Pillar VI : Continuity of Care, Relationships, Information Care should be provided continuously over time. Should foster continuity of relationships.

Pillar VI:Continuity of Care, Relationships, Information

Care should be provided continuously over time.

Should foster continuity of relationships between patients and each of their caregivers.

Should ensure continuity of care for their patients in different health care setting

Pillar VI Continuity of care, relationships and information

Should advocate on behalf of patients to ensure continuity of care throughout the healthcare system.

Should serve as the hub that ensures coordination and continuity of information related to all medical care the patients receive throughout the system.

Pillar VII:Maintenance of the EMR

By 2020, all family physicians in Canada should be using EMRs.

System supports, including funding to support transition from paper records must be in place to enable the practices to introduce and maintain EMRs.

Process for approving vendors must be centralized, include the end users and must provide practices with selection choices.

Pillar VII:Maintenance of EMRs

EMRs must include:– Appropriate standards for recording and

following patient care in the primary care setting; e-prescribing; clinical decision support programs; e-referral and consultation tools; advanced access e-scheduling programs, and systems that support teaching, research, evaluation, and CQI.

http://prezi.com/uetlw7eniy76/ocfp-retreat-jan-25-2012-goel/?auth_key=95f2f67f5902c8b7d019ac0a0292a297e18606e4&kw=view-uetlw7eniy76&rc=ref-4028582

Pillar VIII:Training and Research Site

Supported and identified by medical and other health professional school as prime locations for experiential training of their students and residents.

Should teach and model their core defining elements: Patient-centred care, teams/networks, EMRs, timely access to appointments, comprehensive and continuing are, management of undifferentiated and complex problems, coordination of care, practice-base research and CQI.

Pillar VIII:Site for Teaching and Research

Provide a training environment for family medicine residents that models and enables residents to achieve the objectives of the Triple C Competency-based Family Medicine Curriculum, the Four Principles of Family Medicine and the CanMEDs Family Medicine (CanMEDS-FM) Roles.

Identified as optimum sites for the training experiences for residents in all medical specialities

Pillar VIII: Site for Teaching and Research

Sufficient funding and resources to ensure teaching faculty and faculty requirements are met by every teaching site.

Should encourage and support physicians and other healthcare professionals, students and residents to participate in research in the practice.

Function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services.

Pillar VIII:Site for Teaching and Research

Competitions for research grants relevant to primary care and family practice should be supported.

Family physicians and other healthcare professionals in the Patient’s Medical Home practices should be encouraged and supported to compete aggressively for research grants to study the effectiveness of the services they provide.

Pillar IX:Evaluation/Continuous Quality Improvement

Should establish CQI programs to evaluate the quality and cost effectiveness of the services they provide and the satisfaction of their patients and providers.

Indicators should be developed to help guide the CQI activities, based on the objectives, goals and PMH recommendations and other published quality indicators.

Clinical guidelines to address the complexity of patients (co-morbidities and complex medical presentations)

Pillar IX:Evaluation and CQI

All members of the team including trainees and patients should participate in CQI activities

Annual national multi-stakeholder forums should be held to monitor and evaluate the effectiveness of Patient’s Medical Homes across Canada

Pillar IX:Evaluation/

Continuous Quality Improvement

O Should establish CQI programs to evaluate the quality and cost effectiveness of the services they provide and the satisfaction of their patients and providers.

O Indicators should be developed to help guide the CQI activities, based on the objectives, goals and PMH recommendations and other published quality indicators.

O Clinical guidelines to address the complexity of patients (co-morbidities and complex medical presentations)

O RED = Opportunity for the OCFP/CCFP O Green = expectation of medical home

directly

Pillar IX:Evaluation and CQI

O All members of the team including trainees and patients should participate in CQI activities

O Annual national multi-stakeholder forums should be held to monitor and evaluate the effectiveness of Patient’s Medical Homes across Canada

Red = Areas that OCFP/CCFP should have a role

Quality ImprovementO What it is not…….it is not used for

professional accountability. Not all physicians trust this

O It is designed to help us evaluate what we do as physicians and improve the care we deliver to patients. We measure:

1. outcome measures (HbA1C, LDL, pneumococcal vaccine rate increased)

2. process measures (examining feet, taking blood pressures, counselling re smoking cessation)

3. balance measures (system outcomes) 4. patient/provider satisfaction evaluations

Why Bother with all this?

Standardization of patient visits with evidence based care

Opportunity to improve the physician and AHP job satisfaction

System redesign with cost saving rewards

O Evaluation of outcome targets leading to improvement of patient outcomes

O “Running on time” “Schedule planning = more time for administration, teaching, research…

O Professional satisfaction=meaning and purpose….

O Fewer unnecessary visits/tests, team care with AHP, fewer ER visits, fewer hospitalizations, home deaths

Chronic Disease Programs

Results

www.HQOntario.ca

Percent of patients over 40 years of age who are current/former smokers and have been screened for

referral to spirometry using the Canadian Lung Health Test.

LFHTLearning Community n=4

PROCESS MEASURE:98% patients screened43% required spirometry

OUTCOME MEASURE:Case finding for the COPD Roster

2009 47 patients 2011 66 patients17% with spirometry had COPD

Results

Percent of COPD Patients who report a COPD related visit to the emergency department or hospital

admission over the course of QIIP.

LFHT QIIP0

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ResultsDecrease in patient MRC grades.

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The Impact of Open Access Booking in a Primary Care Office on Patient Utilization of Emergency Departments and After-Hours Services

Billett L,1 Faulds C,2,3 Walsh C3

1 Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario; 2 Lead Physician, London Family Health Group Shared Care Pilot Initiative; 3 Department of Family Medicine, University of Western Ontario

Introduction

Purpose

• Open Access Booking is a relatively new concept in Canadian family practice. It is a booking method in which all patients who contact their primary care physician (PCP) are offered an appointment for the same day.(1)

• Poor access to the PCP is a commonly sited reason for patients seeking care at Emergency Departments (ED) for non-urgent problems. (2)

• Estimates of the prevalence of inappropriate ED use vary from 24 to 40% of all adult visits (58-82% in pediatric EDs) (2,3)

• Open Access Booking has been postulated to decrease utilization of after-hours clinics and emergency services for non-urgent conditions, although few studies have been conducted to validate this theory. (4)

• In the context of one PCP panel, to evaluate:

1) The change in After Hours Clinic visits before and after implementation of open access booking, as compared to data from a PCP using

a traditional booking method.

2) The change in non-urgent ED visits before and after implementation of open access booking, especially non-urgent visits made on week days.

3) Characteristics associated with non-urgent ED visits including most common diagnoses, patient age distribution and repeat customers.

Methods

• A retrospective chart review evaluating visits to local EDs and to an After Hours Clinic that provides same day appointments to the PCPs patients. After Hours Clinic data was also collected for a physician using a traditional booking method.

Results

Conclusions

1. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA 2003;289(8):1035-1040.

2. Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 Jan;25(1):7-28. Review

3. Berry A, Brousseau D, Brotanek JM, Tomany-Korman S, Flores G. Why Do Parents Bring Children to the Emergency Department for Nonurgent Conditions? A Qualitative Study. Ambulatory Pediatrics 2008 Nov;8(6):360-367.

4. O’Hare CD, Corlett J. The outcomes of open-access scheduling. Fam Pract Manag 2004;11(2):35-38.

1. Open access booking resulted in a 16.8% relative reduction in after hours clinic visits. Weekday after hours clinic visits decreased by 10.5%. This was significant in comparison to a simultaneous 12.9% increase in visits by patients in a family practice with a traditional booking model.

2. Non-urgent ED visits decreased by 22.7% over the study period. Weekday non-urgent ED visits were decreased by 26.2%.

3. Non-urgent visits to EDs were most commonly associated with MSK, respiratory, and dermatologic problems. The pediatric population made up the largest proportion of patients.

4. Although open access booking has decreased inappropriate after hours and ED use, there is still a significant and modifiable burden on these services. Future study should focus on effective patient education tools aimed at helping patients choose the most appropriate medical facility.

Emergency Department Use

Primary Care Office Access Data

After Hours Clinic Use

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Figure 1: Average number of days to 3rd next available appointment with Primary Care Physician.

MSK, 32%

Derm, 18%Resp, 17%

ENT, 10%

GI, 7%

Urology, 5%Lacerations, 3%

Optho, 3% Other, 2% Dental, 2% OB/Gyne, 1%

Age in years Total Pts (% of Total)

0-18 58 (38.2%)

19-40 43 (28.2%)

41-65 32 (21.1%)

65+ 19 (12.5%)

Table 1: Proportion of non-urgent ED visits by age. Age category listed on left-hand, total patients and percent total on right-hand.

33.926.7

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Figure 2: After Hours Clinic visits by patients of PCP, calculated per 1000 pts as physician’s panel size changed significantly over the course of the study.

Repeat CustomersOut of a total 129 patients making non-urgent ED visits during the study period, 18 patients (14.0%) were ‘repeat customers’, presenting to the ED with non-urgent conditions on more than one occasion.

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Figure 3: After Hours Clinic use as compared to a physician utilizing a traditional booking method. Calculated per 1000 pts as practice sizes differ.

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Figure 4: Emergency Department visits calculated per 1000 pts over the two six-month study periods. Proportion of total non-urgent and weekday non-urgent visits identified.

Figure 5: Proportion of non-urgent visits resulting in diagnoses pertaining to disease categories. Represented as percent of total non-urgent visits.

Figure 2: After Hours Clinic visits by patients of PCP, calculated per 1000 pts as physician’s panel size changed significantly over the course of the study. Open access booking resulted in a 16.8% relative reduction in after hours clinic visits. Weekday after hours clinic visits decreased by 10.5%.

Figure 2: After Hours Clinic visits by patients of PCP, calculated per 1000 pts as physician’s panel size changed significantly over the course of the study. Open access booking resulted in a 16.8% relative reduction in after hours clinic visits. Weekday after hours clinic visits decreased by 10.5%.

Figure 2: After Hours Clinic visits by patients of PCP, calculated per 1000 pts as physician’s panel size changed significantly over the course of the study. Open access booking resulted in a 16.8% relative reduction in after hours clinic visits. Weekday after hours clinic visits decreased by 10.5%.

Facilitators O Quality coach and educationO EMRO Data managementO Remuneration to offset increased

costsO Staff in FHT O Development of a quality culture

across the health care system (hospital, LTC and community)

O See the “wins” Celebrate them O OCFP !!!!

Barriers to QI O EMR – data extraction O Knowledge in Quality ImprovementO Who decides on outcomes? O What are we to measure? Measurements

at the practice level or the system level or accountability?

O Staff: Data management, nursing, administration

O Time –to evaluate, train staff, develop programs, do education

O Financial remuneration – lack ofO Financial penalties – fear ofO Attitude/buy in ”How does this help

me deliver improved care?”

Willingness to change

As stated in PHAROS, June 2010 by Justin

Palmore,.. “I fervently believe that everyone is

worthy to serve the suffering. It is not a

matter of worth, it is a matter of heart, a matter

of passion, and as this picture so candidly

portrays, a matter of willingness to

progress-----to progress in a way that best serves the human condition, in

every aspect.”

Pillar X:Governance/Administration

Governance, administrative and management roles and responsibilities should clearly be defined and supported in each Patient’s Medical Home.

The persons responsible for governance, administration and management roles may differ from practice to practice and should be determined at the practice level.

Leadership Development programs should be offered to individuals taking on governance, administration and management roles.

Pillar X: Governance/Management

Sufficient system funding must be available to support the clinical, teaching, research and administrative roles of all members of the Patient’s Medical Home

Blended payment models should be introduced in all provinces/territories as the preferred option for remunerating family physicians in practice functioning as Patients’ Medical Homes.