The Peterborough Family Health Team was created by the physicians of Peterborough to address systemic crises in local health care: too many unattached patients, growing strain on outpatient and Emergency Department (ED) services, and a rising incidence of chronic disease. These crises arose from a failing primary care system, as new physicians chose other forms of practice while those who remained lacked the resources to provide the care their patients and our community required.

Family Health Teams reinvigorated primary care practice by integrating nurse practitioners, mental health clinicians, registered dietitians, pharmacists and registered nurses within the traditional family practice; enabling local and health-system partnerships, and introducing a roster-based compensation model for family physicians.

Together, these innovations have already provided over 25,000 unattached patients with access to primary care and continue to bring new physicians into community practice. Evening clinic and tele-health service helped to eliminate 15,000 unnecessary Emergency Department visits in the first eighteen months of Family Health Team operation, and continue to have a substantive impact on ED volumes and projected growth. We are also seeing a new interest in primary care practice among physicians, which has resulted in several new practices opening since 2006. In 2016, 109,000 people in the Peterborough area were  registered with a local doctor.

It is the continued mission of the Peterborough Family Health Team to lead the development of an integrated health care system that meets community needs and provides a seamless experience of care for our patients. We will continue to develop partnerships with local specialists and organizations to share best practices, expertise, and knowledge of the patient across care pathways that include education, prevention, identification, and treatment at all levels of disease acuity and complexity.

Community Response

Seven years ago, Peterborough County faced a developing crisis in primary care that threatened the health of our community and the capacity of the health system to respond to patient needs. Few physicians were entering community practice as a result of stagnant compensation and a lack of support. Many of Peterborough’s existing physicians were nearing retirement, and others were leaving to pursue other opportunities.

As a result, almost 1/4 of Peterborough’s population did not have access to primary care. These patients relied on the Emergency Department at Peterborough Regional Health Centre (PRHC) for episodic care. The community felt increasing fear about the health system’s capacity to provide care, a feeling exemplified by newspaper headlines like “Situation Critical.”

An informal committee of physicians began meeting to identify the problems in primary care and pursue a solution. Four years later, the Peterborough Family Health Team was born with a mission to increase access to primary care through recruitment and retention of new health providers and to meet community health needs.

Almost all of Peterborough’s family physicians joined one of five Family Health Networks/Organizations, which became the Family Health Team in 2006. These five organizations share a common mission and governance structure through the Peterborough Family Health Team (PFHT), a non-profit corporation.

In their first year, PFHT and the five organizations focused their efforts on developing the organizations and increasing capacity in primary care by recruiting other health professionals, such as nurse practitioners, mental health clinicians/social workers, and dietitians. In total, there are now over 80 physicians and over 50 allied health professionals (nurse practitioners, mental health clinicians, registered dietitians, pharmacists, occupational therapists and registered nurses) in the Family Health Team. This expanded capacity made it possible to roster new patients and address the unattached patient crisis.

In particular, the Peterborough Family Health Team committed to provide care for every new baby born at PRHC who would not otherwise have a family physician. The first newborn was rostered in January 2006, and since then, hundreds have been placed with a family physician of nurse practitioner.

Success Story

The results of this activity have been astonishing, as the numbers show. Since 2006, our community has seen:

  • Thousands of new patients rostered
  • Many newborns placed in family practice
  • Fewer ER visits
  • Several new physicians in community practice

Most importantly, the community is experiencing a renewed sense of confidence in the health-care system as the unattached patient crisis has been replaced by a sure sense of progress. Although there are still too many unattached patients in our County, there is no longer a feeling of “Situation Critical,” in fact, as of March 2013 only 2000 patients were registered with Health Care Connect.

Physicians and the other FHT health professionals testify to the impact of the FHT on their practice. “It’s a great way to work, and I think the patient gets the best care that way,” says Joanna Charlton, a nurse practitioner with the Peterborough Family Health Team. “Finally, people are realizing that to stop diabetes, for example, we have to stop obesity. That’s where Family Health Teams really work.”

Underlying these positive feelings are institutional changes that will have far-reaching effects. The emergence of collaborative practice in primary care is only beginning, but it is already improving the provider’s and the patient’s experience. Patients like Heather confirm the impact that integration has on their care: “For well over a decade I have struggled with multiple dietary issues but, due to lack of coverage, was unable to access nutrition counseling. Now, being able to receive the appropriate services, locally and without financial burden, I am on the fast-track to much better health.”

The Peterborough FHT is also approaching 94% adoption of electronic medical records in primary care. Within the FHT, the EMR is an essential tool for sharing information across multiple providers and points of care. The high adoption rate means that Peterborough’s residents are poised to receive the other benefits of an EMR: better documentation, communication, and decision support; engaged patient self-management; and improved health system knowledge and planning.