Integrated System of Care - Table of Contents

Transcription

1 Integrated System of Care - Table of Contents 1 Integrated System of Care Strategic Context 2 Ministry of Health Policy Framework Introduction Requirements for an Integrated Primary and Community Health Care System 3 General Policy Direction: Integrated Health System for Primary and Community Care 4 Supportive Policy Direction: Interdisciplinary Team-Based Care 5 Supportive Policy Direction: Continuity of Care 6 Supportive Policy Direction: Digital Care 7 Supportive Policy Direction: Information Sharing 8 Strategy for Health System Performance Management Monitoring, Analysis, and Reporting 9 Policy Statement: Geographic Boundaries to Support Service Delivery in B.C. Requirements for Primary Care 10 General Policy Direction: Establish Primary Care Networks 11 Supportive Policy Direction: Patient Medical Home Requirements for Specialized Community and Surgical Services Programs General Policy Direction: Specialized Community Services Program for Mental Health and Substance Use General Policy Direction: Specialized Community Services Program for Adults with Complex Medical Conditions and/or Frailty 14 Supportive Policy Direction: Home Support 15 Supportive Policy Direction: Assisted Living 16 Supportive Policy Direction: Residential Care 17 General Policy Direction: Surgical Services Program 18 Supportive Policy Direction: Surgical Wait Times Reduction 19 Supportive Policy Direction: Surgical Waitlist Management 20 General Policy Direction: Specialized Community Services Program for Cancer Care Requirements for Linked Hospital, Diagnostic, Regional and Provincial Services 21 General Policy Direction: Direct Hospital and Diagnostic Access and Effective Discharging 22 General Policy Direction: Direct Access to Regional and Provincial Health Services Funding and Compensation 23 General Policy Direction: Value Based Compensation Models 24 Glossary of Terms

2 An Integrated B.C. Health Care System That Works for Patients; Health Professionals; and Sustainability This series of policies outlines the Ministry of Health strategic vision for a person-centred and integrated health system in B.C. a system that is easy to understand for those who use it, and those who work in it. This work lays the foundation for continued discussions with our health sector partners on how this vision can be achieved but comes with an imperative that we must take effective and sustained action now. Tremendous work has been underway in collaboration with Health Authorities, Doctors of BC, health care professionals, and with other key health service providers and partners across the province to think through the needed shift across the system. The policies that follow were developed using a systems approach intended to build an understanding of how different parts of the system need to work together to achieve our shared goal of improved health for all British Columbians. These policies bring together initiatives and directions that have been developing across the health sector for the last several years. They bring a sharper focus and a stronger emphasis on how, by better designing and linking the health service delivery system, we can truly move patients to the centre of services. By bringing a greater focus on team-based care we can increase access to quality care with the patient as a full partner in decision making. The Case for Change B.C. spends close to $19 billion a year on health -- nearly 46% of direct provincial spending. Reports from the Conference Board of Canada, TD Economics, and the Parliamentary Budget Officer estimate that sustaining existing health services requires the health system budget to grow at approximately 5.2% a year. This presents a significant challenge to the sustainability of the publicly funded health system across multiple jurisdictions. Even with such a sizable budget, the reality is that health services for patients are too often fragmented, untimely and inefficient. Patients are not always connected to the right services at the right time. The service system may have changed significantly over the past 25 years, but it is still a system that remains focused on hospitals and a wide range of independent physician office practices. Spending on home and community care, as well as mental health and addiction services, has grown significantly over the last twenty five years, but those services have been added on to the older system. The result is a fragmented and confusing health system that delivers pockets of excellent care -- but overall is difficult to navigate, challenged to provide coordinated care and inefficient. Layered on to this system is the changing demographics and changing health needs of the population -- health needs that require well-coordinated care across different parts of the system. Draft for Discussion purposes September 20, 2017 Page 1

3 A significant number of people will experience a mental health or substance use issue during their lifetime. Demand for surgery is growing significantly, linked to both an aging population and advances in technology. 15% of our population is more than 65 years old, and over the next 20 years, the proportion of seniors will almost double. Aging brings a growing incidence of chronic disease, with nearly 20% of patients in B.C. living with two or more chronic conditions. With longer lifespans, the need for care of patients towards the end of their lives is increasingly complicated; cancer and dementia are key health issues, as is the need for both in home and out of home long term care, including access to affordable medicines. The overall result is a growing number of patients requiring surgery, with moderate to complex medical conditions, mental health and substance use issues, cancer and patients who are experiencing frailty who all need continuity and coordination of care across providers, time and locations. This challenge is further complicated by the large geography and distribution of our population across sparsely populated rural areas. With a changing population we also have a changing workforce. How best to manage changes in our workforce is a key challenge for all jurisdictions. An aging workforce and the work practice changes of new health professionals are having a significant impact on our capacity to deliver the services we need. On one hand, we have increasing retirements and on the other are younger professionals who are less likely to seek full time positions, but are instead looking for work environments and employment that support better work-life balance. There should be no doubt that the current system will not meet the changing needs and demand for health care over the coming decade and the current pace of health system change will not get us to where we need to be. An over reliance on hospitals to meet these changing needs is not providing quality care for the changing population health needs and it is unaffordable in terms of the net new beds that would be needed, combined with replacement costs of aging hospital infrastructure. Nor is it acceptable that patients increasingly experience overcrowding in both emergency rooms and in-patient hospital care, delays for needed diagnostic services, or excessive wait times for scheduled surgery. These challenges require system level change that focuses on three areas: redesign of how services are delivered in key parts of the system, better coordination and linkages across the system to support improved patient-centred pathways to needed care, and optimizing our health human resources supported by increased use of digital technologies to better enable care, different compensation and approaches to work design. An Integrated System of Care This set of policies lays out the strategic vision for a well-designed, easily understandable, accessible and integrated health system that works better for patients and providers. Strategies will reduce waste and inefficiency to better sustain the publicly funded health system. The Draft for Discussion purposes September 20, 2017 Page 2

4 services will be designed to meet the population health needs in each of the 89 local health service delivery areas across the province and their specific communities. The focus of these policies is to improve outcomes and the service experience for primary care patients, mental health and substance use patients, surgical patients, cancer care patients and complex medical patients and/or frail patients. This focus does not include all population and patient health needs, but represents a large sub-set of patients where significant changes in health needs are occurring and where we need to rethink how services are delivered. The improved outcomes and service experience will be achieved by improving the design and delivery, continuity of care and linkages, as well as the optimal use of health human resources and digital technology for four key parts of the health system: primary care services, specialized community care and surgical services, a sub-set of hospital and diagnostic, regional and provincial health services, and Supportive funding and compensation The overall objective is to deliver an integrated primary and community care health system that is person-centred, coordinated, seamless and easy to understand for patients, family members and care providers that has appropriate access and support from hospital and diagnostic services. This whole system of care aims to help people maintain their health, recover from illness and surgery, improve their quality of life, stay independent longer and avoid unnecessary hospital visits. It is a system that can only be achieved through collaboration across the health sector. The foundation of the integrated system of care is the delivery of person-centred primary care services by interdisciplinary teams. The objective is to support the transformation of family physician practices and health authority primary care clinics into team-based patient medical homes and link them together in a team-based primary care network serving the primary care needs of a community. Our vision is that every individual and family who wants a regular primary care provider a family physician or nurse practitioner will be attached to one in a patient medical home. They will have an ongoing care relationship with their regular primary care provider, who will work in a team-based practice that includes nurse and other health professionals. The team will provide primary care services supported by a broader network of practices that together will ensure access to comprehensive primary care services. These services will be designed to be personcentred, culturally-safe and meet individual and population health care needs. This work will involve practice optimization, service redesign, team work, increased use of digital technology, and different business and compensation models. Individuals, families and caregivers will be able to access or contact their regular primary care provider, or patient medical home team, in a timely fashion using a variety of channels. These Draft for Discussion purposes September 20, 2017 Page 3

5 include in-person face-to-face visits, group visits, telephone and consultations, and online and video calls. People will know how to access advice and care from their patient medical home and the broader primary care network, and how to access urgent care 24 hours a day, 7 days a week. When patients require more specialized health care services related to mental health and substance use, surgery, cancer care or managing complex medical issues and/or frailty, they should not be left to find their way between multiple services, multiple wait lists and multiple providers resulting in sub-optimal, uncoordinated and inefficient care. The second building block of the integrated system of care is to redesign and link these fragmented services into integrated and coordinated Specialized Community Services Programs focused on Adults with Complex Medical Conditions and/or Frailty, Moderate to Severe Mental Health and Substance Use, and Cancer Care, and Surgical Services Programs for patients needing surgery. These programs will be linked to Primary Care Networks and will provide effective and holistic care planning, comprehensive and coordinated service delivery wrapped around the needs of the individual patient and a quality service experience. Services will be delivered by an interdisciplinary team. Once referred to a specialized program, patients will have access to the care services and management they need. Any referrals and appointments will be coordinated for them, along with education and self- management support and round the clock access to care or advice. Whether they live in a rural area, small town, or big city specialized and primary care providers will communicate with patients and each other providing citizens with an understandable, patientcentred system of care. The third building block of the integrated of the integrated system of care is for hospitals and more specialized tertiary regional and provincial services to provide expedited access to diagnostics, care and consults to patients from the Specialized Community Services Programs to enhance the quality of care of these patients and reduce pressure on emergency departments. The fourth building block is to establish targeted and sustained funding and implementing a value-based compensation model that supports the delivery of high-quality integrated and coordinated health services that are team based, cost effective and align with health system priorities. What will change? Explaining the Difference We frequently hear: I can t find a family doctor. In our future state we will hear: When I moved to this community I made one simple phone call and was attached to a Patient Medical Home in my community within a week. Draft for Discussion purposes September 20, 2017 Page 4

6 A story we hear now is: My family doctor or nurse practitioner can t see me when I get sick, so I go to a walk in clinic or the emergency room. In our future state we will hear: Care is available to me in the evenings and weekends through a network of care providers, and I know how to access it. Now patients tell us: Care providers don t know my story. I am referred to new providers who I don t know and I m not sure everyone talks to each other. In the future they will say: Care providers share my information so that everyone who needs to knows my story. An experience now may be: My family doctor or nurse practitioner says I could use more help to manage my mental health problems, but I feel lost trying to find someone to do so. In the future we will hear: My family doctor or nurse practitioner referred me to a local program that specializes in mental health care where I can get the help I need. Nothing is more personal than health care and this vision is focused on making sure there is a personal connection between provider and patient, and between members of the care team so someone on the team is making sure that any needed care is provided, and the patient always knows who is taking care of them. What is In the Policy Framework? The policies are divided into four sections: 1. Requirements for an Integrated Primary and Community Health Care System 2. Requirements for Primary Care 3. Requirements for Specialized Community and Surgical Services Programs 4. Requirements for linked Hospital, Diagnostic, Regional and Provincial Services 5. Requirements for supportive funding and compensation Requirements for an Integrated Health System General Policy Direction Requirements of an Integrated Primary and Community Care System - The integrated system will improve the design and delivery of services, continuity of care and linkages, as well as the optimal use of health human resources and digital technology for four key parts of the health system: primary care services, specialized community care services and a sub-set of hospital and diagnostic, regional and provincial health services, and supportive funding and compensation. Supportive Policy Direction: Continuity of Care - This policy defines clear expectations about providing effective transitions of care between different providers and Draft for Discussion purposes September 20, 2017 Page 5

7 services and how those transitions of care will be managed by care providers and patients. Supportive Policy Direction - Interdisciplinary Team-Based Care - Deploying interdisciplinary teams will guide health sector partners in making the best use of available resources to meet the needs of patients. The size and composition of teams will vary depending on patient needs. Requirements for Primary Care General Policy Direction - Establish Primary Care Networks - Primary care networks, made up of Patient Medical Homes and health authority led primary care services, will be the foundation of an integrated system of person-centred primary and community care. Supportive Policy Direction - Patient Medical Home - The majority of primary care needs will be met through Patient Medical Homes team-based primary care practices. Patients will have ongoing care relationships with a primary care provider who is most responsible for their care, as well as with members of the larger interdisciplinary team. Requirements for Specialized Community and Surigcal Services Programs General Policy Direction Specialized Community Services Program for MHSU Within each Local Health Service Delivery Area, a Specialized Community Services Program will provide streamlined and timely access to comprehensive services responsive to patient and family needs that address mental health and/or substance use issues. General Policy Direction Specialized Community Services Program for Adults with Complex Medical Conditions and/or Frailty Within each Local Health Service Delivery Area, a Specialized Community Services Program will provide streamlined and timely access to comprehensive services responsive to patient and family needs that address older adults with complex medical conditions or who are experiencing frailty. Services will support adults to remain in their homes as long as possible by improving care coordination and timely access to service. This Specialized Community Service Program will include access and close linkages with Home Support, Assisted Living and Residential Care. (Note Supportive Policy Directions for Respite Care, Palliative Care and Special Populations will also support this vision, and are under development.) Supportive Policy Direction - Home Support - A range of services will be provided to enable clients to live in their community as long as possible. This policy defines expectations that home support services be expanded to include some instrumental activities of daily living such as meal preparation and light housekeeping, when those services will help avoid hospital/residential care admission. An option for patient- Draft for Discussion purposes September 20, 2017 Page 6

8 directed home support funding, which allows clients to coordinate their own providers, will also be included. Supportive Policy Direction - Assisted Living A range of services will meet the needs of clients with complex medical and/or frailty to remain as independent as possible in a community setting, support aging in place and avoiding unnecessary hospital and residential care admissions. This policy defines expectations that higher levels of care will be accommodated with assisted living services. Supportive Policy Direction - Residential Care - Services for adults with complex needs who require 24-hour professional supervision and care in a safe environment, and a range of flexible short and long stay facility-based service options for people who can no longer be cared for safely at home. This policy defines expectations that Residential Care Facilities will provide respite, short stay and palliative services, as well as accommodating shared community services such as bathing and foot care for home care clients. General Policy Direction Surgical Services Program Services for patients throughout the surgical continuum from the time surgery is considered as an option through recovery. This policy defines expectations about communication with patients, care management and pre and post-surgery services. It is supported by Supportive Policy Directions for Wait Time Reduction and Waitlist Management Supportive Policy Direction - Surgical Wait Times Reduction - Reduce wait times for scheduled surgical procedures by implementing strategies to eliminate the backlog of waitlisted patients and meet ongoing surgical demand. Supportive Policy Direction - Surgical Waitlist Management - Ensure optimal management of surgical waitlists and consistent, transparent and clear communications with patients while they wait. Ensure waitlist information is accurate, reliable and comparable across the province. General Policy Direction Specialized Community Services Program for Cancer Care- All cancer care services will be delivered as part of a single community-based program with strong connections to regional and provincial services. Care will be well coordinated with patients who are at the center of the services and decision making. Requirements for Linked Hospital, Diagnostic, Regional and Provincial Services General Policy Direction Direct Hospital and Diagnostic Access and Effective Discharging In a great number of cases, emergency departments have become a default access point for hospital admission, or a first step for placement into residential care. This policy defines expectations for direct and timely access to needed hospital services for Draft for Discussion purposes September 20, 2017 Page 7

9 patients of specialized community services programs, without having to go through the emergency department. It also defines expectations that Specialized Community Services Programs will be involved in discharge planning, and that hospital patients will be effectively transferred to an SCSP or SSP to receive care in the most appropriate setting, making sure patients do not fall through the cracks. Patients will have timely access to outpatient diagnostic services through Specialized Community Services Programs General Policy Direction Direct Access to Regional and Provincial Health Services - Patients will have direct and timely access to more specialized tertiary and provincial health services through Specialized Community Services Programs. Requirements for Supportive Compensation General Policy Direction Value Based Compensation Models Draft for Discussion purposes September 20, 2017 Page 8

10 Ministry of Health Policy Instrument Type: Policy Name General Policy Direction Integrated Health System for Primary and Community Care Version 1.0 Effective Date: Division/Branch: Primary and Community Care Policy Division Ministry Contact: ADM Primary and Community Care Document Number: Date: September 15, 2017 Draft for discussion purposes 15-Sept-2017 P a g e 1

11 INTEGRATED HEALTH SYSTEM FOR PRIMARY AND COMMUNITY CARE POLICY OBJECTIVE Create a quality, integrated and coordinated delivery system for primary and community care that is person-centred, effective in meeting population and patient needs, delivers a quality service experience for patients in terms of access, appropriateness, acceptability, safety and efficiency a system that is easy to understand for those who use it and those who work in it. Provide a set of policies to improve outcomes and the service experience for primary care patients; mental health and substance use patients; surgical patients; cancer care patients; complex medical patients and/or frail patients. These policies focus on a large sub-set of patients where significant changes in health needs and demand for services are occurring requiring increased integration and coordination of services. Expected Impact on Health Outcomes and Service Attributes The Integrated Primary and Community Health Care System will achieve meaningful health outcomes (effectiveness) and service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected impacts include: 1. Effectiveness: Care achieves meaningful health outcomes for the individuals based on evidence-informed clinical and service assessment of needs and delivery of evidence informed services. Patients receive the majority of care in the community and there is reduced utilization of emergency departments, hospitals and residential care services by those patients. 2. Accessibility: Timely access to services based on best-practice clinical standards. 3. Appropriateness: Care meets the unique clinical service needs (scheduled, unscheduled and urgent) of the patient based on informed choices of the client in consultation with family/caregiver, using evidence-informed assessment and care planning processes, treatments and services as measured by outcomes. 4. Acceptability: Deliver respectful, compassionate and competent care that is designed around, and responds to, the needs, values, beliefs, language, culture and preferences of people seeking care, as well as their family members and caregivers, to ensure a quality patient/family and provider experience with care and service delivery. 5. Safety: Care provided is evidence-based, ethical and enables safe and competent care delivery that includes physical, emotional and cultural safety. Draft for discussion purposes 15-Sept-2017 P a g e 2

12 6. Efficiency: Services are streamlined to enable the flow of services to meet the needs of clients; deliver the required cross-sector service delivery, information flow and collaborative care and includes formally established linkages to local community-based seniors services. DEFINITIONS See glossary for common definitions. SCOPE This policy applies to health authorities, publicly funded health care providers and communitybased health and social service organizations funded through the Ministry of Health. POLICY DIRECTION Implement a standard system of health care delivery at the Local Health Service Delivery Area level and their component communities to achieve improved outcomes and service experience focused on implementing an integrated and coordinated service design, which makes optimal use of health human resources and digital technology, across four key parts of the health system: primary care services specialized community care services a sub-set of hospital and diagnostic, regional and provincial health services supportive funding and compensation Health authorities, publicly funded health care providers and community-based health and social service organizations funded through the Ministry of Health will collaborate to deliver an integrated primary and community care health system that is person-centred, co-ordinated, seamless and easy to understand for patients, family members and care providers. An integrated primary and community care system that has appropriate access and support from hospital and diagnostic services. This whole system of care will help people maintain their health, recover from illness or surgery, improve their quality of life, stay independent longer and avoid unnecessary hospital visits. Primary Care Services The foundation of the integrated system of care is the delivery of person-centred primary care services by interdisciplinary teams. The objective is to transform family physician practices and health authority primary care clinics into team-based patient medical homes and link them together in a a team-based primary care network. The primary care network will include patient medical homes and primary care services delivered or contracted by a health authority (including First Nations Health Authority) and community-based health and social service organizations (e.g. walk-in clinics, First Nations and Aboriginal agencies). Draft for discussion purposes 15-Sept-2017 P a g e 3

13 Our vision is that every individual and family who a regular primary care provider a family physician or nurse practitioner will be attached to one in a patient medical home. Patients will have an ongoing care relationship with their regular primary care provider who is most responsible for the overall coordination and continuity of the individual s care throughout their life. The regular primary care provider maintains this key role regardless of whether the required care is provided elsewhere in the healthcare system. The regular primary care provider will work in a team-based patient medical home, including nurses and other health professionals, that provides primary care services supported by a network of other patient medical homes and the broader primary care network to ensure access to comprehensive primary care services. The services delivered in a primary care network will be designed to be person-centred, culturally-safe and to meet individual and population health care needs. This work will involve practice optimization, service redesign, team work, increased use of digital technology, and different business and compensation models. Individuals, families and caregivers will be able to access or contact their regular primary care provider, or patient medical home team, in a timely fashion using a variety of channels, including in-person face-to-face visits, group visits, telephone and consultations, and online and video calls. They will know how to access advice and care from their patient medical home and the broader primary care network and get access to urgent care 24 hours a day, 7 days a week. Specialized Community Care Services The second building block of the integrated system of care is to redesign and link a range of what are currently disconnected or fragmented service delivery systems into three integrated and coordinated Specialized Community Services Programs and the Surgical Services Program linked to Primary Care Networks focused on Adults with Complex Medical Conditions and/or Frailty; Moderate to Severe Mental Health and Substance Use; Cancer Care; and Surgery. These programs will provide effective and holistic care planning; comprehensive and coordinated service delivery wrapped around the needs of the individual needs of patients and providing a quality service experience. Services will be delivered by an inter-disciplinary team. Once referred to a specialized services or the surgical services program, patients will have access to the care services and management they need. Any referrals and appointments will be coordinated for them, along with education and self- management support and round the clock access to care or advice. Whether they live in a rural area, small town, or big city specialized and primary care providers will communicate with patients and each other providing citizens with an understandable, patient-centred system of care. Draft for discussion purposes 15-Sept-2017 P a g e 4

14 Supportive Hospital and Diagnostic, Regional and Provincial Health Services The third building block of the integrated of the integrated system of care is for hospitals and more specialized tertiary regional and provincial services to provide expedited access to diagnostics, care and consults to patients from the Specialized Community Services Programs to enhance the quality of care to these patients and reduce pressure on Emergency Departments. Supportive Funding and Compensation The fourth building block is to establish targeted and sustained funding and implementing a value-based compensation model that supports the delivery of high-quality integrated and coordinated health services that are team based, cost effective and align with health system priorities. POLICY FRAMEWORK The Ministry sets out the expectations for the Integrated System of Care in a comprehensive policy framework. This framework includes a range of general policy directions and supportive policy directions categorized into five sections: 1. Requirements for an Integrated Primary and Community Health Care System a. Integrated Health System for Primary and Community Care i. Interdisciplinary Team-Based Care ii. Continuity of Care iii. Digital Care iv. Information Sharing v. Geographic Boundaries in B.C. 2. Requirements for Primary Care a. Primary Care Networks b. Patient Medical Home 3. Requirements for Specialized Community and Surgical Services Programs a. Mental Health and Substance Use b. Complex Medical Conditions and/or Frailty c. Surgery d. Cancer Care 4. Requirements for linked Hospital, Diagnostic, Regional and Provincial Services a. Direct Hospital and Diagnostic Access and Effective Discharging b. Direct Access to Regional and Provincial Health Services 5. Compensation Models a. Value Based Compensation Models Draft for discussion purposes 15-Sept-2017 P a g e 5

15 MONITORING AND EVALUATION The Integrated Primary and Community Care System general policy direction acts as an enabling policy for the entire suite of policies representing Ministry Strategic Initiatives. Enabling policies lay the foundation for overall health system transformation to take place, and help to address structural and systemic issues and enhance the effectiveness, reach and impact of general and supportive policy directions. REVIEW & QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the <insert date of implementation> and following completion of the summative evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. 3. Information from the annual evaluation will be used to understand the performance of Primary and Community Care strategic initiative, areas of success and areas for continuous quality improvement. Draft for discussion purposes 15-Sept-2017 P a g e 6

16 Ministry of Health Policy Instrument Type: Policy Name Supportive Policy Direction Interdisciplinary Team-Based Care Version 2.4 Effective Date: Division/Branch: Clinical Integration, Regulation and Education Division (CIRED) Ministry Contact: Chief Nurse Executive, CIRED Document Number: Date: September 15, 2017 Deputy Minister Ministry of Health Draft for discussion purposes 15-Sept-2017 P a g e 1

17 INTERDISCIPLINARY TEAM-BASED CARE POLICY OBJECTIVE Effective health care delivery requires interprofessional collaboration and coordination to place the patient at the center of care. Interdisciplinary teams of health care providers and support staff will be established across British Columbia as an essential attribute of the Integrated Primary and Community Health Care System to optimize access, service and care. Interdisciplinary team-based care will be supported by structures and processes that enable inquiry and collaboration across all disciplines, promote engaging the patient voice, and ensure cultural safety and acceptability in care delivery. Interdisciplinary teams will provide personcentred care, improve information and understanding, ensure informed decision making, and enhance understanding of self-management strategies for individuals, families and caregivers. The principles of dignity, respect, information sharing, participation and collaboration will be applied by all health care providers within the interdisciplinary team. Interdisciplinary teams will meet the care needs of both individuals across the life span (i.e. staying healthy, getting better, coping with illness and disability, and end of life) and the patient population (i.e. by providing access to quality health care services at sustainable per capita costs and as close to home as feasible). Teams will be designed using a population-data-informed and evidence-based approach. They will be sustained by applying quality improvement and practice related strategies to optimize collective competence and overall team productivity. Expected Impact on Health Outcomes and Service Attributes It is expected establishing interdisciplinary teams will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key services attributes (accessibility, appropriateness, acceptability, safety, equity and efficiency). Measurable expected impacts include: 1. Accessibility: An increased proportion of the community population has timely access to appointments in various health service areas. 2. Acceptability: Patients experience of care and service delivery meets the needs of patients, families and caregivers. Patients are informed decision makers in their care journey to achieve their health goals. Draft for discussion purposes 15-Sept-2017 P a g e 2

18 3. Safety: Improved continuity of patient health information and care management. 4. Efficiency: Increased care delivery by generalist health care providers working to their optimized scope of practice to meet health care needs from prevention to end of life. DEFINITIONS See glossary for common definitions Competency: A principle of professional practice identifying the ability of a health care provider to administer safe and reliable care on a consistent basis. Competencies: The minimal competency requirements for health care providers in an interdisciplinary team, which are common to the overall health care system, as set out by regulatory bodies, legislation and as articulated in job descriptions. Interdisciplinary team: A group of health care providers who work together in a coordinated and integrated manner with patients and populations to achieve health care goals. Effective interdisciplinary teams display collective competency, shared leadership, and active participation of each team member involved in patient care. Optimized scope of practice: A complimentary approach to team design where the most effective configuration of professional roles is determined by the relative competencies of all health care providers on the team. This means that the scope of each team member is optimized to effectively deliver care for patients; for example, nurse practitioners, nurses, social workers, dieticians or other team members may provide an optimized scope of service for patients while the physician focuses on complex diagnostics or other elements to facilitate the optimal contribution of all health provider team members. 1 Partners: Organizations and/or entities that have key leadership roles related to the implementation of the BC Patient Medical Home model (i.e. Ministry of Health, Doctors of BC, the General Practice Services Committee, divisions of family practice and family physicians, BC Nurse Practitioner Association and nurse practitioners), primary care networks (i.e. Ministry of Health and health authorities) and Specialized Care Services Teams (i.e. health authorities). Productivity: A process to evaluate interdisciplinary teams by measuring the physical inputs used (labor, capital and supplies) to achieve a given level of health outcomes in a patient or population. For the purposes of this policy, workforce productivity will be defined as the number of patient encounters per unit of time for a health care provider and/or interdisciplinary team on 1 Optimizing Scopes of Practice New Models of Care for a New Health Care System. Canadian Academy of Health Sciences (Ottawa, 2014). Draft for discussion purposes 15-Sept-2017 P a g e 3

19 the basis of efficiency (cost/patient/encounter), effectiveness (patient outcomes) and access (attachment). Role enhancement: Clinical practice that acts to optimize scope of practice to maximize the health care provider s use of in-depth knowledge and skills (related to clinical practice, education, research, professional development and leadership) to meet patients health care needs. 2 3 Role enlargement: The process of shifting health service delivery and administrative activities from a task-oriented approach toward integrated care carried out by health care providers and support staff (e.g. medical office assistants) who are able to meet patients multiple and complex needs through care management, managing populations, and planning and implementing appropriate levels of health and social care intervention. 4 5 Skill: The ability to use a developed aptitude and knowledge effectively and readily in the execution or performance of a role. 6 Skill mix: The particular combination of health care providers and support staff that will be used in a specific setting, based on the type and level of their skills and competence, to meet identified patient and population health needs. Skill management: The organization s ability to optimize the use of its workforce by understanding, developing, and optimizing the scope of health care providers and their skills through approaches such as role enhancement and role enlargement enabling health care providers to develop new skills, abilities, and techniques they did not obtain during previous clinical preparation. 7 SCOPE This policy sets out Ministry direction to health service partners (the Partners) to effectively and appropriately plan, use, and evaluate interdisciplinary teams as an essential element of the Integrated Primary and Community Health Care System. Interdisciplinary team composition 2 Ibid. 3 Ackerman, MH, Norsen, L., Martin, B., Wiedrich, J., Kitzman, H. Development of a model of advanced practice. American Journal of Critical Care, 1996, 5: Dubois, Carl-Ardy and Singh, Debbie. From staff-mix to skill-mix and beyond: toward a systemic approach to health workforce management. Human Resources for Health 2009, 7:87. 5 Dubois, Carl-Adry and Singh, D and Jiwani, I. The human resource challenge in critical care. In Caring for people wioth chrnonic conditions a health system perspective. Edited by: Nolte, E., and McKee, M. Open University Press/McGraw-Hill p Merriam Webster Dictionary. Source: 7 Dubois, Carl-Ardy and Singh, Debbie. From staff-mix to skill-mix and beyond: toward a systemic approach to health workforce management. Human Resources for Health 2009, 7:87. Draft for discussion purposes 15-Sept-2017 P a g e 4

20 varies by health service area and may include generalists and/or specialists, along with clinical, administrative support staff and volunteers. POLICY DIRECTION The expectation is that the Partners will systematically create and use interdisciplinary teams to provide services to support the integrated model of care, and meet the identified health needs of the population, using the following criteria: Effective Interdisciplinary Teams 1. Have an identified leader who establishes a clear direction and vision for the team and provides support and leadership. The leader uses the Triple Aim framework to establish and evaluate goals for the team. The leader demonstrates collaborative leadership, ensures role clarity amongst the team and ensures the engagement of patients, families and caregivers to achieve a mutually beneficial partnership between patients and providers. The leader can effectively manage conflict resolution or can access resources to assist with conflict resolution within the team. 2. Use a core set of principles that clearly provide direction for the team s service provision. These principles should be visible and consistently portrayed and will include person centredness, cultural safety, self-management, informed decision making, participation and collaboration, efficiency, safety, accessibility and respect. 3. Demonstrate a team culture and interdisciplinary atmosphere of trust where contributions of all providers are valued and consensus is fostered with collaborative leadership. 4. Ensure the patient voice, choice and representation forms a foundation for a mutually beneficial culture of person centeredness that is evident and integrated into team design, behaviours, care, and service delivery. Team members should be supported to demonstrate values, attitudes and behaviours that make patients true partners in the process of making care decisions. This will require creating opportunities for balancing the needs and expectations of the patients and families with the needs of the health care providers to complete their work. 5. Ensure appropriate care processes and management infrastructures are in place to uphold the vision and principles of the service (e.g. referral criteria, communications infrastructure). Draft for discussion purposes 15-Sept-2017 P a g e 5

21 6. Provide person-centred relationship-based care that includes the active participation of the individual, family and caregivers, in collaborative decision making, care planning and service delivery through their words and actions. 7. Provide quality person-centred service with documented outcomes and use feedback to improve the quality of care. 8. Use communication strategies that promote effective team functioning through intrateam communication, collaborative decision making, and effective team processes. 9. Ensure the appropriate use of practitioners and support staff working to an optimal scope to meet the needs of the patient population being served. The team provides staffing informed by population data and evidence to integrate an appropriate and optimal mix of knowledge, skills, and competencies to meet the needs of the population and enhance team functioning. 10. Facilitate recruitment of staff that demonstrates interdisciplinary competencies including team functioning, collaborative leadership, conflict resolution, communication, and sufficient professional knowledge and experience. 11. Promote role interdependence while respecting individual and overlapping scopes, roles, and individual autonomy. 12. Facilitate personal development through appropriate training, recognition, and opportunities for development. Team Design 13. Collaborative planning processes use data and evidence to determine the population health needs with key internal and, where possible, external partners (e.g. patients, divisions of family practice, staff, contracted service providers, local health societies, non-governmental organizations, denominational health care providers, and community members) appropriate for program and service settings. 14. Planning processes include analysis of population health data derived from traditional ministry and health authority sources (e.g. chronic disease registries, Discharge Abstract Data, health system matrix), panel/caseload assessments, community profiles and/or other resources. Data will be validated through consultations with stakeholders and service partners including, but not limited to patients, care providers, community leaders and health care partners such as contracted providers, non-profit health agencies, and denominational agencies. Draft for discussion purposes 15-Sept-2017 P a g e 6

22 15. Use validated population health data to determine the optimal mix of interdisciplinary team members required to address the population needs and to achieve the specific service attributes of the health service area. The team optimization process will consider the appropriate balance of preventative and therapeutic care services in addition to analysis of specialized population care requirements (i.e. core tasks), review of current job descriptions, scopes of practice and/or competency profiles, and alignment with health authority and/or Ministry of Health care guidelines and standards. 16. Ensure the desired skill mix of the interdisciplinary team considers the needs of the population and the full spectrum of available generalist and specialized health care providers and support staff, working at an optimized scope of practice. Ensures available health care providers are working to an optimal scope of practice before exploring the need to increase capacity through net new providers. Flexible and innovative approaches should be considered for rural and remote communities where the number and mix of providers are limited. 17. Develop strategies to mitigate constraints, such as the availability of health care providers, including innovative approaches to recruitment and retention, potential enhancement of scope or skills of current providers, flexible models of service delivery (e.g. practice generalism, job sharing, joint service delivery between health authorities 8, virtual care, over-staffing) and effective use of available providers (e.g. nurse practitioners, traditional healers, staff of non-government organizations) to meet population needs. Role enhancement, enhanced scope, and use of existing providers (i.e. remote certified nurses, community paramedics and first responders) are critical in remote communities. Optimizing Team Functioning 18. Ensure interdisciplinary teams are supported by effective on-site clinical leadership that promotes collaborative trust-based practice, facilitates team problem solving, clarifies team members roles, ensures effective team communications, applies process improvement to optimize team function, and ensures shared accountability for patient care and professional performance. 19. Employ effective change management strategies to support the optimization of the interdisciplinary team. This includes supporting the transition to team-based approaches, using coaching and mentoring approaches to support team members, and establishing a culture of collective competency through improved cooperation, coordination, and 8 For example, in rural communities interdisciplinary teams may be created with health care providers from the regional health authority and First Nations Health Authority. Draft for discussion purposes 15-Sept-2017 P a g e 7

23 communication while focusing on the shared goal of achieving optimal outcomes for all patients. 20. Ensure interdisciplinary team care management and collaborative decision-making processes are consistent and equitable, including but not limited to clear protocols for case conferencing and effective transitions of care within and between networked services, and mechanisms for effective communication (e.g. huddles, case meetings, shared charting/emr) among providers. 21. Use digital technology, where possible, to optimize networking within and between interdisciplinary teams and team members to ensure timely access to care, robust communication, and effective clinical decision making. Digital technology includes, but is not limited to, virtual care which will be embedded into day-to-day operations to link clinicians and care providers with patients to improve effectiveness in care delivery. Interdisciplinary Team Sustainability 22. Use continuous quality improvement and other effective management approaches to optimize team performance and strengthen integration services through process improvement (e.g. patient journey mapping, standing orders/protocols), service harmonization, seamless communication, collaboration within and between teams, and a focus on achieving Triple Aim objectives Encourage individuals, families and caregivers to provide informal and formal feedback that is embedded as a critical component of the interdisciplinary team s cycle of continuous quality improvement. 24. Commit to ongoing skill management to enable interdisciplinary team members to practice at an optimal professional scope of practice, and to access opportunities for continuing professional development that maintains or enhances an appropriate balance of unique and shared clinical skills required to ensure safe, competent, cost-effective, and ethical care. 25. Provide opportunities for interdisciplinary education that enable teams to receive information and training together, rather than in separate disciplines, in areas such as new guidelines, cultural safety and humility, clinical best practices, and information on the functioning of the health system to support system integration activities. 9 The term Triple Aim refers to the simultaneous pursuit of improving the patient and provider experience of care, improving the health of populations, and reducing the per capita cost of health care. Draft for discussion purposes 15-Sept-2017 P a g e 8

24 26. Determine interdisciplinary team productivity by undertaking comprehensive patient and population profile assessments, in addition to continuous improvement strategies, to determine the target interdisciplinary team case load or panel size. It is recognized that team composition will vary due to population needs, team practice models, health human resource available, and geography. 27. Optimize interdisciplinary team productivity by employing process improvement tools (e.g. LEAN) and innovative approaches including, but not limited to, active care management, delegation of clinical tasks, same-day scheduling to enable real time referrals (e.g. advanced access methods), group appointments, on-site Specialist shared care, extended hours of operation, and digitally-enabled care such virtual care and to enhance team and patient communication. LINKAGES Organizational Capacity Data Analytics and Reporting Data collection and submission should be comprehensive, accurate, and timely to support the value proposition of interdisciplinary team-based care, ensure an adequate and thorough understanding of population and patient needs and baseline service levels, and to plan for and assess improvements over time. Data and analysis will be provided by the Ministry of Health to support service delivery planning at both the Local Health Service Delivery Area and Community Service Delivery Area levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting and evaluation in line with the strategy for health system performance management. MONITORING AND EVALUATION The Integrated Primary and Community Care System general policy direction acts as an enabling policy for the entire suite of policies representing Ministry Strategic Initiatives. Enabling policies lay the foundation for overall health system transformation to take place, and help to address structural and systemic issues and enhance the effectiveness, reach and impact of general and supportive policy directions. REVIEW AND QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the <insert date of implementation> and following completion of the periodic evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. Draft for discussion purposes 15-Sept-2017 P a g e 9

25 3. As part of the larger Primary and Community Care Strategic Initiative the performance of this policy contributes to the overall success of the strategy and Review and Quality Improvement will take into account all policies under the strategy. Draft for discussion purposes 15-Sept-2017 P a g e 10

26 Ministry of Health Policy Instrument Type: Policy Name Supportive Policy Direction Continuity of Care Policy Version Effective Date: Division/Branch: Ministry Contact: 1.8 Draft Document Number: Date: September 15, 2017 Hospital, Diagnostic and Clinical Services / Acute and Provincial Services Executive Director, Acute and Provincial Services Deputy Minister Ministry of Health Draft for discussion purposes 15-Sept-2017 P a g e 1

27 CONTINUITY OF CARE POLICY POLICY OBJECTIVE Person-centred care is a core principle for ensuring a strong, sustainable, accessible and effective health care system in British Columbia. Person-centred care requires system integration, which individuals experience as effective continuity of care within and between health service areas. Patients, families and caregivers will experience care as being coherent and connected, and consistent with the patient s needs and personal context. Expected Impact on Patient/Population Outcomes/Service Attributes It is expected that effective continuity of care will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected outcomes include: 1. Acceptability: Experience of care and service delivery meets the needs of patients, families and caregivers. Patients are informed decision makers in their care journey to achieve their health goals. 2. Accessibility: Patients receive coordination of services without delays. Patients, families and caregivers are not responsible for coordinating care and transitions of care. 3. Accessibility: Patient care is seamlessly coordinated between and within health service areas (eg. Between SCSPs and the SSP). 4. Efficiency: Services are streamlined to provide effective cross-sector information flow and collaborative care planning. DEFINITIONS See glossary for common definitions Continuity of care: There are three types of continuity of care: relational continuity, informational continuity, and management continuity. They are closely related attributes that can be identified in every health discipline, and all three types of continuity are important to ensuring quality care. Relational continuity: An ongoing therapeutic relationship between a patient and a provider. Relational continuity provides a link from past to current and future care needs of the individual. Draft for discussion purposes 15-Sept-2017 P a g e 2

28 Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual. Information is the common thread that links care from one provider to another and from one health care event to another. This includes information on the medical condition and knowledge about patient preferences, values and context. Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient s changing needs. Continuity is achieved when services are delivered in a complementary and timely manner. Effective transitions of care: The successful movement of patients between practitioners and within and between health service areas. A smooth transition requires more than just referral for care, and may benefit from an interdisciplinary team approach to communication, collaboration, and coordination of care that includes the patient, family and caregivers at the centre of the information sharing and decision-making process. Health service area: Services offered within a particular network or location (e.g. primary care services in a patient medical home, specialized services in a specialized community services program, or services in a hospital). SCOPE This policy applies to all patient transitions of care within and between the following health service areas: primary care networks (PCNs), patient medical homes (PMHs) and primary care services delivered or contracted by a health authority; services provided by specialist physicians; specialized community services programs (SCSPs); surgical services programs (SSP); hospital and diagnostic services; and other health services delivered or contracted by health authorities, other ministries and community-based organizations across the province. POLICY DIRECTION Health service areas will provide continuity of care for patients, families and caregivers within and between health service areas. The following three types of continuity exist in all settings and are important to facilitate effective transitions of care. Relational Continuity: 1. In their PMH, patients will have a regular primary care provider, a family physician or nurse practitioner, who is familiar with their history, needs, and preferences; who is most responsible for providing longitudinal primary care and who has an ongoing role in ensuring continuity of care throughout the patient s journey in the system of care. 2. PCNs, consisting largely of PMHs and health authority primary care services, will be the foundation of an integrated system of person-centred primary and community care. Draft for discussion purposes 15-Sept-2017 P a g e 3

29 3. When receiving care from a health service area outside of the PCN, patients will also have a most responsible clinician who is familiar with their history, needs, and preferences and has an ongoing role in ensuring continuity of care throughout the patient s journey in the health service area. 4. The ongoing therapeutic relationship between a patient and their provider(s) will ensure the patient s preferences, needs and values will guide transition of care decisions. Informational Continuity: Within a health service area: 1. Information sharing mechanisms will ensure patient information is appropriately and effectively exchanged to support patient care within the health service area. 2. Patients, their provider(s) and team(s) will communicate throughout the patient s journey. 3. Care practitioners will appropriately share information to support integrated and continuous person-centred care. Between health service areas: 1. Health service areas will work with PCNs to ensure information sharing mechanisms are in place so patient information is appropriately and effectively exchanged. Health service areas will have channels to send information to and receive information from the regular primary care provider at appropriate points in the care process. 2. Health service areas will have information sharing mechanisms so patient information is appropriately and effectively exchanged during patient transitions in and out of their care. When coordinating services needed by the patient in another or multiple areas, health service areas will have channels to send information to and receive information from the most responsible clinician at appropriate points in the care process. 3. Wherever health service areas can appropriately share information, they should share it in support of integrated and continuous person-centred care. 4. Providers of episodic care (e.g. at emergency departments or walk-in clinics) and planned care (e.g. mental health and substance use, or surgery) will provide the patient s regular primary care provider in the PMH with visit information, where appropriate, to facilitate follow-up care and add pertinent information into the patient s ongoing health record. 5. Care planning, including discharge planning back to the community, will begin upon admission to hospital and include the patient s regular primary care provider and most responsible clinician in the SCSP or SSP, if applicable, in the care planning team. Management Continuity: Between health service areas: 1. For services required by a patient that are delivered outside of the PCN, the patient s regular primary care provider in the PMH will facilitate coordination of all transitions of care to: SCSPs or SSP, specialists outside of health service areas, and diagnostics and hospital services. Draft for discussion purposes 15-Sept-2017 P a g e 4

30 2. Primary responsibility for management continuity may shift from the patient s regular primary care provider in the PMH to the most responsible clinician in a SCSP or SSP when a patient requires more specialized services related to their acuity, chronicity and complexity. 3. For patients who receive services from multiple health service areas, the health service area that delivers the majority of a patient s care will coordinate any services needed for the patient from other health service areas. 4. Health service areas will establish clear and simple pathways, relationships and expectations for patient transitions of care to other care areas that reflect the principles of an Effective Transition of Care as outlined below. 5. Health service areas will develop processes so the patient s regular primary care provider is involved in the coordination of care between health service areas and maintains informational continuity with and for their patients. Within a health service area: 1. The health service area will establish effective coordination between service elements so that the management of patient care is seamless to the patient. The logistics of managing the care of services will happen in the background on behalf of the patient and according to their decisions for the planning of their care (see SCSP and SSP General Policy Directions). 2. The patient will be an informed partner in all management of care decisions. 3. All care providers will have a shared understanding of how care is to be managed to ensure the patient s plan of care is followed. 4. Each health service area will coordinate all services accessed by patients within that health service area. 5. Health service areas will establish clear and simple pathways, relationships and expectations for patient transitions of care into, within and out of their health service area that reflect the principles of an Effective Transition of Care as outlined below. Effective Transitions of Care: 1. An effective transition of care meets the service attributes outlined in the Expected Impact on Patient/Population Outcomes/Service Attributes section of this policy. 2. The patient will be involved in decision making about options for treatment and transitions of care. They will be informed of all treatment options in plain language, including the benefits and implications of each treatment option as well as no-treatment options. 3. All aspects of care coordination, including logistics, will be facilitated by the patient s regular primary care provider in the PMH or the most responsible clinician in the health service area, as appropriate. This will include a conversation between the health service areas involved in a patient transition of care. Follow-up conversations will confirm services have been scheduled. Draft for discussion purposes 15-Sept-2017 P a g e 5

31 4. The most responsible clinician in the SCSP or SSP will reach in to hospital services to actively transition SCSP or SSP patients back from hospital services as soon as clinically appropriate to reduce unnecessary hospital stays. 5. When transitioning care back into the community, a member of the care team will clearly articulate to the most responsible clinician in the SCSP or SSP, or the patient s regular primary care provider in the PMH where appropriate, what follow-up or step-down care is needed. The primary care provider or most responsible clinician will be responsible for ensuring any follow-up or step-down care indicated in the care plan is booked and communicated clearly to the patient. LINKAGES Organizational Capacity Data Analytics and Reporting Service delivery data collection and submission should be comprehensive, accurate, and timely to support adequate and thorough understanding of population and patient needs and baseline service levels, and to plan for and assess improvements over time. Data and analysis will be provided by the Ministry of Health to support service delivery planning at both the Local Health Service Delivery Area and Community Service Delivery Area levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting and evaluation in line with the strategy for health system performance management. MONITORING AND EVALUATION The Integrated Primary and Community Care System general policy direction acts as an enabling policy for the entire suite of policies representing Ministry Strategic Initiatives. Enabling policies lay the foundation for overall health system transformation to take place, and help to address structural and systemic issues and enhance the effectiveness, reach and impact of general and supportive policy directions. REVIEW & QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the <insert date of implementation> and following completion of the periodic evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. Draft for discussion purposes 15-Sept-2017 P a g e 6

32 3. As part of the larger Primary and Community Care Strategic Initiative, the performance of this policy contributes to the overall success of the strategy and Review and Quality Improvement will take into account all policies under the strategy. Draft for discussion purposes 15-Sept-2017 P a g e 7

33 Ministry of Health Policy Instrument Type: Policy Name General Policy Direction Establish Primary Care Networks Version Effective Date: Division/Branch: Ministry Contact: 14.5 Draft Primary and Community Care Policy Division Executive Director, Primary Care Access Document Number: Date: September 20, 2017 Deputy Minister Ministry of Health Draft for discussion purposes 20-Sept-2017 P a g e 1

34 ESTABLISH PRIMARY CARE NETWORKS POLICY OBJECTIVE Primary care networks (PCNs) will be established across British Columbia to provide comprehensive, person-centred, culturally safe, quality primary care services to the population of a Community Service Delivery Area (CSDA) and, as required, coordinate patients access to specialized community services programs (SCSPs), the Surgical Services Program (SSP) and the broader health system. A PCN is a network of patient medical homes (PMHs) linked with primary care services delivered or contracted by a health authority and community-based social and other health service organizations. PCNs are the foundation of an integrated system of team-based primary and community care. In most instances, an individual s primary care needs will be met by their PMH though some aspects of care may be provided within the broader network. PCN services will be designed and maintained to meet the needs of individuals, families and caregivers to improve population health at sustainable per capita costs. Expected Impact on Health Outcomes and Service Attributes It is expected that establishing PCNs will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected impacts include: 1. Accessibility: The population within a CSDA: a. Are attached to a regular primary care provider who is most responsible for overall coordination and continuity of care; b. Have timely access to appointments (same-day or at a scheduled time, as appropriate) with their regular primary care provider or another in-practice interdisciplinary team member; and c. Are able to access (in person or virtually) primary care advice and the provision of, or direction to, needed care 24 hours a day, 7 days a week, as close to home as feasible. Draft for discussion purposes 20-Sept-2017 P a g e 2

35 2. Appropriateness: Improved patient, family and caregiver experience outcomes through access to comprehensive, evidence-informed primary care delivered by interdisciplinary teams. 3. Acceptability: Improved patient, family and caregiver experience outcomes through access to person-centred and culturally safe care. 4. Efficiency: All appropriate ambulatory care needs are met in the community. DEFINITIONS See glossary for common definitions. SCOPE This policy covers the comprehensive suite of primary care services (see Appendix A) needed throughout an individual s life and across health service areas. This policy applies to family practices, health authority primary care clinics, primary care services delivered or contracted by health authorities (including the First Nations Health Authority) and community-based social and other health service organizations (e.g. community health centres, walk-in clinics). POLICY DIRECTION PCN Design 1. PCNs will be designed to meet the needs of individuals and ensure the comprehensive suite of primary care services (see Appendix A) are accessible by the community population they serve. Each PCN will serve approximately 10,000 to 50,000 people in rural and remote areas, and 50,000 to 100,000 people in urban areas of British Columbia. 2. Ministry of Health will work with each local PCN steering committee to determine the PCN s size, scope and service composition based on a number of design principles including: person- and family-centredness; comprehensive primary care will be delivered as close to home as possible; stable and professional inter-personal working relationships can be built among providers; and financial and other resources are distributed in an equitable and optimal manner. 3. In rural and remote communities, a smaller PCN may be able to provide comprehensive primary care services through a single PMH linked with health authority primary care services. 4. Consideration will be given for physical accessibility (e.g. rural and remote travel distances, public transportation, and limited mobility) and significant efforts will be made to reduce and mitigate access issues through the use of a variety of models, including virtual care, mobile services, group visits and other design elements. Draft for discussion purposes 20-Sept-2017 P a g e 3

36 5. PCN service design will consider both existing patients and those without access. PCNs will identify unattached individuals and families in the community and have a centralized primary care waitlist and protocols for patient-provider attachment. 6. PCN design will align with regional and provincial guidelines that will be co-created with health system partners, including patients, families and caregivers, to ensure comprehensive services are available on a human scale while taking into consideration local context (geography, population, Aboriginal Self Identification, etc.). 7. Within a CSDA a PCN will provide the community population with: a. An explicit, ongoing care relationship (i.e. attachment/relational continuity) with a regular primary care provider who is most responsible for their care for all people who want one; b. Comprehensive primary care services (see Appendix A) ensuring that services and care plans are holistic, person-centred, culturally safe and responsive to individual needs (including consideration of the social determinants of health); c. Timely access to appointments (same-day or at a scheduled time, as appropriate) with their regular primary care provider or another in-practice interdisciplinary team member; d. Access to primary care advice and provision of, or direction to, needed care 24 hours a day, 7 days a week through a variety of mechanisms, e.g. 811, access, call networks; f. Extended hours of care (including evenings and weekends) possibly through PMHs and/or linkages with walk-in clinics, urgent care centres, and community health centres; g. Coordinated service delivery including timely appointments for investigations, treatments and consultations in other health service areas; h. When more specialized care is required by a patient, ensure effective transitions of care as appropriate to the local or nearest SCSP (cancer care, mental health and addictions, and complex medical/frail) or Surgical Services Program, diagnostic facilities, medical specialists, hospital services, community-based service organizations and agencies (including on- and off-reserve First Nations and Aboriginal); and, i. Clear mechanisms and protocols for the patient s regular primary care provider to maintain continuity of care (relational, informational, and management) through contributing to care planning delivered through SCSPs or SSP, hospitals, and regional and provincial programs; j. Regular opportunities for patients, families and caregivers to be engaged and give feedback for quality improvement activities. 8. PCN design will include implementation and sustainment of the following functions: a. Interdisciplinary team care (in-practice and network) to optimal scope of practice; Draft for discussion purposes 20-Sept-2017 P a g e 4

37 b. Technology-enabled solutions with virtual care embedded into daily operations to link patients and providers (e.g. home health monitoring); c. Informational continuity (e.g. appropriate information sharing, single patient health record) and management continuity (e.g. longitudinal care planning, integrated team planning, team-based case management), including working towards linked electronic medical records; d. Case finding to identify individuals requiring care prior to crisis or hospitalization, including consistent use of upstream assessment tools (e.g. frailty scales); e. Provider access to rapid and optimal consultation services from SCSP or SSP, and regional and provincial services, to support the primary care team to appropriately and effectively meet mild to moderate needs of patients, address problems as they arise, and avoid the need for specialized care where possible. f. Partnership with the local community including school-based health promotion programs, community health centres, and community initiatives with citizens, local government, and other organizations focused on areas such as: i. healthy eating, food security and healthy weights, ii. physical activity and non-sedentary living, iii. tobacco and vapour product use prevention, cessation and enforcement, iv. social/emotional health and resiliency, v. culture of moderation of alcohol use, and vi. injury prevention. Patient Medical Home <see Patient Medical Home Supportive Policy Directive> 1. Within a PCN, all family practices and health authority primary care clinics will be supported to become a PMH as defined by the attributes of the BC PMH model. 2. All practices and clinics within a CSDA are considered a part of the PCN, both before and after they have attained PMH attributes. 3. In a PMH, individuals are attached to a regular primary care provider, a family physician or nurse practitioner, who is most responsible for the overall coordination and continuity of the individual s care across the life course. The regular primary care provider maintains this key role regardless of health service area or whether the required care is provided within the PMH or by other health professionals (e.g. specialists) in the system. 4. Primary care services delivered in a PMH will meet the majority of the populations primary care needs. The balance of comprehensive primary care services required by a geographic population will be met through PMH being networked with each other and with other primary care services being delivered or contracted by health authority as part of a PCN. 5. Coordinated and consistent PMH indicators and metrics will be applied across PCNs. Draft for discussion purposes 20-Sept-2017 P a g e 5

38 PCN Administration 1. PCN steering committees will be established, building on existing local structures (e.g. collaborative services committees) or sub-groups (e.g. local action teams) with a clearly defined local governance model including: joint planning, decision making, and accountability to regional and provincial governance structures for reporting and monitoring. 2. A PCN steering committee will start with a core membership representing the health authority and practices (i.e. division of family practice). Steering committee membership will expand as the network develops in the community to include patients/families/caregivers and additional community organizations in the PCN, for example the First Nations Health Authority, walk-in clinics, community health centres, urgent care centres, and community-based social and other health service organizations (on- and off-reserve). 3. PCN steering committees will have effective communication with municipal bodies, including First Nations councils, to inform planning for primary care services to address community needs. 4. PCN steering committees will design and maintain primary care services that meet the needs of individuals and improve population health at sustainable per capita costs through joint planning, implementation, resource management, quality improvement and reporting. 5. Locally developed PCN implementation plans will be reviewed and finalized regionally and provincially, in alignment with PMH, SCSP and SSP implementation. 6. PCN steering committees will implement plans in a sustainable, incremental process within and across geographic areas, leveraging existing assets and services, new innovations and local or regional opportunities as they occur. 7. PCN steering committees will consistently use data and evidence to inform planning and quality improvement activities at a professional, practice, community and system level. The necessary information sharing agreements will be in place to support quality improvement and evaluation work. LINKAGES Health Human Resources PCN interdisciplinary care teams will provide wrap-around, person-centered care using available HHR resources, optimized scopes of practice and where necessary and appropriate virtual care to achieve service objectives. Based on the population served, interdisciplinary care teams may be comprised of, but are not limited to, the following health care providers: 1. Audiologists 2. Counsellors 3. Dentists 4. Dietitians Draft for discussion purposes 20-Sept-2017 P a g e 6

39 5. Medical laboratory and diagnostics professionals 6. Medical office assistants 7. Midwives 8. Nurses and nurse practitioners 9. Occupational therapists and physiotherapists 10. Optometrists 11. Pharmacists 12. Psychologists 13. Physicians (mainly general practitioners) 14. Respiratory therapists 15. Social workers 16. Complementary and alternative providers (e.g. traditional healers) Organizational Capacity Data Analytics and Reporting Service delivery data collection and submission should be comprehensive, accurate, and timely to support adequate and thorough understanding of population and patient needs and baseline service levels, and to plan for and assess improvements over time. Data and analysis will be provided by the Ministry of Health to support service delivery planning at both the Local Health Service Delivery Area and CSDA levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting and evaluation in line with the strategy for health system performance management. PERFORMANCE INDICATORS Initial performance indicators have been developed in collaboration with the Ministry and external stakeholders to measure the expected outcomes of the service attributes of accessibility, appropriateness, acceptability, efficiency. <Insert Number> performance indicators to report on the Primary and Community Care Strategic Initiative include: 1. TBD In addition to the above indicators, Ministry and external stakeholders will continue to collaborate to identify additional indicators that provide insight into the performance of both the Establish Primary Care Networks General Policy Directive and the Primary and Community Care Strategic Initiative overall. Draft for discussion purposes 20-Sept-2017 P a g e 7

40 REVIEW & QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the date of implementation and following completion of the summative evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. 3. Information from the annual evaluation will be used to understand the performance of the strategic initiative, areas of success and areas for continuous quality improvement. 4. The Ministry will work with the program area to develop a quality improvement plan where necessary and will support the program area to manage the review and quality improvement process. 5. The Ministry will lead any monitoring of outcome measures that are identified in the quality improvement plans developed. Draft for discussion purposes 20-Sept-2017 P a g e 8

41 Appendix A Comprehensive Primary Care Services Within a PCN, the majority of the comprehensive primary care services will be provided by PMHs. The balance of primary care will be provided in the PCN by primary care services delivered or contracted by health authorities and other community-based health and social service organizations. Comprehensive primary care services include: POPULATION Staying Healthy Getting Better PRIMARY CARE SERVICES 1. Supports to address health literacy, self-care and self-management 2. Supports to address factors that contribute to health status advocacy for healthy public policy, supportive environments and communities 3. Population health assessment of the PCN population including the identification high risk sub-populations and clinical preventive maneuvers as required 4. Implementation of the Lifetime Prevention Schedule for the general asymptomatic population including: immunizations, screening (e.g., perinatal depression, cancer, etc.), behavioural interventions (e.g., tobacco cessation), preventive medications/devices (e.g. statins) 5. Nutrition counselling 6. Reproductive care: a. sexual health, including prevention and management of sexually transmitted infections b. health promotion services and supports before, during and after pregnancy (e.g. nutrition, exercise, hypertension, smoking cessation and substance use, birth planning) c. low-risk maternity care d. antepartum and postpartum care e. contraception, safe abortion services and post-abortion care 7. Healthy early childhood development: a. implementation of guidelines for developmental surveillance and case finding (see the SPD: Healthy Start) b. provision of information about child health, growth and development and parenting c. breastfeeding and child nutrition education and support d. health promotion services (e.g. immunizations and dental services) 1. Assessment and treatment services for minor illnesses 2. Access to diagnostic services, including point-of-care testing where Draft for discussion purposes 20-Sept-2017 P a g e 9

42 practical 3. Basic in-office emergency services 4. Linkages to community-based resources, including peer and group support Living with Illness or Disability Optimally Coping with End of Life 1. Outpatient diagnostic imaging and laboratory services, as appropriate 2. Early detection, intervention, education and support for self-care 3. Guideline-based chronic disease management and service coordination 4. Post-cancer treatment care and support 5. Pre- and post- surgical care (e.g. pre-habilitation, optimization and rehabilitation services). 6. Local surgical services, as appropriate 7. Use of existing standardized care pathways (e.g. hip surgery) 8. Ongoing monitoring, including medication 9. Home support for mild to moderate complex and frailty 10. Support for care provided in hospital and long-term care facilities 11. Care for mental health and substance use: a. screening, assessment and management of mild to moderate conditions and stable severe or complex disorders including concurrent physical health conditions, b. individual, group and on-line counselling, c. pharmacological treatment and medication monitoring, d. rapid access to crisis intervention services, e. harm reduction resources, f. tools to increase resilience, g. opioid agonist therapy services. 1. Serious illness and quality of life conversations 2. Palliative approach to care (e.g. pain management) 3. Support for the terminally ill Draft for discussion purposes 20-Sept-2017 P a g e 10

43 Ministry of Health Policy Instrument Type: Policy Name Supportive Policy Direction Patient Medical Home Version Effective Date: Division/Branch: Ministry Contact: 7.3 Draft Primary and Community Care Policy Division Executive Director, Primary Care Access Document Number: Date: September 20, 2017 Deputy Minister Ministry of Health Draft for discussion purposes 20-Sept-2017 P a g e 1

44 PATIENT MEDICAL HOME POLICY OBJECTIVE British Columbians will have the majority of their primary care needs met through comprehensive, person-centred, culturally safe, quality primary care services delivered by interdisciplinary teams in family practices (practice) and health authority primary care clinics (clinic). Individuals and families will have a regular primary care provider who knows them and their needs, is committed to their ongoing health and wellbeing, and coordinates with other providers and services to arrange timely access to the care they need, as close to home as possible. This policy provides guidance and sets out supports for practices and clinics as they develop and implement the attributes of the BC Patient Medical Home (PMH) model. As the essential components of a primary care network (PCN), practices and clinics will be supported to become PMHs and to have a voice and central role in establishing effective PCNs. Expected Impact on Health Outcomes and Service Attributes It is expected that establishing PMHs will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected impacts include: 1. Acceptability: Improved patient, family, caregiver, and provider experience outcomes through implementation of PMH attributes including commitment, contact, comprehensive, continuity, and coordination. 2. Appropriateness: Care provided is evidence-based and specific to individual needs. 3. Accessibility: Patients will: a. Be attached to a most responsible regular primary care provider. b. Have timely access to appointments (same-day or at a scheduled time, as appropriate) with their regular primary care provider or another in-practice interdisciplinary team member. 4. Efficiency: Increased patient attachment to a regular primary care provider (i.e. commitment) through interdisciplinary team-based care and office efficiency protocols. DEFINITIONS See glossary for common definitions. Draft for discussion purposes 20-Sept-2017 P a g e 2

45 SCOPE This policy applies to primary care practices and clinics in British Columbia working towards implementing the attributes of the BC PMH model. POLICY DIRECTION Practices and clinics will: PMH Attribute Adoption: 1. Work towards achieving the attributes of the BC PMH model as listed in Appendix A and pictured in Appendix B. 2. Access evidence-based resources and tools for practice optimization including panel size 1, scheduling, operating hours and team deployment to support the implementation of PMH attributes and achieve the expected impacts. 3. Participate in measuring baseline and incremental progress on PMH attributes with available mechanisms and tools, e.g. PMH assessment tool. 4. Meet the minimum readiness criteria to implement an in-practice interdisciplinary team: a. Identify a team champion/leader, b. Use an EMR for a minimum of 12 months, c. Be willing to do a panel review and assessment to gain a full understanding of needs and gaps, and d. Communicate with existing providers and staff to ensure support and participation in new or revised processes and protocols. 5. Engage in quality improvement activities, including understanding baseline, monitoring and measuring performance, and implementing practice changes. 6. Review and optimize business and governance models of the practice or clinic to best enable PMH attribute adoption. PMH Services: 1. Depending on local circumstance, ensure the majority of the comprehensive primary care needs of patients will be met in PMHs by in-practice interdisciplinary teams. Regardless of context, PMHs will provide a set of core services: a. Care of individuals across the life cycle (newborn to end of life and palliative care), b. Care across clinical settings (e.g. ambulatory/office practice, hospital and long term care institutions, emergency care settings, care in the home) and geographic service areas (remote, rural, urban and metro), and c. The full spectrum of services provided within the regulated scope of family practice (e.g. health promotion and prevention, maternity care, diagnosis and management of undifferentiated presenting problems, acute and chronic disease 1 Tools to optimize panel size are available here: or patientsmedicalhome.ca Draft for discussion purposes 20-Sept-2017 P a g e 3

46 management, mental health care, maternity care) and appropriate procedural medicine. PMH Role in PCN: 1. All PMHs within the geographical boundaries of a PCN are considered part of the PCN. 2. Participate in PCN steering committee primary care services planning to coordinate with other practices and clinics (i.e. PMHs),walk-in clinics, community health centres, urgent care centres, the division of family practice, health authority, First Nations Health Authority, and community-based service organizations (including First Nations and Aboriginal) to collectively provide: a. Comprehensive primary care services that are holistic, person-centred, culturally safe, and responsive to individual needs (see <link to Primary Care Networks General Policy Directive> for a list of services), b. An explicit, ongoing care relationship (i.e. attachment), for all people who want one, to a regular primary care provider who is most responsible for their primary care, c. Timely access to appointments (same-day or at a scheduled time, as appropriate) with their regular primary care provider or another in-practice interdisciplinary team member, and d. Access to primary care advice and the provision of, or direction to, needed care 24 hours a day, 7 days a week through a variety of mechanisms (e.g. walk-in clinics, 811, access, call networks, urgent care clinics). 3. Reduce and mitigate access issues for people in urban, rural and remote communities through the use of virtual care, mobile services, and other design elements. 4. Inform PCN steering committee work to adjust the skill mix and numbers of providers and other staff in the PCN to meet local population health needs and circumstances. 5. Inform PCN steering committee work to define the roles and functions of primary care providers in networks of interdisciplinary teams to ensure optimized scopes of practice. 6. Share practice/clinic information, data and experience to support development of inpractice and network teams. 7. Support a data-driven and evidence-informed approach and effective planning through information sharing agreements and providing practice-level data and information, e.g. patient and provider survey results, to the local PCN steering committee. LINKAGES Organizational Capacity Data Analytics and Reporting Service delivery data collection and submission should be comprehensive, accurate, and timely to support adequate and thorough understanding of population and patient needs and baseline service levels, and to plan for and assess improvements over time. Draft for discussion purposes 20-Sept-2017 P a g e 4

47 Data and analysis will be provided by the Ministry of Health to support service delivery planning at both the Local Health Service Delivery Area and Community Service Delivery Area levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting and evaluation in line with the strategy for health system performance management. PERFORMANCE INDICATORS In addition to the initial indicators noted in the Establish Primary Care Networks General Policy Directive, indicators have been developed that evaluate the performance of this supportive policy directive. Including: 1. ACSC Direct age standardized case rate per 100,000 population < 75 yrs 2. ACSC Direct age standardized case rate per 100,000 population >= 75 yrs 3. Rate of persons arriving at ED with CTAS 4 and 5 4. % of Population Attached to a Practice or Primary Care Provider (GP, NP) 5. Rate of persons arriving at an ED who are attached to a GP per capita 6. Attached Patients utilizing EDs during working hours classified as CTAS 4 or 5 The performance indicators developed for each supportive policy directive will complement indicators noted in the General Policy Directive and will contribute to periodic evaluation of the Primary and Community Care Strategic Initiative, providing insight on the measureable expected outcomes stated in each policy. REVIEW & QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the <insert date of implementation> and following completion of the periodic evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. 3. As part of the larger Primary and Community Care Strategic Initiative, the performance of this policy contributes to the overall success of the strategy and Review and Quality Improvement will take into account all policies under the strategy. Draft for discussion purposes 20-Sept-2017 P a g e 5

48 Appendix A BC Patient Medical Home Attributes Person-centred, whole-person Care is easily navigated and centred on the needs of the individual, family and community. Individuals are empowered in optimal self-management and contribute to the development and assessment of the practice/clinic and community care models. Care will be delivered in a culturally appropriate manner with recognition of social determinants of health and attention to marginalized populations. Commitment A PMH will ensure that individuals have access to a regular primary care provider (a personal family physician or nurse practitioner) who is most responsible for their primary care. Physicians and nurse practitioners have a defined patient panel and patients and providers have a shared understanding of their mutual therapeutic relationship. Contact Individuals are able to access their own family physician or nurse practitioner, or their PMH team, on the same day if needed Individuals know how to appropriately access advice and care on a 24/7 basis. Comprehensive The PMH delivers the majority of the comprehensive primary care services that patients need. (See Comprehensive primary care services listed in <GPD PCN>) The specific comprehensive services provided through the PMH and network of PMHs are determined by context, considering both community need and available resources. Continuity Longitudinal relationships support care across the continuum and spanning all settings. The enduring relationship between the individual, family physician or nurse practitioner and PMH team is key and needs to be supported by informational continuity (two-way communication that informs appropriate and timely care). Coordination The PMH serves as the hub for the coordination of care through informational continuity, personal relationships and networks with other PMH, interdisciplinary team members within and linked to the practice, and linkages to speciality and specialized services across care domains. Individuals are empowered to participate in the coordination of their care through access to their own medical information and shared decision making with their physician or nurse practitioner and team. In-practice interdisciplinary teams The PMH generally includes more than one family physician and/or nurse practitioner working within an in-practice interdisciplinary team with a focus on person-centred, relationship-based care. All providers within the practice are working to optimized scope. Draft for discussion purposes 20-Sept-2017 P a g e 6

49 Provider network teams supporting practice PMH networks supporting communities Informationtechnology enabled Education, training and research Evaluation and quality improvement Internal and external supports Family physicians and nurse practitioners are part of one or more clinical network teams working together to meet the comprehensive care needs of their patients and the patients of other PMHs in the community including extended hours of service, cross coverage and/or on-call. PMHs are networked through the divisions of family practice (or other similar community care service organization where divisions may not exist) to enable better coordination, partnership and integration with health authority and non-governmental community services, and the broader system of health care. Providers and staff in the practice are IT enabled, including optimized electronic medical record use and data collection methods to inform quality improvements in patient care and practice workflow, The electronic medical record is able to link appropriately with other providers and parts of the system, including other community providers, pharmacies and acute care facilities. Virtual care options, including access to appropriate , telephone and video conferencing advice/consults, are used and optimized. The PMH promotes mentoring and peer coaching for continuing professional development, training and research. This will include providing support to new grads and recruits coming to the community, providing training to medical students, residents and allied health providers within the practice, participating in peer-led small group learning sessions and research within the PMH or as part of a network. Providers and patients are involved in clinical quality improvement activities at a professional, practice, community and system level. The PMH has a business model which supports longitudinal, comprehensive, coordinated, team-based care and linkages with the SCSPs and SSP. Practices/clinics are supported to enable this model of primary care and integrated care through provincial and regional policies and systems, Draft for discussion purposes 20-Sept-2017 P a g e 7

50 Appendix B BC Patient Medical Home Model Draft for discussion purposes 20-Sept-2017 P a g e 8

51 Ministry of Health Policy Instrument Type: Policy Name General Policy Direction Specialized Community Services Program for Mental Health and Substance Use Version 1.22 Effective Date: TBD Division/Branch: Primary and Community Care Policy Division Ministry Contact: Executive Director, Mental Health and Substance Use Document Number: Date: September 15, 2017 Deputy Minister Ministry of Health Draft for discussion purposes 15-Sept-2017 P a g e 1

52 SPECIALIZED COMMUNITY SERVICES PROGRAM FOR MENTAL HEALTH AND SUBSTANCE USE POLICY OBJECTIVE This policy requires regional health authorities to establish and develop specialized community services programs (SCSPs) for individuals with moderate to severe mental health, substance use, and concurrent mental health and substance use (MHSU) disorders or conditions to achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Expected Impact on Health Outcomes and Service Attributes It is expected that establishing SCSPs for Mental Health and Substance Use will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected impacts include: 1. Effectiveness: Care is based on individuals receiving evidence-informed assessment of clinical and service needs, followed by evidence-informed services, leading to more meaningful health outcomes. Clients receive the majority of care in the community and there is reduced utilization of emergency departments, hospitals and residential care services by those clients. 2. Accessibility: Timely access to services that meet best-practice clinical standards. 3. Appropriateness: Care meets the unique clinical service needs (scheduled, unscheduled and urgent) of the patient based on informed choices of the patient in consultation with family and caregivers, as needed, using evidence-informed assessment and care planning processes and as measured by a patient experience and outcomes survey. 4. Acceptability: Deliver respectful, compassionate and competent care that is designed around, and responds to, the needs, values, beliefs, language, culture, and preferences of people seeking care, their family and caregivers, to ensure a quality client/family and provider experience of care and service delivery. 5. Safety: Deliver evidence-based, ethical, and competent care that protects clients, keeping them free from physical, emotional and cultural disrespect and/or harm. 6. Efficiency: Services are streamlined to enable the flow of services to meet the needs of clients, deliver the required cross-sector service delivery, information flow and collaborative care and includes formally established linkages to local community-based services for mental health, and for substance use. Draft for discussion purposes 15-Sept-2017 P a g e 2

53 DEFINITIONS See glossary for common definitions. SCOPE The policy applies to health authorities, publicly funded health care providers, and health authority contracted service providers delivering these specialized services. It covers all MHSU services to individuals (including children, youth, adults and older adults) with moderate to severe mental health, substance use, or concurrent mental health and substance use disorders or conditions. It includes all specialized voluntary mental health and substance use services as well as involuntary mental health services under the Mental Health Act. It includes assessment, treatment and support related to specialized interventions and highly specialized care. POLICY DIRECTION Regional health authorities establish and develop, at minimum, one SCSP for individuals with moderate to severe mental health, substance use, and concurrent MHSU disorders or conditions in each Local Health Service Delivery Area based on population health needs and geography. Shared SCSP Attributes Regional health authorities will ensure that each SCSP provides an integrated and comprehensive suite of evidence-based services to address the health care needs of a particular population and has the following attributes built in to its design and functioning: 1. The program will serve one or more primary care networks (PCNs) in a Local Health Service Delivery Area. 2. Services will be designed to maintain or improve health status. The effectiveness and quality of the services provided will result in less need for emergency department services or in-patient care. The services will also minimize the time a patient spends in hospital care. 3. A commonly known, single point of contact for SCSP is available both to health care providers in the PCNs for consultation or referral. In addition, patients, families and caregivers will have web-based access to information and the ability to talk with someone directly to discuss and/or access SCSP services. 4. Multiple related services are integrated into a single program structure to provide and coordinate seamless interdisciplinary team-based care to meet the patient s physical and psychosocial needs. Patients will experience an integrated system of care organized by a single care manager who will ensure care is seamless and coordinated across the program. Patients needs will be met by an interdisciplinary team, consisting of the most appropriate skill mix. Any referrals and appointments will be coordinated for them, along with education and self- management support and 24/7 access to care or advice. Draft for discussion purposes 15-Sept-2017 P a g e 3

54 5. Patient access to other specialized services will be coordinated by the SCSP with the patient, including when subsequent to the original referral the patient requires services from a different SCSP. 6. Interdisciplinary team-based care within the SCSP: promotes collective competence, shared leadership, and the active participation of each care provider and support staff in patient care; ensures person-centred goals and values; provides continuous communication among team members; provides opportunities for education and training; enhances participation in clinical decision making within and across disciplines; and fosters respect for the contributions of all team members. 7. Digital and information technology enables flexible and innovative service delivery options including virtual care. Information sharing across providers informs effective and quality person-centred care and enables quality improvements in patient care and practice workflow. 8. Programs will optimize co-location but ensure a single communication network and personal connectivity across all the service elements that make up a specialized program, including program team meetings. 9. Each SCSP will have a single designated leader with fiscal and operational accountability for all aspects of the program and its services. Specific SCSP Attributes Each SCSP integrates multiple related services into a single program structure for the provision of community mental health and substance use services for individuals with moderate to severe (1) mental health, (2) substance use; and (3) concurrent MHSU disorders or conditions. Coordinated and integrated leadership and service planning is established for both mental health and substance use services for each SCSP. Patient Population: 1. The SCSP will be structured to meet the distinct health care needs for three groups of patients, providing and coordinating seamless team-based care to meet the person s biophysical, psychological, and social needs. Needs are based on a person s level of functioning, acuity, behaviour, stage of recovery, legal requirements, and cultural background. The three groups include the following disorders, consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM): a. Mental Health Moderate to severe mental health issues are disorders or conditions that may produce psychotic symptoms, such as schizophrenia and schizoaffective disorder, and moderate to severe forms of other disorders, such as major depression, bipolar disorder, eating disorders, conduct disorders, severe anxiety disorders, and concurrent neuro-developmental disorders. Draft for discussion purposes 15-Sept-2017 P a g e 4

55 b. Substance Use i. Moderate to severe substance use disorders and conditions associated with the risks and harms of moderate to severe substance use in the form of drugs or alcohol (health related issues, social functioning, overdose) and related behaviours (sharing needles and other drug paraphernalia, unsafe sexual practices). c. Concurrent i. Moderate to severe substance use and mental health disorders occurring at the same time. Services: 1. The SCSP will provide timely access to a coordinated and comprehensive suite of MHSU services that are responsive to the full range of disorders and conditions experienced by individuals, their families and caregivers faced with managing moderate to severe (1) mental health, (2) substance use; and (3) concurrent MHSU disorders or conditions. These services will be person-centred and accessible through clear, simple, and well-understood pathways that are coordinated and managed on the patient s behalf and designed to optimize patient functioning and outcomes. 2. The SCSP services will include, at minimum, emergency response and triage services, clinic-based services, home-based community outreach services, assertive outreach services and rehabilitation, recovery and residential treatment services based on the needs of the population. It either directly provides, or has linkages to, acute and tertiary care services. 3. The SCSP provides a range of services to meet both the shared and distinct needs of the three populations for people with moderate to severe (1) mental health, (2) substance use and (3) concurrent MHSU disorders or conditions. a. Common services for people with moderate to severe mental health issues are a combination of proactive screening and case finding, keeping a person engaged in treatment, emergency response services, counselling, cognitive, behavioural and social learning interventions, pharmacological treatment, intensive day programming, psychosocial rehabilitation support services, and residential care. b. Common services for people with moderate to severe substance use disorders and conditions include proactive screening and case finding, keeping a person engaged in treatment, emergency response services, managing a person s intoxication or addiction and associated acute medical problems, counselling, behavioural and social learning interventions, pharmacological treatment including opioid agonist therapy, withdrawal management, intensive day programming, psychosocial support services, supervised injection sites, and short- and medium-term residential treatment and rehabilitation services. Draft for discussion purposes 15-Sept-2017 P a g e 5

56 4. The SCSP integrates court-related forensic psychiatric assessment, treatment and community services to individuals with moderate to severe mental health, substance use, and concurrent MHSU disorders or conditions that are in conflict with the law in order to return individuals safely back into their local community. 5. The SCSP ensures services: a. Align with the (1) trauma-informed and responsive practice principles <link >; (2) wellness-focused and recovery-oriented practice principles <link>;(3) culturally safe and community-centred practice principles <link>. b. Patients and, as appropriate, family and caregiver input into the care planning and design of services and, where possible, patients have a choice of interventions and supports. c. Provide holistic bio-physical, psychological, social, and spiritual care and therapies to the patient and family to address both immediate and longitudinal needs as well as providing access to specialist medical care. d. Address physical health care needs, including prevention/promotion services, and can be provided by the PCN directly for stable patients or through reverse shared care approaches for patients who are unstable and/or have complex behaviours or conditions. e. Are offered in various settings including community-based clinics, a person s home, their community, and assertive outreach services, as well as in residential settings, hospital and specialized inpatient care facilities, and through virtual care and other digital technologies. f. Are delivered according to legislation, provincial clinical practice guidelines and program standards, and are informed by current evidence and best practice where possible. Care Coordination, Key Functions, and Team-Based Care 1. The SCSP ensures a commonly known, single point of contact is available both to health care providers within the PCNs for consultation or referral. In addition, there is webbased access for patients, families and caregivers to information and the ability to talk with someone directly to discuss and/or access SCSP services. 2. The SCSP will assign a most responsible clinician (MRC) to each patient who is responsible for designing seamless, person-centred, culturally safe care provided by the interdisciplinary team and may include care and services outside of the SCSP, as required. 3. The SCSP will establish team-based care around patients that provides relational consistency with the care team members. 4. The SCSP s MRC will ensure the access to direct care and supports for patients and families 24/7, providing care and services as needed to avoid unnecessary emergency department visits and hospital admissions. Draft for discussion purposes 15-Sept-2017 P a g e 6

57 5. The SCSP will have efficient and timely access for patients to pharmacy, diagnostic, hospital outpatient, emergency, and inpatient hospital services. 6. The SCSP will reduce and mitigate requirements for long distance travel by patients for diagnostic tests, treatments and follow-up appointments through the use of virtual care, mobile services and other design elements, where appropriate. 7. The SCSP will work with community MHSU specialists or networks of sub-specialties to establish mechanisms for coordinating patient access to appropriate care to meet the needs of patients as required. 8. The SCSP will establish relationships with local private MHSU community service providers to enable improved quality of services, improved integration and coordination of services between the SCSP and private service providers. 9. The SCSP will deliver the following functions: a. Urgent Response: i. The SCSP will be responsive to urgent needs 24/7, using defined pathways to support individuals in crisis. b. Case Finding and Screening: i. Screening: Initial screening will be conducted within 24 hours unless the person is experiencing a high level of acuity requiring a minimum response time of one to two hours. Response times will vary depending on geography. ii. Case finding and in-reach services: These services will be provided on an ongoing basis in partnership with patient medical homes/pcns, hospitals, community first responders, corrections, and homeless shelters to identify people with moderate to severe mental health and/or substance use issues with unmet MHSU needs. iii. Immediately following screening, an intake and initial assessment is conducted for people who meet initial screening requirements for SCSP. iv. The SCSP will provide general advice and information such as MHSU health literacy to people and families who do not require SCSP services. The SCSP will maintain involvement until the person is linked with the most appropriate service for their needs. c. Consultation to assigned PCNs. d. Intake and Initial Assessment: i. At intake, people will be triaged to determine appropriate service. ii. The initial assessment will be conducted based on standard assessment tools and will address mental health, substance use and physical health care needs. iii. Initial psychiatric consultation for assessment is provided as appropriate. iv. The assessment will take place in a setting that supports appropriate engagement of the individual. This may be a community setting, a Draft for discussion purposes 15-Sept-2017 P a g e 7

58 person s home, hospital, emergency department, community agencies or via virtual care technologies. The assessment will inform the development of an initial care plan overseen by a MRC. v. The initial care plan will include the set of services and interventions required based on individual needs. e. Immediate and short-term supports: i. Following the initial assessment, rapid access to urgent response services will be activated for those with high levels of acuity that require immediate stabilization. Consideration will be given to the context of rural and remote communities where the scope and availability of health providers are limited. ii. A MRC will be assigned the patient to ensure continuity of care. iii. People will be matched with the right service to meet their diverse needs and receive rapid access to short-term intervention, general guidance, and support to address immediate psychological distress and issues concerning determinants of health. iv. The SCSP will be available 24/7 to address immediate needs. f. Specialized team-based care: i. The person will be linked to appropriate SCSP services and supported by an interdisciplinary team with an assigned MRC. ii. Rapid mobilization of services will address changing, urgent or unscheduled needs. This includes expedited access to pharmacy, hospital outpatient, emergency inpatient services, residential treatment, and rehabilitation services with consideration of cultural preferences as appropriate. iii. Care management and coordination: o Services will be designed around, and respond to, the unique needs, values, beliefs, language, culture and preferences of people seeking care, their family and caregivers. o Timely access to specialized MHSU will services follows a stepped-care approach. o All MHSU care will be provided and/or coordinated by a MRC through the interdisciplinary team. Management of care is seamless to the person. The logistics of managing services will happen in the background on behalf of the patient and in alignment with their decisions for the planning of their care. <link to Continuity of Care Supportive Policy Direction> Draft for discussion purposes 15-Sept-2017 P a g e 8

59 iv. Consultation support and collaborative care planning: o General information, education and advice will be provided to patients, families, and caregivers, and PCNs in the prevention, management and treatment of MHSU issues. o The interdisciplinary team provides consultation support and collaborative care planning with other SCSPs (e.g. adults with moderate to severe mental health and/or substance use issues, cancer care) and the Surgical Services Program o The interdisciplinary team participates in collaborative planning and delivery of care with the PCN, provincial specialized MHSU services, specialists, non-governmental organizations, and community service providers, First Nations organizations, and social services provided by other government ministries. o Active PCN involvement in planning and delivery of care to improve patient experience, enable information flow and support access to specialist consultations and services as required. v. Transition and ongoing support: o Patients with moderate to severe MHSU issues who have stabilized and no longer require services of the SCSP will be transitioned to the PCN. The MRC will continue to support the PCN when patients require clinical support from the SCSP. o When an in-hospital admission is necessary, the MRC remains involved in care and planning, working closely with acute care staff to organize and facilitate an effective and timely transition back to the community settings. o The MRC coordinates care to and from local acute care in-patient MHSU services, regional MHSU services, and provincial specialized MHSU services. Care planning is integrated with shared accountabilities, and transition protocols align with Regional and Provincial Services. 10. The SCSP will provide a team-based model of delivery <link to Interdisciplinary Team- Based Care Supportive Policy Direction> ensuring: a. Interdisciplinary teams use an integrated care management model to deliver comprehensive care to patients based on an assessment of need and assignment of appropriate care to meet individual health goals. b. The roles and functions of team members will be clearly defined and scopes of practice optimized. c. Team members will be co-located or linked using technology to facilitate communication and information sharing and clinical supervision of all services provided by the program. Draft for discussion purposes 15-Sept-2017 P a g e 9

60 d. Interdisciplinary teams will work collaboratively with: i. Government services that provide housing, social, educational and skill training, and financial supports; ii. Non-government organizations that provide social supports for patients, families and caregivers; iii. Police and paramedic teams to facilitate assessments in community whenever possible to avoid unnecessary emergency department admissions; iv. Service partners, communities, First Nations on and off reserve, and other Aboriginal organizations to raise awareness of MHSU issues and services available in the SCSP and support the development and delivery of services and supports for populations with MHSU issues. e. Team-based care will include contracted MHSU service providers as full members of the interdisciplinary team. SCSP contracted MHSU services will be expected to adhere to the same quality and safety standards as health authority operated services, including medical and clinical oversight. LINKAGES Health Human Resources (HHR) Interdisciplinary care teams will provide wrap-around, person-centred care using available HHR resources, optimized scopes of practice and, where necessary and appropriate, virtual care to achieve service objectives. Based on the population served, interdisciplinary care teams may comprised of, but are not limited to, the following health care providers: 1. Psychiatrist 2. Physician specializing in addiction medicine 3. Family physician or nurse practitioner 4. Registered psychiatric nurse/registered nurse 5. Psychologist 6. Social worker 7. Clinical counsellor 8. Occupational therapist 9. Trained peer support The interdisciplinary teams include the following allied professionals: 1. Pharmacist 2. Medical specialist (dentist, optometrist, podiatrist, speech and hearing) 3. Nutritionist 4. Naturopathic medicine 5. Recreation therapist 6. Music and art therapists Draft for discussion purposes 15-Sept-2017 P a g e 10

61 7. Physiotherapist 8. Spiritual services 9. Traditional Chinese medicine and acupuncturists 10. Cross-cultural liaison 11. Forensic experts 12. Vocational experts 13. Staff with expertise in public health 14. Staff with expertise in psychosocial rehabilitation, including rehabilitation practitioners with expertise in basic living skills support, supported housing, supported employment, supported education and wellness support (nutrition, weight management, smoking cessation) Organizational Capacity Data Analytics and Reporting Service delivery data collection and submission should be comprehensive, accurate, and timely to support adequate and thorough understanding of population and patient needs and baseline service levels, and to plan for and assess improvements over time. Data and analysis will be provided by the Ministry of Health to support service delivery planning at both the Local Health Service Delivery Area and Community Service Delivery Area levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis, and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting, and evaluation in line with the strategy for health system performance management. PERFORMANCE INDICATORS Initial performance indicators have been developed in collaboration with the Ministry and external stakeholders to measure the expected outcomes of the service attributes of effectiveness, accessibility, appropriateness, acceptability, safety and efficiency. Seven performance indicators to report on the Primary and Community Care Strategic Initiative include: 1. % of MHSU Population Attached to a GP/NP 2. % of people admitted for mental illness and substance use who are readmitted within 30 days 3. Rate of ED visits for people with a mental health and/or substance use diagnosis per capita 4. Average length of stay for people with a mental health and/or substance use diagnosis 5. % of patients receiving follow up care by a primary care physician or specialist within 30 days following hospital discharge for a mental health and/or substance use diagnosis 6. Unplanned ED use for mental health and substance use 7. MHSU Patient Attached to Physician Draft for discussion purposes 15-Sept-2017 P a g e 11

62 In addition to the above indicators, Ministry and external stakeholders will continue to collaborate to identify additional indicators that provide insight into the performance of both the Specialized Community Services Program for Mental Health and Substance Use General Policy Direction and the Primary and Community Care Strategic Initiative overall. REVIEW & QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the <insert date of implementation> and following completion of the periodic evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. 3. Information from the periodic evaluation will be used to understand the performance of the strategic initiative, areas of success and areas for continuous quality improvement. 4. The Ministry will work with the program area to develop a quality improvement plan where necessary and will support the program area to manage the review and quality improvement process. 5. The Ministry will lead any monitoring of outcome measures that are identified in the quality improvement plans developed. Draft for discussion purposes 15-Sept-2017 P a g e 12

63 Ministry of Health Policy Instrument Type: Policy Name General Policy Direction Specialized Community Services Program for Adults with Complex Medical Conditions and/or Frailty Version 6.4 Effective Date: Division/Branch: Primary and Community Care Policy Division Ministry Contact: Executive Director, Seniors Services Document Number: Date: September 15, 2017 Deputy Minister Ministry of Health Draft for discussion purposes 15-Sept-2017 P a g e 1

64 SPECIALIZED COMMUNITY SERVICES PROGRAM FOR ADULTS WITH COMPLEX MEDICAL CONDITIONS AND/OR FRAILTY POLICY OBJECTIVE This policy requires regional health authorities to establish specialized community services programs (SCSPs) for adults with complex medical conditions and/or frailty to achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Expected Impact on Health Outcomes and Service Attributes It is expected that establishing SCSPs for Adults with Complex Medical Conditions and/or Frailty will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected impacts include: 1. Effectiveness: Care achieves meaningful health outcomes for individuals based on evidence-informed clinical and service assessment of needs and delivery of services. Clients receive the majority of care in the community and there is reduced utilization of emergency departments, hospitals, and residential care services by those clients. 2. Accessibility: Timely access to services based on best-practice clinical standards. 3. Appropriateness: Care meets the unique clinical service needs (scheduled, unscheduled and urgent) of the client based on informed choices of the client in consultation with family and caregivers, using evidence-informed assessment and care planning processes and as measured by a client experience and outcomes survey. 4. Acceptability: Deliver respectful, compassionate and competent care that is designed around and responds to the needs, values, beliefs, language, culture, and preferences of people seeking care, their family and caregivers, to ensure a quality client, family, and provider experience with care and service delivery. 5. Safety: Care provided is evidence-based, ethical, and enables safe and competent care delivery that includes physical, emotional, and cultural safety. 6. Efficiency: Services are streamlined to enable the flow of services to meet the needs of clients, deliver the required cross-sector service delivery, information flow and Draft for discussion purposes 15-Sept-2017 P a g e 2

65 collaborative care and includes formally established linkages to local community-based seniors services. DEFINITIONS See glossary for common definitions. Community-Based Seniors Services: A broad definition that includes all non-profit and municipal services that provide programming for older adults (including community centers, multi-service agencies, senior s centres, community coalitions, neighbourhood houses 1 ). SCOPE The policy applies to health authorities, health professionals, and health authority contracted service providers delivering these specialized services. It includes all services to meet the needs of adults with complex medical conditions and/or frailty.these services include program-based clinical care, community nursing and allied services managed (or contracted) by health authorities, specialist medical care, home support, adult day respite, respite care and short-term residential care, assisted living, long-term residential care, and palliative care and formal linkages to local community-based seniors services. POLICY DIRECTION Regional health authorities establish and develop, at minimum, one SCSP for adults with complex medical conditions and/or frailty in each Local Health Service Delivery Area based on population health needs and geography. Shared SCSP Attributes Regional health authorities will ensure that each SCSP provides an integrated and comprehensive suite of evidence-based services to address the health care needs of a particular population and has the following attributes built in to its design and functioning: 1. The program will serve one or more primary care networks (PCNs) in a Local Health Service Delivery Area. 2. Services will be designed to maintain or improve health status. The effectiveness and quality of the services provided will result in less need for emergency department services or in-patient care. The services will also minimize the time a client spends in hospital care. 3. A commonly known, single point of contact for SCSP will be available to health care providers in the PCNs for consultation or referral. In addition, clients, families and 1 Cohen, M., & Kadowaki, L., Raising the Profile of the Community-based Seniors Services Sector in BC. Draft for discussion purposes 15-Sept-2017 P a g e 3

66 caregivers will have web-based access to information and the ability to talk with someone directly to discuss and/or access SCSP services. 4. Multiple related services will be integrated into a single program structure to provide and coordinate seamless interdisciplinary team-based care to meet the client s physical and psychosocial needs. Clients will experience an integrated system of care organized by a single care manager who will ensure care is seamless and coordinated across the program. Clients needs will be met by an interdisciplinary team, consisting of the most appropriate skill mix. Any referrals and appointments will be coordinated for clients, along with education and self-management support and 24/7 access to care or advice. 5. Access to other specialized services will be coordinated with the client by the SCSP when subsequent to the original referral other services are required from a different SCSP. 6. Interdisciplinary team-based care within the SCSP: promotes collective competence, shared leadership, and the active participation of each care provider and support staff in client care, ensures person-centred goals and values, provides continuous communication among team members, provides opportunities for education and training, enhances participation in clinical decision-making within and across disciplines, and fosters respect for the contributions of all team members. 7. Digital and information technology enables flexible and innovative service delivery options including virtual care. Information sharing across providers informs effective and quality person-centred care and enables quality improvements in client care and practice workflow. 8. Programs will optimize co-location but ensure a single communication network and personal connectivity across all the service elements that make up a specialized program, including program team meetings. 9. Each SCSP will have a single designated leader with fiscal and operational accountability for all aspects of the program and its services. Specific SCSP Attributes Each SCSP integrates multiple related services into a single program structure for the provision of community care for adults with complex medical conditions and/or frailty. Client Population 1. The SCSP will be structured to meet the needs of adults with complex medical conditions as set out in the health system matrix and those assessed as frail. Services 1. The SCSP will provide timely access to a coordinated and comprehensive suite of services to meet the needs adults with complex medical conditions and/or frailty. These services will be person-centred and accessible through clear, simple and well-understood Draft for discussion purposes 15-Sept-2017 P a g e 4

67 pathways, coordinated and managed on the client s behalf, and designed to optimize client functioning and outcomes. 2. The SCSP services will include, at minimum: clinical and medical care, family/friend informal caregiver supports, community nursing and allied services managed (or contracted) by health authorities, access to specialist medical care, home support, adult day care (through both adult day respite care centres and where available access to services provided by assisted living and residential care such as cafeteria, social activities, bathing, laundry and personal care), respite care and short-term residential care, assisted living, long-term residential care, and palliative care. Care Coordination, Key Functions and Team-Based Care 1. The SCSP ensures a commonly known, single point of contact is available both to health care providers within the Primary Care Networks for consultation or referral. In addition there is web-based access for clients/families to information and the ability to talk with someone directly to discuss and/or access SCSP services. 2. The SCSP will assign a most responsible clinician (MRC) to each client who is responsible for designing seamless, person-centred, culturally safe care provided by the interdisciplinary team and may include care and services outside of the SCSP, as required. 3. The SCSP will establish team-based care around clients that provides relational continuity with the care team members. 4. The SCSP s MRC will ensure access to direct care and supports for clients and families 24/7, providing care and services as needed to avoid unnecessary emergency department visits and hospital admissions. 5. The SCSP will have efficient and timely access for clients to pharmacy, diagnostic, hospital outpatient, emergency, and inpatient hospital services. 6. The SCSP will reduce and mitigate requirements for long distance travel by clients for diagnostic tests, treatments, and follow-up appointments through the use of virtual care, mobile services and other design elements, where appropriate. 7. The SCSP will work with specialists or networks of sub-specialties to establish mechanisms for coordinating access to appropriate care to meet the needs of clients as required. 8. The SCSP will deliver the following functions: a. Urgent Response: i. The SCSP will be responsive to urgent needs 24/7, using defined pathways to support individuals in crisis. b. Case Finding and Screening: i. Screening: Initial screening will be completed on contact. ii. Case finding and in-reach services: These services will be provided on an ongoing basis in partnership with patient medical homes, PCNs, hospitals, Draft for discussion purposes 15-Sept-2017 P a g e 5

68 and community based seniors services to identify people requiring specialized services. iii. The SCSP will provide general advice and information to people and families who do not require SCSP services. The SCSP will maintain involvement until the person is linked with the most appropriate service for their needs. c. Consultation to assigned PCNs: i. The SCSP will provide consultation to primary care providers to assist in clarifying functions necessary to support adults with mild to moderate complex conditions and/or frailty to remain healthy in community. d. Intake, Initial Assessment and Care Plan Development: i. At intake, people will be triaged using the RAI Contact Assessment to determine appropriate care and services needed for immediate discharge home, including safety and risk assessments based upon standardized assessment tools. This assessment may be completed in a community setting such as a person s home, physician s office, hospital, emergency department, or community agency, or via virtual care. ii. RAI-MDS HC assessment will be conducted in a setting that supports engagement of the individual and their family and in the most appropriate environment conducive to an accurate assessment. This will be a community setting, such as a person s home, assisted living site, or via virtual care technologies. RAI-MDS HC assessments will not be completed in hospital as the outcomes may provide inaccurate results. iii. The assessment will inform the development of an initial care plan, overseen by a MRC. iv. The initial care plan will include the set of services and interventions required based on individual needs. e. Immediate and short-term supports: i. Following the initial assessment, rapid access to urgent response services will be activated for those with high levels of acuity that require immediate stabilization. Consideration will be given to the context of rural and remote communities where the scope of and availability of health providers are limited. ii. People will be matched with the right service to meet their diverse needs, and receive rapid access to short-term intervention, general guidance, and support to address immediate health needs. iii. The SCSP will be available 24/7 to address immediate needs. f. Specialized team-based care: i. The person will be linked to appropriate SCSP services and supported by an interdisciplinary team with an assigned MRC. Draft for discussion purposes 15-Sept-2017 P a g e 6

69 ii. Rapid mobilization of services will address changing, urgent or unscheduled needs. This includes expedited access to pharmacy, hospital outpatient, emergency, and inpatient services, residential respite, home support services, treatment and rehabilitation services, with consideration of cultural preferences as appropriate. iii. Care management and coordination: o Services will be designed around and respond to the unique needs, values, beliefs, language, culture, and preferences of people seeking care, their family and caregivers. o Timely access to specialized services will follow a stepped-care approach. o All care will be provided and/or coordinated by a MRC through the interdisciplinary team. Management of care is seamless to the person. The logistics of managing services will happen in the background on behalf of the client and in alignment with their decisions for the planning of their care. <link to Continuity of Care General Policy Direction> iv. Consultation support and collaborative care planning: o General information, education and advice will be provided to clients, families and caregivers, and PCNs in the prevention, management and treatment of health issues. o The interdisciplinary team provides consultation support and collaborative care planning with other SCSPs (e.g. adults with moderate to severe mental health and/or substance use issues, cancer care) and the Surgical Services Program. o The interdisciplinary team participates in loc al collaborative planning tables which design care delivery and linkages between the PCN, provincial specialized services, specialists, communitybased seniors services (i.e. - NGOs and community service partners, municipalities), First Nations organizations and social services provided by other government ministries. o Active PCN involvement in planning and delivery of care to improve client experience, enable information flow and support access to specialist consultations and services as required. v. Transition and ongoing support: o Clients who have stabilized and no longer require services of the SCSP will be transitioned to the PCN, as well, clients being managed within the PCN requiring additional care and supports will be supported by the SCSP. The MRC will continue to Draft for discussion purposes 15-Sept-2017 P a g e 7

70 support the PCN when clients require clinical support from the SCSP. o When an in-hospital admission is necessary, the MRC remains involved in care and planning, working closely with acute care staff to organize and facilitate an effective and timely transition back to the community setting. o The MRC coordinates care to and from regional services or provincial specialized services. Care planning is integrated with shared accountabilities. 9. The SCSP will provide a team-based model of delivery <link to Interdisciplinary Team- Based Care Supportive Policy Direction> ensuring: a. Interdisciplinary teams use an integrated care management model to deliver comprehensive care to clients based on an assessment of need and assignment of appropriate care to meet individual health goals. b. The roles and functions of team members will be clearly defined and scopes of practice optimized. c. Team members will be co-located or linked using technology to facilitate communication and information sharing, and clinical supervision of all services provided by the program. d. Interdisciplinary teams will work collaboratively with: i. Government services that provide housing, social and financial supports. ii. Non-Government Organizations (NGO s), municipality programs and community coalitions to develop community based seniors services which provide social supports for clients, their families and their care providers. iii. Paramedic teams to facilitate assessments in community whenever possible to avoid unnecessary emergency department admissions. iv. Service partners, communities, First Nations on and off reserve, and other Aboriginal organizations. e. Team-based care will include contracted service providers from home care, adult day care assisted living, and residential care as full members of the SCSP team and the specific client-based care teams. SCSP contracted services will be expected to adhere to the same quality and safety standards as health authority operated services. LINKAGES Health Human Resources Interdisciplinary care teams will provide wrap-around, person-centred care, optimized scopes of practice, and use digital technologies to increase the range and means of service delivery Draft for discussion purposes 15-Sept-2017 P a g e 8

71 (including virtual care) to achieve service objectives. Based on the population served, interdisciplinary care teams may be comprised of, but are not limited to, the following health care providers: 1. Registered nurses 2. Licensed practical nurses 3. Health care assistants 4. Occupational therapists 5. Physiotherapists 6. Rehabilitation assistants 7. Dieticians 8. Social workers 9. Medical specialists 10. Other disciplines may be added to meet the local needs of the population Organizational Capacity Data Analytics and Reporting Service delivery data collection and submission should be comprehensive, accurate, and timely to support adequate and thorough understanding of population and client needs and baseline service levels, and to plan for and assess improvements over time. Data and analysis will be provided by the Ministry of Health to support service delivery planning at the Local Health Service Delivery Area and Community Service Delivery Area levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting and evaluation in line with the strategy for health system performance management. PERFORMANCE INDICATORS Initial performance indicators have been developed in collaboration with the Ministry and external stakeholders to measure the expected outcomes of the service attributes of effectiveness, accessibility, appropriateness, acceptability, safety and efficiency. Eleven performance indicators to report on the Primary and Community Care Strategic Initiative include: 1. Percent of home health clients who received a CTAS score of 4 or 5 for an ED visit 2. % of assessed clients receiving service within accepted standardized response times. 3. # new clients receiving home health care within X days 4. Proportion of Alternative Level of Care (ALC) clients waiting for a home health service 5. % of RAI assessments completed within the appropriate time frames (all HCC services) 6. Maintained or improved performance on QI s across all HCC health client populations Draft for discussion purposes 15-Sept-2017 P a g e 9

72 7. % of clients with a reassessment within one year of initial assessment 8. Clinicians have electronic access to RAI outputs to make decisions about care for clients at point of care (add for AL and RC) 9. % of res care and AL clients hospitalised for a fall (Prevalence of falls all HCC services) 10. % of HH/AL clients with improved IADL/ADL outcome scores 11. Percent of continuous home health clients with a Method of Assigning Priority Levels (MAPLe) score of 4 or 5 In addition to the above indicators, Ministry and external stakeholders will continue to collaborate to identify additional indicators that provide insight into the performance of both the Specialized Community Services Program for Adults with Complex Medical Conditions and/or Frailty General Policy Direction and the Primary and Community Care Strategic Initiative overall. REVIEW & QUALITY IMPROVEMENT 1. The policy will be refreshed as needed and reviewed three years from the <insert date of implementation> and following completion of the periodic evaluation. 2. The policy may also be reviewed as determined through consultation between Ministry and external stakeholders. 3. Information from the periodic evaluation will be used to understand the performance of the strategic initiative, areas of success and areas for continuous quality improvement. 4. The Ministry will work with the program area to develop a quality improvement plan where necessary and will support the program area to manage the review and quality improvement process. 5. The Ministry will lead any monitoring of outcome measures that are identified in the quality improvement plans developed. Draft for discussion purposes 15-Sept-2017 P a g e 10

73 Integrated System of Care Glossary of Terms Aboriginal: The Constitution Act recognizes three groups of Aboriginal people: Indian (First Nations), Inuit, and Métis. Acceptability: Care that is respectful to patient and family needs, preferences, and values. Accessibility: Ease with which health services are reached. Appropriateness: Patients get the right care from the right providers in the right place at the right time resulting in ideal quality care. Care provided is evidence based and specific to individual clinical needs. Attachment: The existence of a clear ongoing care relationship between a patient and a family practice or health authority primary care clinic, where a family physician or nurse practitioner is the patient s regular primary care provider and most responsible for their primary care. Case finding: Actively searching thoroughly for, and identifying, at-risk people or groups in order to target resources, rather than waiting for them to present with symptoms or signs of active disease or disorder that could result in a crisis or hospitalization. Closer to home: Ensuring citizens have access to services locally (where feasible), based on population need, budget, quality and safety. Collective competence: A team of individually competent practitioners shows shared accountability, uses a collective knowledge base and works interdependently. Collective competence will continue to evolve depending on capacity, context and circumstances. Co-location: Multiple services in the same physical space or proximity improves access and health outcomes. Sometimes referred to as a one-stop-shopping model. Community Service Delivery Area (CSDA): A new geographic unit at a sub-local Health Service Delivery Area level that is the most detailed level of geography. Cost-effectiveness: Positive health outcomes relative to the costs of health interventions. Credentialing: Assessing education, training, experience, and ability of a physician, nurse practitioner, dentist or midwife to perform a specific service. Culturally safe: Providing care that recognizes and respects the differences in each individual. Providers listen and learn in a way that maintains personal dignity and supports an authentic relationship of trust, respect, and teamwork to ensure people feel safe receiving health care. Culturally safe care supports access to health care services, improved health outcomes, and healthier working relationships. Draft Sept 20,

74 Culturally-focused care: Providing care that focuses on promoting health and wellbeing in community and cultural settings. Community can be understood in many ways including home community, chosen community, place of residence, cultural group, or social identity. Deployment: The assignment of health care workers to specific roles and responsibilities in a planned and systematic way based on their scope of practice, skill and competence, to meet identified patient and population health needs. May refer to both in-person and/or virtual deployment. Effective transition of care: The successful movement of patients between practitioners and health service settings, while maintaining services as close to home as possible. A smooth transition requires more than just referral for care, and benefits from an interdisciplinary team approach to communication, collaboration, and coordination of care that includes the patient, family and caregivers at the centre of the information-sharing and decision-making process. Effectiveness: Care that is known to achieve intended outcomes. Efficiency: Optimal use of resources to yield maximum benefits and results. Enabler: A supportive condition or asset that makes it possible for a particular event to happen. In the health system context, this could be data and information sharing, shared and informed decision-making, fostering competencies, legislation and regulation, diverse funding models, technology, establishing standards, and change management support, etc. First Nations: First Nations peoples are considered to be members of a First Nation band or tribe. First Nations refers to both Status First Nations and Non-Status First Nations. Status First Nations are those who are entitled to receive the provisions of the Indian Act, while non-status First Nations are those who do not meet the criteria for registration, or who have chosen not to be registered. Health care system: The formal organized system for delivery of health services (e.g. primary care, public health, laboratory and diagnostic, community care, hospital services, emergency services, transportation, specialized and specialist, palliative, end of life) by health organizations (e.g. regional health authorities, Provincial Health Services Authority, First Nations Health Authority) and independent care providers (e.g. general practitioners, nurse practitioners, midwives, specialist physicians, allied health providers). Health literacy: People s knowledge, beliefs and skills to access, understand, and communicate health information. (For example, being empowered in how to seek information; knowledge of risk factors and causes, self-management and professional help available; and attitudes that promote appropriate information and help seeking.) Health status groups: Each person in BC is assigned to a health status group based on their highest need for health care in the year, for strategic planning, reporting and monitoring purposes. In total, there are 14 mutually exclusive health status groups within four broad categories: Draft Sept 20,

75 1. Staying healthy: A population group without chronic or major health conditions, women who received maternity care and their healthy newborns, and/or those who did not use any health care services in the year. 2. Getting better: A population group with one or more minor/major episodic or significant time-limited health condition that needed significant health care. 3. Living with illness or disability: A population group with one or more of 18 key chronic conditions (including Alzheimer s/dementia, heart failure, chronic obstructive pulmonary disease, diabetes, severe mental health or substance use issues, or cancer), a physical disability and/or developmental disability. 4. Coping with end of life: A population group who receive supports for activities of daily living or palliative care in their own homes or in an assisted living facility, or who receive 24-hour nursing care in a residential care facility. Care for this frail population focuses on comfort, quality of life, symptom management, respect for treatment decisions, support for the family, and psychological and spiritual concerns. Inuit: The Inuit people are a distinct population of Aboriginal people, and are registered under a 1924 revision to the Indian Act. BC Inuit live primarily in the north of the province. Integrated Care Pathway (ICP): Outline of planned care by multiple health care providers, in an appropriate timeframe, so patients can move progressively through care to positive outcomes. Interdisciplinary team: A group of health care providers who work together in a coordinated and integrated manner with patients and populations to achieve health care goals. Effective interdisciplinary teams display collective competency, shared leadership and active participation of each team member involved in patient care. 1. In-practice teams: Providers and support staff work together within a cohesive family practice or health authority primary care clinic. Although team members will likely work in a single location, a provider might work virtually or be shared part-time with one other team. 2. Network teams: Providers and support staff from various family practices, health authority delivered or contracted primary care services and community-based organizations working together as part of a broader community-based team. Team members likely work in different locations. Some providers likely travel to multiple locations in the network and/or work virtually. Lens: A lens is a quality improvement tool that clarifies, focuses or filters information. Helps to see a concept from a different perspective to improve decision-making, planning and operations, leading to better policies, programs and services. Local Health Service Delivery Area (LHSDA): Formerly known as Local Health Area, there are 89 geographic regions developed for analytical purposes with no administrative functions. They originally evolved from school district boundaries; however LHSDAs do not reflect any school district boundary changes that have occurred since their inception. They aggregate up to Regional Health Service Delivery Areas and health authorities. Draft Sept 20,

76 Medical staff: Physicians, nurse practitioners, dentists, and midwives who hold privileges to practice medicine, dentistry, or midwifery, providing health care services in health authority facilities and programs. Métis: The Métis population consists of people of mixed First Nation and European ancestry who identify themselves as Métis, and are distinct from Status First Nation, Inuit, and non-aboriginal people. Unlike status First Nations and Inuit, the Métis are not currently entitled to provisions of the Indian Act. Patient medical home (PMH): A family practice or health authority primary care clinic which has a majority of the person-centred service attributes (commitment, contact, comprehensiveness, continuity, coordination) and relational attributes (team-based care and networks) of the BC PMH model. Person- and family-centred: A way of thinking and doing things with patients, families and caregivers as equal partners in health care, rather than doing things to or for them. To be personcentred the health care culture needs to shift away from being disease-centred and provider/administrator focused. Person-centred care is an approach that puts the patient and their family at the centre of every decision and empowers them to be genuine partners in their care at the level of their choosing. This participation could be partnering with health care professionals, working with community organizations, or getting involved in meaningful efforts to design and improve care. Patients, families and caregivers become both participants and beneficiaries of a health system that responds to their needs, values and preferences in a respectful, empathetic and holistic way. Population health: An approach to health that aims to improve the health of the entire population and to reduce health inequities among population groups. Primary care network (PCN): A unified system of primary care consisting of patient medical homes that are networked with each other and with primary care services delivered or contracted by health authorities and community-based social and other health service organizations. Within a PCN, patients, families and caregivers, are able to access comprehensive, person-centred, culturally safe, quality primary care. PCNs maintain strong linkages with specialized community services programs as well as the broader health system. Primary care: Typically a person s first point of contact with the health care system where the majority of health problems are treated by a generalist, and coordinated continuing care occurs with specialists as needed. Priority population: A group of people who use a high percentage of health services, often specialized health care services. In B.C., these groups include: frail seniors, people with medium or high complexity chronic conditions, and people with severe mental illness and/or substance use. Draft Sept 20,

77 Privileges: A permit to practice medicine, dentistry, or midwifery in health authority facilities and programs, granted by the health authority to a member of the medical staff, as per the Hospital Act and Regulations. Privileges define the scope and limits of each practitioner s permit to practice in the facilities and programs of the health authority. Quality care: Quality care recognizes that every patient has a unique journey, that local context matters, and that everyone touched by the health system needs to collaborate to achieve high quality and sustainable health care for all. The seven dimensions of quality are Acceptability, Appropriate, Accessibility, Safety, Effectiveness, Equity, and Efficiency. Regional Health Service Delivery Area (RHSDA): Formerly known as Health Services Delivery Area, there are 16 geographic regions that aggregate up to the five regional health authorities. Regular primary care provider: The family physician or nurse practitioner who is most responsible for the overall coordination and continuity of the individual s care across the life course, regardless of health service area or whether the required care is provided within the patient medical home or by other health professionals (e.g. specialists) in the system. Safety: Avoiding harm resulting from care. Screening: Tests for a disease or condition of people now showing signs or symptoms, with the aim of reducing future risk of ill health or to give them information about their risk. The assumption is that disease diagnosed early responds better to treatment than it does once it has started causing signs and symptoms. Early diagnosis results in better quantity and quality of life for the patient. Specialized community services program (SCSP): Designed by a health authority to provide continuity, flexibility and rapid mobilization of a set of responsive services to meet the needs of a defined population of people. SCSPs will provide personalized relationships between providers and patients with their families and caregivers, and it may have one or more teams, each with linkages to the health system and broader community. Target Operating Model: Vision for the future of the health system in B.C. The model includes a person-centered and integrated system of primary and community care, with strong and clear links to specialized services, including surgical services, mental health and substance use, seniors and patients with chronic conditions/frailty/dementia, and cancer care. Team-based care: Team-based care is fundamentally a person-centred approach to care that promotes patient voice, safety, and acceptability in care delivery, thereby creating better experiences for individuals, their families and caregivers, and providers in the health system. Teams will meet the care needs of individuals (across the life course) and the community population by providing access to quality health care services at sustainable per capita costs. Draft Sept 20,

78 Trauma-informed: An integrated understanding of past and current experiences of violence and trauma in all aspects of service delivery. The goal of trauma-informed systems is to avoid retraumatising individuals and support safety, choice and control, to promote healing. Triple Aim: Framework developed by the Institute for Healthcare Improvement which optimizes health system performance with three dimensions: improving the patient and provider experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita costs of health care. Wellness-focused: Care provision that aims to proactively keep people well through a holistic approach through key dimensions of wellness (e.g. social, emotional, or physical). It acknowledges people s resilience, strengths, and capacity for engagement and self-directed care. It may also incorporate a person s ability to heal and recover. Draft Sept 20,

79 Ministry of Health Policy Instrument Type: Policy Name Supportive Policy Directive Urgent Care Services Version 2.0 draft Effective Date: Division/Branch: Ministry Contact: Document Number: Date: October 11, 2017 Deputy Minister Ministry of Health Draft for Discussion Not for Distribution 11-Oct-2017 P a g e 1

80 URGENT CARE SERVICES POLICY OBJECTIVE Across British Columbia, urgent care services will be available as part of a primary care network (PCN) to the population of a Community Service Delivery Area (CSDA). Urgent care services will increase access to person-centred, culturally safe, quality primary care outside of traditional office hours for unexpected but non-life-threatening health concerns that usually require sameday treatment. An individual s urgent care needs may be met by their patient medical home (PMH), or within the broader network, for example at an urgent care centre or extended-hours walk-in clinic. Urgent care services will be designed and maintained as part of PCNs to meet the needs of individuals, families and caregivers. Expected Impact on Health Outcomes and Service Attributes It is expected that ensuring the availability of urgent care services will achieve meaningful health outcomes (effectiveness) and a quality service experience linked to key service attributes (accessibility, appropriateness, acceptability, safety, efficiency). Measurable expected impacts include: 1. Accessibility: The population within a CSDA are able to access (in person or virtually) needed care 24 hours a day, 7 days a week, as close to home as feasible. 2. Appropriateness: The population within a CSDA are able to access urgent care in the evening, on weekends or on statutory holidays without accessing care through a hospital emergency department. 3. Acceptability: Patient, family and caregiver experience is improved through access to needed care and laboratory, diagnostics, and imaging services outside of a hospital emergency department. 4. Safety: Information on the urgent care received by a patient and necessary follow-up care is shared with a patient s regular primary care provider. 5. Efficiency: All appropriate ambulatory care needs are met in the community. DEFINITIONS Urgent care Primary care for injuries and illnesses that should be seen by a health care provider within 12 to 24 hours but do not require the level of service or expertise found in an Draft for Discussion Not for Distribution 11-Oct-2017 P a g e 2

81 emergency department. Urgent care tends to be provided outside of traditional primary care office hours. SCOPE This policy covers urgent care services, which are components of comprehensive primary care (see GPD: Establishing Primary Care Networks Appendix A), that are needed to meet urgent care needs throughout an individual s life. This policy applies to PCN health care settings that provide urgent care, including extended-hours family practices and health authority primary care clinics, urgent care centres owned/operated by health authorities (including the First Nations Health Authority), and extended-hours community-based health service organizations (e.g. community health centres, walk-in clinics). POLICY DIRECTION Expectations Efforts will be made to adhere to these principles of urgent care; however it is recognized that depending on community variables this may not always be feasible. Urgent care services will: 1. Be part of the PCN and support PCN goals. 2. Provide the PCN population with: a. Access to advice and direction to care; b. Extended hours of care on evenings and weekends; c. Accessible urgent care services, as a component of comprehensive primary care, in particular : Basic in-office emergency services non-life-threatening illness or injury that needs immediate treatment sprains and simple fractures caused by minor accidents and falls minor bleeding/cuts requiring stitches mild to moderate breathing difficulties minor burns rapid access to MHSU crisis intervention services Assessment and treatment services for minor illnesses commonly presenting conditions, e.g. respiratory infections, ear aches, eye irritation/injuries, fever or flu, severe sore throat or cough, headache abdominal pain, vomiting, diarrhea or dehydration mild to moderate back pain and problems skin rashes and infections urinary tract infections On-site or close-proximity access to diagnostic imaging and laboratory services electrocardiograms Draft for Discussion Not for Distribution 11-Oct-2017 P a g e 3

82 x-rays point-of-care testing blood tests 3. Clear mechanisms and protocols for urgent care providers to communicate with a patient s regular primary care provider to maintain informational and management continuity of care (e.g. appropriate information sharing, referrals, ongoing coordination, single patient health record), including working towards linked electronic medical records. 4. Identify unattached individuals and families and/or those requiring care to prevent crisis or hospitalization and support their attachment to a PMH using PCN protocol (e.g. centralized primary care waitlist where available). 5. Provide access to urgent care services without having to attend or be triaged in an emergency department. 6. Have ambulance access in the context of the Transport to Alternate Locations initiatives of BC Emergency Health Services and have protocols for ambulance transport and immediate triage at an emergency department in the event a patient s situation becomes an emergency. Service Design 1. An analysis of the available local, regional and provincial data (e.g. ED usage by hospital by time of day, location of existing walk-in clinics) will determine gaps and opportunities for increased access to urgent care. 2. The following factors will be considered in determining how increased access to urgent care services should be provided in a PCN: Geographic location and population need (attachment rates; ED usage and congestion, size of community, etc.); Supportive local primary care providers; Existing infrastructure and health human resources; Proximity and access to diagnostics; Current gaps in accessibility (e.g. hours of service); Opportunities to use technology-enabled solutions; and Existing services in the community relative to demand. 3. A range of service delivery models, depending on the review of existing primary care services and gaps, will be considered as shown on a spectrum in Figure 1 from enhancement of existing services (e.g. extended hours, new providers, access to diagnostics) to a stand-alone and purpose-built urgent care centre (e.g. emergency assessment, resuscitation capabilities, access to diagnostic tools). 4. A variety of urgent care services may be associated with each service delivery model across the spectrum depending on whether services for a given community are best concentrated in one site or distributed across the PCN. Draft for Discussion Not for Distribution 11-Oct-2017 P a g e 4

83 Figure 1 Spectrum of Increased Access to Urgent Care 5. Urgent care services will be developed using current infrastructure and resources, and will not be valued or compensated more than other primary care services. 6. An interdisciplinary team-based care approach will be taken, where team deployment is based on a primary care setting rather than an emergency services setting. 7. Urgent care will be addressed as part of or aligned with PCN communication plans, including awareness and education for providers, PMH, patients, families and caregivers. 8. Urgent care will be addressed as part of or aligned with PCN community/patient engagement plans, including opportunities for patients, families and caregivers to give feedback for quality improvement activities. LINKAGES Health Human Resources Urgent care interdisciplinary teams will provide person-centered, culturally safe care using available HHR resources, optimized scopes of practice, and where necessary and appropriate, the use of on call and virtual care to achieve service objectives. Organizational Capacity Data Analytics and Reporting Service delivery data collection and submission should be comprehensive, accurate, and timely to support adequate and thorough understanding of population and patient needs and baseline service levels, and to plan for and assess improvements over time. Data and analysis will be provided by the Ministry of Health to support service delivery planning at both the Local Health Service Delivery Area and CSDA levels. Collaboration and dialogue on these products can be used to inform strategic planning, gap analysis and subsequent roll-out in a range of environments. These tools can also be used to understand the baseline for performance. Integrated analytics will support performance monitoring, reporting and evaluation in line with the strategy for health system performance management. Draft for Discussion Not for Distribution 11-Oct-2017 P a g e 5