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February 20, 2015Ken Becotte, Executive Director Chilliwack Division of Family PracticeSarah Metcalfe, Program DeveloperFraser Health Older Adult Program

PCSC Primary Care Seniors ClinicChilliwack

Improving Access through Integration

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The speakers do not have any affiliations to disclose

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Introduction

Chilliwack Primary Care Seniors Clinic (PCSC)

Key part of Integrated Health Networks (IHN)/ Integrated Primary and Community Care (IPCC)

Innovative partnership co-operated by Fraser Health and Chilliwack Division of Family Practice

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Integrated Health Network

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Context

Fraser East (Chilliwack, Agassiz-Harrison, Hope)

Target population: frail seniors

Few specialized geriatric services

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Issue

Collaborative working group, comprehensive needs assessment and patient journey mapping

Scarcity of specialized resourcesBarriers to accessLow dementia prevalence rates (diagnosis)

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Intervention

Innovative “one-stop shop” clinical model

Comprehensive primary care geriatric assessments Additional support of nursing and specialists

Key objective: to improve access, coordination and integration of specialized geriatric care

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PCSC Clinical Service ModelIntake

Link patient to community resources and back to GP

Triage

Geriatric Medicine

GeriatricPsychiatry

Primary Care Geriatrics

Interdisciplinary Team

75%

25 %

Integrated Care Plan

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Service Philosophy

Integrated and provided collaboratively between interdisciplinary team members

Patients and family actively participate in the development of the Health Improvement Plan

Enhance geriatric knowledge, skills, and competencies for the interdisciplinary team in the community to support patients and their families

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Clinic Features

Operates 1.5 days per week Referrals from multiple sources GP and NP services Specialist services Registered nurse Mental health clinician

Primary Care Seniors Clinic entrance (Chilliwack General Hospital)

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Governance Model

Joint Steering Committee

Defines and makes recommendations on evaluation, sustainability, evolution/growth, resource allocation, and operational decisions that require escalation to that level

Oversees the well-being of the Clinic; responsible for problem solvingResource requests go through formal

channels for both FH and the CDoFP board

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Measurement & Evaluation

Patient and family/caregiver satisfaction questionnaire

Quarterly metrics and operations reporting

Pre/post analysis of acute care utilization

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HighlightsSatisfaction

QuestionnaireOperations Reporting

Acute Care Utilization

Majority agreed: PCSC took concerns seriously and “all of the services I needed right now” were available

1,474 patient visits (as of Jan 29, 2015)

Pre/post analysis of ED and acute admissions

82% very or mostly satisfied with experience

Year-over-year increases in volume

PCSC patients with ED visit declined 76% to 73%

Skills and knowledge of SSC staff met or exceeded expectations

391 unique patients (as of Nov 6, 2014)

PCSC patients with acute admission decline from 46% to 41%

Patient feedback included QI ideas for PCSC services

Majority patients from Chilliwack; others from ~7 surrounding communities

Average number of acute admissions per patient decrease from 0.91 to 0.72

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Key Learnings Multiple partners three systems of EMR

Ongoing engagement

Space allocation and capacity for growth

Dynamic decision-making

Sustained on collaboration and resource inputs from many partners

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Thank you

Ken BecotteExecutive DirectorChilliwack Division of Family Practicekbecotte@divisionsbc.ca

Sarah MetcalfeProgram DeveloperOlder Adult ProgramFraser Health Authoritysarah.metcalfe@fraserhealth.ca

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