How Kamloops community health clinics are redefining health care

As Kamloops and B.C. grapple with a crisis of primary care, one local clinic is using a model its operators and health care experts say could help resolve some issues around access to care and the quality of care itself.

But it’s a style of primary care that has been slow to catch on in Canada.

The Supporting Team Excellence with Patients Society (STEPS) runs clinics in Valleyview, downtown and in Sun Peaks using what is commonly called the community health centre (CHC) model of care.

STEPS chief executive officer Christine Matuschewski said the idea for the society came about through an incubator program with the Thompson Region Division of Family Practice to help stabilize community primary care in the area in the early to mid-2010s.

By that point there were already challenges with a low rate of residents in the region being attached to family doctors, and the incubator program devised a team-based care business plan.

Using that business plan, the non-profit society launched, in April 2017, with several physicians on board to open the first clinic in May 2018, Matuschewski said. 

Since then, the organization has grown to three clinics serving over 19,000 family doctor-attached patients, along with providing women’s health services for both attached and unattached patients, gender-affirming care and care for local Indigenous communities.

The intention is to not only improve access to health care, but also to improve health-care outcomes for patients. And it’s able to do that in large part because of the model of care.

“Community health centres are, I would say, a key part in the system design of providing efficient, effective, community-based, very nimble, responsive ways of providing primary care,” Matuschewski said.

That co-operative approach to health care, along with having patients attached to family practitioners, including nurse practitioners and doctors, results in a more well-rounded health-care experience for the patient, and ultimately better outcomes, Matuschewski said.

While most family physicians in Kamloops, and B.C. more broadly, operate out of private practices, proponents of alternative models of primary care say this leaves doctors with the duelling duties of providing care and running a business. By contrast, the co-operative approach in CHCs takes the administration work out of the hands of doctors, allowing them to focus on their patients.

And Matuschewski isn’t alone in believing this.

Andrew Longhurst, a health policy researcher at Simon Fraser University and the Canadian Centre for Policy Alternatives, said the community health centre model goes back nearly a century to a clinic in Winnipeg. But it’s an idea he said hasn’t caught on, despite having promising outcomes.

Longhurst defines the CHC model as one that “really focuses on the social determinants of health and really understanding primary care is not just one of medical intervention, but really situates health within the determinants of health that [patients] face within that community.”

Those determinants broadly include access to things like housing, healthy food, transportation and income, along with systemic factors that negatively impact racialized communities.

“That’s really kind of foundational to how community health centres understand primary care. Practically, though, they provide integrated medical care and social services through a team-based model. They typically have an explicit focus on providing access to care to marginalized communities,” Longhurst said.

He added that CHCs operate in contrast to the traditional model of primary care delivery, which relies on a fee-for-service funding model and on doctors operating as independent contractors, making physicians essentially small business owners. The doctors may work on their own or in a practice with a group of other doctors on a fee-for-service pay structure.

“It’s not to say they don’t provide good care, but there isn’t the explicit provision of care through a team,” Longhurst said, noting CHCs often also provide mental health care or work with social workers, housing advocates or others who can help patients with areas not typically considered to be part of health care.

But that view — that things like poverty, for instance, aren’t connected to health outcomes — isn’t supported by evidence, Longhurst said. “If you don’t have a roof above your head, you’re undeniably going to have worse health outcomes.”

The evidence around CHCs, which mostly comes out of Ontario and the U.S., is about as limited as the availability of the model itself, but what evidence does exist, Longhurst said, is “quite strong” in their favour.

“It’s effective in helping people manage chronic conditions, reduce emergency visits and improve access to medical health care, which is a growing part of what family physicians find themselves treating when patients come through their doors,” he said.

The B.C. government has begun opening urgent and primary care centres (UPCCs), which are intended to address the wrap-around longitudinal care services like CHCs do. But Doctors of BC president Dr. Joshua Greggain said that model has been bogged down by the urgent part of their service model, which is also intended to divert patients from emergency rooms.

And that has left them unable to work on the primary care part for the most part, Greggain said.

“There are relatively few UPCCs across this province that are actually providing longitudinal primary care,” he said.

But moreover, Longhurst and Matuschewski agreed UPCCs still don’t work as well within communities as CHCs do.

The main reason for this, they said, is the model of governance CHCs use, being community-run non-profits.

One way this works better, Matuschewski said, is that they become more nimble.

“As opposed to the health authority leading the work, it’s a group of community members,” she said. “It’s a volunteer board of directors identifying community needs and delivering on responsive health-care services that meet those community needs and gaps.”

One example, she noted, is that they were able to move an obstetrics service located at the hospital to their clinic in the early days of the pandemic out of concern for exposing pregnant people and their unborn babies to COVID-19. 

In other cases, she said, the organization has been able to pay for taxis to get to the clinic, connect them with housing or food or even just get patients a hotel room for the night.

It comes down to having the governance at a local level, Matuschewski said. Where health authority-run clinics with wrap-around services are run within more rigid guidelines set by a distant board of directors, the board at STEPS is local and adaptive to the needs of the community.

But that governance structure is also what sets them apart from the traditional model of physician-run clinics. Longhurst borrowed an analogy used by UBC health researcher Rita McCracken: “We don’t pay teachers and then, with their earnings, expect them to open schools. … So why are we expecting that to happen with primary care?”

Where doctors’ clinics are operated entirely on funding the government provides to doctors themselves, covering everything from the doctors’ wages to administrative costs to nurses and other staff, a CHC is intended to be funded at the clinic level.

This, Longhurst said, takes the practice of operating the clinic out of the hands of doctors, leaving them with the ability to focus on what they do best: working with and managing patients.

“We don’t fund primary care infrastructure, and we don’t fund nonprofit organizations,” he said.

By contrast, Ontario’s Health Ministry has a separate program for CHCs that have envelope funding that covers a certain number of providers, as well as line items for operational and capital costs beyond the doctors.

So if CHCs are so promising, why isn’t the government jumping on this model?

Longhurst said there has been opposition by medical associations in the past to these models, with a reluctance by doctors to give up the independence of running their own businesses.

But Greggain said while that was true some decades ago, it’s not so anymore. Today, he speaks about CHCs with enthusiasm, saying younger doctors in particular talk to him positively about that kind of model, not wanting to run their own businesses as they try to pay off post-secondary debts.

Still, the government has been reluctant to fund CHCs as an entity rather than paying doctors their fee-for-service standard. And the road from May 2018, when STEPS first opened its clinic, to today hasn’t been easy.

“It’s been a battle, let me tell you. It has been so hard,” said STEPS president Colin O’Leary.  “We have almost gone bankrupt twice.”

Despite this, O’Leary helped launch the B.C. Association of Community Health Centres and helped other CHCs open since STEPS got its start. And he says STEPS itself has found its footing as a successful clinic.

“Our doctors are really happy. They’re not burning out,” O’Leary said.

“Our patients can access their doctor, usually they can get same-day appointments. On average, the longest they have to wait for a doctor’s appointment is two days. So my family doctor, I would have to wait like six weeks to get him to see me.”