Family Medicine Update April 2015 Council of Ontario Faculties of Medicine Apr i l 2015
Family Medicine Update April 2015 Interest in Family Medicine as a Career Continues to Grow In the early 2000s, Ontario universities and the Ontario government partnered on a number of initiatives to improve medical student interest in family medicine as a career choice. These initiatives, along with provincial primary care reform, have resulted in a dramatic improvement in the number of medical students going into family medicine. Percent Canadian Medical School Graduates (CMGs) who Ranked Family Medicine as 1st Choice in the CaRMS Match Percent Family Medicine Positions Filled in Canada by Canadian Medical School Graduates (CMGs) in the 1st Iteration of the CaRMS Match Source: Canadian Resident Matching Service (CaRMS) Source: CaRMS Communities Help Train Then Recruit Family Physicians In the mid-2000s, Ontario universities and the Ontario government began expanding family medicine programs to increase the number of family physician graduates. Today, more than 500 family physicians graduate each year, up from 200 in 2003. Family medicine training is largely community based. More than 155 communities across Ontario partner with the university family medicine programs to train family doctors. The communities engaged in this training are able to actively recruit physicians, particularly those providing comprehensive care, who meet their own community s need for family physicians. Recent studies of the impact of family medicine programs on communities indicate: At McMaster University, a number of trainees, having lived in the region of their local academic hub for two years, continue not only to seek employment within Page 1 of 9
the region, but to stay and raise their families and have an impact on the community itself. Recruitment ranges from 50-60% in many areas across the twelve sites (Hamilton, Brampton, Niagara, Halton, Kitchener, Grand Erie Six Nations, Simcoe, Fergus,Mt. Forest, Grimsby, Collingwood and Owen Sound). This is especially important as many current family physicians begin to look for new graduates to take over their practices as they make plans to retire. The scope of practice undertaken by these residents includes general practice, hospital medicine, student health, sports medicine, emergency medicine, community health centres, anaesthesia, obstetrics and care of the elderly. The Northern Ontario School of Medicine s (NOSM) social accountability mandate includes a commitment to graduate health professionals who are able to provide culturally competent, responsive health care for all Northern Ontarians. Data gathered on 2013-14 residency program graduates (predominantly family medicine) show that 69% of NOSM physician graduates are currently practicing within communities in Northern Ontario. Twenty-two percent of these communities are rural according to the Rurality Index, Ontario. When considering physician graduates who also completed their medical degree at NOSM the percentage of graduates practicing within communities in Northern Ontario increases to 94% and the percentage of rural practices increases to 33%. Percentage of NOSM PGE Graduates Practicing, by Geographic Location (Weighted), Dec 2013 The University of Ottawa has established family medicine teaching sites in Pembroke and Winchester, Ontario. The Pembroke site opened in 2008 and, to date, has graduated 10 family physicians, eight of whom continue to work in Renfrew county. The Winchester site opened more recently and takes two residents a year. One of the current residents is from the Cornwall area and intends to work there when she completes her training this year. Page 2 of 9
In early 2014, the Society of Rural Physicians of Canada (SRPC) presented its Keith Award to Queen s University. The award is presented to a Canadian postgraduate family medicine program that has excelled in producing rural doctors. The SRPC looks at the largest number of graduates in rural practices across the country 10 years after graduation, as identified via the Canadian Post-MD Education Registry (CAPER) with practice location taken from the Canadian Medical Association (CMA) database. This marks the second time Queen s University has received this award since it was introduced in 2000: it received the award in 2009 and placed second in 2013. Queen s University s graduates at each of its four expansion sites (Kingston, Belleville, Peterborough and Oshawa) have set up practice around their home site community. The University of Toronto has established new family medicine training sites in Barrie, Markham, Mississauga (2) and Newmarket. Each site graduates about nine family physicians per year, many of whom are recruited to work in the community. For example, the Royal Victoria Regional Health Centre (RVH) in Barrie launched its Family Medicine Teaching Unit in 2009. To date, this site has graduated 28 family medicine residents, with 18 of them staying in the area to set up their own practices or work in the health centre s emergency and hospitalist departments. At Western University, 60.1% of family medicine graduates are practising in southwestern Ontario, 69.8% of these graduates are practising in rural settings, and 77% describe themselves as comprehensive family practitioners, providing a range of services including office-based care, hospital care, house calls, afterhours care, nursing homes, and minor surgery. Eleven percent of graduates are providing family medicine obstetrical care in their practices, including intrapartum care. Over the course of the last 10 years the percentage of unattached patients in the Erie St. Clair and Southwest Local Health Integration Networks has decreased from approximately 20% to approximately 5% largely through changes in primary care delivery and in the recruitment and retention of family physicians. Most of the new family physicians in this area are graduates from Western University s family medicine program. The College of Family Physicians of Canada (CFPC) is conducting a national evaluation to collect information from learners and residency programs to determine the role that competency-based education has in influencing the type of family physicians produced, their type of practice patterns, and their location of practice. Pilot data has been collected from seven schools and all 17 Canadian medical schools will participate in 2015. Early results indicate that exposure in residency to comprehensive care, across the domains of family medicine, results in an increase in likelihood to practice in these domains, e.g., practice in rural locations. (Note: the study recognizes that there are many external factors that affect a resident s choice of practice after graduation; no definitive correlation has yet been established between competency-based curriculum and residents choice of practice.) Page 3 of 9
University Family Medicine Programs Provide System Leadership in Care Integration and Quality Improvement, Placing a Focus on Patients at the Center of Care Through education and research, Ontario family medicine programs are helping to propel primary care reform and the government s transformation agenda, including initiatives such as Health Care Connect and Health Links. Our family medicine residents and medical students are educated in an environment of ongoing innovation, training alongside our faculty who are actively engaged in primary care renewal and health system integration. The following are examples of some of the innovative university family medicine initiatives that are improving care of Ontarians and graduating new system leaders. McMaster University Fostering Optimal Aging through an Interprofessional Primary Care Approach TAPESTRY (Teams Advancing Patient Experience: STRengthening quality) is an innovative, federally and provincially funded program to foster optimal aging using an interprofessional primary health care team-delivery approach that centers on meeting a person s health goals with the support of four main elements: Using trained community volunteers who will visit patients in the home, build a social connection and collect relevant information on personal health goals and on key themes around healthy aging, such as nutritional status, fitness levels, functional independence and social connectedness; Integration of a personal health record including a specialized TAPESTRY Application into patients personal healthcare management; Adapted roles, activities and communication of the interprofessional primary healthcare team; Improved navigation of the health care system including improved linkages between primary health care, acute care and social services as well as improved engagement and mobilization of other relevant community organizations. Early identification of problems such as nutritional deficiencies, inactivity, polypharmacy and social isolation will come from a proactive approach to care, one that allows patients, their families and their health care providers to make changes before a crisis arises. Through the Department s McMaster Personal Health Record (PHR), patients will be able to meaningfully connect their full circle of care, related health information and self-management activities in support of improved and sustained health and wellness. Infant and Child Health Lab (INCH Lab) The INCH Lab is a ground-breaking, innovative research model that creates new knowledge in early child development that will be used to develop tangible and transformative interventions to improve children s physical and mental health. Page 4 of 9
Integrating McMaster learners, faculty, community-based and health care partners, and the public, the INCH Lab leads research that has direct implications for ensuring children receive proper care and attention to optimize their development. INCH s research has been the first of its kind for several aspects of child development. One example of this pioneering work is the Coordination and Activity Tracking in Children (CATCH) study. CATCH focuses on Developmental Coordinator Disorder (DCD), a neurodevelopmental condition that impairs everyday functioning, play and academic achievement. DCD affects 5-6% of children, which means that in every classroom across Canada, there are approximately 1-2 children with DCD. Research has shown that children with DCD are at higher risk for poor cardiovascular health and obesity-related illnesses. With the INCH Lab rooted in a family medicine program, its research is being integrated into the provincial health care system through physicians, caregivers and parents. CATCH and other INCH Lab research will help ensure the right children are targeted, at the right age, for the right reason, with the right intervention in order to improve their physical health outcomes. INCH research is contributing to the well-being of our children, and ultimately, the long-term health and well-being of populations locally, national and internationally. Northern Ontario School of Medicine Addressing Aboriginal Needs in Northern Ontario Forty-one percent of Ontario s aboriginal population lives in Northern Ontario, with the largest proportion in the Northwest. NOSM s Family Medicine Residency Program provides mandatory Indigenous Health elearning modules. In addition, the Chapleau Cree First Nation hosted NOSM s 4 th Aboriginal Community Partnership Gathering in August 2014, called "Walking the Vision." NOSM senior leaders, faculty, and staff gathered with over 100 Aboriginal community members from across Northern Ontario. NOSM has graduated approximately 25 Aboriginal medical students. Comprehensive Community Clerkships There is growing evidence nationally, and internationally, that medical students and residents places of learning and clinical training have a strong influence on their eventual place of practice. The NOSM undergraduate Year Three curriculum, known as the Comprehensive Community Clerkship (CCC), has the entire third year medical class placed in smaller Northern communities for their full clerkship. The CCC is organized so students have parallel exposure to various interprofessional disciplines and medical specialties as encountered in the context of rural family practice. At least 50% of the clerkship year is spent doing rural family practice. During their clerkship, students live and work in a community in Northern Ontario for eight months, where they acquire the necessary skills and strategies to understand and respond to the health care needs of their patients. Page 5 of 9
University of Ottawa Improving Referrals and Access to Specialty Care Improved access to specialist care and decreased wait times have occurred in the Ottawa region through the successful development and implementation of the Champlain BASE (Building Access to Specialist Care through econsultation) econsult service. Through the leadership and collaboration of family physician Clare Liddy and endocrinologist Erin Keely, this web-based service is making a difference by enabling the family doctor or nurse practitioner to submit a clinical question to a specialist who replies within seven days. By providing advice directly to the provider, a referral may be avoided or at least enhanced while the patient remains on the specialist s waitlist. The service is growing and as of Sept 30, 2014, over 4,264 econsults have been answered, most within two days. Fifty-two different specialist services are available and 518 Primary Care Providers (PCPs), representing 50% of all PCPs in our region, are registered, including 93 nurse practitioners. Patients are benefitting by timelier access to specialist advice and providers benefit through more efficient communication channels. Over 40% of cases resulted in avoidance of an unnecessary face-to- face referral and 1400 patients are no longer waiting to see a specialist. Outreach serving marginalized populations Ottawa is home to diverse and vulnerable populations. Immigrants account for approximately 24% of the population and its refugee proportion is the highest in Canada. In addition, Ottawa has a significant homeless population served by a number of shelters. The Department of Family Medicine supports these vulnerable populations through the teaching units and with a Longitudinal Global Health elective focused on inner city health. Faculty physicians and residents provide outreach to: The homeless through the Mission, New immigrants and refugees through Reception House, Unwed mothers in partnership with St. Mary s Home, and Focused clinics for HIV primary care, methadone management and sexual health. Resident physicians participating in the Local Longitudinal Experience in Global Health gain valuable service experience through outreach clinics and by accepting an immigrant family into their practice at the beginning of their residency. These experiences prepare them to continue to serve vulnerable populations in practice. Queen s University Improving Care to Socially Complex Patients Queen s Department of Family Medicine quality improvement (QI) education program provides residents with a foundation in the principles necessary for social accountability and community engagement. Specifically, the program s primary focus is the thorough Page 6 of 9
and thoughtful investigation of problems and gaps in the health-care system, with an eye towards addressing underlying causes. In addition, the program stresses the importance of improving the patients experience and leveraging the expertise of the entire interdisciplinary team (including reaching out to different departments and various sectors). The Queen s Family Health Team (QFHT) also demonstrates social accountability by accepting all unattached newly pregnant women (previously they had no family physician) into its clinic as part of its obstetrical practice. As well, QFHT has a commitment to accepting new patients, particularly patients with complex needs who struggle to find care elsewhere. Many of the QI projects focus on items such as improving access and transition points, as well as population-based prevention initiatives and chronic disease management. QFHT accepted 1,600 new patients in 2013-14 and continues to accept new patients (another 500 patients will be accepted in 2014-15). Resident Immigrant and Refugee Health Initiative The Queen s University Peterborough-Kawartha site, in collaboration with New Canadians Centre, has developed a Resident Immigrant and Refugee Health Initiative that aims to connect refugees, refugee claimants, and immigrants with significant barriers to accessing healthcare with family physicians. Presently, there are approximately 20 to 25 patients eligible to participate annually in this initiative. Under this initiative, family medicine residents from the Queen s University Peterborough-Kawartha site spend a half-day with individuals or families conducting a complete intake history and physical exam. The settlement workers at the New Canadians Centre identify individuals or families interested in participating in the initiative; participation in the project by residents is entirely voluntary. The intake history and physical take place in the office of the accepting family physician, so that the resident can input the assessment findings into the EMR and introduce the new patients to the family medicine clinic and staff. The goals of the initiative are as follows: (a) provide evidence-based, comprehensive, culturally-competent care to refugees and immigrants in the Peterborough area; (2) reduce barriers to care for immigrants and refugees by providing a clear pathway to accessing family physicians; (3) provide opportunities for residents to enhance their knowledge of issues in refugee and immigrant health care, and comfort level in conducting a comprehensive assessment for new Canadians; and (4) enhance resident exposure to multicultural patient populations. Those involved in this initiative also receive an introduction to important aspects of the Canadian healthcare system, including how to access care at the family physician s office and when to visit the emergency room. University of Toronto Integrating Primary and Community Care after Hospital Care Discharge from hospital marks a significant transition in care. Studies indicate that patients with complex medical conditions but without any personal or health care provider network are at higher risk of readmission to hospital. To reduce readmissions by providing that supportive network, the Department of Family and Community Page 7 of 9
Medicine s (DFCM) South East Toronto Family Health Team at the Toronto East General Hospital family medicine teaching unit has established a primary care virtual ward. A virtual ward applies the team-based intensified care found often on a hospital-based ward, but delivers that care virtually in the community. Patients receive up to three months of follow up care from a well-functioning team of primary care providers and hospital, community care and telemedicine partners who monitor daily symptoms, address clinical concerns immediately, and provide equipment and home visits to help patients and their caregivers make a safe transition back home after hospitalization. Patients report highly enhanced experiences compared to other encounters in the health care system. They describe increased continuity of care, and increased access to clinicians and required services. Building Bridges to Integrate Care (BRIDGES) People with complex chronic disease frequently transition between hospital, ambulatory and home care and are poorly served by systems built around single diseases and institutions. These patients account for a large proportion of health care costs, but are subject to sub-optimal care due to poor coordination and services that do not address their complex needs. The U of T Department of Medicine and Department of Family and Community Medicine support innovation and integration in health service through the project Building Bridges to Integrate Care (BRIDGES). BRIDGES aims to develop innovative models of health service delivery to reduce avoidable hospitalizations, readmissions and emergency department visits through better integration of care. The project links academics, clinicians, hospitals, FHTs, Community Care Access Centres (CCACs), LHINs and family medicine teaching practices associated with the university. Nine BRIDGES projects have been funded, including projects targeting complex elderly, frequent users with mental health and addictions problems, and solo primary care physicians whose patients frequently present to the hospital. The projects employ a variety of strategies such as case management, navigation hubs, improved service access and multidisciplinary case conferences. All models have been successfully implemented, are at varying stages of evaluation, and most have been sustained even after the completion of funding. Broad preliminary qualitative findings indicate that patients and caregivers value the care provided through the interventions and team members appreciate the opportunity to engage in interprofessional collaboration. Western University Improving Care for Patients with Chronic Disease Western s family medicine teaching centres, Victoria Family Medical Centre, Byron Family Medical Centre, and St. Joseph's Family Medical and Dental Centre are participating with the London Health Sciences Centre, and the Community Care Access Centre (CCAC) in several initiatives designed to improve care for patients with chronic diseases. One of these initiatives is the Connecting Care Collaborative, designed to strengthen the coordination of care to improve health outcomes for patients with COPD, Page 8 of 9
CHF and diabetes. This is a multi-phase project in which care mapping of patients with chronic conditions will be studied to identify gaps in the system. Creative solutions will then be sought to improve the coordination of care for these patients, many of whom are high users of the system. Another project involves mapping care for patients with COPD specifically with the goal to reduce ER visits and re-admissions. Online Resident Assessment Tool (MyFM) Western s Online Resident Assessment (MyFM) is an innovative web-based tool that allows both residents and faculty to initiate "real-time" feedback about a patient encounter involving the resident. This in-house developed tool provides both the resident and faculty mentor with the ability to have a "snapshot" of the resident's performance using graphs to track key competencies being assessed. This new assessment tool is accessible across multiple electronic platforms (tablet/ipad, PC/Mac, smartphone) and does not require installation of software or an app. MyFM allows the postgraduate program to track and monitor various metrics relating to how assessment is done and feeds into the Continuous Quality Improvement framework currently being implemented. Page 9 of 9