South Okanagan Similkameen (SOS)

Shared Care Committee

Improving Connections and Communications

Between Specialists, Family Physicians and

Patients

PRESENTERSDeanne Neufeld, BSW, MSW, RSW, RPC

SOS Shared Care Coordinator

Harriet Rogan, RN, MA

Patient Voices Network Rep

Shared Care

Formed in 2006

• To support the collaboration of FPs and SPs

• To improve health outcomes and patient journey through the health care system.

AIM: Improve coordination of patient care between FPs and SPs by ensuring:

• Primary care is delivered and managed by FPs

• Ready access to SP advice and support,

• Enabling FPs to more effectively meet their patients’ primary care needs.

• By reducing the primary care currently handled in their offices, SPs are able to focus on diagnosis and treatment of more complex and complicated conditions and can be more accessible and responsive to their FP colleagues.

Shared Care Shared Care initiatives are enabling both FPs and SPs to focus

on their particular areas of expertise and deliver the care their patients need in the right place at the right time through:

• Fewer inappropriate referrals.

• Improved patient preparedness for appointments and tests.

• Improved physician-patient communication.

• Increased access to specialist care.

• Advice and consulting services between SP and FP colleagues.

• Shared treatment plans and follow-up requirements between SP and FP colleagues.

Instilling confidence and self empowerment in the patient

PARTNERSHIP

COLLABORATION

Patient Focus Group – January 2012

SUPPORTING RESEARCH

Increased health outcomes (IHI)

Patients are part of the care team at every level (delivery design, measurement, assessment,

improvements and education)

Supports care and healing

Instills confidence and self empowerment

Patients on Advisory Committees

PDSA CYCLE

Harriet hard at work at our patient focus group

PROCESS MAPPING Referral Process

Areas of Improvement

Improve patient care & patient experience

Communication & Information Flow between

FP/SP and Patients

Areas of Improvement

Role Confusion

Who do patients go to for what?

Continuity of care

Medication renewals

AIM OF INITIATIVE

Aim of QI Initiative

To Improve

Engagement of Physicians/Patients & PVN/IHA/Community

Co-management guidelines

Seamless care

Information flow

Keeping patient in the loop

Aim of QI Initiative cont.

Assist patient in understanding:

Roles/Responsibilities

Limits/scope of each FP/SP/IHC

Educational opportunities

Preparing for an office visit

Self-management tools

Improvement Tools

Patients involvement in trialing of new tools

Providing avenue for patients to engage:

Patient Medication Bag

Personal Health Record (University of Victoria -

Center on Aging)

Appointment Card

Referral Acknowledgement

Actions Taken

Patient Focus Group Contributions on: Appointment card

Trial of PHR Booklet – feedback to improve

Preparing for office visits

How best to share lessons learned to:

o Community

o Family doctors

o Specialists

Community Engagement

Attendance at future Health Fairs

Data Collection Methods

Patient Focus Group - Feedback

Surveys

Tracking form (excel spread sheets -

MOAs, Physicians)

Patients involved in PDSA cycles

eg. Personal Health Record trials

Projected Outcomes

1. Patient Satisfaction/Confidence with experience of co-managed care

continuity of care between FP/SP

improved convenience

patient knowledge of their role in co-managed care

increased role of patient in self-managed care

Projected Outcomes – Con’t

2. Process Improvements:

referrals/ re-referrals, consultation, medications, shared care plans, continuing care, advanced care planning and end of life planning

3. Improved Communication:

timeliness and appropriate transfer of information between FP/SP

4. Family Physicians and Specialists will report improved role clarity in the provision of coordinated care

decrease in duplication of tests

decrease in wait times to see Specialist

Overall Impact

Include the

patient voice

in the

Project Re-design

BURNING QUESTIONS

For more information