Dietitians of Canada (Ontario) Comments on Patients First Discussion Paper February 2016 Dietitians of Canada, the professional association for Registered Dietitians in Ontario, welcomes the opportunity to provide feedback on the Patients First discussion paper. Our feedback reflects the input of our members working across the health system. We have structured our submission to respond to the questions posed in the discussion paper, however a few questions were omitted where we did not feel we had sufficient feedback to provide. While the scope of the discussion paper and questions generate high-level conceptual responses, much of the success of health system transformation will come from the details of implementation. We look forward to being engaged in discussions to provide input on effective and cost-effective deployment of nutrition professionals in the health system. More Effective Integration of Services and Greater Equity How do we support care providers in a more integrated care environment? Provide education on role and scope of all health professionals and providers. Ensure a variety of health professionals are represented in leadership roles. Create opportunities for health care providers to meet across settings. One successful example of this occurs in Hamilton with the creation of the Pediatric Nutrition Network and Diabetes Collaboratives bringing together RDs from a variety of settings in primary care (eg. FHT s, CHC s, PH, LTC, academia, hospital) for care coordination and creation of new care pathways. Dietitians of Canada. 2016. All rights reserved. DIETITIANS OF CANADA I PAGE 1 www.dietitians.ca I www.dietetistes.ca
What do LHINs need to succeed in their expanded role? Effective communication systems including accessible EMRs for the entire system Appropriate legislation/regulation support to enable healthcare providers to work to full scope of practice and clinical practice guidelines, as well as clear accountability mechanisms Broad-based clinician and public engagement with clear requirements for use of feedback Clarity on the role of specific initiatives such as the Special Needs Strategy or other provincial initiatives that overlap with services provided within LHINs Leadership/governance structure has good representation from various sectors and various disciplines to provide for a variety of opinions and perspectives on the health system Representation from patients and patient advocates or representatives. How do we strengthen consistency and standardization of services while being responsive to local needs? Support development of consistent service standards and outcome measurements across the province, developed with interprofessional and inter-sectoral input and current evidence where available What other opportunities for bundling or integrating funding between hospitals, community care, primary care and possibly other sectors should be explored? Funding for specialized expertise should be flexible to follow the patient, for example dietitian expertise in pediatric tube feeding should be accessible throughout acute care, homecare, primary care. Integration of telehealth services to increase access and assist in system navigation. For example EatRight Ontario maintains a database of nutrition services and community programs to link providers and clients. What areas of performance should be highlighted through public reporting to drive improvement in the system? Patient and caregiver satisfaction (if validated and reliable satisfaction surveys are used) Population health measures such as rates of non-communicable diseases Access and wait times for all types of services, including interprofessional health team members Should LHINs be renamed? If so, what should they be called? Should their boundaries be redrawn? Boundaries are mainly of concern when considering closer linkages with Public Health Units, in order to provide consistency in service areas. DIETITIANS OF CANADA I PAGE 2
Timely Access to Primary Care, and Seamless Links Between Primary Care and Other Services How can we effectively identify, engage and support primary care clinician leaders? Expand perspective to consider non-physician health care providers as primary care clinician leaders; emphasizing ability to implement team-based care and outcome measurement activities. Create clinician leadership dyads or triads including health professionals from various disciplines, experience and perspectives. Acknowledge that primary care clinician leaders and the rest of the interprofessional team require time to effectively communicate and build the trust and rapport that underpins effective integrated care. What is most important for Ontarians when it comes to primary care? Using a patient/client-centred approach requires that this question be posed to the clients/patients on a regular basis to capture evolving attitudes and experiences with the primary care system. From our perspective, Ontarians prioritize receiving the right care from the right provider at the right time. Implementing this approach in practice becomes more complex as patients are not always able to identify the care or provider that would best meet their needs for a particular health issue, and a referral-based system with most patients access beginning with physician or NP creates additional delays and potential for missed opportunities (e.g. no referral to the appropriate professional is provided). In addition to providing nutrition counseling services for patients referred by our teams, RDs are spearheading initiatives to help their teams identify vulnerable populations at nutritional risk and future health decline by a) embedding nutrition screening programs into primary care, identifying nutrition risk factors early for more timely intervention, linking patients with appropriate supports whether that s a quick phone call in office or home visit, b) providing consultation to their teams for complex patients, for example a malnourished senior with dementia, the young adult with bipolar disorder and nutritional deficiencies, or the patient with diabetes, dyslipidemia, hypertension and irritable bowel syndrome with a limited food budget c) offering innovative patient driven group education such as group medical visits d) connecting with patients via personal health records in their EMR s e) offering evening clinics and groups f) encouraging patients to access RD via EatRight Ontario Our goal is to ensure that all Ontarians have the opportunity and are encouraged to meet with a RD for individualized or group nutrition counseling to improve their health outcomes (to reduce risk or manage a chronic disease, or support recovery from episodic care), dispel nutrition misinformation and improve their quality of life. Currently in FHT s or CHC s, there is only 1 RD: 15,000-30,000 patients so most Ontarians will not have the opportunity to meet with a dietitian through the current primary care system. DIETITIANS OF CANADA I PAGE 3
How can we support primary care providers in navigating and linking with other parts of the system? Accessible and inter-operable electronic medical records will help to improve linkages across sectors of the health system, sharing patient information and tracking diagnostics, interventions, and outcomes. Time and support for integration and communication activities are required; navigation and communication can be time-consuming activities that will impact upon clinician workload. Workload measurement systems and indicators that do not take this into account may show negative impacts on clinician productivity, however the outcomes for the patient and the system are improved. Dietitians of Canada s Ontario Primary Health Care Action Group are working together to bring RDs together across primary care to build partnerships and create care pathways to synergize nutrition services across the spectrum of primary care from family practice (FHT s and CHC s) to public health, long term care and home care as well as provide RDs with effective tools and resources based on best practices. Meeting and learning about current services with discussions to improve services are a key part of streamlining services across the LHIN s. Time, support, and leadership are needed for this strategy. Another current example is the Hamilton Pediatric Nutrition Network which brings together RDs, NP s, MD s across health settings FHT s, CHC s, PH, hospital, home care and academia to focus on key pediatric issues and coordinate care services in the city. How should data collected from patients about their primary care experience be used? What data and information should be collected and publicly reported? A variety of methods should be used to collect data, to ensure broad representation. Some examples include: o Ongoing feedback gathered via websites, o IPads/kiosks in waiting rooms, o Hard copy evaluations distributed at time of visit and/or at regular intervals via mail Examples of data elements that should be collected: o Satisfaction with timely access to all care providers o What would they change if they could to make the experience more effective, more rewarding? o Did the service make a difference to: lifestyle behaviours such as healthy dietary intake, daily physical activity, moderate alcohol intake, less smoking, managing stress health outcomes such as A1c, BP, LDL, malnutrition, falls, anemia, obesity, disease prevention patient self-efficacy, DIETITIANS OF CANADA I PAGE 4
More Consistent and Accessible Home and Community Care How can home care delivery be more effective and consistent? A clear definition of home and community care is needed along with homecare services provided through CCACs, some primary care settings are doing home visits with their patients who struggle to come into the clinic (e.g. frail elderly, palliative care, and individuals with mental health conditions). Communication is needed to discuss who is involved in care in the home and how to coordinate. The current homecare system administered through CCAC s needs to broaden the lens to include health promotion and restorative care The need for multiple assessments by different providers would be decreased by having common record and sharing information across sectors and disciplines Interprofessional teams concept is not fully practiced in today s homecare system despite evidence that supports positive outcomes Equitable access to services both within LHIN/sub-LHIN boundaries and across the province must be considered, including the role of MOHLTC in setting provincial standards and common levels of service framework Evidence-based standards and carepaths are important however it must be recognized that there has not been sufficient focus on generating evidence of effectiveness for service utilization of professions such as nutrition services provided by RDs. For example, measuring outcomes for effectiveness of nutrition services should be based on studies that allow sufficient RD services to evaluate. Professional judgment (with accountability) is needed in determining length, timing, and frequency of visits, rather than having care coordinator make decisions based only on budget without input from clinicians. How can home care be better integrated with primary care and acute care while not creating an additional layer of bureaucracy? Enabling care coordination and system navigation could be supported through inter-operable EMRs that allow relevant patient information to be shared with the full healthcare team across settings. Comprehensive care pathways need to be developed to identify each sector s role/contribution and indicators for discharge to family practice Further investigation should be conducted on the outcomes of funding and health professionals following the client throughout the continuum of care. The Special Needs Strategy is introducing this approach to create fewer transitions for children, and evaluation of the concept can provide input for the adult population. Currently, transitions from hospital to home are unsatisfactory to many patients and professions; there is distrust between some community and hospital providers due to situations where referral to therapist doesn t happen in homecare DIETITIANS OF CANADA I PAGE 5
even though it was agreed to and part of discharge plan. Care Coordinators need to be allowed to be effective in meeting client needs regardless of the setting in which they are based. Care coordinators should be responsible for whole system coordination, e.g. wrapping a care team around the client across all settings. Further evaluation of the Health Links model should be performed to identify outcomes for different population/care groups and best practices for consistent implementation across the system. How can we bring the focus on quality into clients homes? Enabling professionals and teams to focus on specific types of patients helps build expertise The current CCAC market share approach doesn t always work well in building effective teams or expertise; due to small volumes of service, it is difficult for therapists to specialize in the current environment In a truly integrated system, services could be organized around population needs, leading to quality improvement Clarity and transparency of quality definition is needed, including what clients value and how to measure it accurately; the current quality of care survey system has many limitations, particularly for the smaller professions as the volume of survey responses makes it impossible to determine significant findings An example of an Ontario program that has enhanced quality is the Tapestry study (McMaster University), that uses an interprofessional team as well as community volunteers to meet with seniors in their homes to discuss health concerns and screen for 5 key areas (Falls, frailty, nutrition/malnutrition risk, cognitive functioning) with the hopes of identifying issues early before a decline in health or trip to the emergency room. Screening tools are sent via EMR back to MRP and health care team and referred to appropriate interprofessional team members as indicated for further assessment and a care plan if indicated. The program has demonstrated effective use of resources often requiring brief education/advice either on the phone or in person or in a home visit, leading to dramatic increase in patient confidence and satisfaction with care. Stronger Links Between Public Health and Other Health Services How can public health be better integrated with the rest of the health system? It is noted that the discussion document is titled Patients First which implies a focus on the care system and lower priority given to population health, health promotion, and public health Public health should be linked with health promotion strategies in PHC settings to avoid duplication and ensure all vulnerable populations are served, using a health equity lens in planning and evaluation. Overall population health planning for a geographic area is needed to link all the healthcare settings with the volunteer, charity, and nonprofit organizations providing prevention services in the area. DIETITIANS OF CANADA I PAGE 6
Integrating a preventative model into the primary contact point helps get upstream prevention messaging integrated into the care system and helps merge chronic disease management with prevention of further chronic disease, including mental health issues. An example of integration is the Dietitians of Canada Ontario PHC action group which brings together RDs across settings (FHT s, CHC s, Public Health, LTC, academia, industry) for the purpose of coordinating nutrition services across primary care with a focus on disease prevention and earlier identification of nutrition issues and more timely intervention. Currently we are focusing embedding nutrition screening programs into primary care to identify feeding issues early in our most vulnerable populations: young (eg. Nutri-STEPS), expectant mothers (eg. Prenatal Nutrition Screening) and older adults (eg. Nutri-escreen). Family Health Team RD s are also working in partnership with public health units, physician groups and researchers to advocate for the addition of the validated Nutri- STEPS, screening tool into the Rourke well baby visit screening system used in family practice across the province. For the 18-month well baby visit, some FHT s have parents complete the Nutri-STEP tool on a tablet in the waiting room and integrated in the EMR which can generate a summary and a printable handout based on the answers. If additional support is needed, parent (and child) are referred to the RD for further assessment and education. For a sustainable health care system, disease prevention initiatives are key to healthier populations and lower health care costs. Current evidence strongly identifies a healthy diet as one of the five key risk factors for chronic disease (prevention and management) and nutrition counseling is identified in numerous Clinical Practice Guidelines as the recommended treatment to prevent diabetes, child obesity and malnutrition. Integration can also identify supports for caregivers/family in navigation of system and primary prevention to help them avoid their own health decline. Issues to consider in public health integration: Differences in boundaries and service areas (e.g. Public Health aligned with municipalities and school boards, LHINs have different boundaries) Funding relationships (e.g. PHAC funding direct to PHUs for some programs) Equity within a LHIN particularly for those LHINs with more than one PHU PHU s ability to advocate for healthy public policy could be compromised by a change in reporting/funding relationship Accountabilities for prevention and promotion outcomes not clearly defined which may impact funding decisions Need to mitigate potential that public health resources will be diverted to the health care system LHIN boards should have public health representation DIETITIANS OF CANADA I PAGE 7
System Governance In addition to: Clear and meaningful accountability relationships Strengthened transparent performance measurement Expanded boards and leadership Alignment with the Ministry s objectives to ensure accountability and equity Definition of LHIN activities and performance plans supported and enforced by the MOHLTC Measures to enhance accountability to MOHLTC, what other tools are needed for effective governance? Ensure that each sector of care (FHT s, CHC s, public health, home care, hospitals, academia, LTC) has representation and are invited to participate in LHIN meetings and care planning decisions. Encourage leadership/representation from all health professionals. Many allied health or interprofessional health professionals are taking leadership roles on many quality improvement initiatives in various sectors and have a vast knowledge of behavioural change and quality improvement experience to contribute to the conversations about how care can be re-created within communities. Changes to Legislation Ensure that all providers are able to work to their full scope of practice to provide seamless and integrated care. Ensure systems are in place (eg. beyond medical directives) to allow appropriate providers to provide care based on best practices and current evidence. For example, implementation of the authorization for RDs to order appropriate laboratory tests (bloodwork) as part of their comprehensive nutrition assessment and evaluation, as passed in 2009 in Bill 179. In the Public Hospitals Act, regulation changes to enable RDs to order therapeutic diets and enteral/parenteral nutrition based on comprehensive nutrition assessment. DIETITIANS OF CANADA I PAGE 8
For further information: Linda Dietrich, M.Ed., RD Leslie Whittington-Carter, MHS, RD Regional Executive Director Ontario Government Relations Coordinator Dietitians of Canada Dietitians of Canada 480 University Avenue, Suite 604 27387 Talbot Line Toronto, Ontario M5G 1V2 Wallacetown, ON N0L 2M0 Tel: 905-471-7314 Tel. 519-494-3282 E-mail: linda.dietrich@dietitians.ca E-mail: leslie.whittingtoncarter@dietitians.ca DIETITIANS OF CANADA I PAGE 9