2015 Quality Forum, Hyatt Regency Vancouver

A4 Opening Doors to Primary Care

Serving North Vancouver’s High-Needs, Unattached

Patients through an Innovative Model of

Primary Care: HealthConnection Clinic

Authors: Sarte, A., Edelman, S., Brown, D., Turris, S., Macnutt, J., Simpson, D.

Presenter: Sandra Edelman, ManagerPublic Health, Population Health & Chronic Disease Services

Vancouver Coastal Health, North Shore

Disclosure Statement

I am unable to identify any actual or potential conflict of interest and have nothing to disclose

in relation to this presentation.

Background

individuals on the North Shore do not have regular access to primary care (i.e.,

“unattached”) and are deemed to have “high-needs”

3,000

True Collaboration

Vancouver Coastal HealthDivision of Family PracticeCommunity PartnersPractice Support ProgramPractice Support Program – Technology

Group

To improve the health & wellness of vulnerable pop’ns

To provide better care coordination & health care utilization

To increase attachment to family physicians

To improve patients & providers experience

To plan for sustain-ability

HealthConnection Clinic Goals

Clinic Operations

Open 9AM to 12NoonMonday to Friday

Location: 148 E. 15th Street (close to Lions Gate Hospital)

• Staffed by GP, NP, Case Manager (SW), CDN, MOA

• Community Partners regularly scheduled to sit in clinic: – Hollyburn Family Services– Lookout Society– Canadian Mental Health

Association

Unique Features of the Clinic• Partnership between Division of Family

Practice & Vancouver Coastal Health• Engagement of community partners• Built on Triple Aim Evaluation Model• Use of a Patient Complexity Assessment

Tool (attachment, medical, mental health & addictions & social determinants of health)

• Training opportunities for medical students, residents (e.g., social work, psychiatry, family medicine, nurse practitioners)

Evaluation Approach

• Ongoing evaluation to determine the feasibility and value of the clinic and to idenitfy successes, challenges, and lessons learned

• Guiding principles of evaluation: 1. Participatory2. Utilization-focused3. Synergistic4. Developmental

18-month evaluation results

Data current to December 15, 2014

Who are we seeing?

Client Gender

38.2% 61.8%

Client Age

Average age of client

Client ages range from 2-92 yearsMedian age is 50.5 years

49.5years

Client Housing

of clients have an unstable housing situation (i.e., homeless, staying in shelter, with a friend, or in a

collective dwelling)

39.7%

Aboriginal/First Nations

of clients are Aboriginal/First Nations

18.3%

Referral Sources

Lookout Shelter/Outreach

Emergency Department/Hospital

Family/Friend/Self

GP Referral

Mental Health Program

Multicultural Society0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

44.1%

16.0% 16.0%

8.0% 8.0%4.3%

Total visits since clinic opened

2010Total Visits

350 were new visits(17.4%)

1661 were follow up visits(82.6%)

As of December 15, 2014

Average Number of Visits per Day since Clinic opened

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 770

1

2

3

4

5

6

7

8

9

10

11

Average number of clients per day by week Target number of visits per day Median number of visits per day

Year 2 Begins

Profile of Attached Clients

Average number of visits 8

Minimum number of visits 2

Maximum number of visits 55

Based on 184 who have had two visits or more, i.e. ‘attached’

What services are our clients using?Health Utilization Data

Important Considerations

• ONLY clients with 2 visits or more have been included in the analysis (89 clients)

• ALL clients have been a part of the clinic for a FULL 12 months

• Analyzed by 12 months before first clinic visit, and the time since that visit

• Data is current to January 7th, 2015• Most conservative way to analyze our data

Summary of Health Utilization

22.0%

39.2%

2.6%

Decrease in Hospital Admissions

Slight increase in Emergency Department Visits*

Decrease in Hospital Admissions from the ED

*85% of ED visits occurred when the clinic was closed. Time spent in ED has decreased (7.7 hrs to 4.6 hrs)

Percentage of Alternative Level of Care Days

22

8.8% 5.8%

12 months before 1st clinic visit 12 months after 1st clinic visit*

*see notes section of slide

Increasing Primary Care Capacity

Acute costs

23

Increasing Capacity in Acute

24

What are our clients saying?

Client Interview Results

“It’s very good. It seems to provide a service for those who struggle to fit

in the mainstream system which requires you to advocate strongly for

yourself.”

- Client

“This has been excellent. I’ve had more medical care here than I care

to shake a stick at. It’s been one thing after another. Some small

things, and some big issues with me too. It’s been great. [The NP] is

extremely knowledgeable and right on top of things.”

- Client

27

What are our providers saying?

Memorable Case Studies

“A homeless gentleman with stage 4 cancer was met at the clinic by Outreach. When

discovered that he did not have a place to stay, he was secured a bed at the Lookout shelter. Outreach continues to support this gentleman with getting to the clinic regularly and chemo

treatments at LGH.”- Survey Respondent

“A client was referred by a community agency. He was a low income and isolated senior. He

was reluctant to go to the clinic but had experienced several falls. After meeting the

healthcare professional, he became increasingly comfortable and now sees the

clinic regularly.”

- Survey Respondent

“One of our first patients is a physically disabled man hugely addicted but wanting to get off

meds. Over the course of time, we have developed a trusting working relationship with

him, he is doing much better, and it is very gratifying. “

- Survey Respondent

Learnings | Next Steps• Value of a collaborative approach• Importance of identifying & addressing medical and

social needs (e.g., housing, poverty) of clients to improve health outcomes over long-term

• Ongoing evaluation is key to early success & helps to clarify priorities & identify opportunities for improvement

• Sustainability & clinic growth– Division of Family Practice’s A GP for Me Strategy – Home visiting component to support frail elderly & other

vulnerable groups unable to access services at the clinic– Implementation of EMR

Contact Information

Sandra Edelmane. Sandra.Edelman@vch.ca

p. 604 904-6453f. 604 904-6470

www.healthconnectbc.ca