In Renfrew County: A hybrid solution to the rural family doctor shortage
In this episode of Primary Focus, Dr. Tara Kiran travels to Renfrew County, Ontario, where an innovative team is tackling the family doctor shortage with a new kind of hybrid care - where your doctor is virtual, but your team is on-site. At the Petawawa Centennial Family Health Centre, Dr. Jonathan Fitzsimon shows Tara how patients are matched with virtual family physicians who work alongside local nurses, pharmacists, and other health professionals to provide full-service, ongoing care. The result? More than 6,000 people who once had no family doctor are now receiving comprehensive, team-based care. It’s a story about creativity, access, and what’s possible when rural communities rethink how primary care can be delivered.
Further reading:
Explore more about the Petawawa Centennial Family Health Centre Read a report summarizing Renfrew’s Integrated Virtual Care model
Dive into research on the Integrated Virtual Care model including papers on early patient outcomes, patient experience, and staff experience.
See some photos of Petawawa Centennial Family Health Centre (link to post)
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In Renfrew County: A hybrid solution to the rural family doctor shortage
Primary Focus Podcast
Opening: Meeting the Hills
Dr. Tara Kiran (00:05) Maybe before we start, I'll get you to just introduce yourself, and maybe just spell your name for me.
Charles Hills My name's Charles Hills. Do you want me to spell that? C-H-A-R-L-E-S. Last name is Hills. H-I-L-L-S.
Dr. Tara Kiran This is Charles. In January, I sat down to interview him and his wife, Francine.
Francine Hills Hello, my name is Francine Hills. F-R-A-N-C-I-N-E.
Dr. Tara Kiran They're both in their seventies and both being treated for chronic conditions that are common in older age. They live in Renfrew County, Ontario — but they only moved to this community back in 2022. Here's Francine.
Francine Hills We lived in Calgary for the past ten years and had wonderful healthcare there. Actually, our doctor there warned us about coming to Ontario — that we weren't going to get the same kind of healthcare here. However, when we moved back to the valley, we were able to get onto this way of doctoring. I think it's fantastic, because in a rural community you don't always have all the facilities that maybe a bigger city has.
Dr. Tara Kiran Even though Francine and Charles are in a clinic today to talk to me, the "way of doctoring" Francine is referring to here is a hybrid model — one that combines virtual and in-person care.
Francine Hills We were on a list for about six months. I thought that was fairly quick, actually. I was quite impressed when we got the phone call.
Dr. Tara Kiran Charles and Francine both have a connection with a family doctor.
Francine Hills They presented her name to us — Dr. Saldana.
Dr. Tara Kiran But they never actually visit their doctor in person.
Charles Hills We had a virtual connection with her, like through a Zoom meeting. So we actually got to see her, and she got to see us as well.
Dr. Tara Kiran So how many times have you seen — and I say "seen" in quotation marks, because I understand that some of those appointments might be by phone, some by video —
Francine Hills We have a choice. We can either connect with her visually, or we can just do a phone call. And I think we've had probably in the last two years at least twenty connections with her — between the two of us.
Dr. Tara Kiran The Hills are part of a unique model here in Renfrew County that pairs virtual care from a personal family doctor with the option for in-person care from other health professionals, all working on the same team as the family doctor.
Francine Hills Sometimes it's just for a prescription renewal, sometimes it's for a concern that we might have.
Dr. Tara Kiran (02:29) Obviously, you've never met her in person.
Francine Hills No.
Dr. Tara Kiran And seeing her — but what is that like?
Francine Hills For me it's okay. I mean, if that's the way it is, it's fine with me. Having been in Calgary and had a personal connection with our doctor — that was really fantastic, because he was just phenomenal. But, you know, this is what we have to deal with — not only us, but many people. So we're okay with it.
Dr. Tara Kiran Now, you may have encountered virtual care before — perhaps with your own family doctor, or through a virtual clinic that provides a one-off consultation. But what I love about the model the Hills are a part of is that it's leveraging virtual care to expand access for over 6,000 people in Renfrew County — people who previously didn't have a family doctor. And it's being done in a way that provides ongoing, full-service primary care integrated with in-person touch points when needed, in a rural, underserved area where there's a relatively small population spread out over a very large geography.
In my opinion, having a family doctor you can only see virtually is not as good as seeing one where you also have the option of seeing them in person. But it is far, far better than not having any family doctor and being forced to go to an overcrowded emergency department or urgent care centre, or paying for private virtual services where you don't know the doctor. Or, as Francine says, it's better than having nothing.
So today: how do you serve more people in a rural community spread out over a vast geographic area where there simply aren't enough doctors to go around? We're travelling to Petawawa to find out how this clinic is using virtual tools to provide more people with access to full-service primary care. Because if it's working here, we want to know: will it work in other rural communities facing similar challenges?
Francine Hills (04:32) I think other communities could really benefit from having something like this. For rural communities, this is an ideal way to set up healthcare for people, because we know healthcare is changing and doctors are not as plentiful as they used to be.
Introduction
Dr. Tara Kiran (04:51) I'm Dr. Tara Kiran, a family doctor, researcher, and advocate for a better primary care system in this country. And this is Primary Focus, a podcast about the primary care crisis in Canada and how we're going to solve it. I've been visiting innovative clinics around the world — in places like the Netherlands, Spain, and Costa Rica — to bring back lessons about providing inclusive and comprehensive care to everyone. But I've also spent time in many innovative clinics right here in Canada: clinics that are getting creative as they work to offer better access to care.
And so today: the Petawawa Centennial Family Health Centre, and how one family health team is fighting a shortage of doctors using hybrid virtual care solutions. We're going to explore their approach from many different angles — because when I visited the clinic, they'd already set up interviews for me with a few members of their team, including a pharmacist, a receptionist, a doctor, and patients like the Hills.
Okay, let's get into it.
Arriving in Petawawa
Dr. Tara Kiran (06:06) It's a cold winter morning in the middle of January and I've just arrived here in Petawawa at the Centennial Family Health Centre. I left early this morning from Ottawa and drove along the Trans-Canada Highway for about an hour and forty-five minutes. It's cold outside — minus twenty — but beautiful and sunny, clear blue sky and snow on the ground.
I'm here to visit Dr. Jonathan Fitzsimmons and his team, who have started an innovative initiative here called the Integrated Virtual Care clinic. This is an underserved community — rural, not enough doctors to meet population needs, and the population spread out over a huge geographic area. So access challenges are huge. Jonathan and his team have come up with creative ways to try and address those challenges.
Jonathan Fitzsimmons (07:00) Hi. Thanks for having me here.
Dr. Tara Kiran I got my winter coat because it's very cold outside.
This is Dr. Jonathan Fitzsimmons, who I mentioned just a minute ago. He's the medical lead for both the Integrated Virtual Care program and the Virtual Triage and Assessment Centre here at Renfrew County.
The Petawawa Centennial Family Health Centre is located about a two-hour drive west of Ottawa in Petawawa, Ontario — a town known for being home to one of Canada's largest military bases. The clinic has two satellite locations: one in Pembroke and another in Deep River. But today I'm at the Petawawa location.
Background: Renfrew County
Dr. Tara Kiran (08:04) I asked Jonathan to host me at his practice because I think they're doing a few things really well. I wanted to do a deep dive into exactly how they're offering care in an underserved rural area by integrating virtual care from off-site family physicians with their in-person team.
For context: the 2021 census puts Renfrew County's population at just over 106,000 people. Those people are spread out over 8,000 square kilometres that stretch from the outskirts of west Ottawa along the Ottawa River to the northern tip of Algonquin Park. There are a few well-known small towns within its borders — places like Deep River, Arnprior, Pembroke, and Petawawa, where Jonathan's clinic is located. Many of Renfrew's residents live outside of even these main centres.
Jonathan Fitzsimmons It's a diverse county as well. As well as being home to many smaller rural communities, it's home to the First Nation community of [uncertain: Pikwàkanagàn]. It's home to the large Canadian Forces Base Petawawa, and Canadian Nuclear Laboratories has a site in Deep River — which somebody once told me has the largest concentration of PhDs anywhere in Ontario. So, absolutely a diverse community, but grounded in a sense of being a rural community with a rural history and background, and certainly some more remote, smaller communities as well.
Jonathan's Background
Dr. Tara Kiran (09:30) Jonathan's been working in the county since 2014, but his arrival here was definitely not his first experience in a rural practice. He grew up in the UK and trained as an engineer, then served in the Royal Air Force for six years before attending medical school. After his residency, he spent a year volunteering as a doctor in Bolivia.
Jonathan Fitzsimmons I did community medicine out in some very rural Indigenous communities in the Altiplano — the high part of Bolivia — and the foothills of the Andes. But in Bolivia, I met a teacher at the language school who's Canadian. And I guess the rest is history there. So we went back to the UK for a few years.
Dr. Tara Kiran (10:25) After spending a few years in the UK completing his family medicine residency, he and that Canadian teacher — spoiler alert, now his wife — moved to Ontario, where he set up shop as a family doctor in Arnprior.
Jonathan Fitzsimmons It's the first town into Renfrew County. I did everything you would expect of a family doc in a smaller town in a more rural community. I had a full-time office practice, I was doing hospital medicine, I was on the board of the family health team, I was involved in some other community health activities and committees. So yes, fully part of the healthcare community in a smaller town as a family doctor.
And then COVID came along.
How the Crisis Created a Solution
Dr. Tara Kiran (11:10) I think for everyone who works in the medical field, there is an "and then COVID came along" moment that changes everything. For Jonathan, the pandemic really did change everything about the way he does his work, his position at the clinic, and how the people of Renfrew County receive care. Because in 2019, access to care in Renfrew County looked a lot different than it does today.
Jonathan Fitzsimmons No urgent care centres, no walk-in clinics, a massive problem with lack of primary care access and family physicians. We were looking at around 20 to 25% of the county unattached — meaning zero access to primary care. Go to one of the five emergency departments in the county as your only means of accessing any form of healthcare, essentially.
The question was posed: what are we going to do in this large county where putting a COVID assessment centre anywhere in the county means it won't service most of the county, because it's just too far away from most people? And the idea of putting many assessment centres in all the communities wasn't logistically possible.
Well, I fell into the trap of making a suggestion and then being asked to run with it and see it through. I fell back on an idea from my time in the UK, where in the after-hours service there you can call a single telephone number when your family doctor's office is closed. The options would be: a telephone appointment, the option to go to one or two clinics that remained open in the evening, or even a family doctor being driven around to care for vulnerable homebound patients.
Dr. Tara Kiran (12:42) So Jonathan pitches the idea while on a phone call with the county's chief paramedic, the executive director of the family health team, and the CEO of Arnprior Regional Health. And then, like with many decisions made during a crisis, they hit the ground running.
Jonathan Fitzsimmons Everybody focused around the idea that maybe we could have this combination of virtual and in-person support, to make sure that everybody in the county — that nobody is left behind, everybody has access to care, and we're not going to leave people suffering at home in silence. And at the same time, they're not just all going to turn up to the emergency department, which was clearly one of our goals to avoid.
And that really was how VTAC was born — the Virtual Triage and Assessment Centre.
The Virtual Triage and Assessment Centre (VTAC)
Dr. Tara Kiran Jonathan says VTAC was originally set up to be a COVID assessment centre, but very quickly began providing access to a doctor for any primary care issue. A family doctor was assessing patients virtually, but when needed, patients could be seen by a paramedic in person — at the clinic or even at their home, for those who were homebound.
With the Virtual Triage and Assessment Centre, any Renfrew resident who didn't have a family doctor, or couldn't get a hold of their family doctor, could call a 1-877 number answered by a medical receptionist — just like the model Jonathan remembered from the UK. This line was staffed from 8 AM to 8 PM, seven days a week. When people called, they could arrange to be seen by a doctor by phone or video, arrange to be seen by a paramedic right in their home, make an appointment to see a paramedic at one of the in-person clinics, or in some cases be forwarded to another community service if more appropriate.
The Virtual Triage and Assessment Centre still runs today and continues to provide urgent, episodic care to people in the county — whether or not they have a family doctor. Jonathan tells me that about three-quarters of those who call that line don't have one. He also tells me that about 85% of the care provided through VTAC is delivered by a virtual family doctor. Only about 7% of calls are assessed on-site by a paramedic together with an off-site doctor, and another 7% are seen solely by paramedics. And less than 2% of calls in 2024 resulted in a patient being advised to go to an emergency department or call 911.
Dr. Tara Kiran (15:24) For me, there are a few remarkable things about this virtual triage and assessment model. One is that it's offering care to all of Renfrew County — it's population-based and designed that way, with just one number to call. Two, most care is managed entirely virtually by physicians living in other parts of the province. Three, it integrates in-person care, particularly for people who are most vulnerable and cannot leave the home.
The setup actually reminded me a lot of the after-hours care model in the Netherlands that we explored in Season One — except this is making it work in a rural area right here in Canada.
Jonathan Fitzsimmons (16:05) I am a really strong advocate of publicly funded healthcare available to all — always have been. I always think it's not easy. It's a difficult logistical and financial model to apply fairly and completely. But it absolutely should be our goal. Just because it's tough doesn't mean we shouldn't do it. In fact, it's tough, so we should do it. We should put more resource and energy — mental, financial, and other — into making this happen.
And so those circumstances in Renfrew County were very much front of mind for me. This wasn't abstract. I live in this community. I work here. These are people that I see, and I hear them talk about their families and their neighbours who don't have access to any family physician, or any primary care, or any healthcare at all outside of an emergency department. It really does focus the mind: put some effort in, figure this out, make it work. Be creative. Be innovative.
Dr. Tara Kiran (17:36) Before we move on to how residents of Renfrew County are getting ongoing access to family doctors through the hybrid approach, I want to say one more thing about the Virtual Triage and Assessment Centre model. It's really meant as a bridge. Yes, the assessment centre offers urgent care for hundreds of patients in Renfrew who don't have a family doctor — but it's really only meant as a patch until all residents eventually have ongoing primary care with a family doctor, nurse practitioner, or team with reliable access.
From Crisis Care to Ongoing Primary Care: The IVC Model
Dr. Tara Kiran (18:16) Obviously, the assessment centre was started during COVID and wasn't designed to provide ongoing, continuous care. But it quickly became clear to Jonathan and his team that this hybrid approach could also be used to provide ongoing primary care to more people.
Jonathan Fitzsimmons What we realized very quickly was that this model was very effective, very well supported locally, and very much appreciated — certainly by people who didn't have a family doctor and didn't have access to primary care. It worked well both clinically and technically. And so we said: if it works well linking family doctors working off-site with paramedics locally, why don't we consider having off-site family doctors work with an entire family health team locally, and actually attach patients to that doctor?
Because the county, like many rural communities, has a huge problem recruiting new family physicians to relocate here. But if we could tap into the entire family physician workforce in Ontario — have a system where they can work off-site, but be embedded and connected with a local family health team with all of the in-person supports: other physician colleagues, nurse practitioners, and all of the allied health professionals of the family health team — could we actually deliver team-based, comprehensive primary care, attached to a named family physician, using that same hybrid of virtual, in-person, at-home, in-clinic?
Dr. Tara Kiran If you haven't guessed it yet, the answer to that question is yes. That's how their Integrated Virtual Care approach — or hybrid approach — was born. You'll hear Jonathan refer to it as IVC.
The family health team serves about 6,000 patients who have a family doctor working remotely, often in Toronto, but who are fully supported by an interprofessional team that's on site. This could include dietitians, social workers, pharmacists, respiratory therapists, midwives, nurse practitioners, nurses, and also some on-site family doctors. Your doctor might be in Toronto and only available to you by phone or video, but the rest of your health team is available in person at one of three Renfrew-based clinics. This is the kind of service the Hills — who you heard from in the opening of this episode — are a part of.
Jonathan says one of the challenges is that Renfrew has been a victim of what's sometimes called the inverse care law — a term coined by Julian Tudor Hart in the UK many decades ago, used to describe situations where areas of higher need have fewer resources. So while the Virtual Triage and Assessment Centre was and is important and impressive, Jonathan knew that Renfrew County still needed a permanent fix so that every resident could receive reliable, ongoing access with a family doctor or nurse practitioner — not just a one-off visit. And that's where the hybrid primary care or IVC program comes in.
Jonathan Fitzsimmons We decided to partner with one of our family health teams in the county — the Petawawa Centennial Family Health Centre. I worked with the executive director there, Judy Hill, to bring to fruition this process called Integrated Virtual Care, or IVC. They had funded, salaried positions for physicians but couldn't recruit physicians to fill those slots. So what we did was open it up to physicians working anywhere in Ontario who were able to work off-site and become a member of this team — but as part of a group of physicians, nurse practitioners, and allied health professionals, to roster their own patients and have their own list of patients.
So patients are told: this is your doctor. You have a family doctor. You're not going to see your doctor in person in the clinic, but they are responsible for your care. You'll have telephone, video, secure messaging — all of the virtual options. And for those times where you need an in-person assessment or physical examination, either a physician or a nurse practitioner, colleague of your doctor, will do that in your local clinic. And you'll have access to the nurses, the dietitian, the midwife, and all of the other allied health professionals in the team.
We've grown over the last three years to provide that level of attachment to previously unattached people. Over 6,500 people now have comprehensive, permanent attachment to team-based primary care.
Dr. Tara Kiran (22:56) 6,500 people who had like no access to care at all.
Jonathan Fitzsimmons Yeah — they'd either never had a family doctor, or they'd just lost their family doctor because we've had a number of retirements and relocations. So we were able to make sure that people either didn't become unattached, or that people who had been unattached were able to come into the fold. And we now also have a second site at the North Renfrew Family Health Team in Deep River, which is part of the IVC program as well.
[Note: Jonathan uses the term "attached" to describe someone who has ongoing primary care with a family doctor, nurse practitioner, or team, and "unattached" for someone who doesn't.]
Dr. Tara Kiran Jonathan tells me there are 18 family doctors who are part of this hybrid model — working part-time and virtually, like the Hills' family doctor, Dr. Saldana, who's based in Toronto. And that kind of part-time, very flexible role is something Jonathan says many doctors are actually looking for.
Jonathan Fitzsimmons That's very appealing to some doctors. So we've tapped into an underutilized part of the Ontario family physician workforce — people who were not doing office-based primary care because they couldn't make it work for them, now able to have a practice of 250, 300, 400 patients, and for it to work logistically for them.
Dr. Tara Kiran Jonathan says the physicians working remotely in this hybrid model have a roster of between 250 and 650 patients each, and are typically working four-hour shifts, usually between two and five shifts a week. I should also mention that in this hybrid model, there are two family doctors and several nurse practitioners who work on-site at the local clinic. And whether you see a doctor in person or virtually, patients at Centennial have access to that wider interprofessional primary care team — nurses, social workers, dietitians, a pharmacist, as I mentioned before.
There are also options for patients to come to the clinic in person to have measurements and readings taken — either before an appointment with the doctor, or during one, where the patient is physically in the clinic and taking a virtual visit from right there, with a nurse standing by. When an in-person exam is needed, or even just preferred by the patient, one of the in-clinic physicians or nurse practitioners can do that on-site.
The Doctors: Helen and Mary
Dr. Tara Kiran (25:12) So we've talked about what this kind of hybrid primary care is like for the patient. But what about for all these part-time and largely off-site doctors? To answer that question, Jonathan and Centennial's executive director, Judy Hill, set me up with an interview with two of their hybrid primary care doctors. And of course, I'm meeting them virtually, over video.
[Virtual meeting intro — brief technical exchange as participants join the call]
Dr. Tara Kiran Mary and Helen, I'm wondering how long you've been working for the Integrated Virtual Care clinic and how you like it.
Dr. Helen [uncertain: surname] Mary and I are actually old residents who were together. I've been in practice now since 2016 — eight years at this point. We both just started IVC, so we're just getting our feet wet and getting used to everything. And it's a lot different, obviously, than practicing in Toronto where you have everything at your fingertips within days or a week.
Dr. Tara Kiran Helen says she and Mary both trained at Women's College Hospital in downtown Toronto, and she now works at [uncertain: the Bay Centre for Birth Control] nearby. Here's Mary, who's currently on maternity leave.
Dr. Mary [uncertain: surname] Going well — there are definitely some growing pains in the beginning, just getting to know patients and getting into the system. But I think what really attracts us to this model is it just offers so much flexibility when you have a young family. [uncertain: remainder of sentence unclear due to background noise]
Dr. Tara Kiran (27:26) For Helen, she takes about eight hours of this hybrid primary care work per week, split between clinical hours and administrative time. She also works for the Virtual Triage and Assessment Centre about six to eight hours a week. The rest of her week is made up of in-person clinical hours with her patients in Toronto.
I'm just curious — do you think this is extra work that you've taken on, or do you think it's replacing what you would have done in an in-person clinic in Toronto?
Dr. Helen I like this better. And I think part of it is that post-COVID, like virtual care has become this sort of normal thing. Part of it is that it makes me feel a little bit better, actually, offering care to people who otherwise wouldn't have care in a smaller area. I think sometimes practicing in Toronto, as a patient it can be quite demanding. Whereas I feel like a lot of the patients through VTAC or IVC are genuinely very thankful for the care — very grateful that you're there for them, even though it's in a more limited capacity.
I do think we can do a fair amount virtually. Obviously we can't do everything, but I think we can definitely reduce the amount of non-urgent [uncertain: after-hours] visits that people have by doing this kind of practice.
The growing pains are real — like we don't know a lot of the resources in the area yet. You can't get tests done as quickly, and sometimes there's only so much you can do aside from saying, "I think you need to go to the emergency department." But I do think this is a super unique opportunity that personally gave me a bit more balance in my work life. I have two young kids; it gave me flexibility — clinic whenever I want, even for a couple of hours a day — but also made me feel like I'm contributing to something. I was feeling very burnt out doing family medicine in Toronto, but I actually don't mind doing this at all.
Dr. Tara Kiran Helen says she worked in a family practice right out of school, but during the pandemic she switched to supporting COVID response in a hospital setting. Then she took two maternity leaves a year apart. She says that's why she's working now in Renfrew's hybrid model — it offered her what she needed as a doctor and as a new parent.
Dr. Helen I was just looking for more flexible opportunities, as opposed to like an in-person family practice three or four days a week.
Dr. Tara Kiran So it sounds like this is flexible and meaningful at the same time.
Dr. Helen Yeah, exactly.
Dr. Tara Kiran (30:05) What you're hearing here is something I hear a lot from family doctors these days. And the research backs it up. Many family doctors in Canada and elsewhere are looking for more flexibility. Many also feel drained by the realities of a full-service family practice, especially if they practice without a team that provides additional support and cross-coverage. We talked more about this in our opening episode this season with Dr. Ruth Lavergne. If you missed it, you should definitely go back and listen.
But what's also really striking here is how Helen's satisfaction with this hybrid work includes her role in offering care to people in an underserved community — people who express gratitude for the care she provides. For me, making connections with patients is a really rewarding part of the job. So I wondered: does meeting patients only by phone — which is how both Helen and Mary offer care through Centennial — is the connection still there?
Dr. Tara Kiran How do you find that for connecting with patients? 'Cause I personally find it hard. You find phone hard?
Dr. Helen Yeah, I actually really dislike just phone visits.
Dr. Mary Yeah. I like video, but then video has like technical issues sometimes. I mean, I at least have it set that my default appointment is phone, but if they want video, then certainly they can do that. But I also feel like a lot of patients, they're on the go. I don't think they actually want to do video because they're like, "I'm just in my car" or "I'm at Walmart right now."
Dr. Helen To be honest, that's why I don't like phone. I don't mind it, but — I guess the other thing here is I think most people speak English in this context. Because part of the reason I don't like the phone in my other context is that if English is not your first language, you can often have a good conversation in person with someone, but on the phone you miss a lot because of the body language. Sometimes I do feel like maybe I should see them, or see their face, so they can know me — because it's kind of strange talking to people over the phone without knowing what they look like.
Dr. Mary Our default is phone, at least for me. But patients always have the option to book video. So I've had a patient book a video, but the video didn't work, so we had to go to phone anyway.
Jonathan Fitzsimmons And guys, I know you're only a few weeks in, but the other option is what we call the enhanced video appointment. The patient can come to the clinic. So if you or the patient really wanted a video appointment and their tech or their Wi-Fi isn't up to speed, they can come to the clinic, sit in one of the exam rooms, and one of the staff will have everything set up for them. Then you can either have a nurse with you — so it really is a telemedicine appointment — or it can just be admin staff who set up the computer and walk out once everything's running.
Dr. Tara Kiran One thing I did want to know from Helen and Mary is whether they're taking advantage of the hybrid part of the model, and how it works when they need other team members to help out in person — for things like blood pressure checks, swabs, or someone to listen to a patient's lungs.
Dr. Mary So far it's often for minor, non-urgent things. So you send a message to the reception team, the patient comes in on a different day, and once they've been seen, somebody sends me a message after — whoever saw them — and then if there's any issue, someone calls back.
Jonathan Fitzsimmons We do have a structure in place where you can choose how you handle that. You can have people come in the day before and do a full set of vitals and book with the RPN. You can do it in real-time in a hybrid setup — we'll schedule a medical office assistant to be in the room with the patient. Or you can do what Mary was just saying: you realize mid-conversation you need something done, and you ask them to come in afterwards.
Dr. Tara Kiran It seemed from our conversation that Helen and Mary are in similar spots — both in Toronto, both with very young children, both really appreciating the flexibility this hybrid approach offers in their work week. But they also appreciate how meaningful it feels to provide services to those who've been struggling to access them.
Who's Doing This Work?
Jonathan Fitzsimmons (34:38) I would say the subtle difference between IVC physicians and VTAC is that VTAC has a huge age spectrum. We also have semi-retired physicians working for VTAC — people who have finished doing full-time hospital practice or the traditional full-time rural doc, but didn't want to completely hang up their cleats. So we have the full age spectrum with VTAC. With IVC, it wouldn't be appropriate for a semi-retired physician winding down their clinical practice to now start up a new practice. So IVC tends to be more recently qualified physicians.
We definitely have a good sprinkling of brand new — straight out of residency. But we also have a number of doctors like the two you just spoke to, who've been qualified five to fifteen years, who've previously had that blend of office-based family practice with hospital, with ED, with some other things.
That conversation around "I was not enjoying my practice in Toronto as much — it didn't work for me personally, it wasn't as rewarding professionally, it wasn't what I was expecting" — I hear that a lot. And that reflection of "I love the fact that the patients are so receptive, so grateful, I really feel like I'm contributing to an underserved community, I love doing team-based care" — because a lot of docs don't have the option to join a full team, whereas now they're providing team-based care.
And there's definitely a self-selecting demographic of doctors who like the technology, like digital, like virtual care — totally comfortable flipping between phone, video, and secure messaging. It's a bit of a self-selecting group of physicians as well. But the personal flexibility is huge: coming back from maternity leave, working hours around a school run, you can have a clinic ten till twelve. You do two hours of appointments on a virtual schedule. Those eight patients that you call don't care that you're only working two hours — you could be working eight hours as far as they're concerned. It perfectly works for them and it works for you.
Team Culture Across the Miles
Dr. Tara Kiran (37:02) One thing I love about the practice I work in is that we're really a team. And Jonathan says that in this hybrid approach, they have to think about team culture too — just in a different way.
Dr. Tara Kiran I do think it is definitely possible within an in-person family health team to have that kind of flexibility, if the physician group is supportive of one another and cross-covers. At the same time, I know there's something that goes along with being in a practice — whether you're there 0.2 or 0.8 of the time — like team meetings, partnership meetings — that you're more engaged in and have a better sense of how the team is running if you're there more. So I have experienced both the benefits and challenges when people are working very part-time versus more full-time. And I suspect it's similar here.
Jonathan Fitzsimmons I think you've touched on a really important challenge that we've faced with the IVC program: how do we fully integrate a physician who works off-site and who may never physically come to this location? How do we fully integrate them as part of the team? That is definitely a challenge. We as physicians talk about corridor consults and those opportunities to just touch base with colleagues.
Dr. Tara Kiran So there's a team culture. And especially for the people who are in person and who are not physicians. That's a challenge.
Jonathan Fitzsimmons Exactly. We've identified those things. So Judy has been really creative with some of our in-team training. Last year we had a whole-team training day where the docs joined online and the staff were here in person. We took ideas about how we can make the team more connected. Some of the docs have produced bios with pictures and information about themselves. I make a point of having digital coffee chats with some of the docs — I touch base with all of the new physicians early on and see how things are going. And then we'll have ad hoc meetings and more formal team meetings online.
But we try to recreate that team environment — those opportunities you'd have in person — recognizing that it's not exactly the same. You can't absolutely recreate that experience. But we don't just ignore it and pretend that nothing can be done about the fact that we can't do those in-person things. We try to be creative in introducing those as well.
In-Person Team Members: Steve and Christy
Dr. Tara Kiran (40:58) With the Petawawa Centennial Family Health Team, the hybrid approach seems to be working for both patients and doctors. But a lot of this model hinges on the presence of an in-person health team that's supporting the work the virtual doctors are doing. Next, I talked to two members of that team about how it's going and where they've seen bumps along the way.
Dr. Tara Kiran (41:13) What system do you guys use?
Steve Coolis We use Practice Solutions.
Dr. Tara Kiran And you love it? Or is it also —
Steve Coolis Does anybody ever love their electronic medical records?
Dr. Tara Kiran I have yet to ever meet anyone who loves their EMR.
This is Steve. He's a pharmacist on the family health team at Centennial.
Steve Coolis My name is Steve Coolis. I've been a pharmacist for thirty years. My primary role here is medication management. I do some INR monitoring for some physicians, a lot of medication management, a lot of counselling, and ensuring that people are on the right medication, the right dose, and the right delivery system.
Dr. Tara Kiran And so it sounds like, from an Integrated Virtual Care perspective — or maybe for all new patients, actually — one of your roles when patients are being onboarded is to make sure their medication profile is up to date in the chart, even before the doctor sees them.
Steve Coolis Yeah. It seems a bit administrative, and sometimes it feels that way. But getting the best information we can into the chart medication-wise, having that prepared for the physician so they have a history instantly when they get to see or talk to someone for the first time.
Dr. Tara Kiran I wanted you to hear from Steve because he's one of the team members who's been here since the hybrid model was introduced. He says one of his roles — and the roles of many of his colleagues who are on-site — is to help guide and educate patients about this new form of care delivery.
Steve Coolis Sometimes, especially with Integrated Virtual Care, there's a lot of misunderstanding for the patient. So there's a component of educating the patient that your physician is part of our team and that you still have access to the team members. I've come to refer to them as physicians who work off-site, so that patients understand they're still part of this team.
Dr. Tara Kiran This new role of hybrid-care educator is not just something Steve has taken on — it seems to come as part of being on a family health team that offers this unique model of care.
I also sat down with medical receptionist Christy Hill. She told me about how they recruit and onboard patients.
Christy Hill It's a little bit for people to grasp the idea that they're not going to see the doctor in person, but they can see the doctor over video or have a phone appointment. So I find people are still trying to get used to this new way of healthcare.
Dr. Tara Kiran (43:36) Yeah, of course. It's a big change. And what do you hear from patients when you describe what the model is? Because they're on a wait list — not necessarily for this specific model, I think, right? They're on a wait list to have a doctor, and this is what's being offered. So what kind of reactions do you get?
Christy Hill They're a little bit surprised that they're not ever going to see their doctor in person — although some of the off-site virtual doctors do come up to the clinic from time to time, but the majority don't. They live in Toronto or Ottawa. But I do explain to them that not only do they have a virtual doctor, they have access to the whole team: the pharmacist, the dietitian, social work counselling, nurse practitioners, and nurses. So it's a whole team of providers that they'll have care from.
So the nurse practitioners are the eyes for the doctors. Enhanced eyes.
Dr. Tara Kiran Once you explain what this new kind of care looks like, what are they thinking? What do they say?
Christy Hill I've had some positive feedback — they're very happy with the care. And sometimes we have to remind them what services are available to them. It takes a few times until they get comfortable with the way the process works and how appointments work.
Have you had anyone ever say, "No, I don't want to be part of this. I want an in-person doctor"?
Yes, we have had some people de-roster in order to go on the Healthcare Connect list. We have had some actually do that. And we're not sure how long they're going to be waiting on that list. We always let them know that as well. So it's been an interesting process.
I love being the one who makes that call — telling someone they're getting a family doctor. It's a good call to make and a good call to receive. So I really enjoy what I do. Happy to help the community as much as I can.
Research and Results
Dr. Tara Kiran (46:15) Like both Steve and Christy told me, there have been some growing pains with hybrid primary care in Renfrew, but all things considered, it seems to be going really well. Jonathan would tell you that despite bumps — like needing to educate patients about how this kind of hybrid care works — it's been a really successful launch in Renfrew County.
But Jonathan is not satisfied just with positive feedback from patients and his team, or even knowing the number of people with primary care has gone up. He and his team have launched a number of research studies to more rigorously evaluate the unique model they've developed. Their early research has demonstrated that even within the first few months of getting ongoing primary care as part of this hybrid model, patients receive important preventive care interventions like cancer screening or counselling to stop smoking — things they didn't have access to before. And the research has also shown that the vast majority of patients in the hybrid model are satisfied with the care they're receiving.
There's no doubt that this model is far better than no access to primary care. But research underway is going to help us understand how this model compares to more traditionally delivered primary care.
Jonathan Fitzsimmons Really, five years ago, this dramatic physician shortage — that was what we had. Now, not just better than nothing, it's actually very good. But I think it's an important comparator: if they weren't doing this, they wouldn't have anything. We talk about how far have we moved the needle. If your status quo was "I have no access to healthcare apart from an emergency department," you're pretty close to zero on that scale of how good your healthcare is. Now, a hundred percent, you've got same- or next-day access to your own family doctor, supported by a family health team in your community. Sure, that's the hundred percent that we all want everyone to get to. How close to a hundred percent has IVC brought these people?
And I think what you're finding from talking to patients and staff, and from our own experience, is we're moving a long way toward that. This is not just "well, it's kind of better than what I had before." This is getting pretty close to that gold standard option that we'd love to provide to everyone.
Contrasting Public and Private Virtual Care
Dr. Tara Kiran (49:56) Jonathan is dealing with the realities of delivering primary care in a rural, underserved community where the lack of available family doctors and other health professionals is a real challenge. Additional funding can help. But as he said to me, simply providing more money doesn't always translate to clinicians relocating to places like Renfrew County. In contrast, programs like the one Jonathan launched have shown dramatic increases in access to comprehensive team-based primary care — just by tapping into available family doctors from other parts of Ontario. Doctors can work for the family health team without having to move their spouses, their children, and their lives to a remote part of the province.
And when the options for people without a family doctor are the hospital or nothing, a hybrid model with an off-site doctor who knows you, coupled with access to an in-person health team, is a really good option.
Jonathan Fitzsimmons VTAC has this local ability to help navigate patients as well — so it's not just a one-off phone call. You can go the next step: bring in some in-person care, combine community paramedicine, help navigate to other existing resources. And then ultimately, although our numbers are limited, we have this attachment arm through IVC, which — as I said — is permanent attachment to comprehensive team-based primary care with a named family physician.
Dr. Tara Kiran Here, Jonathan and I are contrasting the nonprofit, publicly delivered IVC model in Renfrew County with the type of episodic virtual care services provided by for-profit, shareholder-driven corporations that have become more common across Canada since the COVID-19 pandemic.
Jonathan Fitzsimmons A very different model. And I think the other key difference, of course, is that you're getting funding from the Ministry of Health to do this work, but all that funding is going directly into things that support patient care delivery. Nothing is going to profit — it's all going to the clinicians themselves.
The County of Renfrew is actually the fund holder. The funding comes from the Ontario government through Ontario Health to the County of Renfrew, and the emergency medical services and paramedic services are delivered through the County of Renfrew. So that governance structure ultimately goes up to the County of Renfrew.
Dr. Tara Kiran And I know there have been reports of upselling — sometimes when patients are given the opportunity to have a free appointment with a virtual service, they might be asked to also pay, say, to see a dietitian. That's not happening here, and there's no private pay option being upsold. And because you're a family health team, you have the same accountabilities as other family health teams — you have to report on quality metrics and deliver an annual report to the ministry.
Jonathan Fitzsimmons It's even more so than that, because we report as the family health team, but we also report as the IVC program separately. So we're doing additional reporting. We report formally to the Ministry of Health about what we're achieving through IVC, in addition to the regular family health team reporting. But we also have a really extensive evaluation programme. We've done both qualitative and quantitative research — looking at Ontario's population-level health databases to dig into the clinical and economic impact compared to other models of care, and also talking to patients and providers to evaluate their experience of this program.
We've published a number of papers, and we've got another couple currently in peer review. We want to be transparent. We're actually quite proud of what we've achieved, and we want to share it — to say, from a patient, a provider, and a funder perspective, this is a win-win-win scenario. It's not perfect, it's not for everyone, it's not the silver bullet.
Dr. Tara Kiran (53:37) But it's working really well for a significant number of people, and there is definitely scope for it to grow further.
Reflections
Dr. Tara Kiran (53:51) As we prepared this podcast, I was struck by how Jonathan and his team have developed something that aligns with what people told us they wanted to see through Our Care. People felt strongly that everyone should have a family doctor or nurse practitioner connected to a publicly funded team that provides both ongoing and timely care. They wanted virtual care as an option, but also felt it should be integrated with in-person care and used to improve equity in access. Specifically, they wanted to see virtual care being used to improve access to primary care in rural and remote areas.
The hybrid approach at Renfrew offers us a model that I think can and should be scaled in Canada. It offers virtual care with a named family doctor who gets to know you over time and can support the prevention, diagnosis, and care coordination that we know is so important in primary care. And if you need to be seen in person, you will be — by another member of the care team who uses the same chart as your family doctor and works alongside them. Not literally, but virtually.
That's a stark contrast to some of the other virtual services offered in Canada — services that I often think about as virtual walk-in clinics, oxymoron though I know that is. In a virtual walk-in clinic, you see a different remote doctor every time, they may not have access to your records, there's usually no option to be seen in person, and services are generally not designed to meet ongoing care needs. Studies we've done have shown that people who access this type of virtual walk-in service end up using the emergency department more than people who get virtual care from their own family doctor.
I really believe that an ongoing relationship with a family doctor who knows you is one of the secret sauces of good primary care. And I love that the Renfrew model has this at its core, and that it's leveraged the use of the broader team in a way that integrates virtual and in-person care. It's impressive that through this innovative model, they've been able to provide primary care to more than 6,000 people who previously had nothing.
Dr. Tara Kiran (56:10) Now, in my perfect world, people would have access to a family doctor who could see them both in person and virtually. And I should note that there are parallel initiatives to get to that ideal. In fact, over the last couple of years, the team has been successful in recruiting new family doctors to the health team — one of whom was a doctor trained in another country who, through a new practice-ready assessment program, received a quick path to licensure, as well as teaching and mentorship in the region, that ultimately led to them settling down and working there. Jonathan also mentioned they successfully recruited a local family doctor to the team, and part of the enticement was actually the hybrid program — knowing they could provide care both in person and virtually.
As challenging as the current situation is for so many people, it's good to know that there are good people out there making good things happen with their passion, energy, and creativity.
Credits and Closing
Primary Focus was created by Dr. Tara Kiran and is made possible by a grant from the St. Michael's Foundation. Maryam Danesh is our research coordinator. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca. And if you'd like to read more content from Dr. Kiran about Canada's primary care system, follow her on LinkedIn.
We'd really appreciate it if you could send this episode along to a friend or colleague. Don't forget to give us a follow on your favourite podcast app. We'd also love to hear ideas from you or comments about what you think of these episodes — email us at primaryfocus@unityhealth.to.
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The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.