We assert the role of primary care providers to lead care coordination.

The Association of Family Health Teams of Ontario (AFHTO) endorses and embraces this position statement adopted with our colleagues in the Ontario Primary Care Council in November 2015.  Primary care providers work to ensure access to interprofessional care for patients and identify a single point of contact to help patients and families navigate and access programs and services. Furthermore, AFHTO implores the Ministry of Health and Long-Term Care to work with primary care teams and LHINs to bring greater efficiency and patient-centredness to care delivery, through steps to transition care coordination resources to primary care teams from community care access centres (CCACs). Primary care is an anchor for patients and families, providing comprehensive care throughout their lives. Primary care providers are the first contact or entry into the system for all new needs and problems, and they directly influence the responses of people to their health needs by listening to their concerns and preferences and providing clinical evidence-based assessment and treatment recommendations. Care coordination in primary care has the potential to significantly:

• Reduce the duplication and role conflict that currently exists in our health system;
• Improve patient outcomes through much greater continuity and coordination of person-centred care.

Click to read AFHTO’s position statement: Transitioning care coordination resources to primary care. Primary care teams want to coordinate care for their patients – this was clearly demonstrated by the 200+ leaders who participated in AFHTO’s October 2015 session on Leading Primary Care through the Next Stage. Through their work in Health Links, many primary care teams have demonstrated readiness to take on this role, and their success when they can mobilize the resources to fulfill this role. The transition of care coordination resources from CCACs to primary care teams is the logical next step.

Resources for AFHTO members:

• Case Study: Effectively Embedding Care Coordinators within Primary Care: explores teams that currently have CCAC care coordinators embedded within their teams and the success factors and principles for establishing effective working relations.

Evidence and background on care coordination in Ontario:

• Health Quality Ontario report Connecting the Dots for Patients: Family Doctors’ Views on Coordinating Patient Care in Ontario’s Health System, showing that family doctors are experiencing systemic barriers when coordinating care for their patients, June 2016
• Case studies of successful care coordination in family health teams and community health centres, in rural and urban settings, are featured in the OPCC’s Position Statement: Care Coordination in Primary Care.
• Globe and Mail article and AFHTO Response, “Ontario plans to target home care in overhaul of health care system”, November 2015
• Guide to Advanced Health Links Model, aligning this model with the work underway to support a strengthened primary care sector, November 2015
• Report on behalf of the Primary Health Care Expert Advisory Committee (Baker/Price Report), October 2015
  • AFHTO members response to the report, November 2015
• Auditor General of Ontario Special Report on CCACs, September 2015
• Family Health Teams participating in “Bundled Care” – a funding model aiming to improve care coordination, September 2015
• Report of the Expert Group on Home and Community Care (Donner Report), March 2015
• Patient experiences of care coordination and communication, Health Quality Ontario (HQO) report, April 2015