatives to ensure FLHCWs receive wages during these unprecedented times. Conclusion Canada’s physicians are important employers. Not only are they responsible for almost 167,000 in direct employment, together with their staff, they are at the front lines of Canada’s response to the COVID-19 pandemic. Our health care system cannot withstand loss of employment or risks to the viability of medical clinics, at this crucial time — and indeed at any time. The CMA strongly encourages the Federal Government to address the issues outlined above in preventing physicians from accessing this critical economic relief program. On behalf of the doctors of Canada, the CMA stands ready to collaborate in resolving these technical and administrative barriers. Appendix A: Welcome to Sudbury Medical Associates (SMA) Dr. Christopher Brown (60) settled in his hometown of Sudbury to practise family medicine about 30 years ago. He operated in his own space, with his own employees until SMA was formed. Dr. Jennifer Lee (45) has been practising in Sudbury for her entire career. Dr. Lee handles all family patients with a special focus on maternity and young family care. Dr. Sarah Assadi (30) recently completed her residency. Dr. Assadi spent time in Sudbury as a locum and enjoyed the strong community feel. Dr. Brown and Dr. Lee are long-time colleagues and recently approached Dr. Assadi to open an integrated health care clinic. Together they would require 10 employees (comprised of nurse practitioners, medical assistants and receptionists) to effectively operate the clinic. Optically, SMA appears to be one business when in fact it is comprised of three distinct medical practices. Each physician or their professional corporation maintains their own distinct patient list. Upon the advice of professional advisors, the physicians entered into a cost-sharing agreement to realize cost efficiencies related to the integrated health care clinic (administration and lease). This structure will ensure the needs of the community are met by the expansion of operating hours facilitated by a flexible staffing model. Understanding that cost-sharing arrangements are accepted by provincial health authorities and the Canada Revenue Agency (CRA), Dr. Brown, Dr. Lee and Dr. Assadi documented this arrangement, which includes the following details: Dr. Brown Dr. Lee Dr. Assadi SMA Legal entity Prof corp Prof corp Sole-proprietor Corp Proportionate share of costs 20% 40% 40%
0% Legal employer (10 staff) ü ü ü Legally responsible — all contracts ü ü ü Payroll, T4 and remittances ü Report for income tax purposes:
Individual billings
Proportionate share of costs administered by SMA including payroll ü ü ü The impact of COVID-19 resulted in a significant slowdown of patient visits between Mar. 15 and May 31 as the residents of Sudbury were social distancing and were only leaving their homes for urgent matters. Dr. Brown, Dr. Lee and Dr. Assadi are concerned about keeping their front-line health care workers employed and at the same time maintaining a sufficient level of family health care in the community. Considering a possible second wave of COVID-19, these physicians need to ensure that their community health clinic remains open and safe so there is no unintended stress on hospitals. Like many small businesses that have experienced significant revenue declines, these physicians are hopeful to access the Canada Emergency Wage Subsidy (CEWS) to ensure they can retain their specialized employees and pivot to the new environment they need to operate within. Upon further review, only Dr. Lee and Dr. Assadi experienced sufficient revenue declines to access the CEWS, but currently they do not qualify because of how they structured the payroll for these 10 employees. They are concerned that without the CEWS, they will not be able to retain all of their staff or see as many patients. The following table summarizes the CEWS analysis: CEWS criteria Dr. Brown Dr. Lee Dr. Assadi SMA Eligible entity ü Prof corp ü Prof corp ü Sole proprietor ü Corp Revenue decline test: March 2020 Not met ü ü No revenues to report Payroll number
ü Payroll expense (eligible remuneration ) ü ü ü
Qualified for the CEWS No (revenue decline test not met) No (payroll account number held by SMA, which manages payroll on behalf of Dr. Lee) No (payroll account number held by SMA, which manages payroll on behalf of Dr. Assadi) No (has no revenue and is not the legal employer) As employers, Dr. Lee and Dr. Assadi do not understand why their businesses are unable to access the CEWS for their proportionate share of their employees’ salaries. Each has met all of the CEWS criteria except for the fact that SMA administers the payroll for their 10 employees under its own payroll number. Appendix B: Illustration of Supporting Documentation to be Retained for a CEWS Claim by Cost-Sharing Entity To the extent that employers operating through a cost-sharing structure are permitted to make a CEWS claim, the following documentation could be requested by the CRA to verify the claim upon desk audit. For illustrative purposes, let’s assume that Dr. Lee and Dr. Assadi both made a CEWS claim. Supporting Documentation Request 1. The legal documentation establishing the agency relationship pursuant to which Dr. Lee and Dr. Assadi delegated authority to SMA to handle the income tax remittances, source deductions and T4 reporting. 2. The employment contracts, which clearly indicate that each of Dr. Lee, Dr. Assadi (and Dr. Brown) are the employers. Alternatively, confirmation from the employees that SMA is not the employer and that they are employed by Drs. Lee, Assadi and Brown. 3. SMA’s accounting records or financial statements, which clearly support its position as an agent. Note: Typically, most cost-share administrators will have NIL revenue and account for all cash inflows and outflows on their balance sheet in a manner similar to a lawyer’s trust account. 4. An analysis demonstrating the revenue decline for the relevant period for Dr. Assadi’s business and Dr. Lee’s business. 5. Calculations supporting the proportionate share of “baseline remuneration” and “eligible remuneration” paid to the employees by Dr. Assadi’s business and Dr. Lee’s business. 6. A reconciliation of the wage subsidy received along with their proportionate share of the wage subsidy so it can be properly accounted for and taxed.
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CMA Pre-budget Submission

https://policybase.cma.ca/en/permalink/policy14259
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
Text
RECOMMENDATION 1 That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care. RECOMMENDATION 2 That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians. RECOMMENDATION 3 That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit. RECOMMENDATION 4 That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs. RECOMMENDATIONS 3 Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now. We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system. While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens. The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients. Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing. The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system. The health of the country’s economy cannot exist without the health of Canadians. INTRODUCTION 4 Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic. At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies. The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them. Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage. The CMA will provide the budget costing in follow-up as an addendum to this submission. RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund 5 It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care. During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual. The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access. A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet. The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service. Create a Digi-Health Knowledge Bank Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy. We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments. Pan-Canadian broadband expansion It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement. RECOMMENDATION 2 Embedding virtual care in our nation’s health care system 6 Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long. The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors. A demographic top-up to the Canada Health Transfer The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors. The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade. Seniors care benefit Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients. RECOMMENDATION 3 Ensuring that better care is secured for our seniors 7 The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short. The CMA recommends the following measures: 1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program. 2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions. 3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member. RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers 8 Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic. Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system. CONCLUSION
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Protecting and supporting Canada’s health-care providers during COVID-19

https://policybase.cma.ca/en/permalink/policy14260
Date
2020-03-23
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2020-03-23
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Health human resources
Text
Dear First Ministers: Re: Protecting and supporting Canada’s health-care providers during COVID-19 Given the rapidly escalating situation both globally and in our country, we know that the health and safety of all people and health-care providers in Canada is uppermost on your minds. We appreciate the measures that have been taken by all levels of government to minimize the spread of COVID-19. However, we must ensure those working directly with the public, including physicians, nurses, pharmacists, and social workers, are properly protected and supported, so that they can continue to play their role in the response. First and foremost, we urge all levels of government to put measures in place to ensure the personal protective equipment that point-of-care providers require to deliver care safely throughout this outbreak is immediately deployed and ready to use. Coordinated measures and clear, consistent information and guidelines will ensure the appropriate protection of our health-care workforce. Given the increased pressure on point-of-care providers, we ask that all governments support them by providing emergency funding and support programs to assist them with childcare needs, wage losses due to falling ill or having to be quarantined, and support of their mental health needs both during and after the crisis has subsided. We also expect all governments to work together to provide adequate, timely, evidence-based information specifically for health-care providers. Clear, consistent and easily accessible guidance will enable them to do their jobs more efficiently and effectively in times of crisis. This can and should be 1/2… done on various easily accessible platforms such as online resources, an app, or through the creation of a hotline. We know there will be challenges in deploying resources and funding, particularly around the supply of personal protective equipment. We ask that you consider any and all available options to support health-care providers through a coordinated effort both during and following this crisis. Our organizations look forward to continuing to work with you in these difficult times. If there is anything we can do to help your teams, you need only ask. Sincerely, Claire Betker, RN, MN, PhD, CCHN(C) President, Canadian Nurses Association president@cna-aiic.ca Jan Christianson-Wood, MSW, RSW President, Canadian Association of Social Workers kinanâskomitin (I’m grateful to you) Lea Bill, RN BScN President, Canadian Indigenous Nurses Association president@indigenousnurses.ca Sandy Buchman, MD, CCFP(PC), FCFP President, Canadian Medical Association sandy.buchman@cma.ca
Documents
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A new vision for Canada: family practice— the patient’s medical home 2019

https://policybase.cma.ca/en/permalink/policy14024
Date
2019-03-02
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Policy endorsement
Date
2019-03-02
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
The evolving needs of patients and their communities place ever-changing demands on the health care system to maintain and improve the quality of services provided. Changing population demographics, increasing complexity, and new technology make for a dynamic system. Family physicians are at the heart of the health care system, acting as the first point of contact and a reliable medical resource to the communities they serve, caring for patients and supporting them throughout all interactions with the health care system. The Patient’s Medical Home (PMH) is a vision that emphasizes the role of the family practice and family physicians in providing high-quality, compassionate, and timely care. The success of a PMH depends on collaboration and teamwork—from the patient’s participation in their care to interprofessional and intraprofessional care providers working together, to policy-makers who can offer infrastructure support and funding. PMH 2019 was created with invaluable feedback from a broad range of stakeholders reflective of such a joint approach. Its goal is to make the PMH a reality for patients and providers across Canada. In 2011 the College of Family Physicians of Canada (CFPC) released A Vision for Canada: Family Practice - The Patient’s Medical Home.1 It outlined a vision for the future of primary care by transforming the health care system to better meet the needs of everyone living in Canada. The vision outlined the 10 pillars that make up the PMH and provided detailed recommendations to assist family physicians and their teams, as well as policy-makers and health care system administrators, to implement this new model across the country. WHY A REVISED PMH? Since 2011 many principles of the PMH vision have been embraced in primary care reforms. New models have been introduced across Canada (see Progress on the PMH to Date). To better reflect current realties, meet the evolving needs of family physicians and their teams, and support continued implementation of the PMH, the CFPC has developed this revised edition of the vision. It reflects evolving realities of primary care in Canada, including the rapid adoption of electronic medical records (EMRs)2,3 and a shift toward interprofessional practice structures.2 While progress has been made, there is still work to be done to fully achieve the PMH vision. In 2016 almost 75 per cent of Canadians rated the quality of care received from their family physicians as good or excellent.4 In 2017 a CFPC survey found that 79 per cent of respondents rate the care they receive from their family doctor as excellent or good.5 However, at the same time 55 per cent of Canadians also believed that the overall health care system still required fundamental changes.4 In addition, Canada continues to perform below the international average on certain aspects of patient-centred care; for example, same- or next-day access to appointments. While most Canadians (84.7 per cent) have a regular doctor or place of care, they generally report longer wait times for medical care than adults in comparable countries.4 PMH 2019 addresses these concerns and proposes solutions that can help further improve the primary care system for all. Although the specific components of the revised PMH have been updated (see What is the Patient’s Medical Home?), the core principles remain the same. PMH 2019 focuses on providing high-quality, patient-centred, and comprehensive care to patients and their families during their lifetime. It embraces the critical role that family physicians and family practices play in the health care system, reflecting the fact that systems with strong primary health care deliver better health outcomes, enhance efficiency, and improve quality of care.6 PMH 2019 recognizes that a patient will not be able to see their personal family physician at every visit, but can rely on the PMH’s qualified team of health professionals to provide the most appropriate care responding to patient needs with continuous support and leadership from family physicians. PMH 2019 highlights the central importance of community adaptiveness and social accountability in primary care with a new pillar. The importance of being responsive to community needs through engagement, and ensuring the provision of equitable, culturally safe, antioppressive practise that seeks to assess and intervene into social determinants of health (SDoH), is now more clearly featured. 2 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 PURPOSE OF THIS DOCUMENT PMH 2019 outlines 10 revised pillars that make up a PMH. Key attributes are defined and explained for each pillar. Supporting research is provided to demonstrate the evidence base for each attribute. This document is intended to support family physicians currently working in a PMH to better align their practice with the PMH pillars, or assist those practices looking to transition to a PMH. Furthermore, this document can guide governments, policy-makers, other health care professionals, and patients on how to structure a primary health care system that is best-suited to meet the needs of Canadians. Many resources for the PMH have been developed and will continue to be available. These include practical Best Advice guides on a range of topics and the self-assessment tool that can help quantify a practice’s progress toward PMH alignment. Moving forward, additional materials that address the new themes identified in PMH 2019 and the tools to support physicians in the transition to PMH structures—for example the PMH Implementation Kit— will be available at patientsmedicalhome.ca. What is a Patient’s Medical Home? The PMH is a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns. The PMH can be broken down into three themes: Foundations, Functions, and Ongoing Development (see Table 1 and Figure 1). The three Foundation pillars are the supporting structures that facilitate the care provided by the PMH. All three aspects are required for the successful implementation and sustainability of a PMH. The Functions are areas central to the operation of a family practice and consist of the five core PMH pillars. These principles govern the type of care provided by the PMH practices to ensure it is effective and efficient for meeting the needs of the patients, families, and communities they serve. The pillars in this section reflect the Four Principles of Family Medicine,7 which underlines the important place they take in the overall PMH 2019. The pillars in Ongoing Development are essential to advancing the PMH vision. These areas make it possible for physicians to provide the best possible care for patients in various settings. Applying these pillars, the PMH will thrive through practising quality improvement (QI) principles to achieve the results necessary to meet the needs of their patients, their communities, and the broader health care community, now and in the future. The PMH is a vision to which every practice can aspire. Many practices across Canada have already begun transitioning to a PMH, thanks to the dedication and leadership of family physicians and their teams across Table 1. 10 Pillars of the revised PMH vision THEME PILLAR Foundations 1. Administration and Funding 2. Appropriate Infrastructure 3. Connected Care Functions 4. Accessible Care 5. Community Adaptiveness and Social Accountability 6. Comprehensive Team-Based Care with Family Physician Leadership 7. Continuity of Care 8. Patient- and Family-Partnered Care Ongoing Development 9. Measurement, Continuous Quality Improvement, and Research 10. Training, Education, and Continuing Professional Development A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 3 the country. This vision is a resource for these practices as they engage in ongoing practice assessment and QI initiatives. It can also assist other stakeholders, including government planners, policy-makers, and funders to better understand what defines an effective patientcentred family practice. By involving patients in all stages of the development, evaluation, and continuous quality improvement (CQI) activities of the practice, the PMH can contribute significantly to furthering the goals of transformation to a patient-centred health care system.8 What the Patient’s Medical Home is Not While it is important to understand what the PMH aspires to be, it is also important to highlight that it is not a one-size-fits-all solution. Solo practices in rural or remote settings or large group practices serving inner-city populations can align with PMH principles by incorporating strategies that match the realities of their unique settings. In fact, social accountability and community adaptiveness is an important new addition to the revised PMH vision to account for the need of every family practice to adapt and respond to the needs of their patients and communities. What works for one practice will not work for all. The PMH vision does not require that all practices be relocated or re-engineered, or that significant financial investments be made by physicians or other health care professionals. Instead, system level support and involvement is required to achieve the vision. The pillars and attributes listed in this document are signposts along the way to reform that aids practices on their journey. It is important to note that this vision is not intended to undermine or change any exciting initiatives involving family practice currently under way across Canada (several of which already embrace and incorporate the medical home concept; see Progress on the PMH to Date). Rather, it is meant to build on and strengthen these efforts. The more that health care initiatives meet PMH objectives, the more likely it is that the overall goals of creating a patient-centred health care system throughout Canada will be realized. Figure 1. The Patient’s Medical Home 4 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 PROGRESS ON THE PMH TO DATE Since the release of the original PMH vision document, system-level change has occurred in almost all jurisdictions in Canada. More specifically, PMH-type practices are gaining traction in various provinces and currently exist in various stages of development. The CFPC took a snapshot of PMH uptake in all provinces in the PMH Provincial Report Card, published in early 2019.9 That report contains grades and descriptions for progress in each province up to late 2018, which acts as a useful gauge for where the vision stands at the time of publication of this new edition. Alberta In Alberta, primary care networks (PCNs)10 were established to link groups of family physicians and other health care professionals. Within PCNs clinicians work together to provide care specific to community and population health care needs. Currently, there are 42 PCNs operating in Alberta, comprised of more than 3,700 (or 80 per cent of) family physicians, and over 1,100 other health care practitioners. PCNs provide care to close to 3.6 million Albertans, 80 per cent of the population in Alberta. Primary care clinics are being asked to collect data for Third Next Available (TNA) appointments to improve access for Albertans.11 TNA measures the delay patients experience in accessing their providers for a scheduled appointment. TNA is considered a more accurate system measure of access than the “next available” appointment, since the next or second next available appointment may have become available due to a cancellation or other event that is not predictable or reliable. British Columbia The British Columbia government’s new primary care strategy focuses on expanding access to team-based care through PCNs.12 PCNs are in the initial stages of adoption and when fully rolled out will provide a systemlevel change—working to connect various providers to improve access to, and quality of, care. They will allow patients to access the full range of health care options, streamline referrals, and provide better support to family physicians, nurse practitioners, and other primary health care providers. The General Practice Services Committee13 (GPSC; a partnership of the provincial government and Doctors of BC) specifically references and builds on the PMH concept in their vision for the future of British Columbia’s health care system. Manitoba In Manitoba, PMHs are Home Clinics and PCNs are My Health Teams. My Health Teams bring together teams of health care providers (physicians, nurses, nurse practitioners, etc.) to collaborate in providing highquality care based on community and patient needs.14 As suggested by the name of the initiative itself, the goal is to improve health care by developing teams of health care professionals who will work together to address primary health care needs of Manitobans.15 The first two My Health Teams were established in 2014, and there are now 15 across the province.16 The Manitoba Centre for Health Policy did some work assessing the impact of My Health Teams. New Brunswick In 2017 the government announced the New Brunswick Family Plan, which placed a specific emphasis on access to team-based care. To achieve this goal, the provincial government and the New Brunswick Medical Society established a voluntary program called Family Medicine New Brunswick. In this team-based model, physicians have their own rosters of patients, but also provide a service to all patients of doctors on their team.17 It was announced in 2018 that 25 family physicians will be added to the provincial health care system to ensure more New Brunswick residents have access to a primary care physician and to help reduce wait times.18 Newfoundland and Labrador In 2015 the Newfoundland and Labrador government released Healthy People, Healthy Families, Healthy Communities: A primary health care framework for Newfoundland and Labrador. The strategy’s goals include ensuring “timely access to comprehensive, person-focused primary health care services and supports,” and “primary health care reform should work to establish teams of providers that facilitate access to a range of health and social services tailored to meet A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 5 the needs of the communities they serve.”19 Both goals align with the general PMH principles. Primary health care teams have been introduced in St. John’s and are planned for Corner Brook and Burin.20 Many initiatives under way as a part of this strategy are in the early stages of development. Continuing in the direction laid out will move Newfoundland and Labrador closer to integrating the PMH vision in their delivery of primary health care. Northwest Territories The recent creation of a single Territorial Health Authority has enabled work on primary care improvements across the Northwest Territories. In August 2018 the NWT Health and Social Services Leadership Council unanimously voted in favour of a resolution supporting redesigning the health care system toward a team- and relationshipbased approach, consistent with PMH values. In several regions, contracted physicians are already assigned to regularly visit remote communities and work closely with local staff to provide continuity of remote support between visits. Planning is under way for implementing PMH-based multidisciplinary care teams in several larger regional centres, with enhanced continuity and access to physician and nursing staff as well as co-located mental health support and other health care disciplines. This work is facilitated by a territory-wide EMR and increased use of telehealth and other modalities of virtual care. Nova Scotia The 2017 Strengthening the Primary Health Care System in Nova Scotia report recommended establishing “health homes,” consisting of interprofessional, collaborative family practice teams. The model is based on a population health approach that focuses on wellness and chronic disease management/prevention and incorporates comprehensive, team-based care. There are approximately 50 collaborative family practice21 teams and a number of primary care teams across Nova Scotia. Ontario The model most aligned with the PMH framework is the family health team (FHT).22 FHTs are comprised of family physicians, nurse practitioners, and other health care professionals, and provide community-centred primary care programs and services. The 184 FHTs collectively serve over three million enrolled Ontarians. Based on the results of a five-year evaluation undertaken by the Conference Board of Canada in 2014, FHTs have achieved improvements at the organizational and service-delivery levels.23 Much progress has also been made through patient enrolment models. Patient enrolment, or rostering, is a process in which patients are formally registered with a primary care provider or team. Patient enrolment facilitates accountability by defining the population for which the provider is responsible. Formal patient enrolment with a primary care physician lays the foundation for a proactive approach to chronic disease management and preventive care.24 Studies show that the models have achieved some degree of success in enhancing health system efficiency in Ontario through the reducing use of emergency departments for non-emergent care.25 Prince Edward Island In Prince Edward Island, primary care is provided through five PCNs.26 Each network consists of a team that includes family physicians, nurse practitioners, registered nurses, diabetes educators, licensed practical nurses, clerical staff, and in some cases dietitians and mental health workers. They offer a broad range of health services including diagnosis, treatment, education, disease prevention, and screening. Quebec The Groupes de médecine de famille27 (GMF) is the team-based care model in Quebec most closely aligned with the PMH. GMF ranking (obligations, financial, and professional supports) is based on weighted patient rostering. One GMF may serve from 6,000 to more than 30,000 patients. The resource allocation (financial and health care professionals) depends on the weighted patient target under which the GMF falls. In a GMF, each doctor takes care of their own registered patients, but all physicians in the GMF can access medical records of all patients. GMFs provide team-based care with physicians, nurses, social workers, and other health care professionals working collaboratively to provide appropriate health care based on community needs. Saskatchewan Saskatchewan has made investments in a Connected Care Strategy, which focuses on a team approach to care that includes the patient and family, and extends from the community to the hospital and back again. It is about connecting teams and providing seamless care for people who have multiple, ongoing health care needs, with a particular focus on care in the community.28 6 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 FOUNDATIONS PMH foundations are the underlying, supporting structures that enable a practice to exist, and facilitate providing each PMH function. Without a strong foundation, the PMH cannot successfully provide high-quality, patient-centred care. The foundations are Administration and Funding (includes financial and governmental support and strong governance, leadership, and management), Appropriate Infrastructure (includes physical space, human resources, and electronic records and other digital supports), and Connected Care (practice integration with other care settings enabled by health IT). ADMINISTRATION & FUNDING PAGE 7 APPROPRIATE INFRASTRUCTURE PAGE 9 CONNECTED CARE PAGE 12 Patients as partners in health care Patient-centred or patient-partnered? Understanding and acknowledging patients as full partners in their own care is a small but powerful change in terminology. Considering and respecting patients as partners allows health care providers to better recognize and include the skills and experience each patient brings to the table. Patient perspectives and feedback can be more inclusively incorporated in the QI processes in place to improve care delivery. Understanding the nature of patient partnerships can help physicians better establish trusting relationships with those in their care.29 Pillar 1: Administration and Funding Practice governance and management Effective practice governance is essential to ensuring an integrated process of planning, coordinating, implementing, and evaluating.30 Every PMH should clearly define its governance and administrative structure and functions, and identify staff responsible for each function. While the complexity of these systems varies depending on the practice size, the number of members on the health care professional team, and the needs of the population being served, every PMH should have an organizational plan in place that helps guide the practice operations. From a governance perspective, policies and procedures should be developed and regularly reviewed and updated, especially in larger practices. These policies and procedures will offer guidance in areas such as organization of clinical services, appointment and booking systems, information management, facilities, equipment and supplies, human resources, defining PMH team members’ clinical and administrative/management roles and responsibilities, budget and finances, legal and liability issues, patient and provider safety, and CQI. In some cases, standardized defaults for these may be available based on the province of practice and existing structures supporting interprofessional teams. Structures and systems need to be in place that allow for compensated time for providers to undertake and actively participate in CQI activities. This needs to be scheduled and remunerated so that it is seen as being as important and critical as clinical time. To ensure that all PMH team members have the capacity to take on their required roles, leadership development programs should be offered. Enabling physicians to engage in this necessary professional development requires sufficient government funding to cover training A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 7 Practices need staff and financial support, advocacy, governance, leadership, and management in order to function as part of the community and deliver exceptional care. 1.1 Governance, administrative, and management roles and responsibilities are clearly defined and supported in each PMH. 1.2 Sufficient system funding is available to support PMHs, including the clinical, teaching, research, and administrative roles of all members of PMH teams. 1.3 Blended remuneration models that best support team-based, patient-partnered care in a PMH should be considered to incentivize the desired approach. 1.4 Future federal/provincial/territorial health care funding agreements provide appropriate funding mechanisms that support PMH priorities, including preventive care, population health, electronic records, community-based care, and access to medications, social services, and appropriate specialist and acute care. 8 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 costs and financial support to ensure lost income is not a barrier (see Pillar 10: Training, Education, and Continuing Professional Development). External supports Every family practice in Canada can become a PMH and an optimal learning environment will only be achievable with the participation and support of all stakeholders throughout the health care system. This includes family physicians; other health professionals who will play critical roles on PMH teams; federal, provincial, and territorial governments; academic training programs; governing bodies for physicians and allied health care providers; and most importantly, the people of Canada themselves, individually and in their communities—the recipients of care provided by the PMH. To achieve their objectives, PMHs need the support of governments across Canada through the provision of adequate funding and other resources. Given that the structure, composition, and organization of each PMH will differ based on community and population needs, funding must be flexible. More specifically, PMH practices will differ in terms of the staff they require (clinical, administrative, etc.). Funding must be available to ensure that PMH practices can determine optimal staffing levels and needs, to best meet community needs. The health care system must also ensure that all health care professionals on the PMH team have appropriate liability protection, and that adequate resources are provided to ensure that each PMH practice can provide an optimal setting for teaching students and residents and for conducting practice-based research. These characteristics are also reflected in the Four Principles of Family Medicine, reinforcing the centrality of family medicine to the delivery of care. Experience through new models of family practice, such as patient enrolment models (PEMs) in Ontario, suggests that blended funding models are emerging as the preferred approach to paying family physicians.31–33 These models are best suited to incentivizing teambased, patient-partnered care. The current fee-forservice (FFS) model incentivizes a series of short consultations that might be insufficient to address all of the patient’s needs, while blended remuneration provides for groups of physicians to work together to provide comprehensive care through office hours and after-hours care for their rostered patients. Capitation allows for more in-depth consultations depending on population need, rather than a volume-based model. Research has also found that blended capitation models can lead to small improvements in processes of care (e.g., meeting preventive care quality targets)34 and can be especially useful for supporting patients in managing and preventing chronic diseases.35 The CFPC advocates for governments to implement blended payment mechanisms across the country to achieve better health outcomes (see the Best Advice guide: Physician Remuneration in a Patient’s Medical Home36 for more information). It is important to ensure that additional practice activities such as leadership development, QI, and teaching are supported through dedicated funding or protected time intended specifically for these activities and are not seen as financially disadvantageous. The sustainability of Canada’s health care system depends on a foundation of strong primary care and family practice.37 Indeed, “high-performing primary care is widely recognized as the foundation of an effective and efficient health care system.”38 Future funding for health care—in particular from the federal government through federal, provincial, and territorial agreements—must be sustained through appropriate and well-designed funding agreements that incentivize PMH visions of primary care; other medical home priorities including preventive care, population health, EMRs; communitybased care; along with access to medications, social services, and appropriate specialist and acute care. For the PMH vision to be successful and a part of the future of family practice care in Canada, we need the commitment and support of everyone in the Canadian health care system, including decision makers and patients. By working with all levels of government and with patients, we can improve the health care system so that everyone in Canada has access to patient-centred, comprehensive, team-based care. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 9 Pillar 2: Appropriate Infrastructure The shift in Canada from paper-based patient records to EMRs is reaching saturation. As delivery of care evolves with greater integration of technology, potential applications to improve patient care expand.39 The proportion of family physicians using EMRs has grown from 16 per cent in 2004 to 85 per cent in 2017.40 As it becomes ubiquitous in health care delivery, information technology can be of great benefit in sharing information with patients, facilitating adherence to treatment plans and medication regimes, and using health information technology (HIT) in new and innovative methods of care. However, HIT also poses new risks and can create new barriers. Providers should be mindful of how the application about new technologies may hinder good quality patient care. When properly implemented, EMRs can help track data over time, identify patients who are due for preventive visits, better monitor patient baseline parameters (such as vaccinations and blood pressure readings), and improve overall quality of care in a practice.1 EMRs can enhance the capacity of every practice to store and recall medical information on each patient and on the practice population as a whole. They can facilitate sharing information needed for referrals and consultations. The information in an electronic record can be used for teaching, carrying out practice-based research, and evaluating the effectiveness of the practice change as part of a commitment to CQI.1 EMRs and HIT actively support other pillars in the PMH vision. In addition to storing and sharing information, the biggest benefit of this technology is the ability to collect data for practice performance and health outcomes of patients served by family practices.41 The data allow practices to measure progress through CQI goals. Larger-scale collection allows for the aggregation of anonymized data sets and measuring performance beyond the practice level.41 Strict privacy regulations ensure that patient data remain secure and confidential. Overall, QI and research benefit patients by guiding more appropriate and efficient care, which forms the basis of another key pillar of Physical space, staffing, electronic records and other digital supports, equipment, and virtual networks facilitate the delivery of timely, accessible, and comprehensive care. 2.1 All PMHs use EMRs in their practices and are able to access supports to maintain their EMR systems. 2.2 EMR products intended for use in PMHs are identified and approved by a centralized process that includes family physicians and other health care professionals. Practices are able to select an EMR product from a list of regionally approved vendors. 2.3 EMRs approved for PMHs will include appropriate standards for managing patient care in a primary care setting; e-prescribing capacity; clinical decision support programs; e-referral and consultation tools; e-scheduling tools that support advanced access; and systems that support data analytics, teaching, research, evaluation, and CQI. 2.4 Electronic records used in a PMH are interconnected, user-friendly, and interoperable. 2.5 Co-located PMH practices are in physical spaces that are accessible and set up to support collaboration and interaction between team members. 2.6 A PMH has the appropriate staff to provide timely access (e.g., having physician assistants and/or registered nurses to meet PMH goals). 2.7 A PMH has technology to enable alternative forms of care, such as virtual care/telecare. 2.8 Sufficient system funding and resources are provided to ensure that teaching faculty and facility requirements will be met by every PMH teaching site. the PMH vision— Pillar 9: Measurement, Continuous Quality Improvement, and Research. As EMR use becomes common, issues shift from rollout to optimization in the practice. Ideally, EMRs must be adequately supported financially and use a universal terminology to allow for standardized data management, and be interoperable with other electronic health records relevant to patient care.1 Training and ongoing technical support for effective use of technology must also be available. Digital information sources, especially in the sensitive areas of patient information and care planning, require a higher level of technical support to maintain faith in their use and application across stakeholder groups. A comprehensive, systematic analysis of peer-reviewed and grey literature found that cost sharing or financial sponsorship from governments is required to support the high cost of EMR adoption and maintenance. Governments in several European countries equip all primary care practices with interoperable, ambulatory care-focused electronic health records (EHRs) that allow information to flow across settings to enhance the continuity and coordination of care.1 Ensuring that government supports enable adoption, maintenance and effective use, coordination, and interoperability of electronic tools is crucial for meaningful use of this technology. A PMH will also use technology for alternative forms of care. Virtual care is clinical interactions that do not require patients and providers to be in the same room at the same time.42 Virtual visits will be financially compensated by provincial health plans. Consultations may be asynchronous, where patients answer structured clinical questions online and then receive care from a physician at a later time (e-visits), or synchronous, where patients interact with physicians in real time via telephone (teleconsultations), videoconference (virtual visits), or text.43 Virtual care increases accessibility for those living in rural and remote areas, but also in urban areas where some patients do not have a regular primary care physician or cannot access their physician for in-person appointments within a time frame that meets their current needs.43 Virtual care can also be an alternative solution for patients living in long-term care facilities and/or with mobility issues.43 Strong communication between team members allows PMH practices to function on a virtual basis when the health care professionals are not stationed in the same physical space. It is important to recognize when colocation is not feasible and maintain effective information flow in these situations, which may be especially relevant in rural and remote areas. Practices should ensure the electronic records they use are set up to support collaboration and interaction between all members of the team as much as possible, which includes all health care providers within the PMH as well as the patient’s circle of support. For example, ensuring that when patients see someone other than their most responsible provider is logged into the system and is easy to review to maintain the continuity of care. This becomes complex in situations where providers are not co-located, and further system level supports up to the level of more interoperable and universal electronic records is a prerequisite for full application of this principle. Appropriate infrastructure in a PMH is not just about technology—it includes efficient, effective, and ergonomically well-designed reception, administration, and clinical areas in the office. This is of significant benefit to staff and patients alike.44 Having a shared physical and/or virtual space where multiple team members can meet to build relationships and trust, and communicate with each other regarding patient care is essential to creating a collaborative practice. Team-based care thrives when care is intentional, when planned and regular patient care meetings are incorporated into usual PMH practice, and when these steps are included in remuneration. This collaboration ensures that patients are involved in all relevant Satisfaction with virtual visits A British Columbia study found that over 93 per cent of patients indicated that their virtual visit was of high quality, and 91 per cent reported that their virtual visit was very or somewhat helpful to resolve their health issue.43 10 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 11 discussions and are receiving the best care from professionals with a comprehensive set of skills. A family practice should be physically accessible to patients and their families. This includes ensuring all public areas, washrooms, and offices are wheelchair accessible.44 An examination room should comfortably accommodate the patient and whatever appropriate companion, or health care professionals, who may be in the room at the same time. Having multi-purpose rooms also reduces or eliminates the need to wait for an appropriate room to be available. To achieve their objectives, PMHs need the support of governments across Canada through the provision of adequate funding and other resources. Research demonstrates that in the case of EMRs, key barriers to adoption by family physicians include financial and time constraints, lack of knowledgeable support personnel, lack of interoperability with hospital and pharmacy systems,45 as well as provincial/territorial EHR systems. Therefore, government must assure funding to support the PMH team in their clinical, research, and administrative responsibilities. There must also be support for core practice components such as EMRs, patient-centred practice strategies such as group visits, and electronic communications between patients and health professionals (see Pillar 1: Administration and Funding). EMRs should help improve the delivery of care in community-based practices by enhancing productivity and processes. They are not intended to reduce time with patients, nor should they cause physician burnout or have a negative impact on physician wellness. While the structures supporting the PMH practices differs by province, it is important they cover a common set of principles enabling the base functionalities described in this document. The system must also ensure that all health professionals on the PMH team have appropriate liability protection and that adequate resources are provided so that each PMH practice can provide an optimal setting for teaching students and residents and for conducting practice-based research. Provider autonomy is critical to provider wellness: as physician leadership within the PMH is one of the key pillars, preservation of physician autonomy, while respecting the autonomy and ensuring the accountability of both patients and other health care professionals, must be addressed. Figure 2. The Patient’s Medical Neighbourhood Pillar 3: Connected Care Canada Health Infoway Established in 2001, Canada Health Infoway47 is an independent, not-for-profit organization funded by the federal government. It seeks to improve health care access, moving beyond traditional in-person care models to innovative strategies that accelerate the development, adoption, and effective use of digital health solutions across Canada. Key digital health priorities include electronic records, telehomecare, virtual visits, and patient portals. Connectivity and effective communication within and across settings of care is a crucial concept of a PMH. This ensures that the care patients receive is coordinated and continuous. To achieve this, each PMH should establish, maintain, and use defined links with secondary and tertiary care providers, including local hospitals; other specialists and medical care clinics; public health units; and laboratory, diagnostic imaging, physiotherapy, mental health and addiction, rehabilitation, and other health and social services. Connected care is a priority for many health care organizations in Canada. For example, the Canadian Foundation for Healthcare Improvement (CFHI) has established a unique program that looks at improving care connections between providers through improved use of technology.41 (See the Canadian Foundation for Healthcare Improvement textbox for more information). The Canadian Nurses Association (CNA), Canadian Medical Association (CMA), and HEAL recognize that giving Canadians the best health and health care requires creating a functionally integrated health system along the full continuum of care—a system based on interprofessional collaborative teams that ensure the right provider, at the right time, in the right place, for the right care.46 Similarly, Canada Health Infoway focuses on expanding digital health across the system to improve quality of and access to care. The PMH exists within the broader patient’s medical neighbourhood (see Figure 2), with links to all other providers in the community. It is important to maintain connections with colleagues in health care as well as social support organizations within the community, as described in Pillar 5: Community Adaptiveness and Social Accountability. Through links within the neighbourhood, PMH practices work with other providers to ensure timely access for referrals/consultations and define processes for information sharing. Establishing and maintaining these links requires open and frequent communication between all those involved in patient care. 12 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Practice integration with other care settings and services, a process enabled by integrating health information technology. 3.1 A PMH is connected with the health and social services available in the community for patient referrals. 3.2 Defined links are established between the PMH and other medical specialists, and medical care services in the local or nearest community to ensure timely referrals. 3.3 The PMH serves as a hub for collecting and sharing relevant patient information through information technology. It ensures the continuity of patient information received throughout the medical and social service settings. Ideally PMH practices act as the central hub for patient care by collecting and coordinating relevant patient information from external care providers and patients. This includes medical care and care accessed through other health and social services; for example, services received through home care programs. PMH practices should also be able to share relevant information with external providers where and when appropriate, while strictly adhering to relevant privacy regulations. This two-way flow of information ensures that all providers in the network of care have access to the most accurate and comprehensive information available, allowing them “… to spend less time looking for information and more time on what matters: treating the patient.” 49 Overall, connected care in the PMH and the health system is enabled through HIT systems. PMH practices continuously strive to work efficiently with other providers in the patient’s medical neighborhood by taking advantage of developing technologies that make links quicker to establish and easier to maintain. To use HIT systems for coordinated care, the following are required:51 Data standardization Interoperable EMR and other health information systems Real-time access to data and the ability to relay accurate information in a timely manner Reliable communication mechanisms between various health and social service providers and the PMH Privacy for patient information It is important to keep in mind that any patient information, generated during the provision of care, belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act (PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information. Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of EMRs50 for more information. Canadian Foundation for Healthcare Improvement The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait times for accessing specialty care by enabling family physicians to more efficiently manage their patients in primary care settings. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 13 14 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 FUNCTIONS The functions describe the heart of the PMH and the care provided by PMH practices. These are the key elements that differentiate a PMH from other forms of primary care. A PMH offers: Accessible Care; Community Adaptiveness and Social Accountability; Comprehensive Team-Based Care with Family Physician Leadership; Continuity of Care; and Patient- and Family-Partnered Care. ACCESSIBLE CARE PAGE 15 COMMUNITY ADAPTIVENESS & SOCIAL ACCOUNTABILITY PAGE 17 COMPREHENSIVE TEAM-BASED CARE WITH FAMILY PHYSICIAN LEADERSHIP PAGE 20 CONTINUITY OF CARE PAGE 23 PATIENT & FAMILY PARTNERED CARE PAGE 25 Equitable and ethical practices The CMA has identified equitable access to care as a key priority for reform in the health care system.53 Similarly, accessibility is a key component of the primary health care approach, which is advocated for by the CNA.54 Through the CNA’s Social Justice Gauge, and with the further development of the social justice initiative, the CNA maintains its position as a strong advocate for social justice and a leader in equitable and ethical practices in health care and public health.55 Pillar 4: Accessible Care A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 15 Accessible primary care is fundamental to a highperforming health care system and is considered by patients52 and other health care organizations as one of the most important characteristics of primary health care. For care to be accessible, all patients should have access to a family physician who acts as their most responsible provider and is supported by a team of qualified health professionals. Patients must be able to access medical care and treatment when needed. While most Canadians currently have a regular family doctor,4 it is important that the goal be for everyone in Canada to have access to their own family physicians. Accessible care is about more than just quick access to appointments. It does include timely access principles, but also advanced access, virtual access, and teambased approaches to care that ensure patients can be seen by the most appropriate provider when they need to be seen. Because visits occur for different reasons it is not useful to define appropriate wait times for each type of visit unlike in other areas of health care, such as surgery. Therefore, the focus in family practice should be on enhancing access to ensure patients can access care when they feel it is necessary. This is not to say that family physicians in a PMH must be on call 24/7/365, but that methods for patients to access care through the design of practice operations and scheduling should be given more attention. On the other hand, as patients are offered more choice (e.g., by phone or e-communication), they should also expect practices to establish realistic parameters for what is reasonable. Practices should communicate clearly about what kind of provider availability and response time is reasonable to expect depending on access method and availability of resources. Obtaining this understanding from a practice’s patients and striving to meet these expectations is a By adopting advanced and timely access, virtual access, and team-based approaches, accessible care ensures that patients can be seen quickly. 4.1 A PMH ensures patients have access to medical advice, and information on available care options 24 hours a day, 7 days a week, 365 days a year. 4.2 Every patient is registered with a PMH. 4.3 PMH practices offer scheduling options that ensure timely access to appropriate care. 4.4 When the patient’s personal family physician is unavailable, appointments are made with another physician, nurse, or other qualified health professional member of the PMH team. 4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking system. 4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and safe, high-quality care. After-hours care A Waterloo, Ontario, study found that providing after-hours clinical services reduced wait times, with services from other health care providers seen as a key for improving patient access.59 Accessible care Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment and also consults another provider in the interim), improves health outcomes, leads to better patient and provider satisfaction, and reduces emergency visits.56–58 16 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 good way to maintain the patient-centred focus of the practice as described in Pillar 1: Administration and Funding. Significant shifts in providing alternative access must be supported by funding bodies. Same-day scheduling has been introduced in many PMH practices to better accommodate patient needs. Frequently referred to as doing “today’s work today,” advanced access offers the vast majority of patients the opportunity to book their appointments on the day they call regardless of the reason for the visit.60 Read more about same day scheduling in the Best Advice guide: Timely Access to Appointments in Family Practice.61 Whenever possible, patients should have clear reasons for the appointment at the time of booking. This ensures that adequate time is planned for each patient visit. If the need to address multiple problems arises, the problems can be triaged on the spot by one of the team and arrangements made to have these concerns dealt with in a timely manner either during the same visit or at another time. It is not always possible for patients to book appointments with their most responsible family physician. To ensure continuity, appointments can be made with other physicians or health care professionals in the team. The decision about who provides care in these cases is based on the patient’s needs, the availability of team members, and the scope of practice for each team member. In these cases, any relevant information from the appointment is communicated to the most responsible provider and taken into account in the long-term care of the patient. PMH practices can further meet patients’ needs through extended office hours, in which the responsibilities for coverage and care are shared by family physicians in one or more practices, as well as by increased involvement of other team members. PMH practices also provide their patients with email, after-hours telephone, and virtual services to guide them to the right place at the right time for the care they need. Appropriately directing patients to the next available appointment, or to a hospital or another emergency service, is critical to the effective management and sustainability of our health care system.62,63 A PMH can help ensure that patients are aware of where they can go to access care and health information 24 hours a day, 365 days a year by providing this information to patients in person or via other systems (website, voice mail messages, etc.). In alignment with Pillar 9: Measurement, Continuous Quality Improvement, and Research, PMH practices offer opportunities for patients to provide feedback on the accessibility of the practice. Specifically, patients should have the opportunity to evaluate and provide input for the appointment booking system. Mechanisms and supports need to be in place to ensure that practices and governing bodies can review and respond to feedback appropriately and communicate this back to patients. Determining the optimal panel size for each PMH practice is critical to ensuring accessible and safe, high-quality care.64 Establishing and incorporating recommendations from the PMH vision may enable practices to consider increasing their panel size. Actual panel size will vary depending on the number of physicians and other team members in the practice, the practice’s obligations and A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 17 Social accountability refers to the family physicians’ obligation to meet the needs of Canada’s communities.66 For health care to be socially accountable, it must be accessible by everyone and responsive to the needs of patients, communities, and the broader population.4 This obligation is embedded in the Family Medicine Professional Profile and the Four Principles of Family Medicine, highlighting that family physicians are community-adaptive, responding to the needs of their patients and communities. These principles of family medicine align well with the principles of social accountability. Family practice is relationship-based care that embraces all issues of need and endures over time and place of care. A generalist keeps the whole in mind while attending to the individual parts, the system in mind when fixing individual problems, and the end in mind when commencing the journey. Tools exist to help family physicians and other health care providers enhance their skills and training regarding social accountability and cultural safety through many professional organizations and cross-Canada resource hubs like the National Collaborating Centre of Determinants of Health67 and the National Collaborating Centre on Aboriginal Health,68 as examples. PMH practices are aware of how the SDoH influence the health of patients and communities. Family physicians are often the best-situated primary care professionals to act on Pillar 5: Community Adaptiveness and Social Accountability A PMH is accountable to its community, and meets their needs through interventions at the patient, practice, community, and policy level. 5.1 PMHs strive to assess and address the social determinants of health (e.g., income, education, housing, immigration status) as relevant for the individual, community, and policy levels. 5.2 Panel size will consider the community’s needs and patients’ safety. 5.3 PMHs use data about marginalized/at-risk populations to tailor their care, programming, and advocacy to meet unique community needs. 5.4 Family doctors in the PMH act as health advocates at the individual, community, and policy levels, using the CanMEDs–Family Medicine (CanMEDS-FM) Framework as a guide to advocacy and are supported in doing so. 5.5 Family doctors and team members within the PMH provide care that is anti-oppressive and culturally safe, seeking to mitigate the experiences of discrimination faced by many patients based on their age, gender, race, class, sexual orientation, gender identity, ability, etc. commitment to teaching and research, and the needs of the population being served (see Pillar 5: Community Adaptiveness and Social Accountability). When deciding panel size, each practice must determine how accepting more patients into the practice might impact the current population, the sustainability of the workload for physicians and other members of the PMH team, and the consequences of panel size on experience of care. Refer to the Best Advice guide: Panel Size for more information.65 issues that affect patients’ SDoH. Advocating for patients and the health care system overall is a natural part of a PMH structure. Advocacy can occur at three levels:69 Micro: In the immediate clinical environment, daily work with individual patients and predicated on the principles of caring and compassion Meso: In the local community, including the patient’s cultural community, the local community of medical providers, and the larger civic community, in which health professionals are citizens as well as practitioners Macro: In the humanitarian realm, where physicians are concerned with the welfare of their entire patient population and seek to improve human welfare through healthy public policy (such as reducing income inequality, supporting equitable and progressive taxation, and expanding the social safety net) The principles of advocacy in family practice are found in the CanMEDS–Family Medicine 201769 competency framework, under the Health Advocate role. The Best Advice guide: Social Determinants of Health70 describes how family physicians in the PMH can make advocacy a practical part of their practice. Poverty is a significant risk factor for chronic disease, mental illness, and other health conditions. Low income and other SDoH also present significant barriers to accessing care.71 To meet the needs of these patients, practices may need to extend hours, be more flexible and responsive, and spend additional time helping patients navigate and access necessary care. PMH practices consider other specific community needs when determining appropriate panel size. Demographics and health status of the patient population can influence the length and frequency of appointments needed, thereby impacting a physician’s caseload.65 For example, a PMH in a community with high rates of chronic conditions may need to reduce the panel size to provide timely and high-quality care, given that patients require more care time and resources. Similarly, a patient’s social situation may impact the time a family physician spends with them. Family physicians and team members may need to use a translator at clinical appointments, and may need to provide written resources in alternative languages, all factors affecting the time required to provide care. Enabling PMH practices to adjust panel size based on community needs requires governments to establish blended payment mechanisms. These remuneration systems ensure family physicians are adequately compensated, and are not financially disincentivized from spending the necessary time with patients (see Pillar 1: Administration and Funding, for more information). Social accountability and cultural competency Part of the response to being more socially accountable with care offered to the community resides within each and every health professional. While courses on cultural competency are now a standard part of medical education, physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the satisfaction of being an effective healer—of ourselves, our patients and our societies. Importance of social accountability Social accountability is a key value for health care organizations and professionals. For example, the Royal College of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability within their organizations and the work they do. 18 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Family physicians and their PMH teams are situated at the nexus of individual and population health, and can engage with their patients in addressing health promotion and disease prevention in creative ways. From accompanying individual patients through teachable moments (e.g., the smoker with pneumonia ready to quit) to influencing civic policy to address homelessness, the stories entrusted to family physicians in daily practice are powerful tools for healthy change. These teams are also key providers in many important public health areas, including illness and injury prevention; health promotion; screening and managing chronic diseases; immunizations; and health surveillance. PMH practices prioritize delivering evidence-based care for illness and injury prevention and health promotion, reinforcing them at each patient visit and other counselling opportunities. PMHs and local or regional public health units should cultivate and maintain strong links with one another. Health care professionals who are part of PMH teams may take on advisory, educational, supportive, or active roles in public health initiatives, in many different occupational, educational, or recreational settings throughout the community. An effective public health system should be inextricably linked to communitybased family physicians and PMHs, recognizing and supporting them as essential to the achievement of the broader population and public health goals. While PMHs focus primarily on the care of individuals and their families, it is important for team members to understand and address the health challenges facing their practice populations and the larger community. These broader challenges represent upstream factors (SDoH) that have greater impact on the health of patients than do the efforts of individual physicians. However, the relationships embedded in individual and collective practices can be central to engaging patients and citizens in building more just and healthier communities and societies. For example, with the help of HIT, details about the needs of populations can be more easily accessed through extraction from practice EMRs, or participation in programs such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).73 The CPCSSN networks collect health information from EMRs of participating primary care providers, extract anonymous data, and share information on chronic conditions with governments, health care providers, and researchers to help inform meaningful systems and practice change. Programs like the CPCSSN allow practices to better understand the needs of their communities and implement specific health promotion and prevention programs that can contribute to the population’s overall well-being. Initiatives like this also ensure the avoidance of data duplication, and recognise that practices do not need (or have the resources) to collect data on their own. However, these data are just a part of caring—the heart of generalism is keeping the whole in mind while attending to its parts, whether it is at the level of the whole patient, the whole family, or the whole society. To meet the needs of their diverse panel of patients, family physicians and other team members in the PMH work to provide anti-oppressive and culturally-safe care, seeking to mitigate experiences of discrimination faced by many patients based on their SDoH. This requires understanding how historical and current injustices have impacted the well-being of certain populations, and working to ensure a safe and welcoming practice environment by focusing on the principles of caring and compassion. Sociodemographic data benefits The FHT at St Michael’s Hospital routinely collects sociodemographic data on all patients. Patients are surveyed about income, housing status, gender identity, and other key SDoH factors, and their responses are integrated into the secure EMR. This information is used to inform and direct individualized patient-centred care. The data will also be used for planning and evaluating the FHT’s programs.74 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 19 Pillar 6: Comprehensive Team-Based Care with Family Physician Leadership Primary care practice teams Many allied health professional organizations have prioritized the importance of working together in a team to provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes implementation strategies for creating a primary practice team, and general descriptions of roles found in a collaborative team. 20 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A broad range of services is offered by an interprofessional team. The patient does not always see their family physician but interactions with all team members are communicated efficiently within a PMH. The team might not be co-located but the patient is always seen by a professional with relevant skills who can connect with a physician (ideally the patient’s own personal physician) as necessary. 6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel of registered patients. 6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or network, collaborating with the patient’s personal family physician to provide timely access to a broad range of primary care and consulting services. 6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged and supported as part of each PMH. 6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team members may be co-located or may function as part of virtual networks. 6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers, physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed. 6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal medical home team. 6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles, professional scopes of practice, and personally acquired competencies. Their roles providing both episodic and ongoing care support and complement—but do not replace—those of the family physician. Team-based care is a core function of the PMH. Building a team with a diverse mix of professional backgrounds creates an opportunity to redefine what is considered optimal, based on the needs of the practice and the community it serves. A high-performing team is essential to delivering more comprehensive, coordinated, and effective care centred on the patient’s needs. While different circumstances call for aspects of patient care to be provided by different health professionals, it is important to ensure that family physician expertise is available to all team members through consultation. To practice effectively in an interprofessional health care team, there must be a clear understanding of each member’s unique contributions, including educational background, scopes of practice and knowledge, and areas of excellence and limitations.76 Practices that draw on the expertise of a variety of team members are more likely to provide patients with the care they need and respond to community needs.77 Relationships across all dynamics within a practice, whether between a patient and family physician or between a patient and other members of the team, should be encouraged and supported in the PMH. Establishing these relationships develops trust and confidence, and works toward the ultimate goal of achieving better health outcomes. While it should be left to each practice to determine who does what (within the boundaries of professional scopes of practice), the most responsible provider for the medical care for each patient in the practice should be the patient’s personal family physician. Family physicians with enhanced skills and family physicians with focused practices play an important role in collaborating with the patient’s personal family physician and team to provide timely access to a range of primary care and consulting services. They supplement their core skills and experience with additional expertise in a particular field, while remaining committed to their core generalist principles.78 These doctors can draw extensively on their generalist training and approach to disease management and patient-centred care, enabling them to work collaboratively at different levels of care, including with other specialists, to meet patient needs.79 These clinicians also serve as a resource for other physicians in their local health system by enhancing care delivery and learning and teaching opportunities. The Best Advice guide: Communities of Practice in the Patient’s Medical Home80 provides more information about intraprofessional collaboration between family physicians. Shared care strategies provide patients with timely access to consultations with other specialists or family physicians with enhanced skills at scheduled times in the family practice office setting. The consultant might assess several patients per visit, at which time a plan for ongoing care can be developed and agreed to by the family physician, consultant, other team members, and the patient. There is no one-size-fits-all model when determining what mix of health care professionals is right. Team composition depends on the professional competencies, skills, and experiences needed to address the health needs of the patient population.81 These needs vary, depending on the communities’ defining characteristics; Additional members of practice teams Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices can also host other health care professionals, such as those employed with a regional health authority, to provide care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other health care professionals often carry the overhead costs associated with these practitioners working on site, and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1: Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly funded and have access to the right infrastructure (physical and governance) to support the initiatives described in this vision. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 21 22 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 for example, geography, culture, language, demographics, disease prevalence. Family physicians are encouraged to identify the gaps in health care provision in the local practice environment and work with other health care providers to meet those needs as much as possible. Data from EMRs—as well as input from patients, community members, and stakeholders—should inform team planning. Factors to consider include: Patient population Identified community health care needs Hours available for patient access Hours available for each physician to work Roles and number of non-physician providers Funds available81 Overlapping or variations of similar competencies can result in ambiguous expectations of what a defined role is within a practice. When teams are planned and developed, roles should be clearly outlined. This is best done at the local practice level relative to community needs and resources. This approach considers changes over the course of a health care professional’s career, including skills development, achievement of certifications, and professional interests.82 It is important to include time for team members to become comfortable in their role, at the outset of team-based care and with any changes to the team. It is also important to recognize that these arrangements are flexible and subject to change, provided the team engages in discussion and reaches consensus on needed adjustments. Team members might be in the same office or in the same building, but this is not necessary. For smaller and more remote practices, or larger urban centres where proximate physical space may be a barrier, some connections may be arranged with peers in other sites. Applying HIT judiciously allows for virtual referrals and consultations. Virtual links between PMH practices and other specialists, hospitals, diagnostic services, etc., can be enhanced with more formal agreements and commitments to provide timely access to care and services. By providing patients with a comprehensive array of services that best meet their needs, team-based care can lead to better access, higher patient and provider satisfaction, and greater resource efficiency.61,77,83 Although there are presently many systems in place that support the creation of health care teams, practices can also create a successful team on their own. To ensure team success, providers must have a clear understanding of the different role responsibilities and ensure that there are tools available to engage open dialogue and communication. Teams within the PMH are supported by a model that is flexible and adaptable to each situation. The skills that family physicians acquire during their training (as described in the CanMEDS-FM framework) make them well suited to provide leadership within interprofessional teams. As an important part of a PMH, teams are central to the concept of patient-centred care that is comprehensive, timely, and continuous. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 23 Pillar 7: Continuity of Care Continuity of care is defined by consistency over time related to where, how, and by whom each person’s medical care needs are addressed throughout the course of their life.84 With strong links to comprehensive team-based care (see Pillar 6: Comprehensive Team-Based Care with Family Physician Leadership), continuity of care is essential to any practice trying to deliver care truly centred on the needs of the patient. Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review.84 From the patient’s perspective, this includes understanding each person’s life journey and the context this brings to current health status, and the trust they have in their provider that is built over time. Past studies show that when the same physician attends to a person over time, for both minor and more serious health problems, the patient-physician relationship is strengthened and understanding grows—an essential element of effective primary health care.85 The personal physician offers their medical knowledge and expertise for a more complete understanding of the patient as a person, including the patient’s medical history and their broader social context, such as personal, family, social, and work histories (see Pillar 5: Community Adaptiveness and Social Accountability). In this model, patients, their families and/or personal caregivers, and all health care providers in the PMH team are partners in care, working together to achieve the patient’s goals and engaging in shared decision making. Understanding the patient’s needs, hopes, and fears, and their patterns of response to illness, medications, and other treatments, deepens the physician’s ability to respond to larger trends, not just the medical issue presented at any given appointment. Continuity of care can ideally support the health and well-being of patients actively and in their daily lives without focusing only on care when they are ill. The strong physician-patient relationship developed over time allows them to maintain good health and prevent illness and injury, as the physician uses their deep knowledge of their patient to work with teams of qualified health professionals to best support the patient’s well-being. Family physicians in the PMH, acting as the most responsible provider, can provide continuous care over the patient’s lifespan and develop strong relationships with patients. Research demonstrates that one of the most significant contributors to better population health is continuity of care.86,87 It found that those who see the same primary care physician continuously over time have better health outcomes, reduced emergency department use, and reductions in hospitalizations versus those who receive care from many different physicians. A Canadian study found that after controlling for demographics and health status, continuity of care was a predictor of decreased hospitalization for ambulatory caresensitive conditions (such as such as COPD, asthma, diabetes, and heart failure) and decreased emergency department visits for a wide range of family practicesensitive conditions.85 Overall “the more physicians patients see, the greater the likelihood of adverse effects; seeking care from multiple physicians in Patients live healthier, fuller lives when they receive care from a responsible provider who journeys with them and knows how their health changes over time. 7.1 The PMH enables and fosters long-term relationships between patients and the care team, thereby ensuring continuous care across the patient’s lifespan. 7.2 PMH teams ensure continuity of care is provided for their patients in different settings, including the family practice office, hospitals, long-term care and other community-based institutions, and the patient’s residence. 7.3 A PMH serves as the hub that ensures coordination and continuity of care related to all the medical services their patients receive throughout the medical community. the presence of high burdens of morbidity will be associated with a greater likelihood of adverse side effects.”86 It has been reported that a regular and consistent source of care is associated with better access to preventive care services, regardless of the patient’s financial status. Continuity of care also requires continuity in medical settings, information, and relationships. Having most medical services provided or coordinated in the same place by one’s personal family physician and team has been shown to result in better health outcomes.88 As described in Pillar 3: Connected Care, when care must be provided in different settings or by different health professionals (i.e., the medical neighbourhood), continuity can still be preserved if the PMH plays a coordination role and communicates effectively with other providers. The PMH liaises with external care providers to coordinate all aspects of care provided to patients based on their needs. This includes but is not limited to submitting and following up on referrals to specialized services, coordinating home care, and working with patients before and after discharge from hospitals or other critical care centres. In addition to this coordination role, the PMH acts as a hub by sharing, collecting, storing, and acting as a steward for all relevant patient information. This ensures that the family physician, as the most responsible provider, has a complete overview of the patient’s history. A record of care provided for each patient should be available in each medical record (preferably through an EMR) and available to all appropriate care providers (see Pillar 2: Appropriate Infrastructure for more information about EMRs). Knowing that medical information from all sources (i.e., providers inside and outside the PMH) is consolidated in one location (physical or virtual) increases the comfort and trust of patients regarding their care. Continuity for patient health Research demonstrates that continuity of care is a key contributor to overall population health. Patients with a regular family physician experience better health outcomes and fewer hospitalizations as compared to those without.69 24 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Pillar 8: Patient- and Family-Partnered Care External factors for patient health care Patient- and family-partnered care is considered a key value to stakeholders across the health care system. In 2011, the CMA and the CNA released a set of principles to guide the transformation of Canada’s health care system.91 Patient-centred care is listed as the first principle, and as a key component of improving the overall health care experience.91 Similarly, in 2016 Patients Canada called on all levels of government to ensure that patients are at the centre of any new health accords and future health care reform.92 * Family caregivers include relatives, partners, friends, neighbours, and other community members. Patient-centred care is at the core of the PMH. Dr. Ian McWhinney—often considered the “father of family medicine”—describes patient-centred care as the provider “enter[ing] the patient’s world, to see the illness through the patient’s eyes … [It] is closely congruent with and responsive to patients’ wants, needs and preferences.”89 In this model, patients, their families and/ or personal caregivers, and all health care providers in the PMH team are partners in care, working together to achieve the patient’s goals and engaging in shareddecision making. Care should always reflect the patient’s feelings and expectations and meet their individual needs. Refer to the Best Advice guide: Patient-Centred Care in a Patient’s Medical Home90 for more information. Family caregivers* play an important role in the PMH. They help patients manage and cope with illness and can assist physicians by acting as a reliable source of health information and collaborating to develop and enact treatment plans.93 The level and type of engagement from family caregivers should always be determined by the patient. Physicians “should routinely assess the patient’s wishes regarding the nature and degree of caregiver participation in the clinical encounter and strive to provide the patient’s desired level of privacy.”94 They should revisit this conversation regularly and make changes based on patient desires. PMH practices focus on providing patient-centred care and ensuring that family caregivers are included. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 25 Family practices respond to the unique needs of patients and their families within the context of their environment. 8.1 Care and care providers in a PMH are patient-focused and provide services that respond to patients’ feelings, preferences, and expectations. 8.2 Patients, their families, and their personal caregivers are active participants in the shared-decision making process. 8.3 A PMH facilitates patients’ access to their medical information through electronic medical records as agreed upon with their care team. 8.4 Self-managed care is encouraged and supported as part of the care plans for each patient. 8.5 Strategies that encourage access to a range of care options beyond the traditional office visits (e.g., telehealth, virtual care, mobile health units, e-consult, etc.) are incorporated into the PMH. 8.6 Patient participation and formalized feedback mechanisms (e.g., patient advisory councils, patient surveys) are part of ongoing planning and evaluation. As part of their commitment to patient-centred care, PMH practices facilitate and support patient self-management. Self-management interventions such as support for decision making, self-monitoring, and psychological and social support, have been demonstrated to improve health outcomes.95 PMH team members should always consider recommendations for care from the patient’s perspective. They should work collaboratively with patients and their caregivers to develop realistic action plans and teach problem-solving and coping. This is particularly important for those with chronic conditions, who must work in partnership with their physician and health care team to manage their condition over time. (Refer to the Best Advice guide: Chronic Care Management in a Patient’s Medical Home96 for more information). The goal of self-managed care should be to build the patient’s and caregiver’s confidence in their ability to deal effectively with illnesses, improve health outcomes, and foster overall well-being. To facilitate patient- and family-partnered care, a range of user-friendly options for accessing information and care beyond the traditional office visit should be available to patients when appropriate. These include email, telehealth, virtual care, mobile health units, e-consults, home visits, same-day scheduling, group visits, self-care strategies, patient education, and treatment sessions offered in community settings. Providing a range of options allows patients to access the type of care they prefer based on individual needs. Patients also need to be informed about how they can access information and resources available to them; for example, resources such as Prevention in Hand (PiH).97 Allowing patients to access to their medical records can improve patient-provider communication and increase patient satisfaction.98,99 The specific information accessible to patients should be discussed and agreed upon by the patient and their care team. Patient education about accessing and interpreting the available information is necessary. Facilitating this type of access requires each PMH to have an EMR system that allows external users to access information securely (see Pillar 2: Appropriate Infrastructure). Patient surveys and opportunities for patients to participate in planning and evaluating the effectiveness of the practice’s services should be encouraged; practices must be willing respond and adapt to patient feedback. To strengthen a patient-centred approach, practices may consider developing patients’ advisory councils or other formalized feedback mechanisms (e.g., using patient surveys) as part of their CQI processes (see Pillar 9: Measurement, Continuous Quality Improvement, and Research). Patient self-management The Ajax Harwood Clinic (AHC) is a good example of how a practice that enables patient self-management can improve long-term health outcomes, especially for patients with chronic conditions.94 The AHC has created an environment of learning and seeks to encourage health literacy among its patients through its various programs. The clinic is focused on patient education and empowerment, and all programs at the clinic are free of charge to patients to remove financial barriers to access. 26 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 27 ONGOING DEVELOPMENT Each PMH strives for ongoing development to better achieve the core functions. The PMH and its staff are committed to Measurement, Continuous Quality Improvement, and Research; and Training, Education, and Continuing Professional Development. MEASUREMENT, CONTINUOUS QUALITY IMPROVEMENT, AND RESEARCH PAGE 28 TRAINING, EDUCATION, AND CONTINUING PROFESSIONAL DEVELOPMENT PAGE 30 28 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Continuous quality improvement CQI is an important value among health organizations such as the CFHI.100 Pillar 9: Measurement, Continuous Quality Improvement, and Research CQI is an essential characteristic of the PMH vision. It encourages health care teams to make practical improvements to their practice, while monitoring the effectiveness of their services, the health outcomes and safety of their patients, and the satisfaction of both patients and the health professionals on the team. Every PMH is committed to establishing a CQI program that will improve patient safety, and enhance efficiency and quality of the services provided to patients. As part of CQI activities, a structured approach is used to evaluate current practice processes and improve systems and to achieve desired outcomes. To engage in CQI, the PMH team must identify the desired outcomes and determine appropriate evaluation strategies. Once the process and the desired outcome are defined with patients, the CQI activity will track performance through data collection and comparison with the baseline. Performance measures can be captured through structured observation, patient and staff surveys (see Pillar 8: Patient- and Family- Partnered Care), the PMH self-assessment tool, and the practice’s EMR (see Pillar 1: Administration and Funding and Pillar 3: Connected Care). The indicators selected should be appropriate to each practice and community setting, be meaningful to the patients and community, and the CQI process could be introduced as a practice’s self-monitoring improvement program or as an assessment carried out by an external group. In some jurisdictions, funding is tied to achieving performance targets, including those that provide evidence for the delivery of more cost-effective care and better health outcomes.101 Some provinces in Canada have begun to link financial incentives to clinical outcomes and targets that have been achieved (“pay for performance” models).102 Although there may be some benefits derived by this approach, there can also be risks if funding incentives and resource supports become overly focused on patients with certain medical problems or on those who have greater potential to reach prescribed targets, while at the same time care is being delayed or denied for others.101,103 Future development A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 28 Family practices strive for progress through performance measurement and CQI. Patient safety is always a focus, and new ideas are brought to the fore through patient engagement in QI and research activities. 9.1 PMHs establish and support CQI programs that evaluate the quality and cost effectiveness of teams and the services they provide for patient and provider satisfaction. 9.2 Results from CQI are applied and used to enhance operations, services, and programs provided by the PMH. 9.3 All members of the health professional team (both clinical and support teams), as well as trainees and patients, will participate in the CQI activity carried out in each PMH. 9.4 PMHs support their physicians, other health professionals, students, and residents to initiate and participate in research carried out in their practice settings. 9.5 PMHs function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 29 of financial incentive models should consider these unintended consequences that might impair the ability of practices to provide good quality patient care to their full population. The objectives that define a PMH could be used to develop the indicators for CQI initiatives in family practices across Canada. These criteria could be augmented by indicators recommended by organizations such as Accreditation Canada, Health Quality Ontario, Health Standards Organization, and the Patient-Centered Medical Home model in the United States. The CFPC is committed to collaborating with these groups to further develop the CQI process for PMHs and family practices. Consult the CFPC’s Practice Improvement Initiative (Pii)104 for a list of available resources. CQI is a team activity and should involve all members of the PMH team as well as patients and trainees. This will ensure buy-in from the team, allow for patient engagement and participation, and provide trainees with valuable learning opportunities.105 PMHs are committed to using the results of CQI initiatives to make tangible changes in their practice to improve operations, services, and programs. Time and effort invested into participation in CQI activities should be recognized as valuable and not be disincentivized through existing remuneration models. Dedicated time and capacity to perform these activities should be built into the practice operational principles. On a larger scale, PMHs function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services. The PMH team should be encouraged and supported to participate in research activities. They should also advocate for medical students, residents, and trainees to take part in these projects. In Canada, the Canadian Primary Healthcare Research Network (CPHRN) and the commitment of the Canadian Institutes for Health Research’s (CIHR’s) Strategy for Patient-Oriented Research (SPOR) are vitally important.106 The focus on supporting patient-oriented research carried out in community primary care settings is consistent with the priorities of the PMH. Competitions for research grants such as those announced by SPOR should be strongly encouraged and supported. PMHs are ideal laboratories for studies that embrace the principles of comparative effectiveness research (CER) and the priorities defined by the CPHRN and CIHR’s SPOR project. They provide excellent settings for multi-site research initiatives, including projects like those currently undertaken by the CPCSSN—a nationwide network of family physicians conducting surveillance of various chronic diseases. 30 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Pillar 10: Training, Education, and Continuing Professional Development PMH practices serve as training sites for medical students, family medicine residents, and those training to become nurses and other health care professionals.107 They create space for modelling and teaching practices focused on the essential roles of family physicians and interprofessional teams as part of the continuum of a health care system. One of the goals of family medicine residency training is for residents to learn to function as a member of an interdisciplinary team, caring for patients in a variety of settings including family practice offices, hospitals, long-term care and other communitybased institutions, and patients’ residences.70,108 A PMH also models making research and QI initiatives a standard feature of a family practice. Professional development and opportunities to participate in these activities should be available and supported within PMH practices through resources, guidance, and specifically dedicated time. Family medicine training is increasingly focused on achieving and maintaining competencies defined by the CFPC’s Triple C Family Medicine Curriculum.109 Triple C includes five domains of care: care of patients across the life cycle; care across clinical settings (urban and rural); a defined spectrum of clinical responsibilities; care of marginalized/disadvantaged patients and populations; and a defined list of core procedures. Triple C also incorporates the Four Principles of Family Medicine and the CanMEDS-FM Roles. PMHs allow family medicine students and residents to achieve the competencies of the Triple C curriculum and to learn how to incorporate the Four Principles of Family Medicine, the Family Medicine Professional Profile, and the CanMEDS-FM roles into their professional lives. Learners gain experience with patient-partnered care, teams/networks, EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated and complex problems, coordination of care, practice-based research, and CQI—essential elements of family practice in Canada. Furthermore, PMH practices serve as optimal sites for trainees in other medical specialties and health professions to gain valuable experience working in interprofessional teams and providing high quality, patient-centred care. Medical schools and residency programs should encourage learners to conduct some of their training within PMH practices. Emphasis on training and education ensures that the knowledge and expertise of family physicians can be shared with the broader health care community, and also over time by creating learning organizations where both students and fully practising family physicians can stay at the forefront of best practice. 10.1 PMHs are identified and supported by medical and other health professional schools as optimal locations for the experiential training of their students and residents. 10.2 PMHs teach and model their core defining elements including patient-partnered care, teams/networks, EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated and complex problems, coordination of care, practice-based research, and CQI. 10.3 PMHs provide a training environment for family medicine residents that models, and enables residents to achieve, the competencies as defined by the Triple C Competency-based Family Medicine Curriculum, the Four Principles of Family Medicine, and the CanMEDS-FM Roles. 10.4 PMHs will enable physicians and other health professionals to engage in continuing professional development (CPD) to meet the needs of their patients and their communities both individually and as a team. 10.5 PMHs enable family physicians to share their knowledge and expertise with the broader health care community. Practising family physicians must engage in CPD to keep current on medical and health care developments and to ensure their expertise reflects the changing needs of their patients, communities, and learners. Mainpro+® (Maintenance of Proficiency) is the CFPC’s program designed to support and promote family physicians’ CPD across all CanMEDS-FM Roles and competencies. CPD refers to physicians’ professional obligation to engage in learning activities that address their own identified needs and the needs of their patients; enhance knowledge, skills, and competencies across all dimensions of professional practice; and continuously improve their performance and health care outcomes within their scope of practice.110 Three foundational principles for CPD in Canada have been recently described: Socially responsive to the needs of patients and communities Informed by scientific evidence and practicebased data Designed to achieve improvement in physician practice and patient outcomes CPD is inclusive of learning across all CanMEDS-FM Roles and competencies, including clinical expertise, teaching and education, research and scholarship, and in practice-based QI. PMH practices support their physicians, and all other staff members, to engage in CPD activities throughout their careers by creating a learning culture in the organization. This includes providing protected time for learning and team-based learning, and access to practice data both to discern patient/community need and practice gaps to inform CPD choices and to evaluate the impact of learning on patient care. This learning culture and the will to be constantly improving quality and access to care is essential to ensuring that the PMH continues to support high performing care teams. To ensure that all PMH team members have the capacity to take on their required roles, leadership development programs should be offered. Enabling physicians to engage in this necessary professional development requires sufficient funding by governments to cover costs of training and financial support to ensure lost income and practice capacity do not prevent this. Physicians in the PMH share their knowledge with colleagues in the broader health care community and with other health care professionals in the team by participating in education, training, and QI activities in collaboration with the pentagram partners.† This is particularly relevant for family physicians who are focused on a particular area of practice (possibly holding a Certificate of Added Competence) and are able to share their extended expertise with others. This can happen either informally or through more official channels. For example, physicians may participate in activities organized by the CFPC or provincial Chapters (e.g., Family Medicine Forum, provincial family medicine annual scientific assemblies), or lend their expertise to interprofessional working groups addressing specific topics in health care. Family physicians should be encouraged to engage in these types of events to share their knowledge and skills for the betterment of the overall health system. Continuing professional development CPD is an integral value across the entire health care system. Organizations such as the Royal College, CMA, and CNA emphasize the value and importance of continuing education for health care professionals to improve patient care. † Pentagram partners: policy-makers—federal, provincial, territorial, and regional health authorities; health and education administrators; university; community; health professionals—physicians and teams A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 31 32 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 CONCLUSION The revised PMH vision of a high-functioning primary care system responds to the rapidly evolving health system and the changing needs of Canadians. The pillars and attributes described in this document can guide practices at various stages in the transition to a PMH, and many characteristics are found in other foundational documents of family medicine such as the Family Medicine Professional Profile111 and the Four Principles of Family Medicine. Supporting resources, such as the PMH Implementation Kit, are available to help those new to the transition overcome barriers to change. Although the core components of the PMH remain the same for all practices, each practice will implement the recommendations according to their unique needs. The PMH is focused on enhancing patient-centredness in the health care system through collaboration, access, continuity, and social accountability. It is intended to build on the long-standing historical contribution of family physicians and primary care to the health and wellbeing of Canadians, as well as on the emerging models of family practice and primary care that have been introduced across the country. Importantly, this vision provides goals and recommendations that can serve as indicators. It enables patients, family physicians, other care health professionals, researchers, health planners, and policy-makers evaluate the effectiveness of any and all models of family practice throughout Canada. Those family practices that meet the goals and recommendations described in this vision will have become PMHs, but the concept is ever evolving. As family physicians commit to making change in their practices, the CFPC commits to supporting developments in the PMH by creating and promoting new resources, which will be available through the PMH website. The CFPC will also play an important advocacy role to ensure that the necessary supports are in place to reach the goals of a PMH. Every family practice across Canada should be supported and encouraged by the public, governments, and other health care stakeholders (the pentagram partners) to achieve this objective. Doing so will ensure that every person in Canada is able to access the best possible primary care for themselves and their loved ones. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 33 REFERENCES 1. College of Family Physicians of Canada. A Vision for Canada: Family Practice - The Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2011. Available from: www.cfpc.ca/uploadedFiles/Resources/ Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 2019 Jan 21. 2. National Physician Survey. 2014 National Physician Survey website. http:// nationalphysiciansurvey.ca/surveys/2014-survey/. Accessed 2019 Jan 22. 3. 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General Practice Services Committee. What We Do: Patient Medical Homes website. www.gpscbc.ca/what-we-do/patient-medical-homes-and-primary-carenetworks. Accessed 2018 Aug 22. 14. Government of Manitoba. Frequently Asked Questions about My Health Teams website. www.gov.mb.ca/health/primarycare/myhts/faq.html#manitoba. Accessed 2018 Aug 15. 15. Chateau D, Katz A, Metge C, Taylor C, McDougall C, McCulloch S. Describing Patient Populations for the My Health Team Initiative. Winnipeg, MB: Manitoba Centre for Health Policy; 2017. Available from: http://mchp-appserv.cpe. umanitoba.ca/reference//hiusers_Report_web.pdf. Accessed 2019 Jan 22. 16. Government of Manitoba. Budget Paper F: Reducing Poverty and Promoting Community Involvement. Winnipeg, MB: Government of Manitoba; 2018. Available from: www.gov.mb.ca/finance/budget18/papers/F_Reducing_ Proverty_r.pdf. Accessed 2019 Jan 22. 17. Government of New Brunswick. New model for family medicine aims to improve physician access [news release]. 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Available from: www.oma.org/wp-content/ uploads/sept2012_primary_care_model.pdf. Accessed 2019 Jan 22. 25. Tiagi R, Chechulin Y. The Effect of Rostering with a Patient Enrolment Model on Emergency Department Utilization. Healthcare Policy. 2014;9(4):105-121. Available from: www.longwoods.com/content/23809//the-effect-of-rosteringwith- a-patient-enrolment-model-on-emergency-department-utilization. Accessed 2019 Jan 22. 26. Health PEI. Health Centres Offer Primary Care [news release]. Charlottetown, PE: Government of Prince Edward Island; 2015. Available from: www. princeedwardisland.ca/en/information/health-pei/health-centres-offerprimary- care. Accessed 2019 Jan 22. 27. Gouvernement du Québec. Groupe de médecine de famille (GMF), groupe de médecine de famille universitaire (GMF-U) et super-clinique website. www. quebec.ca/sante/systeme-et-services-de-sante/organisation-des-services/gmfgmf- u-et-super-clinique/. Accessed 2019 January. 28. Government of Saskatchewan. Fact Sheet: Connected Care [news release]. Regina, SK: Government of Saskatchewan; 2018. 29. Pomey MP, Ghadiri DP, Karazivan P, Fernandez N, Clavel N. Patients as partners: a qualitative study of patients’ engagement in their health care. PLoS One. 2015;10(4):e0122499. 30. Pointer DD, Orlikoff JE. Board Work: Governing Health Care Organizations. 1st ed. San Francisco, CA: Jossey-Bass; 1999. 31. Canadian Foundation for Healthcare Improvement. Mythbusters: Most Physicians Prefer Fee-for-Services Payments. Ottawa, ON: Canadian Foundation for Healthcare Improvement; 2010. Available from: www.cfhi-fcass. ca/sf-docs/default-source/mythbusters/Myth-Fee-for-Service-E.pdf?sfvrsn=0. Accessed 2019 Jan 22. 32. Blomqvist A, Busby C. How to Pay Family Doctors: Why “Pay per Patient” is Better than Fee for Service. Toronto, ON: C.D Howe Institute; 2012. Available from: www.cdhowe.org/sites/default/files/attachments/research_papers/ mixed/Commentary_365.pdf. Accessed 2019 Jan 22. 33. Holden M, Madore O. Remuneration of Primary Care Physicians (PRB 01-35E). Ottawa, ON: Library of Parliament, Parliamentary Research Branch; 2002. Available from: http://publications.gc.ca/collections/Collection-R/LoPBdP/ PRB-e/PRB0135-e.pdf. Accessed 2019 Jan 22. 34. Carter R, Riverin B, Levesque JF, Gariepy G, Quesnel-Vallee A. The impact of primary care reform on health system performance in Canada: a systematic review. BMC Health Serv Res. 2016;16:324. 35. Kiran T, Kopp A, Moineddin R, Glazier RH. Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention. CMAJ. 2015;187(17):E494-502. 36. College of Family Physicians of Canada. Best Advice guide: Physician Remuneration in a Patient’s Medical Home. Mississauga, ON: 34 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 College of Family Physicians of Canada; 2016. 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Toronto, ON: Canada Health Infoway; 2017. 41. College of Family Physicians of Canada. Supporting access to data in electronic medical records for quality improvement and research [position statement]. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Health_Policy/CFPC_Policy_ Papers_and_Endorsements/CFPC_Policy_Papers/CFPC-Position-Statement- Supporting-access-data-electronic-medical-records-EN.pdf. Accessed 2019 Jan 22. 42. Jamieson T, Wallace R, Armstrong K, Agarwal P, Griffin B, Wong I, et al. Virtual Care: A Framework for a Patient-Centric System. Toronto, ON: Women’s College Hospital Institute for Health Systems Solutions and Virtual Care; 2015. Available from: www.womenscollegehospital.ca/assets/pdf/wihv/WIHV_ VirtualHealthSymposium.pdf. Accessed 2019 Jan 22. 43. McGrail KM, Ahuja MA, Leaver CA. Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study. J Med Internet Res. 2017;19(5):e177. 44. Canadian Medical Association. Managing your Practice website. www.cma.ca/ managing-your-practice. Accessed 2019 Jan 22. 45. Chang F, Gupta N. Progress in electronic medical record adoption in Canada. Can Fam Physician. 2015;61(12):1076-1084. 46. Canadian Nurses Association, Canadian Medical Association, Health Action Lobby. Integration: A New Direction for Canadian Health Care—A Report on the Health Provider Summit Process. Ottawa, ON: Canadian Nurses Association; 2013. Available from: www.cna-aiic.ca/~/media/cna/files/en/cna_ cma_heal_provider_summit_transformation_to_integrated_care_e.pdf. Accessed 2019 Jan 22. 47. Canada Health Infoway website. www.infoway-inforoute.ca/en/. Accessed 2019 Jan 22. 48. Canadian Foundation for Healthcare Improvement. Connected Medicine website. www.cfhi-fcass.ca/WhatWeDo/connected-medicine. Accessed 2018 Aug 15. 49. Rajakulendra N, Macintosh E, Salah H. Transforming Health: Toward decentralized and connected care. Toronto, ON: MaRS Discovery District; 2014. Available from: www.marsdd.com/wp-content/uploads/2014/09/Sep15- MaRS-Whitepapers-SmartHealth.pdf. Accessed 2019 Jan 22. 50. College of Family Physicians of Canada. Best Advice guide: Advanced and Meaningful Use of EMRs. Mississauga, ON: College of Family Physicians of Canada; 2018. Available from: https://patientsmedicalhome.ca/resources/ best-advice-guides/best-advice-guide-advanced-and-meaningful-use-ofemrs/. Accessed 2019 Jan 22. 51. Ontario Primary Care Council. Position Statement: Care Co-ordination in Primary Care. Toronto, ON: Ontario Primary Care Council; 2015. Available from: www.afhto.ca/wp-content/uploads/OPCC_Care-Coordination-Position. pdf. Accessed 2019 Jan 22. 52. Wong ST, Watson DE, Young E, Regan S. What do people think is important about primary healthcare? Healthcare Policy. 2008; 3(3):89-104. 53. Canadian Medical Association. CMA Position Statement: Ensuring Equitable Access to Care: Strategies for Government, Health System Planners and the Medical Profession. Ottawa, ON: Canadian Medical Association; 2014. Available from: www.cma.ca/sites/default/files/2018-11/PD14-04-e.pdf. Accessed 2019 Jan 22. 54. Canadian Nurses Association. Position Statement: Primary Health Care. Ottawa, ON: Canadian Nurses Association; 2015. Available from: www.cna-aiic. ca/-/media/cna/page-content/pdf-en/primary-health-care-position-statement. pdf. Accessed 2019 Jan 22. 55. Canadian Nurses Association. Social Justice … a means to an end, an end in itself; 2nd edition. Ottawa, ON: Canadian Nurses Association; 2010. Available from: www.cna-aiic.ca/~/media/cna/page-content/pdf-en/social_justice_2010_e. pdf. Accessed 2019 Jan 22. 56. Barry DW, Melhado TV, Chacko KM, Lee RS, Steiner J, Kutner JS. Patient and physician perceptions of timely access to care. J Gen Intern Med. 2006;21(2):130-133. 57. Glass DP, Kanter M, Jacobsen SJ, Minardi PM. The impact of improving access to primary care. J Eval Clin Pract. 2017;23(6):1451-1458. 58. Hudec JC, MacDougall S, Rankin E. Advanced access appointments: effects on family physician satisfaction, physicians’ office income, and emergency department use. Can Fam Phys. 2010;56(10):e361-e367. 59. Stalker CA. How have physicians and patients at New Vision Family Health Team experienced the shift to a family health team model? Final Report. Unpublished; 2010. 60. Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag. 2000;7(8):45-50. 61. College of Family Physicians of Canada. Best Advice guide: Timely Access to Appointments in Family Practice. Mississauga, ON: College of Family Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/ resources/best-advice-guides/best-advice-guide-timely-access/. Accessed 2019 Jan 22. 62. Lemire F. First contact: what does it mean for family practice in 2017? Can Fam Phys. 2017;63(3):256. 63. Williams DL. Balancing rationalities: gatekeeping in health care. J Med Ethics. 2001;27(1):25-29. 64. Murray M, Davies M, Boushon B. Panel size: How many patients can one doctor manage? Fam Pract Manag. 2007;14(4):44-51. 65. College of Family Physicians of Canada. Best Advice guide: Panel Size. Mississauga, ON: College of Family Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/resources/best-advice-guides/bestadvice- guide-panel-size/. Accessed 2019 Jan 22. 66. Buchman S, Woollard R, Meili R, Goel R. Practising social accountability. Can Fam Phys. 2016; 62(1):15-18. 67. National Collaborating Centre of Determinants of Health website. www.nccdh. ca/. Accessed 2019 Jan 22. 68. National Collaborating Centre on Aboriginal Health website. www.nccahccnsa. ca/en/. Accessed 2019 Jan 22. 69. College of Family Physicians of Canada. CanMEDS–Family Medicine 2017: A competency framework for family physicians across the continuum. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_ Professionals/CanMEDS-Family-Medicine-2017-ENG.pdf. Accessed 2019 Jan 22. 70. College of Family Physicians of Canada. Best Advice guide: Social Determinants of Health. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/bestadvice- guides/best-advice-guide-social-determinants-health/. Accessed 2019 Jan 22. 71. Lightman E, Mitchell A, Wilson B. Poverty is making us sick: A comprehensive survey of income and health in Canada. Toronto, ON: The Wellesley Institute; 2008. Available from: www.wellesleyinstitute.com/wp-content/uploads/2011/11/ povertyismakingussick.pdf. Accessed 2019 Jan 18. 72. White AA 3rd, Logghe HJ, Goodenough DA, Barnes LL, Hallward A, Allen IM, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial Ethn Health Disparities. 2018;5(1):34-49. 73. Canadian Primary Care Sentinel Surveillance Network website. http://cpcssn. ca/. Accessed 2019 Jan 22. 74. Pinto AD, Bloch G. Framework for building primary care capacity to address the social determinants of health. Can Fam Phys. 2017;63(11):e476-482. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 35 75. College of Family Physicians of Canada. Best Advice guide: Team-Based Care in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/ best-advice-guides/best-advice-guide-team-based-care-patients-medical-home/. Accessed 2019 Jan 22. 76. Grant R, Finocchio L, Pew Health Professions Commission, California Primary Care Consortium. Interdisciplinary collaborative teams in primary care: a model curriculum and resource guide. San Francisco, CA: Pew Health Professions Commission; 1995. 77. Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, et al. Creating Patient-Centered Team-Based Primary Care. AHRQ Pub. No. 16- 0002-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016. 78. Department of Health. Part 3: The accreditation of GPs and Pharmacists with Special Interests, In: Implementing care closer to home: Convenient quality care for patients. London, UK: Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/files/articles/attachments/improved_quality_ of_care_p3_accreditation.pdf. Accessed 2019 Jan 22. 79. Department of Health. Part 1: Introduction and overview, In: Implementing care closer to home: Convenient quality care for patients. London, UK: Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/ files/articles/attachments/improved_quality_of_care_p1_introduction.pdf. Accessed 2019 Jan 22. 80. College of Family Physicians of Canada. Best Advice guide: Communities of Practice in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2016. Available from: https://patientsmedicalhome. ca/resources/best-advice-guides/communities-practice-patients-medicalhome/. Accessed 2019 Jan 22. 81. Dinh T. Improving Primary Health Care Through Collaboration: Briefing 2— Barriers to Successful Interprofessional Teams. Ottawa, ON: The Conference Board of Canada; 2012. Available from: www.conferenceboard.ca/e-library/ abstract.aspx?did=5181&AspxAutoDetectCookieSupport=1. Accessed 2019 Jan 22. 82. Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, et al. Optimizing Scopes of Practice: New Models for a New Health Care System. Ottawa, ON: Canadian Academy of Health Sciences; 2014. 83. Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, et al. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16(Suppl1):S26-33. 84. American Academy of Family Physicians. Definition of Continuity of Care website. www.aafp.org/about/policies/all/definition-care.html. Accessed 2018 July 25. 85. Canadian Institute for Health Information. Continuity of Care With Family Medicine Physicians: Why It Matters. Ottawa, ON: Canadian Institute for Health Information; 2015. Available from: https://secure.cihi.ca/free_products/UPC_ ReportFINAL_EN.pdf. Accessed 2019 Jan 22. 86. Starfield B, Chang HY, Lemke KW, Weiner JP. Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences. J Ambul Care Manage. 2009;32(3):216-25. 87. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161. 88. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. 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Interacting with patients’ family members during the office visit. Am Fam Physician. 2011; 84(7): 780-784. 94. Mitnick S, Leffler C, Hood VL; American College of Physicians Ethics, Professionalism and Human Rights Committee. Family caregivers, patients and physicians: ethical guidance to optimize relationships. J Gen Intern Med. 2010;25(3):255-60. 95. Panagioti M, Richardson G, Small N, Murray E, Rogers A, Kennedy A, et al. Self-management support interventions to reduce health care utilisation without compromising outcomes: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:356. 96. College of Family Physicians of Canada. Best Advice guide: Chronic Care Management in a Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2016. Available from: https://patientsmedicalhome.ca/ resources/best-advice-guides/best-advice-guide-chronic-care-managementpatients- medical-home/. Accessed 2019 Jan 22. 97. Prevention in Hand website. www.preventioninhand.com. Accessed 2019 Jan 22. 98. Kruse CS, Argueta DA, Lopez L, Nair A. Patient and provider attitudes toward the use of patient portals for the management of chronic disease: a systematic review. J Med Internet Res. 2015;17(2):e40. 99. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17(2):e44. 100. Health Council of Canada. Which way to quality? Key perspectives on quality improvement in Canadian health care systems. Toronto, ON: Health Council of Canada; 2013. Available from: https://healthcouncilcanada.ca/files/ QIReport_ENG_FA.pdf. Accessed 2019 Jan 22. 101. Mattison CA, Wilson MC. Rapid Synthesis: Examining the Effects of Valuebased Physician Payment Models. Hamilton, ON: McMaster Health Forum; 2017. 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Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians. Seniors Care Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai. Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live. The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process. The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii Recommendation: The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes. 4 Recommendation: The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv Access to Care Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well. However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues. There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1. Figure 1. The Patient’s Medical Home, 2019 The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems 5 safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars. Recommendation: The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
Sustainability plans. Digital/Virtual Care Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health. While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries. To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined. 6 In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy. Recommendation: The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy. Climate Change and Health Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future. The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease. Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world. Recommendation: 7 The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice). 8 i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19). ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19. vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19. vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19. viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19. ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9. x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709. xi Financial Consumer Agency of Canada. About FCAC. xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
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Maintaining Ontario’s leadership on prohibiting the use of sick notes for short medical leaves

https://policybase.cma.ca/en/permalink/policy13934
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submits this brief to the Standing Committee on Finance and Economic Affairs for consideration as part of its study on Bill 47, Making Ontario Open for Business Act, 2018. The CMA unites physicians on national, pan-Canadian health and medical matters. As the national advocacy organization representing physicians and the medical profession, the CMA engages with provincial/territorial governments on pan-Canadian health and health care priorities. As outlined in this submission, the CMA supports the position of the Ontario Medical Association (OMA) in recommending that Schedule 1 of Bill 47 be amended to strike down the proposed new Section 50(6) of the Employment Standards Act, 2000. This section proposes to reinstate an employer’s ability to require an employee to provide a sick note for short leaves of absence because of personal illness, injury or medical emergency. Ontario is currently a national leader on sick notes In 2018, Ontario became the first jurisdiction in Canada to withdraw the ability of employers to require employees to provide sick notes for short medical leaves because of illnesses such as a cold or flu. This legislative change aligned with the CMA’s policy position1 and was strongly supported by the medical and health policy community. An emerging pan-Canadian concern about the use of sick notes As health systems across Canada continue to grapple with the need to be more efficient, the use of sick notes for short leaves as a human resources tool to manage employee absenteeism has drawn increasing criticism in recent years. In addition to Ontario’s leadership, here are a few recent cases that demonstrate the emerging concern about the use of sick notes for short leaves:
In 2016, proposed legislation to end the practice was tabled in the Manitoba legislature.2
The Newfoundland and Labrador Medical Association and Doctors Nova Scotia have been vocal opponents of sick notes for short leaves, characterizing them as a strain on the health care system.3,4
The University of Alberta and Queen’s University have both formally adopted “no sick note” policies for exams.5,6
The report of Ontario’s Changing Workplaces Review summarized stakeholder comments about sick notes, describing them as “costly, very often result from a telephone consultation and repeat what the physician is told by the patient, and which are of very little value to the employer.”7 Ontario’s action in 2018 to remove the ability of employers to require sick notes, in response to the real challenges posed by this practice, was meaningful and demonstrated leadership in the national context. The requirement to obtain sick notes negatively affects patients and the public By walking back this advancement, Ontario risks reintroducing a needless inefficiency and strain on the health system, health care providers, their patients and families. For patients, having to produce a sick note for an 4 employer following a short illness-related leave could represent an unfair economic impact. Individuals who do not receive paid sick days may face the added burden of covering the cost of obtaining a sick note as well as related transportation fees in addition to losing their daily wage. This scenario illustrates an unfair socioeconomic impact of the proposal to reinstate employers’ ability to require sick notes. In representing the voice of Canada’s doctors, the CMA would be remiss not to mention the need for individuals who are ill to stay home, rest and recover. In addition to adding a physical strain on patients who are ill, the requirement for employees who are ill to get a sick note, may also contribute to the spread of viruses and infection. Allowing employers to require sick notes may also contribute to the spread of illness as employees may choose to forego the personal financial impact, and difficulty to secure an appointment, and simply go to work sick. Reinstating sick notes contradicts the government’s commitment to end hallway medicine It is important to consider these potential negative consequences in the context of the government’s commitment to “end hallway medicine.” If the proposal to reintroduce the ability of employers to require sick notes for short medical leaves is adopted, the government will be introducing an impediment to meeting its core health care commitment. Reinstating sick notes would increase the administrative burden on physicians Finally, as the national organization representing the medical profession in Canada, the CMA is concerned about how this proposal, if implemented, may negatively affect physician health and wellness. The CMA recently released a new baseline survey, CMA National Physician Health Survey: A National Snapshot, that reveals physician health is a growing concern.8 While the survey found that 82% of physicians and residents reported high resilience, a concerning one in four respondents reported experiencing high levels of burnout. How are these findings relevant to the proposed new Section 50(6) of the Employment Standards Act, 2000? Paperwork and administrative burden are routinely found to rank as a key contributor to physician burnout.9 While a certain level of paperwork and administrative responsibility is to be expected, health system and policy decision-makers must avoid introducing an unnecessary burden in our health care system. Conclusion: Remove Section 50(6) from Schedule 1 of Bill 47 The CMA appreciates the opportunity to provide this submission for consideration by the committee in its study of Bill 47. The committee has an important opportunity to respond to the real challenges associated with sick notes for short medical leaves by ensuring that Section 50(6) in Schedule 1 is not implemented as part of Bill 47. 5 1 Canadian Medical Association (CMA). Third-Party Forms (Update 2017). Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD17-02.pdf (accessed 2019 Nov 13). 2 Bill 202. The Employment Standards Code Amendment Act (Sick Notes). Winnipeg: Queen’s Printer for the Province of Manitoba; 2016. Available: https://web2.gov.mb.ca/bills/40-5/pdf/b202.pdf (accessed 2019 Nov 13). 3 CBC News. Sick notes required by employers a strain on system, says NLMA. 2018 May 30. Available: www.cbc.ca/news/canada/newfoundland-labrador/employer-required-sick-notes-unnecessary-says-nlma-1.4682899 4 CBC News. No more sick notes from workers, pleads Doctors Nova Scotia. 2014 Jan 10. Available: www.cbc.ca/news/canada/nova-scotia/no-more-sick-notes-from-workers-pleads-doctors-nova-scotia-1.2491526 (accessed 2019 Nov 13). 5 University of Alberta University Health Centre. Exam deferrals. Edmonton: University of Alberta; 2018. Available: www.ualberta.ca/services/health-centre/exam-deferrals (accessed 2019 Nov 13). 6 Queen’s University Student Wellness Services. Sick notes. Kingston: Queen’s University; 2018. Available: www.queensu.ca/studentwellness/health-services/services-offered/sick-notes (accessed 2019 Nov 13). 7 Ministry of Labour. The Changing Workplaces Review: An Agenda for Workplace Rights. Final Report. Toronto: Ministry of Labour; 2017 May. Available: https://files.ontario.ca/books/mol_changing_workplace_report_eng_2_0.pdf (accessed 2019 Nov 13). 8 Canadian Medical Association (CMA). One in four Canadian physicians report burnout [media release]. Ottawa: The Association; 2018 Oct 10. Available: www.cma.ca/En/Pages/One-in-four-Canadian-physicians-report-burnout-.aspx (accessed 2019 Nov 13). 9 Leslie C. The burden of paperwork. Med Post 2018 Apr.
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Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government

https://policybase.cma.ca/en/permalink/policy13940
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
  1 document  
Policy Type
Policy endorsement
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
Text
Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON This open letter is signed by the following organizations and individuals: Bathurst United Church TOPS 1. Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON 2. Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON 3. Michaela Beder, MD FRCPC, Psychiatrist, Toronto ON 4. Ritika Goel, MD, Family Physician, Toronto ON 5. Gordon Guyatt, MD FRCPC, Internal Medicine Specialist, McMaster University, Hamilton ON 6. Melanie Spence, RN, Nursing, South Riverdale Community Health Centre, Toronto ON 7. Yipeng Ge, BHSc, Medical Student, University of Ottawa, Ottawa ON 8. Stephen Hwang, MD, Professor of Medicine, University of Toronto, Toronto ON 9. Gigi Osler, BScMed, MD, FRCSC, Otolaryngology-Head and Neck Surgery, Canadian Medical Association, Ottawa ON 10. Anjum Sultana, MPH, Public Policy Professional, Toronto ON 11. Danyaal Raza, MD, MPH, CCFP, Family Medicine, Toronto ON 12. P.J. Devereaux, MD, PhD, Cardiologist, McMaster University, Brantford ON 13. Mathura Karunanithy, MA, Public Policy Researcher, Toronto ON 14. Philip Berger, MD, Family Physician, Toronto ON 15. Nanky Rai, MD MPH, Primary Care Physician, Toronto ON 16. Michaela Hynie, Prof, Researcher, York University, Toronto ON 17. Meb Rashid, MD CCFP FCFP, Family Physician, Toronto ON 18. Sally Lin, MPH, Public Health, Victoria BC 19. Jonathon Herriot, BSc, MD, CCFP, Family Physician, Toronto ON 20. Carolina Jimenez, RN, MPH, Nurse, Toronto ON 21. Rushil Chaudhary, BHSc, Medical Student, Toronto ON 22. Nisha Toomey, MA (Ed), PhD Student, University of Toronto, Toronto ON 23. Matei Stoian, BSc, BA, Medical Student, McMaster University, Hamilton ON 24. Ruth Chiu, MD, Family Medicine Resident, Kingston ON 25. Priya Gupta, Medical Student, Hamilton ON 26. The Neighbourhood Organization (TNO), Toronto, ON 27. Mohammad Asadi-Lari, MD/PhD Candidate, University of Toronto, Toronto ON 28. Kathleen Hughes, MD Candidate, McMaster University, Hamilton ON 29. Nancy Vu, MPA, Medical Student, McMaster University, Hamilton ON 30. Ananthavalli Kumarappah, MD, Family Medicine Resident, University of Calgary, Calgary AB 31. Renee Sharma, MSc, Medical Student, University of Toronto, Toronto ON 32. Daniel Voloshin, Medical Student , McMaster Medical School , Hamilton ON 33. Sureka Pavalagantharajah, Medical Student, McMaster University, Hamilton ON 34. Alice Cavanagh , MD/PhD Student, McMaster University, Hamilton ON 35. Krish Bilimoria, MD(c), Medical Student, University of Toronto, North York ON 36. Bilal Bagha, HBSc, Medical Student, St. Catharines ON 37. Rana Kamhawy, Medical Student, Hamilton ON 38. Annie Yu, Medical Student, Toronto ON 39. Samantha Rossi, MA, Medical Student, University of Toronto, Toronto ON 40. Carlos Chan, MD Candidate, Medical Student, McMaster University, St Catharines ON 41. Jacqueline Vincent, MA, Medical Student, McMaster, Kitchener ON 42. Eliza Pope, BHSc, Medical Student, University of Toronto, Toronto ON 43. Cara Elliott, MD, Medical Student, Toronto ON 44. Antu Hossain, MPH, Public Health Professional, East York ON 45. Lyubov Lytvyn, MSc, PhD Student in Health Research, McMaster University, Burlington ON 46. Michelle Cohen, MD, CCFP, Family Physician, Brighton ON 47. Serena Arora, Medical Student, Hamilton ON 48. Saadia Sediqzadah, MD, Psychiatrist, Toronto ON 49. Maxwell Tran, Medical Student, University of Toronto, Toronto ON 50. Asia van Buuren, BSc, Medical Student, Toronto ON 51. Darby Little, Medical Student, University of Toronto, Toronto ON 52. Ximena Avila Monroy, MD MSc, Psychiatry Resident, Sherbrooke QC 53. Abeer Majeed, MD, CCFP, Family Physician, Toronto ON 54. Oluwatobi Olaiya, RN, Medical Student, Hamilton ON 55. Ashley Warnock, MSc, HBSc, HBA, Medical Student, McMaster University, Hamilton ON 56. Nikhita Singhal, Medical Student, Hamilton ON 57. Nikki Shah, MD Candidate, Medical Student, Hamilton ON 58. Karishma Ramjee, MD Family Medicine Resident , Scarborough ON 59. Yan Zhang, MSc, Global Health Professional, Toronto ON 60. Megan Saunders, MD, Family Physician, Toronto ON 61. Pooja Gandhi, MSc, Speech Pathologist, Mississauga ON 62. Julianna Deutscher, MD, Resident, Toronto ON 63. Diana Da Silva, MSW, Social Worker, Toronto ON Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government Sign here - https://goo.gl/forms/wAXTJE6YiqUFSo8x1 The Right Honourable Justin Trudeau, Prime Minister of Canada The Honourable Ginette P. Taylor, Minister of Health The Honourable Ahmed D. Hussen, Minister of Immigration, Refugees and Citizenship CC: Mr. Dainius Puras, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON
Documents
Less detail

Care to new immigrants and refugees

https://policybase.cma.ca/en/permalink/policy13699
Date
2017-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC17-04
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC17-04
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
Text
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
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Lack of access to insured health services

https://policybase.cma.ca/en/permalink/policy13711
Date
2017-08-23
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC17-12
The Canadian Medical Association calls on governments to address the lack of access to insured health services for those residing in Canada, regardless of immigration status.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC17-12
The Canadian Medical Association calls on governments to address the lack of access to insured health services for those residing in Canada, regardless of immigration status.
Text
The Canadian Medical Association calls on governments to address the lack of access to insured health services for those residing in Canada, regardless of immigration status.
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National guide on levels of medical intervention

https://policybase.cma.ca/en/permalink/policy13712
Date
2017-08-23
Topics
Health systems, system funding and performance
Resolution
GC17-18
The Canadian Medical Association will develop a national guide on levels of medical intervention for use across the continuum of care.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Resolution
GC17-18
The Canadian Medical Association will develop a national guide on levels of medical intervention for use across the continuum of care.
Text
The Canadian Medical Association will develop a national guide on levels of medical intervention for use across the continuum of care.
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A review of Canada’s medical liability system

https://policybase.cma.ca/en/permalink/policy13713
Date
2017-08-23
Topics
Health systems, system funding and performance
Resolution
GC17-19
The Canadian Medical Association supports a review of Canada’s medical liability system and an evaluation of alternative models.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Resolution
GC17-19
The Canadian Medical Association supports a review of Canada’s medical liability system and an evaluation of alternative models.
Text
The Canadian Medical Association supports a review of Canada’s medical liability system and an evaluation of alternative models.
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Transferability of existing medical data

https://policybase.cma.ca/en/permalink/policy13717
Date
2017-08-23
Topics
Health systems, system funding and performance
Resolution
GC17-A26
The Canadian Medical Association calls on governments to ensure improved accessibility and transferability of existing medical data residing in electronic health records across provincial/interprovincial interfaces.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Resolution
GC17-A26
The Canadian Medical Association calls on governments to ensure improved accessibility and transferability of existing medical data residing in electronic health records across provincial/interprovincial interfaces.
Text
The Canadian Medical Association calls on governments to ensure improved accessibility and transferability of existing medical data residing in electronic health records across provincial/interprovincial interfaces.
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Innovative health system pilot projects in Canada

https://policybase.cma.ca/en/permalink/policy13721
Date
2017-08-23
Topics
Health systems, system funding and performance
Health information and e-health
Resolution
GC17-23
The Canadian Medical Association will support new projects and mechanisms to facilitate the expansion and increase the scale of innovative health system pilot projects in Canada.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Health information and e-health
Resolution
GC17-23
The Canadian Medical Association will support new projects and mechanisms to facilitate the expansion and increase the scale of innovative health system pilot projects in Canada.
Text
The Canadian Medical Association will support new projects and mechanisms to facilitate the expansion and increase the scale of innovative health system pilot projects in Canada.
Less detail

Social equity and increasing productivity

https://policybase.cma.ca/en/permalink/policy13725
Date
2017-09-21
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-09-21
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. This is due in large part to Canada’s health care system, the people working in it, research and medical school excellence, public and private investments and the many advances that have been made over the decades in medicine. However, the Canadian Medical Association (CMA) is deeply concerned that Canada’s health care system isn’t keeping up with the health care needs of older Canadians. When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 30 million and the average life expectancy is 10 years longer. The aging of our population is both an immense success story and the most pressing policy imperative of our time. Our submission and recommendations focus on seniors care. We believe the ability of our country to meet the health care needs of this segment of our population is indeed of such high priority that we have come to these consultations with this single issue in mind. While daunting, the task ahead is by no means impossible and will ultimately result in numerous health and financial benefits. By providing the means to expand long-term care and home care capacity, the Government of Canada will improve health care for seniors and others, create new jobs and add billions of dollars annually to the Gross Domestic Product. Furtherbed demand will vary over this period, peaking in 2032 and beginning to decline thereafter. The five-year projection for beds is as follows: Table 1: Projected shortage in long-term care beds, 2017–2021 Number of additional Year beds required 2017 15,740* 2018 6,940 2019 6,450 2020 6,620 2021 7,140 Projected 42,890 five-year shortage *Note: the figure for additional beds required in 2017 includes 8,420 beds’ worth of demand that is currently unmet, in the form of patients in alternate level of care beds in hospitals. The Conference Board estimated the cost to construct 10,500 beds (the average number of new beds required per year from 2017 to 2035) at $3.4 billion per year and $63.7 billion in total, on the basis of a cost estimate of $320,000 per bed (all figures in 2017 dollars). These figures include both public and private spending. This forecast does not include the significant investments required to renovate and retrofit the existing stock of residential facilities. The average number of new long-term care beds needed in Canada every year up to 2035 is 10,500. The Conference Board of Canada estimates the cost of this to be $3.4 billion per year, for a total public and private expenditure of $63.7 billion. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes. Construction of new residential care models and renovation/retrofitting of existing facilities will provide significant economic opportunities for many communities across Canada. The construction and maintenance of 10,500 new residential care beds will yield direct economic benefits that include a $1.4 billion annual average contribution to GDP supporting 14,600 jobs yearly during the capital investment phase and a $5.3 billion annual average contribution to GDP supporting an average of 58,300 jobs annually during the facility operation phase. By comparison, nursing homes and residential care facilities employed about 412,000 people in 2016. These investments would also close the significant gap between the projected residential care bed shortages and currently planned investment. When indirect economic contributions are included, the average estimated annual contribution to Canada’s GDP from the construction and operation of the new beds reaches $12.4 billion, supporting an average of 130,000 jobs annually between 2017 and 2035 (in construction, care provision and other sectors). This bed projection provides a sense of the immense challenge Canada faces in addressing the needs of a vulnerable segment of its population of older seniors. A recent report by the Canadian Institute for Health Information indicated that residential care capacity will need to double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided in Canada across the continuum of care.13 Efforts to de-hospitalize the system and deal with Canada’s aging population should be part of an overall national seniors strategy. Such a strategy was called for previously by the CMA, other organizations (e.g., the National Association of Federal Retirees), the Standing Senate Committee on National Finance14 and over 50,000 Canadians.15 Fixing seniors care will contribute to the renewal of the entire health system and will improve the productivity of health care delivery across the country. The differing fiscal capacities of the provinces in the current economic climate will mean that improvements in seniors care will advance at an uneven pace. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure models. GDP # of jobs contributions Capitalinvestment phase Operation phase 14,600 58,300 $1.4 billion $5.3 billion With indirect contributions 130,000 $12.4 billion RECOMMENDATIONS: The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Caregivers are the backbone of any care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend. While this care was most often received by a senior in their own residence, 62% of caregivers said the care recipients lived in a home separate from the caregiver’s home.16 Age-related needs are the most common reason for care requirements.17 Caregivers are of all ages; for instance, 27% of caregivers were between the ages of 15 and 29 years.18 One study has forecast that the number of Canadians requiring care will double over the next 30 years.19 Caregiver costs Work $5.5 in lost absence: productivity billion Personal upwards of or more out-of-a yearpocket: $2,000 A Statistics Canada study found that 56% of caregivers living with the care recipient provided at least 10 hours of care a week. Approximately 22% of caregivers helping a resident in a care facility also provided at least 10 hours of care a week. The chief condition for which care was provided was dementia or Alzheimer’s disease (25%).16 The cost to employers in lost productivity because of caregiving-related absenteeism is estimated at $5.5 billion annually.20 Caregivers also report high out-of-pocket expenses. This is especially true for those living with the care recipient: over 25% spend at least $2,000 annually on out-of-pocket expenses.16 Caregivers require a range of supports including education/training, peer support, respite care and financial assistance. Canadians want governments to do more to help seniors and their family caregivers.21 The federal government’s new combined Canada Caregiver Credit (CCC) is a non­refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Notwithstanding these changes and the greater flexibility for caregivers to use Employment Insurance benefits, caregivers will require more support. The CMA recommends making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit, resulting in a refund payment to provide further financial support for low-income families. RECOMMENDATION: The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcomed step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it will be important to establish clear operating principles between the parties to oversee the funding implementation including support for caregivers. RECOMMENDATION: RECOMMENDATION: The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investment in home care and mental health is a recognition that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. 5 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. T he CMA recognizes the federal government’s commitment to help Canadians be as productive as possible in their workplaces and in their communities. Implementing these recommendations as an integrated package is essential to stitching together the elements of community-based and residential care for seniors. In addition to making a meaningful contribution to meeting the future care needs of Canada’s aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_ final.pdf (accessed 2016 Sep 22). 2 Canadian Institute for Health Information. Seniors and alternate level of care: building on our knowledge. Ottawa: The Institute; 2012 Nov. Available: https://secure.cihi.ca/ free_products/ALC_AIB_EN.pdf (accessed 2016 Sep 22). 3 Access to Care, Cancer Care Ontario. Alternate level of care (ALC) [Prepared for the Ontario Hospital Association]. Toronto: Ontario Hospital Association (OHA); 2016 May. 4 McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014 Sep 5;17(3):88–94. 5 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www. homecareontario.ca/home-care-services/facts-figures/ publiclyfundedhomecare (accessed 2016 Sep 22). 6 Sponagle J. Nunavut struggles to care for elders closer to home. CBC News. 2017 Jun 5. Available: http://www.cbc. ca/news/canada/north/nunavut-seniors-plan-1.4145757 (accessed 2017 Jun 30). 7 Health Quality Ontario. Wait times for long-term care homes. Toronto: Health Quality Ontario; 2017. Available: http://www.hqontario.ca/System-Performance/Long­ Term-Care-Home-Performance/Wait-Times (accessed 2017 Jun 22). 8 Alzheimer Society Canada. The Canadian Alzheimer’s Disease and Dementia Partnership: a collective vision for a national dementia strategy for Canada. Toronto: Alzheimer Society Canada; undated. Available: http:// www.alzheimer.ca/~/media/Files/national/Advocacy/ CADDP_Strategic_Objectives_e.pdf (accessed 2016 Sep 22). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada. ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/ dq140917a-eng.htm (accessed 2016 Sep 19). 11 The Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; forthcoming. 12 Lazurko M, Hearn B. Canadian continuing care scenarios 1999–2041. KPMG final project report to FPT Advisory Committee on Health Services. Ottawa: KPMG; 2000. Cited by Canadian Healthcare Association. New directions for facility-based long-term care. Ottawa: The Association; 2009. Available: https://www.advantageontario.ca/ oanhssdocs/Issue_Positions/External_Resources/ Sept2009_New_Directions_for_Facility_Based_LTC.pdf (accessed 2017 Jun 30). 13 Canadian Institute for Health Information. Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi. ca/sites/default/files/document/seniors-in-transition­ report-2017-en.pdf (accessed 2017 Jun 30). 14 Standing Senate Committee on National Finance. Getting ready: for a new generation of active seniors. First interim report. Ottawa: The Senate; 2017 Jun. Available: https:// sencanada.ca/content/sen/committee/421/NFFN/Reports/ NFFN_Final19th_Aging_e.pdf (accessed 2017 Jun 30). 15 Canadian Medical Association. Demand a plan. Ottawa: The Association; 2017. Available: http://www.demandaplan.ca/ (accessed 2017 Jun 30). 16 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006­ X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/ article/14142-eng.pdf (accessed 2016 Sep 22). 17 Sinha M. Portrait of caregivers, 2012. Spotlight on Canadians: results from the General Social Survey. Cat. No. 89-652-X – No. 001. Ottawa: Statistics Canada; 2013 Sep. Available: http://www.statcan.gc.ca/pub/89-652­ x/89-652-x2013001-eng.htm (accessed 2016 Sep 22). 18 Bleakney A. Young Canadians providing care. Spotlight on Canadians: results from the General Social Survey. Cat. No. 89-652-X – No. 003. Ottawa: Statistics Canada; 2014 Sep. Available: http://www.statcan.gc.ca/pub/89-652­ x/89-652-x2014003-eng.htm (accessed 2017 Jun 30). 19 Carrière Y, Keefe J, Légaré J, et al. Projecting the future availability of the informal support network of the elderly population and assessing its impact on home care services. Demography Division Research Paper Cat. No. 91F0015M – No. 009. Ottawa: Statistics Canada; 2008. Available: http://publications.gc.ca/collections/collection_2009/ statcan/91F0015M/91f0015m2008009-eng.pdf (accessed 2017 Jun 30). 20 Ceridian Canada. Double duty: the caregiving crisis in the workplace [Blog post]. Ottawa: Ceridian Canada, 2015 Nov 5. Available: http://www.ceridian.ca/blog/2015/11/ double-duty-the-caregiving-crisis-in-the-workplace/ (accessed 2016 Sep 22). 21 Ipsos Public Affairs, HealthCareCAN, National Health Leadership Conference. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20 Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 6).
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Advancing Inclusion and quality of life for seniors

https://policybase.cma.ca/en/permalink/policy13729
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead. Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue. The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods. The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians. Dr. Laurent Marcoux, CMA President The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health. Improving access to housing for seniors As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system. A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls. Daily costs - Ontario $842: acute care hospital, per patient $126: long-term care residence, per patient $42: home care, per patient # of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges. The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs. The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors. Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure. RECOMMENDATION 1 The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Improving income security for vulnerable seniors Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5 Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6 Incidence of low income (2012) Seniors overall: 12.1% Single seniors: 28.5% Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care. On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers. RECOMMENDATION 2 The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse. Improving the overall quality of life and well-being for seniors Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7 Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11 When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue. National seniors strategy Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes. The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca). RECOMMENDATION 3 The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. Improving assistance for home care and Canada’s caregivers Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important. RECOMMENDATION 4 The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15 Caregivers provide... Personal and Medical Care Housekeeping worth $25 billion in Advocacy unpaid labour Financial Managemen Social-emo ional Suppor RECOMMENDATION 5 The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers. Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit (CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families. RECOMMENDATION 6 The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance. RECOMMENDATION 7 The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. RECOMMENDATION 8 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. Programs and supports to promote healthy aging The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17 The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression). RECOMMENDATION 9 The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians. For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary. RECOMMENDATION 10 The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination. RECOMMENDATION 11 The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly. RECOMMENDATION 12 The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13 RECOMMENDATION 13 The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs. An environment and society that is “age friendly” One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens. Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers. RECOMMENDATION 14 The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire. The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors. RECOMMENDATION 15 The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment. Conclusion The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population. To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages. References 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22). 2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22). 3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication. 4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30). 5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23). 6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17). 7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19). 8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11­ 402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19). 11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20). 12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18). 13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23). 14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22). 15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23). 16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06). 17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20). 18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23). 19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23). 20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23). 21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23). 22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23). 23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23). 24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age­ friendly-environments/en/ (accessed 2017 Oct 23).
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Review of Pan-Canadian health organizations

https://policybase.cma.ca/en/permalink/policy13737
Date
2017-11-24
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-11-24
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes this opportunity to provide input to the review of the Pan-Canadian health organizations (PCHOs). The CMA has had the opportunity to interact with all of them at one time or another. This review is timely, as there is a burning issue: Canada continues to languish near the bottom of the Commonwealth Fund's 11-country rankings, and the leading edge of the baby boom will reach age 75 in 2021, at which point per capita health care costs in Canada will escalate. We will discuss major unmet needs, make some general observations and offer two recommendations. References are provided in the bibliography. Unmet needs National focal point for quality: Our impression is that none of the PCHOs is pursuing a comprehensive approach to quality improvement (QI) consistent with the framework set out by the Institute of Medicine (IOM) in its 2001 report Crossing the Quality Chasm. The framework is built around the need for health care to be safe, effective, patient-centred, timely, efficient and equitable. To our knowledge Accreditation Canada is the only national organization that has adopted such a framework, but their QI mandate is to set standards and accredit health care organizations although it could potentially play an expanded role. The Canadian Patient Safety Institute has done an excellent job of highlighting the importance of patient safety, but that is only one of the six dimensions outlined in the IOM framework. Work needs to be done in Canada to address each of the other five dimensions. In terms of effective care, although the concept of evidence-based medicine was pioneered in Canada, we do not have a national developer of guidance to clinicians like the United Kingdom's National Institute for Health and Care Excellence (NICE). It is noted that there are some localized efforts in this area, such as Alberta's Toward Optimized Practice program, and the CMA Infobase maintained by CMA Joule contains some 1,200 clinical practice guidelines. Patient-centred care will be discussed below. Since the expiry of the 2004 Health Accord and the Wait Times Reduction Fund (WTRF), which the CMA spent years trying to get on the policy agenda, timely access to care has fallen out of the spotlight. The Wait Time Alliance did its best to promote the expansion and adoption of wait time benchmarks beyond the five treatments initially included in the WTRF, with very limited success. It is no surprise that according to the Commonwealth Fund's 2016 survey of 11 countries, Canadians faced the longest waiting times for a specialist appointment. In terms of efficiency there has been a rapid uptake of the Choosing Wisely Canada initiative by medical organizations, but the campaign could benefit from resources to conduct a thorough evaluation of its impact. The dimension of equitable care will be considered below as part of the discussion of social determinants of health. At least six provinces have established health quality councils, and if they had a national focal point for their efforts they could cross-pollinate their expertise and learnings with respect to all six of the Institute of Medicine's dimensions of care. National patient voice - While it is encouraging to see the emphasis on patient and family-centred care among the PCHOs, the lack of an organized national patient voice is a key gap. Previously the Consumers' Association of Canada provided an articulate patient/consumer voice on health issues, and indeed it was one of the seven charter members of the Health Action Lobby in 1991. However, the association's ability to speak in this capacity was greatly diminished after its federal funding dried up in the 1990s. At present there are various patient groups sponsored by health charities and industry but they tend to focus on specific interests. Patients Canada, an organization established in 2011, is showing promise, but with annual expenditures of just under $130,000 in 2014 it is insufficiently resourced to function as a national patient voice representing all regions of the country. There is a need for an independent go-to focal point that can speak on behalf of patients on national issues and that can help national health organizations with their advocacy and policy development initiatives. With better resources, Patients Canada might be able to play this role. Health equity - Given the impact of health inequalities in Canada they have a relatively low profile on the national scene, aside from the inequity between the health status of Canada's Indigenous Peoples and that of the general population. For example, Mackenbach and colleagues estimated that socio-economic inequalities accounted for 20% of health care costs in the European Union in 2004. There is little reason to imagine that the situation in Canada would be much different, but health inequalities have not been a preoccupation of the PCHOs. The Public Health Agency of Canada (PHAC) has done some good work in helping the federal government to meet its commitments in regard to the World Health Organization's 2011 Rio Political Declaration on Social Determinants of Health and it also funds the National Collaborating Centre for Determinants of Health, but these efforts have little profile outside of the public health community. The pronounced socio-economic gradient across virtually all causes of morbidity and mortality tends to be overlooked in the pursuit of strategies to address individual diseases. PHAC's Health Inequalities Data Tool shows that that the Canadian crude mortality rates for circulatory system disease and lung cancer in the lowest income quintile for census metropolitan areas are 1.6 and 1.7 times the rates in the highest income quintile, respectively. There are groups in Canada such as the Wellesley Institute and Health Providers Against Poverty that focus on health equity issues, and Canada should look at the leadership role being played by Sir Michael Marmot's Institute of Health Equity at University College London in England. Driving innovation - The Canadian Agency for Drugs and Technologies in Health is widely recognized for its work evaluating drugs and technologies but it is not in the business of promoting system-wide implementation. The Advisory Panel on Healthcare Innovation (David Naylor, Chair) recommended the establishment of a Healthcare Innovation Agency and a Healthcare Innovation Fund with the objective of effecting "sustainable and systemic changes in the delivery of health services to Canadians." More recently, the Standing Senate Committee on Social Affairs, Science and Technology called for a national conference on robotics, artificial intelligence and 3D printing that would give rise to working groups and a secretariat with a view to integrating these technologies into health care systems across Canada. One can cite examples where Canada has developed innovative technologies but has not made them mainstream. For example, telemedicine was pioneered by the late Dr. Maxwell House in Newfoundland in the mid-1970s. It is now being used regularly for clinical sessions, but the logical extension to telehome monitoring is barely in its infancy. According to the 2015 Canadian Telehealth Report there were 411,778 telehealth clinical sessions in 2014, but there were just 3,803 patients being monitored through telehomecare. Furthermore. the number of telehealth clinical sessions represents just 0.15% of the 270.3 million physician services reported by the Canadian Institute for Health Information (CIHI) in 2015-16. In contrast, Kaiser Permanente reported in 2016 that 52% of the 110 million physician-member interactions in the previous year took place through virtual means. One example of the use of a fund to bring about sustainable change was the two-step process that began with the establishment of the $150 million Health Transition Fund following the 1997 report of the National Forum on Health and the $800 million Primary Health Care Transition Fund that was part of the 2000 Health Accord. These resulted in the sustained adoption of new models of primary care delivery in Ontario and Alberta. It is noteworthy that the Canadian Foundation for Healthcare Improvement is doing interesting work in spreading and scaling up innovative treatment for patients with chronic obstructive pulmonary disease. The need for a dedicated entity to drive innovation is illustrated by the experience of the Health Care Innovation Working Group, which was struck by the premiers in 2012 and which included the unprecedented participation of professional associations including the CMA. The group released an ambitious report in the summer of 2012, but the effort was run by senior bureaucrats and association staff "off the sides of their desks" and has essentially stalled. Such a body could also play a role in sharing innovations across jurisdictions. Enhanced analytical capability - Since the demise of the Economic Council of Canada (ECC) in the 1990s Canada's national analytical capability in health care has diminished. The ECC employed health economists like the late Ludwig Auer who undertook detailed analysis of health sector data to examine issues like hospital productivity. CIHI does an excellent job of turning out reports such National Health Expenditure (NHEX) Trends in Canada, but these are not sufficient for an in-depth examination of a $242 billion industry. As journalist André Picard commented on the 2017 NHEX release, "We don't actually know how much we spend on administration, because it is hidden in places like hospital spending ... nor do we know the cost of labour ... we should certainly have a better idea of how much we spend on nurses, physician assistants, personal support workers, laboratory technologists and technicians and so on." Looking ahead, the widespread adoption of electronic medical records is going to present a major analytical opportunity and challenge. In 2008 PHAC provided a grant to the College of Family Physicians of Canada to establish the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and subsequently provided additional funding until 2015. The goal of CPCSSN was to establish a database on eight chronic diseases and neurologic conditions by extracting de-identified patient information from electronic medical records. As of the last update, in October 2016, CPCSSN now includes 11 university-affiliated primary care research networks and almost 1,200 physicians contributing data from 1.5 million patients. A recent report concludes that CPCSSN's diagnostic algorithms show excellent sensitivity and specificity for hypertension, diabetes, epilepsy and parkinsonism. The CMA highlighted CPCSSN in its submission to the Advisory Panel on Healthcare Innovation as being worthy of ongoing federal support. General observations We would like to make three general observations. First, the future of the PHCOs should not be decided in isolation. Instead, we believe that the big picture of federal funding for the advancement of health and health care should be considered, including the investments that the federal government is making in the Canadian Institutes of Health Research and the Strategy for Patient-Oriented Research. Second, the CMA's engagement with the PCHOs has been haphazard. While we have had the opportunity to participate in consultations and technical and working groups with the PCHOs, these interactions have generally fallen short of what we would consider to be early, meaningful and ongoing engagement. Third, the PCHOs have developed considerable expertise within their mandates and spheres of activity. They could almost certainly harness their potential to mount a synergistic effort to successfully address pressing national issues that might otherwise seem almost impossible to confront, such as seniors care. Recommendations The CMA respectfully offers two recommendations: 1. That the government's implementation plan following the PCHO review include mechanisms to address the following needs: * for a national focal point that promotes a comprehensive approach to quality health care; * for a well-resourced national patient voice that advocates for patient- and family-centred health care; * for greater recognition of the importance of the social determinants of health and health equity; * for a national mechanism to drive the sustainable adoption of innovative technologies in health care across Canada; and * for advanced analytical capabilities to conduct in-depth assessments of funding mechanisms and advance the collection and analysis of data generated by electronic medical records. 2. That the federal government challenge the PCHOs and other federal agencies to work with the provincial/territorial governments and stakeholders to develop and implement a national action plan to address the health and health care of Canada's seniors. Bibliography Accreditation Canada. Client- and family-centred care in the Qmentum program. Ottawa: Accreditation Canada; 2015. Advisory Board. A milestone: Kaiser now interacts more with patients virtually than in-person. Washington, DC: Advisory Board; 2016 Oct 13. Available: www.advisory.com/daily-briefing/2016/10/13/kaiser-telehealth (accessed 2017 Nov 10). Advisory Panel on Healthcare Innovation. Unleashing innovation: excellent healthcare for Canada. Ottawa: Minister of Health; 2015. Available: http://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf (accessed 2017 Nov 10). Birtwhistle R. Update from CPCSSN. Can Fam Physician 2016;62(10):851. Canadian Institute for Health Information. National Physician Database. Table B.1 Number of services, by physician specialty, national groupin system strata and province/territory, 2015-2016. Ottawa: The Institute; 2017. Canadian Medical Association. CPG Infobase: clinical practice guidelines. Ottawa: The Association; 2017. Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2017 Nov 10). Canadian Medical Association. Submission to Advisory Panel on Healthcare Innovation. Ottawa: The Association; 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA-Submission-Adv-Panel-on-HC-Innovation.pdf (accessed 2017 Nov 10). Canada's Health Informatics Association. 2015 Canadian telehealth report. Toronto: The Association; 2015. Available: https://livecare.ca/sites/default/files/2015%20TeleHealth-Public-eBook-Final-10-9-15-secured.pdf (accessed 2017 Nov 10). Health Providers Against Poverty(HPAP). Canada: HPAP; 2017. Available: https://healthprovidersagainstpoverty.ca (accessed 2017 Nov 10). Institute of Health Equity. London: Institute of Health Equity; 2017. Available: www.instituteofhealthequity.org (accessed 2017 Nov 10). Mackenbach J, Meerding W, Kunst A. Economic costs of health inequalities in the European Union. J Epidemiol Community Health 2011;65(5):412-9. National Academy of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001. The National Institute for Health and Care Excellence (NICE). Improving health and social care through evidence-based guidance. London: NICE; 2017. Available: https://www.nice.org.uk/ (Accessed 24 November 2017). Osborn R, Squires D, Doty M, Sarnak S, Schneider E. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Aff (Millwood) 2016;35(12):2327-6. Patients Canada. Toronto: Patients Canada, 2017. Available: www.patientscanada.ca/ (accessed 2017 Nov 10). Picard A. It's time for a data-driven approach to health care. Globe and Mail 2017 Nov 7. https://beta.theglobeandmail.com/opinion/its-time-for-a-data-driven-approach-to-health-care/article36858079/?ref=http://www.theglobeandmail.com& (accessed 2017 Nov 10). National Collaborating Centre for Determinants of Health (NCCDH). Antigonish, NS: NCCDH; 2017. Available: /www.nccdh.ca/ (accessed 2017 Nov 10). Public Health Agency of Canada. Health inequalities data tool - public health infobase. Ottawa: Public Health Agency of Canada; 2017. Available: https://infobase.phac-aspc.gc.ca/health-inequalities/ (accessed 2017 Nov 10). Schneider E, Sarnak D, Squires D, Shah A, Doty M. Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. New York, NY: Commonwealth Fund; 2017. Available: www.commonwealthfund.org/~/media/files/publications/fund-report/2017/jul/schneider_mirror_mirror_2017.pdf (accessed 2017 Nov 13). Standing Senate Committee on Social Affairs, Science and Technology. Challenge ahead: integrating robotics, artificial intelligence and 3D printing technologies into Canada's healthcare systems. Ottawa: The Senate; 2017. Available: https://sencanada.ca/content/sen/committee/421/SOCI/reports/RoboticsAI3DFinal_Web_e.pdf (accessed 2017 Nov 10). Tinkham & Associates LLP. Financial statements of Patients Canada. Toronto: Tinkham & Associates LLP; 31 Dec 2014. Available: www.patientscanada.ca/site/patients_canada/assets/pdf/patientscanada-financialstatements-2014.pdf (accessed 2017 Nov 10). Toward Optimized Practice (TOP). Edmonton, AB: TOP; 2017. Available: www.topalbertadoctors.org/home/ (accessed 2017 Nov 13). Wellesley Institute. Toronto: Wellesley Institute; 2017. Available: www.wellesleyinstitute.com/about (accessed 2017 Nov 10). Williamson T, Green M, Birtwhistle R, Khan S, Garies S, Wong S, Natarajan N, Manca D, Drummond N. Validating the 8 CPCSSN case definitions for chronic disease surveillance in a primary care database of electronic health records. Ann Fam Med 2014;12(4):367-72. World Health Organization. Rio political declaration on social determinants of health. Geneva: The Organization; 2011. Available: www.who.int/sdhconference/declaration/Rio_political_declaration.pdf?ua=1 (accessed 2017 Nov 10).
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Response to Health Canada's proposed order amending the Schedule to the Tobacco Act (Menthol)

https://policybase.cma.ca/en/permalink/policy13797
Date
2017-01-10
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2017-01-10
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide this response to Health Canada's Proposed Order Amending the Schedule to the Tobacco Act (Menthol), as found in the Canada Gazette, Part I, on November 5, 2016. The CMA believes that the federal government has an important role in prevention and smoking cessation, particularly among youth, to end smoking within Canada. As early as 2008, the CMA called for the federal government to ban menthol in tobacco products. In 2014, the CMA submitted a brief to Health Canada on the proposal to amend the Tobacco Act to restrict the use of additives in tobacco products. One of the CMA's concerns at that time was that the Act excluded menthol as a flavouring agent in tobacco products. Therefore, the CMA strongly supports Health Canada's proposed order to prohibit menthol in cigarettes, blunt wraps and cigars. The proposed order has the ability to deter youth from smoking since menthol makes smoking more palatable by masking the harshness of tobacco smoke. This may lead to not only a decline in youth smokers but a decline in the number of smokers in the overall Canadian population as well. The CMA issued its first warning to the public about the dangers of tobacco in 1954, and we continue to advocate for stronger measures to control smoking. Banning the use of menthol is one step towards achieving this goal. Sincerely, Jeff Blackmer, MD, MHSc, FRCPC Vice-President, Medical Professionalism Canadian Medical Association
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A new mission for health care in Canada: Addressing the needs of an aging population. 2016 pre-budget submission to the Minister of Finance

https://policybase.cma.ca/en/permalink/policy11803
Date
2016-02-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2016-02-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) is pleased to confirm its strong support for the federal government's health and social policy commitments, as identified in the ministerial mandate letters. In this brief, the CMA outlines seven recommendations for meaningful and essential federal action to ensure Canada is prepared to meet the health care needs of its aging population. The CMA's recommendations are designed to be implemented in the 2016-17 fiscal year in order to deliver immediate support to the provinces and territories and directly to Canadians. Immediate implementation of these recommendations is essential given the current and increasing shortages being experienced across the continuum of care in jurisdictions across Canada. In 2014, the CMA initiated a broad consultative initiative on the challenges in seniors care, as summarized in the report A Policy Framework to Guide a National Seniors Strategy for Canada. This report highlights the significant challenges currently being experienced in seniors care and emphasizes the need for increased federal engagement. Finally, if implemented, the CMA's recommendations will contribute to the federal government's strategic commitments in health, notably the commitment to the development of a new Health Accord. 1) Demographic Imperative for Increased Federal Engagement in Health Canada is a nation on the threshold of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership. In 2015, for the first time in Canada's history, persons aged 65 years and older outnumbered those under the age of 15 years.1 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.2 It is increasingly being recognized that the projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments.3 Today, while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5 The latest National Health Expenditures report by the Canadian Institute of Health Information (CIHI) projects that health spending in 2015 was to exceed $219 billion, or 10.9% of Canada's gross domestic product (GDP).6 To better understand the significance of health spending in the national context, consider that total federal program spending is 13.4% of GDP.7 Finally, health budgets are now averaging 38% of provincial and territorial global budgets.8 Alarmingly, the latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories, who "cannot meet the challenges of population aging under current policy."9 Taken together, the indicators summarized above establish a clear imperative and national interest for greater federal engagement, leadership and support for the provision of health care in Canada. 2) Responses to Pre-Budget Consultation Questions Question 1: How can we better support our middle class? A) Federal Action to Help Reduce the Cost of Prescription Medication The CMA strongly encourages the federal government to support measures aimed at reducing the cost of prescription medication in Canada. A key initiative underway is the pan-Canadian Pharmaceutical Alliance led by the provinces and territories. The CMA supports the federal government's recent announcement that it will partner with the provinces and territories as part of the pan-Canadian Pharmaceutical Alliance. In light of the fact that the majority of working age Canadians have coverage for prescription medication through private insurers10, the CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance. Prescription medication has a critical role as part of a high-quality, patient-centred and cost-effective health care system. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.11 It is an unfortunate reality that the affordability of prescription medication has emerged as a key barrier to access to care for many Canadians. According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.12 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.13 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.14 The CMA has long called on the federal government to implement a system of catastrophic coverage for prescription medication to ensure Canadians do not experience undue financial harm and to reduce the cost barriers of treatment. As a positive step toward comprehensive, universal coverage for prescription medication, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.57 billion in 2016-17 (Table 1). Table 1: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)15 Age Cohort 2016 2017 2018 2019 2020 Share of total cost Under 35 years 113.3 116.3 119.4 122.5 125.2 7% 35 to 44 years 177.2 183.5 190.5 197.8 204.3 11% 45 to 54 years 290.2 291.9 298.0 299.2 301.0 18% 55 to 64 years 383.7 400.6 417.6 433.1 444.6 25% 65 to 74 years 309.2 328.5 348.4 369.8 391.6 21% 75 years + 303.0 315.5 329.8 345.2 360.1 20% All ages 1,566.8 1,617.9 1,670.5 1,724.2 1,773.1 100% B) Deliver Immediate Federal Support to Canada's Unpaid Caregivers There are approximately 8.1 million Canadians serving as informal, unpaid caregivers with a critical role in Canada's health and social sector.16 The Conference Board of Canada reports that in 2007, informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.17 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.18 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009. Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent receive any form of government support.19 Only 5% of caregivers providing care to parents reported receiving financial assistance, while 28% reported needing more assistance than they received.20 It is clear that Canadian caregivers require more support. As a first step, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure would cost $90.8 million in 2016-17.21 C) Implement a new Home Care Innovation Fund The CMA strongly supports the federal government's significant commitment to deliver more and better home care services, as released in the mandate letter for the Minister of Health. Accessible, integrated home care has an important role in Canada's health sector, including addressing alternate level of care (ALC) patients waiting in hospital for home care or long-term care. As highlighted by CIHI, the majority of the almost 1 million Canadians receiving home care are aged 65 or older.22 As population aging progresses, demand for home care can be expected to increase. Despite its importance, it is widely recognized that there are shortages across the home care sector.23 While there are innovations occurring in the sector, financing is a key barrier to scaling up and expanding services. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. As outlined in the Liberal Party of Canada's election platform, the CMA recommends that the fund deliver $3 billion over four years, including $400 million in the 2016-17 fiscal year. Question 2: What infrastructure needs can best help grow the economy...and meet your priorities locally? Deliver Federal Investment to the Long-term Care Sector as part of Social Infrastructure All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.24 In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. More than 50% of ALC patients are in these hospital beds because of the lack of availability of long-term care beds25. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an inefficiency cost to the health care system of $2.3 billion a year.26 Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been unduly excluded from federal investment in infrastructure, namely the Building Canada Plan. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 2), if implemented on a cost-share basis. Table 2: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)27 Forecasted shortage in long term care beds Estimated cost to address shortage Federal share to address shortage in long term care beds (based on 1/3 contribution) 2016 6,028 1,621.5 540.5 2017 6,604 1,776.5 592.2 2018 8,015 2,156.0 718.7 2019 8,656 2,328.5 776.2 2020 8,910 2,396.8 798.9 Total 38,213 10,279.3 3,426.4 In addition to improved delivery of health care resources, capital investment in the long-term care sector would provide an important contribution to economic growth. According to previous estimates by the Conference Board of Canada, the capital investment needed to meet the gaps from 2013 to 2047 would yield direct economic benefits on an annual basis that include $1.23 billion contribution to GDP and 14,141 high value jobs during the capital investment phase and $637 million contribution to GDP and 11,604 high value jobs during the facility operation phase (based on an average annual capital investment). Question 3: How can we create economic growth, protect the environment, and meet local priorities while ensuring that the most vulnerable don't get left behind? Deliver new Funding to Support the Provinces and Territories in Meeting Seniors Care Needs Canada's provincial and territorial leaders are struggling to meet health care needs in light of the demographic shift. This past July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer (CHT) to 25% of provincial and territorial health care costs to address the needs of an aging population. It is recognized that as an equal per-capita based transfer, the CHT does not currently account for population segments with increased health needs, specifically seniors. The CMA was pleased that this issue was recognized by the Prime Minister in his letter last spring to Quebec Premier Philippe Couillard. However, the CMA is concerned that an approach to modify the transfer formula would potentially delay the delivery of federal support to meet the needs of an aging population. As such, rather than the transfer formula, the CMA has developed an approach that delivers support to jurisdictions endeavoring to meet the needs of their aging populations while respecting the transfer arrangement already in place. The CMA commissioned the Conference Board of Canada to calculate the amount for the top-up to the CHT using a needs-based projection. The amount of the top-up for each jurisdiction is based on the projected increase in health care spending associated with an aging population. To support the innovation and transformation needed to address the health needs of the aging population, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 3). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment. Table 3: Allocation of the federal demographic-based top-up, 2016-20 ($million)28 Jurisdiction 2016 2017 2018 2019 2020 All of Canada 1,602.1 1,663.6 1,724.2 1,765.8 1,879.0 Ontario 652.2 677.9 692.1 708.6 731.6 Quebec 405.8 413.7 418.8 429.0 459.5 British Columbia 251.6 258.7 270.3 270.1 291.3 Alberta 118.5 123.3 138.9 141.5 157.5 Nova Scotia 53.6 58.6 62.3 64.4 66.6 New Brunswick 45.9 50.7 52.2 54.1 57.2 Newfoundland and Labrador 29.7 30.5 33.6 36.6. 46.1 Manitoba 28.6 30.6 33.5 32.5 36.6 Saskatchewan 3.5 4.9 7.3 12.7 15.4 Prince Edward Island 9.1 9.7 10.6 10.9 11.5 Yukon 1.4 2.6 2.1 2.5 2.5 Question 4: Are the Government's new priorities and initiatives realistic; will they help grow the economy? Ensure Tax Equity for Canada's Medical Professionals is Maintained Among the federal government's commitments is the objective to decrease the small business tax rate from 11% to 9%. The CMA supports this commitment to support small businesses, such as medical practices, in recognition of the significant challenges facing this sector. However, it is not clear whether as part of this commitment the federal government intends to alter the Canadian-Controlled Private Corporation (CCPC) framework. The federal government's framing of this commitment, as released in the mandate letter for the Minister of Small Business and Tourism, has led to confusion and concern. Canada's physicians are highly skilled professionals, providing an important public service and making a significant contribution to our country's knowledge economy. Canadian physicians are directly or indirectly responsible for hundreds of thousands of jobs across the country, and invest millions of dollars in local communities, ensuring that Canadians are able to access the care they need, as close to their homes as possible. In light of the design of Canada's health care system, the majority of physicians are self-employed professionals and effectively small business owners. As self-employed small business owners, they typically do not have access to pensions or health benefits. In addition, as employers, they are responsible for these benefits for their employees. In addition to managing the many costs associated with running a medical practice, Canadian physicians must manage challenges not faced by many other small businesses. As highly-skilled professionals, physicians typically enter the workforce with significant debt levels and at a later stage in life. For some, entering practice after training requires significant investment in a clinic or a practice. Finally, it is important to recognize that physicians cannot pass on the increased costs introduced by governments, such as changes to the CCPC framework, onto patients, as other businesses would do with clients. For a significant proportion of Canada's physicians, the CCPC framework represents a measure of tax equity for individuals taking on significant personal financial burden and liability as part of our public health care system. As well, in many cases, practices would not make economic sense if the provisions of the CCPC regime were not in place. Given the importance of the CCPC framework to medical practice, changes to this framework have the potential to yield unintended consequences in health resources, including the possibility of reduced access to much needed care. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations. 3) Conclusion The CMA recognizes that the federal government must grapple with an uncertain economic forecast and is prioritizing measures that will support economic growth. The CMA strongly encourages the federal government to adopt the seven recommendations outlined in this submission as part of these efforts. In addition to making a meaningful contribution to meeting the future care needs of Canada's aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. Summary of Recommendations 1. The CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication; this would be a positive step toward comprehensive, universal coverage for prescription medication. 2. The CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance. 3. The CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. 4. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. 5. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. 6. The CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer. 7. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations. References 1 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily, Wednesday, September 17, 2014. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.htm 2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm 3 Conference Board of Canada. A difficult road ahead: Canada's economic and fiscal prospects. Available: http://canadaspremiers.ca/phocadownload/publications/conf_bd_difficultroadahead_aug_2014.pdf. 4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf 5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending. 6 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf. 7 Finance Canada. Update of Economic and Fiscal Projections 2015. http://www.budget.gc.ca/efp-peb/2015/pub/efp-peb-15-en.pdf. 8 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf. 9 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf 10 IBM for the Pan-Canadian Pharmaceutical Alliance. Pan Canadian Drugs Negotiations Report. Available at: http://canadaspremiers.ca/phocadownload/pcpa/pan_canadian_drugs_negotiations_report_march22_2014.pdf . 11 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf 12 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf 13 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013. 14 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014 15 Conference Board of Canada. Research commissioned for the CMA, July 2015. 16 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm 17 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx 18 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59. 19 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml 20 Ibid. 21 Conference Board of Canada. Research commissioned for the CMA, July 2015. 22 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf. 23 CMA. A policy framework to guide a national seniors strategy for Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/about-us/gc2015/policy-framework-to-guide-seniors_en.pdf. 24 Conference Board of Canada. Research commissioned for the CMA, January 2013. 25 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf 26 CMA. CMA Submission: The need for health infrastructure in Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Health-Infrastructure_en.pdf. 27 Ibid. 28 Conference Board of Canada. Research commissioned for the CMA, July 2015.
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Relationships among all health care professionals

https://policybase.cma.ca/en/permalink/policy11893
Date
2016-08-24
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC16-23
The Canadian Medical Association supports educating health care teams to foster collaborative approaches and promote healthy relationships among all health care professionals.
Policy Type
Policy resolution
Date
2016-08-24
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC16-23
The Canadian Medical Association supports educating health care teams to foster collaborative approaches and promote healthy relationships among all health care professionals.
Text
The Canadian Medical Association supports educating health care teams to foster collaborative approaches and promote healthy relationships among all health care professionals.
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