Closing the gap between primary and specialist care

Primary Health Care Integration Network launched to address integration challenges

November 29, 2017

One of the most substantial challenges for physicians is system integration between primary care clinics, Primary Care Network services and the rest of the health care system, according to Dr. Brad Bahler.

Dr. Bahler believes there is a solution. He is the senior medical director of the newly launched Primary Health Care Integration Network (PHCIN), which was established to broker connections to advance initiatives that improve transitions and integration of care.

“Primary and specialty care physicians are faced, on a daily basis, with a difficult system that is poorly coordinated and creates challenges for our patients,” said Dr. Bahler, adding that when patients can’t access the services they need such as specialty procedures or diagnostics, primary care physicians are the ones closest to the issues.

“We designed this network to work locally with partners on real life challenges of integration,” said Dr. Bahler. “That’s important rather than working conceptually at a higher level.”

Dr. Bahler said improving these challenges can’t be done well unless there is an organized group of both primary and specialty care physicians working together to solve the problems. “Also, this only works if you keep the patient experience and journey top-of-mind during the entire process.”

The PHCIN is a customized Strategic Clinical Network™ (SCN) within the Alberta Health Services (AHS) Provincial Primary Health Care Program. Working closely with several key partners including patient/family advisors, AHS zones and provincial programs, PCNs, the Alberta Medical Association, the Primary Care Alliance, other SCNs, Alberta Health and academic partners, the PHCIN will work to improve transitions of care at every level.

Several system integration initiatives were already underway even before the PHCIN officially launched. Dr. Bahler outlined the challenges in central Alberta involving COPD and heart failure patients who were transitioning out of the hospital. “How do we work collaboratively with specialty and acute care to make sure? First, every one of those patients has a medical home. Secondly, those family physicians get the right information when their patients are discharged. Finally, when patients are back in the community, they have good access to advice and medical care to keep them from being readmitted to hospital.”

These are the types of initiatives the PHCIN will tackle. In addition to its many partners, the PHCIN receives guidance from a coalition for integration. Dr. Bahler co-chairs the coalition, along with a patient representative. “This is an independent think tank to bring knowledge, ideas and connections to integration challenges.”

The structure of the PHCIN will align with the new zonal councils that were recently announced as part of the new governance framework for PCNs. Physicians, clinics and PCNs will work collaboratively through the five zonal councils to identify challenges in realizing high-functioning medical homes for patients in the system and to pursue solutions to address them.

Anticipated benefits to primary care physicians and teams for strengthening the patient’s medical home include the following:

  • Improved and appropriate access to specialist physicians for advice and patient referrals.
  • Improved ability to participate in care planning for patients in other parts of the health system.
  • More comprehensive and timely information about patients who are transitioning from acute care into the community, resulting in better continuity of care.
  • Opportunities to provide leadership in provincial initiatives that improve integration and advance other aspects of health system transformation in alignment with PCN evolution plans.
  • Improved access to care pathways, guidelines and other tools that enable better care for patients.

The Alberta Medical Association stands as an advocate for its physician members, providing leadership & support for their role in the provision of quality health care.