Primary Health Care and Chronic Disease Prevention and Management

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Primary Health Care and Chronic Disease
Prevention and Management

• A Healthier Tomorrow
• March 6, 2009

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The South West LHIN Webcast Series

• Health System Integration January 9
• Health System Design January 23
• Health Human Resources February 6
• Seniors Adults with Complex Needs February 20
  
• Primary Health Care and Chronic Disease
  Prevention Management March 6
• eHealth Strategy March 27

A Healthier Tomorrow
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Objectives for South West LHIN Webcast Series

• Inform partners of LHINs vision, mission,
  values, and health system improvement goals.
• Inform partners of how the Priority Action Teams
  future directions align with the LHIN goals and
  how recently funded projects move us closer to
  the desired state identified by the Priority
  Action Teams.
• Acknowledge contributions of volunteers and
  partners who were actively involved in defining
  the development of the LHINs work.

A Healthier Tomorrow
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Purpose of this Presentation

• Share the work of the Primary Health Care, Mental
  Health and Addictions, and Chronic Disease
  Prevention and Management and Diabetes Priority
  Action Teams
• Describe how the PAT recommendations are
  affecting system change
• Highlight initiatives aligned with South West
  LHIN Health System Goals

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Strengthening and Improving Primary Care
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Strengthening and Improving Primary Care

• Primary Health Care PAT
• Primary Health Care Mental Health and Addictions
  PAT

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Primary Health Care (PHC) PAT Objective

• Support the evolution and development of a more
  connected system across primary health care, by
  focusing on primary health care renewal models
  and through greater awareness and connection of
  independent and small group family physicians to
  other community primary health care services

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PHC PAT Target Population

• Everyone in the South West LHIN including
• Individuals unattached to a Primary Care
  Physician or Nurse Practitioner
• Those who are marginalized or have barriers to
  access for reasons of transportation,
  language/culture, financial, mental health,
  addictions, stigma, immigrants, age
• Those who border the South West LHIN
  geographically (i.e., live in neighbouring LHIN
  but seek primary health care in the South West
  LHIN geographic area)

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PHC PAT Scope of Services - System-level

• Basic primary care services available at a local
  level No community is without access to these
  basic services
• Centres across the South West LHIN that would
  provide access to a broader and more extensive
  range of services
• Integrated accessibility i.e., better
  integration of transportation and use of e-health
  services, such as telemedicine

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PHC PAT Scope of Services - System-level

• Services are made more accessible to others
  through outreach (e.g., providers can travel to
  the individual)
• Support of interprofessional teams Education
  and continuing education incorporate
  interprofessional team practice
• Promotion of the Nurse Practitioner role in the
  Integrated and Comprehensive Primary Health Care
  Services Model

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PHC PAT Points of Entry/Access

• Form hubs of services around existing gathering
  places and/or non-traditional access points
• Individuals can access Primary Health Care
  Services through multiple access points (i.e.,
  through any interprofessional team member)

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PHC PAT Care Coordination

• Encourage primary health care professionals,
  individuals and community partners to engage in
  care coordination
• Encourage primary health care professionals to
  engage in case management
• Encourage active practice management (e.g.,
  collaboration and pooling of resources around
  programs and services)
• Connect with practices that have demonstrated
  successes

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PHC PAT Information Requirements Flow

• Sustainable and accessible method of
  communication between individuals and providers
  and between providers (i.e., via EHR or
  provincial portal system)
• Interactive web portal for medical protocols,
  algorithms, and best practices is accessible to
  all health care professionals
• Create a client web portal that allows client to
  access own test/diagnostic results to improve own
  self-management of health and chronic disease

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PHC PAT Information Requirements Flow

• Create a central repository of information
  registry that is accessible (via Internet,
  phone) to individuals and providers and is kept
  up-to-date and accurate
• Underlying infrastructure (i.e., training,
  education and funding) is required for EHR. IT
  support person should be available to all primary
  care sites.

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Primary Health Care Initiatives

• Chronic Disease Prevention and Management
• Partnerships for Health
• Access to Family Health Care (Diabetes Strategy)
• Self Management Tool Kit
• Developing Community Health Centres

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Primary Health Care Initiatives Development of
3 new Community Health Centres (CHCs)
The CHC Model of Care

• Comprehensive
• Accessible
• Client and community-centred
• Interdisciplinary, salaried providers
• Inclusive of the social determinants of health
• Community-governed
• Grounded in a community development approach
• Integrated

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CHCs are Comprehensive

• CHCs offer primary health care through five
  areas of service
• Health assessment, diagnosis and treatment
• Illness prevention
• Health promotion
• Community capacity building
• Service integration

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How are CHCs different from other Primary Care
Models, such as Family Health Teams (FHTs)?

• Salaried health care professionals
• A unique model
• Governed differently than FHTs

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The CHCs in the South West LHIN

• There are two existing CHCs and one Aboriginal
  Health Access Centre
• London InterCommunity Health Centre
• Main site on Dundas Street
• Satellite on Huron Street, part of 2004 satellite
  expansion
• West Elgin Community Health Centre
• Located in West Lorne and serves West Elgin,
  including Dutton-Dunwich
• Southwest Ontario Aboriginal Health Access Centre
• Two locations in London and one in Muncey
• Not funded by the LHIN but receive some funding
  under Community Support Services program

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The CHCs in the South West LHIN

• There are three developing CHCs.
• Central (Elgin) Community Health Centre
• South East Grey Community Health Centre
• Woodstock and Area Communities Health Centre

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Developing CHCs in the South West LHIN
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How CHCs Align with Primary Health Care PAT
Future State

• Communities have local access to basic primary
  care services
• Create Hubs of services around existing
  gathering places and/or non-traditional access
  points
• Services can be provided not only in a central
  location, but through outreach and partnership
  with other community agencies
• All three developing CHCs have proposed that they
  will provide mental health services. The two
  existing CHCs also provide mental health services
• Communities have access to primary health care
  and a wide range of client-centered services and
  programs
• Integration and partnership with existing
  community services in order to build community
  capacity

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Primary Health Care Mental Health and
Addictions (MHA) PAT

• Primary Objective
• Focus on improving access to comprehensive
  primary care with an emphasis on education about
  mental illness and addiction, early intervention
  and wellness for people with mental health and
  addictions conditions.

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MHA PAT Target Population

• Individuals of all ages who are at risk for or
  who have mild, moderate or serious mental health
  and/or addiction problems that are severe enough
  to hamper their functional ability and their
  capacity to develop and maintain essential
  relationships.
• e.g., Individuals who are at risk for or are
  experiencing anxiety, depression, trauma,
  situational stress, substance use or abuse,
  dementia and chronic disease/illness.
• Also includes caregivers

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Future State Mental Health Addictions

• Onsite primary mental health and addiction staff
  (employees or staff deployed from MHA services)
  for assessment and brief treatment in primary
  care settings
• Incorporate education about MHA and related
  primary care competencies in core curriculum,
  ongoing education for primary health care
  providers
• Incorporate information about MHA and related
  self care as a component of public/patient
  education

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Future State Mental Health Addictions

• Address service gaps and capacity issues within
  formal MHA system - attention to services for
  people with mild and moderate MH problems,
  seniors, youth, peer support for clients and
  caregivers, and respite care
• Standardized comprehensive assessment for at-risk
  populations that includes consideration of
  caregiver needs and risk factors
• Timely referral to MHA services for those at
  high risk, those with complex needs and/or
  requiring longer term treatment

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Future State Mental Health Addictions

• Monitoring and follow-up for patients treated for
  MHA problems and issues
• Increased MHA providers (psychiatrists and nurse
  practitioners) through recruitment and retention
  efforts
• Expand opportunities and incentives for primary
  care provider participation in collaborative care
  models and consultation resources

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Future State Mental Health Addictions

• System navigation resources (e.g. care
  coordinators) and/or advocates for vulnerable
  populations, those with complex needs, access
  barriers
• Equip electronic record with prompts to ensure
  completion of required assessment and treatment,
  with reminders for monitoring and follow up

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Mental Health Addictions Initiatives

• RMHC, Schedule 1, Community MHA partners, and
  the LHIN working together to map MHA services
  across the LHIN to better understand where
  services are provided, by whom, and identify gaps
  and pressure points
• Collaborative Mental Health Project (DEEP care)
• Training for Implementation of the GAIN-CD
  Screener
• Local provider initiatives

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Preventing and Managing Chronic Illness
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Preventing and Managing Chronic Illness

• PATs
• Chronic Disease Prevention and Management PAT
• Diabetes PAT

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Preventing and Managing Chronic Illness Overall
Objectives

• Develop and implement a comprehensive chronic
  disease prevention and management program across
  the South West LHIN.
• Implement a comprehensive chronic disease
  management program for individuals with diabetes
  including those with mental health co-conditions,
  through a selected number of pilot initiatives
  across the South West LHIN.

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Chronic Disease Prevention and Management (CDPM)
and Diabetes PATs Target Population

• All individuals and their families/support
  networks residing within the South West LHIN,
  specifically those at risk (e.g., obesity) or
  diagnosed with chronic disease(s), including
  pre-diabetes or diabetes of any type.

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CDPM Diabetes

• The PATs developed recommendations that included
  advancing team based care, increasing the use of
  care guidelines and algorithms, the development
  of tool kits to support person-centred care and
  self-management strategies, as well as the need
  to use technology to support care.
• The CDPM framework adopted by the MOHLTC will
  guide the South West LHIN strategy for CDPM in
  the region. The framework identifies the
  evidence-based attributes of a high functioning
  health system. Capacity for change amongst health
  service providers and consumers must be further
  advanced to ensure there is system readiness for
  the transformation required.

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Goals Recommendations for Future State

• Recommendations were structured around the
  following five goals
• To advocate, develop and/or implement healthy
  public policies
• Through community action, develop local solutions
  for issues that affect overall health
• To have collaborative, integrated Health Care
  Organizations working as a system
• To enhance the capacity and integration of
  prepared, proactive health care professional
  teams
• To enhance the capacity and integration of
  information, engaged individuals and families

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Targeted, Integrated, Coordinated Care
Kaiser Permanente Triangle Source UK Department
of Health (2005)
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Chronic Disease Prevention Management and
Diabetes Initiatives

• Self-Management Toolkit
• Chronic Kidney Disease provincial strategy
• Partnerships for Health
• Enhancing Access to Family Health Care (Diabetes
  Strategy)

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Self-Management Tool Kit

• The LHIN sponsored the development of a South
  West LHIN Self Management Tool Kit for health
  care practitioners.
• Self Management in Theory and Practice A Health
  Professionals Guide and an on-line Tool Kit will
  be released in April 2009
• Further opportunities to promote self management
  as a strategy to support CDPM will be considered.

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Chronic Kidney Disease (CKD) Strategy

• July 2008 MOHLTC allocation of 220 million
  dollars for the prevention and management of CKD,
  as part of the Ontario Diabetes Strategy.
• 40 of End-Stage Renal Disease (ESRD) patients
  are diabetic
• goal is to increase Peritoneal Dialysis (PD) use
  in Ontario to 30 by 2010 and expand home
  dialysis to 40 by 2012
• The strategic direction of the CKD program is to
  strengthen disease prevention, early
  identification and disease mitigation.
• Phase II is to approve at least one LTC home per
  LHIN where there is no LTC homes currently
  providing PD care

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Partnerships for Health
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Background

• Funded by Ministry of Finance Strengthening Our
  Partnerships program
• In partnership with MOHLTC
• Sponsored by the South West LHIN

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The Goal

• Integrate the component parts of the health care
  system by sharing information across the
  continuum of care, advancing primary care
  partnerships and linkages to tertiary care,
  engaging the patient in self-care and enabling
  improved information management

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In other words.

• Building teams family physicians, home care,
  community health providers, specialists within
  primary care and across organizations to take an
  integrated approach to the prevention and
  management of chronic disease

Keeping people at the base of the pyramid!
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Why Diabetes?

• Prevalence rate of diabetes mellitus per 100 SW
  LHIN residents, aged 20 years and older 7.2
  (2004/05)
• 58 of diabetes patient in Ontario are tested for
  A1C, and of those tested, lt 50 had optimal
  glucose levels
• 49 of diabetics in Ontario have gone gt1yr
  without an eye examination
• Co-morbidities (e.g., depression)
• Research to support system impact r/t clinical
  change

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Why is this project important?

• Aligns with government priorities
• Responds directly to public need
• Engages providers in a new way
• Leverages technology
• A natural next step for the South West

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Project Participants

• Twelve primary care practices 100
• South West CCAC
• Diabetes Educators
• Mental Health teams
• Community providers
• Physician specialists
• Thames Valley Family Practice Research Unit
• South West LHIN

Team composition varies according to patient
need, patient load, organizational constraints,
resources, clinical setting, and professional
skills.
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Anticipated Outcomes

• Patients will experience highly coordinated care
• Clear sense of why collaboration
• Role satisfaction
• Partnership sustainable
• Improved clinical outcomes / quality of life
• Improved patient self-management
• Appropriate system utilization

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Very busy serving patient needs one visit at a
time
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Highly effective teams
Optimizing care
Partnership
Building team processes
Productive Collaboration
...the team must truly function as a team and
activate key processes to have a positive effect
on confidence in the health care system.
Support
Transaction
Exercising individual leadership
St. Onge, CHCA Conference 2004
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Key Success Factors

• Maintain a focus on patient needs
• Have clarity of purpose, objectives, roles
• Meet often as equals with shared capacity in
  decision making
• Have leadership but do not allow anyone or
  organization to take over
• Allow time to establish rapport
• Share workload
• Accept that partnership will evolve over time

St. Onge, 2004
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A Recipe for Improving Outcomes
QI strategy
Learning Model
System change strategy
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QI Strategy - the PDSA Cycle for Learning
Improvement
Act
Plan
Objective Questions and predictions (why) Plan
to carry out the cycle (who, what, where, when)
What changes are to be made? Next cycle?
Study
Do
Complete the analysis of the data Compare
data to predictions Summarize what was learned
Carry out the plan Document problems and
unexpected observations Begin analysis of the
data
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Strategies
Testing and adaptation
Self- Manage- ment Support
Community Resources
Delivery System Design
Clinical Information Systems
Leadership
Decision Support
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Resources to support integrated care

• Shared planning
• Shared EMR
• Simple team communication mechanisms
• Evidence based care plans
• Algorithms
• Community resource information to support
  self-management

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Progress to Date

• DEC RNs reviewing patients in common with their
  primary care partners
• CCAC case managers are case conferencing with
  primary care
• Mental health social workers are treating
  depression in conjunction with primary care

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Progress to Date

• Improvements in care processes
• Increased foot, eye and renal screening
• Increases in patients setting self care goals
• A1C and lipid testing 
• Improvements in business processes
• Flow mapped
• Changes tested and implemented
• Moving toward right work by right team member

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Indicators of integration

• Potential Measures
• Reduction in handoff time (at any step)
• Number of daily/weekly inter-disciplinary
  communication re huddles, process of care, case
  mgmt
• Number of visits saved due to new team service
  delivery model (theoretical)
• Increase in appropriate referrals and decrease in
  unnecessary referrals (as defined/measured by
  team)
• Quality is not an extra process, it is our work

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From the Front Lines

• The best part.. is using the experience of many
  partners to improve outcomes.
• The initiative focuses on how to improve
  communication and teamwork
• Were not letting people fall through the cracks
  and in fact we are helping them manage better.

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What does it take?

• Commitment to improvement, make it a priority, be
  prepared to give up old activities
• Patient centredness is hard, needs a lot of focus
• External facilitation support is helpful
• Strong physician leadership, and nurturing of all
  leaders is a must
• Step wise approach to chronic disease management
  concrete resources give each team member a role
  to support clinical care

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Next Steps

• Learning Collaboratives
• Wave 1
• Wave 2
• Spread Wave 3
• Spread collaborative
• Knowledge Transfer Day
• Web-based
• Coaching only
• Outcomes Congress

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Want to participate?Want more information?www.pa
rtnershipsforhealth.ca
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Enhancing Access to Family Health Care
Diabetes Strategy
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Diabetes Strategy

• The LHIN will be working closely with the MOHLTC
  to implement the provincial Diabetes Strategy
  beginning with the goal of enhancing access to
  family health care
• PAT recommendations are being advanced through
  establishment of a detailed service delivery
  model
• The South West LHIN is currently working with the
  province to establish a pilot initiative to
  support a population at high risk for diabetes
  (aboriginal and/or mental health focus)
• The LHIN is also an early adopter for the
  provincial diabetes registry

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South West LHIN Implementation Model (draft)

• System Level Goals
• Healthier Community
• Equitable Access
• Quality
• Sustainability
• Integration

South West LHIN Board
Health Professionals Advisory Committee
South West LHIN CEO and Staff
CDPM Steering Committee
Best Level of Care Quality Steering Committee
Health System Design Steering Committee
eHealth Adoption Steering Committee
Partnerships for Health
Access to Family Health Care
Diabetes Registry
PAT RECOMMENDAT I ONS
Self Management Tool Kit
LHIN-Project Management Office Coordination/Tracki
ng/Reporting
COMMUNICATION
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CDPM Steering Committee

• Provide a conduit for a number of projects and
  initiatives that collectively advance the LHINs
  efforts to improve the quality of and access to
  the range of care available to South West LHIN
  residents when they need it.
• To provide oversight, guidance and advice to a
  number of initiatives including but not limited
  to the following (Partnerships for Health, etc.)
• Includes local experts in primary health care as
  well as specialist services related to diabetes
  care and other relevant co-conditions

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Key Messages

• Alignment to System Level Goals
• Building on PAT recommendations to create a
  compressive approach to CDPM
• Person Centred Integrated Care
• Changing health care through continuous quality
  improvement

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Survey
Your feedback is valuable to us. Please take a
few moments to complete our short Online Survey
about this webcast. Just go to the South West
LHIN website homepage, and click on the link to
the survey
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Please join us for our next Webcast

• When March 27, 2009
• Time 930 1100
• Topic eHealth Strategy
• Details See the South West LHIN Website
  www.southwestlhin.on.ca

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Questions
Dial 1-866-507-1212 and ask for South West
Local Health Integration Network Please note
If you have questions after the webcast, feel
free to email questions in to southwest_at_lhins.on.
ca. A full QA document will be posted on our
website at the end of the webcast series.
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Thank you for joining us!
A Healthier Tomorrow