Primary Care PanoramaA 360 Degree Look at Primary Care

2015 Quality Forum

Dr. Bill Cavers- President, Doctors of BCDr. Brenda Hefford- ED,Practice Support and Quality, Doctors of BCShana Ooms, Director, Primary Health Care,Ministry of HealthPetra Pardy- ED Primary Care, Fraser Health

Evidence for benefits of Primary Care:

“… helps prevent illness and death, regardless of whether

the care is characterized by supply of primary care

physicians, a relationship with a source of primary care,

or the receipt of important features of primary care…

associated with a more equitable distribution of health in

populations.” - Barbara Starfield (2005)

“…available evidence confirms improved population

health outcomes and equity, more appropriate

utilization of services, user satisfaction and lower costs

in health systems with a strong primary care

orientation.”

Atun R (2004) What are the advantages and disadvantages of

restructuring a health care system to be more focused on primary care

services? Copenhagen, WHO Regional Office for Europe

Primary Health Care Charter

“Family physicians are the cornerstone of Primary Health Care.

They are part of a broader community network and professional team…”

www.gpscbc.ca

• Ministry of Health Services + Doctors of BC

• Operational rather than structural solutions

• Input from Health Authorities

• Responsible for:

- Care incentives (fee codes)

- Practice Support Program (PSP)

- Divisions of Family Practice

- A GP for Me

“Finding solutions to support and sustain full service

family practice in British Columbia”

General Practice Services Committee (GPSC)

www.gpscbc.ca

Experience of Care

Improved Experiences for Patients and

Providers

Per Capita Cost

More Sustainable Health Care System

Population Health

Improved Healthof the Population

Triple Aim

www.gpscbc.ca

• Chronic Disease Management (CDM)

• Conferencing fees

• Complex Care Initiative

• Maternity Network Initiative

• Mental Health Initiative

Family Practice Incentive Program

Evidence from BC

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“…the more higher-care-needs

patients were attached to a primary

care practice, the lower the costs

were for the overall health care

system (for the total of medical

services, hospital services, and

drugs).

The majority of the cost reductions

stemmed from decreases in the

costs of hospital services.”

- Marcus Hollander

Healthcare Quarterly, Vol 12 no 4, 2009

Learning modules:

• Advanced Access/Office Efficiency, Group Medical Visits, Practice Self-Assessment

• Adult Mental Health

• Child and Youth Mental Health

• Chronic Disease Management

• End of Life

• Advanced Care Planning

• Shared Care - COPD/Heart Failure

Practice Coaching

Practice Support Program

• Formed in 2006 (PMA)

• Mandate to provide funding and project support to family

physicians and specialist physicians to improve the flow of patient

care from primary to specialist services.

• Works closely with the other collaborative committees; the GPSC

and SSC

• has helped more than 2,500 family physicians and 240 specialist

physicians to work together on over 240 projects across BC.

www.sharedcarebc.ca

Shared Care Committee

• Partners in Care (PIC)

• Transitions in Care (TIC)

• Polypharmacy

• Rapid Access to Psychiatry

• Teledermatology

• Youth Transitions

• Child and Youth Mental Health Collaborative (CYMHC)

www.sharedcarebc.ca

Shared Care Committee

• Improve patient care

• Increase family physicians’ influence on

health care delivery and policy

• Provide professional satisfaction for

physicians

www.divisionsbc.ca

Doctors of BC

MoHMinistry of Health

PMAPhysician Master

Agreement

GPSCGeneral Practice

Services Committee

DoFPDivisions of Family

Practice

Divisions of Family Practice was founded to:

Local Divisions of Family Practice are community-based groups of family physicians working together to achieve common health care goals.

A new way of working together

GP

Doctors of BC

Health Authorities

GP

GP

GP

GP

GP

MoH

Divisions

HealthAuthority

Doctors of BC

Municipalities Community Groups Non-profit Societies

Results

Divisions of Family Practice Growth 2009 to current

14

5

17

8

31

0

5

10

15

20

25

30

35

40

2009 2010 2011 2012 2013 2014

Existing Divisions New Divisions

22

30

33 34 34

5

22

30 33

Promoting Clinical Integration Through Collaborative Services Committees

Chilliwack Primary Care Seniors Clinic

Home Health Integration in White Rock-South Surrey

Residential Care Program in South Okanagan Similkameen

Attachment Initiative: Three prototype communities

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A province-wide initiative funded jointly by Doctors of BC and the Government of BC to strengthen the primary care system

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Goals of A GP for Me

• Enable patients who want a family

physician to find one

• Strengthen and support the family doctor

- patient continuous relationship, including

better support for vulnerable patients

• Increase capacity of the primary health

care system

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Multi-pronged approach

1. Physician practice level incentive fees

2. Community patient attachment strategies

through Divisions of Family Practice

3. Integration, alignment, and leveraging of

existing health authority, ministry, joint clinical

committees, and partner initiatives, programs and

policies

4. Patient and public engagement and education

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Practice Level - attachment incentives

Four new family physician fees.The fees are for:

• Attaching unattached patients with complex health needs;

• Managing the care of frail patients;

• Providing patient care over the telephone for all patients;

• Conducting conferences with other health care providers for all patients.

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Practice level results to date*

3,101 family physicians have ‘signed-up’ to participate in A GP for Me locally via their Division of Family Practice.

• 75% of full service family physicians.

More than 415,000 patients have received attachment related services

$31.0 million has been paid for these services

*Based on services from April 1, 2013 to

December 31, 2014, paid to December 31, 2014

Community supports:Local divisions of family practice

$40 million over three years to:

• Engage and assess: community and patient needs, local family doctor needs, strengths and gaps in local primary care resources

• Develop and implement community plans for improving local primary care capacity, including finding doctors for patients who want one

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Principles and Funding Parameters

1. Contribution to A GP for me Goals

2. Patient Centred

3. Accountable

4. Quality Improvement Oriented

5. Locally based and community developed

6. Collaborative

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Principles and Funding Parameters

7. Aligned with regional and provincial

strategies and initiatives

8. Contribute to integration

9. Comprehensive (promoting generalism and

full scope of practice)

10. Sustainable

• www.divisionsbc.ca; http://agpforme.ca/; www.gpscbc.ca/attachment-initiative

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Key Community Strategies

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• Physician retention and recruitment

• Practice Efficiency and Clinical Improvement

Supports

• Inter-professional team based care

• Public Education and Health Promotion

• Attachment mechanism

Community level results to date

1

10

20

3

0

5

10

15

20

25

Not Interested Assessment and PlanningPhase

Implementation Phase Sustainability Phase

Divisions' Participation in Attachment - Jan 2015

Planning and

AssessmentImplementation Total

Expenditure as of

December 2014$10,746,231 $7,832,000 $18,578,231

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Integrate and Navigate Primary and Community Care - Supporting Frail Seniors

1. Creation of meaningful connections between clients’ GPs and case managers.

2. The expansion of the care management team to include a Surveillance Nurse (SN) and a client services assistant (CSA) .

3. Incorporation of the CARE Management approach into daily practice by Case Managers and the SN

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Progress to Date

Integration Achievements 2010 -2014

Completed Potential

1. # HH Offices with Surveillance Nurse Implemented

12 12

2. # HH Offices with Client Services Assistant Implemented

12 12

3. # Divisions of Family Practice connected to HH offices

10 10

4. # GPs engaged across all communities 405 405

5. # Home Health Long Term clients impacted - 10,015

6. # Clients with the Surveillance Nurse - 2,500

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Impact of the Surveillance Nurse on Client Outcomes

Clients with the Surveillance Nurse (SN) are 3.2 times more likely to survive in the community than clients not with the SN.

Clients who are with the SN and who are contacted more frequently by the SN, survive for longer in the community.

A CARE Management approach appears to delay death or transition to AL /RC.

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Survival In the Community(SN vs non-SN clients, N=590)

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Survival In the Community

(Total N= 954)

Clients who were seen less

frequently by SN

( who had 1 or 2 RVs n=408)

Clients who were seen more

frequently by SN

( who had 3 or more RVs n=546)

Days between initial call from SN to any adverse event (AL, RC or Death)

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Added Value & Impact

1. Case Manager – GP Connections:

“This is the missing link..” Surrey Case Manager

“I met (Case Manager) last week. It was one of the most productive 20 minutes I’ve spent in medicine. She had a list of my patients on her books. We decided on the best way to contact each other quickly…(This initiative) is a wonderful positive example of the new relationship between MOH, BCMA & HA’s. When something is so right for your patients, it’s obvious” Dr. Ralph Jones (Chilliwack Family Physician / President, SGP)

“Very efficient use of my time, a no-brainer.” Dr. Robert Hepburn, Surrey Family Physician

Success Factors

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Relationships• Doctor/ patient

• Members of the health care team

• GPs and specialists, multi-disciplinary providers, system planners, administrators, community

• Patients and families, as partners

Orca Pod Pacific Coast, British Columbia

Success factors

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Shared Perspectives

• Shared vision

• Common ground

• Flexibility, adaptable

• Bottom-up

• Stimulating for all

It is not the answer that enlightens, but the question.Eugene Ionesco Decouvertes British Columbia

Coastal Rain Forest

“”

Success Factors

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Annual Polar Bear Swim,

Pacific Coast, British ColumbiaPhoto: Mark Klotz, Vancouver, BC

Courage

• Unfamiliar territory

• Letting go of old ways

• Okay to fail and learn

• Trust in the process

• Open to new possibilities

If you want to travel fast, travel alone.

If you want to travel far, travel together.

“

”

West Coast Trail,Vancouver Island, British Columbia

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An initiative of the GPSC, funded by Doctors of BC and the Government of BC

Thank you!