Integration in Primary Health Care: Lessons Learned from Three Innovations. Lisa Dolovich Clare Liddy Gina Agarwal Noah Ivers

Transcription

1 Integration in Primary Health Care: Lessons Learned from Three Innovations Lisa Dolovich Clare Liddy Gina Agarwal Noah Ivers

2 Integration and Integrated Care defined (Denis Kodner, PhD, FGSA, Health Council of Canada National Symposium on Integrated Health CareNational Symposium on Integrated Health Care Toronto, 10 October 2012 Integration is a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors...[to] enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex problems cutting across multiple providers, services and settings...[where] the result of such multi-pronged efforts to promote integration...is called integrated care. Kodner & Spreewenberg, 2002 Trillium Primary Health Care Research Day 2016

3 Disconnected System Example: Atrial Fibrillation Patient Flow through the System (Morra D et al Reconnecting the Pieces to Optimize Care in Atrial Fibrillation: A white paper on the management of atrial fibrillation in Ontario)

4 Integration is a Complex Simultaneous Equation (Denis Kodner, PhD, FGSA, Health Council of Canada National Symposium on Integrated Health CareNational Symposium on Integrated Health Care Toronto, 10 October 2012 Integration solutions must be found on three (3) distinct, but highly interconnnecected levels: 1. Macro (where policy, financing, and regulation sets the stage) 2. Meso (where provider organizations interact) 3. Micro (where professionals and patients meet in the caring enterprise Trillium Primary Health Care Research Day 2016

5 Ontario policy context Patient s First Action Plan (Access, Connect, Inform, Protect) We propose to truly integrate the health care system so that it provides the care patients need no matter where they live (page 2) 4 components: More effective integration of services and greater equity Timely access to primary care and seamless links between primary care and other services More consistent and accessible home and community care Stronger links between population and public health and other health services Other related policy initiatives: Patient s First: A Roadmap to Strengthen Home and Community Care Expert Committee report: Patient Care Groups: a New Model for Population Based Primary Health Care for Ontario

6 INSPIRE-PHC Research Themes: Primary Care Reform Community-Based Care Sex and Gender based Analysis Knowledge Translation and Exchange Other activities Knowledge Translation and Exchange Capacity Building Research Consultation Trillium Primary Health Care Research Day 2016

7 INSPIRE-PHC: Community-Based Care Three main applied integration projects anchored in primary care Each project will present the following: The integration problem (ie through an integration lens) The solution The implementation Results and impact How the implementation addressed the integration issue Next steps

8 SCOPE Home Hospital Primary Care Community Specialists

9 Improved integration of care: the Champlain BASE TM econsult service 2016 Trillium Conference, June 1 Clare Liddy, Associate Professor, Dept of Family Medicine, University of Ottawa CT Lamont Primary Care Research Centre, Bruyère Research Institute

10 The econsult Team A collaboration between: The Champlain Local Health Integration Network The Ottawa Hospital Bruyère Research Institute Winchester District Memorial Service Funding Champlain Local Health Integration Network Ontario Ministry of Health and Long-term Care Current Research Funding Canadian Institutes of Health Research Bruyère Research Institute Inspire PHC ( ) Clare Liddy Primary Care Lead Erin Keely Specialist Lead Amir Afkham Engagement & Implementation Lead cliddy@bruyere.org ekeely@toh.on.ca Amir.Afkham@lhins.on.ca , Ext , Ext

11 Access to Specialists Across Canada 12 Figure 1 7 in 10 primary care doctors in Canada say their patients often experience long wait times to see a specialist, the highest proportion of all 10 countries in the Commonwealth Fund 2015 Survey. 13

12 Poorly integrated care along primary care to specialty service journey Challenges in scheduling/travel Duplication of tests/ procedures Excessive wait times (median 87 days) Unnecessary testing Poor care coordination Patient referred to specialist Patient has specialist visit Patient begins treatment Patient follow-up appointments

13 A Solution: econsult Patient referred to specialist Patient has specialist visit Patient begins treatment Patient follow-up appointments

14 How Does econsult Work? PCP logs onto secure webpage Completes simple form to submit to a specialty Assigned to an appropriate specialist (availability/rotation)) Response received within 7 days; back and forth communication can occur between PCP and specialist PCP closes econsult and completes survey

15 Current Status (as of April 30, 2016) Cases Completed 1030 PCPs (879 MDs, 160 NPs) from 397 clinics in 92 towns/cities * * Includes select group of clinics outside of the Champlain region (SE, Central, HNHB, CE, NE, NSM, NW, SW, TC, WW, MH, & Nunavut) in support of funded research initiatives for a more detailed quantitative assessment of econsult s impact on referrals 16

16 Results-Population health 14,395 cases completed* 1,030 PCPs (879 MDs and 160 NPs) from 397 clinics in 92 towns/cities have joined the service 86 specialty groups available PCP Engagement Specialty Engagement * As of April 30, 2016

17 Results Population Health Specialists responded to econsults in a median of 0.8 days (Improved access) Over 60% of cases did not require a face-to-face specialist visit (efficient, coordinated care) In 4 % of cases, econsult prompted a medical referral (patient safety )

18 Results Patient Experience Patients appreciated econsult s impact on access, care quality, and continuity of care. Very Fast! Reassuring

19 Patient experience It just kind of gives me a bit of peace of mind knowing that there s more than one person involved in making the decision [ ] It s kind of nice to know that there s other people involved in looking at the file and making that determination.

20 Strengthened Role of Primary Care improves integration Avoided unnecessary appointments Access to specialist knowledge PCP can advocate on patient s behalf Streamlined. service, one stop shop

21 Creating a virtual community of providers through econsult Enhances communication between providers Recognizes challenges of PCPs Supports better clinical decision making Facilitates engagement through feedback to specialists Provides platform for education and capacity building It s the right thing to do for our patients

22 Our Collaborations International econsult Collaborative Network of researchers and knowledge users from Canada and from US (UCSF, MAYO, VA) National Organizations: College of Family Physicians of Canada Canadian Foundation for Healthcare Improvement Canadian Medical Protective Association Canadian Patient Safety Institute Canadian Nurses Association Royal College of Physicians and Surgeons Canada Health Infoway Provincial Organizations Health Quality Ontario MOHLTC Québec College of Family Physicians NFLD Medical Association

23 Access to Specialist Consult ecollaborative McGill University Health Centre 24

24 econsults : Put the patient first. Highly acceptable to patients. Provides care that is coordinated and integrated, so a patient can get the right care from the right providers. Delivers integrated care in the community, closer to home. 25

25 Thank You! For more information, check out our ebook Available in ibook (for Mac) and pdf (for PC) from

26 The Evidence Base for Champlain BASE Better Population Health 1) Building Access to Specialist Care through E-Consultation. Open Med ) Utilization, Benefits and Impact of an e-consultation Service across Diverse Specialties and Primary Care Providers. Telemed J ehealth ) Improving access to chronic pain services through econsultation: A crosssectional study of the Champlain BASE econsult service. Pain Medicine w038 4) Rationale and model for integrating the pharmacist into the outpatient referral-consultation process. Can Fam Physician Improved Patient Experience 5) Patients perspectives on wait times and the referral-consultation process while attending a tertiary diabetes and endocrinology centre: Is econsultation an acceptable option? J Diabetes Lower Costs 6) Applied Health Research Question Report: Understanding needs and impact of econsult in the Champlain LHIN. MOHLTC Report stract_inspire.pdf 7) What are the costs of improving access to specialists through econsultation? The Champlain BASE experience. Stud Health Technol Inform Improved Provider Experience 8) Impact of and satisfaction with a new econsult service: a mixed methods study of primary care providers. J Am Board Fam Med ) A comparison of referral patterns to a multispecialty econsultation service between nurse practitioners and family physicians: the case for econsult. J Am Assoc Nurse Pract ) Perspectives of Champlain BASE Specialist Physicians: their experiences and recommendations for expanding econsult services across Ontario. Stud Health Technol Inform ) Impact of Question Content on e-consultation Outcomes. Telemed J ehealth ) Harnessing econsultations to Improve Practice-Based Learning in Endocrinology. Can J Diabetes Exploring Policy/Implementation Issues 13) Ten Steps to Establishing an e-consultation Service to Improve Access to Specialist Care. Telemed J ehealth ) The Current State of Electronic Consultation & Electronic Referral Systems in Canada: an Environmental Scan. Stud Health Technol Inform ) Critical requirements and considerations for establishing and participating in an econsultation service: Lessons learned from the Champlain BASE team. E Healthc Law Rev Review_5%231.pdf 16) Policy Innovation is Needed to Match Health Care Delivery Reform: The Story of the Champlain BASE econsult Service. Health Reform Observer

27 Health TAPESTRY-HC-DM Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management Supported by: Health Canada Government of Ontario (INSPIREphc) Labarge Optimal Aging Initiative McMaster Family Health Organization Gina Agarwal, MBBS MRCGP CCFP FCFP PhD

28 The Problem Lack of integration between home, community and primary care A patient population with poorly controlled diabetes Home Primary Care Community

29 The Solution Health TAPESTRY including the HC-DM project creates linkages through: Volunteers ehealth technology Interprofessional teams Community engagement System navigation System Navigation ehealth Technology Home Primary Care Where the person is FHTs, including family physicians, allied health professionals interprofessional team huddles including volunteers, community agencies Community

30 What Was Done Health TAPESTRY-HC-DM Iterative Participatory Co-development Initiatives

31 Health Tapestry HC DM Results/Impacts Across the iterative initiatives, engagement of: 77 patients with diabetes and hypertension In feasibility RCT thus far (n=38), ranged in age from 49-88, mean 64.6 (7.6); on 0-21 medications, mean 7.6 (5.0); self-reported 1-11 chronic conditions, mean 4.0 (2.1) Challenges: a computer-based intervention; a complex population 22 volunteers (age 19-62, including undergrads, foreign-trained professionals, those with personal experience with diabetes) 2 clinics within McMaster FHT, with over 35 practices, 32,000 rostered patients, & over 160 health care practitioners (full interprofessional team) 1 community volunteer agency (Volunteer Hamilton) Multiple early stakeholders (patients, health care practitioners, community agency members) in persona scenarios

32 Health Tapestry HC DM Results/Impacts Created the online Healthy Lifestyle App and ran usability testing (modules on: Diabetes, Hypertension, Sleep, Exercise, Medication, Nutrition, Goals, PHR) App contents developed based on review of evidence, multiple healthcare provider, patient, community persona group scenarios and expert input 14 patients participated in usability testing Age years (SD 5.56); 53.85% female; had a diagnosis of both hypertension and diabetes; 76.93% graduated from post-secondary education; ALL were users of technology to some extent (1) Content: usefulness/volume/depth/completeness 84.62% of participants said the content presented was useful; though 69% expressed some confusion over modules and their specificity (2) Layout 38.46% commented on ways to improve the layout (3) Utility 84.62%) said they would use this app again in the future (4) Unified Theory of Acceptance and Use of Technology (UTAUT) Questionnaire Results: majority of participants felt the app would be useful in managing their healthy; would give them better access to the health care system; would be helpful for their health Changes were made based on the findings

33 Selected Health Tapestry overall program implementation results To date: implementation in older adults (n=360), HealthLinks (n=8), homebound seniors (n=17), preventative care (n=17), and mobility challenges (n=36). Underway in First Nations and new immigrant populations. Average time to train volunteers is 11.5 hours (on-line + FtF) In welderly older adults 162 (93.6%) had at least 1 alert while 46 (26.6%) had 5+ alerts Most common alert was suboptimal physical activity (>80%) Primary care team workflows changed in planned and unexpected ways Remains a challenge to link to primary care to community resources: tendency to look within the team to address health goals/risks/needs

34 How Health TAPESTRY Addresses Integration Cultural shift in health care delivery re-focusing everyone in the circle of care to the same patient goals First 11 clients set 51 goals. Most common: more/different exercise (9), eating better (7), improving A1C/blood sugar (7), weight loss (7) Adding volunteers to help an overburdened primary care system First 65 volunteer narratives of client visits, most commonly discussed: tech support (20), goals (19), connections [clinic, community, online resources] (19), reducing blood sugar/a1c (17), increasing exercise (16), motivation to change (12), other health issues/pain (12), eating better (12) Introducing technology to help connect people (patients, health care providers, volunteers) Social engagement, building community

35 Next Steps Complete HC-DM RCT and continued analysis of outcomes from other Health Tapestry initiatives Integrate learnings with the overall Health TAPESTRY and other system transformation projects Continue to work to fully integrate a person-focused ehealth technology ecosystem (including kindredphr, Healthy Lifestyle App, OSCAR EMR) Expand current community engagement and linkages Emerging work with maternity patients, CHF, frailty, mobility, hospital to home, last year of life (as an effort to foster compassionate accountable communities)

36 Seamless Care Optimizing the Patient Experience June 1, 2016 Trillium Primary Health Care Research Day 2016

37 The Current Challenge Individuals with complex chronic conditions are at an increased risk for Emergency Department visits and hospitalization. Solo practitioners have difficulty accessing hospital and community resources. Some lack infrastructure to respond proactively to complex patients needs. Trillium Primary Health Care Research Day 2016

38 Builds a partnership between primary care physicians and acute and community care providers GIM Internist CCAC Nurse Navigator Imaging A virtual interdisciplinary team around the community practice

39 SCOPE as a Platform Identify needs in the community Facilitate information sharing Connect PCPs and their patients to care Build capacity

40 SCOPE 1 Outcome Propensity-Matched Time Series Analysis - quarterly ED visit rates, 3 years prior to 18 months post-intervention (Oct 1, 2009 Mar 31,2014) ED visits per quarter Controls SCOPE Time

41 Qualitative Evaluation Helped overcome a sense of isolation Increased ability to practice shared primary-specialty care Improvement in the coordination of care they are able to provide to their complex/comorbid patients Increased ability to find the most appropriate resources for their patients Timely access to services, more comprehensive care, and coordinated care follow-up

42 GIM Urgent advice Access to specialty care Strengths Novel Approach Access to community services Engaged a group of PCPs previously not connected Created a platform for linking services to needs Access to acute services Access to medical imaging services Limitations Patients bypass their PCP in favour of the ED Lower than expected call volumes PCPs unable to identify their complex patients

43 Summary SCOPE succeeded in engaging previously isolated physicians in health system reform by utilizing grassroots planning and focusing on the needs of the primary care provider SCOPE identified service gaps in hospitals and the community for many high needs patients SCOPE is a valuable platform that matches primary care needs with hospital and community services

44 Next Steps / Expansion Plans are currently underway to expand services to more PCPs across the Toronto Central LHIN SCOPE will expand their suite of services and offer more specialty services (e.g. GYN, psychiatry) across more institutions (St. Joseph s Health Centre and Mount Sinai Hospital) The SCOPE expansion is being evaluated as a Quality Improvement initiative and will include measures for broader system impact and cost savings Trillium Primary Health Care Research Day 2016

45 A few reflections Our projects: working from the bottom up in pieces Focused on meso/micro levels of engagement Yet aligned with macro context Keeping many of the key principles of integration in mind to help improve chance of a sustainable solution Well working technology connections are key Different solutions needed for different types of patients/medical problems/acuities etc that still work well together Opportunity costs & unintended consequences not well understood Trillium Primary Health Care Research Day 2016

46 Panel discussion Trillium Primary Health Care Research Day 2016