All physicians, especially family physicians, should be aware that the College of Physicians and Surgeons of Ontario (the “College”) is seeking feedback on a ‘suite’ of new draft policies pertaining to continuity of care which is comprised of a foundational Continuity of Care draft policy (referred to as the umbrella policy), as well as four companion draft policies that set out expectations regarding: Availability & Coverage; Managing Tests (this draft policy is a revision of the College’s current Test Results Management Policy); Transitions in Care; and Walk-in Clinics. The new policies and new obligations are of particular importance to a family physician’s practice.
The purpose of these new policies is to address potential breakdowns in continuity of care that may negatively impact patient health outcomes and quality of care. The draft policies acknowledge that achieving continuity of care can be influenced by factors beyond the control or influence of individual physicians. Hence, the suite of policies focuses only on elements of continuity where the physician has a role to play.
The College’s recommendations regarding broader systems issues will be set out in a companion ‘white paper’ at a later date.
Below is a summary of the information on the background and key expectations of each draft policy:
Continuity of Care: This draft umbrella or foundational policy sets out the general expectations of the College regarding physicians, patient engagement, technology and the role each of these factors plays in continuity of care.
The draft policy requires physicians to:
- Collaborate with other health-care providers and enable effective communication and information sharing;
- Use their expertise and influence to help advance the health and well- being of their patients and the broader community;
- Facilitate and support patient engagement, in a professional, sensitive manner;
- Capitalize on advances in technology that can facilitate continuity of care. Physicians’ responsibilities under the draft policy exist regardless of the availability or use of such technology.
Availability & Coverage: This draft policy sets out the College’s expectations regarding coverage arrangements put in place by physicians during after-hours and temporary absences. The policy does not require physicians to personally provide on-demand access to care but to ensure that measures are taken for care to remain continuous.
Under this policy physicians must:
- Have an office telephone that is answered and/or a voicemail that allows messages to be left during operating hours and outside operating hours.
- Appropriately triage patients with time-sensitive or urgent issues.
- Respond in a timely and professional manner when contacted by physicians or other health-care providers regarding a patient;
- Have a system that ensures critical test results can be received and responded to 24 hours a day, 7 days a week.
- For patients receiving care as part of a sustained physician-patient relationship: Physicians must use their professional judgment to structure a suitable plan for coordinating care outside of regular operating hours and make coverage arrangements during temporary absences from practice.
Managing Tests: This draft policy sets out the College’s expectations regarding the management of tests. Much of the previous version of the policy has been retained but some of the content has been clarified and some new provisions have been added.
The draft policy requires physicians to:
- Use their professional judgment when ordering tests. They are advised to include contextual information on requisition forms, a copy of which must be provided to the primary care physician;
- Ensure test results for high-risk patients are tracked and use their professional judgment to determine whether to track results of patients who are not high-risk;
- Be confident that no test results will be missed;
- Use their professional judgment to determine whether the ‘no news is good news’ strategy is appropriate in the circumstances. If such strategy is used physicians must inform the patients and give them the option to contact the physician’s office for the test result;
- Physicians who receive critical or clinically significant test results in error have an obligation to report the result to the patient or others involved in their care. In cases where the results are received incidentally, the physician must make reasonable efforts to notify the patient or ordering health-care provider if the physician has reason to believe that the ordering provider will not get the test result;
- Inform patients of the availability of patient portals. Note: the use of patient portals does not absolve physicians of their responsibility to provide appropriate follow-up;
- Encourage patients to discuss their test results with the physician and ask questions. Physicians are advised to be proactive in informing patients of the significance of the test ordered, the importance of getting the test done in a timely manner and complying with requisition instructions.
Transitions in Care: This draft policy sets out the College’s expectations where patient care or an element of patient care is transferred to another physician or healthcare provider, including expectations in relation to keeping patients informed about who is responsible for their care, patient handovers within a hospital or health-care institution, discharges from hospital, and the referral and consultation process.
Below is a summary of the key expectations for physicians:
- Within hospitals and health-care institutions: coordinate with others to keep patients informed about who is their most responsible provider. Referring and consultant physicians must inform patients about their role in managing care.
- Approach patient handovers in a systematic manner and to set time aside to allow for a real-time and personal exchange of information between health-care providers.
- Ensure that a discussion is had with the patient and/or substitute decision-maker prior to discharge about issues such as ongoing monitoring and potential complications etc.
- Where there is interest and consent to do so, take reasonable steps to involve the patient’s family and/or caregivers in this discussion. Physicians must also use their professional judgment to determine whether elements of the discharge discussion should be captured in writing.
- Complete a discharge summary for all in-patients in a timely manner. If a delay in distribution is anticipated, a brief summary must be provided to the health- care providers responsible for post-discharge care.
- Referring physicians must make referrals in writing and must take reasonable steps to confirm that the referral is within the scope of practice of the receiving physician.
- Consultant physicians must acknowledge referrals no later than 14 days (i.e., indicate whether they can accept the patient and if so, give an actual or estimated appointment date). Consultation reports must also be distributed no later than 30 days following an assessment, new finding or change in the management plan.
- Referring physicians must communicate the estimated or actual appointment date to patients, but consultant physicians must communicate any other appointment information.
Walk-in Clinics: Expectations for physicians pertaining to continuity of care in a walk-in clinic setting. Physicians practising in a walk-in clinic must:
- Use their professional judgement to determine whether it would be appropriate to sensitively remind patients about the nature of walk-in clinic care and that receiving care within a sustained physician-patient relationship facilitates continuity of care.
- Meet the standard of practice of the profession.
- Provide or arrange for the provision of appropriate follow-up care when ordering a test or making a referral.
- When ordering tests ensure that critical test results can be received and responded to 24 hours a day, 7 days a week (which will necessitate establishing coverage arrangements when physicians are unavailable).
- Provide the patient’s primary care provider with a record of the encounter and take reasonable steps to identify others who would benefit from knowledge of the encounter and provide them with one as well.
- Physicians practising in a walk-in clinic are advised (but are
not required) to offer, where their scope of practice permits, comprehensive primary care to patients without a primary care provider who regularly attend the same clinic.
The College’s usual 60-day consultation period has been extended to December 9, 2018, (approximately 6 months) for this suite of policies, given the importance and breadth of the project.
The College is inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals. Comments can be submitted through the College’s discussion forum, via email, by completion of an online survey, or through regular mail. The draft policies’ consultation page can be found here. The College has indicated that it will carefully review the feedback obtained and use it to evaluate each draft Policy within the suite. To ensure transparency, the College will post all consultation feedback in accordance with their posting guidelines.
If you have any questions about this new suite of policies, please contact us. We will provide more information on our blog as it becomes available.
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