Care coordination is a critical component of a strong primary care system. The Commonwealth Fund (CMWF) 2019 International Health Policy Survey of Primary Care Physicians polled physicians in 11 countries, allowing international and pan-Canadian comparisons of physicians' perspectives in this area. Canadian physicians indicated that there was room for improvement in coordinating care with those outside their practice, particularly specialists, home-based care providers and social services. Opportunities may arise in learning from higher-performing CMWF countries and in adopting new information technologies that are growing methods of facilitating communication across care settings.

Introduction

Primary care clinicians, as patients' first point of contact with the healthcare system, are a vital component of the overall health system. Countries with strong primary care have better health outcomes, lower mortality rates and lower healthcare costs (Starfield et al. 2005). The Commonwealth Fund (CMWF) 2019 International Health Policy Survey of Primary Care Physicians elicits the perspectives of primary care physicians in 11 countries, including Canada. The survey delivers international and pan-Canadian comparisons on topics such as access to primary care, providing patient-centred care, coordination of care and adoption of information technologies.

Good care coordination is widely recognized as a crucial part of primary care provision (Hofmarcher et al. 2007; McMurchy 2009). In Canada, the primary care landscape has been undergoing reform, with jurisdictions using differing approaches (Peckham et al. 2018). Against this dynamic backdrop, it is useful to examine what Canadian primary care physicians think about the current state of care coordination across the country. Survey responses highlight that primary care physicians, similar to their CMWF counterparts, have challenges in coordinating patient care with providers outside their practice (CIHI 2020).

Methodology

The CMWF 2019 International Health Policy Survey of Primary Care Physicians polled physicians in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA. In Canada, there were 2,569 respondents and an overall response rate of 39.3%.

The 2019 survey included Yukon, the Northwest Territories and Nunavut for the first time. Owing to small sample sizes, the results from all territories were reported together (with permission and support). As the territories altogether do not represent one jurisdiction, no statistical tests were performed to compare this grouping to the CMWF average.

Primary care physicians were randomly selected in most provinces. In Prince Edward Island and the territories, all primary care physicians were invited to participate. Physicians were contacted by mail and could respond via either a paper survey or an online link.

The Canadian Institute for Health Information (CIHI) applied statistical methods to determine whether Canadian and provincial results were significantly different from the international average of 11 countries.

Key Findings on Coordination of Care

The responses of Canadian primary care physicians illuminate challenges in communication and patient information exchange with sites and providers outside their practices. Although 90% of physicians send the patient history to the specialist (higher than the CMWF average of 85%), only 17% of physicians receive timely results back from the specialist (lower than the CMWF average of 21%). Patients have also noticed this communication gap: in a 2016 CMWF survey, 21% of Canadians reported that their primary care doctor did not seem informed and up-to-date on the specialist care they received (CIHI 2017).

Canadian physicians responded similarly to CMWF physicians regarding their communication with hospitals. About half of primary care physicians receive a notification about a patient's emergency department visits (49%), similar to the CMWF average (51%). The highest proportion was in New Brunswick, though there was a wide range across jurisdictions (from 17% to 87%). Also, about half of Canadian physicians receive a notice of a patient's hospital stay (54%, compared to the CMWF average of 55%). Notably, a few countries achieved high proportions of physicians receiving notices that their patients were seen in the emergency department (New Zealand: 85%, the Netherlands: 84%) and that their patient was admitted to a hospital (the Netherlands: 82%; New Zealand: 79%).

In all, 24% of Canadian primary care physicians communicate with home-based nursing care providers about their patients' needs and services, which is less than the CMWF average of 31%. Figure 1 illustrates the variation across the provinces and territories. Likewise, about a third of Canadian physicians (36%) are advised by home-based nursing care providers about changes in their patients' condition or health status, similar to the CMWF average (37%).

Many Canadian physicians screen their patients for social needs (60%), such as problems with housing, financial security and food insecurity. Fewer physicians frequently coordinate the care with social services (43%), and this proportion has decreased since 2015 (from 50%). Both of these are similar to responses from other CMWF physicians (the CMWF average for screening is 60% and for coordinating care is 46%). Germany (at 75%) and the UK (at 65%) have higher proportions of doctors frequently coordinating care with social services than the CMWF average.

Canadian physicians reported various barriers when coordinating care with social services, with one of the top challenges being inadequate staffing to make referrals and coordinate care (Figure 2). Challenges ranked differently across the provinces/territories.

Although Canada has had more physicians using electronic medical records (EMRs) in 2019 (86%) than in 2015 (73%), fewer Canadian doctors are able to share patient information electronically with physicians outside their practice compared to their CMWF counterparts. While information sharing has increased in Canada and in other surveyed countries since 2015, fewer Canadian physicians exchange patient clinical summaries, laboratory and diagnostic test results and patient medication lists with doctors outside their practice than the CMWF average (Figure 3). Most provinces and territories were below the CMWF average in these areas, and none was above the average.

When surveyed on their perception of the health system's performance, 65% of Canadian physicians thought that better integration of primary care with hospitals, mental health services and community-based social services is the top priority to improve quality of care and patient access.

Conclusion

The results of the CMWF 2019 International Health Policy Survey of Primary Care Physicians show that there is room for improvement in how Canadian physicians coordinate their patients' care. While the proportion of Canadian physicians receiving notifications about their patients' hospital interactions is similar to the CMWF average, it is still below the average in receiving timely information from specialists and in communicating with home-based care providers.

Canada's provinces and territories may be able to learn from higher performing countries. One approach, used by many CMWF physicians and increasingly adopted in Canada, is to utilize electronic technologies, such as EMRs, and other means of electronic communication with patients. If properly integrated with each other, these tools may facilitate information sharing and communication.

Most Canadian primary care physicians indicated that better integration of primary care with other sectors is the top priority, underlining the importance of making gains in this area. By improving their patients' care coordination, Canadian primary care physicians can further realize their potential as the hub where patients can receive safer, more effective and more integrated care.

Additional information that highlights the Canadian results can be found online at https://www.cihi.ca/en/commonwealth-fund-survey-2019. Full data sets of the survey results are available to researchers upon request at cmwf@cihi.ca.

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