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Physicians Leading Integration & Continuity:

The Tools You Need to Lead System Transformation

Presented By: Dr. Tobias Gelber and Eileen Patterson

March 3rd, 2018

ASA, Banff, Alberta

Faculty/Presenter Disclosure

• Faculty/Presenter: Dr. Tobias Gelber

• Relationships with commercial interests:

Grants/Research Support:   Not applicable 

Speakers Bureau/Honoraria:     Honorarium from the AMA for attending meetings

Consulting Fees:    Not applicable

Other:     This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses.

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Faculty/Presenter Disclosure

• Faculty/Presenter:  Eileen Patterson

• Relationships with commercial interests:

Grants/Research Support:   Not applicable 

Speakers Bureau/Honoraria:     Not Applicable

Consulting Fees:    Not applicable

Other:     This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses.

ACFP 63rd ASADisclosure of Commercial Support

This program has received financial support in the form of sponsorship from:

• Potential for conflict(s) of interest: Those speakers/faculty who have made COI disclosure are noted in the   63rd ASA Program and on the Salon A/B slide scroll.

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Mitigating Potential Bias

• ACFP: → The ACFP’s Sponsorship Guidelines apply to ASA Sponsorship. The ACFP abides by the College of 

Family Physicians of Canada’s Understanding Mainpro+ Certification Guidelines, the Canadian Medical Association’s Policy Guidelines for Physicians in Interactions With Industry and the Innovative Medicines Canada Code of Ethical Practices (2016). As a non‐profit organization, the ACFP complies with Canada Revenue Agency regulations. When deliberating acceptance of sponsorship, the ACFP considers and accepts sponsorship only from those whose products, services, policies, and values align with the ACFP vision, values, goals, and strategies priorities.

• ASA Planning Committee: → Consideration was given by the 63rd ASA Planning Committee to identify when Planning 

Committee members’ and speakers’ personal or professional interests may compete with or have actual, potential, or apparent influence over program content.

→ Material/Learning Objectives and/or session description were developed and reviewed by a Planning Committee composed of experts/family physicians responsible for overseeing the program’s needs assessment and subsequent content development to ensure accuracy and fair balance.

→ The 63rd ASA Planning Committee reviewed  Sponsorship Agreements to identify any actual, potential or apparent influence over the program.

→ Information/recommendations in the program are evidence‐ and/or guidelines‐based, and opinions of the independent speakers will be identified as such.

What you will get from this• Develop a better understanding of how system partners are working together to improve the three types of continuity in order to affect better patient care

• Identify how clinical leadership can impact broader system initiatives

• Understand the purpose of the Physician Leadership Network and how they can share their expertise to drive positive change.

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What’s the big idea?

Physician leadership is a strong driver for 

health system transformation.  

Plus …

Continuity and integration are interventions 

that physician leaders can use to significantly improve care for their patient populations.

Transformational Leadership by Alberta physicians

• Members of provincial planning committees• Primary Care Alliance• PCN Zone Committees• PCN Boards• Primary Health Care Integration Network• Faculty for QI (AIM, Panel, Practising Wisely, etc.)• Family physician on SCNs and health system committees

• Physician Leaders Network• Most importantly, leadership for PMH in practice

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Management Continuity & Transitions

Value – Patient

With increased continuity, patients are:

• Healthier

• More satisfied

• Receive better care

• Take better care of themselves

• Better health outcomes

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As Continuity Increases, Mortality Decreases

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If we could only do one thing…

• “Having a family doctor, being able to access the family doctor, and most importantly, continuity of care with a family doctor, is probably the single most important thing a health care system can provide to its population.” 

• Dr. Richard Lewanczuk, Senior Medical Director, Primary Health Care, AHS

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Resources in Alberta: Driving Continuity Forward 

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Knowledge: Continuity, what is it?

• Relational, informational, management

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Relational Continuity

The ongoing, trusting therapeutic relationship between a patient and a primary care provider(s)

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Haggerty 2003 

Informational Continuity

• The transfer of relevant patient information between multiple care providers and locations. Includes accumulated knowledge about the patient’s preferences, values, and context. 

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HQCA 2016

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Management Continuity

• The coordination and handoff of care between relevant care providers using a shared care plan in a way that is both consistent and flexible to meet patient needs. 

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HQCA 2014Haggerty 2003

Why Focus on Continuity?

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• Better health outcomes• Decreased mortality • Increased patient and provider satisfaction • Reduced overall health cost to the system • Fewer ER visits & preventable hospital admissions • Enabler for new physician compensation models 

• Better communication and handoffs 

• Less duplication• Increased provider satisfaction 

• Better coordination between providers of care 

• Improved patient‐reported outcomes

• Increased patient satisfaction

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Continuity: A Unifying Goal

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Physicians and teams Public and Patients Specialty and Community

• Alberta College of Family Physicians

• Alberta Medical Association• Health Quality Council of 

Alberta• Primary Care Networks• Imagine

• Alberta Health • Alberta Health Services • Primary Care Alliance• College of Physicians and 

Surgeons of Alberta

Too big for one person ?! … let’s break it down

• What you can achieve in your practice …              

• And where you can influence and contribute …

Pixabay.com

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Key Leadership Action

1. Ask questions– What are frustrations or opportunities? What does 

your EMR data or HQCA report show?

2. Learn– From and with colleagues and team members

– Do small tests of change to get to big results

3. Shared vision– Create as a team, repeat it at every opportunity

4. Sustain and spread– Make a focus on improvement normal and routine

– Share across clinic, PCN and zone to inspire and help others 21

1. Relational Continuity Actions

• We can’t control what our patients do or where they seek care…but we can do our part to improve continuity. – Maintain panel

– Work in teams

– Offer panel based care; ASaP, Opioid Care, PACT, etc

– Schedule for continuity

– Promote continuity to patients

– Improve access

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2: Informational Continuity Actions

• We can’t control the system informational infrastructure, but we can improve our part. – Use EMR for practice informational continuity with your colleagues and team members

– Have a team process for using Netcare

– Participate in CPAR and CII (coming soon)

Pixabay.com

3: Management Continuity Actions

• We can’t control hospitals, specialists, or community programs, but we can be pro‐active partners within integration initiatives. – Prepare for sharing care plans, Green Sleeves, etc

– Communicate expectation of post‐hospital follow‐ups

– Participate in PCN/Zone activities for integration

Pixabay.com

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New Support! PHC Integration Network

Helping you connect across the system

Transformational leader behaviours:

• Vision– is guided by vision of success based on performance and value of the 

positive impact

• Team– leverages team for answers as part of decision‐making process

• Measure– behave like a scientist: continually measuring and testing for 

improvement

• Learn– continually learning and developing self and others

• Impact– tends to financial performance, customer satisfaction, staff 

engagement, community impact, and cultural cohesion.

• Adapated from: Transformational Leadership Field Guide; Re‐envisioning Leadership and Innovation; pg. 9

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Physician Leaders’ Network drives transformation

• The Physician Leaders’ Network offer supports, networking, mentorship and a wide collection of resources that respond to leaders and team members active in advancing Patient’s Medical Home and System Integration.

Supporting physicians

as they lead

Physician Leaders’ Network

• Contact information:

• www.pcnpmo.ca/PLN

• pln@albertadoctors.org

Supporting physicians

as they lead

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Physician Leaders …• Link to a community that is advancing continuity and integration

• Promote continuity within the practice as an effective intervention for quality of care

• Participate in integration initiatives to achieve better transitions of care

“Attention is the currency of leadership” 

Ronald A. Heifetz 

The Practice of 

Adaptive Leadership

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TranslationDon’t underestimate your ability to influence through a few well placed words.

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Transformational Leadership by Alberta physicians

• Members of provincial planning committees• Primary Care Alliance• PCN Zone Committees• PCN Boards• Primary Health Care Integration Network• Faculty for QI (AIM, Panel, Practising Wisely, etc.)• Family physician on SCNs and health system committees

• Physician Leaders Network• Most importantly, leadership for PMH in practice