Home Improvements:Using the Patients Medical Home as a Guide to

Improvement Initiatives in our practice

61 Annual Scientific Assembly Alberta College of Family Physicians

Banff AlbertaMarch 2016

Dr Rob Wedel MD CCFP FCFPFamily Physician, Taber, Alberta

Faculty/Presenter Disclosure

•Faculty/Presenter: Rob Wedel

•Relationships with commercial interests:–Grants/Research Support: Not applicable–Speakers Bureau/Honoraria: Not applicable–Consulting Fees: Not applicable– Other: This presentation has received financial

support from the Alberta College of Family Physicians in the form of a speaker fee.

Objectives:• Identify the pillars of the PMH that help guide

practical QI initiatives in our practices• Discuss the physicians’ role within our clinics that

create the conditions that contribute to successful improvement initiatives

• Identify practical applications of the models, and principles of QI improvement that help us ‘know where to start”

• Examples of successful activities, along with practical, available resources will be discussed.

What we Know Works…“The Medical Home”• The greater the range of services provided by primary care clinic,

along with a family physician providing a continuous care relationship to a defined patient population had one third lower overall costs and were 19% less likely to die

• “Attachment to a practice” was more significant than all other variables, such as age.

• For most aspects of care and health outcomes, identification of a particular practitioner provides even better services than mere identification of a particular place”.

Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 2002;603:201–218The Future of Family Medicine. Annals of Family Medicine, 2004 Hollander, MJ, et al. Increasing Value for Money in the Canadian Healthcare System: New Findings on the Contribution of Primary Care Services. Healthcare Quarterly Vol.12 No.4 2009

The Patient’s Medical HomeThe Pillars

The Patients Medical HomePatients receive care that is centered on their needs from a

team that knows their story

http://www.patientsmedicalhome.ca

The Patient’s Medical HomeThe Pillars

The Patients Medical HomePatients receive care that is centered on their needs from a

team that knows their story

Clinical Supports provided by the Medical HomeTimely Access to care and information Team based Care

Continuity to personal family doctor Comprehensive, Coordinated care

The Patient’s Medical HomeThe Pillars

The Patients Medical HomePatients receive care that is centered on their needs from a

team that knows their story

System Supports for the Medical HomeProvincial Support Programs Integrated Information Systems/EvaluationSupportive Payment Structures Workforce Development

What do we know works in Canada…Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing

on eliminating delays for appointments and at appointments.

• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)

• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not

• Have a strong emphasis on self management

• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc

• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008

What do our patients value?• The single most important

issue for Canadians is poor access to health services. (p>0.01)– Access to primary care (for appts)– Timeliness at the appointment– Respect and empathy– Time available in the consultation– Medication and Treatment costs

• Delay in seeing a doctor and getting treatment is the longest among the seven developed countries.

(2015 Commonwealth Fund Survey)

• Physicians prioritize:– ER visits– Self efficacy– Multidisciplinary teams– Collaboration between

healthcare organizations– Self care support– Technical quality of Chronic

disease management– Physical activity counselling

Boivin et al. Implementation Science 2014, 9:24. http://www.implementationscience.com/content/9/1/24

What do we know works in Canada…Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing

on eliminating delays for appointments and at appointments.

• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)

• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not

• Have a strong emphasis on self management

• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc

• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008

PRINCIPLES FOR CAPACITY IMPROVEMENT

‘Know your own patients’ (Empanelment)

‘See your own patients’ (Continuity) ‘Don’t make them wait’ (Access)

Moore, Escaping the Tyranny of the Urgent by Delivering Planned Care. Family Practice Management. May 2006Brousseau, et al. Association Between Infant Continuity of Care and Pediatric Emergency Department Utilization Pediatrics Apr 2004Saultz et al. Interpersonal Continuity of Care and Care Outcomes; A Critical Review Annals of Family Medicine. Vol 2:5. Sept 2004

Access(Principle: “Don’t make them wait”)

Is it OK to wait?

“Without Access, there is no Quality.”US Surgeon General

ER Visits for Asthma: Taber

0

50

100

150

200

250

300

350

400

97-'98 98-'99 99-'00 00-'01 01-'02 02-'03 03-'04 04-'05 05-'06 06-'07 07-'08

Taber Asthma Program

Advanced AccessFamily Practice Teams

Total Visits to ED Relative to Population Growth – Taber Residents

5301

50844860 4926

47074853

5407 5513 56195725 5831

4000

4200

4400

4600

4800

5000

5200

5400

5600

5800

6000

2006 2007 2008 2009 2010 2011

Projected by Population Growth

Actual ED Visits

What do we know works in Canada…

Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing

on eliminating delays for appointments and at appointments.

• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)

• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not

• Have a strong emphasis on self management

• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc

• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008

Panels and Registries(Principle: “Know your own patients.”)

360 Patients are Over 65

60 Patients had more than 10 Office

Visits Last Year

130 are Clinically Depressed

228 have Hypertension

160 have Heart Disease

248 have Arthritis

113 have Asthma

66 have Diabetes

Panel Size 2000

Continuity/Attachment (Principle: “See your own patients”)

When patients see their own physician-

Patient, physician, and staff satisfaction rise, Visit length is shorter and compliance is better. Chance of ‘re-visit’ goes down Earlier detection of serious illness and clinical care and outcomes improve.

Increased sense of ownership by provider, patient and team.

Starfield and Shi. (2004). Hollander, M.J., Kadlec, H., Hamdi, R., & Tessaro, A. (2009). Increasing value for money in the Canadian healthcare system: New findings on the contribution of primary care services. Healthcare Quarterly, 12(4), 30-42.

Panels and Registries(Principle: “Know your own patients.”)

www.topalbertadoctors.org

Assessing you Practice. Dartmouth College. IHI. www.clinicalmicrosystems.org

Resources unique to your community(Principle: “Know your own patients.”)

www.patientsmedicalhome.org

What do we know works in Canada…

Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing

on eliminating delays for appointments and at appointments.

• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)

• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not

• Have a strong emphasis on self management

• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc

• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008

Functional and Clinical Outcomes

Informed,ActivatedPatient

Prepared,Proactive

Practice Team

DeliverySystem

RedesignDecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Modified Chronic Care Model

ProductiveInteractions

PRINCIPLES FOR CLINICAL IMPROVEMENTWhat Characterizes a “Prepared, Proactive Practice Team”?• Standardized, supported team care, linked to the

provider with clear accountability and leadership.• Embed clinical protocols and guidelines to assist

the team and reduce variations in practice. Identify the ‘high leverage’ clinical areas Pre-Plan patient interventions Train team members to support their clinical roles

Batalden, Nelson, et al. Continually improving the health and value of health care for a population of patients; the panel management process. Quality Management in Health Care, 1997, 5 (3). 41-51

Service Delivery Changes

Medical Management

Case Management

Self Management

Outcomes: Patient/Provider Satisfaction• Patient Satisfaction has remained high• Providers (Physician and others) are significantly

happier with…– Ability to impact patient health behaviours– Job satisfaction– Communication flow and sharing of information– Increased autonomy in performing their job– Current work situation overall

Wedel, et al. Turning Vision into Reality: Successful Integration of Primary Healthcare in Taber, Canada, Healthcare Policy, Aug 2007

Patients Medical Home-Links to Resources:

– CFPC ‘Best Advice’: www.patientsmedicalhome.ca

– Compilation of Resource Tools: • http://www.topalbertadoctors.org/file/pmh-implementation-field-kit.docx

– Compilation of PMH Evidence:• http://www.topalbertadoctors.org/file/top--evidence-summary--benefits-of-pmh.pdf

– Advanced Access, Measurement Tools: www.albertaaim.ca/index.php/resources

– Panel Management, Team based care:• www.pcnevolution.ca; www.pcnpmo.ca• http://www.albertaaim.ca/index.php/resources/• https://www.youtube.com/watch?v=cqGsHB3vvj0&feature=youtu.be

– McMaster U: Quality Book of Tools. 2010• http://qualitybookoftools.ca/wp-login.php