Practice Features Associated With Patient-Reported Accessibility
Practice Features Associated With Patient-Reported Accessibility
Purpose: On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients.
Methods: Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic.
Results: One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office.
Conclusions: The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.
In Quebec—as in the rest of Canada—primary care is delivered principally by independent, physician-run practices, supported as private practices through reimbursement for medically necessary services on a fee-for-service basis. Approximately 15% of primary health care in Quebec is delivered in territorially based community health centers (CLSCs) that receive block funding and have salaried personnel who deliver health and social services. These 2 subsystems have operated in parallel, and their independent functioning is considered to be an important cause of the problems in accessibility and continuity of care that have been highlighted in a recent health care commission.
In 2002, Family Medicine Groups (FMGs) were proposed as a new organizational model to enhance integration between private practices and community health centers. The FMG is a volunteer administrative arrangement for existing practices or networks of 8 to 10 physicians who are accredited by the regional health authority to provide a basket of planned services, have extended service hours (including evenings, Saturdays, and Sundays), and have formal agreements with other establishments to offer the full range of services to a population of registered patients. In turn, the FMG receives 1 or more nurses paid from the budget of the local community health center. These organizational features are similar to those of primary health care models that are being introduced throughout Canada in an effort to strengthen primary health care.
In 2002, we conducted a survey to measure first-contact accessibility and continuity as perceived by primary care patients and to identify characteristics of clinic organization and physician practice that explain the observed variance in these attributes. Continuity refers to both relational continuity between the patient and physician and to care continuity between the family physician and specialist, which we refer to as coordination continuity. The goal was not only to inform policy content for FMGs but also to guide decisions within the independent, physician-led practices that continue to be the predominant primary care model.
Purpose: On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients.
Methods: Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic.
Results: One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office.
Conclusions: The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.
In Quebec—as in the rest of Canada—primary care is delivered principally by independent, physician-run practices, supported as private practices through reimbursement for medically necessary services on a fee-for-service basis. Approximately 15% of primary health care in Quebec is delivered in territorially based community health centers (CLSCs) that receive block funding and have salaried personnel who deliver health and social services. These 2 subsystems have operated in parallel, and their independent functioning is considered to be an important cause of the problems in accessibility and continuity of care that have been highlighted in a recent health care commission.
In 2002, Family Medicine Groups (FMGs) were proposed as a new organizational model to enhance integration between private practices and community health centers. The FMG is a volunteer administrative arrangement for existing practices or networks of 8 to 10 physicians who are accredited by the regional health authority to provide a basket of planned services, have extended service hours (including evenings, Saturdays, and Sundays), and have formal agreements with other establishments to offer the full range of services to a population of registered patients. In turn, the FMG receives 1 or more nurses paid from the budget of the local community health center. These organizational features are similar to those of primary health care models that are being introduced throughout Canada in an effort to strengthen primary health care.
In 2002, we conducted a survey to measure first-contact accessibility and continuity as perceived by primary care patients and to identify characteristics of clinic organization and physician practice that explain the observed variance in these attributes. Continuity refers to both relational continuity between the patient and physician and to care continuity between the family physician and specialist, which we refer to as coordination continuity. The goal was not only to inform policy content for FMGs but also to guide decisions within the independent, physician-led practices that continue to be the predominant primary care model.