Engaging Primary Care Physicians in LHIN Processes:

Engaging Primary Care Physicians in LHIN Processes: LHIN Survey Results June 2010

Table of Contents 1.0 EXECUTIVE SUMMARY 3 2.0 PROJECT OVERVIEW 4 2.1 Introduction 4 2.2 Purpose 4 2.3 Project Scope 5 2.4 Survey Methodology 5 3.0 SURVEY FINDINGS 6 3.1 Engagement Trends 6 3.2 Methods of Engagement 7 3.3 Role of the Health Professional Advisory Committee 9 3.4 Current Gaps in Engagement 9 3.5 Strategies to Improve Engagement 9 3.6 Challenges to Effective Engagement 11 4.0 ANALYSIS & NEXT STEPS 12 5.0 CONCLUSION 13 APPENDIX I 14

1.0 Executive Summary The role of the Local Health Integration Networks (LHINs) is to fund health service providers, put local health dollars where they are most needed based on community priorities, and integrate health services so care is better coordinated and more efficient. Primary care physicians, while not funded by the LHINs, play a central role in health service delivery. As a result, successful engagement of primary care physicians in LHIN processes is a critical enabler to achieving the LHIN mandate. This report presents the findings of a survey completed by all 14 LHINs on current primary care physician engagement practices. The report provides preliminary, high-level observations based on initial survey results. Survey highlights demonstrated: The majority of LHINs viewed primary care physician engagement as central to achieving the LHIN mandate to plan, fund and integrate the local health system All LHINs indicated that they engage primary care physicians on a regular basis Primary care physicians are most commonly engaged in strategic planning, program planning and integration initiatives A variety of approaches have been adopted by the LHINs to engage primary care physicians, each with varying degrees of effectiveness Several incentives or strategies are used by the LHINs to promote attendance and involvement of primary care physicians at engagement events, each with varying degrees of effectiveness Several gaps and challenges in current methods of engagement were identified and need to be addressed to sustain responsive and effective physician engagement for the long term There are a number of suggested strategies and new initiatives being explored to improve the engagement of primary care physicians that require further investigation 3

2.0 Project Overview 2.1 Introduction A key goal underpinning the establishment of the LHINs is to improve the coordination and integration of health system service delivery at the local level. Successful community engagement (i.e. provider and public participation) is seen by the government and the LHINs as essential for realizing this goal. In Ontario, primary care physicians are the point of entry or gatekeeper for most health care services. Due to this central role, early and meaningful involvement of physicians can help to produce positive results in health care planning, healthy physician relations, and comprehensive, sustainable local health care solutions. Since their inception, LHINs have been working on building relationships with primary care physicians to involve them in planning and priority setting at the local level. A challenge for LHINs in this important pursuit is that primary health care is not funded by the LHINs. As a result, it is not easy to identify all of the practitioners providing primary health care, nor is it easy to communicate key messages to them and to involve them all in designing changes to system level care. A review of primary care physician engagement strategies is significant because LHINs have used a wide range of different engagement methods and forums, and an evaluation of these strategies and the sharing of best practice has not been undertaken. This report presents the findings of a survey completed by the 14 LHINs on current practices of primary care physician engagement and highlights areas and opportunities requiring further investigation. 2.2 Purpose The project Engaging Primary Care Physicians in LHIN Processes, was identified by LHINC Council 1 as a priority area where best practice models should be developed to support the effective engagement of primary care physicians. The purpose of the project is to: Identify best practice models for engaging primary care physicians in LHIN activities. Develop an implementation strategy to support the implementation of best practice models for engaging primary care physicians. 1 The LHINC Council is advisory and accountable to the LHIN CEOs. LHINC Council is comprised of six LHIN representatives and nine representatives of the various health sectors, including: Cancer Care, Community Care Access Centres, Community Health Centres, Community Support Services, Hospitals, Long-Term Care Homes, Mental Health and Addiction Services, Primary Care and Public Health. 4

2.3 Project Scope The project is being conducted in two phases: Phase One: Identify current approaches used across all LHINs to engage and partner with primary care practitioners Examine the effectiveness of these approaches from a LHIN perspective Phase Two: Identify/establish a focus group with LHIN and stakeholder representatives Engage stakeholders establish a Physician Expert Panel Develop a detailed analysis of current models and best practice opportunities Recommend model(s) and implementation strategies An illustration of the key phases and steps in the project is shown below: Project Start Up, Survey Design & Distribution Survey Synthesis, Analysis and Report Establish Focus Group & Physician Expert Panel Develop a comprehensive analysis of primary care physician engagement Toolkit to promote best practice adoption & implementation steps 2.4 Survey Methodology The project commenced in March 2010. The methodology used to develop a current inventory of primary care physician engagement practices involved a survey sent to all LHINs. The survey consisted of 21 questions and was piloted through two LHIN communicators with feedback incorporated into the final survey. The purpose of the survey was to identify current approaches used across all LHINs to engage and partner with primary care practitioners with the objective of providing lessons learned for future LHIN/physician engagement activities. The survey focused on the following key areas: Areas that primary care physicians are currently engaged (ex. health service planning, Integrated Health Service Plans) Current strategies and techniques Effectiveness of engagement methods Gaps in engagement methods Barriers and/or challenges Mitigation strategies 5

Methods to improve effective engagement Questions were both open and close ended with sections for narrative. Respondents were given 1 week to submit the survey. 3.0 Survey Findings Survey responses from all 14 LHINs were received. There were 2 separate responses from 2 LHINs, resulting in a total of 16 survey submissions. The survey has been analyzed and information is provided in the following section. As part of the survey collection, follow up phone interviews were held as required to gain further clarity in regard to survey responses. 3.1 Engagement Trends LHINs recognized that primary care is the initial entry point to the health care system for many patients and their families. Because of this central role, all LHINs indicated that they actively engage primary care physicians on a regular basis. The importance of this engagement was primarily attributed to physicians being a critical success factor in achieving the LHIN mandate. LHINs recognized that they are not likely to achieve system-level improvements without the enthusiasm, knowledge, cultural clout and personal leadership of primary care physicians. When asked what areas primary care physicians are engaged in, several areas were identified. The most common areas of engagement are listed below: Integrated Health Service Plan (IHSP) - planning & priorities Health Service Planning/Program Planning Integration Planning & Initiatives All LHINs identified primary care as an important part of their IHSP and a key enabler for achieving IHSP priorities. Primary care was identified by 5 LHINs as a specific strategic priority. The role of physicians in IHSP priorities was found to vary depending on the priority and activity but responses suggested a need to educate physicians on the current priorities and how their work/practices can impact these priorities (namely ER/ALC pressures, integrated diabetes care, and mental health and addiction services). In terms of specific objectives for engaging primary care physicians, responses from all LHINs centered around 5 common themes: Ensure successful implementation of strategic initiatives & directions To obtain input on priority areas and to align primary care physicians with the strategic direction of the LHIN to ensure achievement of strategic goals. Provide information on LHIN activities and collect physician input 6

Educate primary care physicians on LHIN activities and seek their input/suggestions for health system improvements. Involve in planning & foster collaboration Actively partnering with primary care physicians to better understand their local needs and services and to identify areas for collaboration between the LHIN and primary care physicians. Secure buy-in for health system change Establish physician champions for change. By obtaining primary care support, LHINs recognized that health system change will be more readily accepted by patients and the public. Incorporate primary care into an integrated system of health care Develop a system of primary health care as opposed to primary care. Engaging primary care physicians in LHIN processes will support the development of an integrated system that is patient-focused, collaborative, & responsive to the needs of the population. Although all LHINs viewed primary care physician engagement as central to achieving the LHIN mandate to plan and integrate the local health system, only one LHIN responded that their engagement efforts are extremely effective. Half of the LHINs viewed their overall primary care physician engagement efforts in 2009 as only somewhat effective. Overall Effectiveness of Primary Care Physician Engagement Activities in 2009 6 1 7 Not Effective Somewhat Effective Effective Extremely Effective Graph 1: Overall Effectiveness Responses indicated that seven LHINs viewed their overall primary care physician engagement efforts in 2009 as Somewhat Effective ; six LHINs viewed their efforts as Effective ; and one LHIN viewed their efforts as Extremely Effective. 3.2 Methods of Engagement A variety of approaches have been adopted by the LHINs to effectively engage primary care physicians. In addition, LHINs were asked to rank the effectiveness of these engagement methods. Effectiveness was defined to include both the level of engagement achieved and the 7

number of physicians engaged. The table below identifies the five most common methods used by LHINs, and reflects the number of LHINs that use the identified method of engagement and their perceived level of method effectiveness. For example, conducting focus groups was identified by eleven LHINs as a method to engage primary care physicians, and nine out of the eleven LHINs (82%) rated this as being an effective method. The survey results point to varying levels of effectiveness, from Somewhat Effective to Extremely Effective for each method listed. A leading engagement practice used by all LHINs was not identified. Table 1: Methods of Engagement & Level of Effectiveness Method of Engagement Not Effective Somewhat Effective Effective Extremely Effective Total # of LHINs using Method Focus Groups 1 (9%) 9 (82%) 1 (9%) 11 LHIN Committee 2 (22%) 6 (67%) 1 (11%) 9 Participation Targeted Education 3 (37.5%) 3 (37.5%) 2 (25%) 8 Sessions Project/Task 1(10%) 2 (40%) 2(40%) 5 Groups Newsletters/ Bulletins 2(50%) 2(50%) 4 Other methods to engage primary care physicians involved one on one interviews, surveys, web-casts, open house, ad hoc meetings with Family Health Teams and Community Health Centres, and presentations at medical meetings. The frequency of the identified engagement methods varied and was most often conducted on an as-needed basis. A few LHINs have also initiated site visits to primary care practices as a mechanism of communicating and engaging with primary care physicians either as a common practice, on an ad hoc basis, or for specific planning initiatives. This tactic, although useful, was limited in terms of time and resource constraints, and requires further investigation to examine feasibility and value. Other approaches to enhance primary care physician engagement are being explored by some LHINs. These unique approaches include: Primary Care Networks Elite econsultation Intranet Service Catalogue Leadership Council Primary Care Physician Leads More detailed information on these engagement models can be found in Appendix I. The majority of these initiatives are in the early development stages, and as such, the effectiveness has not yet been determined. 8

3.3 Role of the Health Professional Advisory Committee A Health Professional Advisory Committee (HPAC) was established in each LHIN in 2007 and is comprised of members from a range of health services professions. The role of this multidisciplinary committee is to provide advice to the LHINs on how to achieve patient centered health care. Membership was mandated to include four members of the College of Physicians and Surgeons of Ontario, including one member who is authorized to practice in the area of family medicine and who practices in the community. Views on the role of HPAC and the effectiveness of this forum to engage primary care physicians were generally consistent across the LHINs. It was expressed that HPAC has the potential to be an effective method for primary care physician engagement, but it has not been utilized to its full potential. Many LHINs responded that HPAC provides limited engagement, is difficult to use as an effective forum for physician consultation and has not been used to target broad/regional primary care physician engagement. Survey responses suggested the need to clarify the role of HPAC in engaging primary care physicians. However, three LHINs reflected positive experiences using HPAC to identify physician champions who will support engagement activities. 3.4 Current Gaps in Engagement The survey pointed to a variety of gaps in current methods used by the LHINs to engage primary care physicians. Below is a summary of the gaps identified: An inability to identify all primary care physicians where they are and how to reach them. This was the most common gap mentioned. No effective two-way communication channels or tools. The survey showed a lack of knowledge on the preferred communication techniques of physicians. Lack of frequent engagement approaches. Strategies for engaging solo primary care physicians are limited. Lack of leadership connect between LHINs and primary care physicians - there is no formal forum for collaboration. Not reaching the majority of primary care physicians. The survey suggested engagement efforts are limited to the same physician champions and leaders. Lack of involvement over a broad spectrum. The survey showed physicians are generally involved in a few specific initiatives but there is no defined scope for the areas they should be or could be engaged. 3.5 Strategies to Improve Engagement A variety of strategies and incentives to promote attendance and involvement at primary care physician engagement activities have been identified. The following table depicts the strategies used by the LHINs, the number of LHINs that identified using the strategy, and their perceived 9

level of strategy effectiveness. The survey results pointed to varying levels of strategy effectiveness. One leading strategy or incentive is not currently used by all LHINs. Table #2: Strategies to Improve Engagement & Level of Effectiveness Strategy to Promote Attendance & Involvement Not Effective Somewhat Effective Effective Extremely Effective Total # of LHINs using Strategy CME Credits 2(15%) 5(38%) 3(23%) 3(23%) 13 Board/CEO/ Senior Mgt Presence Direct Influence on Decision Making Compensation (food, mileage) Convenience (time, location) 1(14%) 2(29%) 3(43%) 1(14%) 7 4(100%) 4 2(67%) 1(33%) 3 3(100%) 3 Recognition 1(33%) 2(67%) 3 CME credits are used most often to entice physicians, but are not always an effective method to increase attendance or participation at engagement events. Many of the listed strategies also have inherent limitations, for example providing physicians with the direct capacity to influence decision making has been shown to be effective, but it may not always be achievable depending on the purpose of engagement (information sharing vs. focus groups/collaboration). In addition, all LHINs leveraged their partnership with the Ontario Medical Association (OMA) to promote or coordinate some engagement activities. Similarly, some LHINs have partnered with the Ontario College of Family Physicians (OCFP) as an additional tool to endorse engagement events by circulating information to members. Other promotional tactics include website postings, newsletters, and direct email (where available); however the effectiveness of these tools for improving engagement turnout is difficult to determine. Health Force Ontario (HFO) was identified by eight LHINs as a source to facilitate communication to physicians through HFO local recruiters. However the exact nature of collaboration, and their role in facilitating or promoting engagement activities remains unclear. Potential Opportunities: A number of opportunities were identified by the LHINs as potential ways to improve the effectiveness of primary care physician engagement in the future. These suggestions are outlined below and deserve further investigation and attention. Develop a comprehensive contact database of primary care physicians including characteristics of their practice (size, type, and demographics) 10

Establish preferred methods and tools to engage primary care physicians; specify the mechanisms that should be used to support information sharing, communication and consultation between LHINs and primary care physicians such as newsletters, email, website, virtual communities/blogs; and streamline communication on LHIN priorities and engagement opportunities to all primary care physicians Develop a focused Primary Care Engagement Strategy to identify the scope of primary care physician engagement within the LHIN Develop physician champions/regional primary care physician leads and/or dedicate a staff member as a physician lead. (HNHB is the only LHIN to have hired a full time Physician as a lead for primary care engagement. See Appendix I for further details on this role) Support development of primary care Networks/Councils/Advisory Committees. (See Appendix I for a list of LHINs that have established or are currently developing these models) Provide education and information to the LHINs on primary care services, including the different primary care models and lead contacts for the model(s) Develop new and innovative approaches to primary care physician engagement 3.6 Challenges to Effective Engagement A few challenges have also been identified through the survey and will be important to keep in mind as the project progresses: Accountability Primary Care funding falls outside of the LHIN funding structure and as a result survey responses indicated that the lack of direct accountability to the LHIN can make engagement difficult. LHIN Resources The time and staffing requirements placed on the LHIN, and the limited availability of funding or incentives pose further barriers to effective engagement. Physician Constraints Similar to LHIN constraints, primary care physician availability and time can also limit opportunities for engagement. Geographical Barriers The survey revealed that the geographical size of LHINs, and the unique characteristics of the many local communities present challenges to the number and 11

Cultural type of engagement activities that can conducted. This is especially cumbersome in more rural communities. Responses pointed toward the need to demonstrate the value-add of the LHINs. Shifting the culture and showing how LHINs can improve primary care processes, and have direct benefits to primary care practitioners and their patients is instrumental to achieving effective engagement. Alignment Current funding models for primary care physicians are not aligned with LHINs and other Health Service Providers. Survey responses suggested funding is a potential barrier to physician involvement in integration opportunities & regional program development/implementation. 4.0 Analysis & Next Steps Finding the right mechanisms to engage primary care physicians and to obtain meaningful input is essential to ensuring a high quality, cost effective, and patient-centered health system. The challenge being faced by all LHINs is how to ensure appropriate and effective involvement of primary care physicians in health system planning. Currently, a variety of strategies are used across the LHINs for the engagement of primary care physicians, each with varying levels of effectiveness. The fact that 50% of LHINs view their overall primary care physician engagement efforts in 2009 as only somewhat effective suggests the need for stronger engagement methods and strategies. Survey findings did not provide information on the number of physicians engaged, the extent to which they were actively engaged, or the point at which they were engaged in planning processes (before, during or after). This will require more detailed discussions with the LHINs and stakeholders. In addition, current gaps need to be further addressed and potential mitigation strategies need to be further explored. Recognizing these gaps and the potential opportunities they present is essential to influence and strengthen future engagement activities and initiatives. New and innovative approaches to enhance primary care physician engagement are being explored by some LHINs and also require further investigation. Next Steps: Detailed discussions with LHINs and stakeholders to obtain additional information on successful engagement practice models needs to be undertaken. Suggested methods to improve engagement and potential opportunities need to be further explored. Best practice methods of primary care physician engagement in other jurisdictions need to be reviewed. 12

A comprehensive analysis of current approaches and the dissemination of leading practice information need to be shared with the LHINs in order to strengthen future engagement activities and influence health system planning and integration initiatives. A toolkit to promote best practice adoption and steps for implementation needs to be developed. 5.0 Conclusion Physician input is an important element in undertaking transformational change in the way health services are delivered within the LHIN. An effective and inclusive partnership with primary care physicians can provide valuable input on system planning and resource allocation needs, and can support improved patient care and health outcomes. To achieve their mandate it is critical for the LHINs to develop primary care physician engagement activities that are comprehensive and inclusive both at the hospital and community level. There is a growing recognition, as evidenced in this report, of the need to develop more sophisticated engagement approaches as well as greater capacity and support for this initiative. 13

Appendix I Primary Care Networks Toronto Central Primary Care Advisory Group Target Date Q2 2010/2011 Advise the LHIN on priority initiatives for IHSP-2 implementation. Advise the LHIN on various initiatives to meet physician needs. Purpose Primary care leaders will be challenged to come up with options/primary care agenda related to specific LHIN initiatives. Primary care leaders will be champions/ambassadors of LHIN initiatives within their own communities of practice, networks, etc. Membership Leads Frequency Significant Contributions A cross section of primary care leaders: family physicians practicing within the TC LHIN including the Chiefs of Family Medicine at TC LHIN hospitals, representatives from Community Health Centres (CHCs) and Family Health Teams as well as Toronto Public Health. Co-chaired: Senior Director & Primary Care Lead To be determined Not applicable Mississauga Halton - Primary Health Care Steering Committee Target Date May 2010 To provide tactical and implementation advice to the MH LHIN on the rollout of actions to achieve the strategic priorities outlined in the 2010-2013 IHSP Purpose Membership To develop, implement and monitor a primary health care communications and engagement strategy for addressing the key areas of interest To provide advice to the MH LHIN on opportunities to improve access to family health care through different models of care Family physicians (Family Health Teams, Hospitals, CHCs, & community), retail pharmacist, nurse practitioner, associate medical officer of health, OMA, OCFP, local Health Care Connect representative, and a representative from the Ministry of Health & Long Term Care Leads Frequency Significant Contributions To be determined Quarterly Not applicable 14

Established May 2007 Central East Primary Care Working Groups Provide advice on issues related to integration, performance & sustainability Purpose Membership Leads Frequency Significant Contributions Provide advice on IHSP priorities Provide advice on current and emerging trends and issues in Primary Health Care and population health Act as a communication liaison on primary health care issues Family physicians (Family Health Teams, Hospitals, Community Health Centres, & community), retail pharmacist, & nurse practitioners. - 18 members Co-Chairs: Clinical & Administrative Monthly Not provided Target Date Q1 2010 Erie St. Clair Primary Health Care Task Group To improve access to primary health care and to maximize the current services available. Purpose Increased availability of primary health care options Greater equity of service Membership Leads Frequency Significant Contributions Improved health outcomes May include: Community member (3), Community Health Centre / Family Health Team, Emergency Medical Services representative, Long-Term Care Sector representative, Mental Health Sector representative, Nurse Practitioner, Pharmacist, Physician, Registered Nurse, Social Worker, Other Membership will be capped at 20. To be Determined Approximately 7-10 meetings per year, or as required Not applicable 15

Target Date September 2008 South East Primary Health Care Council Purpose Membership Leads Frequency Significant Contributions To provide an opportunity for primary care health care providers to network and learn of collaboration opportunities throughout the South East LHIN. Includes representation of primary care physicians from FHTs, ER, GP anesthesiology as well as public health, CHCs, NPs, family residents. Lead by Dean of Family Medicine at Queen s University (also lead of Queen s FHT) Quarterly Development of an annualized primary health care forum bringing together best practices from across the LHIN. Leadership Council North Simcoe Muskoka October 2009 Established Purpose Membership Leads Frequency Significant Contributions Local Leadership Councils have also been established in five geographical regions (with primary care representation) and report directly to the LHIN Leadership Council Provide strategic advice to the LHIN on issues related to the design and realization of an integrated health services system Includes system leaders in all health care sectors: LHIN CEO, all 6 hospital CEO s, LHIN Senior Director, 5 Community Sector Executive Directors, 5 Long Term Care Executive Directors, Medical Officer of Health, Family Health Team Executive Director, Municipal Chief Administration Officer, Aboriginal representative, Francophone representative LHIN CEO Monthly or at the call of the Chair Not applicable Physician Lead Hamilton Niagara Haldimand Brant a full time Physician Lead has been hired for clinical planning and integration. The purpose of this role is to engage and involve medical practitioners (including primary care physicians) in the implementation of the Clinical Service Plan and IHSP initiatives. The survey completed by HNHB promotes having a dedicated physician on site for 16

coordinating physician activities across the LHIN and supports the development of this role across other LHINs. A further evaluation of this role should be conducted. Elite econsultation Central West currently working with a national research firm to develop a dedicated website for physicians. The website will contain specific interest areas for physicians and detailed information on IHSP priorities. This would provide a forum for an online physician focus group and would allow physicians to comment on posts and react to other comments made. The LHIN will also be able to track information on content viewing and time spent browsing. Two reports examining the potential value and use of the site are expected in late September. LHIN Intranet Service Catalogue Mississauga Halton - The aim of this unique initiative is to develop a web based listing of services and programs available in the hospitals and community along with the ability to list specific areas of interest/expertise for each physician. The service catalogue could also contain specific referral forms for specialists or community treatment programs. This mechanism provides an opportunity to communicate specific key messages to physicians when they log onto the site home page. LHIN Collaborative (LHINC) LHINC is a provincial advisory structure. LHINC engages health service providers, their Associations and the LHINs collectively on system-wide health issues related to the LHINs mandate. 17