THIS NEW HOUSEHOW NORTHERN HEALTH STAFF AND PHYSICIANS ARE BUILDING PRIMARY CARE HOMES TO IMPROVE CARE

BC QUALITY FORUMFebruary 25, 2016

Dr. Garry KnollFamily PhysicianLead PhysicianPrince George Division of Family Practice

Suzanne CampbellDirector, Community ServicesPrince GeorgeNorthern Health

Michael McMillanChief Operating OfficerNorthern Interior HSDANorthern Health

History of the Work• Over 8 years ago Northern Health started the journey towards a more

integrated system of care, with strong Primary Care as the cornerstone of the system and clear connections to specialized and specialist services.

• A number of consultations and streams of work to improve care for seniors and other people with complex needs. These include but are not limited to:– Northern Health’s Primary Health Care Strategy - Care North (2008)– Prince George Division established 2009 – collaboration started– Understanding Our System Work– Uptake of electronic medical records by physicians in Northern BC– Aging well in Northern and Rural Communities (2008) – Development of 2009 -15 Northern Health vision and strategic plans– Seniors Consultation and Action Plan 2014

Strategic Plan

“Northern Health is known for our strong primary health care system. People experience seamless and coordinated service. The Primary Care Home is the foundation for multidisciplinary health care and helps people navigate across services.” Northern Health Strategic Plan 2009-2015

Objective of the WorkA Primary Care Home is the place where people• establish long-term relationship with a primary care

provider and inter-professional team,• receive seamless, coordinated, and longitudinal care• are supported in managing their own health

In Northern Health, the Primary Care Home is embedded in a Healthy Community. Health promotion and prevention is an integral part of the work

Primary Care Home

Primary Care Home

Goal 3 – Team Based Care

A Patient’s Primary Care Home will offer its patients a broad scope of services carried out by teams or networks of providers, including each patient’s personal family physician working together with peer physicians, nurses, and others.

Primary Care Home

Goal 5 – Comprehensive Care

A Patient’s Primary Care Home will provide each of its patients with a comprehensive scope of family practice services that also meets population and public health needs.

Primary Care Home

Goal 6 – Continuity

A Patient’s Primary Care Home will provide continuity of care, relationships, and information for its patients.

Primary Care Home

Goal 7 – EMR

A Patient’s Primary Care Home will maintain electronic medical records (EMRs) for its patients.

Partnership and Collaboration

Northern Health Idealized System of Services

Inter-professional Team Members & Functions

• Members (not all teams will have all members)– Primary Care Physician / Nurse Practitioner– Primary Care Nurse– Mental Health Clinician– Rehab Professionals– Pharmacists, Dieticians, other

• Roles– Case Finding– Care Planning– Care Coordination / Monitoring

Current State

Inter-professional Team Example

Small Community Example

Interprofessional Team Formation – Phase 1

Interprofessional Team Formation – Phase 2

Interprofessional Team Formation – Phase 3

Interprofessional Team Formation – Phase 4

Work in Progress

• Supporting people through change • Workforce Transition– Leadership Structure – Front-line staff team assignments

• Work process redesign– Documentation (options)

• Logistics

Logistics – Team Location

What are staff saying - Challenges

• Loss of identity• Loss of team members / connections• Stressful environment with so much change• Is this a business model or a model of care?• Transition (transformation) is difficult and takes

a long time• Change affects people (in a negative way)

What are staff saying - Opportunities

• Chance to participate in change for better care• Challenge the system• Small teams encourage team development• Keep the big picture in mind (don’t sweat the

small stuff)

Key Messages• Objective is to provide better care, particularly for

patients with complex needs• Never too early to meaningfully engage medical staff• Structure change is insufficient – care process changes

are essential• Change – significant, emergent, at all levels, needs to

be supported• The system is complex and this work is hard• PARTNERSHIP!

QUESTIONS?