Request for Feedback on the CPSO's Continuity of Care Policy

As family physicians, you play a vital role on the front-lines of care and are a cornerstone of your patients’ lifelong medical needs and journey. In addition to the many ways you care for patients, and in a variety of settings, continuity of care1 has a measurable impact on patient outcomes, and is a unique contribution made by family physicians in the health system.

The College of Physicians and Surgeons of Ontario (CPSO) recently developed a draft umbrella Continuity of Care Policy, with four companion draft policies that set out expectations2 on:

  1. availability and coverage;
  2. managing tests;
  3. transitions in care; and
  4. walk-in clinics.

Each draft policy can be found here, along with a ‘primer’ for each policy.

The CPSO’s consultation period presents an important opportunity for you to provide your feedback on these proposed policies. The CPSO is accepting individual and organizational input until December 9, 2018, and the Ontario Medical Association (OMA)3 is also gathering input from their broad physician membership. To specifically support our members, the OCFP is leading its own consultation efforts and we want to hear from you. Given the anticipated impact on your day-to-day practice, your feedback on any of the content in these policies will be used to shape the OCFP’s organizational response to the CPSO from a family physician perspective.

Read below for an overview of key areas highlighted by OCFP staff and how you can Share Your Feedback with us.

Share Your Feedback

You can share your feedback directly to the CPSO through its consultation page. CPSO’s consultation closes December 9, 2018. The OCFP welcomes copies of your feedback provided to CPSO as it will help further inform the OCFP’s response.

Next Steps

The OCFP-led consultation is now closed. The OCFP will continue to keep members informed about this policy development, including sharing the OCFP’s official organizational response once developed (anticipated in November 2019).

We thank you for your participation.

Overview: Key Areas Highlighted by OCFP Staff

1. Availability and Coverage:

This new draft CPSO policy sets out expectations of physicians regarding after-hours coverage, and coverage during temporary absences from practice. The CPSO does not currently have a policy related to this area (see the CPSO Policy link for a list of and access to all of their current policies4). Key elements for consideration include the following proposals that physicians:

  • co-ordinate after-hours care and care for patients during temporary absences, as well as making reasonable attempts to minimize uncoordinated access to care and inappropriate utilization of emergency rooms or walk-in clinics.
  • maintain an active telephone line or voicemail and structure their practice to enable triaging of patients with time-sensitive issues.
  • respond in a timely manner to other health care providers.
  • who order tests must ensure that critical test results can be received and responded to 24 hours a day, 7 days a week (coverage arrangements are permissible).
  • What's Happening in Other Provinces/Territories?

    Like Ontario’s draft policy, Alberta’s5 policy requires physicians to provide or have arrangements in place for ‘continuous care’ including receiving and responding to critical test results “after-hours”. Other provinces also set out expectations for managing critical test results after-hours, such as New Brunswick6 and Manitoba7. In contrast to Ontario, Alberta’s policy8 does not require an active telephone line or voicemail, but rather states that patients must be directed (e.g., it can be a recorded message) to a health care provider or service to provide access to care. A written agreement with that service or provider must also be in place. The Yukon Territory9 has adopted Alberta’s policy.

    PEI’s policy10 is based on Alberta’s and sets out similar requirements. For example, that physicians must make arrangements for patients needing ongoing care outside of usual business hours and to have a system in place to advise patients. Unlike the policy proposed by the CPSO, PEI’s policy does not set out how these requirements are to be achieved). BC’s11 policy is also outcome based and states that there must be a system in place for urgent care but does not outline the ‘how this is to be achieved’. The BC, Alberta and PEI policies – as with Ontario – also state that patients must be informed of the process for accessing after-hours care and when the physician is temporarily absent.

    2. Managing Tests (Revised draft policy)12

    This draft CPSO policy builds on the current policy and pertains to the management of all types of tests. As noted in #1 above, the CPSO is proposing that critical test results can be received and responded to 24 hours a day, 7 days a week. The requirements listed below highlighted by OCFP staff are new, apart from tracking test results for high-risk patients. In the case of tracking tests, while the current policy requires physicians to communicate the significance of taking a test to high-risk patients and track results, it is not clear in the new policy what is meant by “verification” or how physicians can ensure that lab results are sent to them. Key elements for consideration include the following proposals that physicians who order any type of test:
    1. track test results for high-risk patients, including verifying whether the patient has taken the test and ensuring that the result is sent to the physician.
    2. use professional judgment to track tests for patients who are not high-risk.
    3. provide contextual information on the requisition form and copy the patient’s primary care provider.
    4. ensure (or have staff ensure) patient contact information is correct at every visit.
    5. tell patients they have the option to personally contact the physician’s office for a test result if a “no news is good news” approach is being used.

    What's Happening in Other Provinces/Territories?

    Alberta’sand Manitoba’s policies13 are like Ontario’s in their requirement for contextual information pertinent to the patient and the test being provided on the test requisition. However, neither Alberta’s nor Manitoba’s policies require physicians to track if the patient has taken the test or to check if patient information is correct at each visit. They are also silent on a “no news is good news” approach. Patients in Alberta must be notified of necessary follow-up and informed about how to access after-hours care. New Brunswick has a policy on preventing failure in follow-up care that includes having a system in place to review test results and arrangements for follow-up care when necessary, though it contains few details about what that system must include14.

    BC’s policy establishes requirements for after-hours care(see Availability and Coverage comparison in #1 above), and within its walk-in policy14 (see Walk-in Clinic comparison in #4 below) outlines requirements for physicians working in this type of setting and sharing test results. It neither specifies the need for ‘24/7’coverage for urgent test results nor gives specific details regarding how critical test follow-up is to be achieved.

    3. Transitions in Care

    The CPSO policy requires referring physicians to communicate the estimated or actual specialist appointment date and time to the patient, unless the specialist has indicated they have already done so (or intend to do). There is no current CPSO policy that includes these expectations.

    Several responsibilities for physicians within a hospital or healthcare institution are outlined. For example, physicians handing over patient care to another care provider are strongly advised – wherever possible – to have a real-time and personal exchange of information that includes an opportunity for a discussion to occur and for questions to be asked.

    What's Happening in Other Provinces/Territories?

    Several Canadian jurisdictions have referral and /or transitions in care policies (e.g., Alberta15, Yukon16, Manitoba17, New Brunswick18 and Nova Scotia19).

    No jurisdiction requires the referring physician to provide the patient with details related to the consultant appointment. Instead, this is set out as a specialist / consultant physician responsibility. In terms of requirements for a “real-time and personal exchange of patient information”, this expectation for physicians in hospitals was not found in any provincial or territorial policy or standard reviewed. PEI’s Continuity of Care policy does give guidance on informing a physician colleague taking over care in any circumstance where follow-up care may be needed but provides no details regarding the setting where this may occur or how it may be accomplished.

    4. Walk-In Clinics

    As outlined in the draft CPSO policy, physicians practising in a walk-in clinic would be required to provide the patient’s primary care provider with a record of the encounter. The requirements set out in this policy are new.

    Walk-in clinic physicians are advised to offer comprehensive primary care to orphaned patients unable to locate a primary care provider.

    What's Happening in Other Provinces/Territories?

    There are similarities and differences between the CPSO draft policy and other jurisdictions regarding these requirements related to walk-in clinics and episodic care. For example,

    • Alberta requires the patient’s primary care provider to receive a record of the walk-in encounter; it does not require that the physician practicing in a walk-in clinic provide ongoing care20. The policy states that the walk-in clinician must inform the patient that they will not provide ongoing care beyond addressing the patient’s current condition(s). The Yukon Territory policy is adopted from Alberta and outlines the same expectations21.
    • New Brunswick’s22, Saskatchewan’s23 and BC’s24 walk-in / episodic care policies require physicians to ask for and record the name of the patient’s family physician / primary care provider (where applicable), however patients must consent before information and test results can be shared with the patient’s family physician / primary care provider.
    BC’s policy also requires walk-in clinics to provide ongoing care if the patient visits repeatedly and does not have a family physician. Although not explicitly stated as an expectation, Saskatchewan and Newfoundland25 both reference the CMA Code of Ethics statement 1926 as underpinning the policy respecting physician care obligations for patients without a family physician.

    1 ‘Continuity of care’ is a hallmark of family medicine and a critical element within the CFPC and OCFP Patient’s Medical Home vision for primary care It is defined as consistency of care over time, throughout the course of a patient’s life. Having most medical services provided or coordinated in the same place by one’s personal family physician and team has been shown to result in better health outcomes.
    2 The CPSO acknowledges there are health system issues that impact continuity of care and that a white paper will be released at a future date about these issues
    3 OCFP’s Consultation Guide is modeled on the OMA Member Consultation Guide (July 2018). See the OMA Guide here:
    CPSO, (no date), Policy at
    5 CPSA, (2015; Reissued 2017), Continuity of Care at 
    6 CPSNB (2012; revised 2014) Preventing Follow-up Care Failures
    7 CPSM (2015; Revised 2017) Standard of Practice for Medicine: Practice Coverage - Critical Test Results at
    8 CPSA, (2015; Reissued 2017), Continuity of Care at
    9 YMC, (2015; Reissued 2017), Continuity of Care at
    10CPSPEI, (2017) Continuity of Care at
    11 CPSBC, (2018) Care and Coverage outside of Regular Office Hours at
    12 Much of the content of the current Test Results Management policy has been retained in the draft policy, with some clarifications and additions. The current Test Results Management policy can be accessed at:
    13 CPSM (2015; Revised 2017) Standard of Practice for Medicine: Practice Coverage - Critical Test Results at
    14 CPSNB (2012; revised 2014) Preventing Follow-up Care Failures
    15 CPSA (2010; Revised 2017) Referral Consultation at
    16 YMC, (2017) The Referral Consultation Process at pdf
    17 CPSM (2015; Revised 2017) Standard of Practice of Medicine: Patients Rights in the Referral Process at
    18 CPSNB, (2010; Revised 2014) Consultations / Referrals at
    19 CPSNS, (2013) Referral and Consultation at
    20 CPSA, (2015; Reissued 2017) Episodic Care at
    21 YMC, (2017) Episodic Care at
    22 CPSNB, (2012) Walk-in Clinics at
    23 CPSS, (2015; Revised 2018) Clinics that Provide Care to Patients Who Are Not Regular Patients of the Clinic at %20Clinics%20that%20Provide%20Care%20to%20Patients%20Who%20are%20Not%20Regular%20Patients%20of%20the%20Clinic.pdf 
    24 CPSBC, (2015; Revised 2017) Practice Standard: Walk-in, Urgent Care and Multi-physician Clinics at
    25 CPSNL (2008) at Practice Guideline: Responsibility for Continuity of Care for Patients without a Family Physician: Practice Guideline at
    26 CMA (2004; Reviewed 2018) Code of Ethics at