Family medicine for all: Community health centres serve their neighbours, but capacity issues remain
Advocates say the location-based model, similar to catchment areas, could fix Canada's primary care crisis
Originally published on May 20, 2023.
On any given day, the employees of Centretown Community Health Centre near downtown Ottawa see a diverse range of patients, from the unhoused to seniors to families with young children who have struggled to find family doctors.
Similar to a school catchment area, the idea is that anyone who lives in the area — which includes the Glebe, Centretown and Old Ottawa South — is automatically able to qualify for the centre's services. It's an attempt to patch the gaps in a province where over two million people are without primary care.
Now, though, much like primary care offices across the country, it's contending with capacity issues of its own. While community health centres (CHCs) are aiming to be more efficient with their existing staff to address some of these issues, advocates are calling for ministries of health to expand their efforts toward providing more team-based health care.
Clinic staff and other primary care providers say there's a lot the rest of Canada can learn from Centretown's model of collaborative, comprehensive care and location-based access to family doctors.
Unlike a family doctor's office, which deals just with primary care, the CHC model teams up family physicians with other health professionals, like nurses, social workers and dietitians. This way doctors can focus on the medical piece while patients can access a range of care under one roof.
Centretown started in 1969 as a community resource centre, the first of its kind in Ontario, and then became a community health centre in 1974.
Clients are able to access an array of services, from harm reduction and showers for the unhoused, to mental health services, help finding emergency shelter and an early years program for families with kids under five.
There are also community health workers, dietitians and physiotherapists on hand.
The centre's mission is to meet the health and social needs of clients who are complex and could be turned away by doctors restricted to standard, short appointments.
"If they are too complex, we say, 'Yes, we are the place to serve you,'" says Michelle Hurtubise, executive director of the clinic.
It is also one of the few primary care practices in Ottawa that provides gender-affirming care for transgender individuals.
Family docs avoid small biz headaches
Another unique aspect of Centretown's model is how the clinic is staffed. Unlike traditional family practices, where doctors usually function like small businesses — bearing high overhead costs and significant administrative responsibilities, like hiring and firing — Centretown is set up as a not-for-profit organization where the more than 220 full-time and part-time physicians and nurse practitioners are employees of the centre.
"I don't want to be a small business owner. I want to do what I was trained to do, which is to be a clinician," says Dr. Erin Hanssen, one of Centretown's physicians.
Physicians are also salaried in a way that's distinct from their fee-for-service counterparts, giving them a stable income plus pension and benefits.
That difference has made hiring much easier, says Hurtubise. While family practice residencies and staff positions have gone unfilled elsewhere in the country, she says they've "been fortunate that we have not actually had difficulty with recruitment."
Centretown is largely funded by the Ministry of Health, with 85 per cent of their funding coming from the province.
Responding to a critical need echoed across the country, the physicians at Centretown point to their expansive patient list — they have close to 15,000 clients — and successful health outcomes as proof that this health care model is working well.
Team-based approach to care
There are currently about 120 CHCs across Canada, with new ones in the works. The model is part of a shifting landscape of front-line care, one that many doctors say puts the patient first.
"I think that the team-based approach gives the best to the client because they can get the service they need when they need it," says Centretown physician Dr. Alison Eyre.
We are preventing limb amputations, retinopathy, high blood pressure and hypertension and we then become a very cost-effective model.- Michelle Hurtubise
She points to the clinic's ability to get patients specific services quickly, whether it's immunization, a social worker or an outreach nurse. "Most of our fee-for-service [clinics] don't have access to such resources," she says.
Hurtubise also says CCHC has "better outcomes across the board," for their clients when it comes to issues like diabetes, blood pressure control and smoking cessation. "So that's a massive health care savings," she says.
For example, she says someone with diabetes using a CHC can see an OHIP-covered dietitian to gain control of their blood sugar, and other health professionals they may need like a chiropodist for foot insoles.
"We are preventing limb amputations, retinopathy, high blood pressure and hypertension and we then become a very cost-effective model," she said.
Plus, they may encounter a smoother referral process, as physicians know they're sending patients to specialists with experience in vulnerable or underserved communities.
"I think team-based care provides better outcomes, period," echoes Dr Jennifer Rayner, the director of research and evaluation at Alliance for Healthier Communities, a research program helping to determine how Ontario's health care system can better serve vulnerable populations.
Rayner also sees potential for places like Centretown to reach communities that may be overlooked by the medical field.
She points to "tons and tons of evidence" that settings like Centretown support communities that are "often not visible" elsewhere. And in doing so, reduces the amount those communities go to the emergency room.
"We saw that despite CHC's serving a population that was 70 per cent more complex than the average Ontarian, they were going to the emergency room less often," she says.
Researchers also found a 21 per cent lower-than-expected rate of emergency department visits for CHC clients compared with the provincial average.
Dr. Andrew Boozary, a primary care physician and the executive director of population health and social medicine at Toronto's University Health Network, agrees. He says CHCs in Canada regularly take on more racialized and low-income patients than traditional doctor's offices.
"There is not a risk adjustment, or an incentive, for family health teams to take on sicker, poorer, racialized patients," he said.
That's why, he says, there is often such a "mismatch in where health-care needs are and the kind of primary care resources that are being made available."
Hanssen says that's definitely the case for patients like Amanda Massia who would otherwise struggle to find appropriate care.
"Amanda is on a fixed income. Amanda has significant medical and mental health challenges and she's a smoker. So substance use is also part of her challenges," she says.
For Massia, the care she receives at Centretown is "very, very important." She says she's been in and out of mental health facilities for much of her life and prefers the approach at CCHC. "It's not nice to be locked up on a ward. To be free and to be able to come in and talk to somebody, it's a lot better," she says.
At Centretown, Massia receives what's known as comprehensive primary health care, which is distinct from standard primary care, says Dr. Hanssen. She sees primary care as managing illness, whereas primary health care also includes health promotion and disease prevention.
Centre now maxed out
However, even Centretown is not immune to the kinds of capacity issues that often hamper Canadians' search for family care.
"Unfortunately, we are at max capacity," says Hurtubise of the clinic. Though it remains open for drop-in services like mental health and addiction, when it comes to family physicians, even those who live in the catchment area are being turned away.
"Unfortunately, although we are in the Centretown CHC catchment area and have tried in the past, it is well-known that they don't take new patients," says Ottawa resident Carolyn Inch, a senior who says while she thinks the Centretown model is superior to traditional fee-for-service providers, so far she's been unable to access their services. "There is a need for a complete rethinking of our approach to health care," she said.
Hurtubise understands Inch's frustrations. "Some of the conversations we are having [are] 'So what can we do in our own systems to increase capacity? What are the ways that we could look at improving some of our own efficiencies?'" she says.
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With files from Amina Zafar