the integrated home-based primary care (ihbpc) project dr. sabrina akhtar twfht dr. thuy-nga pham...
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The Integrated Home-Based Primary Care (IHBPC) Project
Dr. Sabrina Akhtar TWFHT Dr. Thuy-Nga Pham SETFHT
Dr. Mark Nowaczynski House Calls Dr. Samir Sinha UHN/MSH Geriatrics
Dr. Tracy Smith-Carrier King’s, Western Dipti Purbhoo TC-CCAC
Photo Credit - Toronto Star, 2011
Rationale for our Collaborative – Why?
• 93% of Canadians aged 65 and older live at home, > 100,000 of them are homebound
• Since 2000, five English systematic reviews published on home-based primary care with conflicting results on mortality, functional status and health care use and costs
Source: Stall et al, 20th IAGG WORLD CONGRESS OF GERONTOLOGY AND GERIATRICS 2013
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Background3
FEATURE HOME-BASED PRIMARY CARE OUTREACH HOME VISITS
Functional Model
Ongoing comprehensive primary care in the home
Home-based multidimensionalGeriatric assessments
Care Focus Complex and interrelatedchronic disease management and social care issues
Needs assessments
Time Course Ongoing Consultation with possible limitedfollow-up
Personnel Primary care provider–ledinterprofessional teams
Varied, but typically nursingand allied health professionals
Goals of Care
Improve access to primary care Assess needs and develop careplan
Source: Stall N, Nowaczynski M, Sinha SK. Back to the future: home-based primary care for older homebound Canadians: part 1: where we are now. Canadian family physician Medecin de famille canadien 2013;59(3):237-40.
Who are our patients?4
Taddle Creek FHT
MSH FHT
Integrated Home Based Primary Care Catchment
Patient Site Totals6
Site Current Total
Mount Sinai Hospital 25
SMH 31
SETFHT 61
Sunnybrook 57
Taddle Creek 62
TWH 73
SPRINT 425
*TOTAL 734*Totals as of March 26, 2014
IHBPC Models of Primary Care
FHT Model: Family Health Teams taking care of homebound patients that benefit from an
interprofessional team delivery model (FPs, NPs, SW, OTs, Pharmacists)
CSS Model (SPRINT House Calls Model): Primary Care Team (3 FPs, 1 NP, 2 OTs, 1 PT, 1 SW, 1 Team Coordinator etc.)
embedded in a Community Support Services Agency Early Analyses show 67% Die at Home Rate, and 14% and 29% lower hospital
readmission rates at 30 and 90 days.
Emerging CHC/Hospital/CCAC Models: In development! One of the FHT graduating PGY3 Care of the Elderly Fellows has
joined a West End CCAC interprofessional team in providing IHBPC.
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Program Objectives – What are we doing?8
Provide a comprehensive and integrated approach to patient and client care
Improve transitions in care between acute, primary care and community care settings
Establish a network of specialists to support home-based primary care with recent urban telemedicine expansion
Patient Care Objectives Integrated Care Team Objectives
Develop shared understanding of roles, responsibilities and accountabilities between providers
Improve communication among team
members and across the continuum of care and organizations
Enhance care management partnerships between primary care and community care providers“Skype in
your specialist
”
What are we measuring?
Qualitative
Analysis
Interviews with
Patients, Caregivers,
Team Members &
External Stakeholde
rs
Quantitative and
Economic Analysis
Analysis of Hospitalizations, ED
visits using ICES data
Quality Improvem
ent Measures
Immunization rates, 7 day follow up after
hospitalization,
medication reconciliatio
n, team conferences
,Advance
Care Planning
Training &
Education Operations
and Education Toolkits &
Curriculum Developme
nt for Competenc
y Based Training of
Family Medicine
Residents in IHBPC
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Qualitative Research
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Interprofessional Team Experience
Explored Team members’ experiences
providing IHBPC services vis-à-vis providing usual care
The key characteristics of successful team functioning within the IHBPC environment
The facilitators of effective IHBPC service delivery
Areas of improvement (barriers)
Analysis Information Grounded theory methodology Sample = 7 sites (6 FHTs + 1 IHBPC
CSS team) in Toronto - winter of 2013
Purposive sampling approach (Patton, 2002) by team member role
Team Members (n=17) CCAC Care coordinators Social Workers Physicians Occupational Therapists Physician Assistant Nurse Practitioners & Nurses Pharmacists
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Dimensions of IHBPC Service Delivery to Team Members
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There are a significant number of seniors who can’t access their family doctors office for a variety of reasons:
Can’t access transportation Dementia and cognitive impairments Can’t sit in an office and wait for hours Mental health
CCAC
…The introduction of CCAC in house, has streamlined the process which is amazing.
Now, I would say my role is more of a team player. I am letting our nurse leader take more of the leadership of this & coordination role. So for me it is easier.
Well the doctor is the lead…I mean we all have roles…But there has to be somebody in charge of all of that, because if we all had control it would be not doable for anybody…
It’s, from what I can tell, it’s all through our physician assistant. So she’s sort of the quarterback & she gathers all of us together & whoever she needs help with, & then she helps carry out the plan.
The Population & Necessity of the Service and CCAC Involvement
Types of Teams
Context of IHBPC13
Benefits of IHBPC
…(I)t is making it easier because you can visually understand what their needs are: you can tell if they are taking their medications you can tell if they have safety issues the extent of their dementia becomes more
rapidly obvious to you you can see where they keep their
medications and can tell whether they can take their medications as you prescribed
do they have dexterity issues with the blister packs, can they read the pills bottles, do they have somebody to administer them
are they living in a second floor bedroom & they can’t access food on the main floor or a bathroom on the main floor & they are living on the 2nd floor
So you can address multiple issues quickly, so from that respect I find it easier to create a care plan that works for the patient.
I love the population and I think that we are stemming some emergency visits although that remains to be born out, that’s a difficult thing to measure as we all know. But based on the kind of presentations, and the phone calls we get from their providers, and the treatments that we’re giving, I think that probably we’re deferring visits…
I went out to see this guy last week and I could see something was brewing on his foot so I could deal with it before he went to emergency, you know?
That’s the one major change, that they can actually manage their care through us now without having to access emergency department services on every occasion.
Benefits of the Context of Home
Sense that IHBPC Defers Hospital Visits
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Barriers
…After seeing the patient there’s a lot of kind of paper work & stuff that needs to be attended to, you know, you’re not seeing people with colds, you know.
One of the biggest barriers would be how far away the doctor or the person has to drive, right. It really should be no longer than 15 minutes, because than that’s a half hour for the drive, not including wherever you have to park.
Administrative Load Travel
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Facilitators & Barriers of Team Collaboration
Using our computers and our blackberries, which everything goes into the client’s file…We are not missing anything using the interdisciplinary approach.
We also have biweekly meetings where we sit down & discuss new referrals, we discuss current cases, issues, good stories, bad stories, & housekeeping…
The weekly rounds seem to be the venue where things are discussed. I know there’s also some email correspondence that I have been part of as well around plans & they are sort of an on going dialogue.
We use a program called One Note for our patient charting. If a patient has passed away or needs urgent attention usually that warrants a phone call to another team member or at the very least an email. Communication folder is just a “Hey I just wanted to give you the heads up about this…”
I guess one of the other challenges…was that some of our physicians are not as embracing of a nurse going out to see their patients, or not their nurse going out to see their patient. I find that one of the very frustrating things, that there’s this protectionism of “my practice” attitude, & we really have to move away from that. We need to remember it’s the patient that’s at the center of what we do, not the physician or the physician’s views. And that’s a challenge. It’s a challenge I have had in complex continuing care, it’s a challenge being out here.
Variety of Communication Mechanisms (Facilitators)
Turf Issues (Barrier)
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System Wide Gains Thus Far
• Annual FHT ministry reports now require number of home visits provided by MDs and team members
Family Health Teams
• Dedicated care coordinator embedded within primary care team highly effective
CCAC
• OTN urban telemedicine access to specialists, team conferences with specialists and hospital teams in case of admissions beneficial for complex patients
Communication with specialists and hospitals
• Academic curriculum expansion in competencies in home-based and team based care
Increasing number of Family Medicine Trainees exposed to IHBPC
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Tia Pham, MDTracy Smith-Carrier, PhDThuynga.pham.utoronto.ca
Questions?