Analysis of Primary Health Care Teams and Integration Policy in Ontario

Catherine Donnelly
Queen’s University, Kingston, Ontario, Canada

Simone Parniak
Queen’s University, Kingston, Ontario, Canada

Nelly Oelke
University of British Columbia (Okanagan), Kelowna, British Columbia, Canada

Ashmita Rai
University of British Columbia (Okanagan), Kelowna, British Columbia, Canada

Sharon Johnston
University of Ottawa, Ottawa, Ontario, Canada

A Provincial / Territorial Health Reform Analysis

Abstract

Key Messages

• Primary care teams played an important goal in supporting access to comprehensive primary care during early reforms.
• There has been a more recent shift to focusing on health care integration, guided by the quadruple aim framework.
• Primary care and teams are seen as an important component of health services integration, but are not specifically highlighted as a strategy in itself.

• Les équipes de soins primaires ont joué un rôle important en soutenant l'accès à des soins primaires complets au cours les premières réformes.
• Plus récemment, la tendance a été de se concentrer sur l'intégration des soins de santé, guidée par le cadre du quadruple objectif.
• Les soins primaires et les équipes sont considérés comme une composante importante de l'intégration des services de santé, mais ne sont pas spécifiquement mis en évidence comme une stratégie en soi même.

Brief Description of the Health Policy Reform

Strong primary care systems have been described as the cornerstone of high functioning health care systems (Starfield et al., 2005). Primary health care (PHC) reform in Canada has been underway for almost 20 years, during which time various models of interprofessional PHC teams were introduced across the country (Aggarwal, 2009; Hutchison et al. 2011; Carter et. al, 2016). In Ontario, team-based primary care expanded substantially in 2005 with the establishment of Family Health Teams (FHTs), providing approximately 25% of Ontarians with access to comprehensive primary care services (Association of Family Health Teams of Ontario, 2018). The introduction of interdisciplinary FHTs to such a large segment of the population was a significant change that has influenced primary care policy in Ontario and across Canada (Marchildon and Hutchinson, 2016), and created an important opportunity to examine the role of PHC teams in health care across the country. Team-based care, in which an interprofessional team of health care providers work together to provide care, has been linked to more timely access to primary care services, better care coordination, and improved management of chronic disease (Gocan et al. 2014; Wranik et al., 2019). This paper aims to examine the policies that have shaped the evolution of team-based PHC in Ontario and the role of PHC teams in supporting integrated care for patients across the system.

In 2009, Ontario’s PHC landscape shifted, moving from an earlier decade devoted to building inter-professional PHC teams and implementing new modes of delivery and payment, to a decade aimed at utilizing these teams to better integrate the entire health care system, including hospital care. Between 2009 and 2019 Ontario introduced three new Acts that aimed to ensure greater accountability and to make the system more integrated from a patient’s perspective: The Excellent Care for All Act (2010), the Patients First Act (2016), and the People’s Health Care Act (2019).

History and Context

Though this review focuses particularly on Ontario policy documents released between 2009 and 2019, we recognize that significant primary health care reforms in the province began in 2002 with a focus on improving access to primary care as the first entry into the health system for all Ontarians. The Ontario reforms were initiated at a time when the federal government had provided $800 million to support pan-Canadian primary care reforms, through the Primary Health Care Transition Fund (Carter et al., 2016). The first five years of this reform involved the iterative rollout of new models of payment and service delivery (Aggarwal, 2009). These primary care reforms were crucial in providing the infrastructure for later policies that focused more broadly on the rest of the system. Therefore, in addition to the ten-year policy analysis, we have included key policies from the beginning of the primary health care initiatives in 2002. Figure 1 illustrates the timeline of Ontario reform.

Primary Care Models in Ontario

Primary care, identified as a driving force to improve health care in the province, was the target of substantial reforms between 2000 and 2010 (Marchildon and Hutchison, 2016; Aggarwal and Williams, 2019). Community Health Centres (CHCs) existed prior to these reforms and continue today, offering both primary care and health promotion programs to individuals and communities, using a salary funding model. (Suschnigg, 2001 and Aggarwal, 2009). The provincial government also announced Aboriginal Health Access Centres (AHACs) in the mid-1990s to support Indigenous-informed health care delivery both on and off reserves across the province (Ontario Aboriginal Health Access Centres 2015).

Between 2002 and 2007, the province radically altered the then-dominant solo practitioner fee-for-service model of primary care (Aggarwal, 2009). A multitude of payment and delivery models was created to encourage physicians to change their practice patterns, its key goals being to enhance access and provide comprehensive and coordinated care (Government of Canada 2007; Marchildon and Hutchison 2016). Newly implemented models included blended capitation Family Health Networks (FHNs) in 2002; blended fee-for-service Family Health Groups (FHGs) in 2003; blended capitation or salary Family Health Teams (FHTs) in 2005; and blended capitation Family Health Organizations (FHOs) and salary sessional payment and fee for service Nurse Practitioner-Led Clinics (NPLCs) in 2007.

The introduction of FHTs represented a significant investment in PHC teams, and at the time, it was considered North America’s largest example of a patient-centred medical home, earning Ontario recognition as a leader in team-based primary care (Rosser et al. 2011). The addition of FHTs came at a time when family physician shortages were a concern and offered access to a team that supported comprehensive care for patients with chronic conditions, supported smaller roster sizes than comparable fee-for-service models, and provided incentives to expand preventative services (Rosser et al. 2011). To date, there are 185 FHTs serving 3.4 million Ontarians (approximately 25% of the population) in 200 communities across the province (Ministry of Health 2022).

Ontario Local Health Integration Networks

In 2006, Ontario’s Local Health System Integration Act launched the establishment of 14 Local Health Integration Networks (LHINs) with the goal of providing “an integrated health system to improve the health of Ontarians through better access to high quality health services, co-ordinated health care in local health systems and across the province, and efficient management of the health system at the local level” (Local Health System Integration Act 2006). Previously, the provincial government funded and monitored the overall Ontario health care system, while 16 district health councils conducted planning and engagement activities at the local level (Ministry of Health and Long-term Care Act 1990). The new LHINs would be guided by provincial policy, but would themselves be responsible for allocating funding, planning activities and monitoring progress, with the intention to improve overall integration of the Ontario health system (Office of the Auditor General of Ontario 2015). Of note, only CHCs were accountable to the LHINs, while all other primary care models reported directly to the province (Office of the Auditor General of Ontario 2017), meaning that the only influence LHINs with regards to primary care was through the CHCs.

Goals of the Reform

In 2009, the goal of the reforms evolved to focus on systems integration, with regional management and accountability (Ministry of Health and Long-Term Care 2015; Ministry of Health and Long-Term Care 2018). Early policy documents released between 2009 and mid-2012 clearly emphasize the need to provide access to PHC teams to better support specific populations with higher health needs and use, improving integration and coordination of their health services. The 2012 Ontario Action Plan for Health Care explicitly lists steps toward improvement, including “open[ing] 200 Family Health Teams providing care to over 2.7 million Ontarians” (Government of Ontario 2012). At the regional level, the importance of teams was reinforced by the LHINs in their 2010-2013 Integrated Health Service Plans (IHSPs); six of 12 (50%) publicly available 2010 IHSPs cited improved access to teams as a critical priority.

More recent reforms seek to develop integrated care systems with local collaborative governance (Ministry of Health 2019). With an increasing emphasis on systems integration, there has been less specific focus on FHTs, with goals more broadly relating to the quadruple aim of the system including: better health, better care, lower costs, and better provider experience with an overarching emphasis on healthy equity (Sikka, Morath, and Leape 2015).

Factors that Influenced the How and Why

Using a primary health care integration lens, we conducted a policy analysis of documents released in Ontario between 2009 and 2019. The purpose of this analysis was to examine the regional implementation and operationalization of key priorities identified in provincial policy over that decade and to identify themes related to the integration of care and the roles of primary and team-based care that shaped the development and launch of Ontario Health Teams (OHTs). We conducted a longitudinal policy analysis of 15 publicly available provincial and 40 publicly available regional (LHIN) documents (see Appendices A and B).

Both provincial- and regional-level documents referred to several key actors responsible for the development and implementation of the policies. Actors involved in pre-development consultations included patients, providers, staff, policy makers, and researchers. Actors involved in the implementation of policies were diverse: provincial-level documents listed patients, health care professionals, the Ministry itself, and the LHINs as critical to the implementation of policies, including the 2012 and 2015 action plans. The Ministry of Health also referred to organizations such as Health Quality Ontario (HQO) and a series of working groups, including the Primary Health Care Expert Committee and the Expert Group on Home and Community Care. Strategic documents released by governing organizations like the Ontario College of Family Physicians (OCFP) and the Association of Family Health Teams of Ontario (AFHTO) included actors that they represent in their work; AFHTO cited actors including the AHACs, CHCs, FHTs and NPLCs.

At the regional level, each LHIN released an Integrated Health Service Plan (IHSP) every three years, implementing the strategic directions of the Ministry of Health’s plans to improve quality of care at the local level. Actors cited in the implementation of these IHSPs included patients and community members, and service providers. Some LHINs implemented working groups or advisory panels for accountability over three-year terms.

How the Reforms Were Implemented

By the mid-2010s, a series of efforts had also been made to develop measurement frameworks for primary care, including work by HQO and the Ontario Primary Care Performance Measurement Steering Committee, to better track the impacts of primary care and teams in the province. By 2012, the Ontario government had invested more than $1 billion in primary care funding, particularly in the development of comprehensive team-based models of care, with few measures of success to show for the investment (Carter et al. 2016; Marchildon and Hutchinson 2016; Aggarwal and Williams, 2019). There was limited evidence to demonstrate increased access and only preliminary evidence that teams supported chronic disease management (Office of the Auditor General 2011). An investigative report conducted at the Institute of Clinical and Evaluative Sciences (ICES) showed that FHTs had higher than expected emergency department (ED) visits and served patients with fewer chronic conditions and less social disadvantage than other primary care models (Glazier, Zagorski, and Rayner 2012). CHCs, however, were found to provide services to Ontarians with the highest proportion of chronic conditions and those living in lower income neighbourhoods, with substantially lower ED visits than expected (Glazier, Zagorski, and Rayner 2012). Across the province, late 2012 saw the establishment of the Health Links program to better integrate regional health services implemented at the LHIN level. Health Links took a ‘low-rules’ approach, where each LHIN had flexibility to design initiatives to best meet the needs of their local population (Angus and Greenberg, 2014). While this enabled a locally driven solution, there was high variability with no core framework or large-scale evaluation (Grudniewicz et al. 2018). Funding for Health Links quietly ended with the initiation of OHTs, and it is unclear which, if any, Health Links initiatives have continued within the OHTs.

Provincial government funding cuts to health resulted in a series of negotiations between the Ontario government and the Ontario Medical Association. Further cuts in 2015 coincided with the release of the 2015 Price-Baker Report, developed by the Primary Health Care Expert Advisory Committee, convened by the Ontario government in 2013 (Price et al. 2015). This report drew on research and experiences in the United Kingdom and proposed Patient Care Groups as a solution to: 1) enhance access to interprofessional primary care providers and after hours care; 2) ensure all Ontarians are attached to a primary care provider; and 3) improve integration within primary care and between primary care and other sectors (Price et al. 2015). Patient Care Groups sought to accomplish this by organizing primary care by geography, with funding on a per capita basis and accountability to the LHINs. This report was significant for PHC teams for several reasons. First, it recognized the inequitable access to interprofessional primary care providers and sought to remedy this through system restructuring versus the addition of new funds. Second, there was a central focus on system integration, with primary care having a central role. Third, regional accountability and funding became a lever to integrate primary care into regionally governed systems.

The province responded by building on the Price-Baker Report in their own proposal in late 2015, Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario, then the following year, introduced Bill 41: The Patients First Act (Government of Ontario, 2015). Bill 41 sought to give LHINs an even larger role by introducing smaller sub-regions to enable more local planning and to respond to the unique health needs of communities (Patients First Act 2016). Additionally, the Bill called for enhanced accountability from the LHINs to ensure patients had timely access to care. The goal of implementing the sub-regions was to improve local integration, patient experience and quality. For PHC teams, Patients First sought to address the issue of inequity of access to teams by proposing primary care providers be organized around the needs of a population (Government of Ontario 2015). PHC teams were no longer specifically identified as a solution in these reforms; rather, they formed part of a larger focus on system integration including primary health care as whole.

The goals of Bill 41 were never realized, as a change in government in 2018 resulted in the disbanding of the LHINs and shifted health care towards a centralized governance structure with the passing of Bill 74, The People’s Health Care Act, 2019 and the creation of Ontario Health, the provincial body now responsible for coordinating care across all regions. Ontario Health Teams (OHTs), described as integrated care delivery systems, were subsequently introduced as a mechanism to integrate care within local communities (Ministry of Health 2019). This radical structural change was introduced with a new government and may have reflected the new policy approach. The move towards OHTs may also have been influenced by persistent challenges faced by LHINs attempting to implement meaningful regional primary care reform and the potential additional bureaucratic layers of the sub-LHIN regions that Bill 41 introduced. Unlike the previous LHINs and sub-regions that sought to organize care around geographical boundaries, OHTs are organized around patterns of care use, or attribution networks. Coalitions of local service providers are charged with identifying priority areas and developing service models to deliver integrated care for these populations. In 2019, the government released a guidance document to support these local coalitions of health organizations in the OHT application process, with no changes noted to physician remuneration or PHC teams.

OHTs are still in their early stages, with 54 teams approved to date (Ministry of Health 2023). At the time of this policy analysis, there were no policy documents at either the provincial or team levels, and it is uncertain what impact OHTs may have on PHC teams. The growing focus is on whole system integration, with PHC teams potentially playing an important role; however, there is no indication whether there will be new or ongoing funding to expand PHC teams within OHTs.

Evaluation

There are several academic evaluations of primary care reform in Ontario. Aggarwal conducted a comprehensive analysis of Ontario policy reform up to 2009, specifically focusing on changes to physician remuneration and the delivery of primary care in the province. She found that while these shifts existed, there had not been fundamental changes to the institutional and structural relationships within the Ontario health care sector (Aggarwal 2009). Primary care reform models that required fundamental shifts in thinking such as salary models of payment or geographical organization of primary care had less uptake by physicians in the sector. Subsequent examinations of Ontario policy reform conducted around the time of substantial government funding cuts also highlighted physician remuneration reforms, the ongoing negotiations between the Ontario government and organizational bodies such as the Ontario Medical Association, and echoed Aggarwal’s findings that fundamental system reforms had yet to take place in Ontario (Hutchison and Glazier 2013; Marchildon and Hutchison 2016).

Beginning in 2009, systems integration was emphasized through the Health Links program. Health Links rolled out slowly and differed by region; only eight (57.1%) of 2013-2016 IHSPs refer the Health Links program. By the release of the 2016-2019 IHSPs, all LHINs refer to the program and its potential to improve coordinated access to primary care for patients with complex needs. While primary care and teams were indeed important components of the Health Links strategy to improve integration, there was less emphasis on their role in leading integration themselves. In fact, in the LHINs’ 2013-2016 and 2016-2019 IHSPs, improving access to teams was listed as a strategic priority in only three reports (10.7% of all reports); all three of which were from 2013 (Central West LHIN IHSP 2013-2016; Mississauga Halton LHIN IHSP 2013-2016; Southwest LHIN IHSP 2013-2016). By 2019, this shift to broader integration without a focus on teams was evident; the 2019 OHT guidance document included primary care within a list of 16 different services that would fall within a continuum of care.

The creation of HQO in 2011 was a clear reflection of the province’s desire to systematically evaluate the health care system’s performance. The 2014 release of HQO’s A Primary Care Measurement Framework for Ontario identified nine attributes of a high-quality health care system, one of which was integration. Each of these nine attributes had specific measurement indicators and the PCPM Steering Committee would be responsible for implementing the framework across Ontario over the following two years. The framework outlines then-existing primary care performance data sources, which included various stakeholder surveys and LHIN-based administrative data through the Institute for Clinical Evaluative Sciences (ICES). Similar administrative data would also be collected outside the LHINs for CHCs, AHACs, and NPLCs (HQO 2014). Though somewhat comprehensive, the framework was developed with a biomedical lens and failed to measure processes related to teams and other health care providers – which were expected to play a significant role in improving integration. At this same time, the AFHTO sought to measure the performance of teams within their membership, primarily FHTs and a handful of NPLCs through their Data to Decisions (D2D) framework (Mulder and Rayner 2020). D2D was designed from a quality improvement lens and sought to demonstrate the value of team-based care through a set of quality indicators. Details of the framework are not found in any of the included policy documents and funding cuts in 2018 ultimately ceased the implementation of this framework, with no further mention in any future policy documents. Given the absence of a central coordinating body, it is difficult to know the legacy of D2D and what has been sustained at a team level.

In 2012, HQO released an evaluative report, Quality in Primary Care, highlighting provincial progress in three key areas: accessibility, specific primary care services, and coordination with other sectors in the health care system. This report revealed that while some improvements had been made to primary care, gaps still existed in the timeliness and equity of access to primary care. The report reflected on these findings as “a baseline” for measuring advances in primary care in Ontario (HQO 2015). Following the release of this evaluation, the PCPM Steering Committee released an amendment to the original primary care framework, acknowledging the difficulty in measuring primary care with 299 different performance measure indicators. One such difficulty was that the methodology used to calculate certain measures differed for CHCs, AHACs and NPLCs, resulting in discrepancies in the denominator definitions (HQO 2015b). The amendment proposed a modified set of indicators divided into system- and practice-level priorities but concluded that the PCPM Steering Committee would continue to develop primary care performance measurement.

Despite the groundwork laid by HQO for primary care evaluation, our analysis found no clear reference to either the PCPM Framework, nor HQO guidance documents at the regional level, likely because it was still in development as of 2015. The LHINs present performance data in each of their IHSPs, referring to the Ministry/LHIN Accountability Agreement (MLAA), formerly known as the Ministry/LHIN Performance Agreement and corresponding score cards, but the MLAA does not refer specifically to indicators connected to primary care. From 2016-2019, only one LHIN IHSP (Erie St. Clair) included their own indicators to measure primary care, with a focus on measuring provider attachment, timely access, reduction of emergency department visits and overall patient experience.

Conclusion

Despite a strong emphasis on improving access to comprehensive care through PHC teams in the early and mid-2000s, ongoing reforms continue to focus on more effectively addressing the persistent fragmentation of care across the system, and the lack of accountability in primary care and within primary care teams. Since 2019, reporting structures have been disrupted, with more centralized health regions and locally driven OHTs working to integrate care across traditional regional silos from PHC to home care to tertiary care. To date, however, there has been no new funding to develop governance structures or accountability frameworks to support this integration.

Early reforms focused on the development of primary care teams to increase patient access and outcomes, and decrease costs. Evidence from this time is mixed and current policies have turned to integrated care across the system, not just within primary care, as the path forward. This focus on integrated care models has stagnated the growth of interprofessional primary care team. Only one in four Ontarians have access to a team of interprofessional providers, and while it was an important starting point in the early reforms, the province must build on this foundation to ensure more equitable access. As patient complexity increases, access to interdisciplinary health care –disease prevention, health promotion, inpatient care, home care and end-of-life care – will only become more important. Primary care is supposed to be the entryway into the health system for most patients, and its role in ensuring appropriate access to interdisciplinary health care continues to evolve.

As whole-system integration and virtual care change the provincial health care delivery landscape Ontarians may have opportunities to access interdisciplinary care beyond the minority of patients who are part of FHTs. As part of ongoing reforms, identifying which patients would most benefit from interdisciplinary care, and at which stage in their interactions with the health care system will be important and will help to further clarify when primary care teams lead to best outcomes. Evaluation and quality improvement initiatives must be robust, and include data on all team members to ensure that the evaluation goes beyond traditional physician-centred administrative data to assess the impact of integrated care patients receive.

Strengths, Weaknesses, Opportunities, Threats

Table 2: SWOT analysis

Strengths	Weaknesses
Early regional documents emphasized primary care teams as critical to supporting high-needs populations and overall increased quality of patient experience. HQO was developed to support provincial health care system improvements and released frameworks and supporting documents for the evaluation of primary care. Provincial Strategic Plans left room for interpretation at the regional level, allowing regions to develop priorities to address specific critical needs. Regional policies emphasize improving the patient experience; patients are key actors in the development of many strategic documents.	Over time, there is a shift in strategic direction, from improving access to team-based care for better coordination to a focus on more general integration with no clarity on the role of PHC teams. There is no support or consideration of HQO’s primary care frameworks at the regional level (no infrastructure); framework has a biomedical lens, and does not evaluate team processes, which leaves a poor understanding of how teams might improve integration. Lack of specificity at the provincial level left it up to regions to determine who had control of PHC teams and what implementation would look like, resulting in inconsistencies and varying degrees of success. Disconnect in the early 2000s between where investment in PHC was held (provincial level) and where change would be enforced (regional level).
Opportunities	Threats
OHTs present a novel bottom-up approach to system-level integration, moving from team-based care coordinating the care for individuals, to integration bringing providers and systems together to deliver coordinated care. There are long-standing and well-developed primary care evaluation frameworks for OHTs to build on and infrastructure to collect data to measure the impact of PHC teams on integration. Highly developed and mature teams can lead in the development of integrated care strategies in OHTs.	Because there was a policy focus shift away from team-based primary care over time, primary care’s role is now unclear. OHTs require a fundamental shift in thinking from what currently exists in practice with strategic planning across traditionally siloed sectors of the health care system. Despite organizational reform, currently there is no specific funding reform – an example of how there is still disconnect between provincial levers of influence and regional expectations.

References

Aggarwal M. 2009. Primary care reform: a case study of Ontario. PhD dissertation, University of Toronto. https://tspace.library.utoronto.ca/bitstream/1807/17722/1/Aggarwal_Monica_200906_PhD_thesis.pdf.

Aggarwal M, Williams AP. 2019. Tinkering at the margins: evaluating the pace and direction of primary care reform in Ontario, Canada. BMC Family Practice, 20:128. https://doi.org/10.1186/s12875-019-1014-8.

Angus H, Greenberg A. 2014. Can better care for complex patients transform the health system?. HealthcarePapers, 14(2), 9-19. https://doi.org/10.12927/hcpap.2015.24103.

Carter R, Riverin B, Levesque JF, Gariepy G, Quesnel-Vallée A. 2016. The impact of primary care reform on health system performance in Canada: a systematic review. BMC Health Services Research, 16(1), 1-11. https://doi.org/10.1186/s12913-016-1571-7.

Glazier RH, Zagorski BM, Rayner J. 2012. Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10. ICES Investigative Report. Toronto: Institute for Clinical Evaluative Sciences.

Glazier RH, Hutchison B, Kopp A. 2015. Comparison of family health teams to other Ontario primary care models, 2004/05 to 2011/12. Toronto: Institute for Clinical Evaluative Sciences.https://www.ices.on.ca/Publications/Atlases-and-Reports/2015/Comparison-of-Family-Health-Teams.

Gocan S, Laplante MA, Woodend AK. 2014. Interprofessional collaboration in Ontario’s family health teams: a review of the literature. Journal of Research in Interprofessional Practice and Education 3(3): 1-19. https://doi.org/10.22230/jripe.2014v3n3a131.

Government of Canada. 2007. Primary health care transition fund. https://www.canada.ca/en/health-canada/services/primary-health-care/primary-health-care-transition-fund.html.

Government of Ontario. 2012. Ontario’s action plan for health care. https://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthychange.pdf.

Government of Ontario. 2015. Patients first: a proposal to strengthen patient-centred health care in Ontario. Discussion Paper, December 17. https://www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_paper_20151217.pdf.

Grudniewicz A, Tenbensel T, Evans JM, Gray CS, Baker GR, Wodchis WP. 2018. ‘Complexity-compatible’ policy for integrated care? Lessons from the implementation of Ontario’s health links. Social Science & Medicine 198:95-102. https://doi.org/10.1371/journal.pmed.0030449.

Health Quality Ontario. 2014. A primary care performance measurement framework for Ontario: report of the steering committee for the Ontario primary care measurement initiative. http://www.hqontario.ca/portals/0/documents/pr/pc-performance-measurement-report-en.pdf.

Health Quality Ontario. 2015a. Quality in primary care: setting a foundation for monitoring and reporting in Ontario. http://www.hqontario.ca/portals/0/Documents/pr/theme-report-quality-in-primary-care-en.pdf.

Health Quality Ontario. 2015b. Primary care performance measurement: priority measures for system and practice levels. http://www.hqontario.ca/Portals/0/documents/system-performance/priority-measures-system-practice-primary-care-performance-measurement-ontario-en.pdf.

Hutchison B, Levesque JF, Strumpf E, Coyle N. 2011. Primary health care in Canada: systems in motion. The Milbank Quarterly 89(2): 256-288. https://doi.org/10.1111/j.1468-0009.2011.00628.x.

Hutchison B, Glazier R. 2013. Ontario’s primary care reforms have transformed the local care landscape, but a plan is needed for ongoing improvement. Health Affairs 32(4): 695-703. https://doi.org/10.1377/hlthaff.2012.1087.

Local Health System Integration Act, 2006, S.O. 2006, c.4. https://www.ontario.ca/laws/statute/06l04.

Marchildon GP, Hutchison B. 2016. Primary care in Ontario, Canada: new proposals after 15 years of reform. Health Policy 120(7): 732-738. https://doi.org/10.1016/j.healthpol.2016.04.010.

Ministry of Health and Long-Term Care Act, R.S.O 1990, c M.26, Reg. 784: District Health Councils. https://www.ontario.ca/laws/regulation/900784.

Mulder C, Rayner J. 2020. High and sustained participation in a multi-year voluntary performance measurement initiative among primary care teams. International Journal of Health Policy and Management 11(4):514-520. https://doi.org/10.34172/ijhpm.2020.186.

Office of the Auditor General of Ontario. 2011 Annual Report. https://www.auditor.on.ca/en/content/annualreports/arbyyear/ar2011.html.

Office of the Auditor General of Ontario. 2015 Annual Report. https://www.auditor.on.ca/en/content/annualreports/arbyyear/ar2015.html.

Office of the Auditor General of Ontario. 2017 Annual Report. https://www.auditor.on.ca/en/content/annualreports/arreports/en17/2017AR_v1_en_web.pdf.

Ontario Ministry of Health. 2019. Ontario health teams: Guidance for health care providers and organizations. https://health.gov.on.ca/en/pro/programs/connectedcare/oht/docs/guidance_doc_en.pdf.

Ontario Ministry of Health 2021. Family health teams. https://www.health.gov.on.ca/en/pro/programs/fht/.

Ontario Ministry of Health. 2022. Ontario health teams. https://health.gov.on.ca/en/pro/programs/connectedcare/oht/.

Ontario Ministry of Health and Long-Term Care. 2015. Patients first: Action plan for health care. https://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_patientsfirst.pdf.

Ontario Ministry of Health and Long-Term Care. 2018. Guide to the advanced health links model. https://www.health.gov.on.ca/en/pro/programs/transformation/docs/Guide-to-the-Advanced-Health-Links-Model.pdf.

Ontario’s Aboriginal Health Access Centres. 2015. Our health, our seventh generation, our future: 2015 Aboriginal health access centres report. https://soahac.on.ca/wp-content/uploads/2015/02/AHAC_Report_2015-FINAL.pdf.

Patients First Act, 2016, S.O. 2016, c.30 – Bill 41. https://www.ontario.ca/laws/statute/s16030.

Price D, Baker E, Golden B, Hannam R. 2015. Patient care groups: a new model of population based primary health care for Ontario. https://www.health.gov.on.ca/en/common/ministry/publications/reports/primary_care/primary_care_price_report.pdf.

Rosser WW, Colwill JM, Kasperski J, Wilson L. 2011. Progress of Ontario’s family health team model: a patient-centered medical home. Annals of Family Medicine 9(2): 165-171. https://doi.org/10.1370/afm.1228.

Sikka R, Morath JM, Leape L. 2015. The quadruple aim: care, health, cost and meaning in work. BMJ Quality & Safety 24: 608-610. http://dx.doi.org/10.1136/bmjqs-2015-004160.

Starfield B, Shi L, Macinko J. 2005. Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), 457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x.

Suschnigg C. 2001. Reforming Ontario’s primary health care system: one step forward, two steps back? International Journal of Health Services, 31(1):91-103. https://doi.org/10.2190/APRU-D9HF-LR1M-6FGL.

Wranik WD, Price S, Haydt SM, Edwards J, Hatfield K, Weir J, Doria N. 2019. Implications of interprofessional primary care team characteristics for health services and patient health outcomes: a systematic review with narrative synthesis. Health Policy, 123(6):550-563. https://doi.org/10.1016/j.healthpol.2019.03.015.

Appendix 1

Appendix 1: Provincial-Level Policy Documents

Policy Document	Year	Leadership	Boundary People
Ontario Action Plan for Health Care	2012	Ministry of Health and Long-term Care	A strategic document to guide health care in Ontario and focuses on four key objectives: improve access, connect services, inform and protect people and the health system.
Strategic plan, 2012-2015	2012	Association of Ontario Health Centres	A strategic document that outlines the roles and directions of the Association of Ontario Health Centres.
A Primary Care Measurement Framework for Ontario	2014	Health Quality Ontario	A framework intended to provide performance measurement priorities for regular evaluation of the primary care system to inform planning, management and quality improvement.
Patients First: Action Plan for Health Care	2015	Ministry of Health and Long-term Care	A strategic document building on the 2012 action plan with the aim to provide Ontario patients’ health care experiences.
Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario	2015	Ministry of Health and Long-term Care	A proposed plan to expand the role of the Local Health Integration Networks, which will be followed by active engagement with public and providers to discuss document.
Quality in Primary Care: Setting a Foundation for Monitoring and Reporting in Ontario	2015	Health Quality Ontario	An evaluative document describing the performance of Ontario primary care in three key areas: access to primary care providers, provision of specific primary care services, and coordination with other sectors of the health system.
Primary Care Performance Measurement: Priority Measures for System and Practice Levels	2015	Health Quality Ontario	This management document describes the high priority indicators that can advance primary care quality. Previously, 299 measures were selected; this document acknowledges the impracticality of the number of measures and the gaps in data for many of the measures. High priority measures are divided into system- and practice-level measures.
Championing Transformative Change, Strategic Plan 2015-2020	2015	Association of Ontario Health Centres	A strategic document that guides the work of the Aboriginal Health Access Centres, Community Health Centres, Family Health Teams and Nurse Practitioner-Led Clinics.
Patients First: Reporting Back on the Proposal to Strengthen Patient-Centred Health Care in Ontario	2016	Ministry of Health and Long-Term Care	A management document created in response to feedback from the 2015 Patients First strategic plan. It proposes legislative changes through the Patients First Act, as well as operational and regulatory changes. The Patients First Act, 2016 would amend the Local Health System Integration Act, 2006.
Framework for Primary Care in Ontario	2016	Ontario Primary Care Council	A framework to guide the delivery of primary health care in Ontario.
Better Has no Limit: Partnering for a Quality Health System, A Three-Year Strategic Plan 2016-2019	2016	Health Quality Ontario	A strategic document to describe the three-year priorities of Health Quality Ontario and the essential activities through which it will meet the set priorities.
AFHTO Strategic Plan, 2017-2020	2017	Association of Family Health Teams of Ontario	A strategic document to guide high-level practice of Family Health Teams in Ontario.
Family Physicians – Leaders for a Healthy Ontario, Strategic Plan 2018-2021	2018	Ontario College of Family Physicians	A strategic document to guide practice of family physicians and the role of the College as an advocate for systems-level change.
Guide to the Advanced Health Links Model	2018	Ministry of Health and Long-term Care	A management document to direct the transition of operations and processes in the Health Links program to the Advanced Health Links Model across the province.
Ontario Health Teams: Guidance for Health Care Providers and Organizations	2019	Ministry of Health	A management document to direct groups of health care providers and organizations in the process of becoming an Ontario Health Team.

Appendix 2

Appendix 2: Regional-Level Policy Documents

Publishing Organization	Year	Title
Central East LHIN	2016-2019	Integrated Health Service Plan 2016-19
Central East LHIN	2013-2016	Community First Integrated Health Service Plan 2013-2016
Central East LHIN	2010-2013	Integrated Health Service Plan 2010-2013
Central LHIN	2016-2019	Caring Communities, Healthier People: Integrated Health Service Plan (IHSP4)
Central LHIN	2013-2016	Creating Caring Communities: Advancing Excellence in Local Health Care Together, An Integrated Health Service Plan for the Central Local Health Integration Network 2013-2016
Central LHIN	2010-2013	Creating Caring Communities, Health People…Together. An Integrated Health Service Plan for the Central Local Health Integration Network 2010-2013
Central West LHIN	2016-2019	Integrated Health Service Plan 2016-2019
Central West LHIN*	2013-2016	Integrated Health Services Plan 3, 2013-2016
Champlain LHIN	2016-2019	Integrated Health Service Plan 2016-19
Champlain LHIN	2013-2016	Integrated Health Service Plan 2013-2016
Champlain LHIN	2010-2013	Transforming Health Care: One Person at a Time, Integrated Health Service Plan 2010-2013
Erie St Clair LHIN	2016-2019	People First: Our Foundation for Local Health Care Change, Integrated Health Service Plan 4
Erie St Clair LHIN	2013-2016	Better Care, Better Experiences, Better Value 2013–16 Erie St. Clair Local Health Integration Network Integrated Health Service Plan 3
Erie St Clair LHIN	2010-2013	Navigating Change in the Right Lane, Integrated Health Service Plan IHSP 2010-2013
Hamilton Niagara Haldimand Brant LHIN	2016-2019	Integrated Health Service Plan 2016-19
Hamilton Niagara Haldimand Brant LHIN	2013-2016	Working Together for Better Health Care: Integrated Health Service Plan 2013-2016
Hamilton Niagara Haldimand Brant LHIN	2010-2013	Improving our Health Care Experience: Integrated Health Service Plan 2013-2013
Mississauga Halton LHIN	2016-2019	Partnering for a Health Community, Integrated Health Services Plan 2016-2019
Mississauga Halton LHIN	2013-2016	Partnering for a Healthier Tomorrow, Integrated Health Service Plan 2013-2016
Mississauga Halton LHIN	2010-2013	Integrated Health Service Plan: 2010-2013, Leading Health System Integration
North East LHIN	2016-2019	Integrated Health Service Plan 2016-2019
North East LHIN	2013-2016	Integrated Health Service Plan 2013-2016
North East LHIN	2010-2013	Integrated Health Service Plan (IHSP)
North Simcoe Muskoka LHIN	2016-2019	2016-2019 Integrated Health Service Plan
North Simcoe Muskoka LHIN*	2013-2016	Healthy People. Excellent Care. One System. North Simcoe Muskoka Local Health Integration Network, Integrated Health Service Plan 2013 - 2016
North West LHIN	2016-2019	IHSP IV
North West LHIN	2013-2016	Integrated Health Services Plan 2013-2016
North West LHIN	2010-2013	Integrated Health Services Plan 2010-2013
South East LHIN	2016-2019	Health Care Tomorrow – Putting Patients First, Integrated Health Services Plan 2016-2019
South East LHIN	2013-2016	Better Integration, Better Health Care South East Local Health Integration Network
South East LHIN	2010-2013	Reaching for Excellent – Integrated Health Services Plan IHSP2
South East LHIN	2016-2019	Integrated Health Service Plan 2016-2019
South East LHIN	2013-2016	Living Healthy, Independently and Safely at Home Integrated Health Service Plan 2013-2016
South East LHIN	2010-2013	A Healthier Tomorrow: Integrated Health Service Plan 2010-2013
Toronto Central LHIN	2016-2019	The Future of Health Care is Local, Integrated Health Services Plan 2016-2019
Toronto Central LHIN	2013-2016	A Plan to Transform Local Health Care for All, Integrated Health Service Plan 2013-2016
Toronto Central LHIN	2010-2013	Delivering High-Value Local Health Care Through Collaborative Action, The Toronto Central Local Health Integration Network’s 2010-2013 Integrated Health Service Plan
Waterloo Wellington LHIN	2016-2019	Integrated Health Service Plan 2016-2019
Waterloo Wellington LHIN	2013-2016	Better Health - Better Futures The Local Integrated Health Service Plan for Our Community
Waterloo Wellington LHIN	2010-2013	Working Together Toward A Healthier Future, Integrated Health Services Plan 2010-2013 (French-only)

* 2010-2013 IHSPs for these LHINs were not publicly available and were thus omitted from analysis

Health Reform Observer - Observatoire des Réformes de Santé, Volume 10 | Issue 1 | Article 4 https://doi.org/10.13162/hro-ors.v10i1.4728.