SOLO PRACTIONERS IN NEED

Transcription

1 SPIN SOLO PRACTIONERS IN NEED (of CHC resources) 2015 National Health Leaders Conference Prince Edward Island Co-presenters: Cliff Ledwos Director, Primary Health Care Access Alliance Multicultural Health and Community Services, Toronto & Pauline Pariser Lead, Mid West Toronto Health Link Associate Professor, Department Family and Community Medicine, University of Toronto

2 Disclosure Potential for conflict(s) of interest: None to declare Mitigating Potential Bias: Not applicable Relationships with commercial interests: Grants/Research Support: 0 Speakers Bureau/Honoraria: 0 Consulting Fees: 0 Other: 0

3 Objectives 1. Set the context for developing a primary care integration project in an urban setting. 2. Highlight a model linking primary care resources between two types of health service providers. 3. Demonstrate the essential elements in establishing a referral network for solo family physicians to enable direct access to inter-professional resources. 4. Understand both the barriers and enablers in establishing and maintaining this integrated model

4 Patient-focused, provider-enabled, culturally sensitive

5 What is a Health Link? Patient-focused, provider-enabled, culturally sensitive Health Links were announced by the Ministry of Health and Long-Term Care in December 2012 across Ontario as a means of enhancing care coordination for complex patients at a local level. There will be approximately 69Health Links across the province 9 in Toronto. Health Links are geographic networks of health service providers who commit to enhanced communication and forging of new linkages. Health Links have been charged with reducing duplication, closing gaps and improving communication and collaboration in order to augment care for the patients most in need. The Health Links aim to stimulate partnerships across acute care, community care, and the many primary care providers in their respective areas.

6 Mid West Toronto Downtown Toronto: Lake to St. Clair, Yonge to Dovercourt One of the largest HLs in the province Diversity of populations and providers - approx. 20 % whose first language is not English Fastest growth of any of the Health Links High proportion of seniors % over active family physicians Largest number of patients in the top 5% in using health care resources.

7 Health Link Priority Communities Low SES Immigration Status High Incidence of Chronic Disease Incidence of Mental Health Low Access to Services Low Access to Primary Care

8 Community Health Centres What is a Community Health Centre? Non-profit, community-governed organizations using interdisciplinary teams to offer health and social services CHCs offer care to populations that traditionally face barriers accessing health care CHCs offer culturally-adapted programs for socioeconomic factors, as well as the needs and preferences of the communities they serve. Who Accesses CHC Services? Those facing access barriers to health care and social services Mental Health Language Physical Disability Homelessness Addiction Culture Uninsured Poverty

9 Contextual Factors Impacting SPiN Lack of literature Lack of access to EMR data analysis X A C B Limited ability to track patient outcomes Critical to success Lack of infrastructure Engaging these practices in grassroots development and monitoring of the integration project Number one need Counseling for uninsured patients

10 Why Offer SPiN? Solo PCPs lack resources and access to the most appropriate community based services for their complex patients CHCs have community based programs and services that can be better utilized by external providers and clients Health and social service access is difficult for patients with complex psycho-social and medical issues

11 Strategic Conditions to Address in SPiN 1) Create a win-win solution Enhance coordination and communication for GPs while decreasing hospital usage/health care costs 2) Develop a collaborative plan with GPs and CHCs working together 3) Be nimble 4) Improve patient outcomes and experience Especially for the complex poorly served 5) Reduce fragmentation. Silo-busting!

12 The SPiN Development Process 1 Identify a test group of solo physicians in the area with complex patients in need of greater support. 2 Define services in need, community based services that can be accessed by external providers and clients, and eligibility criteria. 3 Identify an organization to act as central intake.

13 The SPiN Development Process 4 Design a referral and reporting process. 5 Develop referral forms, tracking mechanisms, and targets. 6 Begin the project 7 Meet with a steering committee to inform continuous improvement, address challenges and ensure quality service delivery.

14 SPiN Goal and Population Served Goal: To increase access to resources for vulnerable populations and achieve full resource utilization in primary care settings Population Served: SPiN serves vulnerable (medically and socially complex) people living in Toronto

15 The SPiN Process Complex PT sees PCP who determines need of CHC services PCP completes referral form and faxes to Central Intake Central Intake Nurse receives referral and faxes referral to most appropriate CHC CHC receives fax and coordinates services with PT. Appointment confirmation faxed to PCP Information shared with PCP based on current CHC/PCP processes Within 10 business days

16 Solo Physicians in Need (SPIN) OF CHC SUPPORT SUPPORT FOR YOUR COMPLEX CLIENTS THROUGH COMMUNITY HEALTH CENTRES (CHCs) 1 on 1 Services (excludes NPs & PCPs) Dieticians, Social Workers, Children s Services, Dental, Sexual Health, Foot Care etc 1 on 1 Counseling (*there may be a wait list) Chiropractor, Naturopath, Harm Reduction etc THIS SERVICE WILL NOT AFFECT YOUR ROSTER Group Services On-going Programs Group Counseling, Women s Health Workshops, Prenatal Support, ODSP Group Support etc Diabetes Education Programs Traditional Programs, Cultural Activities etc Social classes and programs Legal Aid, Youth Employment, Income Tax Clinics etc Aboriginal Programs Settlement Services, Housing Services etc PARTICIPATING CHCs WHO CAN I REFER FOR THIS SERVICE? Any complex patient in your practice! ACCESS TO SIX CHCS THROUGH ONE SIMPLE REFERRAL FORM AND ONE CENTRAL INTAKE Women s Health in Women s Hands

17 The SPiN Network Youth (13-29) Pro-choice agency promoting healthy sexuality Sexual health services, primary care and counseling. Racialized women Primary care, health promotion, community outreach, counselling, dietician, chiropody and more. Immigrants and refugees Community health, settlement and integration, advocacy and more. Francophone community Primary care, family services, settlement work, legal aid, employment and more. Marginalized population Health promotion, harm reduction, education, community development, advocacy, primary care, dental and counseling services. Aboriginal people Traditional Healing, Elders, Medicine People, physicians, chiropractors, naturopaths, RMT, psychiatry, chiropody, dental and more.

18 Outcomes: Total Referrals CHC Q1 May Jul Q2 Aug - Oct Q3 Nov - Jan Q4 Feb - Apr Total Access Alliance Anishnawbe Central Toronto Centre Francophone Planned Parenthood Women's Health Total referrals sent by PCPs

19 Outcomes: Service Referrals Service Q1 Q2 Q3 Q4 Total Counseling Services Dietitian Foot Care / Chiropody Dental Care Peer Support Groups Diabetes Services/ Education Youth/Adult Employment Services Legal & Income Services Youth/Adult Social Classes/Programs Housing Support/ Homeless Services Case Management Settlement Services LGBTTQI Services Harm Reduction/ Addiction Services/ Needle Exchange Early Years/Child/ Youth Services (Centre Francophone) Traditional Medicine / Healing (Anishnawbe) Chiropractic Services (Anishnawbe) Sexual Health Child/Youth Education Assessments Psychometric Assessments (Anishnawbe) Total Service Referrals

20 Enablers Establishing working relationships within Health Links Existing model of primary care integration (i.e. SCOPE) Shared philosophy among CHCs about extending services to those in need Project management A defined Central Intake resource

21 Lessons Learned 1. Bigger is better, but small is good too - if you leverage what you have. 2. Provider-centred in order to be client-centred. What we learned from family physicians Accessing counseling services for clients without coverage was the #1 need. Connecting language-based services for new immigrants would be welcome Specific population-based services would be of value (e.g. diabetics, adolescents and young adults, aboriginal, LGBT ) Solo, non-team-based providers were unaware of the range of services on offer and welcomed this support

22 Lessons Learned 3. Be prepared to look at things differently. Bi-weekly, and monthly, calls with CHCs Quarterly reviews held among stakeholders to review progress, tests of change and improvements. 4. Warm handovers were critical to build sustainability. 5. Communication is essential. 6. It s not a SPiN patient it s our patient.

23 Benefits Increased and seamless access for patients with complex medical and psychosocial issues in the community Complex patients receive most appropriate and supportive community based services and resources + Assist physicians to collaboratively manage their complex patients through the services, resources and multidisciplinary teams based at CHCs Increase access and utilization of CHC services in the MWTHL Help build the CHCs community profile and new relationships with PCPs

24 Patient Story Referred to SPiN year old female with a history of generalized anxiety disorder. Presented as distraught, unable to concentrate with school and examinations. Daily panic attacks. Has no support. Called within 10 days and had appt. with Planned Parenthood Toronto the following week. Seen weekly and after 4 appointments had new strategies to deal with her panic. Consequently... Her confidence increased. Able to restart school in the fall and is excelling. Returned to her GP as primary therapist. No longer at Planned Parenthood Toronto, but has building blocks to go forward.

25 Going Forward 1) Make adjustments to the SPiN process based upon learnings and recommendations from the pilot phase and SPiN Report to be released in June ) Leverage SPiN into a city and province-wide solution

26 Thank you.