Concept: Models of Primary Care Delivery

Introduction

This concept identifies and describes five models of primary care service delivery that are provided in the Winnipeg Health Region. This includes a brief description of each model and a list of summary characteristics for each. Information for this concept is taken directly from the deliverable A Comparison of Models of Primary Care Delivery in Winnipeg by Katz et al. (2016).

The concept also identifies additional areas of research investigated in this project and how these relate to models of primary care. This includes primary care provider characteristics by model of primary care, social complexities by model of primary care, and models of primary care and primary care quality indicators. Links are provided to the relevant sections of the deliverable for access to the discussion and results.

Models of Primary Care Delivery in Winnipeg

Primary care service delivery in Winnipeg is provided by primary care physicians (PCP) and nurse practitioners through five different organizational and funding models. The following list identifies each of the five models of primary care delivery and describes some of the characteristics of each model.

1. Non-PIN FFS (Non-Physician Integrated Network (PIN) Fee-For-Service (FFS))

The dominant model of primary care delivery in Winnipeg is the fee-for-service (FFS) model, in which primary care providers submit claims for each service provided to an eligible Manitoba resident according to a predetermined fee schedule. Over 80% of primary care services within Winnipeg are provided by independent FFS primary care providers. This is the traditional model of primary care service delivery and remains the dominant model in Winnipeg. This model includes clinics providing full service family practice as well as walk-in clinics. While some FFS clinics participate in the PIN initiative, most do not. For analyses in Katz et al. (2016), all FFS clinics that are not included in PIN are in this category. It should be noted that certain financial incentives for management of specific chronic diseases were available to all FFS clinicians during the third year of the study period. It was not possible to determine the impact of this funding on clinical practice in this (2016) research project.

2. PIN FFS (Physician Integrated Network (PIN) Fee-For-Service (FFS))

The Physician Integrated Network (PIN) is a reform model that was offered to FFS primary care providers working in group clinics. The main objectives of PIN are to improve the public’s access to primary care, the primary care providers’ access to and use of information, the work life of all primary care providers, and to strive for high-quality primary care, with a focus on chronic disease.

PIN is a model of primary care developed by Manitoba Health, Healthy Living and Seniors (MHHLS) based on guidance from an advisory committee with representation from the University of Manitoba, the Colleges of Registered Nurses and Physicians & Surgeons of Manitoba, the Manitoba Medical Association, the Winnipeg and former Assiniboine Regional Health Authorities, and other primary care stakeholders.

One mechanism for engaging primary care providers in PIN is quality-based incentive funding (QBIF); pay-for-performance funding that is provided to clinics meeting quality targets on certain primary care indicators. These indicators were established by the Canadian Institutes for Health Information (CIHI) and modified by a committee of relevant stakeholders. The funding provided to clinics meeting these quality targets is in addition to the usual FFS funding mechanism. Thirteen clinics in Manitoba received QBIF to support high quality prevention and chronic disease management care. All five PIN clinics in Winnipeg were included in Katz et al. (2016), including:


• Assiniboine Medical Centre;
  
• Clinique St. Boniface Clinic;
  
• Concordia Health Associates;
  
• Prairie Trail Medical Clinic; and
  
• Tuxedo Family Medical Centre.

3. WRHA Primary Care (Winnipeg Regional Health Authority (WRHA) Primary Care)

The Winnipeg Regional Health Authority (WRHA) developed these clinics over the past decade to address the primary care needs of specific underserved populations. The human resources in these integrated care centres are also intended to match the local needs. These clinics provide health and social services that are unique to the communities in which they are located. Services include frontline healthcare from physicians or nurse practitioners to assist with mental health, home care, employment, and income assistance programs. Primary care providers at these clinics receive alternative funding (see alternate payment plan (APP) glossary term for more information) or are funded on a sessional basis.

There are six such centres in Winnipeg, of which five were included in Katz et al. (2016) - Access Winnipeg West was excluded because it was not fully operational during the entire study period. The centres included in this research are:


• Access Downtown Primary Care Clinic (formerly Health Action Centre);
  
• Corydon Community Health Centre;
  
• Aikins Community Health Centre;
  
• Access River East Primary Care Clinic; and
  
• Access Transcona Primary Care Clinic.

NOTE: Access Downtown, Access River East, and Access Transcona also provide services beyond primary care. In Katz et al. (2016), only the primary care clinics at these locations were included.

4. Community Health Clinic

These clinics - also called "Community Health Agency Centres" - were established well over 40 years ago in response to a national movement that promoted interdisciplinary team-based care focused on specific target groups. The staffing at each of these clinics has evolved over the years as different programs that are run out of these centres have been developed. The staff and funding are based on the needs of the population served. These clinics are located throughout the city and provide a variety of health and social services. Some clinics focus on particular practice areas or population groups (e.g., Francophones, women), while others provide general care. They are operated by Community Boards. Primary care providers at these clinics receive alternative funding or are funded on a sessional basis. Seven primary care clinics of this type in Winnipeg were included in Katz et al. (2016). They include:


• Aboriginal Health and Wellness Centre;
  
• Centre de Santé Saint Boniface;
  
• Hope Centre Health Care Inc.;
  
• Klinic Community Health Centre;
  
• Mount Carmel Clinic;
  
• Nor’West Co-op Community Health Centre; and
  
• Women's Health Clinic.

NOTE: The Nine Circles community health clinic was not included in this research project because they do not shadow bill/submit claims and thus service information is not available for this clinic in the Medical Services data.

5. Teaching Clinic

The fifth model comprises the three interdisciplinary clinics in Winnipeg whose initial mandate was to provide a site for the education and training of family physicians. The vast majority of the clinical care provided at these sites is provided by these trainees under the supervision of their preceptors, who include family physicians, nurse practitioners, and an interdisciplinary team of nurses, social workers, pharmacists, and nutritionists. These clinics are funded through different mechanisms due to their mandate for education, with the supervising primary care providers being funded through a mechanism similar to the Community Health Agency clinics and WRHA Primary Care clinics. There are three such sites in Winnipeg, including:


• Family Medical Centre;
  
• Kildonan Medical Centre; and
  
• Northern Connection Medical Centre.

Summary Characteristics of Different Primary Care Service Delivery Models

The following table summarizes several characteristics of each model of primary care service delivery investigated in Katz et al. (2016). In the table, the following terms have specific meaning:


• "alternative-funded" refers to the payment of primary care providers via a salary or contract - not on a fee-for-service (FFS) basis;
  
• "funding for multidisciplinary staff" refers to whether financial support is available to hire additional staff, such as nurses, nutritionists, and social workers; and
  
• "IT support" refers to financial support provided for implementation and support of electronic medical records (EMR).

Table 1: Summary Characteristics of Primary Care Models

CHARACTERISTIC	PIN FFS	WRHA PRIMARY CARE	COMMUNITY HEALTH CLINIC	TEACHING CLINIC	NON-PIN FFS
Primary Method of Provider Payment	FFS	Alternative-funded*	Alternative-funded*	Alternative-funded*	FFS
Quality-Based Incentive Funding (for Provider vs. Clinic)	Yes – Clinic	No	No	No	No
Funding for Multidisciplinary Staff	No	Yes	Yes	Yes	No
IT Support	One-time cost of purchase off set (Infoway)	Full Support	Full Support	Full Support	One-time cost of purchase off set (Infoway)

NOTE: * Alternative Funded: Primary care providers sign a contract to fulfill a certain number of hours of work.

Research Related to Models of Primary Care

This section briefly describes three areas of research related to models of primary care that were investigated in Katz et al. (2016), and provides links to the relevant sections of the deliverable for direct access to the discussion and results.

1. Primary Care Provider Characteristics By Model of Primary Care

In this research they identified and reported on characteristics of the primary care providers involved in each of the five models of primary care service delivery. The characteristics included: the number of providers, the types of providers (e.g.: physicians, nurse practitioners, females), average (median) provider age, years of practice, percentage of non-allocated patient visits, and full time equivalent measure. For more information and discussion of the results, please see:


• Table 3.3 - Primary Care Provider Characteristics by Model of Primary Care in the deliverable.

2. Social Complexities By Model of Primary Care

In this research they investigated and reported on the relationship between social complexities and the five different models of primary care listed in this concept. For more information and discussion of the results, please see:


• Table 3.2 and Figure 3.5 - Crude Rates of Patient Social Complexities by Model of Primary Care in the deliverable; and
  
• Figure 3.6 - Crude Rates of the Number of Patient Social Complexities by Model of Primary Care in the deliverable.

3. Models of Primary Care and Primary Care Quality Indicators

In this research they compared the relationship between the five models of primary care and the 29 individual primary care quality indicators. This included reporting the eligible populations and the crude rates for each model of primary care for each indicator, and comparing the models of primary care using adjusted odds ratios for each primary care quality indicator. For more information on the results and discussion related to the comparison of models of primary care and the primary care quality indicators, please see the relevant information in each of the following chapters of the deliverable:


• Chapter 4: Prevention and Screening Indicator Results - contains information on indicators for different types of cancer screening and vaccinations.
  
  
• Chapter 5: Chronic Disease Management Indicator Results - contains information on indicators for diabetes eye examinations; congestive heart failure (CHF); post-myocardial infarction; and asthma medication use.
  
  
• Chapter 6: Medical Care Indicator Results - contains information on indicators for benzodiazepine prescriptions; Beers Criteria prescriptions; and depression care prescriptions; and
  
  
• Chapter 7: Health Services Delivery and Use Indicator Results - contains information on indicators for continuity of care; referral rates; hospitalizations for ambulatory care sensitive conditions (ACSC); x-rays for lower back pain; hospital readmissions; emergency department visits that are potentially inappropriate; and for a variety of types of ambulatory visits.