Calgary Foothills Primary Care Network. Annual Report

Transcription

1 Calgary Foothills Primary Care Network (Go live date July ) Annual Report Sections 1 & 2 Version 9.0 For the period April 1, 2013 to March 31, 2014 To be submitted to the PCI Program Management Office no later than July 1, 2014

2 SECTION 1 Summary of PCN Highlights (2-3 paragraphs) Calgary Foothills Primary Care Network (CFPCN) continued to build on a strong group of core programs during the fiscal year. New program highlights included the emergency department referral pilot, in which appropriate patients were referred from the Foothills Medical Centre Emergency Department to the CFPCN After Hours Clinic. The initiative was first introduced during the flooding of the Bow and Elbow rivers in June 2103, before a pilot was held during a non-crisis period, from December 2013 to March The pilot was a success and the program will be continued indefinitely. In June 2013 the geriatric psychiatry program built on the on the success of the Extended Team s Navigation stream by introducing a one-time psychiatric assessment, while Population Health programming was boosted with the October 2013 addition of Craving Change TM, a free, four-class workshop for adults who struggle with their choices around eating. Throughout the year there was also a strong focus on helping physicians to implement quality improvement initiatives in their practices Annual Report sections 1 & 2 version 9.0 {PCN Name} 2

3 Period Overview (5 pages or less) Name of priority initiative: After Hours Care Elements Planned Achievement Status* Status Explanation** After Hours Clinic (AHC) Continuity Clinic Partnership with Health Link Physician On Call Provide support for patients when family physician offices are closed on evenings, weekends and statutory holidays. Increase ability to provide same day access for primary care issues during the day when family physicians are not available. Triage patients to the After Hours Clinic and available physician through Health Link. Provide on-call support to patients after hours, through Health Link triage. 9,832 patients were seen at AHC this fiscal year (14% increase from FY 12/13). 783 patients were seen at the Continuity Clinic this fiscal year (71% in average number of patients seen per month from FY 12/13). Health Link Alberta triaged 49,719 Calgary Foothills PCN (CFPCN)- related calls (1% decrease from FY 12/13). Health Link referred 59 patient calls this fiscal year to the physician available by phone after hours (45% decrease from FY 12/13). Name of priority initiative: Chronic Disease Management Elements Planned Achievement Status* Status Explanation** Crowfoot Primary Care Centre MDT Provide primary care services for complex patients who may be difficult to attach; clinic has multidisciplinary team (MDT) for patients with chronic disease. Provide comprehensive team-based care in the medical home to assist in chronic disease management. 932 patients with complex conditions are currently attached to the clinic and benefiting from enhanced MDT care (6.8% decrease from FY 12/13). As of March 2014, 96.3% of physicians with a family practice had at least one team member in the medical home (99.6% in FY 12/13). Teams consisting of pharmacists, health management nurses and dietitians had 20,532 patient interactions (9.4% decrease from FY 12/13). Support physicians and team to increase their capacity of diabetes care, through a Diabetes Outreach Educator (DOE). Provide MDT with current and evidencebased education to support patient care. Support MDT to provide high quality care. On target DOE received 62 referrals. 71% of patients (n=21) saw an improvement in HbA1c following treatment. Additional education and resource support provided to MDT. A resource library provides MDT with remote access to evidencedbased information and patient handouts. 4 MDT educational seminars were held, with +/- 55 attendees at each session. 14 pharmacists have prescribing privileges (13 in FY 12/13), 14 pharmacists have their Certified Diabetes Educator (CDE) (9 in FY

4 Provide member physicians with evidencebased information. Partnership with University of Alberta (Best Practice Support Visits). On target 12/13), and 5 health management nurses have their CDE (4 in FY 12/13). 46 physicians received a Best Practice Support Visit education session during the fiscal year. The topic of these sessions was Dyslipidemia & New US Guidelines. Name of priority initiative: Clinic Innovations Elements Planned Achievement Status* Status Explanation** Exploring a variety of models to support physicians to optimize the medical home and support the recruitment and retention of family physicians. Calgary PCN Managed Clinics Extended Team Increase the ability of the medical home to provide comprehensive care for patients with complex issues, and link medical homes with specialty care: Chronic pain stream, Medical MSK stream, GI stream, and Navigation stream. 4 Primary Care Centres (PCCs) operating: Crowfoot PCC, Cochrane PCC, Foothills PCC, and Riley Park PCC. Each PCC also supports PCN programs which increase access to primary health care. Chronic Pain Stream: Received 346 referrals this fiscal year. Patients demonstrated improvements in pain intensity, severity and self-reported depression symptoms. Medical MSK Stream: Received 184 referrals for non-inflammatory and non-surgical concerns in multiple joints. On target GI Stream: Received 193 referrals from AHS Central Access and Triage for patients with dyspepsia, gastro esophageal reflux disorder, and Irritable Bowel Syndrome. Information Technology Support all member physicians to have completed their PIAs and encourage EMR uptake. Facilitate signing of the CFPCN Data Sharing Agreement to allow member to share data in a secure manner with their Physician Corporation. Navigation stream: 376 patients were referred regarding falls, cognitive screening, function and safety, and community resources. All members have completed PIAs. 83% of physicians use an EMR (69% in FY 12/13). 84% of physicians use Netcare (85% in FY 12/13). 76% of member physicians have signed the DSA as of March 2014 (81% in FY 12/13). Facilitate the use of online resource (Up-To- Date) for physicians, staff and CFPCN allied health professionals. 48, 849 Up-To-Date topic views (26% decrease from FY 12/13). Communicate information about health promotion, AHS services and CFPCN information to patients via Health Unlimited Television (HUTV). Complet ed The four CFPCN Primary Care Centres and Riley Park Maternity Clinic received HUTV monitors in patient waiting areas Annual Report sections 1 & 2 version 9.0 {PCN Name} 2

5 Liaisons Liaisons meet with physicians on a regular basis in order to provide regular PCN updates and father physician feedback. Member physicians met with their liaisons an average of 5.3 times over the fiscal year (4.8 in FY 12/13). Liaisons received practice facilitation training from Towards Optimized Practice. Complet ed Liaison confidence in overall facilitation skills, knowledge increased by 177%. Support clinics in screening activity (Alberta Screening and Prevention- ASaP). Complet ed Liaisons received training from TOP to facilitate ASaP processes. Over the fiscal year, 16 physicians have enrolled with ASaP. Support clinics in Alberta AIM (Access Improvement Measurement) collaboratives. Two clinics participated in AIM this fiscal year (33 physicians). One clinic completed the initiative; time to third next available appointment decreased by 75%. Partner with AHS Calgary Zone and Health Quality Council of Alberta (HQCA) to support physicians to receive data on their patient panels. Liaisons facilitated the signing of HQCA data sharing agreements. 62% of full member physicians received HQCA physician-level reports (53% in FY 12/13). Support physicians to engage in quality improvement initiatives in their practices. 146 physicians participated in liaison-facilitated practice enrichment projects. Projects were related to treatment (47%), efficiency (28%), understanding patient panel (24%), screening and prevention (22%), access (15%) and continuity (2%). Program Promotion & Education New Grad (New) Primary Health Care Service Delivery Model (New) Provide family physicians, staff and team ongoing education opportunities to support uptake of PCN services and programs. Provide new family physicians the opportunity to experience a variety of practice settings in primary care with financial and mentoring support. Provide a primary health care service delivery model to support medical homes by coordinating care in the community and enhancing team. On target On target Four CME events were held with 392 physicians, clinic staff and MDT in attendance. 4 new physicians positioned in the four CFPCN Primary Care Centres. In the Cochrane PCC, 128 patients were attached to the clinic as part of a New Grad panel. The Cochrane PCC has been identified as the initial Community Hub site, to be implemented in fall Name of priority initiative: In-Hospital Care Elements Planned Achievement Status* Status Explanation** In-Hospital Care Enhanced Hospital Discharge transitioning discharges from Foothills Medical Centre (FMC) to the community. 2,316 packages have been sent to member physicians (58% of discharges). Seamless Care identification of pharmacists concerns at discharge 10 pharmacist-to-pharmacist referrals for CFPCN patients (56% decrease from FY 12/13) Annual Report sections 1 & 2 version 9.0 {PCN Name} 3

6 Name of priority initiative: Mental Health Elements Planned Achievement Status* Status Explanation** Access to Psychiatry Behavioural Health Consultants Offer tele-psychiatry consultations with a psychiatrist for Calgary Foothills PCN physicians. Offer Adult Psychiatric Assessment service available to Calgary Foothills PCN physicians. Behavioural health consultants work alongside physicians to address mental health concerns in the medical home, as part of the MDT. Tele-psychiatry provided 32 consults (10% increase from FY 12/13) to 20 different physicians. Psychiatrist received 394 referrals, concerning topics such as diagnostic assessment, depression/mood, and anxiety. 91% of physicians with a family practice have a behavioural health consultant (of those who requested one). BHCs saw approximately 11,954 patients (24% increase from FY 12/13). Name of priority initiative: Population Health Elements Planned Achievement Status* Status Explanation** Cochrane: Teen Health Ask a Dietitian Pediatric Kids in Care (PKIC) Tobacco Cessation Program Craving ChangeTM (New) Unattached Patient Registry Provide sexual and reproductive health care and education for young adults in the Cochrane area. Increase access to registered dietitians by offering Ask a Dietitian group appointments. PKIC is a joint program with Pediatricians, Calgary Child & Youth Services and Calgary Foothills PCN. Support patients to quit tobacco use through a comprehensive program of four classes, including education, group support and access to medications. Workshops focused on helping patients understand their eating patterns and develop a healthier relationship with food. Manage the pan-pcn Registry in order to help connect unattached patients with family physicians. 3 patients have used this program. The small number is believed to be due to lack of publicity. The program will continue in the FY 14/15 year. 95 people attended a group appointment (6% increase from FY 12/13). 10 children from the Child Protective Services were attached to a family physician. 326 referrals were made (11% decrease from FY 12/13), 31% registered (61% in FY 12/13) and 88% of registrants attended the first class (51% in FY 12/13). After three months, 50% of those contacted (n=36) reported they had quit (37% in FY 12/13). 67 registrations, 88% attended first class. Overall patients reported a positive change in their ability to cope with their cravings. The website/registry received 6,257 registrations from CFPCN (33% increase from FY 12/13). Walking Program Promote physical activity in the community by supporting a walking program. 12 new participants this fiscal year, for a total of 226 registrants (5% increase from FY 12/13). Connect patients with physicians in an informal setting while promoting physical activity through Walk with Doc program. 10 session were held, attended by a total of 119 walkers Annual Report sections 1 & 2 version 9.0 {PCN Name} 4

7 TrymGym Promote physical activity by subsidizing the TrymGym program (partnership with University of Calgary). 126 Calgary Foothills PCN patients participated (same in FY 12/13). Name of priority initiative: Seniors Health Elements Planned Achievement Status* Status Explanation** Pan PCN Long Term Care Availability Group A Pan-PCN service for residents in long term care, where physicians provide afterhours coverage on weekdays and weekends. 61 physicians (39 from CFPCN) cover 28 LTC facilities. 5,302 calls received (8% increase from FY 12/13). Nurse Practitioner program Seniors Outreach Senior Primary Care Service Provide a nurse practitioner at Bethany Cochrane to increase access and improve coordination. Provide education events to seniors in the community. (Now known as Navigation Team; merged with extended team) On target The nurse practitioner continues to provide care to Calgary Foothills PCN patients. Five events have been held, with 103 participants in total. See Extended Team. Restricted Grants & Central Allocation Key Activities: (E.g. Evaluation, IT, etc ) Activities Planned Achievement Status* Status Explanation** Atrial Fibrillation Pilot Deferred Enhanced Participation in Cancer Screening (EPICS) Specialist Linkages Restricted grant funded by Boehringer- Ingelheim (Canada) Ltd., to identify high risk patients and reduce preventable strokes. Restricted grant funded by Alberta Cancer Prevention Legacy Fund (ACPLF), testing impact of improved clinic processes, electronic registries and EMRs on cancer screening. Specialists Linkage funding discontinued. We provide tele-consult programs to continue the linkage. Project being considered at level of Calgary Zone Primary Care Action Plan (CZPCAP). Further action pending CZPCAP decision. This fiscal year, Calgary Foothills PCN has been an active partner in implementing phase 2 of the study. Tele-programs include: psychiatry, cardiology, orthopedics, rheumatology, chronic pain, GI, ENT (new), geriatric psych (new), hematology (new), perinatal psych (new). Connect member physicians and teams with specialty through lunch and learn educational opportunities in member clinics. 26 sessions were held: 13 Chronic Pain, 7 MSK, 5 Geriatric Psychiatry, and 1 Endocrinology (diabetes). *Completed, On-going, On Target, Delayed, Deferred or Discontinued **Briefly describe achievements or explain delays, deferrals or discontinuations Annual Report sections 1 & 2 version 9.0 {PCN Name} 5

8 SECTION 2: EVALUATION Objective 1: To increase the proportion of residents with ready access to primary care 1.1 Comment on any key achievements by the PCN toward increasing access to primary care in the past year. ATTACHMENT Many Calgary Foothills PCN family physicians attach people to their medical homes. Patient attachment to a medical home helps improve patient care and population health, and is supported by the College of Family Physicians of Canada (2009). As of March 31, 2014, there were 361,464 people paneled to Calgary Foothills PCN, an increase of 2,077 people (0.58%) from last fiscal year. The PCN has developed PCN-specific web registry processes to connect people who request a family physician to family physicians who are building their practice. Web Registry Calgary Foothills PCN operates and manages a Calgary Zone pan-pcn Web Registry to coordinate patient connections to family physicians. The Web Registry is an online data collection tool designed to connect people who do not have a family doctor to a physician in their surrounding community on a first come, first served basis. People who are looking for a family physician may register online at or by calling Health Link Alberta. This is an example of how PCNs are collaborating to improve patient access to primary care services. During the period of April 1, 2013 to March 31, 2014, the Need-a-Doctor website received 17,794 registrations from the Calgary Zone area (a 50.5% increase from FY 12/13), which may be due to simplification of the registration process which occurred in April This fiscal year, Calgary Foothills PCN received 6,257 registrations from the PCN catchment area (a 50% increase from FY 12/13). The PCN provided 4,482 patient names to family physicians in the community from the Web Registry (a 165% increase from FY 12/13). When patients were contacted, some no longer required attachment to a family physician. The average wait time before connection was 119 days (a 33% increase from FY 12/13). As of March 31, 2014, a total of 4,370 patients were attached to a medical home from the web registry. 2,748 were attached to family physicians in member clinics (13% increase from FY 11/12. Comparison for FY 12/13 is not available). 1,622 were attached to Crowfoot Primary Care Centre. (18% decrease from FY 11/12. Comparison to FY 12/13 is not available). Prioritizing Attachment for Patients with High Needs Calgary Foothills PCN monitors and prioritizes attachment to Crowfoot Primary Care Centre for people with high needs such as people discharged from hospital without a family physician, pregnant women, and people with chronic disease. Crowfoot Primary Care Centre is a PCN Annual Report sections 1 & 2 version 9.0 {PCN Name} 6

9 managed clinic with a mandate to attach high needs patients. The PCN has developed PCNspecific processes to support connecting people who need or request a family physician. In addition to the Web Registry, patients were also attached from the following sources: 49 from Foothills Medical Centre 5 from Peter Lougheed Hospital 24 children (and their biological families and/or foster families) from Pediatric Kids in Care 60 from After Hours Clinic 92 from other sources such as community physicians and retirement homes. 51 from Riley Park Maternity Clinic New grad program The New Grad Program was developed in July 2013 to allow new family physicians to experience a variety of practice settings in primary care with financial and mentoring support. This program provides support and additional time as the new grads continue to develop their expertise and make their career choices. The program was piloted with 4 new graduates in the PCN Primary Care Centres (PCCs) this fiscal year. In the Cochrane Primary Care Centre, 128 patients were attached to a new grad panel. In the other PCCs, New Grads see patients from clinic physician panels. The additional provider practicing in the clinic increases the number of patients who can be seen each day. Feedback from New Grads following each rotation (n=7) indicates that there is room for improvement with regards to patient variety and opportunities for diverse practice experiences. The program continues to be developed in order to meet New Grad needs. Further evaluation is underway to assess patient satisfaction and impact on access. AFTER HOURS Calgary Foothills PCN operates, in partnership with Health Link Alberta, an After Hours Clinic and Physician On-call Service (in Calgary and Cochrane) to increase access to primary care for patients of member physicians and unattached people living in the PCN catchment area. The objective is to provide primary care support (the issue needs to be seen within four 24 hours) for patients when physician members offices are closed, and when physicians do not capacity for same-day access. The After Hours Clinic provides primary care from 5 p.m. 9 p.m. during the week and 10 a.m. 4 p.m. on weekends and statutory holidays. Referrals are received from Health Link Alberta and directly from member physicians. The Physician On-call service provides after hours advice from 9 p.m. 8 a.m. during the week and 4 p.m. 10 a.m. on weekends and statutory holidays. Referrals are received through Health Link Alberta. Health Link Alberta Referrals Over the fiscal year, Health Link Alberta received 49,719 Calgary Foothills PCN-related calls (average of 4,143 calls per month), which is a one per cent decrease from the previous fiscal year (50,109 in FY 12/13). Of these calls, 95% were made by attached patients and five per cent were made by unattached patients, which is the same as the previous fiscal year Annual Report sections 1 & 2 version 9.0 {PCN Name} 7

10 Sixteen per cent of these Calgary Foothills PCN-related Health Link calls were triaged to the After Hours Clinic over the fiscal year, to a total of 7,963 calls (17% in FY 12/13). Consistent leading categories of health concerns referred to the After Hours Clinic included pediatric cough/hoarseness/stridor (5%); abnormal urination (5%); adult cough/hoarseness (5%), and sore throat (5%). After Hours Clinic Approximately 9,832 patients were seen at the After Hours Clinic over this fiscal year (8,628 in FY 12/13, a 14% increase). On average, 82% of referred patients were seen (73% in FY 12/13). Some of the reasons patients did not come to the clinic after being referred were: staff are unable to reach patients; patients prefer to wait and see their family physician; or patients report feeling better. 1.8% of total Calgary Foothills PCN patients seen were unattached (2% in FY 12/13). These patients were subsequently referred to the Crowfoot Primary Care Centre to be attached. Direct physician referrals accounted for about 23% of all patients seen in the clinic (24% in FY 12/13). During the fiscal year, the clinic operated close to capacity: on average, 73% of possible appointments were booked (69% in FY 12/13). From November 2012 February 2014, Mosaic and Calgary Foothills PCN harmonized Health Link Alberta referral algorithms to provide patient-centered choice of location. The patient s medical home received a visit report regardless of which PCN After Hours Clinic the visit occurred in. Mosaic PCN closed their clinic in February 2014, and in order to continue to provide access to convenient after hours care, Calgary Foothills PCN has maintained availability for Mosaic patients. Health Link Alberta continues to offer patients the option of being seen at the Calgary Foothills PCN clinic. Attached and unattached patients from Mosaic accounted for approximately 4% of the patients seen (2.5% in FY 12/13). A brief anonymous survey was conducted with patients at the After Hours Clinic in October 2013 and March This survey has been conducted six times over the past three fiscal years. All patients are asked to complete a single-question survey indicating where they would have gone for medical help if the After Hours Clinic was not available. On average, the findings suggest that the After Hours Clinic diverted at least 37% of patients from emergency rooms and urgent care centres during this fiscal year. This finding is roughly consistent with the previous year (41% in FY 12/13) Annual Report sections 1 & 2 version 9.0 {PCN Name} 8

11 Chart: Patients choice for medical help if the After Hours Clinic was not available, October 2013 and March 2014 (n=156) 50% 40% 30% 35% 37% 20% 20% 10% 6% 0% Walk-in clinic UCC or ER Wait to see GP Stay home Continuity Clinic The Continuity Clinic is a service offered by Calgary Foothills PCN since November 2012, which provides patients with access to a primary care team (physician, nurse practitioner and pharmacist) when their family physician is unexpectedly absent or absent during a planned vacation and does not have a locum or call group to cover. Absent physicians keep their clinics open and staffed in order to take patient calls, and staff refer patients to the Continuity Clinic if appropriate. The clinic is available Monday to Friday from 1:00-5:00pm. Over the fiscal year, 783 patients were seen at the Continuity Clinic (average of 65 per month, a 71% increase from FY 12/13). A survey of physicians who used Continuity Clinic was administered to understand their experiences (n=8). Five respondents (63%) would consider using the clinic again (100% in FY 12/13, n=7) and six respondents (75%) would recommend it to colleagues. In the annual physician survey, 42% of physicians foresee using the service in the future (44% in FY 12/13). In the comments, many physicians noted that they have cross-coverage within their clinics and therefore have no need of the service. Some noted that the costs to keep their clinic open and the administration requirements to coordinate patients are burdensome. A brief anonymous survey was conducted with patients at the Continuity Clinic (n=15). The findings suggest that the Continuity Clinic diverted at least 20% of patients from emergency rooms and urgent care centres. 93% of surveyed patients are very satisfied with the service (n=15) In order to improve efficiency, the Continuity Clinic and After Hours Clinic were merged on April 1 st, 2014 now called Access 365. The services provided remain the same, but access to the After Hours component is enhanced through extended hours. Reporting for the fiscal year will reflect the combined structure of this clinic. PHYSICIAN ON-CALL SERVICES Physician On-call Service Annual Report sections 1 & 2 version 9.0 {PCN Name} 9

12 The Physician On-call service provides on-call support to patients in the Calgary Foothills PCN catchment area once the After Hours Clinic closes: 9 p.m. 8 a.m. during the week and 4 p.m. 10 a.m. on weekends and statutory holidays. Referrals are received through Health Link Alberta. During the fiscal year, 59 calls were referred to the Physician On-call service by Health Link Alberta. This is a 45% decrease in referrals from the previous fiscal year. Health Link Alberta suggests that referrals may be in decline because not all PCNs in the Calgary Zone have an on-call service, and thus this option may not be top-of-mind for Health Link nurses. Calgary Foothills PCN and Health Link are working to better understand this trend. Chart: On-Call Referrals from Health Link, 2011/ / / / /14 The top categories of health concerns referred to the on-call physician included: non-trauma eye concerns (5%); medication reaction (5%); vaginal bleeding and abnormal cramping (3%); and visual disturbance and loss (3%). The most common recommended action by the physician on call was to follow up with a family physician (39%; 43% in FY 12/13). Recommendations to proceed to the ER or Urgent Care Centre (29% of recommendations) are fairly consistent with the previous fiscal year (26% of recommendations) Annual Report sections 1 & 2 version 9.0 {PCN Name} 10

13 Chart: Recommendation by on-call physicians, 2011/ /14 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 43% 41% 39% 33% 28% 28% 29% 26% 19% 4% 4% 4% Family physician Self Care ER or Urgent Care After Hours Clinic Pan PCN Long Term Care (LTC) On-call Service Calgary Foothills PCN manages and coordinates a Pan PCN LTC On-call service with Calgary West Central PCN for residents of 28 long term care facilities in the city of Calgary. The service increases efficiencies by providing one telephone number (for each call group) to LTC facilities, increasing the continuity of the support with one week interval coverage (two physicians on call for the city, one for the north and one for the south) and decreasing physician travel time. Physicians are supported to attend the LTC site when appropriate, which is particularly important because on-site assessment can reduce unnecessary patient transfers to emergency. As of March 31, 2014, the LTC on-call service consists of 61 physicians across Calgary Foothills PCN (39), Calgary West Central PCN (20), South Calgary PCN (1) and Mosaic PCN (1) in 28 long term care facilities throughout Calgary. This represents a decrease of one physician from March Approximately 5,746 calls were received in this fiscal year (8% increase from 5,302 in FY 12/13). 7% of patients were sent directly to emergency following a call (7% in FY 12/13) 2% of patients were visited following a call (3% in FY 12/13) Following a visit, 16% of patients were transferred to emergency (21% in FY 12/13) ACCESS TO COMPREHENSIVE OBSTETRICAL CARE AND DELIVERY Riley Park Maternity Clinic Riley Park Maternity Clinic provides perinatal care for women of the greater Calgary area (including CFPCN and non-cfpcn patients) who wish to deliver at Foothills Medical Centre. Services are provided for attached and unattached patients Annual Report sections 1 & 2 version 9.0 {PCN Name} 11

14 This fiscal year, there were 39,474 appointments (an average of 3,290 per month) at Riley Park Maternity Clinic. This is a 14% increase from the previous fiscal year. Riley Park Maternity Clinic received 3,109 referrals women were early referrals at weeks (9% increase from FY 12/13). This accounts for 67% of referrals (68% in FY 12/13). 668 were late referrals at 30 weeks (17% increase from FY 12/13). This accounts for 21% of referrals (21% in FY 12/13) 33 were shared care referrals at 36 weeks (120% increase from FY 12/13). This accounts for 1% of referrals (1% in FY 12/13). 334 patients self-referred to the clinic (15% increase from FY 12/13). This accounts for 11% of referrals (10% in FY 12/13). Riley Park Maternity Clinic physicians attended 2,910 deliveries this past fiscal year, averaging 242 per month (a 0.1% decrease from FY 12/13). 95% of physicians who responded to the annual survey (n=227) are satisfied with the services provided by Riley Park Maternity clinic (93% in FY 12/13). 95% indicated that patients are being seen in a timely manner once referred (88% in FY 12/13). Nurse Practitioners work alongside physicians increasing access to low risk maternity care. Nurse practitioners had 1651 appointments with patients (29% decrease from FY 12/13). This decline is due to a decrease in nurse practitioner FTE in the clinic. Of total clinic visits, 96% were with physicians (93% in FY 12/13) and 4% were with nurse practitioners. A lactation consultant and maternity-focused shared mental health care psychologist are colocated in the Riley Park Maternity Clinic. These care providers link directly with patients, lowrisk maternity physicians and family physicians. This fiscal year, the lactation consultant provided 3,740 visits (11% increase from FY 12/13). In September 2013, a survey was administered to patients at Riley Park Maternity Clinic to ascertain their experience and satisfaction with their care (n=113). The results will help the PCN understand the patient experience and highlights areas for improvement. On a scale of 0-10, patients rated their care 8.6 on average. 96% of surveyed patients felt they were treated with courtesy and respect by health care professionals. 95% of surveyed patients felt they were appropriately involved in decisions about their care. 86% of surveyed patients were satisfied with the wait for their appointment. 86% of surveyed patients felt they had an acceptable wait in the waiting room and 85% had an acceptable wait in the exam room. 86% of surveyed patients felt providers listened carefully and explained things in a way patients could understand. In September 2013, the Medical Home task group for the pan-pcn/ahs Calgary Zone Primary Care Action Plan Secretariat developed an initiative to improve access for breastfeeding support. In Calgary, mothers with breastfeeding concerns often have long waits to see providers; this initiative created new partnerships between Low Risk Maternity family physicians and Public Health. As part of this process, mothers see family physicians in Riley Annual Report sections 1 & 2 version 9.0 {PCN Name} 12

15 Park Maternity for non-complex concerns (e.g., frenotomies), thereby shortening wait times and freeing the time of family physician lactation consultants for complex issues. In Calgary Foothills PCN, Riley Park Maternity Clinic saw 35 patients for frenotomies and other non-complex breastfeeding issues during this fiscal year. Patients seen at Riley Park Maternity Centre were surveyed following their appointment. Some patients may have been seen in the fiscal year. 85% of patients waited three days or less for their appointment, and 100% were satisfied with this wait (n=39). 97% of patients were satisfied with the services provided in the clinic (n=39). At three weeks follow up, 93% agreed that the experience helped them meet their breastfeeding goals, and 100% agreed the visit helped keep them and their babies healthy. (n=15) At three weeks after their appointment, 100% of patients were still breastfeeding their babies (27% partially supplementing with formula) (n=15). Health care providers and staff who are involved in this process across the PCNs (n=42) were also surveyed: 87% felt adequately prepared to participate in the referral process. 64% found the referrals were simple and straightforward to make. 71% found the process helped streamline care for their clients/patients. 88% felt the process prevents adverse outcomes related to breastfeeding. 79% felt their patients received the service they needed in a timely manner. 88% felt their patients received high quality care. 67% felt their patients received exactly the care they needed. Respondent suggestions and comments will be used to help improve the referral process following the pilot. Following the success of the pilot, this partnership and process will continue. Further report to follow. PCN-MANAGED MEDICAL HOMES (PRIMARY CARE CENTRES) Calgary Foothills PCN is exploring a variety of models of PCN-managed primary care centres, to optimize the medical home and support the recruitment and retention of family physicians. Each primary care centre also supports PCN-specific programs which increase access to primary health care. The fundamental principles of the medical home 1 which guide the PCNmanaged clinics are: 1) Everyone should have access to a family practice/primary care setting that they can call their medical home. 2) Everyone should expect the medical home to be patient-centred and provide team-based, collaborative, comprehensive and continuous care. 3) The care should be supported by an electronic medical record to facilitate quality improvement and evaluation. A brief description of PCN-managed clinics is listed below: Crowfoot Primary Care Centre provides primary care services for unattached patients with high needs in the PCN catchment area. This site is a single point of contact for other health care providers who have identified a patient in need of a medical home. Hospitals, Annual Report sections 1 & 2 version 9.0 {PCN Name} 13

16 outpatient clinics, home care nurses, social services, low risk maternity clinic, and other services, fax in a referral form and clinic staff will contact the patient within 24 hours (M-F) to attach the patient and book an appointment. The clinic has a multidisciplinary team of healthcare professionals focused on increasing access to primary care for patients with complex chronic disease and helping these patients manage their health conditions. 932 patients with complex conditions are currently attached to the clinic and benefiting from the enhanced multidisciplinary team care (a 6.8% decrease from FY 12/13). This decrease is attributed to 2 CDM physicians reviewing their patient panel in 2013 and moving stable CDM patients out into the community. Crowfoot Primary Care Centre builds medical home capacity by providing a location for new medical graduates or physicians starting a family practice in Calgary. Physicians build their patient panel in a supportive environment with a physician mentor, multidisciplinary team and access to an electronic medical records (EMR) system. Once physicians panels are full, Calgary Foothills PCN assists physicians in moving out into the community. This initiative increases the proportion of people with ready access to primary care and supports new physicians setting up in Calgary. Over this fiscal year, 2219 patients were attached to family physicians building a practice in the clinic and then moved to the community with their physician (47.5% increase from FY 12/13). The clinic has 3,517 patients who are attached to a family physician within the clinic as of March 2014, of which 2,233 patients are waiting to be transferred to a family physician building a practice in the clinic or community. There is an Extended Team that operates out of the Crowfoot Primary Care Centre which services the whole PCN. The extended team is an extension of the medical home team, which works closely with specialist partners to increase access of team care for patients with complex issues. The extended team has four streams: Muscular Skeletal, Gastro-intestinal (GI), Chronic Pain and Navigation. (For more information please see objective 3.1). This site also provides centralized access to health promotion education; AHS Living Well education programs and CFPCN-specific health education sessions such as Tobacco Cessation, Ask a Dietitian and Craving Change TM group appointments are offered from this site. Foothills Primary Care Centre was developed to provide access to a multidisciplinary team for all family physicians practicing in the Foothills Professional building. This centre is piloting the efficiencies and processes required when providing centralized multidisciplinary team care from a medical home hub, versus a co-located team. The clinic has also facilitated semi-retired physicians to continue to provide care to a full panel of patients. Starting in January 2014, Foothills PCC started the AIM collaborative where 2 out of the 5 sessions are completed; see Quality Improvement under Objective 3 for more details. During the year, this site went through an EMR transition from MD Practice Solutions to Wolf. Riley Park Primary Care Centre provides a setting for member family physicians seeking to join a medical home. The PCN opened the centre at a time when the cost of operating a family practice was prohibitive for many new and transitioning family physicians. The site also houses two PCN clinic-programs, the After Hours Clinic and Continuity Clinic. This site provides centralized access to health promotion education: AHS Living Well programs and Annual Report sections 1 & 2 version 9.0 {PCN Name} 14

17 PCN-specific health education sessions such as Tobacco Cessation, Ask a Dietitian and Craving Change TM group appointments are offered from this site. Cochrane Primary Care Centre joined physicians in three family physician offices in one medical home to optimize multidisciplinary team care by increasing efficiencies and opportunities for team work. This site provides centralized access to health promotion education, including partnering with AHS Public Health to provide a Teen Health Clinic for the young people of Cochrane and offering PCN specific health education sessions such as Tobacco Cessation and Ask a Dietitian group appointments on site. Cochrane PCC has also been selected as the initial Community Hub site for the primary health care service delivery model; see Primary Health Care Service Delivery Model under Objective 3 for more details. LINKING MEMBER PHYSICIANS IN CALGARY FOOTHILLS PCN Calgary Foothills PCN uses a number of methods such as the PCN website, PCN publications, weekly , annual board of directors visits, regular liaison visits and health education events to communicate with physician members, patients and people in the catchment area to facilitate PCN objectives and access to primary care. Calgary Foothills PCN Communications The Calgary Foothills PCN website is designed to increase patient and provider knowledge of PCN services. Visits to the website increased by 15,559 visits compared to last fiscal year for a total of 97,141 visits. This fiscal year, 22% of visitors to the site used a mobile device (up from 15% last fiscal year). Over the fiscal year, two surveys were administered to gain feedback from PCN members, MDT, staff and patients regarding the CFPCN website. This information will be used to help guide redevelopment of the website in the future. Calgary Foothills PCN began rebranding in fall It aims to give the organization a warmer, more approachable feel. Physician Member Engagement Liaisons are trained facilitators who visit member physicians in their offices on a regular basis to support access to primary care programs and integration of multidisciplinary teams in the medical home. Member physicians (308 of whom have a liaison) had a total of 1,640 visits with liaisons over the fiscal year. On average, each physician met with their liaison 5.3 times (4.8 in FY 12/13). Physicians meet with a board member on an annual basis in the spring and summer (not aligned with fiscal year). This year, 83% of eligible members attended or sent a proxy for the annual general meeting. Objective 2: To provide coordinated 24 hour, 7-day-per-week management of access to appropriate primary care services 2.1 Has the PCN implemented any new strategy in the past year to provide after hours coverage (beyond 9:00 am to 5:00 pm Monday to Friday) for its practice population. Yes Annual Report sections 1 & 2 version 9.0 {PCN Name} 15

18 2.2 If the answer to Q. 2.1 is Yes, what are key achievements by the PCN in provision of coordinated 24 hour, 7-day-per-week management of access to appropriate primary care services? See ED referral strategy in Objective 4.1 Objective 3: To increase the emphasis on health promotion, disease and injury prevention, care of the medically complex patient, and care of patients with chronic disease 3.1 What are key achievements, in the past year, by the PCN in the areas of health promotion, disease and injury prevention, care of the medically complex patient, and care of patients with chronic disease? CFPCN PRIMARY HEALTH CARE SERVICE DELIVERY MODEL Calgary Foothills PCN has designed a primary health care service delivery model to meet the future demands of primary care such as the development of Family Care Clinics, the Alberta Primary Health Care Strategy, and PCN Evolution. The service delivery model is designed to align with provincial developments and support medical homes while leveraging the strengths of the PCN. The model consists of two features, a service delivery structure and team-based care components. The service delivery structure is best described as a hub and spoke structure. There are three levels in the hub and spoke structure: the Medical Home, the Community Hub, and the PCN Neighbourhood. A key feature of the service delivery structure is expanding circles of team-based care surrounding the patient with a Core Team, Enhanced Team and Extended team. Care is integrated between levels through defined roles, responsibilities and care pathways. Care is also supported with information flow between levels as appropriate and always back to the Medical Home. The Cochrane Primary Care Centre has been identified as the initial Community Hub site, to be implemented in fall Figure: Primary Health Care Service Delivery Model Annual Report sections 1 & 2 version 9.0 {PCN Name} 16

19 POPULATION HEALTH UNDERSTANDING THE PCN POPULATION Health Quality Council of Alberta (HQCA) PCN Patients In March 2014, HQCA released the report Primary Healthcare Measurement Initiative, their analysis of administrative data to understand the impact of primary care networks on Alberta s healthcare system. HQCA determined that: 1) Physician attachment substantially impacts healthcare service resource utilization. Overall, patients who consistently see the same family physician over a period of time utilize less acute care services (emergency department visits and hospitalizations). 2) Acute care services decreased in most patient populations after the patients involvement with a PCN, while visits to family physicians increased. 3) Conclusions about the performance of individual PCNs should not be drawn based only on a comparison of healthcare service utilization of their patients. There are differences between PCNs that cannot be controlled and accounted for with the currently available province-wide data. 4) Conclusions about the impact of PCNs should not be drawn based on a comparison of PCN and non-pcn patients. These two populations differ substantially on characteristics known to influence utilization of healthcare services: age, gender, burden of illness and physician attachment. They conclude that province-wide data is currently insufficient to effectively measure the overall performance and quality of primary healthcare in Alberta. In 2013, Calgary Foothills PCN received a report from HQCA on the demographics, health status and health system utilization of its panel, with comparisons to the Calgary Zone and the province. These outcomes are based on data from the fiscal year Annual Report sections 1 & 2 version 9.0 {PCN Name} 17

20 In general, patients attached to Calgary Foothills PCN physicians are very similar to those within the Zone and Alberta. Calgary Foothills PCN patients are slightly older and more female, are more highly attached to a physician and business arrangement (e.g. clinic), have slightly more hypertension, and have slightly more visits per year with specialists; they are less healthy by clinical risk group, and they have slightly fewer visits to the ER in general and for GPsensitive conditions. Table: CFPCN patient characteristics (HQCA, administrative data) Indicator CFPCN Calgary Zone Alberta % Female 53% 52% 50% % Aged years 51% 47% 46% % in Clinical Risk Group #1 Healthy - no major conditions 47% 48% 52% Mean degree of attachment to a physician 69% 64% 57% Mean degree of attachment to a business arrangement 73% 69% 62% Percent with hypertension 14% 13% 13% Percent with diabetes 5% 5% 5% Percent with depressive and/or other psychoses 7% 7% 7% Percent with acute stress and anxiety diagnoses 4% 4% 4% Average visits per year with GP (This number has steadily increased since ) 4.8 (4.3 in 07-08) 4.9 (4.3 in 07-08) 4.6 (3.9 in 07-08) Average visits per year with specialists Average visits per year in ER Average visits per year to ER that are for GP Sensitive Conditions HQCA also provided information about where Calgary Foothills PCN patients live and the local catchment area population, based on data from the 2011/12 fiscal year: Calgary Foothills PCN has 323,798 patients. Of these, 64% live in the 13 postal codes which make up the catchment area. 36% of CFPCN patients live outside the catchment area. 359,358 people live in the catchment area. Of this total population, 57% are attached to Calgary Foothills PCN physicians. 43% of the people who live in this area do not have a Calgary Foothills PCN physician. Calgary Foothills PCN is working further with HQCA to better understand this population and its needs. Unattached Patient Registry Calgary Foothills PCN uses the Unattached Patient Registry to increase the understanding of the unattached patient population in the Calgary Foothills PCN catchment area. The PCN plans to use this information to guide program development. 62% of registrants were female. When asked how they heard about the service, 44% of registrants reported they learned about it through an internet search (37% in FY 12/13), 13% had learned about it at a clinic (17% in FY 12/13), and 14% had heard through Health Link Annual Report sections 1 & 2 version 9.0 {PCN Name} 18

21 33% of registrants had been without a family physician for two years or more (35% in FY 12/13); 30% had gone without for less than six months (31% in FY 12/13). When asked why they did not have a family physician, the top three reasons given are: new to the area (39%), physician either moved, closed practice or retired (23%) and couldn t find a physician (14%). The most common issues are: anxiety (14%), depression (11%) and high blood pressure (9%). This marks a shift from FY 12/13 when the most common problems were sleep issues, anxiety and depression. HEALTH PROMOTION IN THE PCN Seniors Outreach This initiative seeks to educate seniors in the community about health topics through events held in the Calgary Foothills PCN catchment area. Over the fiscal year, five events have been held, presented by multidisciplinary team members (dietitian, occupational therapist, social work) and Heart and Stroke foundation representatives. Topics covered community resources, healthy eating, aids to daily living and preventing heart attack and stroke. A total of 103 participants attended the five presentations. Participant evaluations indicate that the presentations were well-received, and made attendees more aware of health risks and available resources. The PCN is connecting with community group leaders (e.g. at community associations and church groups) to explore challenges when reaching out to this population. Ask a Dietitian Calgary Foothills PCN increased access to dietitians through the Ask a Dietitian program. Ask a Dietitian is a group appointment for the patient with general nutrition questions. Patients may be referred by member physicians or patients may self-refer to the appointment. 95 people attended an Ask a Dietitian group appointment this fiscal year (a 6% increase from FY 12/13). The most common reasons for coming to the group appointment were weight loss/management, healthy eating, and high cholesterol. The majority of participants (93%; 92% in FY 12/13) found their understanding of healthy eating improved by taking the class, 91% (94% in FY 12/13) were confident they could set goals, and 89% (92% in FY 12/13) felt they could make changes around their eating/nutrition. TrymGym Calgary Foothills PCN works in partnership with the University of Calgary to offer an accredited weight management program called TrymGym. The program runs twice per semester for eight weeks and consists of three parts: a behavioural change component, nutritional education and a physical activity program with optional pre and post measurements taken during each session. Six separate sessions were held over the fiscal year. Results from the optional measurements indicate the program helps participants take an active role in their own health Annual Report sections 1 & 2 version 9.0 {PCN Name} 19

22 A total of 187 people participated in TrymGym (a 2.2% increase from FY 12/13); of which 126 were Calgary Foothills PCN patients (same in FY 12/13). PCN participants are asked to complete a survey following their TrymGym session (n=62). 52% rated their physicians recommendation as a high influence on their decision to attend (66% in FY 12/13), and 72% rated the $200 discount as a high influence (84% in FY 12/13). 60% heard about the program through Calgary Foothills PCN (physician, MDT, CFPCN advertisement, website) (63% in FY 12/13). The following table outlines changes in participant outcomes for weight, BMI, Sit and reach, 6- min walk, and waist circumference, for the six sessions of TrymGym held between April 1, 2013 and March 31, Table: Changes in participant outcomes % Increase/Decrease Weight (kg) BMI Sit and 6 min Waist Reach (cm) walk (m) Circumference (cm) Total (n=187) -2.3% -2.1% 16.7% 8.2% -2.9% Tobacco Cessation Calgary Foothills PCN offers a comprehensive program, four classes per session, which includes education, group support and access to medications for people interested in tobacco cessation. Calgary Foothills PCN then follows up with participants at one week, two weeks, one month, three months, six months and one year to offer support and track their cessation progress. Evaluation of the program consists of the self-reported data from patient referral to the last follow-up period (attendance to at least one class triggers the follow-up calls). Patients reached at each follow-up period were not mutually exclusive; some patients were only reached once, while others were reached in more than one follow-up period. Therefore, results are susceptible to bias and must be interpreted with caution. Referrals have declined by 11% since the previous fiscal year, as has attendance in the first class by 25%. The PCN is working on a communication strategy and exploring the characteristics of this tobacco-using population. Quit rates are comparable to the last fiscal year; 50% self-reported quitting at the 3-month follow-up (37% in FY 12/13) and 28% reported reduced use (34% in FY 12/13). Table: Tobacco Cessation program patient referrals, 1st class attendance and followups contacted 13/14 12/13 11/12 Referrals st class registered 110 (31%) 239 (61%) 346 (46%) Decline registration 240 (69%) 151 (39%) 407 (54%) 1 st class attended 97 (88%) 121 (51%) 270 (78%) 1 month follow up calls Reached 32 (34%) 62 (36%) 100 (40%) 3 month follow up calls Reached 36 (37%) 83 (44%) 94 (37%) 6 month follow up calls Reached 36 (34%)* 80 (39%)* 89 (34%)* 12 month follow up calls Reached 42 (31%)* 99 (38%)* 126 (39%)* Annual Report sections 1 & 2 version 9.0 {PCN Name} 20

23 Notes: 1) *Denotes program activity during the current fiscal year, but follow-up calls may be from referrals in previous fiscal year. 2) Percentage is of participants reached for a follow-up call. Table: Tobacco Cessation participant quit rates over time 1 Month Follow up 3 Month Follow up 13/14 (n=32) 12/13 (n=62) 13/14 (n=36) 12/13 (n=83) 6 Month Follow up 13/14 (n=36) 12/13 (n=80) 12 Month Follow up 13/14 (n=42) 12/13 (n=99) Quit 31% 35% 50% 37% 39% 31% 40% 31% Reduced use 44% 47% 28% 34% 33% 28% 36% 16% No change 25% 18% 22% 29% 28% 41% 24% 53% Notes: Percentage is of participants reached for a follow-up call. Walking Program Calgary Foothills PCN operates a peer led Walking program that seeks to promote healthy lifestyles and active living within a safe and social environment. Approximately 30 participants walk regularly either at Northhill Mall, or at Confederation Park. There are 226 registered participants, 12 of whom were newly registered in 2013/14 (5% increase from FY 12/13). Walk with a Doc Calgary Foothills PCN has licensed the Walk with a Doc program, which was piloted in spring of 2012 and formally launched to occur once per month beginning in March, Up to 20 registered walkers are invited to attend Walk with a Doc where a PCN physician provides a minute talk on a health related topic and then walks with the participants. During the fiscal year, 10 sessions were held, attended by a total of 119 walkers. Enhanced Participation in Cancer Screening (EPICS) This fiscal year Calgary Foothills PCN has been an active partner in implementing EPICS II. Alberta has low screening rates for cancer (breast cancer 55%, cervical cancer 65% and colorectal cancer ~60%). EPICS II set out to improve cancer screening rates through two approaches; panel linkages and process redesign. Whilst longer term data is required to accurately assess the impact of this program, there is some initial evidence that cancer screening uptake has increased within the study population Annual Report sections 1 & 2 version 9.0 {PCN Name} 21

24 The chart below shows percentage of patient records with documented cancer screening status before and after process redesign with repeated measures at 9 and 12 months sampling 50 patient records. Craving Change TM Craving Change TM started in October It is a free, four-class workshop for adults who struggle with their choices around eating. The workshop focuses on helping patients determine why they eat the way they do and learn new ways of thinking and behaving to develop a healthier relationship with food. Craving Change TM is open to patients who are at least 18 years old and who are attached to a member physician. This program is offered at two different locations, Crowfoot and Riley Park Primary Care Centres. 6 series of classes have been held 67 people registered; 88% of registrants attended the first class and, of those, 73% attended the final class. Feedback from participants (n=45) indicates that the classes are very well-received. Respondents found the information is useful for daily life (98% agree), and the class taught them something new about their choices around eating (100% agree). Participants also complete the Eating Self-Efficacy Scale questionnaire at their first session, at the end of the class, and again in 6 months time. Self-efficacy describes confidence in coping ability in a specific situation. Patients self-rate their self-efficacy on a scale of 1-7 for a variety of situations (high scores indicate poor eating self-efficacy). Data is currently available for the baseline and 4-week measures. 40 participants completed the survey at both baseline and 4 weeks. 75% had an improvement in their self-efficacy score. The table below shows that following the four-week class, average self-efficacy scores decreased. The biggest improvement is for self-efficacy related to negative affect (problematic eating when experiencing negative emotions). Table: Change in eating self-efficacy for Craving Change patients Baseline (n=59) 4 Weeks (n=45) Negative Affect Socially Acceptable Circumstances Overall score Annual Report sections 1 & 2 version 9.0 {PCN Name} 22