COMPREHENSIVE AND CONTINUOUS CARE IN A COLLABORATIVE CARE ENVIRONMENT

Transcription

1 Comprehensive and Continuous Care in a Collaborative Team Environment: COMPREHENSIVE AND CONTINUOUS CARE IN A COLLABORATIVE CARE ENVIRONMENT CHALLENGES FOR 21 ST CENTURY FAMILY MEDICINE AND HOSPITALS Contact: M. Janet Kasperski, RN, MHSc, CHE Chief Executive Officer THE ONTARIO COLLEGE OF FAMILY PHYSICIANS 357 Bay Street, Mezzanine Toronto, Ontario M5H 2T7 Tel: (416) Fax: (416) jk_ocfp@cfpc.ca Website: May 5, 2008

2 Comprehensive and Continuous Care in a Collaborative Team Environment: INDEX 1.0 Key Facts Introduction Challenges and Potential Solutions Hospital Based Respect for Family Physicians Respect from Other Members of the Medical Staff Admission and Discharge Policies The Hospitalist Model anchored in Family Medicine or Focused Scopes of Practice Emergency Department and Obstetrics Hospital Restructuring and Re-engineering/Hospital Mergers Workload Implications Remuneration for Hospital-Based Care Training for Medical Students, Family Medicine Residents and CPD for Practicing Family Physicians Major Strategies to Engage in Hospital-Based Care Summary Appendix Listening to the Voices of Family Physicians Key Papers on Continuity of Care...24

3 Comprehensive and Continuous Care in a Collaborative Team Environment: Family physicians are ribbons that tie everything together. We walk through The health and life journey with our patients from birth to death. Dr. L. P.

4 Comprehensive and Continuous Care in a Collaborative Team Environment: Key Facts CFPC conducted a Decima Poll 81% of Canadians rated their family physicians participation in their hospital care as important 97% believed it was important that a discharge summary be sent to their family doctor 93% of patients cared for by their family physicians while in hospital were satisfied with their care 2. National Physician Survey % of physician practice time was spent in hospital-based activities nationally compared with 33% in Ontario % of physicians nationally provided inpatient care compared with 33% in Ontario. 3. Commonwealth Fund 2005 (Report on Canadian Physicians based on the six country survey) 95% of family doctors report that they often or sometimes experience long wait times for their patients to see a consultant 80% report long wait times for diagnostic tests 94% report long wait time for selective surgical procedures or hospital care 79% report difficulties getting appropriate home care when needed 95% of family doctors have patients in their practices with multiple chronic problems. Only 55% of them feel well-prepared to provide optimum care 89% have patients with mental health problems and only 40% feel well-prepared to provide optimum care 69% have palliative care patients and only 33% feel well-prepared to provide optimum care 46% of family doctors report that their patients experience problems because care was not well coordinated across multiple sites or providers Only 3% report that they receive a discharge report in less than 48 hours when their patient is discharged from hospital. 16% report waiting more than 30 days and 9% report that they rarely receive a report. 40% report having patients who acquired an infection while in hospital. 4. Cancer Quality Council of Ontario Findings from focus groups, comprised of cancer patients, conducted summer 2007 by the Cancer Quality Council of Ontario, included: - Very little interaction with family physician after referral to specialist - It was unclear who was responsible for communicating results to them - Test results not always available at family physician visit; test results go missing so patients carried copies of records/test results from one healthcare professional to another to avoid delays

5 Comprehensive and Continuous Care in a Collaborative Team Environment: Ottawa Study - There was more likely to be breakdowns in communication if tests were performed in different locations (hospitals, cities, etc.) - Significant delays in getting a diagnosis without family physician The safety of patients is compromised when family physicians are not involved in the care of inpatients and especially when discharge information is not made readily available to the family physician. 30% of all patients discharged from the medical unit were re-admitted within thirty days, mostly because medication management was not undertaken as a shared responsibility between the discharging physician and the family doctor. 6. OCFP Research Many family physicians have withdrawn from the provision of hospital-based care. Their valid reasons fall into two broad categories; namely, overwhelming workload in their community-based practices and dissatisfaction with the roles assigned to them in the hospital environment. Some family physicians describe the hospital environment as hostile to family medicine and report feeling stressed by conditions that reduce their level of confidence in their abilities to provide acute inpatient care.

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7 Comprehensive and Continuous Care in a Collaborative Team Environment: Introduction The father of family medicine in Canada, Dr. Ian McWhinney described the relationship between a family doctor and his or her patients as a covenant as opposed to a contact. A contract states that one will do this much and no more; whereas, a covenant implies that the family doctor will do anything and everything to assist his or her patients. It is this covenant that underpins the trusting patient-physician relationship that is central to the specialty of family medicine. It is also the central tenet of an effective and efficient healthcare system, resulting in better health outcomes at less cost. Over the course of time, mutual trust and respect builds as family physicians deliver continuous and comprehensive care for his or her patients and their family members. Continuity of care in family medicine is referred to as the ability of patients to access healthcare from and through the same family doctor over the course of time from cradle to grave. Continuity of care is almost inseparable from comprehensive care. The former implies the ability to access one s own physicians; the later implies that the family physician is able to provide and/or access a wide range of health services to respond to patient s needs over the course of time. Family medicine has been undergoing a transformation that is challenging how we deliver continuous and comprehensive care. Building upon the patient-centred model of care, family physicians are incorporating health promotion and prevention at all points in the care continuum to assist our patients to become and remain as healthy as possible, as long as possible. This model of care includes partnering with patients to empower them to make decisions about their own care, as well as actively supporting them to manage their own health. Given the complexity of care in our community-based practices, family physicians are increasingly adopting an integrated and interprofessional approach to patient-centred, proactive care. The redesigned system is anchored in the principles of collaborative care which includes family physicians working in an inter-professional team with nurses and other healthcare providers including sharing care with other specialists. The challenge that family physicians and their patients face is the maintenance of the trusting patient-physician relationship, central to family medicine and crucial to insuring continuity and comprehensiveness of care, in a team-based environment. Research clearly demonstrates the value Canadians place on the trusting relationship with their family physicians. That relationship affects their assessment of the quality of care in the rest of the system. Patients who have a family doctor rate every part of the system much more positively than do orphaned patients. Keeping the trusting patient-physician relationship as the foundation of our healthcare system should be an important goal for all of us. Evidence suggests that continuity and comprehensiveness of care improves preventive care, enhances adherence to therapy, increases patient and physician satisfaction and improves the health status of our patients and the outcomes of chronic disease management. Tests and referrals to specialist consultants are reduced and emergency department and, subsequent admissions to hospitals, are reduced in the presence of strong primary care system anchored in the primacy of the patient-physician relationship. A number of forces have combined to make access to competent, continuous and comprehensive care more difficult for many patients in Ontario. The increasing number of

8 Comprehensive and Continuous Care in a Collaborative Team Environment: orphan patients, the evident gaps in the quality of care especially in the arena of chronic disease prevention and management, the increased number of adverse events in hospitals and the high rates of readmission are all too obvious indicators of the lack of continuity and comprehensiveness in the system. Many family physicians have withdrawn from hospital-based services and no longer deliver care to their own inpatients and/or have withdrawn from intrapartum care and emergency medicine. Increased fragmentation has occurred as a result of the development of problem-specific clinics (memory clinics, secondary stroke prevention clinics, anticoagulation clinics, etc). Walk-in clinics and Hospitalists programs originally were organized as band-aid solutions: however, they have become the norm and have further reduced the ability of family doctor to promote continuity and comprehensiveness of care for their own patients. Those individuals who are unfortunate enough not to have a family doctor at all are reduced to having access to episodic care only. While the term continuity of care is often used to imply relational continuity (i.e. the ongoing patient-physician relationship), it also implies both informational and management continuity. Informational continuity (i.e. the availability of information to assist in the management of patients) can be supported by information technology but there is nothing that can replace the input of the family doctor into the care plan for an inpatient or into the discharge plan of that same patient to ensure safe transfer back to community. Management continuity means that there is a consistent and coherent approach to management that responds quickly to the patients changing needs. The lack of a consistent approach in a fragmented system and lack of involvement of family doctor when care is delivered in other parts of the system interferes with the ability of the family doctor to work with his/her own patients to plan and manage optimum care. Continuity and comprehensive care implies 24/7/365 responsibility for care; however, this does not mean that the individual physician needs to deliver all the care that a patient requires. While patients benefit greatly by having the majority of care delivered by the same physician, maintaining this level of continuity/comprehensiveness is almost impossible today. As a result, the vast majority of family physicians are working in group practices. As more family physicians develop special areas of interest and focused scopes of practice, we need to have in place organizational structures to integrate physicians in a co-ordinated practice environment. The OCFP has also been actively supporting sharedcare collaborations to link family physicians with specialist consultants and team-based interprofessional collaborative practices including nurses, dieticians, social workers, pharmacists etc. As we build organizational structures such as Family Health Teams and other models of interprofessional care in the community, the Seven C s need to be taken into account. The Seven Characteristics of Continuity of Care Contact regular access to a consistent family doctor and consistent team members Collaboration patient and family physician participation in planning Communication accurate collection and timely transfer of patient data, care plan Co-ordination delineation of roles and responsibilities amongst the team members Convenience minimizing travel; avoiding repeats of basic patient data Consistence patient data and care plan agreed upon and shared various providers Contingency readiness to respond to questions and acute care needs. Adapted from an article by Dr. H. Jay Biem - Canadian Journal of CME, November 2004

9 Comprehensive and Continuous Care in a Collaborative Team Environment: Governments all across Canada are promoting system changes that are felt to result in positive health outcomes for the population and will serve as the foundation for a sustainable healthcare system. Currently, over one third of our health dollars are spent on the hospital sector; however, in any given month, the sector deals with less than 1% of the population. 25% of the public report that they are perfectly healthy; another 50% experience symptoms but selfmanage their care; of the 25% that seek care, 24% are cared for by family doctors and other community-based service providers. Advances in technology and medication mean that hospital stays are shorter and shorter, and in many cases can now be avoided completely for problems previously requiring hospital care. As our population ages, even more care will take place outside hospital walls. Expansion of primary care and community-based services is simply good planning; however, as we concentrate on the development of strong community-based primary care systems, in some settings, planning for the involvement of the primary care team members in inpatient care has been somewhat neglected. It is a sad state of affairs to see the withdrawal of family doctors from the hospital bedside. Traditionally, inpatients have benefited greatly from the active participation of their family doctor in their care. The bond of trust that develops over time deepens when the family doctor is present during a hospital admission. This is the time when the patient is sickest and most vulnerable. Their family is most often in need of support as well. In addition to the hundreds of thousands of patients who do not have a family doctor, many patients are admitted to hospitals in the absence of their own family physician. Hospitalists have been described as an appropriate step in the evolution of healthcare. It should be noted that the OCFP makes a distinction between family physicians who do inpatient care and hospitalists. Family physicians who are part of a family practice partnership and/or a community-based system of care and provide inpatient care to their own patients and other family physicians patients are distinct from hospitalists who are part of a hospital-based system of care. Hospitalists provide inpatient care and refer back to the community; whereas, family physicians who provide inpatient care are part of system that transcends the walls of the hospital. The commitment to the ongoing care of patients in the community separates the two groups. Patients would argue that hospitalists are a band-aid solution and not a cure, since these physicians face significant problems in dealing with orphaned patients due of lack of knowledge about the patient and lack of trusting relationship. The patient s own family doctor should function as the Most Responsible Physician or work in collaboration with the most appropriate consultant. The two models of care will provide a level of care that cannot be matched by Hospitalist or any other model of family physician substitution.

10 Comprehensive and Continuous Care in a Collaborative Team Environment: Patients, families and family physicians: at the heart of the healthcare system

11 Comprehensive and Continuous Care in a Collaborative Team Environment: Challenges and Potential Solutions 3.1 Hospital-based Respect for Family Physicians Hospitals in rural and smaller communities value family physicians and are entirely dependent upon family doctors for the provision of medical care. Hospitals in large communities and especially, in academic health centres, have varying degrees of respect for the role that family physicians play. Moreover, patients are admitted to a variety of hospitals in these communities and regions. All hospitals should have a policy on privileges that recognizes and supports family physicians to provide as much care as possible for their own patients in the local hospital(s) of their choice. All other hospitals should permit the development of a system for encouraging family physicians to receive privileges to carry out appropriate roles in the care of their patients while in hospital and especially to provide and receive information on the admission and discharge of their patients. LHINs should consider LHIN-wide privileges for family physicians. 3.2 Respect from the Other Members of the Medical Staff Medical students, family medicine residents and practicing family physicians report that the just-a-gp mentality is still alive and well within many hospitals. All physicians, and especially physicians in leadership roles, need to demonstrate respect for the important roles that family physicians play in the care of their own patients. Processes need to be in place to make family physicians feel welcome at the hospital, and hospitals need to demonstrate that family physicians are valued for the knowledge they have about the patient, respected for their contributions to inpatient care and recognized as key members of the patient care team. In addition, family physicians need to be informed of changes in policies and procedures, included in the development of effective communication systems, and supported in their roles by appropriate consultant back-up, especially during the after hour period when patients may require urgent intervention. 3.3 Admission and Discharge Policies Many patients are admitted to hospital without any information being sought from or provided by the family doctor. The physicians assigned the Most Responsible Physician (MRP) role for an individual patient frequently fail to inform the family doctor of the admission nor do they consult with the family physician to ensure a clear understand of all of the patients health problems and their care regimen.

12 Comprehensive and Continuous Care in a Collaborative Team Environment: The official hand-over of the responsibilities from one MRP to another during hospitalization requires the sharing of information; however, the discharge from hospital most often takes place in the absence of a formal turn over of responsibilities to the family physician and frequently without any information sharing. Hospitals should develop a policy to ensure that the family doctor is contacted and provides essential information within 24 hours of admission. On discharge, a formal transfer of care, including information sharing should occur between the hospital-based MRP and the family doctor. This is best accomplished by having the family doctor as an integral part of the care team while the patient is in hospital. 3.4 The Hospitalist Models Anchored in Family Medicine or Focused Scopes of Practice Some hospitals have actively supported family physicians to maintain privileges and to care for their own patients. The Hospitalist Program in these hospitals includes family doctors who are willing to provide care for orphaned patients, in addition to their own patients or may have full-time Hospitalists providing care for orphaned patients. The combination of providing family doctors with support to look after their own patients and a formal program of Hospitalist caring for the orphan patients seems to be a factor in retaining family physicians in the provision of inpatient care. Other hospitals have required physicians to participate in the Hospitalist Program and if they refused, their privileges were withdrawn. In these hospitals, the patients of physicians who withdrew from the hospital are deemed orphaned and add to the list of patients admitted without a family doctor. In many hospitals, the creation of full-time Hospitalist positions has drawn family physicians away from broad scope of practicing family medicine creating orphaned patients amongst these physicians former patients. The lack of capacity in the community to provide broad-based family medicine places pressure, not only on the Hospitalist program but also on the emergency department. Key to the Emergency Wait-time strategy is increased capacity in family practices. All hospitals should actively encourage every family physician in their community/region to maintain (or re-establish) privileges and care for their own patients. Hospitals should recognize that the patient s own family doctor is the preferred member of the care team and Hospitalists should be assigned to a patient only if the patient does not have a family doctor. Family physicians who choose to work as a Hospitalist should be encouraged and supported to practice in the community and to work as

13 Comprehensive and Continuous Care in a Collaborative Team Environment: Hospitalists proportionately to their available practice time to increase capacity in the community amongst broad scope of practice physicians. Community based family physicians and hospitalists alike should be supported to be active participants in the patient s care team and included in all committees that address patient care issues. Consideration should be given to the role of a hospital co-ordinator whose responsibility is to ensure liaison occurs between the hospital inpatients units and community based family doctors and between hospitalists and family physicians. Since Hospitalists are expected to develop higher levels of knowledge and skills in regards to inpatient care, their role as mentor/coach and CME/CPD resources for family physicians seeking further education and support in inpatient care should be developed and supported provincially and locally. 3.5 Emergency Departments and Obstetrics In rural and small hospitals, family physicians provide 24/7 care throughout the hospital including the emergency department and the obstetrical unit. Frequently, they do so without the medical back up from the rest of the system. In addition, most hospitals are experiencing problems in staffing specialty departments such as emergency and obstetrics. In 2006, the closure of larger hospitals was imminent and family doctors were encouraged to return to practice to provide 3 to 4 shifts per month in their local emergency department to ensure adequate coverage (The Primer in Emergency Medicine for Family Physicians program). Many family physicians have dropped intrapartum care from their basket of services. Reports of these units being viewed as hostile environments need to be addressed. High volume obstetricians are on the verge of retiring and, while more midwives are being trained, their low volume practices will not replace retiring obstetricians. Obstetrical units can expect to have the same problems with coverage in the very near future as emergency departments are experienced. Hospitals in rural and smaller communities should be supported regionally and provincially by systems that provide adequate back-up from emergentologists and other critical care specialists including anaesthetists and obstetricians (see OCFP s proposal to support family physicians in emergency medicine). Larger hospitals should develop systems of supports to encourage family physicians in their communities to participate in the emergency department rotations. Many of the factors related to the rural and small communities also need to be taken into account; however, respect for their contributions to the ED and the hospital in general needs to be built into the strategy.

14 Comprehensive and Continuous Care in a Collaborative Team Environment: Hospital obstetrical units need to develop strategies to encourage family physicians to participate in the care of their own obstetrical patients including intrapartum care (see OCFP s Babies Can t Wait recommendations). 3.6 Hospitals Restructuring and Re-engineering/Hospital Mergers The hospital restructuring that occurred in 1990s had a major impact on family practices in every community in the province. The impact of bed closures, accompanied by the drive for efficiencies and reduced health human resources within hospitals especially in the outpatient s arenas, has negatively impacted on family practices. Family physicians are now responsible for more complex patients in their practices without the community-based resources to address the identified problems. While FHTs are replacing some of the lost services that were readily available in hospital outpatient departments, the number of patients served within FHTs is very limited compared with the needs in communities throughout the province. Hospital mergers have also impacted on family medicine. With the loss of fullservice hospitals, patients tend to be admitted to a variety of hospitals, making it difficult for family doctors to connect with every admitted patient. As LHINs, and the hospitals reporting to them, begin to address changes in programs within hospitals (and within the CCACs and the community services sector), the impact on family practices needs to be given due and thorough consideration. Planning for a growing and aging population needs to consider the supports needed for family practices. The majority of care for patients with chronic diseases is delivered by family doctors. The system enhancements in the area of chronic disease prevention and management need to be implemented with this thought in mind. Communication systems need to be employed to ensure that family doctors can provide input to patient care and can communicate with their patients while they are in hospital. 3.7 Workload Implications Managing complex care in their offices, in the patients home, in long term care facilities and in the hospital has proven to be a major cause of burnout for family doctors. Hospitals need to take into account these competing demands when trying to engage family physicians. In turn, family physicians often fail to work together to plan for group involvement with their local hospitals that may reduce the burden on the individual physician.

15 Comprehensive and Continuous Care in a Collaborative Team Environment: Demands for committee work and other hospital based administrative responsibilities need to take into account the competing demands placed on family doctors. Finding ways to support family doctors to provide clinical care in the hospital should be the major thrust of engagement activities. Innovative ways to provide family doctors with input into decisions and to keep them informed of changes should be developed, out of respect for their other time commitment. In turn, family physicians should organize themselves into practice groups and/or networks of an appropriate size to share responsibilities and the workload associated with the provision of hospital-based care (see North York General Hospital Network of Networks model). 3.8 Remuneration for Hospital Based Care Family physicians who provide hospital-based care express concerns regarding hospital-based incentives. The MRP funding envelope may be insufficient to provide an incentive for family doctors to take on this role and the supportive care funding barely compensates for the cost of hospital parking in the larger hospitals. HOCC funding helps to provide on call income; however, in rural communities, the physician is frequently on call for a variety of services but can only receive HOCC for one activity. Moreover, the HOCC funds depend on the number of staff. If a community loses a physician, funding is reduced. The remaining physicians, under these circumstances, are required to work more frequently to provide adequate coverage throughout the hospital and the community. Working harder and more frequently for reduced income is, needless to say, a major disincentive. OMA, OHA and the Ministry need to review all funding available to family physicians proving hospital-based services to ensure that appropriate remuneration is available and the incentives are aligned with the responsibilities for patient care in hospitals. 3.9 Training for Medical Students, Family Medicine Residents and CPD for Practicing Family Physicians. Medical students are frequently unaware of the roles that family physicians play in hospital-based care. Family medicine residents report that they feel unprepared to provide care in hospital, especially emergency and obstetrical care. Practicing family physicians are made to feel that inpatient care is so complicated that their patients require the care of other specialists. Medical schools should increase the exposure of medical students to family doctors who can act as role models. Medical students should be provided with opportunities to engage with family physicians who competently provide care in hospitals and throughout the community. The culture within medical schools should support medical students to

16 Comprehensive and Continuous Care in a Collaborative Team Environment: recognize the importance that patients attach to the role of the family doctor and celebrate the contributions that family physicians make in our healthcare system. The CFPC s accreditation standards should require all academic Departments of Family Medicine to provide family medicine residents with multiple opportunities to acquire acute care skills needed for both rural and urban hospital care including experiences in delivering inpatient, obstetrical and emergency care. The training for hospitalbased care should be delivered, wherever possible, by family doctors modeling the roles that family doctors play in the system, as a condition of full program accreditation. PGY3 programs and re-entry programs should be available to practicing family physicians to develop specific skills in hospitalbased care required in their community. The OCFP and the University CME Departments should be funded to provide accredited CME/CPD programs to support knowledge and skill acquisition related to all aspects of hospital-based care. 4.0 Major Strategies to Engage Family Physicians in Hospital-based Care Hospitals have an opportunity to address the issues related to decreasing participation of family physicians in hospital-based care; however, they will be unsuccessful unless family physicians are aware of how important is it to their patients and the healthcare system in general that they provide hospital-based care. Family physicians need to hear these messages: 1. Every hospitalized patient needs to have their own family physician participating in their care, whenever possible. For those patients who do not have a family doctor, a Hospitalist with family medicine training should be made available to them. 2. Appropriate communications will be maintained between hospitals and family doctors including timely notification of their patients upon admission, the progress of their patients during the admission and effective discharge information prior to or, at a minimum, within 24 hours of discharge. 3. Family physicians will be represented in the hospital and LHIN committees whenever policies are developed that affect their patients and their practices. 4. Hospitals will recognize the important roles that family physicians play in the following areas of practice: o Continuity of care Inpatient hospital care should be considered an integral part of a patient s continuum of care that includes office-based care; home care, rehabilitation and long term care provided by interdisciplinary teams with family physicians in clinical

17 Comprehensive and Continuous Care in a Collaborative Team Environment: leadership roles. o Coordination of care Upon discharge, patients should continue to be cared for by their own family physician. If they do not have a family physician, they should be supported in finding a community family physician for their ongoing care. o Efficient use of resources Since patients are now enrolled with their family doctor and family physicians are the custodian of patients medical information, they are in the ideal position to manage the patient s use of effective hospital and healthcare resources. This should be reflected in policy, for example the e-health strategy provincially and in each LHIN. o Patient advocacy In ensuring continuity of care and in understanding patients wishes regarding their own care, the family physician plays a key advocacy role for both the patient and his or her family. 5. In providing hospital-based care, family physicians will be supported in delivering care and will reap the following benefits: o Access to specialists Interactions with colleagues enhance patient management and outcomes for family doctors and other specialists. o Maintenance and enhancement of knowledge and skills Hospital rounds, formal CPD/CME and re-entry programs provide opportunities to maintain and enhance knowledge, skills and confidence. o Stimulating Environment The hospital environment decreases the danger of isolation in the healthcare system and promotes collegiality and team building skills.

18 Comprehensive and Continuous Care in a Collaborative Team Environment: Summary In addressing the interactions between family physicians and their local hospitals and the Ontario Hospital Association, the following questions will be addressed: 1. Does the scoring in the hospital report card include a measure of how engaged family physicians are in the care of patients at the hospital? 2. Does hospital accreditation clearly include indicators to measure and evaluate the structures, processes and outcomes associated with the effective engagement of family physicians in the care of hospitalized patients? Does the accreditation process include a review of information sharing between hospitals and community-based family physicians? 3. Are family physicians included in strategic planning exercises and is the impact of changes on family practices taken into consideration? 4. Are family physicians included on the Board of the Ontario Hospital Association (OHA) and does the OHA have a Working Group looking at hospital/family practice interfaces, as well as, how to engage family physicians in hospital-based care? 5. Has OHA (or any of the hospitals) thought about establishing Patient Registries to begin the process of identifying and address the issues that arise for patients without family doctors? 6. Does OHA have a list organized by LHIN boundaries of hospitals of comparable size and program mix? 7. Would OHA consider promoting Family Physician Week in Ontario in same way that Nurses Week is promoted? 8. Will the OHA join with the OCFP to address the education needs of practicing family physicians as key to supporting their re-entry to inpatient care?

19 Comprehensive and Continuous Care in a Collaborative Team Environment: Appendix Listening to the Voices of Family Physicians

20 Comprehensive and Continuous Care in a Collaborative Team Environment: Listening to the Voices of Family Physicians There are several administrators who maintain that effective system designs can provide the elements of continuity of care over time and across locations without the necessity of maintaining the trusting patient-physician relationship. I believe that this is incorrect and will remain incorrect for a very long time. Healthcare and relationships are too complex to be managed by our continued predation for specialization. I will give you today s example. I am on the inpatient service at the moment and one of patients is from my own practice a woman with multiple severe co-morbidities of CHF, COPD, DM, renal insufficiency, morbid obesity you get the picture. I admitted her because of her intractable heart failure. Today, I saw her and, based on immediate first impressions, it was evident to me she was worsening. Reviewing the notes from yesterday, she had been converted to oral lasix. Although conventional, the change was based on parameters that did not take into account several nuances that were immediately apparent to me as soon as I saw her. WE CANNOT DESIGN A SYSTEM THAT SUBSTITUTES FOR THAT LONG TERM RELATIONSHIP AND RESULTANT TACIT KNOWLEDGE. I recognize we cannot be everywhere --- however, I believe that, if we provide care to a reasonable size roster of patients, with appropriate supports to our population needs, there remains no substitute for that family physician role. Dr. E. I am fortunate that I live in an environment where a broad scope of practice and continuity of care are expected and feasible. I am not a saint and that is what is required for this environment where it makes no sense to have full-time emergency physicians, hospitalists, office-based physicians, full-time anaesthestologists etc. Because rural practice is so unique and seems daunting to others, we are having a difficult time recruiting. (Our ER hourly rate isn t great and does not compete with the near north in cottage county adding to our problems). Has family medicine giving up on broad scope of practice and continuity of care? What will separate us from NPs if we don t follow our patients and provide care outside of the office? How will we provide care in rural communities if family physicians are not capable of delivering comprehensive and continuing care throughout the system? Dr. G.

21 Comprehensive and Continuous Care in a Collaborative Team Environment: I think the rural situation is different. Docs in most suburban and urban communities have walked away from hospital inpatient care, ER, OBS, long term care and most unfortunately, end-of-life care and also into focused areas of practice for some valid and some not-so-valid reasons and I won t repeat all of the reasons for this happening. Most who have done so were struggling daily just to keep up. Running harder and harder with a sense of not meeting expectations weighs heavily on all of us. Dr. N. In the urban reality, care tends to be physically located in the family doctor s office where the physician develops a long-term relationship with the patient. The physician maintains personal contact over time and directs and collates visits to elsewhere, as well as the care delivered by other allied healthcare professionals. The family practice is where the patient s records and care plans are centred. The Americans would call this the patients medical home. My biggest question and concern is how to maintain this core relationship with my patients with the advent of the allied health team, whose help is invaluable in providing care for patients with complex chronic problems. We are being asked to take on more and more intense areas of care. Should we also provide care in the hospital? Yes. Are we able to do so? Not really. Dr. N. I already have 2200 rostered patients in my FHT, they are asking us to take on 200 extra patients to reduce the 10,000 people in our community who do not have a family doctor. I can t do it and feel, in fact, that to do the job expected, even with lots of other allied healthcare professionals working with me, that I should say good-bye to about 700 of my current patients. We cannot berate family doctors for not working in the ER, inpatients units etc. nor should we set up expectations that are unrealistic in urban centres. Until we have enough family doctors to reasonable cover rational patient rosters, we all face a challenge in maintaining the patient-physician relationship in a climate where the answer that seems to be pushed upon us is a team of allied healthcare professionals where it is tempting to give over even more visits to others and lose the thread of personal contact. The challenge is to work out a collaborative system where this continuity of relationship does not suffer. Dr. N. I left my hospital where I had been a nurse before I went to medical school. I watched nursing care deteriorate before my eyes. My last patient experience convinced me that my license was at risk so I left. My patient was admitted with severe gastro. They gave her bag after bag of IV fluid. On day one, I was pleased to see that there was plenty of urine. On day two, the level and the colour of the urine was the same. I thought it was an unusual coincidence. On day three, the level was same and I knew something was wrong. My patient with congestion heart disease had not had her urine bag emptied in the previous

22 Comprehensive and Continuous Care in a Collaborative Team Environment: two days. What was there was three days old. They were drowning her. I asked about intake and output flow sheets. They told me they were too busy to keep track. I quit the hospital. Dr. N. The hospital has a new computer system. As a family doctor, I am not allowed to access my patients charts any more. They treat us like friendly visitors. Why would I bother to go there? The disrespect for family doctor is a major barrier for us and our patients and remember, they are our patients. Patients don t refer to us as my doctor for nothing. Dr. K. My urban reality: I work largely out of my office. If I have an in-patient at my primary hospital, (closest to my office) I will leave my home at 7:30am to do supportive visits, unless it s a new baby, who is then directly under my care. There are three hospitals in town with some sub-specialization. With the bed situation, I have no or little control which hospital my patient will be admitted to, and of course, another hospital may be more appropriate for the problem. I pay $600+ a year for parking at this hospital. Going to the other hospitals regularly would mean a huge time commitment, even if done in rotation. Colleagues have frankly said, hospitals are a loss leader and you are crazy to go. As well, GPs cannot admit directly, but need admission under a consultant (unless maternity or newborn). I do go because I translate for my patients what is happening, what is planned and diagnosis, etc, which they frequently are not aware of and I do get a better idea of what is actually happening, although my voice (despite talking to residents, writing in the chart) is not infrequently ignored. I also go to try and develop at least a passing acquaintance and relationship with consultants. I attend Grand Medical rounds and Family Practice rounds 2 days a week after seeing any in-patients. I gave up assisting in surgeries when laparoscopic surgery came in and I found myself 3 rd in line, just standing, scrubbed behind the resident and clerk. I do not have the ER skills for a tertiary hospital nor the time. Back at the office, I start at 8:30am with seeing about patients a day of a 2200 patient roster with at least 2 hours of paper time stolen from lunch, or spent at the end of the day. My practice has grown old with me, so lots of chronic care. I have put in fair effort on my EMR with stamps, reminders, etc to ensure I am hitting the main parts of screening, prevention, and appropriate monitoring of e.g. diabetes but am running most of the day as it is a general practice with lots of well babies and prenatals which also means keeping on with current management here. My FHO group of 23 docs has largely walked away from long-term care as almost all of our nursing homes have a medical director, with or without a NP assistant, who often works part-time office/parttime nursing home or has retired to doing only nursing home care. In the past, I would be visiting my long-term patients over lunch and in the evenings and over a very wide geographic area. Unsatisfying, rushed care and in the end,

23 Comprehensive and Continuous Care in a Collaborative Team Environment: untenable. This is my most guilt-inducing constriction of services, but after many 45 minutes drives from one end of the city to another, to see one patient, I finally decided that it was just as important to occasionally have supper with my family. Yes, one could share by setting up rotations, but then I would not be seeing my own patients most of the time either. I currently have 2 palliative care patients very near the end of life. I do at least weekly house calls and telephone support and will commit to long drives for them. I take after-hour call about 2 days over a month covering about 50,000 patients and these are busy days. I think this is descriptive of most family docs care in town, and I probably do more hospital visits than most. Dr. N. You can t pay me enough to do more. I am drowning now. Dr. W. Most hospitals in this country could not function without family physician. Sadly, large urban hospitals and Academic Health Science Centres seem to be happy to function without them. The hook is that a large proportion of FM residents gets their training in those institutions and quickly learns that there is no place for them in hospitals. They then set up their office in a community and have no formal linkages with their local hospital to the detriment of their patients. I believe this tendency needs to be reversed and having a well organized primary care system with appropriate administrative support will certainly help us to get there. Dr. L. How many family physicians would be willing to return to hospital service even if the environment was appropriate? What skill set is required for the competent management of today s hospital patients? What courses would be needed to improve their knowledge, skills and, mostly importantly, their confidence? Family physicians that only do a little hospital-based care lose some of their confidence and eventually stop because it is too stressful. Perhaps, if primary care was better co-coordinated, the care of the patients of a group of family doctors could be provided amongst the group rather than by each physician making a daily trek to the hospital to see their own patients. Dr. L

24 Comprehensive and Continuous Care in a Collaborative Team Environment: I have listened to some very loud voiced opinions of comprehensive care, meaning the physician providing all the different forms of care themselves. Having trained recently and realizing that we are trained in a model of interdisciplinary care with a team based patient-centred approach as opposed to an individual paternalistic approach, I recognize the great benefits of being able to admit that one person can never provide the quality of care of a team, and it is a fallacy of pride to think that we can be providing top quality in all areas without help from very well trained healthcare professionals. Comprehensive care, to myself being trained in an interdisciplinary setting, places a great emphasis on the patient-physician relationship and the continuity is a huge part of quality of care. The physician acts as the ribbon that ties everything together. We walk through the health and life journey with our patient from birth to death. This does not mean we personally do every single part of their management, but it does mean we are involved, and we circle them with the best possible support and care team that we can. I worry about a very black and white definition of comprehensive care because the implementation of comprehensive care will change according to the resources, location and population served, etc. A tick system in which those with the most ticks are deemed to be providing comprehensive care is very limiting in my view and may be too simplistic to capture the complexity of it all. Dr.L-P

25 Comprehensive and Continuous Care in a Collaborative Team Environment: Key Papers on Continuity of Care 1. Continuity & Comprehensiveness of Care: Primary Care Toolkit for Family Physicians by the College of Family Physicians of Canada 2. Promoting continuity of care should be integral to any health care system by Drs. Walter Rosser and Karen Schultz 3. Implementation Strategies: Protecting Trust in the Patient-Physician Relationship by the Ontario College of Family Physicians 4. Continuity of Care in Family Practice, Part 1: Dimensions of Continuity by Dr. B. K. Hennen published in the Journal of Family Practice Vol.2, No.5, Continuity of Care by Dr. B.K. Hennen 6. Defusing the Confusion: Concepts and Measures of Continuity of Healthcare. Canadian Health Services Research Foundation, Robert Reid et. al. March 2002