Symposium)Report) Collaborating)on)aVision)for)Integrated ...€¦ · Figure!4!R!PMH!Vision!!)...

Symposium Report

Collaborating on a Vision for Integrated Family Practice in BC -‐ The Patient's Medical Home April 29, 2015

Acknowledgements The BC College of Family Physicians would like to thank the seventy-‐five individuals and organizations who participated in this daylong symposium including BC College of Family Physicians and College of Family Physicians of Canada members, BC Ministry of Health, patients, members of the General Practice Services Committee, health authorities, Doctors of BC, Society of General Practitioners, members from Divisions of Family Practice, UBC Continuing Professional Development, and allied health professionals. This broad range of perspectives led to rich discussion and foundational directions on which to move forward. We would also like to thank the very dedicated members of the BCCFP’s Patient’s Medical Home Committee and staff including: Dr. Lisa Gaede, Dr. Denise McLeod, Dr. Louise Nasmith, Dr. Christie Newton, Dr. Amy Weber, Toby Kirshin and Ian Tang.

Table of Contents

Page 1. Introduction 1

Symposium Objectives 1

Participants 1 2. Setting the Context 2

Policy Context 2

PMH Vision and Concept 2 PMH in Manitoba 4 PMH in Ontario 5

3. Potential Benefits and Opportunities for PMH in BC 6

Potential Benefits 6

Potential Opportunities 8 4. Directions and Priorities for Collaboration 10

Potential Directions and Actions 10

Priorities for Collaboration 12 5. Next Steps 13 Interest in Collaboration 13 Next Steps 13 6. Appendix A -‐ List of Participants 14

Patient's Medical Home Symposium Report 1

1. Introduction On April 29th, 2015 the BC College of Family Physicians hosted a symposium in Vancouver titled Collaborating on a Vision for Integrated Family Practice in BC. SYMPOSIUM OBJECTIVES The symposium was an opportunity to explore interest in collaborating on implementation of the Patient's Medical Home model in BC. The Patient's Medical Home is a model developed by the College of Family Physicians of Canada (CFPC) for a patient-‐centred family practice identified by its patients as the place that serves as the home base or central hub for the timely provision and coordination of all their health and medical care needs. The objectives of the symposium were to: • Build understanding of the Patient's Medical Home (PMH) vision and concept and its

application • Discuss the potential benefits and opportunities for implementing the PMH concept in BC • Identify directions of interest to participants that would advance implementation of the model • Identify priority directions and partners interested in collaborating on implementation • Discuss next steps for moving forward

PARTICIPANTS The symposium involved seventy-‐five participants from the groups shown in Figure 1 below. The diversity of participants reflected the goal of assessing interest among key stakeholders in working together to implement this model in way that best fits the provincial and community context in BC. A list of participants is provided in Appendix A of this report.

Figure 1 -‐ Overview of Symposium Participants


2. Setting the Context POLICY CONTEXT Mr. Doug Hughes, the Assistant Deputy Minister of Health provided background on the context for pursuing a new model for primary and community care in BC as part of the government's broader policy objectives of repositioning key aspects of the British Columbia health system. He outlined the overarching policy goals of ensuring quality and effective and efficient budget allocation and cost management. He presented a model that outlined the elements of the health care system that need to be in place and working as an effective system in order to achieve these goals. This model includes achieving meaningful health outcomes, understanding population health needs, service systems delivering services that meet population health needs, health human resources delivering effective and efficient services, IM/IT technologies and workplace infrastructure enabling effective and efficient service delivery, all underpinned by effective planning, governance, management, health professional and workforce accountability and engagement, and change management strategies. The Ministry policy discussion papers on repositioning key aspects of the health care system referenced can be found at the following link(s): -‐ Primary and Community Care in BC -‐ Future Directions for Surgical Services -‐ Rural Health Services -‐ BC Patient-‐Centered Care Framework -‐ A Provincial Strategy for Health Human Resources NATIONAL PMH VISION AND CONCEPT Dr. Rob Wedel, Vice-‐Chair of the College of Family Physicians of Canada's Patient's Medical Home Steering Committee and a family physician at the Taber Clinic in Alberta, gave an overview of the PMH vision and concept. The PMH concept is defined as a patient-‐centered family practice identified by its patients as the place that serves as the home base or central hub for the timely provision and coordination of all their health and medical care needs (see Figure 4).

Figure 4 -‐ PMH Vision

The emphasis of the model is the concept of a home, the patient's medical home. Patients receive care that is centred on their needs from a team that knows their story. Patient-‐centeredness is the first of the ten pillars that define the PMH model. The pillars also include a personal family physician, team-‐based care, timely access, comprehensive care, continuity, and a range system supports (see Figure 5).

Figure 5 -‐ Pillars of the PMH Model

The PMH model recognizes the need for engaging a broader network of health care providers, something described as "medical neighbourhoods". Medical neighbourhoods include access to and relationships with a wide range of health professionals, public health, community services, family supports, and private services; often unique to each community.


The key research findings underpinning the CFPC's development and endorsement of the PMH model include the positive impacts of the model on satisfaction with care, access to services, quality of care, mortality, cost-‐effectiveness, and service utilization. American and Canadian research demonstrates the additional value to the health care system of patients identifying with a particular practitioner, rather than just with a particular place, and that "physician connected patients" were more likely to receive guideline care. PMH IN MANITOBA Dr. Paul Sawchuk, a member of the CFPC's Patient's Medical Home Steering Committee, presented his experiences with implementing a PMH model in Manitoba. He characterized the Patient's Medical Home as perhaps the biggest initiative of this decade that will help the health care system work more effectively. He provided a comparison of two different PMH models:

Dimension

ACCESS River East

Concordia Clinic

Resources • 10 family physicians sharing 5 "salaried"

positions • 3 Nurse Practitioners and 5 primary care

nurses • Dietician • Four midwives • Two social workers and a full-‐time

counselor • 9 clerical staff and a full-‐time manager

• 5.6 EFT fee for service physicians • 4 clerical staff • 0.2 EFT mental health counselor • 0.1 EFT psychiatrist

Patient

Population

• 5,800 area residents • Highest need individuals in our area • Most patients referred from home care,

hospitals and other family physicians

• 12,000 -‐ 15,000 mostly suburban, middle class patients

Scope of Services

• Mental health counseling • Diabetes education class • Teen clinic • Hospital in-‐patient care • Low risk obstetrics • System navigation including housing,

programming

• Primary care • Hospital inpatient care • Mental health counseling


The Access River East model has been shown to reduce hospital bed days per patient per year by 60% for the highest 100 hospital bed users among its patient population. The data also showed that while large interdisciplinary teams are effective and result in reducing costs elsewhere in the health system when dealing with complex patients, it is more difficult to show cost savings for less complex patients. Key PMH success factors were outlined: • Assess the health care needs of your community • Differentiate between your patients' needs • Focus most resources on those patients with greatest needs • Keep your physicians engaged and build their sense of ownership • Invest in interdisciplinary team building (with lots of focus on having fun) and shared

decision-‐making • Important to work at both ends of one's scope of practice • Partner with others to meet community needs • Need to measure success • One size never fits all -‐ bottom-‐up leadership is the key to finding the right size that does fit

PMH IN ONTARIO Dr. Michael Green, a CFPC PMH Steering Committee member and Associate Professor in the Departments of Family Medicine and Public Health Sciences at Queen's University, gave a history of primary care reform in Ontario, described the features and uptake of different primary care models, and focused on the evaluation and impact of Family Health Teams (FHTs), which are the most common PMH model in Ontario. In Family Health Teams:

• Physicians must be in blended, capitated or salaried compensation models • Governance can be community or provider based • Additional funding is provided for programs, allied health, capital etc. • Individualized agreements are formed with each team • Numbers are limited based on funding allocation

Voluntary adoption of payment reforms was a tool that was used to support implementation of Family Health Teams and encourage Family Physicians to move away from fee-‐for-‐service


arrangements. In terms of governance, most FHTs are still under the direct control of the participating family physicians. Family Health Teams have an average of 15.2 physicians, 2.6 nurse practitioners, and 9.6 other independent health professionals in 2012 and offered a wide range of services. Patient satisfaction with the FHT model is significantly higher than among those in fee-‐for-‐service arrangements. Use of electronic health records has increased from 30% of GPs in 2004 to 78% in 2013 and includes all Family Health Teams. While structural and process improvements have occurred, there has been no overall improvement found in same or next day access to primary care at the provincial level and no overall improvement in FHTs vs. other models in access or overall patient experience. However, there have been some minor improvements documented in some process measures (e.g. cancer screening). It was acknowledged that FHTs are still relatively new and that it will take time to see results at a patient level. Community Health Centres, another PMH type model, perform best for some chronic disease management and overall patient experience. 3. Potential Benefits and Opportunities for PMH in BC POTENTIAL BENEFITS Participants identified the potential benefits of implementing the PMH model in BC. The results are shown below, organized by frequency of mention and by summary theme.

Benefits Theme Specific Benefits Mentioned

Comprehensive, integrated care for patients (9 mentions)

• More comprehensive and coordinated care for patients with complex core needs

• Integrated care plans for patients • Comprehensive services through team-‐based care delivery by an array of

health professionals • Reduced complexity for patients in navigating the health care system • Decreased burden on patients for coordinating their own care • PMH allows access in an integrated fashion to multiple providers who are co-‐

located (most responsible health care provider does not necessarily have to be the physician)



• Access to the most appropriate provider allows for best use of provider 's skills and knowledge

• Allows patients to see the right provider at the right time • Increased capacity to provide quality care

Cost effectiveness (7 mentions)

• Sustainable health care costs by reducing duplication, reducing use of less appropriate services (e.g. ER) and reducing competing treatments

• Reduced per capita cost for overall health system over time • Most appropriate use of resources • More cohesive system with less duplication and better cost effectiveness • Cost-‐effective system through improved alignment and use of resources • Productivity increased • Improved time allocation

Providers able to work to their full scope (5 mentions)

• Team members have opportunity to work to their full scope and focus on areas of interest

• Providers can work to their full scope and make use of their skills • All providers, including specialists, are able to work to their full scope of

practice • More attractive and rewarding model for recruitment and retention of

providers as they can work at full scope of practice • Increased capacity to provide quality care through providers being able to

work at the top of their scope of practice

Access to care (4 mentions)

• Improved access for patients in terms of geography, range of providers, timeliness, and getting the right care at the right time

• Improved access, better attachment to and matching with multiple providers for patients

• Increased opportunity for flexible hours will increase accessibility of care • Greater access to services

Improved satisfaction for both patients and providers (3 mentions)

• Increased patient and provider satisfaction • Improved patient and provider experience and satisfaction • Improved patient and provider experience

Improved health outcomes (2 mentions)

• Improved health outcomes for population • Improved health outcomes



Responsive, community-‐based care (2 mentions)

• Increases capacity for community-‐based primary care • Flexible model that can adapt and be responsive to the needs of the

community

Other (2 mentions)

• Co-‐design and ongoing governance of PMH with patients, community, and providers

• Able to incorporate social determinants of health in measurements of success

POTENTIAL OPPORTUNITIES The opportunities for implementing the PMH model in BC were also identified. The results are shown below, organized by frequency of mention and by theme. Opportunity Theme Specific Opportunities Mentioned

Frameworks for collaboration exist (7 mentions)

• Use existing organizational frameworks to develop model, share ideas and resources, support implementation and conduct evaluation

• GPSC visioning process about to begin • GP for Me enables community partners engagement, community needs

assessment, and innovative models of care • Divisions of Family Practice offer opportunities to discuss and try new ideas • Divisions of Family Practice provide a framework for collaboration • Can use Divisions of Family Practice to look at community and practice needs • Collaborative Services Committee can be a vehicle for collaboration among

family physicians, other providers and the community

Innovation and change (5 mentions)

• Increased opportunities for innovation and to deliver care in a culturally sensitive way

• Younger physicians are ready to embrace this type of model • Cultural changes taking place in communities and among providers creating

openness to this type of model • Increased opportunities for innovation • Continuous quality improvement in practices and care


Opportunity Theme Specific Opportunities Mentioned

Community and population-‐based approaches and engagement (5 mentions)

• Increased community interest in customized, local primary care models that work best for the attributes of the local patient population

• Involve the community in the planning of the care delivery system • Work with specific populations and communities to develop the PMH • Capitalize on opportunities that already exist in the community and further

strengthen community relationships • Population-‐based health information technology exists

Team-‐based care (4 mentions)

• Increased shared care models with multiple specialties and allied health providers

• Ministry focus on team-‐based care • People are being trained and want to work in teams • Lots of acknowledgement of teams

Education and learning from others (4 mentions)

• Shared learning among multiple providers will improve efficiency and effectiveness of care

• Learn from other jurisdictions and what was done • Teach students and residents about this model and how it works • Have an opportunity to develop a diversity of models so that we can learn

Ministry policy • Ministry policy changes align with desire by health care groups to make meaningful reforms to primary care

• Ministry of Health policy papers suggest there is the will to make changes

Patient involvement (2 mentions)

• GP for Me and the general environment have enabled increased patient involvement in primary care reform

• Increased involvement of patients enhances practice capacity

Other (2 mentions)

• Creation of common language/terminology • Reset the relative value of primary care services versus specialized services


4. Directions and Priorities for Collaboration Based on the described benefits and opportunities, participants recommended actions that could be taken to move the Patients' Medical Home model forward in BC. Thirty-‐three actions were identified and categorized into seven potential directions:

Potential Directions Specific Actions Mentioned

1. Develop alignment around the vision across sectors

• Align the current strategic planning processes going on within various groups (e.g. the Ministry of Health, Doctors of BC, GPSC etc.) to create a shared vision for primary care

• Develop inter-‐sector agreement on the principles and goals of the PMH as the foundation for primary care delivery

• Promote use of common language and a common set of principles and achieve explicit endorsement of the PMH concept by all stakeholders to create co-‐ownership, not just buy-‐in

2. Develop a change framework and implementation plan that is used across the province

• Provide engagement, support and training to the community, health care providers, and government stakeholders to develop and sustain PMH primary care models for their communities

• Establish project leads to plan the design of the PMH, engage communities, and implement a business focused customer model of patient centered care using a common change management framework

• Engage in a step-‐wise change process 1. Determine what patient population we are trying to serve 2. Identify core and peripheral team members needed 3. Reflect on how services are best delivered 4. Incorporate training needs for upcoming physicians and

other providers

3. Develop innovative models/prototypes with evaluation metrics that build on existing data and share them across the province

• Learn from the GP for Me initiative and how to sustain the momentum and relationships that this process of community engagement has created

• Evaluate and learn what works and what doesn't from existing prototypes in BC

• Test and try several different prototype PMH models in different communities

• Encourage a diversity of models by requiring that certain core



elements be present without mandating the specifics of how they must be designed or operate

• Increase the emphasis on evaluation to help guide decision-‐making as we develop the Primary/Community Care Policy Framework

• Define and develop an evaluation process that is based on agreed upon indicators of success

• Test out different innovative models such as intermittent co-‐location for team-‐based care, virtual multi-‐disciplinary teams, and co-‐located services where high needs patients are geographically concentrated

• Develop functional governance models and other mechanisms for citizen and patient input

• Develop the PMH based on the patient-‐family physician relationship and determine which allied health care providers are needed based on community/panel needs assessment

• Determine what services patients need and what provider can provide them with the best quality care

4. Develop a business model that considers a variety of funding sources to support the model

• Review funding framework options and their impact on health outcomes, patient experience and financial sustainability

• Change the funding system so that it supports personalized patient care including community support, healthcare collaborations etc.

• Redirect current funding for separate health care services in an innovative model that supports physicians and other providers to work together, ideally under one roof

• Develop a comprehensive funding model that supports the preferred model while recognizing specific contexts and requires the right stakeholders to be involved

• Develop a business model that supports the development of the multi-‐disciplinary team, addresses current barriers, and is supported by human resource planning

• Provide Ministry policy direction and funding models • Decentralize targeted Health Authority clinical resources to the

Divisions to allocate equitable across the patient population



5. Determine the information management/information technology requirements to support the PMH provincially

• Identify the infrastructure needs of the PMH and develop a plan to address these needs, including, but not limited to, the facilitation of IT interoperability

• Create a robust communication system between different levels of care and require interoperability of healthcare records so that primary care workers are aware of the patient's journey

6. Establish and support 'PMH tables' at various levels (provincial, regional, local) with relevant stakeholders

• Begin a collaborative, inclusive, community-‐oriented needs and readiness assessment process

• Create a PMH table to bring all relevant stakeholders together in the community (community specific) to move the model forward

• Develop medical neighbourhood relationships (volunteers, MOA, NGOs etc.)

• Approach Health Authorities to discuss PMHs for the community • Embed patient voices in all levels of system design, change

implementation, and governance • Engage a broader audience of community-‐based services (not

just health care providers and patients) including transportation, housekeeping, childcare etc.) to achieve improved horizontal integration

7. Determine infrastructure needs and opportunities

• Partner with communities and local governments to find innovative ways to use/build on existing spaces to use as facilities for PMHs

PRIORITIES FOR COLLABORATION The seven potential directions were prioritized by participants; ranked highest to lowest below:

Potential Directions

Votes

Develop a business model that considers a variety of funding sources to support the model

45

Develop alignment around the vision across sectors 44

Develop innovative models/proto-‐types with evaluation metrics that build on existing data and share them across the province

34


Develop a change framework and implementation plan that is used across the province

25

Establish and support 'PMH tables' at various levels (provincial, regional, local) with relevant stakeholders

17

Determine infrastructure needs and opportunities

13

Determine the information management/information technology requirements to support the PMH provincially

11

5. Next Steps COLLABORATION AND NEXT STEPS Participants were asked to indicate their interest in building on the work of the day and collaborating on the three priority directions that were identified. As a next step, the BC College of Family Physicians will invite interested individuals/ organizations to reconvene and to discuss roles, leadership, strategies and resources to support collaboration to develop: • Alignment around the vision across sectors • A business model that considers a variety of funding sources to support the model • Innovative models/prototypes with evaluation metrics that build on existing data and share

them across the province

The BC College of Family Physicians is looking forward to working together to support a patient-‐centred, high performing and sustainable health system in British Columbia.


Appendix A -‐ List of Participants Mark Armitage Ministry of Health Jeff Malmgren Doctors of BC Mary Augustine Division of Family Practice Ed Martin Patient Tom Bailey Family Physician Nora Martin Patient Peter Barnsdale Family Physician Zak Matieschyn Allied Professional Georgia Bekiou Doctors of BC Garey Mazowita Family Physician Curtis Bell Health Authority Annette McCall Family Physician Doug Blackie Ministry of Health Sandi McCreight Patient Jeanette Boyd Family Physician Katharine McKeen Family Physician Eric Bringsli Ministry of Health Patricia Mirwaldt Family Physician Dean Brown Family Physician Tracy Monk Family Physician Ken Burns Family Physician Richard Moody Family Physician Carolyn Canfield Patient Louise Nasmith Family Physician Ernie Chang Family Physician Christie Newton Family Physician Jean Clarke Family Physician Colleen O'Neil Patient Cathy Clelland Family Physician Shana Ooms Ministry of Health Marjorie Docherty Family Physician Carol Park Health Authority Fiona Duncan Family Physician Robin Patyal UBC Resident Dewey Evans Family Physician Parkash Ragsdale Allied Professional Mitchell Fagan Family Physician Elizabeth Rhoades Family Physician Karen Forgie Family Physician Shelley Ross Family Physician Lisa Gaede Family Physician Michael Rowland Facilitator Mike Green Family Physician Kuljit Sajjan Family Physician Brenda Hefford Family Physician Paul Sawchuk Family Physician Khati Hendry Family Physician Wendy Scott Patient Katie Hill Doctors of BC John Sherber Patient Dan Horvat Family Physician Dana Sibley Division of Family Practice Doug Hughes Ministry of Health Leora Simon Patient Toby Kirshin BCCFP Gina Sloan Health Authority Gayle Klammer Family Physician Shirley Sze Family Physician Kerri-‐Michele Larson-‐Mandick Patient Yvonne Taylor Health Authority Selena Lawrie Family Physician Helen Thi Doctors of BC Ann Li UBC Medical Student George Watson Family Physician Rebecca Lindley Family Physician Rob Wedel Family Physician Sandra Loeppky Patient Lawrence Welsh Family Physician Linda Low Ministry of Health Leo Wong Family Physician Elaine Lowes Health Authority Joanne Young Family Physician Jillian Lusina Family Physician Peter Zed Allied Professional Brenna Lynn UBC CPD

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