SHAPING YOUR FUTURE DR. BRAD BAHLER PROVINCIAL MEDICAL DIRECTOR PCN EVOLUTION, AMA ACTT, CHAIR OF THE PRIMARY CARE ALLIANCE
LOOKING BACK TO LOOK FORWARD - PRACTICE IN SYLVAN LAKE – CIRCA 2003/2004 • Family Medicine Sylvan Lake - Hospital Medicine in Red Deer • Obstetrics • Long T erm Care + Palliative Care • Rural ER Locums • Clinical T eaching Site Coordinator Medical Students and Residents • My panel size at that time was 1750
Utilization by Attachment to a Family Doctor (probability of being in the top 5%)
Continuity vs. Cost by Clinical Risk Group
Mortality by Continuity of Care
EVERY SYSTEM IS DESIGNED PERFECTLY TO YIELD THE RESULTS IT GETS . . .
Primary Care Networks QI/Practice T eam Improvement Practice Personal Facilitation Agency
Primary Care Networks QI/Practice T eam Improvement Practice Personal Facilitation Agency
PRIMARY CARE NETWORKS IN ALBERTA Become Board Chair of Wolf Creek Primary Care • Network Started to experiment with different types of team • members and different roles and responsibilities – both clinical and non-clinical CDM Nurse, Panel Manager (MOA role), MH therapist, • MH liaison, Social Work, Improvement Facilitator, Dietician, Foot Care, Senior’s nurse, Pharmacist, Kinesiology, Home Care liaison, Public Health Integration Exposed leaders to quality improvement, practice • facilitation, supported physicians to make changes Networked physicians behind a common call to action and • started to combat isolation
PRIMARY CARE NETWORKS • Clinical resources Patie ient nt’s ’s Medic dical al Accou ount ntabl able & e & Home me Effec ectiv ive G e Gov over erna nanc nce • Practice Facilitation • Connection to Health Healt alth h Strong ong Nee eeds of of the he Neighbourhood Partnersh rships & s & Commu mmunity y Trans nsitions ions o of & Populat pulatio ion Care re
SCALING UP PATIENT’S MEDICAL HOME IMPLEMENTATION;
SCALING UP PRIMARY CARE TRANSFORMATION: majority Shifting in Early, visible Mass thinking at all win customization levels Focused efforts on Greater investment into a team-based, chronic workforce equipped to Policymakers, decision disease management support the early majority makers, leaders in the profession, frontline change agents
OLD PARADIGM VS. NEW “ The Old Paradigm” “The New Paradigm” • Single physician • Physician and T eam • One visit at a time (responsible • Responsible for patient for that visit only) panel/caseload (population) • Focus is acute and episodic • Focus on: • No measurement - continuity - Guidelines - optimizing visits - Outcomes • Same day access -Value (accountability) • Screening and surveillance • High return visit rates • Chronic disease management • Low continuity of care • Measures of process and outcomes • Follow up sporadic • Integration with specialty programs/medical specialists (service agreements) • Information systems and technology to support
NOTHING IN THIS WORLD COMES FOR FREE
KEY POINTS – HOW TO MAKE IT WORK • The Non-Clinical staff are JUST AS IF NOT MORE important to the success of implementing PCNs and team based care models (improvement facilitation and panel managers) • Be prepared that you will need to adjust your initial plans in terms of what your staff will do and what role they will fill (continuous improvement mindset) • Implement roles in a staged fashion whenever possible • This will be a paradigm shift for many practices and leaders must engage, engage, engage!
KEY POINTS – HOW TO MAKE IT WORK • Know the problem you are trying to solve and the outcomes you are looking for, but allow for maximum flexibility on the how (tight-loose-tight) • Provincial frameworks are very helpful to draw the “lines in the sand” around the problems and the outcomes, less useful in the “how” of implementation • Provincial Primary Care organizations must be on the same page • A true partnership between the health authority (AHS in Alberta) and PCNs essential
KEY POINTS – HOW TO MAKE IT WORK • You need strong change management supports do not underestimate – but the goal is to train clinics to be self sufficient – we call this training the trainer • Governance is important and all leaders should have training • Leadership is absolutely critical – create space to share and learn and find a way to support leaders with administrative support and mentorship • Include patient advisors at all levels of design and from the start
CAPACITY TO ENGAGE AND SPREAD CHANGE Phy hysi sici cian C n Cham hampi pions/ ons/Leader Leaders 476 476 455 455 230 230 152 152 57 57 34 34 10 10 2012 2013 2014 2015 2016 2017 2018
REMEMBER TO HAVE FUN!
WHAT A TEAM COULD DO . . . Sinusitis, URTI, Influenza, UTI, STI screening, treatment and HTN management, Medication Review, Opioid / Benzo • • counselling, vaginosis, PAP testing Tapering, Anti-coagulation starts, Chronic Pain Reviews/Management, De-prescribing 12 week prenatal, 1,6 week post-natal • Comprehensive geriatric assessments, Trails A+B, (DMED • Warts, lesion treatment (LN2) • screening), MMSE, MOCA, family interviews and liaison work Long T erm Care Management • All screening of every kind at every visit • Care Planning (CDM Care Plans), Advanced Care Planning • COPD management, Diabetes management, Smoking cessation, • (GOC) Weight loss Active Case Management (High Needs – First Contact) • Hyperlipidemia management, dietary consulting (IBS, picky • eaters (kids), pregnancy, weight) Post-hospital reviews and chart updates • Insurance form completion New patient reviews and updates • • Mild-Mod, Mod-Severe MH supports, Social Support Navigation Home Visits • •
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