Complex Care Management Project
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Transcript of Complex Care Management Project
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Complex Care Management Project
Rapid Fire Session B6 Reaching Out: Proactive Approaches to Primary Care
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Hello from Vancouver’s North Shore! • Dr. Joanne Larsen, Family Physician, Practice Management
Working Group Chair
• Candace Travis, Practice Support Program Coordinator, Vancouver Coastal Health
• Claire Doherty, Project Lead, North Shore Division of Family Practice
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Disclosure
Nothing to disclose.
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Aims
•Strengthen patient-physician relationship
•Improve office efficiency
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Context •Working Group funded by A GP for Me
•Partners: • Practice Support Program – Vancouver Coastal Health
• North Shore Division of Family Practice
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Complex Care Incentive Fees
•14033 for patients with 2+ chronic diseases
•14075 for patients with frailty level 6 or 7
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Strategies •Created chronic disease registries
•Implemented process to recall patients
•Set reminders for incentive fee due dates
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Process
Baseline data Registries Visits and
billings Sustainability
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Results
Indicator Maximum Average
Newly identified complex care patients 76 14
Increase in complex care and chronic disease management billings
$13,860 $5,623
Increase in accuracy of patient registries
52% 13%
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Lessons Learned
•Every practice was different
•Different “aha” moments
•Staff engagement
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Challenges
•Time commitment
•Reluctance to change
•Technical difficulties
•Sustainability
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Feedback Loop
•Assumptions
•Quotes
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Next Steps • Patient Medical Home and Primary Care Home
• Other patient populations
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Thank you for listening!
Any questions?
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For more information, contact:
Claire Doherty, Project Lead, North Shore Division of Family Practice