Connecting patients with home care a big challenge for Ontario family doctors

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Less than a third (29%) of family doctors in Ontario say they, or staff, in their practice routinely communicate with their patients’ community case manager or home care provider. This is just one of the findings of a new report on coordinated care by Health Quality Ontario, the provincial advisor on the quality of health care.

According to the report, Connecting the Dots for Patients, Ontario has one of the lowest reported percentages of family doctors communicating with home care and community services when compared to family doctors in other parts of Canada as well as those in Australia, France, Germany, the Netherlands, New Zealand, Norway,Sweden, Switzerland, the United Kingdom, and the United States. The new report, based on the 2015Commonwealth Fund International Health Policy Survey of Primary Care Doctors, shows that family doctors are experiencing systemic barriers when coordinating care for their patients in home and community services, which affects the experiences of patients and caregivers. The report also shows positive results in coordinating care with hospitals and specialists.

Increasingly, often due to chronic conditions, people need multiple types of care in more than one setting — an office setting, rehabilitation center, emergency department, hospital ward, outpatient hospital clinic, their own home, or other. Poor care coordination can contribute to hospital admissions that could have been prevented, unnecessary emergency department visits, medical errors, repeated tests and poor health outcomes for the patient.

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“Despite significant efforts by many primary care providers to ensure good care coordination, it takes dedicated effort on behalf of everyone in the system. It needs to be easy to do the right thing for patients,” says Dr.Joshua Tepper, President and CEO of Health Quality Ontario.

Coordinating patient care is a fundamental role of primary care, which is the foundation of Ontario’s complex health system. Recognizing that gaps remain in this area, Health Quality Ontario’s strategic plan, Better Has No Limit: Partnering for a Quality Health System, includes a focus on enhancing transitions between different types of settings of care.  The Ministry of Health and Long-Term Care speaks to the need for improvement in primary care in its discussion paper, Patients First: A proposal to strengthen patient-centered health care in Ontario.


  • 29% of Ontario family doctors say they, or other personnel in their practice, routinely communicate with their patient’s case manager or home care provider about the patient’s needs and services to be provided. More than twice as many family doctors in Saskatchewan (62%) report regularly communicating with home care. More family doctors in seven other countries report regular communications with home care than in OntarioNorway (63%); Netherlands (56%); Switzerland (54%);United States (52%); Germany (51%); and France (36%).
  • 36% of Ontario family doctors say it’s easy, or very easy, to coordinate their patients’ care with social services or other community providers when needed. More than twice as many family doctors inSwitzerland (74%) report this ease of care coordination, and family doctors in other parts of Canada and other countries fare better than OntarioSaskatchewan (55%); Norway (48%); Nova Scotia (45%); New Zealand (45%); and Germany (45%).
  • 71% of Ontario family doctors say they always, or often, receive notification when their patient is discharged from hospital. That’s better than in Quebec (52%), Manitoba (58%), Saskatchewan (61%) andAlberta (63%), and better than in Sweden (35%), Australia (65%) and Canada (65%). However, family doctors in New Zealand (86%) and the Netherlands (97%) fare better with discharge notifications.
  • 90% of family doctors receive a report from specialists, similar to other provinces in Canada, exceptQuebec (66%). This is better than other countries: Sweden (56%), United States (76%), Germany (82%),Australia (83%), United Kingdom (84%).
  • 25% of Ontario family doctors say that during the past month, tests or procedures for their patients had to be repeated because results were unavailable. That was better than family doctors in Manitoba (39%),Quebec (34%) or Saskatchewan (34%), and better than in the United Kingdom, where almost half (48%) of family doctors report needing to repeat tests or procedures.
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Connecting the Dots for Patients also includes stories from various primary care providers on their experiences of helping patients transition through the health system in Ontario. Nurse practitioner Stephanie Skopyk reflects on the integration of primary care and social services at her Oshawa clinic. Dr. Pham, a family doctor from East Toronto, talks about the benefit of having a dedicated case manager to more effectively coordinate home care for patients in her practice, an exception in Ontario. A family doctor from Collingwood, Dr. O’Halloran, shares the challenges of obtaining information for patients outside of the local system and the impact that has on patient outcomes. Although Connecting the Dots for Patients discusses data specific to family doctors, primary care is made up of many types of providers.

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The 2015 Commonwealth Fund International Health Policy Survey of Primary Care Doctors surveyed nationally representative random samples of primary care doctors. Samples of practicing doctors were drawn from government or private lists of primary care doctors in each country. – CNW

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