Family Practice Teams: Professional Role Identity

1
Family Practice Teams Professional Role Identity

• Introduction to the session
• Overview of the literature
• Marie-Dominique Beaulieu
• And Associates

2
Primary Care RenewalLessons to Learn

• We would like to express our thanks to
• Health Canada
• for its support related to this FMF Session and
  its ongoing support related to the work of
• The College of Family Physicians of Canada
• in Primary Care.

3
Why This Session at FMF 2007?

• Increasing focus on primary care at the CFPC
• Establishment of Advisory Committee on Primary
  Care Renewal
• Creation and maintenance of Primary Care Toolkit
  at www.toolkit.cfpc.ca
• Increasing interest in the roles of nurses
  working with family physicians in primary care /
  family practice
• Increasing need to focus on process in primary
  care / family practice, e.g. access to care,
  continuity of care and quality of care
  (performance)

4
Objectives of FMF Session

• What do we know about the effectiveness of team
  work in primary care and FP-nurse collaboration?
• How to define collaborative practice ?
• What is the evidence that it works in PC?
• What have we learned so far about success
  factors?

5
Plan of the session

• Overview of Interprofessional Collaboration in
  Primary Care
• Optimizing the Family Practice Nurse role in
  family practice settings (C Todd)
• FPN and FPs working together to improve
• Continuity of care (J. Brewer/A. Alsaffar)
• Access to care (R. Wedel/C. Todd)
• Quality of care (D. Gelhorn/A. Kowalski)
• Conclusion

6

• Overview of Interprofessional Collaboration in
  Primary Care

7
Collaborative practice

• Collaborative practice is an inter-professional
  process for communication and decision-making
  that enables the separate and shared knowledge
  and skills of care providers to synergistically
  influence client/patient care provided.
• Ontario College of Family Physicians 2000

8
Seven Components of Collaboration

• Responsibility and accountability
• Co-ordination
• Communication
• Co-operation
• Assertiveness
• Autonomy
• Mutual trust and respect

9
Research on Interdisciplinary Teams in Primary
Care

• Most of the evidence comes from research on
   integrated  care for specific clients
•  Team work  is part of the intervention but
  poorly defined or conceptualized.
• A handful of studies have looked at the impact on
  health outcomes
• Few studies on primary care in family practice
  settings, but some interesting ones ...

10
Nurses and Family Physicians Working Together in
Primary Care

• Evaluation and triage (Lattimer et al 1998,
  Thompson et al 1999, Reveley 1998)
• Management of acute problems (Butler Rees 2001,
  Shum et al 2000, Caldows et al. 2006)
• Follow-up of chronic problems (Lyons 2005,Evans
  et al 2005, Keanaly 2004)

11
Effectiveness of Primary Care Teams

• In a study of 68 PC health care teams (and 568
  members), Poulton and West showed that team
  process was an independent predictor of team
  effectiveness while team structure (size, tenure,
  budget) was not associated with outcome.
• Poulton BC, West MA, J Interprofessional
  Care,1999

12
Effectiveness of Primary Care Teams in General
Practice

• In an observational study of a random sample of
  60 general practices in the UK, team process - as
  measured by the Team Climate Inventory - was an
  independent predictor of increased access to care
  as perceived by patients and of diabetes control
  (Hba1c)
• Campbell SM et al, BMJ 2001

13
Who are the Canadian Family Physicians and Nurses
Working in Primary Care?

• Of primary care providers in Canada
• GPs 140 per 100,000 inhabitants
• RNs 790 per 100,00 inhabitants (40 in PC)
• NPs 878 in 2004.
• 25 of FPs work in solo practices
• 46 in inner cities
• 19 in remote areas
• 13 of FPs reported working closely with NPs and
  43.6 with FP nurses from NPS 2007

14
FPs working with nurses
From NPS 2007
15
The Canadian Scene Experiences Supported by the
PHCTF

• 47 initiatives
• Health Care Renewal in New Brunswick
• Five community health centres / interdisciplinary
  teams
• Newfoundland and Labrador Primary Health Care
  Initiative
• Eight interprofessional PHC teams
• Family Medicine Groups in Québec
• Ontario 100 new practices (FHG, FHN, FHT)
• The Manitoba PHCTF Initiative
• Saskatchewan 17 PHC teams
• British Columbia PHCTF Initiative
• 92 practice models implemented

16
What barriers to expect?What levers to mobilize?

• Determinants of effective collaboration and
• team work
• Systemic determinants
• Cultural, professional, educational
• Organisational determinants
• Organizational philosophy and structure,
  administrative support, team resources,
  communication mechanisms
• Interactional determinants

17
Systemic Determinants of Collaboration

• Liability issues
• Scopes of practice
• Professional regulation policies variability
  across provinces and territories
• Remuneration of professionals and funding schemes
  for primary care fee-for service is not a
  facilitator.
• Training issues
• Human resources
• Current Canadian context of shortage of human
  resources is an asset and a barrier

18
Examples of Organisational Factors That Foster
Collaboration

• Team meetings in which goals are discussed
• Patient-centeredness assessing practice needs
• Formalization of protocols
• Statutory meetings
• Leadership
• Access to expertise in collaboration /shared
  professional education

19
Interactional Determinants of Collaboration

• Willingness to collaborate
• Trust
• Level of trust based on perception of competence
  and on the knowledge of the other professions
  field
• Mutual respect
• Capacity to discuss role identities and to
  clarify responsibilities

20
The Challenges Facing PC Teams

• Integration of the nursing and the medical
  models evolving scopes of practice
• Making team care visible to patients
• Relationships with specialized care teams

21
In summary

• What we mean by team work varies considerably
• There is evidence suggesting that  Primary Care
  Teams  are associated with better outcomes in
  general practice settings
• No magic bullet team effectiveness depends on
  the  quality  of team processes and the support
  it receives
• Teams operate in systems all the actual
  knowledge we have on team work is very context
  sensitive

22
Primary Care Toolkit

• www.toolkit.cfpc.ca

23
Optimizing the Family Practice Nursing Rolein
the Family Practice Setting Carol Todd
24
Nova Scotia Advisory Committee on primary health
care renewal states

• The core team would include the
• family physician, family practice nurse,
  pharmacist, nurse practitioner, social worker,
  dietician, the appropriate
• health providers and midwife.

25
What we knew.

• Family practice nursing not new
• Ontario family practice nursing group
• No contact with any FP nurses in NS
• Nothing in the literature

26
Our Journey of Discovery

• Received grant through the NS Department of
  Health Nursing Strategy Program
• Strategic Planning Day - Feb 2004

27
Project Goals

• Determine the current role of FP/PHC nurses in
  Nova Scotia
• Identify common issues, concerns and challenges
• Establish links with FP/PHC nurses for further
  networking

28
Methods

• RNs identified from CRNNS 2004 registration
• Limitations of identifying target group
• 112 questionnaires mailed out
• 61 returned
• 41 met the criteria for participating in the
  survey (45 response rate)
• 30/41 respondents agreed to participate in a
  telephone interview (22 were contacted)
• Ethics approval by CDHA

29
Survey

• Key themes of collaboration, scope of practice,
  patient education, triage, documentation and
  continuity of care
• Demographics
• Concerns and challenges
• - published in June issue of the Canadian Nurse
  Journal

30
Collaboration
31
Triage Reasons for Contacting the Nurse

• 100 Reassurance and support
• 100 Clarification of physicians advice
• 98 Advice and health teaching
• 90 Medication clarification
• 87 Test results
• 85 Urgent calls
• 78 of nurses indicated response-time-to-call was
  within 30-60 min

32
Continuity of Care

• 85 believe they have an active role in providing
  continuity of care
• 66 are asked to follow-up on patients when the
  physician is away
• 71 are contacted by other health care providers
  when the physician is not available

33
Concerns and Challenges
34
Infrastructure

• Isolation and limited networking
• Need for more FP/PHC nurses
• Difficulty taking time from practice to attend
  educational sessions
• Leadership and support for the role of the FP/PHC
  nurse

35
Education/ Scope of Practice

• Need for a clear definition or understanding of
  scope of practice
• Lack of understanding of the role
• Continuing education needs
• Continuing education funding
• Lack of awareness and sharing of resources and
  tools

36
Remuneration

• Lack of adequate benefits and job security
• Underpaid when compared to unionized nurses
• Unable to bill the provincial medical insurance
  program for nursing services
• Too much time on non-nursing services

37
Progress

• Networking (chat line)
• NS Family Practice Nurses Website
• (www.cdha.nshealth.ca/programsandservices/familypr
  acticenurses/index.html)
• Educational Conferences
• Publications/Presentations
• Round Table Discussion - Nov 2006

38
Other things happening in NS

• Capital Health Professional Practice Nursing
  Council
• Nursing in Your Family Practice Program
• Educational Program for FP nurses
• Family Practice Nurses Association of NS

39
National Collaboration

• College of Family Physicians of Canada
• Canadian Nurses Association
• Ontario Family Practice Nurses
• Networking with FP nurses nationally

40
If the millions of nurses in a thousand
different places articulate the same ideas and
convictions about primary health care, and come
together as one force, they could be a powerhouse
for change. (Mahler,1985)
41
References

• Todd, C., Howlett, M., MacKay, M., Lawson, B.
  (2007, June)
• Family Practice/Primary Health Care Nurses in
  Nova Scotia,
• Canadian Nurse, p 23

42
Questions or Comments?
43
Continuity of Care in the Family Practice Setting

• John Brewer Ann Alsaffar

44
Pedroage 74

• Sister with Colon Cancer, age 70
• Father died with Colon Cancer, age 75
• Mother with Type 2 Diabetes
• Fatigue for 3 months
• Recent blood tests at walk-in clinic
• OTC Meds
• Poor dietary habits
• Smoker
• Bp156/ 84
• 25 pound weight gain (BMI 34)
• Random blood sugar 15.6, urinalysis , 2 sugar,
  (rest normal)
• High cholesterol (LDL 4.3 , HDL lt 1 , Total 6.52)

45
Pedros To do ListWho does What? Doctor
Nurse

• Dietary Counseling for diabetes, cholesterol and
  weight loss
• Prescription Writing
• Medication Counseling/ Compliance Monitoring
• Discussions of non-pharmacologic options , if any
• Referral to Diabetic Nurse Educator
• Exercise Prescription
• Ophthalmologist referral
• Chiropodist/Podiatry referral
• Gastroenterology referral for colonoscopy
• Repeat office visits for BP and sugar and weight
  monitoring
• Patient notification and fast track triage when
  FOBT is positive

46
The Physicians Perspective

• Do I want to be a Quarterback?
• Do I want to be an Orchestra Conductor?

47
The Nurses Perspective

• Do I want a traditional Role?
• Do I prefer a team approach?

48
The Patients Perspective

• Comfort level in seeing the same doctor and/or
  nurse
•       
• Continuity of care impacts on improved
• quality of care, on the reduction of errors, and
  on reducing costs.

49
How Do We Ensure Continuity for Pedro?

• Relational continuity
• Informational Continuity
• Managerial Continuity

50
Key Factors for Success

• Team Building
• CME
• Consider Teaching , Community Outreach and
  Research to be Multidisciplinary Team Building
  exercises
• Infrastructure (space)
• Governance
• Job descriptions
• Time for meetings
• Feedback , open and honest
• Proper Charting!!!

51
Challenges

• Changing practices (walk-in clinics , less focus
  on in-patient care, obstetrical care, etc.
• Increasing 3rd party care (the Doc must do it)
• Liability (?)
• Current physician payment schemes
• Time

52
Access to Care in the Family Practice Setting

• Rob Wedel Carol Todd

53
Access and Family Practice Teams

• Pedro, a 74 yr old man in your practice, has a
  sister who is recently diagnosed with colon
  cancer.
• Hmm, its been a few years. Maybe its time I see
  my family doctor.
• Pedro is lucky. He has a family doctor.
• Many Canadians do not. Their doctor has retired,
  moved away, limited their practice.
• They use the ER and walk-in clinics when they
  have to, even tho they would prefer their own
  personal family doctor.
• Continuity and followup is sporadic, chronic
  diseases are not addressed.
• Re-visit rates are high, as is cost to the
  system.

54
Access and Family Practice Teams

• Pedro calls his doctors office and gets an
  appointment 34 days later (average time to next
  available appointment in Alberta).
• Once there, he sits in a standing room only
  waiting room for over an hour.

55
Does Pedro have an Access Problem?
56
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57
Finally, Pedro gets in to see the doctor..

• Pedro comes into the office for his 15 minute
  appt with Dr. L.
• Dr. L quickly does a blood pressure measurement
  revealing a significantly high result. Dr. L
  searches for Pedros most recent lab work in his
  medical record.
• Dr. L thinks he made a referral to the diabetes
  program in the past, but did not have time to
  look for any notations. Pedro has had high blood
  pressure, elevated cholesterol, and is
  overweight, all of which have been noted for the
  past 20 years.
• Dr. L only finds pieces of the information, and
  in frustration, schedules another visit for Pedro
  in three weeks.
• Pedro books his next appointment on his way out
  the door.

58
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59
Access and Family Practice Teams

• 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 care.
• 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
• Crossing the Quality Chasm Report, US Inst of
  Med 2004

60
Could Pedro gain better access using a more
organized collaborative, team based approach to
care?
Access and Family Practice Teams
61
Pedros 2nd Visit

• Assessment (physical, social, emotional,
  cultural)
• Physical (BP, pulse, waist circumference, BMI)
• Preventative Health (immunizations)
• Flow Sheets - Hypertension and Diabetes (CFPC
  Toolkit)

62
FP and FPN Collaborative Care

• Health Education (survival diet, self-blood sugar
  testing, hypoglycemia, diagnostic tests)
• Triage
• Advocacy / Navigator

63
Days to Third Next Available Appointment Taber
Clinic
64
ER Visits for Asthma in Taber
Family Practice Teams
Taber Project
65
Access and Family Practice Teams

• Clear roles within the team are the key.
• Protocols and directives pre-planned and embedded
  into daily practice improve reliability and
  outcomes.
• The EMR is an essential component for team
  communication, decision supports, patient
  management, and measurements that guide
  improvement changes.
• Team meetings with common goals understood by all
  (The people that do the work must change the
  work.)
• Education in team building, and CPD around roles
  and responsibilities is essential.
• Knowing each other and understanding each others
  roles builds confidence and trust within the
  team.
• Strong teams promote consistent and reliable
  care, every time, on time.

66
Taber Health Project

• Satisfaction
• Health providers are significantly happier with
• Communication flow and information sharing
• The amount of time communicating with patients
  and other providers about care
• Ability to impact patient health behaviors
• Their autonomy in the performance of their jobs
• Current work situation
• Improved job satisfaction expressed by several
  disciplines
• Patient and Community satisfaction remained high.

Wedel et al, Turning Vision into Reality
Successful Integration of Primary Healthcare in
Taber, Canada. Healthcare Policy. Aug 2007
67
Access and Family Practice Teams

• Without access there is no quality.
• Dr. Jonathan Perlin, MD,
• Under Secretary for Health

Mark Murray and Don Berwick, Advanced Access
Reducing Waiting and Delays in Primary Care. JAMA
Feb 2003 Bodenheimer et al. Improving Timely
Access to Primary Care Case Studies of Advanced
Access JAMA 2006 Ohara et al. The Outcome of
Open-Access Scheduling Family Practice
Management, Feb 2004
68
Questions or Comments?
69
Quality of CareWorking together to make it
better Attaining clinical and practice targets

• Don Gelhorn

70
QUALITY

• STRUCTURE
• PROCESS
• OUTCOME

71
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72
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73
Back to Pedro

• Trust
• Access
• Comprehensiveness
• Continuity
• Caring demeanor
• Communication

74
Access

• Demand vs. Supply
• Be willing to attempt change
• Adjust appointment scheduling
• Make small fine tuning changes until it works

75
Community Involvement

• Interagency Committee
• An umbrella organization
• Identifies community issues and needs
• Leadership Team
• Sets long and short term goals
• Provider Team
• Program and project implementation

76
Community Programming

• Diabetes monitoring clinics
• Wellness clinics for seniors
• Youth and mental health projects
• Tobacco initiatives
• P.A.R.T.Y.
• KIDSPORT
• Drug education and awareness programming
• Living Well with Chronic Disease TM Program

77
Tangible Benefits for physicians

• Reduction in on-call demands
• Community preventative health initiatives
• Distribution of work load
• Enhanced role as educators

78
Secrets to Success
79
Quality Collaborative Practice Lessons from an
Urban Primary Care Centre a Nurse Practitioners
Perspective

• Alex Kowalski

80
Presentation Outline

• The Team
• The Scenario
• Quality indicators
• Have we made a difference?

81
The Team

• Who are we?

82
The Scenario

• Key points
• Role of the Nurse Practitioner
• Integrated health care for Pedro
• Our work is different and yet complimentary

83
Research on the NP Role in Primary Health Care

• Spitzer WO et al. ( NEJM 1974290251-256)
• Conclusions
• NPs can provide first contact primary clinical
  care safely and effectively, with as much
  satisfaction to patients as a family physicians.
  
• NPs can provide a major increase in total
  quantity of clinical service, without a reduction
  in quality

84
Quality Indicators

• What are quality indicators and to Whom?
• Quality to patient
• Quality to the provider

85
Quality for the Patient

• How do we measure up to our patient?

86
Quality to the Provider
87
Goals Have We Made a Difference?

• Goals
• To improve access to primary care services for
  community
• To promote continuity of care between hospital,
  the primary care provider and the home
• To reduce hospital readmission
• To provide additional health resource to clients
  and families

88
Conclusion Lessons in Quality Primary Health
Care

• Primary Health Care should
• - be integrated and inter-sectoral
• - emphasize health promotion
• - address the main health problems within a
  community from the community perspective
• - depend on a diversity of trained workers
  functioning as a multi-disciplinary team

89
Primary Care RenewalLessons to Learn
QUESTIONS or COMMENTS?