Home Improvements:Using the Patients Medical Home as a Guide to
Improvement Initiatives in our practice
61 Annual Scientific Assembly Alberta College of Family Physicians
Banff AlbertaMarch 2016
Dr Rob Wedel MD CCFP FCFPFamily Physician, Taber, Alberta
Faculty/Presenter Disclosure
•Faculty/Presenter: Rob Wedel
•Relationships with commercial interests:–Grants/Research Support: Not applicable–Speakers Bureau/Honoraria: Not applicable–Consulting Fees: Not applicable– Other: This presentation has received financial
support from the Alberta College of Family Physicians in the form of a speaker fee.
Objectives:• Identify the pillars of the PMH that help guide
practical QI initiatives in our practices• Discuss the physicians’ role within our clinics that
create the conditions that contribute to successful improvement initiatives
• Identify practical applications of the models, and principles of QI improvement that help us ‘know where to start”
• Examples of successful activities, along with practical, available resources will be discussed.
What we Know Works…“The Medical Home”• The greater the range of services provided by primary care clinic,
along with a family physician providing a continuous care relationship to a defined patient population had one third lower overall costs and were 19% less likely to die
• “Attachment to a practice” was more significant than all other variables, such as age.
• For most aspects of care and health outcomes, identification of a particular practitioner provides even better services than mere identification of a particular place”.
Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 2002;603:201–218The Future of Family Medicine. Annals of Family Medicine, 2004 Hollander, MJ, et al. Increasing Value for Money in the Canadian Healthcare System: New Findings on the Contribution of Primary Care Services. Healthcare Quarterly Vol.12 No.4 2009
The Patient’s Medical HomeThe Pillars
The Patients Medical HomePatients receive care that is centered on their needs from a
team that knows their story
http://www.patientsmedicalhome.ca
The Patient’s Medical HomeThe Pillars
The Patients Medical HomePatients receive care that is centered on their needs from a
team that knows their story
Clinical Supports provided by the Medical HomeTimely Access to care and information Team based Care
Continuity to personal family doctor Comprehensive, Coordinated care
The Patient’s Medical HomeThe Pillars
The Patients Medical HomePatients receive care that is centered on their needs from a
team that knows their story
System Supports for the Medical HomeProvincial Support Programs Integrated Information Systems/EvaluationSupportive Payment Structures Workforce Development
What do we know works in Canada…Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing
on eliminating delays for appointments and at appointments.
• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)
• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not
• Have a strong emphasis on self management
• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc
• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008
What do our patients value?• The single most important
issue for Canadians is poor access to health services. (p>0.01)– Access to primary care (for appts)– Timeliness at the appointment– Respect and empathy– Time available in the consultation– Medication and Treatment costs
• Delay in seeing a doctor and getting treatment is the longest among the seven developed countries.
(2015 Commonwealth Fund Survey)
• Physicians prioritize:– ER visits– Self efficacy– Multidisciplinary teams– Collaboration between
healthcare organizations– Self care support– Technical quality of Chronic
disease management– Physical activity counselling
Boivin et al. Implementation Science 2014, 9:24. http://www.implementationscience.com/content/9/1/24
What do we know works in Canada…Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing
on eliminating delays for appointments and at appointments.
• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)
• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not
• Have a strong emphasis on self management
• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc
• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008
PRINCIPLES FOR CAPACITY IMPROVEMENT
‘Know your own patients’ (Empanelment)
‘See your own patients’ (Continuity) ‘Don’t make them wait’ (Access)
Moore, Escaping the Tyranny of the Urgent by Delivering Planned Care. Family Practice Management. May 2006Brousseau, et al. Association Between Infant Continuity of Care and Pediatric Emergency Department Utilization Pediatrics Apr 2004Saultz et al. Interpersonal Continuity of Care and Care Outcomes; A Critical Review Annals of Family Medicine. Vol 2:5. Sept 2004
Access(Principle: “Don’t make them wait”)
Is it OK to wait?
“Without Access, there is no Quality.”US Surgeon General
ER Visits for Asthma: Taber
0
50
100
150
200
250
300
350
400
97-'98 98-'99 99-'00 00-'01 01-'02 02-'03 03-'04 04-'05 05-'06 06-'07 07-'08
Taber Asthma Program
Advanced AccessFamily Practice Teams
Total Visits to ED Relative to Population Growth – Taber Residents
5301
50844860 4926
47074853
5407 5513 56195725 5831
4000
4200
4400
4600
4800
5000
5200
5400
5600
5800
6000
2006 2007 2008 2009 2010 2011
Projected by Population Growth
Actual ED Visits
What do we know works in Canada…
Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing
on eliminating delays for appointments and at appointments.
• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)
• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not
• Have a strong emphasis on self management
• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc
• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008
Panels and Registries(Principle: “Know your own patients.”)
360 Patients are Over 65
60 Patients had more than 10 Office
Visits Last Year
130 are Clinically Depressed
228 have Hypertension
160 have Heart Disease
248 have Arthritis
113 have Asthma
66 have Diabetes
Panel Size 2000
Continuity/Attachment (Principle: “See your own patients”)
When patients see their own physician-
Patient, physician, and staff satisfaction rise, Visit length is shorter and compliance is better. Chance of ‘re-visit’ goes down Earlier detection of serious illness and clinical care and outcomes improve.
Increased sense of ownership by provider, patient and team.
Starfield and Shi. (2004). Hollander, M.J., Kadlec, H., Hamdi, R., & Tessaro, A. (2009). Increasing value for money in the Canadian healthcare system: New findings on the contribution of primary care services. Healthcare Quarterly, 12(4), 30-42.
Panels and Registries(Principle: “Know your own patients.”)
www.topalbertadoctors.org
Assessing you Practice. Dartmouth College. IHI. www.clinicalmicrosystems.org
Resources unique to your community(Principle: “Know your own patients.”)
www.patientsmedicalhome.org
What do we know works in Canada…
Practices that provide the best, most effective care...• Enhance capacity through effective patient flow processes, focusing
on eliminating delays for appointments and at appointments.
• have a sound knowledge of patient population, and of their community resources. (Four Principles of Family Medicine)
• Have pre – planned and prepared for patient encounters, using protocols and guidelines to support collaborative team-based care, whether co-located or not
• Have a strong emphasis on self management
• Use and share sophisticated electronic medical records that include clinical decision support, prompts, reminders, registries, communication tools for other providers, etc
• Use continuous measurement and evaluation to inform changeKatz, Glasier et al. “Applying what works in Canada: Closing the Gap”. CHSRF Working Group. Jan 2008
Functional and Clinical Outcomes
Informed,ActivatedPatient
Prepared,Proactive
Practice Team
DeliverySystem
RedesignDecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Modified Chronic Care Model
ProductiveInteractions
PRINCIPLES FOR CLINICAL IMPROVEMENTWhat Characterizes a “Prepared, Proactive Practice Team”?• Standardized, supported team care, linked to the
provider with clear accountability and leadership.• Embed clinical protocols and guidelines to assist
the team and reduce variations in practice. Identify the ‘high leverage’ clinical areas Pre-Plan patient interventions Train team members to support their clinical roles
Batalden, Nelson, et al. Continually improving the health and value of health care for a population of patients; the panel management process. Quality Management in Health Care, 1997, 5 (3). 41-51
Service Delivery Changes
Medical Management
Case Management
Self Management
Outcomes: Patient/Provider Satisfaction• Patient Satisfaction has remained high• Providers (Physician and others) are significantly
happier with…– Ability to impact patient health behaviours– Job satisfaction– Communication flow and sharing of information– Increased autonomy in performing their job– Current work situation overall
Wedel, et al. Turning Vision into Reality: Successful Integration of Primary Healthcare in Taber, Canada, Healthcare Policy, Aug 2007
Patients Medical Home-Links to Resources:
– CFPC ‘Best Advice’: www.patientsmedicalhome.ca
– Compilation of Resource Tools: • http://www.topalbertadoctors.org/file/pmh-implementation-field-kit.docx
– Compilation of PMH Evidence:• http://www.topalbertadoctors.org/file/top--evidence-summary--benefits-of-pmh.pdf
– Advanced Access, Measurement Tools: www.albertaaim.ca/index.php/resources
– Panel Management, Team based care:• www.pcnevolution.ca; www.pcnpmo.ca• http://www.albertaaim.ca/index.php/resources/• https://www.youtube.com/watch?v=cqGsHB3vvj0&feature=youtu.be
– McMaster U: Quality Book of Tools. 2010• http://qualitybookoftools.ca/wp-login.php