The Canadian Melting Pot Transforming Primary Care

1
The Canadian Melting Pot Transforming Primary Care

• Canadian Health Improvement Forum
• March 21,2009
• Dr. Robert Wedel MD,CCFP,FCFP
• Physician Lead, Chinook Primary Care Network
• Co-Chair, Alberta AIM Initiative
• Facilitated by Arvelle Balon-Lyon RN, BN
• Alberta Toward Optimized Practice Program ( TOP)

2
Overview

• The Way we Were
• The Way we Are
• The Way forward in Canada

3
Primary Care Renewal in Canada
4
The Evidentiary Vacuum

• Discussions of innovations in primary care
  invariably take place in an evidentiary vacuum.
  Strong evidence is lacking to support the
  superiority of any one model of organizing,
  funding, and delivering primary care and of many
  suggested model components, including group
  practice, multidisciplinary practice and
  remuneration methods.
• Hutchison B, Abelson J, Lavis J. Primary care in
  Canada so much innovation, so little change.
  Health Affairs 200120116-31.

5
New Script, same old Play?

• Commission on the Future of Health Care in
  Canada. Building on Values The future of Health
  Care in Canada ( Romanow, Ottawa2003)
• Standing Senate Committee on Social Affairs,
  Science and Technology. The Health of Canadians
  the Federal Role, Final Report on the State of
  the Health Care System in Canada (Kirby, Ottawa
  2003)
• Alberta, Premiers Advisory Council on Health. A
  Framework for Reform. (Mazenkowski,
  Edmonton2001)
• Saskatchewan Commission on Medicare. Caring for
  Medicare, Sustaining a Quality System (Fyke,
  Saskatoon 2001)
• Ontario Health Services Restructuring Commission.
  Looking Back, Looking Forward, A Legacy Report
  (Toronto2000)
• Quebec Study Commission on Health Services and
  Social Services. Emerging Solutions, Report and
  Recommendations (Quebec2000)
• Health Services Review Committee.
  Fredericton1999
• Jeffery Simpson, Globe and Mail editorial, Jan 8,
  2004
• New script, same old play?
• Reform primary health care.
• (pick a model, any model)

6
National Primary Care Forum, CFPC 2005

• The most obvious revelation here today is the
  huge provincial variation in approaches to
  primary care renewal initiatives across this
  country.
• Closing remarks, Dr Ruth Wilson

7
2003 First Ministers Accord on Health Care Renewal

• 800M invested in primary health care between
  2000 and 2006 through the Primary Health Care
  Transition Fund (www.hc-sc.gc.ca)
• With a goal toward Timely and equitable
  access, a higher quality of care, a healthier
  population, a solid future

8
The Problem

• Despite all our best efforts
• using our traditional medical model,
• and the resources currently available to us,
• we have been singularly ineffective in meeting
  targets and providing guideline level quality
  of care.
• While once Canada was seen in middle of the pack
  in primary care (Starfield et al,2002),
• other countries of similar wealth and health
  systems have advanced and left us behind.
• Health Quality Council of Canada 2007
• 2008 Commonwealth Fund Survey

9
CROSSING THE QUALITY CHASMA NEW HEALTH SYSTEM
FOR THE 21TH CENTURY DON BERWICK

• These quality problems occur typically not
  because of failure of good will, knowledge,
  effort or resources directed to health care, but
  because of fundamental shortcomings in the way
  care is organized

10
What we Know

• Practices that provide comprehensive and
  coordinated quality primary health care confer
  the most benefit to their patients.
• Generally, such practices
• have a sound knowledge of their patients and of
  their community resources
• have effective patient flow processes
• use protocols and guidelines to support provision
  of evidence-based care
• provide collaborative team-based care, whether
  co-located or not
• use and share sophisticated electronic medical
  records that include clinical decision support,
  prompts, reminders, registries, etc.

Katz, Glasier et al. Applying what works in
Canada Closing the Gap. CHSRF Working Group.Jan
2008
11
The Medical Home

• The greater the range of services provided by
  primary care practitioners, the lower the
  all-cause mortality, life expectancy, and overall
  costs for health services.
• those who had a primary care physician as their
  regular source of care had one third lower costs
  and were 19 less likely to die, even after
  controlling for several other predispositions to
  dying

Starfield B, Shi L. Policy relevant determinants
of health an international perspective. Health
Policy. 2002603201218 The Future of Family
Medicine. Annals of Family Medicine, 2004
12
Patient-Physician Connectedness Quality of
Care

• Academic network of 4 community based health
  centres and 9 hospital affiliated family
  practices
• 155,590 patients
• 59.3 connected to a specific physician
• 34.5 connected to a specific practice
• 6.2 could not be connected
• Physician connected pts significantly more likely
  to receive guideline level care than practice
  connected pts
• Mammograms 78.1 vs 65.9
• HgA1C 90.3 vs 74.9

Atlas, et al. Ann Int Med1505. 325-335. March
2009
13
What will it take?

• Quality doesnt just happen.
• Working harder helps, but is not sustainable.
• We need to work smarter.

14
The Power of People

• Patients as Partners
• Unleashing Patients Power
• Community Engagement sensitive to family and
  culture
• Group visits From Need to Nutrition

15
From One to Many Team Based Care

• Too much work not enough hands
• Creating Links outside the Box
• Reconstructing not only our professional identity
• But also Reconstructing our system approach to
  program planning in silos
• Are you up there for you, or are you up there
  for the audience?

16
Professional Identity Under Reconstruction

• Most difficult shift identified was for
  physicians
• From a traditional role, with physicians holding
  the sole responsibility for patient care.
• To shared responsibility, recognizing the
  expanded capacity for high quality care offered
  by a team.
• Other disciplines are also struggling with the
  same issues
• Gradual recognition of the subtle difference
  between substituting other providers and
  supplementing the work with a team made all the
  difference.

Wedel, et al. Turning Vision into Reality
Successful Integration of Primary Healthcare in
Taber, Canada, Healthcare Policy, Aug 2007
Chreim S, et al. Inter-Level Influences on the
Reconstruction of Professional Role Identity.
Academy of Management Journal. Dec 2007.
17
Care Coordination The jam of integration

• Connecting the Dots to coordinated Care
• Service agreements to integrate care
• Why cant specialists get their act together?
• Capacity at the front end is only as good at the
  back end
• Packaging sending the work in the right way
• Avoiding Duplication, Waste and Errors
• Specialists caring about FPs and vice versa
• We are in this together.

18
Access the single most important issue for
Canadians

• Office Redesign
• Without access there is no quality
• Impact BC, BCMA
• Alberta AIM (AHW, AHS, AMA)
• HQC Sask
• Manitoba Health Mb Access Initiative
• PIN Pointing Physician Integrated Networks
• Ontario (Health Quality Council, FHT)

19
The Infinite Role of the Measurement

• EMR Implementation The sweat of it all
• A Disruptive innovation'
• Measurement .. the drumbeat of change
• What identifies change and what sustains it
• Indicators and Pay for Performance
• Hows my ing?
• Clinical Data Assessments, Scorecards, Checklists
  
• Outcomes feed our spirit

20
The Medical Home

• Bringing the Pieces Together
• Access
• Co-location taking service to the people
• Connectedness and Comprehensiveness
• Safe, High Quality Clinical Care through evidence
• Collaborative teams, not autonomous substitute
  providers
• Sensitive to the culture and resources of the
  community

21
The Way Forward

• The role of the public, our patients, should not
  be underestimated.
• Accountability in all directions
• Accountability that supports a culture of
  continuous quality improvement and ongoing
  performance measurement and monitoring.
• The requisite governance and organizational
  effectiveness.
• a clear mission and vision,
• sustained leadership and change management
  strategies, with a focus on Clinical Excellence.

22
The Way Forward

• What we need is more work to disseminate the
  knowledge arising from these initiatives we heard
  about today
• this is the body of knowledge that is filling the
  evidentiary vacuum we have been working in
  until now.
• It is time to share and publish
• Do it!
• The Canadian Melting Pot

23

• With diligence, we can achieve good health for
  all.
• John Wesley, 1745