Transcript Presentation by Dr. Tia Pham on the IHBPC Model

Photo Credit - Toronto Star, 2011
The Integrated Home-Based
Primary Care (IHBPC) Project
Dr. Sabrina Akhtar TWFHT
Dr. Mark Nowaczynski House Calls
Dr. Tracy Smith-Carrier King’s, Western
Dr. Thuy-Nga Pham SETFHT
Dr. Samir Sinha UHN/MSH
s
Dipti Purbhoo TC-CCAC
Geriatric
Rationale for our Collaborative – Why?
2
•
93% of Canadians aged 65 and older live at home, > 100,000 of them
are homebound
•
Since 2000, five English systematic reviews published on home-based
primary care with conflicting results on mortality, functional status and
health care use and costs
Source: Stall et al, 20th IAGG WORLD CONGRESS OF GERONTOLOGY AND GERIATRICS 2013
Background
3
FEATURE
HOME-BASED PRIMARY CARE
OUTREACH HOME VISITS
Functional
Model
Ongoing comprehensive primary
care in the home
Home-based multidimensional
Geriatric assessments
Care Focus
Complex and interrelated
chronic disease management and
social care issues
Needs assessments
Time Course
Ongoing
Personnel
Primary care provider–led
interprofessional teams
Consultation with possible limited
follow-up
Varied, but typically nursing
and allied health professionals
Goals of
Care
Improve access to primary care
Assess needs and develop care
plan
Source: Stall N, Nowaczynski M, Sinha SK. Back to the future: home-based primary care for older homebound Canadians: part 1: where we are
now. Canadian family physician Medecin de famille canadien 2013;59(3):237-40.
Who are our patients?
4
Integrated Home Based Primary Care Catchment
Taddle Creek FHT
MSH FHT
Patient Site Totals
6
Site
Current Total
Mount Sinai Hospital
25
SMH
31
SETFHT
61
Sunnybrook
57
Taddle Creek
62
TWH
73
SPRINT
425
*TOTAL
734
*Totals as of March 26, 2014
IHBPC Models of Primary Care
7
FHT Model:

Family Health Teams taking care of homebound patients that benefit from an
interprofessional team delivery model (FPs, NPs, SW, OTs, Pharmacists)
CSS Model (SPRINT House Calls Model):


Primary Care Team (3 FPs, 1 NP, 2 OTs, 1 PT, 1 SW, 1 Team Coordinator etc.)
embedded in a Community Support Services Agency
Early Analyses show 67% Die at Home Rate, and 14% and 29% lower hospital
readmission rates at 30 and 90 days.
Emerging CHC/Hospital/CCAC Models:

In development! One of the FHT graduating PGY3 Care of the Elderly Fellows has
joined a West End CCAC interprofessional team in providing IHBPC.
Program Objectives – What are we doing?
8
Patient Care Objectives
Integrated Care Team Objectives

Provide a comprehensive and integrated
approach to patient and client care



Develop shared understanding of roles,
responsibilities and accountabilities
between providers
Improve transitions in care between
acute, primary care and community care
settings

Improve communication among team
members and across the continuum of
care and organizations
Establish a network of specialists to
support home-based primary care with
recent urban telemedicine expansion

Enhance care management
partnerships between primary care and
community care providers
“Skype in
your
specialist”
What are we measuring?
9
Qualitative
Analysis
Interviews with
Patients,
Caregivers,
Team
Members &
External
Stakeholders
Quantitative
and
Economic
Analysis
Analysis of
Hospitalizatio
ns, ED visits
using ICES
data
Quality
Improvement
Measures
Training &
Education
Immunization
rates, 7 day
follow up after
hospitalization,
medication
reconciliation,
team
conferences,
Advance Care
Planning
Operations
and Education
Toolkits &
Curriculum
Development
for
Competency
Based Training
of Family
Medicine
Residents in
IHBPC
10
Qualitative Research
Interprofessional Team Experience
11
Explored

Team members’ experiences
providing IHBPC services vis-à-vis
providing usual care

The key characteristics of successful
team functioning within the IHBPC
environment

The facilitators of effective IHBPC
service delivery

Areas of improvement (barriers)
Analysis Information



Grounded theory methodology
Sample = 7 sites (6 FHTs + 1 IHBPC
CSS team) in Toronto - winter of
2013
Purposive sampling approach
(Patton, 2002) by team member role
Team Members (n=17)

CCAC Care coordinators

Social Workers

Physicians

Occupational Therapists

Physician Assistant

Nurse Practitioners & Nurses

Pharmacists
Dimensions of IHBPC Service Delivery to
Team Members
12
Figure 1: Dimensions of IHBPC Service Delivery According to Team Members
Benefits
Provider Satisfaction
Enhanced Care Planning
Smooth Access to Services
Perception of Deferred Hospital Visits
Perceived Effectiveness in Improving Patient Outcomes
Improved Medication Management
Perceived Patient Satisfaction
Barriers
Demands on Time and Energy
Lack of Resources & Equipment
Administrative Load
Travel
Coordination Challenges
Negotiating the Home Environment
Integrated
Home-Based
Primary Care
Context of Team
Variety of Sizes & Composition of Teams
Differing Team Leads
Embedded in Diverse Organizational
Structures
CCAC/CSS Agency Supports
Facilitators of Interprofessional Working
Positive Relationships
Mechanisms for Communication
Organizational Supports in Place
Team Learning
Structural Context
Growing Population Requiring Care
Complexity of Patients
Recognition that Service is Necessary
Funding Restraints
Reluctance of Care Providers to Engage
in IHBPC
Obstacles to Interprofessional Working
Conflict
Turf Issues
Unclear Roles
Context of IHBPC
13
The Population & Necessity of the
Service and CCAC Involvement
There are a significant number of seniors who
can’t access their family doctors office for a
variety of reasons:

Can’t access transportation

Dementia and cognitive impairments

Can’t sit in an office and wait for hours

Mental health
Types of Teams
Now, I would say my role is more of a team
player. I am letting our nurse leader take more
of the leadership of this & coordination role. So
for me it is easier.
Well the doctor is the lead…I mean we all have
roles…But there has to be somebody in
charge of all of that, because if we all had
control it would be not doable for anybody…
CCAC
…The introduction of CCAC in house, has
streamlined the process which is amazing.
It’s, from what I can tell, it’s all through our
physician assistant. So she’s sort of the
quarterback & she gathers all of us together &
whoever she needs help with, & then she
helps carry out the plan.
Benefits of IHBPC
14
Benefits of the Context of
Home
Sense that IHBPC Defers
Hospital Visits
…(I)t is making it easier because you can visually
understand what their needs are:

you can tell if they are taking their
medications

you can tell if they have safety issues
I love the population and I think that we are
stemming some emergency visits although that
remains to be born out, that’s a difficult thing to
measure as we all know. But based on the kind of
presentations, and the phone calls we get from
their providers, and the treatments that we’re
giving, I think that probably we’re deferring visits…

the extent of their dementia becomes more
rapidly obvious to you

you can see where they keep their
medications and can tell whether they can
take their medications as you prescribed
do they have dexterity issues with the blister
packs, can they read the pills bottles, do they
have somebody to administer them

are they living in a second floor bedroom &
they can’t access food on the main floor or a
bathroom on the main floor & they are living
on the 2nd floor
So you can address multiple issues quickly, so
from that respect I find it easier to create a care
plan that works for the patient.

I went out to see this guy last week and I could
see something was brewing on his foot so I could
deal with it before he went to emergency, you
know?
That’s the one major change, that they can
actually manage their care through us now without
having to access emergency department services
on every occasion.
Barriers
15
Administrative Load
…After seeing the patient
there’s a lot of kind of paper
work & stuff that needs to be
attended to, you know, you’re
not seeing people with colds,
you know.
Travel
One of the biggest barriers
would be how far away the
doctor or the person has to
drive, right. It really should be no
longer than 15 minutes, because
than that’s a half hour for the
drive, not including wherever
you have to park.
Facilitators & Barriers of Team Collaboration
16
Variety of Communication
Mechanisms (Facilitators)
Using our computers and our blackberries, which
everything goes into the client’s file…We are not
missing anything using the interdisciplinary
approach.
We also have biweekly meetings where we sit
down & discuss new referrals, we discuss current
cases, issues, good stories, bad stories, &
housekeeping…
The weekly rounds seem to be the venue where
things are discussed. I know there’s also some
email correspondence that I have been part of as
well around plans & they are sort of an on going
dialogue.
We use a program called One Note for our patient
charting. If a patient has passed away or needs
urgent attention usually that warrants a phone call
to another team member or at the very least an
email. Communication folder is just a “Hey I just
wanted to give you the heads up about this…”
Turf Issues (Barrier)
I guess one of the other challenges…was that
some of our physicians are not as embracing of a
nurse going out to see their patients, or not their
nurse going out to see their patient. I find that one
of the very frustrating things, that there’s this
protectionism of “my practice” attitude, & we
really have to move away from that. We need to
remember it’s the patient that’s at the center of
what we do, not the physician or the physician’s
views. And that’s a challenge. It’s a challenge I
have had in complex continuing care, it’s a
challenge being out here.
System Wide Gains Thus Far
17
Family Health Teams
• Annual FHT ministry reports now require number of home visits provided
by MDs and team members
CCAC
• Dedicated care coordinator embedded within primary care team highly
effective
Communication with specialists and hospitals
• OTN urban telemedicine access to specialists, team conferences with specialists
and hospital teams in case of admissions beneficial for complex patients
Increasing number of Family Medicine Trainees exposed
to IHBPC
• Academic curriculum expansion in competencies in home-based and team based
care
Questions?
18
Tia Pham, MD
Tracy Smith-Carrier, PhD
Thuynga.pham.utoronto.ca
[email protected]