conference abstracts apcc... · oral presentation 6 jasneet parmar, mbbs, dipcoe inventories of...

November 28–29

2016EDMONTON, ALBERTA

ConferenceAbstracts

Edmonton, Alberta — Nov. 28-29 — A B S T R A C T B O O K L E T — 2 0 1 6 Accelerating Primary Care Conference

PEOPLE

1 Carolyn Nowry, MD CCFP“Quality Street”- using a process improvement approach to maximize the value of patients’ time during attendance at an academic Family Medicine clinic.POSTER PRESENTATION

2 Sudha Koppula, BSc (Hons), MD, MClSc, CCFP, FCFPWhere Are We Now? Using Health Quality Council of Alberta Data for Improvement Work at an Academic ClinicORAL PRESENTATION

3 Debra Paches, BScN, RN, GNCC The Caregiver Experience - Recognizing Caregiver Needs to Support them in their JourneyORAL PRESENTATION

4 Jasneet Parmar, MBBS, DipCOE Discovery Toolkit for Family Caregivers of Seniors: Facilitating Conversations and Scholarship ORAL PRESENTATION

5 Jasneet Parmar, MBBS, DipCOE Screening for Stress and Burden in Caregivers of Seniors: Screening Assessment Tools ORAL PRESENTATION

6 Jasneet Parmar, MBBS, DipCOE Inventories of Resources and Supports for Caregivers in AlbertaORAL PRESENTATION

7 Krystin Minns, LPN, CDE, Team Lead - Clinical Programs Breaking Down Barriers: Benefits of our Medical Health Home POSTER PRESENTATION

8 Peter Rymkiewicz, MSc Bcomm, Director of Measurement and Evaluation, Mosaic PCN We Care for Our Patients but Do We Understand Them: Impact of Patient Activation on Program EvaluationPOSTER PRESENTATION

9 Shannon Sim, (4th Honors Undergraduate Student) Balancing Perspectives: An Exploration of Patient and Team Perception of Clinical Service QualityPOSTER PRESENTATION

10 Sophie Piroozfar, MSc, BSc, Information Analyst The South Calgary PCN’s Happiness Project – The Next Chapter ORAL PRESENTATION

11 Ping Mason-Lai, BA, MA Engaging the voices that matter: Depression Research Priority Setting ORAL PRESENTATION

12 Oliver Schmid, PhD Using Information to gain better insights into our PatientsORAL PRESENTATION

13 Oliver Schmid, PhD Time 2 Doc: Engaging with our Patients through mobile apps to keep them out of Emergency RoomsORAL PRESENTATION

14 Elaine Wilson, Eimear Ryan and Dr Van NguyenCUPS Coordinated Care Team: Transitional Support For Vulnerable Calgarians With Complex Needs POSTER PRESENTATION

Abstract Table of Contents


PATIENTS

15 Jane Schlosser MPHEvaluation of the Frail Elderly Outreach ProgramPOSTER PRESENTATION

16 Marsha Kucera, BSc, MD, CCFPImplementation of the Alberta Screening and Prevention Program at Sunridge Family Medicine Teaching CentreORAL & POSTER PRESENTATION

17 Jeff Decker, Tobias Gelber, MD Providing Primary Care Clinics with User Friendly Access to Comprehensive Patient DataPOSTER PRESENTATION

18 Tasha Stainbrook, LPN Implementation of Alberta Screening and Prevention project: preliminary reportPOSTER PRESENTATION

19 Lawrence J. Lee Assessing Panel Size in Academic Teaching Clinics POSTER PRESENTATION

20 Maeve O’Beirne, PhD, MD, FCFP Developing a PREM for Primary Care: cognitive interviewing POSTER PRESENTATION

21 Maeve O’Beirne, PhD, MD, FCFPImplementing Quarterly Clinical Metrics in the Department of Family MedicinePOSTER PRESENTATION

22 Cheryl Andres, BN, MScRelational Continuity: A Concept AnalysisPOSTER PRESENTATION

23 Dr Sonika Kainth, R2, Dr Anna Zhang, R2Advance care planning in primary care: examining barriers and facilitators at Sunridge Medical Teaching Centre POSTER PRESENTATION

24 Alvin Yapp, BSc Clinician Activity Tracking: Lessons for ImprovementORAL & POSTER PRESENTATION

25 Alvin Yapp, BSc Experiences of Measuring Patient Experience POSTER PRESENTATION

26 Margo Schmitt-Boshnick, BA, MEd, Moving to the Medical Home: Patients, Physicians and Panel Managers ORAL PRESENTATION

27 Lisa L. Cook, PhD The Value of Measuring Access from the Perspective of Early Adoptersp ORAL PRESENTATION

28 Agnes Dallison, MSc, CE Measuring the Impact of Research Support Services in an Academic Medicine Department Using the Boyer Model of Scholarship ORAL & POSTER PRESENTATION

29 Agnes Dallison, MSc, CEMaking Scholarly Activity Accessible to the Public: Moving the Importance of Public Availability from “Nah” to “Now”ORAL & POSTER PRESENTATION

30 Carol Cullingham, MA, BA, BSc Making Mosaic PCN Accountable to its Member Physicians and their PatientsORAL, POSTER & PANEL PRESENTATION

31 Michael Kolber, BSc, MD, CCFP, MSc Alberta Family Physician Electronic Endoscopy (AFPEE) StudyORAL PRESENTATION

32 Dr. Ceara Tess Cunningham, PhD Exploring Processes That Link Patients To Primary Care Providers: The Alberta Context ORAL, ROUND TABLE & PANEL PRESENTATION


33 Scott Jalbert, RN, BScN Tackling Panel Identification in an Academic Teaching Centre ORAL & POSTER PRESENTATION

34 Charisa Flach, MA Steps Toward Comparable Reporting: Using EMR Data for Performance MeasurementORAL PRESENTATION

35 Sarah Rogers Primary Care Initiatives: Continuity and Transitions in the Urban Calgary ZonePOSTER PRESENTATION

36 Ron Garnet, MD, CCFP(EM), The Application of Change Management Principles in Initiative Adoption POSTER PRESENTATION

37 Ashi MehtaImplementation of a Primary Care Network targeted educational session combining data with feedback and Choosing Wisely Recommendations ORAL PRESENTATION

38 Darrel Melvin, RRT,CRE, CTETobacco as a Vital Sign in Primary Health Care SettingsPANEL PRESENTATION

39 Scott Jalbert, RN, BScN Initiating a Site Level Quality Management Framework: Clinical Improvement Team (CIT) ORAL & POSTER PRESENTATION

40 Scott Jalbert, RN, BScN Panel Identification and Improvements — The Big CleanPOSTER PRESENTATION

41 Tasha Stainbrook, LPN Alberta Screening and Prevention (ASaP) POSTER PRESENTATION

42 Lee A Green, MD, MPH Local Data for Evidence Based Decision Making ORAL PRESENTATION

43 Lee A Green, MD, MPH How Best to Help Patients with Obesity? Examining Mental Models of Clinicians to Optimize Obesity PreventionPOSTER PRESENTATION

44 Lee A. Green, MD MPH Scaling Up Chronic Disease Management in Alberta POSTER PRESENTATION

PARTNERS

45 Lee A. Green, MD MPH Bridging the Valley of Death in Health System Innovation: Taking Innovation to Scale in Alberta POSTER PRESENTATION

46 Lee A. Green, MD MPH Building Partnerships to Improve Care of Early Knee Osteoarthritis (KOA) Patients: Co-Developing a Mobile-Health Prediction Tool for KOA ProgressionPOSTER PRESENTATION

47 Eileen Patterson, BA, MCE, PMP Low Back Pain Care Physician Decisions and Patient ExperiencesPOSTER PRESENTATION

48 Marion Relf, RN, MHSA Engaging Patients in Improvement – “Nothing about us, without us” ORAL, POSTER, ROUND TABLE & PANEL PRESENTATION

59 Kathy Stewart, RN, BNHealth Management Program POSTER PRESENTATION

50 Jasneet Parmar, MBBS, DipCOE Facilitating Resident and Family Engagement in Alberta Continuing Care FacilitiesORAL & POSTER PRESENTATION


51 Kara Patterson, MSc, MHSc Pan PCN Collaboration to provide After-Hours Medical Coverage to Long Term Care Facilities.ORAL PRESENTATION

52 Douglas Strilchuk, MD Multidisciplinary Teams approach to Quality Improvement Measures for Better Patient Outcome ORAL, POSTER, ROUND TABLE, PANEL & WORKSHOP PRESENTATION

53 Alvin Yapp, BSc Transitioning to Adult Autism Care ORAL & POSTER PRESENTATION

54 Andrew KennedyGuide to Patient Level Data Sharing Standards in Primary Care ORAL & POSTER PRESENTATION

55 Scott Garrison, MD, PhDPragmatic Trials Collaborative – Measuring What Matters POSTER PRESENTATION

56 Nicole Olivier, RVT Patient & Public Engagement in Primary Care Research – A collaboration between the BedMed Initiative and Alberta SPOR SUPPORT Unit (AbSPORU) Patient Engagement (PE) PlatformPOSTER PRESENTATION

57 Peter Rymkiewicz, MSc, Bcomm Partnering with Member Physicians to Improve Equity in Patient Care Through the Medical HomeORAL, POSTER & PANEL PRESENTATION

58 Jon LeMessurier, (CSEP- CPT), (NASM Corrective Exercise Specialist)Aspen PCN Wellness Program Partnerships POSTER PRESENTATION

59 Jessica Law, MPH Primary Care Immunization Integration Project (PCIIP): Partnering to make immunization POSTER PRESENTATION

60 C. Joe Tabler, BScPharm, PharmD, BCPS Does Embedding a Pharmacist in a Primary Care Clinic Make Sense: An Alberta Take on an International InitiativeORAL, POSTER & WORKSHOP PRESENTATION

61 Mary V. Modayil, MSPH, PhD Supporting health provider practice changes to embed HealthChange® Methodology within a team environmentORAL & POSTER PRESENTATION

62 Sylvia So, MED PROMs in Primary Care Networks (PCNs)ORAL, & POSTER PRESENTATION

Edmonton, Alberta — Nov. 28-29 — A B S T R A C T B O O K L E T — 2 0 1 6 Accelerating Primary Care ConferenceEdmonton, Alberta — Nov. 28-29 — A B S T R A C T B O O K L E T — 2 0 1 6 Accelerating Primary Care Conference

Abstract“Quality Street”- using a process improvement approach to maximize the value of patients’ time during attendance at an academic Family Medicine clinic.Sunridge Family Medicine Teaching Centre, Department of Family Medicine, Cumming School of Medicine, University of CalgaryCarolyn Nowry, MD, CCFPKeith Wycliffe-Jones, MBChB, FRCGP, CCFPNicole Phillips, BN, CPCC, ACC Vanessa Daams, Certified Lean Six Sigma Black Belt, Senior Process Improvement Consultant

What was the issue or problem you wanted to address?

Our academic Family Medicine clinic utilized a structured, process improvement approach to identify opportunities for “value-add” activities for patients attending our clinic. Through this process we identified that patients are spending significantly longer than their scheduled appointment time in our clinic. Although part of this was due to resident teaching/supervision requirements, patients did seem to still spend additional significant “down time” on top of this as they progressed through their clinic appointment.

What did you want to achieve?

We used a principle-based, strategic approach improve clinic workflow and the experience of patients in our clinic. We wanted to develop a better understanding of the time patients spend during each step of their journey in our clinic, and what patients’ value most during their visit.

How did you go about addressing the issue to reach your goal?

A clinic-wide brainstorming session was conducted to understand potential areas for improvement. The team created a current-state process map of daily clinic operations around patient visits. This activity was completed by involving multiple subject-matter experts from each area of the clinic. The team was able to narrow their focus to areas where discrepancies in steps and variance between providers was evident. Data, which was collected from patient surveys, was added to the process map to provide the team with evidence to support decisions, moving forward. We then

held a half-day retreat with all team members to gain a common understanding of the current state of clinic operations, and develop themes to be addressed. The retreat involved education, discussion of the current process map and brainstorming in multidisciplinary breakout groups. Working groups were subsequently formed based on five themes that emerged during the retreat. These groups identified specific problems and root causes, and are currently developing solutions and implementation plans for each issue.

What did you find?

Having a structured, planned approach to process improvement was beneficial in terms of helping us to focus in on a specific problem to address in our clinic. We were able to clearly identify what was within the scope of our project, and ground this in evidence. This allowed us to develop specific and achievable goals for improvement.

How can others use what you have learned?

We would encourage other clinics to use a structured approach to quality improvement.

1)


AbstractWhere Are We Now? Using Health Quality Council of Alberta Data for Improvement Work at an Academic ClinicDepartment of Family Medicine, University of AlbertaSudha Koppula, BSc (Hons), MD, MClSc, CCFP, FCFPMirella Chiodo


The Royal Alexandra Family Medicine Centre (RAFMC) is an academic clinic affiliated with the Department of Family Medicine, University of Alberta. RAFMC prides itself on high-quality patient care, team-based care, and education of healthcare professionals, primarily family medicine residents. RAFMC has engaged in quality improvement since 2007, and has used their own data to evaluate their improvement journey. RAFMC therefore wished to determine how they currently perform as a clinic with respect to specific patient care measures, but it was realized that their clinic data was limited in demonstrating practice patterns of their patient population. To determine a broader perspective, a measurement partner who had access to data outside of RAFMC itself was required.


Using Health Quality Council of Alberta (HQCA) data, RAFMC sought to obtain patient panel characteristics such as chronic condition prevalence, social deprivation index, complexity, and health service utilization for primary care sensitive conditions. Doing so, RAFMC could then compare itself to its peers in the community and province.


RAFMC requested data from HCQA for all of the clinic’s patients. Those measures were used to create representations comparing RAFMC’s performance to that of similar clinics, and the Primary Care Network with which RAFMC is affiliated. The data was interpreted to determine RAFMC’s current performance, determine the starting point for further improvement work, and to aid in their transformation towards a Patient’s Medical Home model.

What did you find?

RAFMC practices have appropriate-sized patient panels, and RAFMC patients are of greater complexity than similar primary care clinics. RAFMC patients have a high degree of attachment and are more likely to be seen at RAFMC itself (rather than urgent or emergency care centres) for primary care sensitive conditions than similar clinics. As an academic teaching unit, RAFMC learners are consistently functioning and learning patient care in this environment where improvement work is role-modelled.


RAFMC has set an example that other clinics are encouraged to follow. By similar processes, other clinics can request their HQCA data. From this, they can determine their current performance and set improvement goals. They can also share this work with learners, peers, and similar clinics interested in their work.

2)


AbstractThe Caregiver Experience — Recognizing Caregiver Needs to Support them in their JourneyCaregivers AlbertaDebra Paches, BScN, RN, GNCC


One in four Albertans is a caregiver, providing unpaid care for a loved one living with illness, disability or age related challenges. The impact on their lives can be physical, psychological, emotional and financial. To prevent caregiver burnout, health professionals and community agency staff need to identify, support and facilitate caregiver access to timely and appropriate resources and supports.


The objective of this presentation is to understand the caregiver experience, identify their needs and learn about resources/supports provided by Caregivers Alberta.


The presentation will have a short interactive exercise to “share” the experience of being a caregiver. Then it will explore the challenges that caregivers face and introduce the supports, resources and programs that are available through Caregivers Alberta

What did you find?

Within healthcare and community settings, resources and supports are often client focused and caregivers can be left out of the process. This adds to their stress and complicates their ability to support their loved ones and continue in their role.


By understanding the caregiver journey and knowing about resources and supports that are focused on caregivers - health care professionals and community agency personnel can feel empowered to assist caregivers to prevent them from becoming overwhelmed and thereby allowing them to continue to care for their loved ones in the community.

3)


AbstractDiscovery Toolkit for Family Caregivers of Seniors: Facilitating Conversations and ScholarshipNetwork of Excellence in Seniors’ Health and Wellness, Covenant HealthJasneet Parmar, MBBS, DipCOELesley Charles, MBChBv CCFP(COE) Suzette Brémault-Phillips ,PhDBonnie Dobbs, PhD Peter George Tian, MD, MPHMelissa Johnson, MSc


Family caregivers are an integral, yet increasingly overburdened, part of the healthcare system. In Canada, there is an estimated 3.8 million family caregivers caring for seniors. To address the lack of supports for caregivers, we have successfully held a CIHR-funded conference in 2014 on Supporting Family Caregivers of Seniors. Knowledge users and researchers from Alberta and across Canada discussed the state of family caregiver support and initiated research plans.


We wanted to develop a Discovery Toolkit from learnings and resources in the conference Supporting Family Caregivers of Seniors.


(1) Each speaker’s slide deck was presented in a page containing six representative slides and a hyperlink to the full slide deck.

(2) Evidence Summaries were shortened to a page.

(3) Notes from discussions were subjected to thematic analysis and summarized.

(4) A caregiver’s account was presented as a personal communication to a government official.

(5) Relevant articles, webpages, and organizations were collated and listed.

What did you find?

The toolkit is 44 pages long and designed for online viewing. It contains an executive summary and five parts:

(1) Supporting Family Caregivers of Seniors with Complex Needs,

(2) Voices of Family Caregivers: A Window into their Experiences,

(3) Online Support for Caregivers of Seniors,

(4) Support for Caregivers in End-of-Life Care, and

(5) Research and Resources.


This Toolkit is a timely resource on family caregivers. We’ve disseminated it to caregivers, healthcare providers, researchers, healthcare organizations and community organizations, and other stakeholders.

4)


AbstractScreening for Stress and Burden in Caregivers of Seniors: Screening Assessment ToolsNetwork of Excellence in Seniors’ Health and Wellness, Covenant HealthJasneet Parmar, MBBS, DipCOELori Sacrey, PhDKathy Classen, BAMeighan Sommer, MPH Peter George Tian, MD MPH


Family caregivers are an integral part of the healthcare system. Yet, caregiving is provided at significant burden to the caregiver: physical, emotional, and financial burden. This could lead to health deterioration, social isolation, loss of income, and family conflict. We wanted to better inform healthcare providers on the array of tools for assessing caregiver stress/burden.


We reviewed the literature for tools in assessing caregiver stress and/or burden.


We did a systematic review of the literature for tools measuring stress and/or burden among informal caregivers. We, then, compared the tools for accessibility, cost, domains measured, utility across caregiving (e.g., end-of-life, homecare), and psychometric properties (reliability and validity).

What did you find?

We evaluated 10 tools. Nine tools were brief, self-reported or clinician-delivered assessment screens. These tools were the following: Caregiver Burden Inventory, Caregiver Reaction Assessment, Caregiver Self-Assessment Questionnaire, Caregiver’s Burden Scale in End-of-Life Care, Cost of Care Index, Modified Caregiver Strain Index, Screen for Caregiver Burden, Social Support Questionnaire, and the Zarit Burdent Interview. 1 tool, the Caregivers’ Aspirations, Realities, and Expectations tool was a clinician-led interview that determines needs and potential interventions for caregivers who are identified as being at increased risk of caregiver burnout.


Healthcare providers could use the tools to assess for caregiver burden/stress.

5)


AbstractInventories of Resources and Supports for Caregivers in AlbertaNetwork of Excellence in Seniors’ Health and Wellness, Covenant HealthJasneet Parmar, MBBS, DipCOEKathy Classen, BAJulie-Ann Babiuk, MSc, PMP Peter George Tian, MD, MPH


Caregivers provide ongoing care and assistance without pay to family members or friends. They are the backbone of the healthcare system. However, caregivers are becoming increasingly overburdened. They need services and supports to continue working and provide care. Access to information is one form of support that may alleviate stress. This project seeks to improve the access to information for caregiver resources and services.


We developed inventories of resources, services and support organizations that will help support caregivers in Alberta.


We searched and compiled resources, services, and support organizations. Moreover, we adapted lists from Alberta Health, the Discovery Toolkit for Family Caregivers of Seniors, and Covenant Health’s Palliative Institute.

What did you find?

The document has 48 pages, with four inventories. (1) Inventory of Current Support Organizations for Caregivers in Alberta. This was an updated version of a list from Alberta Health. (2) Inventory of Caregiver Resource Documents. This was updated version of a list from the Discovery Toolkit for Family Caregivers of Seniors. (3) Palliative and End-of-Life Resources for Caregivers in Alberta. This was a compilation from the Palliative Institute. (4) Financial Supports Available for Caregivers in Alberta.


These inventories provide useful information to support family caregivers.

6)


AbstractBreaking Down Barriers: Benefits of our Medical Health Home Aspen Primary Care NetworkKrystin Minns, LPN, CDE, Team Lead – Clinical ProgramsJanene Kargus, Community & Public Relations


We wanted to address the barriers that our clients have when accessing primary health care services in rural, remote locations in Athabasca and surrounding areas. Access to primary health care services is an important social determinant of health. A remote and rural location such as Athabasca must take a collaborative and integrated approach towards providing high quality care for clients while still being cost effective.


We wanted to create a patient’s medical home for our clients where they could access a wide variety of services while being linked to all other services in the community. Our core program is centered around patient access. We wanted to alleviate some of the strain the health care system be reducing unnecessary visits to the emergency room that could have been avoided by patients receiving services at the PCN Medical Home instead. This includes receiving proper education on managing their chronic illness to avoid exacerbations that can lead to ER visits and ensuring that patients can obtain prescription refills as needed rather than visiting an ER for this. We are often patient’s first point of entry to the healthcare system and if we are not able to directly help the client we can navigate them to the appropriate care provider or service.


We have centralized our team into a Medical Home that has served as our foundation for serving our patients. We have been removing barriers by having specialists from the capital region travel to Athabasca. This has included a cardiologist and a respiratory therapist. Also, we utilize members of our healthcare team to their full scope of practice which ensures we are cost effective. This also allows for staff growth and education. Based on community need, two of our LPNs became Certified Foot Care Nurses and now run a very busy healthy foot clinic out of our Health Home. The PCN Medical Home integrates services from AHS and the community to allow patients easier access to the services they need,

e.g. Dietitian, Social Services and Home Care.

What did you find?

We have found the centralized Medical Home has been an asset for our patients and community. It helps us better serve our patients and reduces the burden on the healthcare system. Community members are now using the PCN Medical Home as their first place to go for primary care needs rather than the family physician’s clinics or AHS ER. This allows the physicians too spend more time seeing their patients to develop long term care plans and allows the ER to manage more acute type care.


The Medical Home could be integrated into any community and similar services could be tailored based on the needs of that community. We have listened to our community and that is how we decided what programs and services to offer here. This collaborative approach to care puts the patients needs first, and allows to the patients to get to the right car, at the right time by the right professional. Integrating the other service providers in the community is the key to the success as well integrating your PCN team members.

7)


AbstractWe Care for Our Patients but do We Understand Them: Impact of Patient Activation on Program EvaluationMosaic Primary Care NetworkPeter Rymkiewicz, MSc, Bcomm, Director of Measurement & EvaluationCarol Cullingham, MA, BA, BSc, Evaluation CoordinatorMarjan Rekabdar, MPH, Evaluation AnalystRuth Fermin, Administrative AssistantAmanda Brockman, RN, MHA, Primary Care ManagerEileen Cha, MOA, SupervisorTannis Andersen, RN BN GNC(c), Senior Manager, Multi Disciplinary Team


Patients’ knowledge, skills and confidence in managing their own care is predictive of the preventative health and self-management behaviours that lead to better patient outcomes and reduced impacts on the health system. Not accounting for patient activation can have a material impact on program evaluations leading to incorrect conclusions about program effectiveness and value.


Mosaic PCN had two goals: (1) Validate and adopt a public domain patient self-

management survey against the Patient Activation Measure© (PAM), and

(2) Characterize our patient population to better understand the proportion of the population engaged in and able to manage their health.


We completed a literature review to identify alternative candidate surveys for measuring patient activation and validation against the Patient Activation Measure© (PAM) from Insignia Health ltd. We purchased the PAM survey license and selected the Health Confidence Score (HCS) from R-outcomes ltd in the UK. We designed a validation study and created a survey which required patients to complete both HCS and PAM surveys and provide additional demographic information. Surveys were distributed in 5 member physician clinics and 1 centralized MPCN clinic.

What did you find?

Based on the results of our patient surveys we concluded that the HCS was unable to properly discriminate, overestimating patient activation when compared to the gold standard (PAM). Using the PAM scores, we characterized our overall patient activation. In addition, our analysis included other factors related to self-management (education level, English fluency, home language). We concluded that only 10% of patients had the knowledge, skills and confidence to manage their own care.


In response to our study findings MPCN has started to plan the incorporation of PAM surveys into clinical workflow. Where possible, future program evaluations will include patient stratification on activation level to answer questions such as: 1) Does the program improve clinical outcomes for patients who are able to self-manage? and 2) What proportion of patients requires help with self-management?

These findings are important for provincial health partners because program evaluations combining patients who are self-managed and those who are not self-managed may incorrectly conclude lack of program effectiveness.

8)


AbstractBalancing Perspectives: An Exploration of Patient and Team Perception of Clinical Service QualityAlberta Health ServicesShannon Sim, (4th Honors Undergraduate Student)Richard Golonka, MScTony Mottershead, MSc Scott Oddie, PhD


Primary health care is a patient’s first and often most frequent contact with the healthcare system. Understanding the differences between patient and provider perspectives is essential for identifying quality improvement opportunities.


This study examined whether patients and staff in the same clinic have differing views regarding access and clinical care practices.


Two separate surveys were used, one for staff and one for patients. Completion of both surveys was voluntary. Staff were asked how they felt their clinic functioned in terms of access while patients were asked to rate their satisfaction with their usual wait. Staff were also asked to rate how they felt their clinic functioned in terms of clinical care practices while patients were asked to rate the overall quality of the healthcare services received.

What did you find?

Data was available from 23 clinics for the access measure, representing 1331 patients and 117 staff. For clinical care, data was available from 25 clinics, representing 1511 patients and 119 staff. Overall for all clinics, staff rated both access and clinical care lower than patients (p<0.05). Additionally, no individual clinic in either analysis exhibited significantly higher staff ratings.


This study suggests that staff members in a clinic that is just starting QI work hold a more negative perception of the quality of the service they provide compared to their patients. This result is not unexpected considering the potential for participation bias in this sample; teams embarking on QI work likely have a pre-existing recognition of the need to improve. It is however a reminder for QI programs to develop recruitment tools for the specific subset of the mid-late adopters who may possess a high presumption of clinic functioning and are therefore less likely to actively seek participation. It must be stressed that the accuracy of such presumptions can only be confirmed through routine and systematic measurement of relevant indicators.

9)


AbstractThe South Calgary PCN’s Happiness Project – The Next Chapter South Calgary Primary Care NetworkSophie Piroozfar, MSc, BScSheena Clifford, MSW, RSWAmanda Wilhelm, MASophie Piroozfar, MSc, BS


In the fall of 2014, the South Calgary Primary Care Network, along with our Calgary Zone PCN partners, began to offer a no-cost workshop called Happiness Basics. Developed by the Red Deer PCN, this positive psychology initiative focuses on fostering positive experience and emotions to create a positive state of mind. Taking part has been shown to improve mood, vitality and energy, as well as physical and mental health.

Happiness Basics is for people 18 years and older who are not experiencing severe anxiety, depression or suicidal thoughts. Participants committed 2 hours a week for 7 weeks. We piloted the program by offering daytime and evening classes on a weekly and bi-weekly basis.

In May 2016, Happiness Basics at SCPCN was shortened from 7 to 4 weeks. We evaluated if the change in workshop length had any impact on participant outcomes. Quality of Life was measured using the European Quality of Life (EQ-5D-5L). Positive mental health was measured with the Mental Health Continuum Short Form (MHC-SF).


In comparing the 4-week program to the 7-week program, three outcomes were examined: 1) Was there any change in EQ5D VAS scores? 2) Was there any change in EQ5D Index scores? 3) Was there any change in MHC-SF scores?


Participants completed the EQ-5D-5L and MHC-SF at the first and last class. Participants were only included in the analysis if they completed the pre- and post-measures. Normality testing and analysis was performed in R (Programming Language and Software for Statistical Analysis). Two-Sample t-tests (statistical tests for making quantitative decisions on the data) were run to test for significant differences in scores.

What did you find?

Based on the analysis we did there was evidence of an improvement in the EQ5D Index Score result in the four-week program compared to the seven-week program. This result was statistically significant. Drop-out percentages were also calculated for the 4 and 7 week groups. The total drop-out rate was lower in the 4 week classes compared to the 7 week classes.


Changing the workshop length to 4 weeks had no negative impact on patient outcomes thus far. The impact may even be a positive one.

10)


AbstractEngaging the Voices that Matter: Depression Research Priority Setting Patient Engagement Platform Alberta SPOR SUPPORT UnitPing Mason-Lai, BA, MALorraine Breault, PhD R PsychKatherine Rittenbach, PhDKelly Hartle, PhDBrad Necyk MFAScot Purdon, PhD R PsychSharon UngerAshton MichaelGinger Sullivan, RN MNEmily Ardell, MD Yamile Jasaui, BSc Robbie Babins-Wagner, PhD RSWCatherine deBeaudrapLorin Vandall-WalkerDorothy Anderson


There is world class research being conducted in Alberta on depression. However, there are still many questions that matter to patients/persons with lived experience, carers and clinicians that are not being answered. The Patient Engagement (PE) Platform, Alberta SPOR SUPPORT Unit, the Addictions and Mental Health Strategic Clinical Network and the Canadian Depression Research Intervention Network are working together to develop research priorities for depression that give patients/persons with lived experience a voice.


Depression research priorities (questions that are relevant to patients) that are determined through meaningful engagement between patients/persons with lived experience, carers, clinicians and researchers together.


This priority setting process uses a modified James Lind Alliance methodology. A group of people with lived experience and clinicians make up the Steering Committee. The Steering Committee meets frequently (once a month) and designed, developed, and spread a survey questionnaire to collect priorities from the public across Alberta. They will also be primarily responsible for the necessary data analysis and literature reviews

that will be required to consolidate the priorities that will be reduced to the top 30 research questions. The final prioritization will be done by a larger group that includes the Steering Committee and others with lived experience in a full day workshop that will result in a top 10 list of depression research questions.

What did you find?

This project is ongoing. We are monitoring demographics as the survey is completed and have concluded one ‘round’ of review of the questions that have been submitted from Albertans. We can share the experience of being involved with the depression research priority setting process and project from the perspective of patients/person with lived experience. The project will be complete in Spring 2017 and the early results are indicative that meaningful engagement of patients/persons with lived experience, carers in a research priority setting process will be beneficial to all involved.


The experience and voices of patients/persons with lived experience, carers and clinicians working collaboratively together as partners in research can enhance how research questions are developed. A more diverse approach to the development of research questions is possible with engagement of many perspectives and experiences.

11)


AbstractUsing Information to gain better insights into our Patients. South Calgary PCNOliver Schmid, PhDRebecca Carter


As a PCN we wanted to better understand all of our patients, who are paneled with our member physicians, and their social determinants of health. We also wanted to support our physicians with analytical capabilities to better understand their panel and form more effective person-provider relationships.

Understanding your panel, bet it on a single provider level or a PCN level is critical to drive improvement in outcomes.


The South Calgary PCN wanted to develop key scalable information resources and analytical capabilities to support our member physicians in improving their understanding of their patient panels and clinical workflows to drive quality improvements resulting in better access and continuity of care.


The South Calgary PCN developed a web based application which enables processing of all physician panels as well as EQ5D, AsAP and TNA data. Information can be imported from EMRs and is processed to support pro-active screening and measurement thereof, identify patients appearing on the panels of multiple physicians and measure impact on access (TNA) of changes made to the clinical workflows. The system further shows information on physician panels including distribution of chronic conditions, EQ5D score tracking over time to see if patients improve, identify patients who have not been seen for extended periods of time and geographical distribution of chronic conditions. Information is planned to be linked to social determinants of health data to provide further insights into our patients and their health needs by using the information and doing statistical analysis of determinants which might affect uptake or success of patients health care.

What did you find?

We are currently in the pilot phase of the roll-out of the system. To date information of 35,000 patients have been imported with a goal of reaching around 250,000 patients in the near future. We have already identified a number of patients who appear on the panels of more than one physician. We are in early stages of working with our member physicians to use the analytical capabilities to closely monitor their panel. On a PCN level we get for the first time detailed insight into our people and their health conditions.


The system was always designed as a cross-institutional platform for other providers and PCN to benefit not only in regards to the analytical capabilities and gaining insight into physician and/or PCN level panels but also as a platform to share knowledge and best practices across institutions, disciplines or providers.

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AbstractTime 2 Doc: Engaging with our Patients through mobile apps to keep them out of Emergency Rooms. South Calgary PCN & MedDuckOliver Schmid, PhDJaron Easterbrook


Significant number of patients show up in Emergency Departments with conditions which could easily be handled within a primary care setting. The problem was that patients did not know where they could go especially after hours and how long would they have to wait to be seen. How do you efficiently with your patients and show them their options without having to go to Emergency Departments.


We wanted to be able to give our patients instant access to up-to-date information on same day appointments they have available, how to get to those available appointments and how long they would have to wait. Most same day appointments are available within minutes of the need as compared to the hours patients have to wait in Emergency Departments. Furthermore, we wanted to use the mobile app to show patients the different services which are available to them within the network of clinics.


We partnered with MedDuck in developing a mobile app which shows patients up-to-date wait times for all walk-in clinics as well as specific additional services clinics offer (eg: breastfeeding, travel clinic, circumcisions). All participating clinics enter the current number of patients in their waiting room via a web interface which uses an algorithm to wait time for our patients. The app then displays live information for all clinics on a map to the patients and tracks if users went to a clinic which has appointments available or if they went to Emergency departments or Urgent Care centers. Patients can easily get directions to clinics and see where the clinics are in relation to their location.

What did you find?

The mobile app, called Time 2 Doc, has been available for South Calgary patients for 6 months. Over 1,500 patients have downloaded the app and on average the app is used 2-3 daily by users. We received very good feedback from patients about the app and its benefits to our patients. We are currently in the final stages of the development to track the behavioral change we hope to infer in patients in regards to using the app and then going to a primary care clinic rather than the Emergency Department.


The Time 2 Doc app is finished its pilot in the South Calgary PCN and was always designed to be available to other PCNs or individual clinics to support cross-institutional collaborations.

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AbstractCUPS Coordinated Care Team: Transitional Support For Vulnerable Calgarians With Complex Needs CUPS 1001 10th Ave SW, Calgary, AB T2R 0B7

Low-income individuals with unstable housing often experience complex health problems such as chronic diseases, mental illness, or addiction. These contribute to disproportionately high utilization of acute care services, poorer health outcomes and high health care costs, compared with the general population.

Our intervention, the CUPS Coordinated Care Team (CCT) aims to provide intensive case management to socially vulnerable patients in Calgary to improve patient care, patient and staff satisfaction and reduce acute care use. CUPS CCT is a mobile community outreach team that provides intensive case management and care coordination to homeless and unstably housed patients with frequent acute care use. The team consists of two registered nurses who coordinate care for vulnerable Calgarians transitioning from acute care to the community. The team supports clients to navigate the systems, including primary care, housing, mental health and addiction treatment, social supports, and finances. The team collaborates with various other social serving agencies, including the justice system and housing programs as well as the health care system, to provide the most effective and appropriate care for this vulnerable and marginalized population.

CUPS CCT was recently awarded a Partnership for Research and Innovation in the Health System (PRIUS) Grant which will allow for expansion of the program to include Community Health Workers as well as an evaluation and research component over the next three years.

In the first 10 months of the program, over 400 unique individuals have been referred to the program. Preliminary findings, successes and challenges will be discussed at the time of presentation. It is anticipated that the CCT intervention will enhance community-based care for vulnerable patients and reduce acute care utilization and costs, while improving quality of life, self-reported health status, and patient, staff, and partner experience

With the support of the PRIUS Grant we will work to disseminate our findings and knowledge of how best to provide appropriate and cost-effective care for socially vulnerable patients, improve their health and reduce potentially avoidable acute care use.

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AbstractEvaluation of the Frail Elderly Outreach Program. Edmonton West Primary Care Network and Alberta Health ServicesJane Schlosser, MPHLaura EwatskiLindsay Wodinski


Within the Edmonton West PCN patient population, there is a cohort of frail elderly patients that has complex social and medical problems that make them among the most vulnerable and marginalized patient population and the most difficult to medically manage.


Goals include: • Improve access to primary care in the home

• Maximize patient functioning and maintain independence

• Reduce risk of hospitalization and LTC admissions

• Include and support caregivers


Through a prioritization exercise with physicians, the EWPCN identified a need to better support frail elderly patients and implemented the Frail Elderly program in October 2015.The program consists of a nurse practitioner with a specialization in geriatrics who visits patients in their home. Patients are also supported through the PCN by a geriatric pharmacist, social worker, and occupational therapist. Patients are referred to community and social supports and services available in the community where appropriate.

The program underwent a one year evaluation drawing from the following data collection methods: patient file review to determine levels of functioning and independence, number and range of social and health supports patients are accessing and to which they are referred; review of program data to determine program utilization and patient demographics; patient and provider interviews to better understand experiences with the program; and caregiver surveys to determine

level of stress or burden.

What did you find?

Midpoint findings indicate that the program is operating at a high capacity with many physicians referring patients to the program. Patients were found to have moderate levels of functioning and independence, had moderate QoL scores and were not as homebound as expected. Nearly half of all patients were referred to community health supports, while a quarter were referred to social supports. Overall, caregivers reported little stress or burden related to care taking. Providers expressed satisfaction with the program and stated that it was meeting patient needs. Year-end evaluation findings (available October) will build on midpoint findings and will incorporate the patient perspective.


The program has the potential to serve as a model for other primary care providers as a way to support frail elderly patients in the community.

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AbstractImplementation of the Alberta Screening and Prevention Program at Sunridge Family Medicine Teaching Centre Sunridge Family Medicine Teaching CentreMarsha Kucera, BSc, MD, CCFPCarolyn Nowry, MDKathy Stewart, RN, BNNicole Phillips, BN, CPCC, ACC


Towards Optimized Practice’s (TOP) data has shown that physicians in Alberta do a great job of screening individual patients during focused screening visits, such as a Preventative Health Exam (PHE) . For a multitude of reasons, both patient-related and physician-related, about 30% of patients do not present for these specific screening visits, and most of them miss their opportunity to have discussions around prevention and screening.


Through the Alberta Screening and Prevention Program (ASaP), we have taken the opportunity to engage our clinical team in screening and preventative improvement work as part of our Patient Medical Home transformation and to provide education to patients and care providers about the importance of screening and prevention through opportunistic screening at scheduled visits, and eventually through planned outreach methods


We accomplished this by completing a chart review for each of our panelled physicians. We chose to implement 6 of the 11 ASaP screening maneuvers first, and these included: height and weight, smoking, blood pressure, plasma lipid profiles, colorectal cancer screening, and cervical cancer screening. We designed clinical flow sheets for each of our chosen ASaP maneuvers with the involvement of a multidisciplinary team including physicians, nurses, and our clinic manager.

What did you find?

Throughout this process, we learned that some features of our EMR were quite powerful for opportunistic screening, however, they were not accurate at the time of our analysis and the staff were unaware of how to use these tools. Other observations included incorrectly scanned results and inconsistent charting of screening maneuvers, which highlighted the need for a systematic approach to opportunistic screening.


With the goal of improving screening rates through a systematic approach to opportunistic screening, our multidisciplinary team worked together to develop clinical flow sheets that would aid our staff in determining whether or not a patient was due for for a screening maneuver and to highlight the need to review this with the physician seeing that patient. Our team is currently planning a trial rollout of the workflow sheets with three physicians in the clinic in mid-September 2016, and developing workflow sheets for the remaining maneuvers, with the goal of implementation sometime in 2017.

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AbstractProviding Primary Care Clinics with User Friendly Access to Comprehensive Patient DataChinook Primary Care NetworkJeff DeckerTobias Gelber, MD


As a result of patients’ low attachment or multiple attachments to primary care physicians, patients and primary care clinics were negatively affected by the lack of continuity of care and the uncertainty surrounding the patient and provider relationship. Additionally, primary care clinics did not have ready access to data needed to increase patient attachment or accurately measure clinical performance indicators.


In order to increase patient attachment, provide clarity around the relationship between patient and provider, and support clinical quality improvement, primary care clinics need access to relevant patient data and the foundation of this activity is accurate panel information.


To address this issue, a first of its kind web based central data repository was developed. Data from clinic electronic medical records (EMRs), Alberta Health billing and Alberta Health Services was matched to create comprehensive patient paneling and attachment data, and clinical indicator data. Physicians and physician team members are given access to the repository and can view and export data directly from the repository.

What did you find?

The web based central data repository provides clinics with easily accessible patient data. Clinics are using the tools available on the repository to review patient attachment and gain valuable information about their patient panel. As a result, there has been a large decrease in patients paneled with multiple physicians. Similarly, clinics are using the tools on the repository to view their preventative screening rates and to determine which patients are overdue for screening. maneuvers, which highlighted the need for a systematic approach to opportunistic screening.


Giving primary care clinics access to relevant patient data has supported patient attachment and clinical quality improvement. The patient attachment data allows clinics to increase communication with those patients that have potentially moved on from the current practice which increases access for prospective patients in the community. The clinical performance indicator data provides a platform that supports clinical quality improvement.

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AbstractImplementation of Alberta Screening and Prevention project: preliminary reportDepartment of Family Medicine at University of Calgary and Alberta Health ServicesTasha Stainbrook, LPNBehi Raissi, MD, CCFP, MPH


Studies in primary care show that screening is more likely to be offered during focused visits for regular health checkups. Screening status of patients is not routinely reviewed during patient encounters for reasons other than health checkups. There is vast literature about the importance of implementation of a system to ensure timely screening in primary care. However, there is a gap in information when it comes to recommended processes, workflows and responsibilities of each member of the health care team. At our clinic we recognized that we follow the same trend in timely screening as the rest of Alberta and we did not have any clear system in place to ensure such goals would be achievable.


We divided the project into three main phases. First phase of this project focused on establishing regular opportunistic screening in one of our four micro-systems (clinics) as a pilot. We started with five maneuvers from the list of 12 maneuvers recommended by TOP AB ASaP Initiative.


We went through the following steps: Review of ASaP Initiative by Clinical Improvement Team, establishment of formal project plan and working group, continuous communication with other family medicine clinics with established ASaP, engagement of various other stakeholders at different phases of the project, chart reviews, regular meeting of the working group to review and prepare workflows and protocols, and training the staff in the micro-system about their role and expectations.

What did you find?

Findings were as follows: Opportunistic screening performed in 61% of patients, inconsistency with documentation of the patient screening status in the EMR, lack of clear process for approach towards opportunistic screening, need for modifications in EMR to facilitate the process, and knowledge gap about ASaP among nursing staff and clinicians.


We believe that our products and our story of evolution can support other primary care providers to optimize their efforts in establishment of their screening program. They would also be able to estimate necessary resources based on their panel size and type of care they provide along with composition of their multidisciplinary team.

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AbstractAssessing Panel Size in Academic Teaching ClinicsAlberta Health Services, Calgary Zone, Family MedicineLawrence J. LeeAllison Mirotchnik


Panel size is the number of active patients assigned under the care of a family physician. If panel demand exceeds available appointments, timely access and continuity of care may suffer, which can further impact clinical outcomes. Equitable panel sizes help maintain equitable workload between physicians in a practice. However, varying complexity of patient needs makes equitable adjustment of target panel sizes challenging.


The objective of this work was to assess various methods for evaluating panel size and to develop a more comprehensive picture of physician panels.


Our three teaching clinics conducted semi-annual panel cleaning, in which patients not seen in the three years were contacted to determine if they are still patients of the practice. We then tested several methods of assessing panel size to address appointment availability, and complexity of patient needs.

To address supply of available appointments, we calculated panel size per scheduled clinical FTE of physicians and the rate of appointment no-shows. To address patient complexity, we evaluated two previously reported predictors of primary care visits: age and number of medications. Panel sizes were adjusted for age and gender using a weighting system based on expected annual visits (Murray, 1999). We also measured time to the third next available appointment (TNA) and continuity (proportion of patient visits with primary provider).

What did you find?

Panel size per physician FTE across all physicians was 1,308 patients, whereas the age/sex adjusted panel per FTE was 1,415. With a no-show rate of approximately 0.30 per physician half-day clinic, the maximum age/sex adjusted panel was 1,872 patients with a model of 3.19 visits per patient per year.

Preliminary analysis indicated that age was a better predictor of annual appointments (Spearman’s R-squared=14.1%) than the ASAME score (5.4%) or number of medications (2.9%) (all p-values < 0.01).


Age and sex adjusted equivalents may be a viable method for adjusting panel size. Although Murray’s weighting may not be representative of our clinic’s population, it provides a standard for clinics that may not have the capacity to develop their own weights.

We recommend reviewing panel size together with physician FTE, no-show rate, time to third next available appointment and patient-physician continuity.

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AbstractDeveloping a PREM for Primary Care: Cognitive InterviewingUniversity of Calgary and Health Quality Council of AlbertaMaeve O’Beirne, PhD, MD, FCFPRoland Simon, MAJeanette Jackson, PhDVladislav Degtiarev


Patient reported experience measures (PREMs) have been shown to be a useful tool in determining how well a clinic is meeting the needs of its patients and allowing the clinic to focus its energies on improving areas that are not working well. These tools have been developed for use in acute care settings as well as for use in primary care settings in the United States. Because language and system differences exist between the United States and Canada, the Health Quality Council of Alberta (HQCA) has developed a PREM tool for use in Canadian community based primary care practices. This tool has been tested in a number of different clinic populations but mostly in clinics that are composed of patients from a higher socioeconomic status. Also previous testing has found that some of the questions did not perform well. Since it is crucial to ensure that the instruments used for assessment accurately measure patient experiences, and more specifically, that the questions measure what is intended and that respondents understand and correctly interpret items, cognitive interviewing is required.


A high quality and valid PREM for primary care.


We will be using the cognitive interview method to ensure the quality and accuracy of survey instruments and to identify and analyze sources of response error in the survey questionnaire:

“Cognitive interviewing is meant to identify and analyze sources of response error in survey questionnaires by focusing on the cognitive processes respondents use to answer questions on a survey or questionnaire. Specifically, the purpose of the method is to understand whether subjects understand the question, both consistently across subjects and in the way intended by the researcher (Collins, 2003)”. Moreover, cognitive interviewing allows probing for preferences around aspects of the concept being measured, such as access and coordination of care. Consequently, items can be identified that are clear and meaningful to Albertans.

What did you find?

We will be conducting the interviews with patients in 2 of our Family Medicine Teaching Clinics in Oct/Nov.


The cognitive interview method is an established method for survey development in a number of disciplines but we have not seen it used in community based practice research. Others can learn how to use this method to improve the accuracy and quality of their patient surveys.

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AbstractImplementing Quarterly Clinical Metrics in the Department of Family MedicineUniversity of CalgaryMaeve O’Beirne, PhD, MD, FCFPAllison Mirotchnik, BSc, BEd, MScDave Jackson, BCommLucie Vlach, BA Lawrence Lee, BHSc


In order to accomplish improvements in service delivery, it is necessary to have appropriate measurements in place to determine if changes are required and if changes have made an improvement in patient care.


To focus improvement in service delivery and patient care in the Department of Family Medicine teaching clinics by using defined metrics and to evaluate the effect of interventions aimed at improving delivery of care.


An accountability framework was developed around the Patient’s Medical Home model in order to determine what metrics were required. Algorithms were developed in order to analyze data extracted from the EMR. Data is also obtained from TNA reporting, Ministry billing data, research publications, and patient feedback. Metrics that are currently being measured include: panel size adjusted for physician FTE and for patient age and gender; return rate; time to third next available appointment; continuity of care with primary providers, microsystems and residents; patient feedback; visit volume; visits per physician half-day clinic; billing volume; dollars billed per physician half-day clinic; proportion of bills with modifiers; proportion of bills submitted as shadow bills; locum usage; research publications; residency match rates; resident surveys; as well as qualitative measures of clinic governance and stakeholder input. Each clinic receives a quarterly report of how the clinic and individual physicians are performing in each of the metrics, and how they compare to the other two clinics.

What did you find?

It is possible to use algorithms to analyse meaningful data from our EMR and other sources. Regular reporting helps to establish a greater awareness of areas that require improvement.


Other clinics can determine which of the metrics we are measuring would be useful to their setting and learn about our algorithms and extraction methods.

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AbstractRelational Continuity: A Concept AnalysisAlberta Health ServicesCheryl Andres, BN, MSc


Patient Centered Care has been part of the healthcare agenda since at least the 1978 World Health Organization’s International Conference on Primary Health Care and the identified need for improved support to those with chronic conditions. It still has managed to escape us. How do we truly provide whole person evidence informed patient centered continuity of care from a healthcare system perspective?


Although there is clear recognition that continuity of care is needed in the publicly funded health care system to reduce the high costs of fragmented care, support whole person evidence informed patient centered care and improve patient outcomes; implementation of a better way to deliver care is hampered by a lack of agreement on an appropriate and clear definition of continuity of care. This subsequently hampers efforts to implement and measure continuity, and guide reforms to the organization of primary health care in Alberta and the other Canadian provinces. To address this critical shortcoming, my purpose in this study was to gain a conceptual understanding of relational continuity in today’s context of primary care and how it has evolved within the context of continuity of care as a whole.


Rodgers’ Evolutionary View of Concept Analysis was employed to identify attributes, antecedents, and consequences of relational continuity.

What did you find?

A comprehensive understanding of relational continuity in the context of primary care and continuity of care as a whole is presented as an outcome of this concept analysis.


In 2002 Berwick stated that “health care tends to regard human interactions more as a toll or price than as a goal or product” and proceeds as though interactions between providers and patients are the “burden it must bear so that it can deliver the care”, when in reality it is these interactions themselves that are the care. “To perfect care, we must perfect interactions” (Green et al., 2008, p. 10). Relational continuity as conceptualized in this study will contribute to the work that is focused on perfecting the interactions that produce the outcomes we have been unable to consistently achieve in primary health care improvement.

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AbstractAdvance care planning in primary care: examining barriers and facilitators at Sunridge Medical Teaching CentreSunridge Family Medicine Teaching CentreDr Sonika Kainth, MDDr Anna Zhang, MDDr Carolyn Nowry, MD, CCFP Dr Amy Tan, MD, CCFP, MS


Canadian research has shown that only ~25% of primary care physicians are comfortable having discussions regarding advance care planning (ACP) despite 60% of Canadians wanting their health care professionals to discuss end of life care with them. This highlights a clear gap between optimum patient care and actual practice in this area. A similar gap also exists within our clinic, and our aim is to increase the number of ACP discussions that take place.


Through a quality improvement project we aim by February 2017 to have 75% of patients over age 65 at our clinic to have a documented ACP or ACP discussion.


First we conducted focus groups with residents, staff physicians and allied health professionals to identify barriers and facilitators to ACP in our clinic. Second a reminder to initiate ACP discussions was added to the EMR, as recommended by the focus groups. This intervention is currently still occurring and we are determining if this can increase the number of ACP discussions which are initiated.

What did you find?

A random chart review prior to the interventions revealed that only 21.7% of patients >65 yoa had a documented ACP discussion. Preliminary data from our focus groups suggest that a) lack of training in discussing ACP with patients is a barrier for residents b) poor physician compensation for taking part in ACP discussions might be a systems barrier c) normalizing these discussions may improve patient engagement in them and d) a lack of standardization amongst the clinic on where in the chart to document these discussions. Interventions such as adding a reminder to discuss ACP during the periodic health exam and running a workshop for residents to improve communication around ACP emerged from the focus groups.


This project identifies barriers and facilitators to ACP discussions in an urban clinic and may encourage other clinics to identify barriers within their own clinics. Our interventions to improve gaps in care for ACP may inform similar interventions at other urban clinics.

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AbstractClinician Activity Tracking: Lessons for ImprovementEdmonton Oliver PCNAlvin Yapp, BSc Al-Bakir Ali, BA


Patient activity and encounters data at the Edmonton Oliver Primary Care Network has been collected, analyzed, and reported on in order to guide improvement activities at the PCN; however, clinicians are finding these reports decreasingly useful.

With a new focus on clinical indicators, patient outcomes, and cost-savings, introspection at the PCN is valued more than ever, especially looking at the activities of the clinicians. The tracking processes that have been in place for years will need to be revamped to better suit the emerging data needs of the PCN.


A retrospective exploration of the activity tracking ongoing at the PCN was done to assess the efficiency of data collection/management/analysis procedures, and how these findings are reported and used.


Tracking clinician report changes from the past five years and informal feedback from clinicians regarding data collection and use of the findings.

What did you find?

Dataset maintenance has become inconsistent and inefficient with PCN growth. The lack of a centralized IT infrastructure is a weakness that needs to be addressed. As the PCN grows and the clinicians visit more and more sites, it becomes increasingly difficult to maintain clean datasets.

Use of the results has stagnated as the reports do not currently provide much insight into patient outcomes. Additional patient-level indicators will need to be incorporated, as well as a PCN-wide look at how patients utilize all the services of the PCN, rather than only their utilization by clinician area.

A centralized database of patient clinical indicators that all PCN clinicians have access to may increase the usefulness of clinician reports. For example, the EQ-5D is collected by all clinicians, but the results are not kept in a centralized location, therefore, clinicians may not be aware that it’s already been done, or note any changes in quality of life score.


Attendees will learn how to start activity tracking and how it can inform clinical and strategic decision-making. For those already tracking, this presentation provides some insight into how to improve the logistics around activity tracking or the use of the findings.

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AbstractExperiences of Measuring Patient ExperienceVarious Primary Care NetworksAlvin Yapp, BSc Shelby Corley, MA, CE Kristy Madsen, MPH, CEJessica Schaub, MPHLindsay Wodinski, MALaura Ewatski


Patient satisfaction is one of the indicators that Alberta Health is requiring PCNs to report on, however, a simple measure of satisfaction does not provide enough data to inform improvement efforts. As such, there was a need for a more comprehensive patient experience tool that measures the six different dimensions of patient experience identified by Wong & Haggerty (2013): (1) access, (2) interpersonal communication, (3) continuity and coordination, (4) comprehensiveness of services (5) patient reported impacts of primary health care, and (6) trust.


Our goal was to measure six dimensions of patient experience across the PCNs we work with using a comprehensive patient experience tool, and to inform ongoing development and quality improvement at the PCNs.


This poster will describe 1) the development of a comprehensive patient experience tool, 2) the deployment of the patient experience tool, 3) lessons learned about the process of deployment and, 4) how the results from the survey informed decisions at the PCN-level.

What did you find?

Across the different PCNs and clinics, the development of the survey has received mixed responses. Some have identified that patient experience is not currently a priority and therefore has not yet been deployed. Through attempting to deploy the survey across different clinics, we found 3 barriers to conducting a patient experience survey at the clinic-level. We also offer some potential solutions to each of these barriers.:

Barrier #1: Patient surveys add to workload of busy clinics

Solutions:

• PCN support of data collection via trained PCN Project Assistant in waiting room

• Simplify data collection with electronic collection (tablets)

• Create clinic interest via patient draw, signage

Barrier #2: Clinics are not interested in patient experience

Solutions:

• Engage with clinics who are interested in improvement work

• Promote the value of patient experience

Barrier #3: Clinics struggle to utilize survey results

Solutions:

• Facilitate discussion of results and potential implications for clinics through support of a PCN Improvement Facilitator – how can results drive quality improvement projects?

• Use concise, visual reporting

• Allow clinics to modify surveys to add specific questions of interest and importance


Others can use the tool that was developed as well as learn from our experiences in deploying the survey in clinics and at the PCN level using different methods.

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AbstractMoving to the Medical Home: Patients, Physicians and Panel Managers Red Deer Primary Care NetworkMargo Schmitt-Boshnick, BA., MEdCarol Maskowitz RN


Red Deer Primary Care Network (RDPCN) sought to assist clinics in becoming Medical Homes by embedding Support Nurses (panel managers) into the clinics, ensuring a successful introduction and transition for the Support Nurse, the Physicians and Clinic Team.


Creating an appropriate model for implementing this initiative was the primary goal, along with developing an appropriate service agreement, and role descriptions for the Support Nurses and the clinic Physician Champions.


RDPCN identified models in other PCNs and modified them for implementation within the PCN’s context. Three pilot clinics, each of a differing size, were identified for a two month project. Each clinic had initial meetings with RDPCN administration, completed a Medical Home Assessment and a Health Team Effectiveness survey prior to the arrival of the Support Nurse in the clinic. Improvement facilitation was provided to support the clinics.

What did you find?

Qualitative interviews with Physicians, Clinic Staff and PCN Staff determined that communication was key, both formally and informally, to ensure that the implementation of the Support Nurses into the clinics is successful. There will be an initial “dance” between Physicians and Support Nurses as they determine how best to work together for the benefit of patients. Physician Champions play a critical role and need to be supported by the PCN. Patients were happy about the improved access and screening that they received.


Led by a Physician, a Support Nurse, an Improvement Facilitator, and an Evaluator, this session will highlight videos from our patients and will provide an overview of the model that RDPCN developed, the issues of implementation, the successes of the pilot and our next steps. Audience members will be encouraged to provide their Medical Home experiences in the last part of the session.

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AbstractThe Value of Measuring Access from the Perspective of Early Adopters Alberta Health ServicesLisa L. Cook, PhDTony Mottershead, MScKelly Malach, MAShannon SimmsRichard Golonka, MScCharles Cook, PhDScott Oddie, PhD


Alberta AIM is a program that introduces quality improvement concepts to primary care through a series of interactive learning sessions. While there are several examples of AIM teams who have permanently adopted a culture of improvement, many struggle to sustain this culture after the learning sessions have ended.


The objective of this study was to determine the common characteristics of improvement teams who were successful in creating and sustaining a culture of improvement within their clinic.


A phenomenological methodology was used within five primary care teams Alberta. A focus group lasting approximately 45 minutes was conducted with each clinic between June and August 2016, structured around their experiences with measuring time to the third next available appointment (TNA), enablers of sustainment as well as barriers encountered.

What did you find?

All teams agreed that TNA was easy to implement. Sustainability was attributed to a clinic champion who was also positioned in a role able to deal with potential resistance, such as a manager or a physician. The collection and utilization of TNA for improvement was eventually seen as value added, however most physicians and team members admitted that this value

was not initially apparent. Regular and transparent reporting enabled all team members to participate in small tests of change, which when successful reinforced the importance of measurement. Successful TNA reductions invariably lead to tangible improvements in workplace satisfaction such as reduced stress, more manageable workloads and/or more positive patient interactions.


Sustaining an improvement culture requires constant support and reinforcement in the form of a clinic champion, transparent reporting and regular quality improvement themed discussions. Successful tests of change acted to reinforce the importance of measurement, with the most powerful changes in respect to cultural sustainment occurring where reduced wait times were accompanied by tangible improvements in staff satisfaction. Education for clinics who are considering embarking on a quality improvement journey should illustrate the benefits of an improvement culture on both staff and patient satisfaction as well as the potential for improvement in other external areas such as reduction in emergency department visits, increases in continuity and improved patient outcomes.

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AbstractMeasuring the Impact of Research Support Services in an Academic Medicine Department Using the Boyer Model of Scholarship University of Calgary, Department of Family MedicineAgnes Dallison, MSc, CEMonica Cepoui-Martin, MD, PhD


Using Boyer’s Model of Scholarship as a foundation, the Department of Family Medicine (DFM) wanted to see if physicians who utilize the services of the Research Hub within the DFM would have increased their scholarly output relative to physicians who did not utilize research services. The Research Hub is a group of staff members within the DFM who are available to assist physicians with all aspects of their research. This might include submission of ethics applications, methodological advice, qualitative and quantitative analysis, biostatistics support, journal selection assistance, and editorial services.

The Boyer model advocates the expansion of the traditional definition of scholarship into four domains that are more consistent with the present role of academic physicians: 1) original research, 2) synthesis of information within and across disciplines, 3) application of scholarly expertise in clinical practice, 4) scholarship of teaching.


We wanted to develop a reliable measure of scholarship that integrates all the aspects of academic physicians’ contribution to achieving best practices in healthcare. Further, we wanted to evaluate the effect of DFM academic physicians’ access to Research Hub support on their scholarship output, using the measure developed in the first step..


We reviewed the literature on the Boyer Model and criteria used to evaluate its four scholarship domains. Further, we layered additional information for each academic physician, including the proportion of time spent teaching and fulfilling clinical and administrative obligations and their research output as indicated by the number of grant applications, scholarly publications and scientific presentations. Further, the effect of engaging with the Research Hub on each domain of scholarship was quantified.

What did you find?

This initiative was still underway at the time this abstract was written. However, we expect to find that physicians who have utilized the Research Hub support have improved their scholarly productivity.


Other academic medicine sites can systematically analyze the scholarship output of their faculty utilizing the measure of scholarship developed in our department. The results of this analysis can be used to guide investments in research support for their academic physicians.

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AbstractMaking Scholarly Activity Accessible to the Public: Moving the Importance of Public Availability from “Nah” to “Now” University of Calgary, Department of Family MedicineAgnes Dallison, MSc, CEDave Jackson, BCommCharles Leduc, MD, MSc, FCFP


Academic medicine has traditionally been observed by its inner circles but is often overlooked by the most important stakeholders; the patients and public it serves. After all, will the public understand that the academic physician’s work is combination of teaching, research, clinical obligations, and administrative duties? Do patients know that their family physicians also conduct research, present at conferences, write grant proposals, all while providing the high level of care patients are accustomed to?

We’ve learned that it is the public at large that makes the decisions about funding, about public policy as taxpayers, as voters, as members of boards and committees. In addition, patients are savvy in researching a new physician they will potentially visit, their own symptoms, and medical resources available to them.


We felt it was essential for our Department to provide access to scholarship information to the public and community it serves. After mobilizing resources and communicating the need internally, we undertook developing an interactive, real-time dashboard of faculty scholarly activity that is freely available on the Department of Family Medicine website.


We translated the information related to scholarly publications documented in a static annual report (generally accessed only by internal stakeholders in the academic community) into a comprehensive real-time dashboard. The process of developing this easy-to-navigate dashboard included the following steps: inform our academics about the project, collect scholarly activity data and summarize it in a clear and understandable manner, translate these data to an interface on the Department of Family Medicine website, and collect feedback from stakeholders.

What did you find?

We found that in 18 months, we were able to achieve the type of dashboard we wanted in a cost effective manner, without relying on costly external software. The essential components of this initiative were committed resources, communication with faculty members, reliable sources of data, a dedicated project manager and IT consultants, and support from administration.


The information in this project may be of use to any organization considering collating their scholarly and professional output and organizing it into a format for consumption by colleagues and the public.

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AbstractMaking Mosaic PCN Accountable to its Member Physicians and their Patients Mosaic Primary Care NetworkCarol Cullingham, MA, BA, BScPeter Rymkiewicz, MSc, BcommNicole Gleeson, RN, MSNJason Shenher, MBAOliver David, MDCindy Simpson, RN, BN, MSAN


There is an increasing focus on PCN accountability within Alberta. Since 2015, Mosaic PCN has created a structured approach to its Measurement and Evaluation (M&E) strategy supporting strategic partnerships, comprehensive physician Data Sharing Agreements (DSAs), and in-house customized data collection and real-time reporting systems. This has resulted in increased capacity to support M&E demands.


Mosaic PCN Accountability and Evaluation Frameworks (AEFs) were developed to support integrated clinical service planning, delivery, and evaluation, with the ultimate goal of improving patient care. Specific objectives include:

• development of detailed program descriptions and clear goals aligned with provincial, PCI, and PCN objectives;

• M&E feasibility assessment;

• support for evaluation planning, collaboration, and accountability delineation between and within the M&E and Clinical teams; and

• production of robust, useful evaluations that inform program improvement and operational decision-making.


The foundation MPCN AEF document (November 2015) outlines the M&E process (design, data collection, etc.). Clinical teams must document detailed program descriptions, objectives, and draft evaluation questions using corresponding AEF templates before making M&E requests. The M&E team provides support for

articulation of program objectives as needed and, after assessing the measurement strategy feasibility, drafts the measurement, analytical, and reporting plan and reviews with the Clinical team for finalization and implementation.

What did you find?

MPCN Leadership required all Clinical managers to complete a first draft of the AEF for each of their programs and subprograms by March 2016 (25 in total). Since then, the M&E team has been collaborating with teams to refine program descriptions and objectives, and implement M&E strategies.

In addition to the above objectives, AEFs have:

• structured conversations and collaboration between Clinical and M&E teams;

• clearly documented decisions about and changes in planned M&E activities;

• provided a way to structure and prioritize requests for changes to existing data collection information systems; and

• contributed to annual report and business plan development.


Evaluation frameworks are not new, but when built on foundational DSAs and information systems and backed by PCN Leadership, they contribute to strong partnerships between M&E and Clinical teams, leading to robust measurement and evaluation supporting quality patient care.

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AbstractAlberta Family Physician Electronic Endoscopy (AFPEE) Study University of AlbertaMichael Kolber, BSc, MD, CCFP, MScNicole Olivier, RVTOksana Babenko, PhDCaitlin Finley, BHScRyan Torrie, MD, CCFPLee Green, MD, MPH


Previous studies have reported that Family Physicians perform high quality endoscopic procedures, while others claim that colorectal cancer rates of patients increase after colonoscopies performed by non-gastroenterologists. The Alberta Primary Care Endoscopy Study (APC-Endo) demonstrated that Alberta Family Physicians were able to meet quality benchmarks in colonoscopy with high patient satisfaction. However, APC-Endo was limited by its short duration (2 months) and small sample size. We set out to replicate this study on a larger scale and to determine if an electronic reporting platform would facilitate physician participation.


To electronically measure quality colonoscopy data from colonoscopies performed by Albertan Family Physicians and compare to existing quality benchmarks.


The REDCap electronic data collection tool was created with stakeholder input to ensure it met end-user needs without adversely impacting patient procedures or data collected.

Alberta Family Physicians performing colonoscopies collected data in real-time, using quality variables with corresponding pathology directly via study iPadsTM. Outcome measures were the proportion of cases with adenomas, number of adenomas per colonoscopy, successful cecal intubations and complication rates.

What did you find?Nine Alberta Family Physician colonoscopists collected data on 1769 procedures during the 6-month period, making this the largest multi-centre study examining the quality of colonoscopies performed by Family Physicians. The results show Family Physician endoscopists perform high quality colonoscopies, individually and collectively meeting important quality benchmarks.


When designed to meet procedure flow and reporting needs, physicians and their support teams are willing to participate in electronic, real-time data collection. Electronic data collection facilitates data reporting to the practitioner, providing the opportunity for self-reflection and improvement of patient outcomes. In today’s climate of health care measurement and quality, this tool could be expanded for zonal and provincial data collection and to other procedures or surgeries where reporting and end-user reflection could lead to improving practices and performance as well as improving credentialing process for learners and hospital program accreditation.

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AbstractExploring Processes That Link Patients To Primary Care Providers: The Alberta Context Alberta Health ServicesDr. Ceara Tess Cunningham, PhDScott Oddie, PhDTanmay Patil, HBSc, MPHShawna McGhan, RN, MN


In 2014, the Office of the Auditor General report on Chronic Disease Management Services indicated there are currently no processes to identify patients with chronic diseases who cannot find, and therefore are “unattached” to a primary care physician in Alberta, and no process to provide them with ongoing care.


Alberta Health Services (AHS) Primary Health Care (PHC) Portfolio formed three working groups for the Informing the Attachment Process project, focused on informing the processes that link patients to a regular primary care provider in Alberta. These three groups had provincial representation from groups within PHC and across five zones of AHS.


(1) Used administrative data to identify and determine characteristics of patients with or without chronic disease who present to a PHC provider

(2) conducted an environmental scan of AHS initiatives that support linking patients to a PHC provider; and

(3) assessed the literature and processes that lead patients to securing a regular PHC provider.

What did you find?The majority of patients in Alberta without a regular provider were men (62.6%), did not have a chronic disease (94.9%), and belonged to the healthy or health care non-user status based on administrative data. The environmental scan revealed many processes both active (n=19) and passive (n=15) that facilitate linking patients to PHC services. Barriers related to these processes include primary care access issues (i.e. complex patients), patient preferences (i.e. young males) and cultural norms (i.e. immigrant populations). The literature review identified five key themes related to linkage processes; patient perspectives, provider factors, characteristics of the unattached, and structural and organizational factors.


Our findings dispel commonly held beliefs that those who do not have a regular PHC provider are mostly complex patients with multiple chronic conditions. Given these results, better understanding the PHC patient population and evaluating which processes are effective for linking patients to PHC services is critical to meet the health needs of Albertans.

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AbstractTackling Panel Identification in an Academic Teaching Centre Central Family Medicine Teaching CentreScott Jalbert


The Central Family Medicine Teaching Centre (CFMTC) prior to 2015 had no clearly identified process to address routine management of our patient panel. The concern was many operational decisions were being made based on our patient panel levels which had not been reviewed routinely or systematically, and were likely to contain many patients whom had moved on to other provider options without our awareness.


CFMTC sought to improve the accuracy of our patient panel by reaching out to a specific population (patients on our active panel list whom had not had a visit in the clinic in greater than 3 years) in hopes of clarifying if the patient continues to see us as their Patient Centered Medical Home, or if they had moved on to another service for their primary healthcare needs. This declaration exercise was anticipated to improve the accuracy of the active patient roster, thus leading to improved visit utilization (not holding capacity for a non-existing demand) and operational management.


A multi-staged initiative was created, with the first step to identify and contact all patients not seen within the clinic for more than 3 years for all physicians whom had panels active in the clinic greater than the same timeframe. Phase 1: The “Big Clean” was launched in April 2015 and completed August 2015. Phase 2: The “Re-Attachment” phase focused on identifying and contacting all patients whom, due to transitioning of various exiting and newly contracted physicians, needed to confirm their desire to remain within the clinic. Lastly, Phase 3: “Routine Panel Identification” processes were launched April 2016, enabling routine panel cleaning for all physician panels every 6 months.

What did you find?What did you find?

Of a total active patient panel of 10500 patients at CFMTC, Phases 1 & 2 lead to the identification of 2493 patients whom either had a new provider for their family medicine care or were “unreachable” after multiple attempts to contact them, thus were “inactivated” within our clinic panel. Data for our Routine Panel Identification (Phase 3) is still awaiting analysis, but approximately another.


Whether an academic teaching centre or community family medicine clinic setting, knowing your panel is an essential aspect to running a high quality Patient Centered Medical Home. The literature which looks at best practice for panel identification is limited, so our hope is to share our journey to date, both successes and the lessons learnt in hopes it will be of use to other centres.

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AbstractSteps Toward Comparable Reporting: Using EMR Data for Performance Measurement Canadian Institute for Health InformationCharisa Flach, MA, Project Lead, Primary Health Care InformationTanya Khan, MHSc, Project Lead, Primary Health Care Information


There is currently a gap in primary health care data and efforts to improve data availability would help support comparative reporting and performance measurement across Canada’s jurisdictions. Some of the challenges include local variations in data collection, different vendor systems and differences in indicator technical specifications.


In 2014, CIHI released a priority subset of Primary Health Care EMR Content Standard (version 3.0) to enable the collection of a minimum set of data elements for both clinical and health system use.


In 2015-16, CIHI undertook demonstration projects in Ontario with two primary health care organizations that aimed to test the feasibility of implementing PHC EMR Content Standard within an existing system. The projects looked at the impact of implementing the Content Standards on data collection, data quality and the ability to calculate PHC performance measures.

What did you find?Key findings for the demonstration projects are as follows:

• Project partners were able to extract and submit usable EMR data for analysis;

• Different models of care influenced aspects of data extraction, analysis and interpretation;

• The project evolved to include multiple data extraction, submission and analysis cycles (i.e., iterative approach) to resolve issues; The projects emphasized the strong need for clinician change management and education;

• There was high interest in practice profile and clinical indicators. However, more refined technical specifications and longer period of data collection are required to derive benefit for performance measurement.


The demonstration projects tested the feasibility of implementing PHC EMR Content Standard in existing EMR systems. Further engagement with EMR vendors, as well as enhanced clinician change management support, will drive future progress in EMR data standardization and data collection efforts across different types of PHC practices in Canada. For performance measurement in PHC, a more established and defined set of EMR-based practice indicators will enable comparable reporting. Going forward, the broader uptake of these indicators across Canada would help to fill a current data gap by supporting pan-Canadian PHC performance measurement.

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AbstractPrimary Care Initiatives: Continuity and Transitions in the Urban Calgary Zone Alberta Health ServicesSarah Rogers, Service Planning Consultant, Department of Family Medicine


Multiple initiatives are currently intended to support a person-centered health care system, specifically those developed with the goal of enhancing communication between providers as it relates to patient care plans. To ensure our Primary Care Partners and Physician Membership are aware of and not replicating work in either within Acute Care and Primary Care programs and services, we need to understand the work currently underway.


To develop a comprehensive report on current activities and resources related to primary care transition and provide an update on the status of well-known initiatives. Particular attention to information sharing and communication strategies was an important part of this work. This direction will help determine areas of support required for our physicians, primary care partners, and in turn our patient population.


An environmental scan and gap analysis was conducted to obtain information on past, present, and future initiatives targeting continuity of care in primary care. Multiple health care stakeholders were interviewed from August 2016 – October 2016. A completed report will be available for distribution in November 2016.

Information gathered was grouped by Clinical Sections within our Department, and included: • target populations • key resources• stage of initiative• budget• gaps in services• risks• scale/spread• method of evaluation

What did you find?Multiple collaborative initiatives are currently in various stages of implementation, ranging from provincial to local in scope. Multiple overlapping themes were identified and include work relating to complex high needs populations, Case Management strategies, multiple communication barriers between providers, restricted resources leading to lack of measurement and/or evaluation and Information Technology (IT) system issues.


Work happening in silos can cause duplication of efforts in primary care. Our hope is that primary care partners can look to this report to understand the local landscape of transitions in the health care system. This report will also provide a template for similar work to be completed in other zones.

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AbstractThe Application of Change Management Principles in Initiative AdoptionSouth Health Campus - Academic Family MedicineRon Garnett, MD, CCFP(EM), DipSportMed, Medical Site LeadJane Bowman ManagerJoe Tabler, PharmDNancy Hermann, RNMelina McArthur, RN


The transition from traditional practice to medical home involves change, sometimes away from the familiar and comfortable. Often this involves adopting initiatives seeking to improve quality in areas of population health, workflow or clinical process. Some initiatives easily achieve acceptance and success, while others struggle. Conventional management teaching holds that 70% of transformation efforts fail, often from lacking a holistic approach in which the entire workforce is engaged effectively.


We sought to establish whether a relationship might exist between the degree of adherence to change management principles, and the probability of acceptance and success in the adoption of initiatives in the medical home setting.


We retrospectively analyzed the degree to which three initiatives adopted by the South Health Campus Academic Family Medicine clinic complied with the eight change management principles of John Kotter, then compared that to the estimated level of acceptance and impact.

What did you find?Attention to components of the Kotter change model may be predictive of success. Steps fostering a climate for change, particularly around the development of a sense of urgency and engagement in those most affected by, and necessary, for a workflow modification, are important. Initiatives allowing only minimal direct design influence and decision-making by local participants may be prone to struggle.


Medical home leadership hoping to optimize the impact and success of an initiative may wish to refer to some change model checklist early in the planning stages. In particular, the creation of a “guiding coalition” deserves consideration. This ideally would include and engage in the decision-making, those local people whose efforts will be required in the implementation.

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AbstractImplementation of a Primary Care Network targeted educational session combining data with feedback and Choosing Wisely RecommendationsAlberta Physician Learning ProgramAshi Mehta, Project ManagerDiane Duncan, Senior Project ManagerSampson Law, Operational ManagerDr. Shawn Dowling, Medical DirectorLaura Rivera, Research AssociateDr. Jim Bell, Family Physician, St. Albert and Sturgeon PCNDr. Lara Cooke, Associate Dean Continuing Medical Education, University of Calgary


Engaging family physicians to reflect on their practice can be challenging. Data-with-feedback is a knowledge translation intervention which aims to optimize practice by providing a measure of a clinician’s performance coupled with a feedback component. We describe a partnership between Choosing Wisely Alberta (CWA) and The Alberta Physician Learning Program where we administered a data-with-feedback educational event for a group of family physicians.


Our aim was to determine whether this multi-faceted educational event was able to engage physicians to use their individual data to explore and reflect on the potential for clinical practice changes with respect to the three Choosing Wisely topics.


An accredited continuing medical education event was administered in February 2016, where family physicians affiliated with St. Albert-Sturgeon Primary Care Network (PCN) were eligible to participate. The multi-faceted educational session provided family physicians: 1) health administrative data reports presenting individual and aggregate-level (i.e. PCN and provincial) data on three Choosing Wisely recommendations (i.e. pap smear testing, osteoporosis screening, and lumbar spine imaging); 2) a didactic session by a subject matter expert on pap smear best practices; and 3) a feedback session where family physicians had the opportunity

to discuss the data reports and their implications. To evaluate the impact of the educational intervention, we administered surveys to all participants and conducted an interview with the PCN physician project lead 6 months later.

What did you find?The surveys revealed that the event was well-received by practicing physicians with 100% of them recommending a similar event to their colleagues. The interview with the physician lead revealed that 100% of physicians in one PCN clinic participated in self-directed reviews of their own electronic medical record data with peer comparator, discussions with peers relating practice data to their local context and evidence, and plans to conduct periodic data reviews going forward.


The provision of data reports coupled with a didactic session from a subject matter expert and opportunity for reflection with peers in a feedback session resulted in engaged discussions and sustained impact. Based on the positive results of this project, we are offering similar events to other PCNs.

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AbstractTobacco as a Vital Sign in Primary Health Care SettingsAlberta Health ServicesDarrel Melvin, RRT,CRE, CTE


Tobacco use is considered to be a global health epidemic and is the leading cause of preventable death and disease worldwide. According to the World Health Organization, the use of tobacco is a risk factor for six out of the eight leading causes of death worldwide (World Health Organization, 2013).

Tobacco is the only consumer product which will kill one out of every two users who use as directed. In terms of overall health, there is sufficient evidence that smoking diminishes a person’s overall health, the manifestations of which included impairment in self-reported poor health, increased absenteeism from work and increased use of health-care resources and associated costs. Furthermore, over the last 50 years, the risk of dying from smoking cigarettes has increased. In Canada, approximately 17% of all deaths are due to smoking (20% for males and 12% for females) (Yoshikawa, Hellstrom-Lindahl, & Grill, 2005).


Smoking cessation is the most important, cost-effective preventive maintenance that clinicians can offer patients who smoke. It has been called the “gold standard” of prevention interventions (Eddy DM, 1992). Primary care clinicians can play a key role in identification, assessment and treatment of smoking. Tobacco dependence is considered to be a chronic relapsing condition involving nicotine addiction and cycles of relapse and remission. As such it should be managed as any other chronic disease.


Primary care clinics may experience challenges in implementing tobacco cessation within their busy, fast-paced setting. In most cases it requires the development and implementation of a systematic approach that involves many clinic staff in many roles.

What did you find?In the last three years, the Alberta Health Services Tobacco Reduction Program and primary health clinics across the province have been working together to integrate systematic tobacco cessation approaches along with standardized cessation training and resources for primary health care service providers.


This session, moderated by AHS Tobacco Reduction Program, will feature panel presentations by primary care clinicians who will showcase their models for the identification and treatment of tobacco, tools and resources, and group cessation programs that can be easily shared and used by other primary care clinics. The panel will also include a primary care patient discussing their tobacco cessation journey using primary care cessation supports and services.

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AbstractInitiating a Site Level Quality Management Framework: Clinical Improvement Team (CIT)AHS — Department of Family Medicine — Central Family Medicine Teaching CentreScott Jalbert, RN BScNSarah Willis, RN, BN


The University of Calgary’s Central Family Medicine Teaching Centre (CFMTC) had a large number of quality improvement ideas with a limited amount of resources to review or address.


The CFMTC needed a process to develop quality improvement priorities in alignment with local site needs, internal & external stakeholders. To facilitate intake, promotion, prioritization, and support quality improvement initiatives by establishing a multidisciplinary quality improvement team to plan, implement and sustain QI projects.


CFMTC formally launched our Clinical Improvement Team (CIT) on May 19, 2015. CIT is a multidisciplinary group with leadership from each discipline. CIT developed an opportunity tracking tool (OTT) to assist with tracking intake and prioritization of purposed enchancements.

What did you find?CFMTC found that within the last fiscal year the CIT prioritized and completed 41 specifically identified projects of various scales.


The Opportunity Tracking Tool (OTT) reaffirms how to prioritize and ensures all projects are evaluated equally.

Priorities can change, tracking trough PDSA worksheets (Plan, Do, Study, Act) allows you to stop and start projects as they’re prioritized.

CIT acknowleges that further Education is recommended, AIW “Core Training” to develop further prioritization & QI project management skills.

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AbstractPanel Identification and Improvements — The Big CleanAHS — Department of Family Medicine — Central Family Medicine Teaching CentreScott Jalbert, RN BScNJulie Wilson, Head Receptionist


CFMTC identified several discrepancies with the clinic utilization levels and the accuracy of our patient panels.


CFMTC wanted to clean our patient panels by identifying which patients no longer see our clinic as their patient centered medical home.

We also wanted to open clinic capacity to introduce new patients.


The formal “Panel Management Initiative” was launched in April 2015. Initiatives consisted of the following components:

The Big Clean - reaching out to all patients whom have not been seen in over 3 years to see if they still wanted to be seen here. (Completed August 2015)

Re-Attachment - of all patients whom used to be paneled to MD’s who no longer worked within the clinic. (Completed August 2015)

Increasing New Patient Volume - to ensure we have enough visit to volume to match our clinic capacity and learner experiences.

What did you find?Panel Identification and New Patient Numbers:

A total of 2493 patients were identified to either have found a new provider or were unreachable after multiple attempts, thus “inactivated” in our system.

With an “uncleaned” total clinic panel on July 1, 2014 of 10500 patients, and a “cleaned” total clinic panel as of March 31, 2016 of 14250, when considering the number of inactivated patients through the cleaning efforts, our clinic has in the last 16 months enrolled 6243 new patients - a 43% increase.


A process to contact patients was developed and data was collected to it’s effectiveness. Patients were contacted both verbally and written word. Responses were tracked and the process was amended for future rounds of panel cleaning.

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AbstractAlberta Screening and Prevention (ASaP)AHS — Department of Family Medicine — Central Family Medicine Teaching CentreTasha Stainbrook, LPNScott Jalbert, RN BScN


Patient screening and prevention management is done well when patients book screening appointments. Approximately 30% of patients do not book screening appointments. CFMTC would like to increase the number of patients approached about preventative screening.


CFMTC wanted to create a proactive opportunistic screening and prevention management process that could be implemented clinic wide.


Preparations included engagement with various stakeholder groups with previous experiences related to ASaP roll outs, training in ASaP concepts, formalized detailed project plan development including the creation of ASaP working group in April 2016. Development of formalized protocols and workflows.

What did you find?An initial chart review revealed low numbers of screening outside of peridoc health visits. Lack of standardization in the location that screening information is captured with in the EMR, which makes it difficult to find.


Detailed processes for screening including multidisciplinary workflows have been developed. Standardization of practices in EMR charting have increased the capture of screening and notification of over due screening.

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AbstractLocal Data for Evidence Based Decision MakingEnhancing Alberta Primary Care Research Networks (EnACt)Lee A Green, MD, MPHArvelle Balon-Lyon, RN, BNMark Watt, RN, BNRandy Campbell, ACS, HIA, FLMIKylie Kidd Wagner, MScTanya Barber, MA Lee A Green, MD, MPH


Primary care providers do an excellent job of providing screening and preventative care to patients who present for these services, but a gap exists in providing this care to a large portion of Albertans who are attached to a primary care provider, but do not present for screening. In 2013 80% of Albertans had a family physician, yet nearly one third of patients were not receiving appropriate screening care.


The Alberta Screening and Prevention (ASaP) initiative sought to improve the rate of offering population-based screens and preventative care by primary care provider and their teams across Alberta.


ASaP supported Primary Care Networks (PCNs) and their member physicians to engage in process improvements, including opportunistic and/or outreach screening methods to target the non-presenting population. A menu of evidence-based clinical maneuvers was developed and chart reviews were conducted to assess baseline and follow-up screening offer rate. Physicians and their clinic teams were supported by a trained improvement facilitator.

The design required participants to explore Patient’s Medical Home (PMH) concepts of panelling, quality improvement, team-based care, evidence-informed care and patient-centred care.

What did you find?PCN member physicians and their clinic teams volunteered to participate in the initiative. By September, 2016 474 physicians had completed a follow-up chart review. Logistic regression analysis is underway. It is anticipated that we will be able to show a statistically significant effect of the intervention by showing improvements in overall screening offer rate before and after the improvement period.


This initiative provides Alberta with meaningful, local data on which to base evidence-informed decisions. As well, closely aligning clinical improvement opportunities to PMH principles allows practices to develop PMH competence.

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AbstractHow Best to Help Patients with Obesity? Examining Mental Models of Clinicians to Optimize Obesity Prevention Enhancing Alberta Primary Care Research Networks (EnACt)Lee A Green, MD, MPHSonja Wicklum, MD, FCFPThea Luig, PhDAshlee McGuire, PhDMaureen McNaul, BN, MBAJennifer Corrales, MD, LMCC, CCFPKylie Kidd Wagner, MScSandee Foss, RNBarbra McCaffrey, BSc, DipEdLaurie deBoer, RN, BNMichele Hannay, BScTanya Barber, MAMelanie Heatherington, MEdArya Sharma, MD, PhDDenise Campbell-Scherer, MD, PhD, CCFP, FCFP


There is a substantial lack of capacity in primary health care to deliver effective obesity prevention and management to patients. To support primary care clinicians with this work, Calgary Foothills Primary Care Network recognizes a care pathway is needed to i) optimize and organize their thought processes around obesity, ii) look at patient readiness and challenges, and iii) identify resources they can leverage to address challenges. Such a pathway would not only support the delivery of more effective obesity prevention and management, its implementation may also help with the identification of gaps in care which can then be addressed.


To inform the development of an obesity prevention and management care pathway, this project sought to understand the existing mental models of the different providers who care for patients living with obesity – e.g., knowledge, attitudes, how decisions are made, how teams manage and coordinate care, approaches/processes used and best practices followed.


Family physicians, allied interdisciplinary clinician team members and managers were asked to participate. Facilitators trained in a qualitative technique called concept mapping captured participants’ mental models around obesity prevention and management using a focus question – i.e., “how do you, as a primary care clinician, help a patient who is accumulating body weight?” along with prompting questions as needed. Interviews lasted one hour and were conducted individually with participants.

What did you find?The project is currently in progress. Early results, mental models developed and key findings will be shared.


The care pathway developed from these findings can be used and adapted by practices, other PCNs and similar entities outside Alberta. Over time, gaps may be identified and addressed. Investing time and resources to explore the existing mental models of the target audience for which a tool or resource is being developed has broad application

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AbstractScaling Up Chronic Disease Management in Alberta Enhancing Alberta Primary Care Research Networks (EnACt)Lee A Green, MD, MPHLaurie deBoer, RN, BNSandee Foss, RNJune Cooper, RNBarbra McCaffrey, BSc, DipEdKylie Kidd Wagner, MScSue Peters, MClScJohn Lester, BSc, CPFAndrea Atkins, MBAJune Austin, RNKari Remington, BSc Michele Hannay, BScEileen Patterson, BA, MCE, PMPMark Watt, RN, BNTanya Barber, MA


When chronic disease management (CDM) is done well it can achieve significant clinical improvements quickly and across large populations. The evidence on “doing CDM well” in the Alberta context relies on leading edge practices’ experiences, however there are a growing number of practices who are gaining their first experiences with CDM through Primary Care Networks. Providing the right tools and supports for practices engaging in CDM requires more than replicating what worked for the leading teams; it requires understanding how different teams conceptualize CDM and perform the work day-to-day.


This project sought to understand how different physicians and team members (individually and collectively) manage their patients living with chronic diseases – i.e., the teamwork behind the care. By interviewing teams who have been successful with CDM and teams engaging in CDM we will develop valuable insight into what supports and strategies teams new to this work will find useful.


Physicians and 1-2 of their team members from a variety of practices (e.g., urban/rural, small/large) were asked to participate. Interviewers trained in a qualitative technique called cognitive task analysis (CTA) conducted one hour, one-on-one interviews with participants. The CTA interview method was effective in eliciting tacit knowledge about how teams perform CDM; this is the type of information which is often so automatic that the methods and reasons behind them go unnoticed or are misperceived unless specifically and skillfully elicited.

What did you find?The project is currently in progress. Early results, mental models developed, and application of the findings will be shared.


The findings will be shared with policy makers, leaders in medicine and other stakeholders to develop evidence-informed approaches to take the implementation of CDM key initiatives (new and existing) in our province to impactful scale. In general, the method of “going to see” how care providers “do things” is a strategy for successful project implementation.

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AbstractBridging the Valley of Death in Health System Innovation: Taking Innovation to Scale in AlbertaEnhancing Alberta Primary Care Research Networks (EnACt)Lee A Green, MD, MPHSandee Foss, RNKylie Kidd Wagner, MScJohn Lester, BSc, CPFSue Peters, MClScBarbra McCaffrey, BSc, DipEdLaurie deBoer, RN, BNJune Cooper, RNAndrea Atkins, MBAJune Austin, RNKari Remington, BSc, BScMichele Hannay, BScEileen Patterson, BA, MCE, PMPMark Watt, RN, BNTanya Barber, MA


Transforming practices to a new way of organizing care delivery [i.e., the Patient’s Medical Home (PMH)] is easier said than done. While many successful demonstrations of PMH elements can be found in our province broader adoption has yet to occur. Diffusion of innovation theory, a long standing, large body of literature across many industries (including healthcare) addresses this very topic. The jump from successful pilots among “early adopters” to reaching the mainstream is the critical point where many innovation projects/initiatives get trapped – the “valley of death”. To cross it, a better understanding of how a variety of mainstream teams earlier on in their transformational journeys think about and approach the work of change is needed.


This project sought to gain insight into different teams’ mental models when adopting a new way of working in their practices. By understanding how physicians and team members think and work when presented with complex change projects/initiatives, more effective strategies for broader engagement and support can be developed.


Physicians and 1-2 of their team members from a variety of practices (e.g., urban/rural, small/large) were asked to participate. Interviewers trained in a qualitative technique called cognitive task analysis (CTA) conducted one hour, one-on-one interviews with participants. Unlike traditional interview methodologies, CTA was effective in eliciting tacit knowledge; the information and processes which are often so automatic that the methods and reasons behind them go unnoticed or are misperceived unless specifically and skillfully elicited.

What did you find?The project is currently in progress. Early results, mental models developed, and application of the findings will be shared.


The findings of this research will provide policy makers, leaders and other stakeholders with a framework for designing or modifying large scale interventions to increase spread. In general, the “going to see” approach can be used by others exploring how to spread and scale innovations.

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AbstractBuilding Partnerships to Improve Care of Early Knee Osteoarthritis (KOA) Patients: Co-Developing a Mobile-Health Prediction Tool for KOA ProgressionEnhancing Alberta Primary Care Research Networks (EnACt)Lee A Green, MD, MPHBehnam Sharif, PhDSylvia TeareJean Miller, PhDSandee Foss, RNBarbra McCaffrey, BSc Dip EdEileen Patterson, BA MCE PMPLaurie deBoer, RN BNMark Watt, RN BNMichele Hannay, BScKylie Kidd Wagner, MScTanya Barber, MALee A Green, MD MPHDeborah A Marshall, PhD


A gap exists between our knowledge about Knee Osteoarthritis (KOA) progression and the application of this knowledge in routine clinical practice. Would a prediction tool for KOA progression assist in promoting healthier outcomes?


We sought to understand patients’ and family physicians’ perspectives on the need for a mobile-health prediction tool for KOA progression to improve patient care.


Preliminary work included collaborating with Patient and Community Engagement Research (PaCER) and Enhancing Alberta Primary Care Research Networks (EnACt) to explore how early KOA was managed and if a prediction tool would be used by physicians and patients. This qualitative approach included: 1) focus groups and interviews with 25 patients conducted by Patient Engagement Researchers from PaCER applying Set, Collect and Reflect methodology; and 2) Cognitive Task Analysis (CTA) interviews with 3 family physicians to elicit their tacit knowledge and gain understanding of their mental models of KOA.

What did you find?PaCER identified 3 themes: 1) patients need information about the stages of KOA progression; 2) shortage of physician and PCN knowledge of self-management strategies and local resources; 3) patients want integrated personal self-management planning. The CTA interviews revealed family physicians have

( 1) a solid knowledge of early KOA and managing with lifestyle interventions;

(2) no use for a progression calculator in managing KOA, but suggested it be used as a self-management strategy for patients;

(3) one global mental model of KOA that includes categorizing knee pain as osteoarthritis vs. other conditions; importance of clinical assessments of the knee; management and treatment; and addressing patient expectations.


By exploring how providers and patients manage early KOA it became apparent that physicians would not use a progression prediction tool for their treatment of KOA, while patients wanted information, resources, and a way to engage with supported self-management strategies. This insight led to a re-examination of our approach and assumptions about developing a progression tool for early KOA. Our new vision is to co-design a self-management tool that will increase patient and physician communication and engagement in terms of shared decision-making and evidence-based self-management planning. Working in partnership with providers and patients is imperative for meaningful project implementation.

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AbstractEngaging Patients in Improvement – “Nothing about us, without usAlberta Medical Association, Choosing Wisely AlbertaEileen Patterson, BA, MCE, PMPMarlyn Gill, MSWMark Watt, RN BNEileen Patterson, BA MCE PMPTanya Barber, MALee A Green, MD MPH


Over 20% of Canadians experience low back pain (LBP) lasting more than six months. LBP has been cited as the third most prevalent reason patients consult their family physicians. Choosing Wisely Alberta’s (CWA) initiative to decrease unnecessary tests and procedures included a study of family physicians’ and patients’ experiences dealing with LBP in cases without red flags.


We sought insight into patient perspectives of prevailing services for those with non-red flagged LBP, and into physician drivers of care decisions. Understanding these perspectives would be useful for family physicians consulted by these patients and might avoid potential demands for unnecessary DI and repetitive consults. Quality improvement (QI) was the goal.


The Patient and Community Engagement Research (PaCER) programme was engaged to conduct a qualitative study of the patient perspective. Using the PaCER SET – COLLECT- REFLECT framework the team conducted five focus groups and two narrative interviews. The data was analyzed using participatory grounded theory.

Enhancing Alberta Primary Care Research Networks (EnACt) conducted Cognitive Task Analysis interviews with physicians of diverse practice profiles to understand the key drivers which affected their decisions related to care. Data was analyzed for key themes that could inform future QI interventions.

What did you find?Five major patient themes emerged outlining

(1) patients’ experience with the larger healthcare system,

(2) relationship with the family physician,

(3) patient perspectives of DI,

(4) patient responsibilities and

(5) patient experiences living with LBP.

Patients perceived being caught in a revolving door; incomplete information and lack of specific referrals led to patients entering a confusing array of alternative treatments.

Physicians were using evidence based decision making, with patient and system factors influencing their choices of imaging and care options.


Promote key elements to be included in LBP patient-provider healthy conversations:

• Communication of the assessment for red flags symptoms which, when absent, indicate imaging is not required and may even harm improvement

• Guidance about which alternative services would fit best for them

• “Warm handoff” to known allied providers or groups

• LBP educational pamphlet to support the discussion and care planning.

• Address external demand

Facilitate conversations among health system stakeholders to build consistency and appropriateness of imaging messages.

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AbstractEngaging Patients in Improvement – “Nothing about us, without us” Toward Optimized Practice (TOP)Marion Relf, RN MHSAJohn Lester, BSc CPFShannon Horricks, BEdArvelle Balon-Lyon, RN BN


How to effectively involve people living with MS in the design and delivery of a learning collaborative.


We wanted to ensure the perspective of people living with MS was included in every step of the collaborative, from development to delivery, and used as a guiding light.


• Included diversity of perspective, geography, etc.

• Engaged community partners (MS Society and the MS Clinic) to identify people who would be interested

• Asked for best practices of how to engage people living with MS from partners

• Captured their stories to frame the collaborative (video interviews to set the guiding light and follow up interviews)

• Involved with webinars, feedback and face to face meetings

• Specific considerations of respecting the patient perspective (see next question)

• Sought permission (feedback) every step of the way

What did you find?“Nothing about us, without us,” was one of the quotes that came out of the feedback process. People living with MS were surprised at the challenges that clinicians also had with “the system”.

Some key learnings:

• Tap into community not for profit organizations and support groups to accelerate recruitment and add credibility to recruitment efforts.

• Consider diversity of participants for additional depth to the discussion.

• Recruit enough public/patient members to allow for their voices to be heard among professionals.

• Include practical supports, such as covering expenses, explaining acronyms and system issues, and clarifying roles.

• Plan additional contacts as part of orientation and continuing throughout the period of engagement to define and reinforce the contribution of public/patient representatives.

• Respect individual preferences and conditions: adapting plans, adjusting timetable, allowing participants to withdraw or honoring other requests.

• Seek consent after full disclosure of intent of participation, how/if names will be used and expectations.


During the entire process we documented key learnings and steps for future improvement work. We have also reflected on how it could have been improved. One key learning about engaging patients is how to set an environment to ensure their voice is heard and that it becomes the foundation of the work. Recruit, Engage, Orient.

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AbstractHealth Management Program Alberta Health Services, Sunridge Family Medicine Teaching CentreKathy Stewart, RN, BNNicole Phillips, RN, BN, CPCC, ACC


To develop a patient centered approach to improve the general health of identified patient populations at the Sunridge Family Medicine Teaching Centre.


To optimize the health management of identified at risk patients by using a collaborative approach between the patient, health management nurses, physician, resident and the allied health team. Goal is to help patients regain/maintain optimum health, improve functional capability, provide high quality patient centred care and ultimately improve patients’ and providers’ experience of care.


(1) Identified the target population at the Sunridge Clinic (ie. Chronic disease; High system utilization; Poorly controlled patients; Complex conditions; Struggling with life style changes).

(2) Referrals to the program occur from various sources within the clinic: Allied health team, staff, physician and residents. Patients can also self-refer to the program. Involved with Partners for Better Health - identify high system utilizers of the Peter Lougheed Hospital.

(3) Patients are connected with a health management nurse. The health management nurse assists patients in optimizing their health through comprehensive case management.

(4) Program was started with Complex Care Plans (CCP). CCP is reviewed annually and as needed based on the patient.

(5) Team collaboration with the clinics large and specialized allied health team.

(6) Developed standard care plans to allow the health management nurses to adjust patient treatment within specific parameters. Developed a Diabetes Care Pathway, now starting to develop a Hypertension Care Pathway.

(7) Monthly Case Conferences with the Health Management Team to discuss patients and strategize on ways to improve patient outcomes.

What did you find?Two patient surveys have been completed to evaluate the Health Management Program. Overall, the results were positive indicating the Health Management Program was well received. Third patient survey is in process.

Physicians and health management nurses are finding there is an improved understanding of patient needs and goals, improved patient care, patients are developing the skill to better manage their own care, better connection with the patients’ medical team and understanding of how everyone works together for the care of the patient.

Case conferences are well received by the Health Management Team. Benefits expressed: Ability to address complex issues from different points of view and scope of practice, learning what other disciplines can do to assist the patient, increased ability to make important decisions as a team, better communication in person verses reading entries in the EMR and increased interaction with physicians.


The Health Management Program is an example of a team approach for optimizing health management of high risk patients. Using a patient centered approach and encouraging/supporting patients to manage their own health, is a win for the patients and health care.

Patients are more ready to help themselves when they are leading their own health and have better success in making permanent lifestyle changes. We are anticipating this program will reduce patient high utilization rates of ER, hospitals and repeat visits to family physicians, thereby decreasing health care costs and opening appointments in primary care.

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AbstractFacilitating Resident and Family Engagement in Alberta Continuing Care Facilities Network of Excellence in Seniors’ Health and Wellness, Covenant Health Jasneet Parmar, MBBS, DipCOEKathy Classen, BAJulie-Ann Babiuk, MSc, PMPPeter George Tian, MD, MPH


Resident and Family Councils (RFCs) are mechanisms for families to share their ideas and for operators to proactively share information and to develop plans in cooperation with families. Implementing effective RFCs in continuing care facilities will help ensure that families and residents are active partners in care. We will address the lack of RFCs in continuing care settings.


The goal of this project is to positively impact and support effective Resident and Family Councils based on evidence of best practice adjusted to the Alberta environment.

How did you go about addressing the issue to reach your goal?Two patient surveys have been completed to evaluate the Health Management Program. Overall, the results were positive indicating the Health Management Program was well received. Third patient survey is in process.

Physicians and health management nurses are finding there is an improved understanding of patient needs and goals, improved patient care, patients are developing the skill to better manage their own care, better connection with the patients’ medical team and understanding of how everyone works together for the care of the patient.

Case conferences are well received by the Health Management Team. Benefits expressed: Ability to address complex issues from different points of view and scope of practice, learning what other disciplines can do to assist the patient, increased ability to make important decisions as a team, better communication in person verses reading entries in the EMR and increased interaction with physicians.

What did you find?Anticipated Results: Findings from the pilot projects for implementation of the RFC toolkits will be broadly disseminated through the Network’s’ communications mechanisms. Recommendations will be sent to AHS and Covenant Health for consideration and follow through.


Continuing care facilities would have the capacity to create their own Resident and Family Councils.

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AbstractPan PCN Collaboration to provide After-Hours Medical Coverage to Long Term Care Facilities.Calgary Foothills Primary Care Network and Calgary West Central Primary Care NetworkKara Patterson, MSc, MHScChristopher CameronDr. Peter ThorntonDr. Mike Geoghegan


The Long Term Care On Call program, operated by the Calgary Foothills PCN and Calgary West Central PCN, manage and support a group of 90 family physicians who provide after hours medical coverage to 29 long term care (LTC) facilities in the city of Calgary. Two physicians are on-call each week to provide coverage between the hours of 4:30pm-8am on weekdays and 24 hours on weekends and holidays; facilities are divided into a north and south geographic area and one physician is on call for each. The goals of this on-call group are to increase access to medical services in order for residents to stay in their facility.


The goal of this program is for LTC residents to receive coordinated after hours medical care in order to remain in place.

How did you go about addressing the issue to reach your goal?Since the introduction of this program, statistics have been collected to understand whether LTC residents are able to access the care they need in place.

What did you find?Since the introduction of the program, there have been over 25,000 calls to on-call physicians, with each physician averaging approximately 10 calls per day. Analysis of patient disposition following the physician call indicates that this service helps most patients to receive the care they need within the LTC facility, without a visit to the emergency department. Overall, 91% of patients care needs were addressed in place with support from the physician call, whereas 9% of patients are sent directly to emergency following a call. In the 2015/16 fiscal year, 2% of patients were visited following a call and of these 0.3% were transferred to the emergency department. In collaboration with Alberta Health Services, preliminary data shows an overall decrease of emergency room visits for patients at these long term care facilities after the introduction of the program. A return on investment analysis is underway.


In conclusion, a pan PCN collaboration to support family physicians to provide after-hours medical coverage has provided several benefits including permitting long term care residents to receive care in place, providing LTC nursing staff after-hours access to medical advice and phone orders and the overall financial benefit to the health system of decreasing emergency room visits.

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AbstractMultidisciplinary Teams approach to Quality Improvement Measures for Better Patient Outcome Yellowbird Family ClinicDouglas Strilchuk, MDCecilia Gordillo, EMR Coordinator EWPCN


Yellowbird Family Clinic found the necessity to address areas in which room for improvement were identified and could be objectively measured. Areas identified through multiple clinic meetings were Chronic Disease Management in Diabetic Population and Preventative measures such as immunization for Herpes Zoster.


Identify the diabetic population, measure a baseline of patients who have met a target of HbA1C,Lipid Profile testing and Blood Pressure according to current clinical practice guidelines and create a goal of 11% increase over time.

Identify all patients over 60 years of age, measure a baseline of patients who have not received a prescription for Herpes Zoster Vaccination and create a goal of 25% increase over time.

How did you go about addressing the issue to reach your goal?Retrieving data from the clinic’s EMR (Electronic Medical Record –Telus/Wolf ) to generate the pertinent patient population as per the goals set in collaboration with PCN ( Primary Care Network).

Work in collaboration with Merck to forward the data for analysis.

Merck presents the data to the clinic and creates a recall list.

Patients requiring follow up care are then recalled to the clinic and the multi-disciplinary healthcare team (physician/nurse/pharmacist/dietician) collaborates to determine which interventions should be implemented for their care.

A proactive health screening tool was developed and utilized to ensure patients are up to date on all screening parameters according to evidence based guidelines including immunization recommendations.

What did you find?Baseline measures for the diabetic population on 2011 showed that 45% of patient were within the HbA1C target (HbA1C < 7.0%) and that by 2016, 18% increase was reached surpassing the goal expectation. A Lipid Profile baseline was measured at 40% for LDL and has had a 3% increase meanwhile the cholesterol/HDL ratio was measure in two occasions in 2012 with a 59% baseline and increased by 7% increase in 2014 with no other data available. A Blood Pressure baseline was not retrieved at the time and the only reference stands in 2016 at 39%.

Baseline measurement for 60 + patient population with prescription given for Herpes Zoster stood at 6.2% in 2011 and increase by 8.7% in 2015.

The clinic recognized the importance of data entry and has then created workflows that enable this data to be collected in a more efficient way to later on be retrieved accurately.


Collaboration of different teams, lead by the clinic, allowed the clinic to analyze, reach or surpass the goals set. Integrating all the resources available in the health system such as AIM, PCN, private sector (Merck) has provided support that enables good quality control and better patient outcome which in turn reduces the burden on the health care system.

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AbstractTransitioning to Adult Autism Care Edmonton Oliver Primary Care NetworkAlvin Yapp, BScAlayna Burnstad


There was a gap in the system around supports for adults with autism, and the transition process from the youth system to the adult system was not a smooth one. There is a need for a program to help transition these patients from the youth system to the adult system, as well as the provide a more robust support network for adults with autism.


The creation of a transition program for youth with autism to adult programming and to establish linkages within the community for adults with autism.

How did you go about addressing the issue to reach your goal?Edmonton Oliver Primary Care Network partnered with the Glenrose to link youth with autism to family doctors willing to take in patients with autism.

What did you find?The development of such a complex program can take some time, and initial uptake has been slow. However, initial patient experience has been promising, although the sample size is small. The collaboration with the Glenrose has also been valuable in finding family physicians for patients with autism.


Others can look to our example of identifying a difficult transition and creating process to help make that process smoother. They can also look to our example of partnering and forging links with community resources.

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AbstractGuide to Patient Level Data Sharing Standards in Primary Care Alberta Health ServicesAndrew KennedyReverdi Darda, Executive Director, PHC, AHSMarkus Lahtinen, Director, HQCADr. Heidi Fell, Family Physician & Clinical LeadJudy Seidel, Director, ARES, AHSNataliia Slobodianyk, Senior Advisor, Business Intelligence, ARES, AHS


Alberta Health Services (AHS), Alberta Health (AH) and the Health Quality Council of Alberta (HQCA) hold a wide range of valuable data on how Albertans use and experience the healthcare system and would like to share the data with physicians to support Patient-Centred Medical Home implementation.


The purpose of the Guide is to help primary care providers access aggregate and patient identifiable data from various provincial datasets, provide a framework that supports an incremental process towards patient attachment and continuity of care, and support a culture of data driven continuous improvement.

How did you go about addressing the issue to reach your goal?The Guide was developed by AHS and the HQCA in collaboration with AH, the AMA (PCN PMO, TOP), AIM, and physician leads

What did you find?The Guide describes a process and privacy requirements to enable secure data sharing between custodians in order to provide aggregate or patient-identifiable data for primary care providers/teams and their PCN authorized representatives. Patient-identifiable data will be available for physicians who have confirmed their patient panels, where confirmed means a conversation between the physician or clinic staff member and the patient where both agree that the physician is the patient’s primary care provider, and who have communicated to the data provider a PHN list and date of confirmation for each patient. If the family physician has not confirmed the relationship with their patients, AH, AHS & the HQCA can still provide physicians with aggregate data. The Guide also provides information on various supports available with paneling, privacy requirements and data literacy.


The presentation describes the purpose and key components of the Data Sharing Standards in Primary Care which includes a road map for data sharing, privacy requirements and support available to enable this work. Primary care custodians can receive patient level data and enhanced information to design services around the needs of their patients to improve patient care and health outcomes of Albertans.

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AbstractPragmatic Trials Collaborative – Measuring What Matters University of AlbertaScott Garrison, MD PhDLee Green MD MPHMichael Kolber BSc MD MScChristina Korownyk MDAdrienne Lindblad BSP PharmDNicole Olivier RVTG. Michael Allan MD


Randomized controlled trials (RCTs) are the cornerstone upon which clinical decision making pivots. However, there are systematic gaps in RCT evidence due to the narrower population range eligible for participation. Pragmatic trials that pursue optimal use of existing therapeutics in more representative “real-world” populations better address the clinical questions facing primary care practice. Primary care providers can play a significant role in answering questions that are also meaningful to patients and decision makers.


Form a primary care-based platform, the Pragmatic Trials Collaborative (PTC), using pragmatic clinical trials designed to fit research into practice without disrupting workflow.

How did you go about addressing the issue to reach your goal?We began building relationships with primary care providers in BC and AB who were interested in our pragmatic trial approach to clinical research. We then conducted a pilot study the “INRange RCT” to set up and refine the infrastructure and processes that will be the foundation for how this network engages in research. This study had 248 providers participate from 53 Alberta and BC communities.

What did you find?The PTC has grown to an extended reach of 425 providers including physicians, medical residents, nurses, and pharmacists in BC, Alberta, Manitoba, Ontario and NWT. During the “INRange RCT”, for each provider that participated another 1.58 providers joined the study. Feedback from clinic staff and providers indicated that they learned more about the condition being studied and they used it as an opportunity to refine their own clinic processes surrounding this patient population.


Clearly primary care providers are interested in participating in research and answering questions that are meaningful to them. By working together and using patient oriented outcomes that matter pragmatic trials can be conducted using existing health data with minimal impact on primary care workflow. In turn, these studies optimize the care of primary care patient.

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AbstractPatient & Public Engagement in Primary Care Research – A collaboration between the BedMed Initiative and Alberta SPOR SUPPORT Unit (AbSPORU) Patient Engagement (PE) Platform University of AlbertaNicole Olivier RVTPing Mason-Lai, BA, MARobyn Laczy, BA Grant Geldart, BAChristine Nichiporik, BSc PharmDavid Nichiporik, B Comm, CPA Bruce Perry, CGA, CPA Mariann Rich, MSc, RN Gerry Robinson, BSc, RNDarryl Trueman, ACCI PAPPC(R)Scott Garrison, MD, PhD


The BedMed Initiative is a primary care-based pragmatic clinical trial launching in October 2016 to evaluate antihypertensive medication timing in adults with high blood pressure. Project collaborators include interdisciplinary primary care providers, provincial stakeholder groups and academics, but should we also include the public and potential participants? So began collaborations between BedMed as a demonstration project for AbSPORU Patient Engagement (PE) Platform to include the knowledge and voice of patients and caregivers in as many phases of the project as possible.


Form a Working Group of up to 10 individuals having diverse backgrounds with respect to age, gender and location, as well as cultural, educational, employment and volunteer experiences. Together, openly share our collective experiences for the benefit of the research project. From this input, design and run a primary care based pragmatic trial.

How did you go about addressing the issue to reach your goal?By word of mouth and web-ad, those interested applied and were interviewed about their interest in the study. Initial group meetings were in person to facilitate learning about each other and the study work to be performed. A Terms of Reference for the group was created and the 3-year project task list identified. The study team was supported and mentored by the PE Platform on incorporating meaningful patient engagement and gathered feedback on the progress of the group for evaluation purposes.

What did you find?The study plan, methods and tools evolved with the collective experience of the Working Group. This feedback strengthened the project design as concepts important to patients; caregivers or potential study participants were included. Through this process a partnership was established.


Include all of your target audience from the beginning of concept development. We already knew we needed to include feedback from primary care providers to design a meaningful study and fit research into practice. We learned the value and benefit of creating research with the patient, for the patient.

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AbstractPartnering with Member Physicians to Improve Equity in Patient Care Through the Medical Home Mosaic Primary Care NetworkPeter Rymkiewicz, MSc, Bcomm, Director of Measurement & EvaluationCarol Cullingham, MA, BA, BSc, Evaluation CoordinatorJanelle Richer, BScN, RN, Primary Care ManagerAmanda Brockman, RN, MHA, Primary Care ManagerMarjan Rekabdar, MPH, Evaluation AnalystKristian Orr, Business AnalystChris Naugler, MDSyed Mehdi, MCS BSc, Business Analyst


Aging populations and increased disease burden are increasing pressure on primary care. MPCN’s mission “Better Health For All” includes ensuring equitable access and quality of care for our diverse multicultural, immigrant and refugee populations. Working with member physicians, the MPCN-funded Primary Care Coordinator (PCC) program was developed to support the patient centered medical home. Since April 2015, The PCC program has focused on panel management, better office efficiency, enhanced chronic disease screening and proactive patient care, leading to greater early disease detection, prevention and management. Mosaic PCCs have made 129,209 screening offers in the past 18 months.


The objective of this evaluation was to determine if patients receiving a PCC intervention (offer of screening) were more likely to get screened for diabetes, cholesterol, and cervical and colorectal cancers compared to those not receiving a PCC intervention.

How did you go about addressing the issue to reach your goal?PCCs are trained to use the EMR to support notification of required screenings for specific patients. Offers of screening made to patients are documented in MPCN’s PCC data collection system (PCC Tracker). PCC Tracker data was merged with visit data from MPCN’s multidisciplinary team (MDT) Workload Tracker, MPCN physician panel data obtained through the AHS Partners for Better Health initiative, and with data obtained from Calgary Lab Services (CLS). Screening completion rates for patients receiving PCC services were compared to those of patients not receiving PCC services.

What did you find?Patients were significantly more likely to complete each type of screen if they were offered that screen as the result of a PCC intervention. There was also an 11% improvement in diabetics’ adherence to Canadian Diabetes Association screening guidelines. Because of limited control group data the effect of the PCC on screening compliance is likely overestimated.


This evaluation provides evidence for the effectiveness of the PCC role for enhanced screening, which is useful for other PCNs considering a PCC-type role. This evaluation also shows how strong partnerships facilitated by Data Sharing Agreements and solid data collection infrastructure support evidence based improvements in proactive patient care. Building on this work, MPCN is partnering with Cancer Care and AHS to improve PAP screening in the most challenging patient groups.

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AbstractAspen PCN Wellness Program PartnershipsAspen Primary Care NetworkJon LeMessurier (CSEP- CPT), (NASM Corrective Exercise Specialist)


We wanted to ensure that our clients had a safe and practical environment to participate in fitness related programs. This was an issue as our Health Home did not have the space to house these types of programs.


We overcame this issue by partnering with the community multiplex to give clients the space and tools to successfully take part in a variety of wellness programs we were able to start (walking group, fitness for life, community yoga).

How did you go about addressing the issue to reach your goal?Aspen PCN built a strong relationship with management of the multiplex to find a way to bring PCN programs to the multiplex. This was beneficial to the PCN as our patients were able to incorporate physical activity into their lives, as well as to the multiplex as it brought more community members to their facility.

What did you find?Aspen PCN found that every program held at the multiplex had a positive response due to the proper location and atmosphere. Individuals now have a safe place to walk during winter months. Other programs such as a total body fitness class have been able to take place throughout the year as we aren’t dependent on weather.


Other PCNs may be able to build similar relationships within their communities and create mutually beneficial partnerships with an organization like the multiplex to ensure we are providing a variety of programs for individuals to achieve their fitness and wellness related goals.

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AbstractPrimary Care Immunization Integration Project (PCIIP): Partnering to make immunizationAlberta Health Services, Alberta Cancer Prevention Legacy FundJessica Law, MPHLori Meckelborg, MPH (Cand.)Joan Ing, Director Public Health-Central ZoneDoreen Parcels, Executive Director- Wolf Creek PCNAnna Pujadas Botey, PhDLiz McGregor, PhD


Vaccines are essential to the prevention of cancer and other vaccine preventable diseases. Although Alberta has a comprehensive publicly funded immunization program, the coverage rates for children and adults (61.2-84.3%) are below the provincial targets (95-98%). Primary care physicians are trusted sources of health information and play an important role in increasing the uptake of immunization but they lack access to immunization status for their patients.


The purpose of the project was to assess the feasibility of an intervention to support primary care physicians to advocate for immunization (including HPV, HBV and other vaccines) with their un/under-immunized patients under 18 years of age.

How did you go about addressing the issue to reach your goal?Working together, Central Zone Public Health, Communicable Disease Control, and participating primary care providers of the Wolf Creek PCN developed a process to match primary care patient panels to public health immunization data to identify un/under-immunized patients. Immunization advocacy tools, immunization overdue lists for flagging in EMRs, and performance feedback reports were provided to support physicians in their advocacy role. Public Health played a critical role in following up on patient referrals from primary care and making additional immunization clinic times available to meet potential patient demand.

What did you find?About 1 in 5 panel patients under 18 were un/under-immunized. Primary care providers want access to meaningful and timely immunization data. An opportunity for communication and collaboration between primary care and public health to work together to increase immunization was created. Immunization data is very complex and developing the data solution (including research and information sharing agreements) took longer than expected making it difficult to maintain engagement of partners.


Collaboration made it possible to share immunization information between primary care and public health. Given the complexity of immunization data, it proved difficult to provide timely, actionable immunization data to physicians in an efficient and sustainable way. New data sharing solutions are required. Projects such as Surfacing Population Public & Indigenous Health (PPIH) offer a sustainable and scalable way to provide real-time access to meaningful immunization data. It is possible for primary care and public health to work together to meet immunization needs of patients.

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AbstractDoes Embedding a Pharmacist in a Primary Care Clinic Make Sense: An Alberta Take on an International InitiativeDepartment of Family Medicine University of CalgaryC. Joe Tabler, BScPharm, PharmD, BCPSJane Bowman, RN, MNRon Garnett, MD, CCFP(EM), FCFP


Within the development of the current primary care delivery model is the concept of collaborative care between multiple disciplines. Pharmacists have been considered part of the allied health team but in the Primary Care Network model, pharmacists have been used only on a consult basis and have not been embedded into each particular clinic. With the advent of increased scope of practice for pharmacists it may be applicable to have pharmacists in the primary clinic where the increased scope of practice may be utilized to benefits both the clinic team and the patient involved.


The initiative at South Health Campus is unique in that a pharmacist is readily visible for rapid informal consultations, continuity and timely interdisciplinary dialogue over patient care issues. We researched to find if the model of collaboration and the use of the increased scope of practice were unique to this site or if other models existed.

How did you go about addressing the issue to reach your goal?We did a search of the literature and found that two other jurisdictions were in the process of initiating pilots or were moving forward with the introduction of non-dispensing pharmacists into primary care: Australia and Great Britain. Australia was using a model of public funding and Great Britain has a sliding scale of funding. In researching we looked at what the scope of practice was in each jurisdiction and the roles that the non-dispensing pharmacist would fulfill.

What did you find?The review of the mandates of both programs showed that the role of the pharmacist was similar: expertise in practical therapeutics, development of complex care plans, refill management, perform drug utilization evaluation and mentor and precept learners in the clinic environment. Australia went a step further and had Deloitte do a cost benefit analysis which exhibited a $1.56 (Aussie Dollar) benefit for every dollar spent. At SHC we have not embarked on a benefit analysis, but have had similar results to those seen in other jurisdictions.


International initiatives coupled with pharmacist scope of practice in Alberta would be a topic for further research and the possible initiative of the Primary Care Networks in Alberta.

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AbstractSupporting health provider practice changes to embed HealthChange® Methodology within a team environment.Alberta Health ServicesMary V. Modayil, MSPH, PhDJudith Krajnak, PhDOlivia McCreary, BHSc, BAJake Jennings, MA, MBAJennifer Alexander, MHS, RDJulie Robison, RN, BN


HealthChange® Methodology (HCM) is offered as a two-day workshop by Alberta Health Services, with the goal of operationalizing and embedding a person-centred approach into health service delivery in a systematic and measurable way. It focuses on a patient’s readiness to make health changes by promoting shared decision-making, health literacy, behaviour change and self-management support. We wanted to focus on increasing our understanding of changes that could take place as a result of HCM implementation at the patient level, provider level and clinic level.


We wanted to strengthen our understanding of the implementation supports required to embed HCM into team and clinic processes.

How did you go about addressing the issue to reach your goal?The AHS Primary Health Care program collaborated with the East Calgary Family Care Clinic. Using a combination of qualitative approaches (key informant interviews, focus groups) and quantitative approaches (skills audits, patient experience surveys), we wanted to look at changes taking place at three levels: patient level, provider level and clinic level.

What did you find?Preliminary results from the focus groups show that adoption of the HCM language and use of select HCM practice principles is evident at an early stage of implementation. FCC providers started incorporating HCM language after participating in HCM training, such as including ‘above/below-the-line’, ‘check RICk’, and ‘address barriers’ into the regular charting and interdisciplinary communications. Six months after the HCM training took place, 76.3% of patients reported that their clinic team asked them what might get in the way of patients looking after their own health concerns; this compared to 57.4% before training. Post-training, patients also reported that providers were more likely to talk to them about what could happen to their health if their concerns were not looked after (75.0% post- versus 61.1% pre-training).


In contrast to what we expected, we learned that a staged approach may be needed to best support clinic teams with the implementation of the HCM. Early stages should focus on the adoption of a common language and using HCM practice principles. Understanding of intermediate and longer term stages will be examined as work on this project continues and as we collaborate with more health care teams.

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AbstractPROMs in Primary Care Networks (PCNs)Applied Research And Evaluation Services, Primary Health Care, Alberta Health ServicesCalgary Foothills Primary Care NetworkSylvia So, MEDTanmay Pail, HBSc, MPHScott Oddie, PHDDorren Ma, MSc


A key goal of our health system is to integrate information systems that support measurement and evaluation of chronic condition and disease prevention/management, which in turn enable informed decision by individuals and providers. Patient Reported Outcome Measures (PROMs) are used to assess patients’ perspective of their overall health and key indicators in advancing this goal. PROMs are connected to healthcare funding, service provision, and management. Implementing PROMs in Primary Health Networks (PCNs) poses unique issues in terms of with whom and how the data should be collected, analyzed and reported so that it is reliable and of value to program managers and service providers.


We conducted repeated measures analyses on information collected from patients referred by physicians to PCN team members and programs. Our aim was to develop reliable analytical methods and effective reporting standards to communicate information of value to providers and assess program impact on clients.

How did you go about addressing the issue to reach your goal?We brought information together from clinic EMRs, PCN programs and health systems to assess program impact, relevance, effectiveness and efficiency. We collaborated with PCNs on planning, analyses, interpretation and application of results. Our joint effort provides learning opportunities for both PCNs and AHS analytic team to apply evidence in identifying successful care pathways for diverse patient groups experiencing team-based primary health care and inform program development and improvement.

What did you find?On-going collaboration with the data user and analysts are imperative to the quality and applicability of the results. A measurement plan that identifies appropriate analytic method and a core set of indicators are indispensable in assessing program and service impact. Threats to validity (e.g. ceiling effects of data reported by referred patients) were identified. Through collaboration, a standardized reporting format able to communicate value was generated.


Analytical methods, limitations, data and reporting templates will be discussed and shared with conference participants. This will help to further develop standard approaches to the implementation and reporting of PROMs in PCNs to enhance outcomes and communicate service impact and value.

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