Transcript 6 retirements resulted in total shift of ______

PATIENTS
FUNDERS
PHYSICIANS
Presenters
Marty Crapper: Executive Director
Cheryl English: Director of Programs and Services
Brandice Hartin: Manager of Primary Care
Relationships with Commercial Interests: none
Grants/Research Support:
none
Speakers Bureau/Honoraria:
none
Consulting Fees: We wish!
none
Other:
none
Mr. and Mrs. Crapper
Clients of a bank in Brighton for 40 years
Longstanding relationship based on trust
Personal relationship with manager
Ways in which the bank offered
help
 We notified patients with a prominent ad in the
newspaper 3 months before we closed
 We could not possibly contact each of our clients
directly
 You will need to seek a new bank who will accept you
on your own. Here is a list of bank manager names
 Good luck!
Objectives
Given the certainty that every provider will eventually
retire and that every patient will experience provider
transition……..
• Share the experiences of managing the transition of care for patients in
Rideau Lakes Township and the village of Westport over the past 10 years
• Reflect on three provider retirement “types” and the variables that might
result in higher patient satisfaction
• Recommend approaches for funders, physicians and patients that could be
used when we are faced with physician retirements in the future
Physician Retirements in North Leeds 2006-2015
5650 patients
change doctors!
650
1000
1200
750
850
500
700
In 3 of the 5 physician retirements, there was
little or no advanced planning for patients to
ensure a smooth transition to a new provider.
How do we move towards a health
system that guarantees patients a
smooth transition when their provider
retires?
5 MD RETIREMENTS RESULTED IN TOTAL SHIFT OF
3,000 PEOPLE IN NORTH LEEDS IN PAST 3-5 YEARS
3 of 5 had no advanced planning
Impacts
 Anxiety
 Continuity of care
 Provider Client therapeutic relationship *
 Trust breakdown
 Provider burdens
 Confusion
 Misinformation
*American Medical Association, 2003
Limited literature on effect of health
outcomes & continuity of care when a
provider leaves, however………
“Comfort with a provider and trust were the attributes of
the therapeutic relationship that are most poignantly
mentioned by patients”
Journal of General Internal Medicine, 2008
Capacity & Supports
Team Based Retirement
Solo Provider Retirement
 Administrative capacity
 Limited capacity
 Support for clients ongoing
 Limited coverage
 Absorbed
 Communication barriers
 Coverage model in place
 Limited inter-professional
 Inter-professional team
 Communication capacity
support
Our Experiences
 Team based practice
(internal CHC)
 Solo Practice setting (less
common in 2016 but still
out there!)
 LHIN funded pilot
Client Experience
What did we want to know?
Were there any differences in experiences
for people who had providers from
different models?
What type of supports best help people
who experience a loss of provider?
What We Asked
 Age (age 70 average)
 What support did you
receive?
 Specific experience
(how they learned of
their doctor leaving)
 Emotional impact
 What additional
support would have
helped you?
How We Asked
 Random telephone
survey
 Name of previous
doctor (for “type”
assignment)
 20 from each of the 3
types: solo
(unsupported), team
(CHC) and LHIN
funded pilot.
 3 questions about
overall satisfaction with
the way they learned
about and were
supported through the
transition to a new
provider.
How did you find out your doctor was leaving?






Doctor told me directly
I received a letter
I received a phone call
I read it in the newspaper
I heard it informally through a friend or neighbour
Other
How did you feel when you first found
out that your doctor was leaving?
(Scale 0 to 5)





Confused vs. Not Confused
Anxious vs. Calm
Alone vs. Supported
Angry vs. Not Angry
Other Feelings
What types of support did you receive when you found
out that your doctor was leaving?





I received direct assistance from my doctor’s office
I was given the name and number of my new doctor
I was provided enough medication for the length of
time needed
I got a call from someone at the new provider office
quickly
Other
Given your experience this past year,
what do you think should happen when a
doctor leaves or retires to make it a
better process for the patient?
Provider Type
20
20
Solo (unsupported)
Team with administration
Pilot (one time LHIN
funding)
20
How did you find out that your doctor was leaving
or retiring?
grapevine
newspaper
letter
team
solo
phone call
doc told me
0
20
40
% of respondents
60
80
How did you feel when you first found out that your
doctor was leaving or retiring?
Angry vs. Not Angry
Alone vs. Supported
Team
Anxious vs. Calm
Solo
Confused vs. Not
Confused
0
1
2
3
4
5
_______________________________________________________
Most Negative
Least Negative
Average Response to Scaling Questions
What type of support or help did you receive when
you got the news that your doctor was leaving or
retiring?
Quick call from new
provider office
Provided with prescriptions
Team
Given name and number of
my new doctor
Direct assistance from
doctor
Solo
Other
0
10
Number of Respondents
20
What support did you receive when you got the
news that your doctor was leaving?.....
Other
The “free text” comments from clients of the solo providers who were
informed by newspaper, word of mouth or letter are eye opening…..
I feel I got no help at
all
I just had to search by
myself
I got very little
support. There was
nothing in place
I did not really get any
assistance until the
new service contacted
me
Was totally up to me
I had to buy my files
back and shop for a
doctor
I did not think this
could happen in
Canada
I had to do the leg
work myself
Abandoned, loss of trust, loss
of sleep, felt like I was not
important
75% of the patients surveyed
who had solo providers gave a
negative answer to the
question of type of support
provided to them.
Team Supported Transition
 I was given quite a
bit of advance
notice so I was
able to prepare
 I was fine
 I was anxious
about seeing
a female
doctor
 I am happy
with the new
doctor
 I did still access
nursing support
while I waited
 It was ok as I
was told not
to worry and
that a new
doctor would
be assigned.
What We Heard….
 There should be a plan & provider responsibility that
results in immediate access
 It should not be up to me to find another MD
 Planned assistance and direct help for patients
 Much better communication when providers retire
What We Heard cont’d….
 The government should not let physicians decide
on their own that they will not see a complex
patient, there should be a process
 Someone needs to be in charge of making sure
patients get service
 The MD on their own did not have the resource to
figure out the solution, support from the system is
needed!
Nov 2nd CRCHC
integrates with FHT
office in Westport- 600
clients needed
transitioning
Mid March Dr. X
announces plans to close
practice in Westport via
letter and in newspaper .
700 Patients need a new
PCP
Evolution Of
Our Client
Transition Pilot
Letter to clients
identifies that doors are
closed as of May 31
How do we deal with
influx of 1300 clients?
CRCHC proposes short
term funding of a
transition team through
the SELHIN to facilitate
smooth transition of all
patients without PCP
Pilot Structure
 Funded for 8 months, LHIN supported and in-kind
contribution provided by CRCHC. Goal is to effectively
transition clients to the existing CHC team.
Transition Team
 Transitions Coordinator
 Intake Receptionist
 Nurse Practitioner
 Pharmacist
 Existing Inter-professional team, SW, RD, RT, MD, NP, RN
 1300 potential clients
Registration and Triage
 Clients registered in person or online, forms at
pharmacy or Dr. X’s office
 Consent for release of information was signed by all
new clients for release of records
 Introductory letter outlining process and reassurance
 Clients triaged and assigned a provider based on
urgency, complexity of the individual, provider
preferences, and scope of practice
Multiple complex
comorbidities (>5)
Unstable health
conditions
Identified by current
provider as a high risk
client
Example: mentally
unstable patients,
terminally ill patients,
uncontrolled diabetes
Should be seen within
3 months time
Multiple comorbidities
( >3)
Stable conditions
Multiple medications
Advanced age
Mental health
concerns
Healthy
Need to be seen within
1 months time
Complex
Urgent
Triage Process
Need to be seen
within 8 months
(extra funding
runs out)
Few comorbidities
(<3)
Stable conditions
Few medications
Example: Younger,
well population
Client A- recent
DVT requiring
hospitalization,
started on
Warfarin with no
follow up from
PCP and no INR
bloodwork
Urgent
Case Examples
Client B- suffering
from CHF, COPD,
AFib, past hx of
CVA, prostate ca,
EF of 35%, 14
medications
Healthy
Complex
Client C- suffers
from
developmental
delay and epilepsy
but has not had
seizure in 32
years, lives with
his parents, only 3
medications
Content of Intake Interviews
* Introduction to the CHC
* Health Questionnaire
* EHR Entry and Chart Review
Barriers to Transition
 Time and number of clients needing
service
 Communication
 Access for existing clients
 Needs of new clients
 Lack of trust from new clients
Timelines
How did we deal with lack of time?
• ~600 clients need to be seen from Apr to Nov
• Six 30 min. intake assessments per day starting in April by the
Transition Coordinator
How did we schedule appointments?
 Clients called in order of urgency and complexity for each
assigned provider
 Intake assessments completed prior to the Meet and Greet
with the provider
 Need for Meet and Greet appointment was determined
during the intake assessment
Case Example
Healthy
Client C-55 y.o.
suffers from
developmental
delay and epilepsy,
no CCC on file,
medications
renewed by Dr. X,
no bloodwork since
2014, needs up to
date Td
What was my role with this
client?
Communication
Communication with
Clients
Communication with
Physician
• Methods that were used in the past
to communicate practice closures
• Letters
• Newspaper articles
• Discussion with leaving physician
• Word of mouth
• Social Media
• Discussion of time restraints and
capacity on both accounts
• Dr. X to identify those clients who
were high needs/high acuity
• Understanding that all incoming
records would be forwarded to us by
Dr. X on an ongoing basis
• CRCHC agreed to accommodate
those clients who require bloodwork
or routine injections beginning in
March
Communication with Staff
• Need to communicate intake
process to our existing staff
• Discussion around how to
manage influx of internal
referrals to our existing programs
• Clients who were on >5
medications
• We identified practice
differences/ preferences
Access
How did we address the need for our existing clients to be
unaffected by the influx?
 Locum NP to accommodate the urgent needs and follow up
appointments for existing clients
 Existing clients managed as much as possible by members
of our interdisciplinary team in order to free up the
providers
 Mental Health clients to social work
 Diabetes clients to DB program
 Requests for medication renewals to pharmacist
Needs of New Clients
How did we address the urgent needs of the new
clients?
 New clients were seen for urgent issues by primary care
team even prior to the intake assessment
 New clients were referred internally to members of our
team during intake
 Mental Health clients to social work
 Clients on >5 medications to Pharmacist
 Diabetes clients to DB program
Case Example
Client D- 40 y.o man with Asperger’s who identified
during the intake appointment that he felt depressed,
stressed, anxious, ashamed, trapped, angry, and was
suffering from suicidal ideation
 Never been seen by psychiatry
 No counselling services provided
 No psychiatric medications
 No form of support other than his mother
How did we support this client?
Trust
How did we address the lack of trust?
By addressing the issues as the client brought them up
By identifying what is important to the client
What is important to you?
What are you worried about right now?
Why is it important to ask these
questions?
Case Example
Client E- 50 y.o female with hypertension,
bipolar disorder, and fibromyalgia.
Biggest concern?
Teeth!
She reported constant taste of blood in her mouth,
and teeth breaking off anytime she tries to eat
something solid.
Lessons Learned
What worked
 Upfront intake admin support
 Transitions Coordinator role was critical for triage & support
 Documentation & health record “work up”
 Collaborative work with solo MD & staff
 Social media messaging
 Board of Directors role in communication
Improvements
 Communication, communication, communication– INSIDE & OUT
 Reduce steps for intake & registration process
Transition Pilot Client
Experience
How did you find out that your doctor was leaving
or retiring?
grapevine
newspaper
pilot
letter
team
solo
phone call
doc told me
0
20
40
% of respondents
60
80
How did you feel when you first found out that your
doctor was leaving or retiring?
Angry vs. Not Angry
Alone vs. Supported
Pilot
Team
Anxious vs. Calm
Solo
Confused vs. Not Confused
0
1
2
3
4
5
_______________________________________________________
Most Negative
Least Negative
Average Response to Scaling Questions
What type of support or help did you receive when
you got the news that your doctor was leaving or
retiring?
Quick call from new
provider office
Provided with prescriptions
Pilot
Team
Given name and number of
my new doctor
Solo
Direct assistance from
doctor
0
10
Number of Respondents
20
Transition Pilot
What type of support did you receive when you got
the news that your doctor was leaving?
 I just had to wait for
someone to call. A
young lady got in
touch. She worked
for the new doctors
office
 I was introduced to a
pharmacist who
helped me prepare
for my visit with a
new doctor.
 Was told of new
provider and given a
f0rm to fill out
 I had a phone call
from the new service
and they made an
appointment
 Very poor support,
too little, too late
 I felt abandoned but
fortunate that
Country Roads
stepped in
 Took a long time to
get appointment
6 Months Later….
 I think that the idea of reaching out to patients on FB is a smart
idea
 I think your communication with the community is a big
strength
 You helped me when my doctor retired, she did not give me
much notice and I needed help, you were there for us
 Professional and very efficient, the clinic runs like a charm
 I think the new system of using a variety of professions is much
more efficient than having one everyone see the doctor.
How do we move towards a health
system that guarantees patients a
smooth transition when their provider
retires?
Dr. Ian Shiozaki
•
•
•
•
•
Location: Newboro, Ontario
History: Over 30 years in same location
Clients: 1200
Age 63
Team composition: 1 RN, 1 Medical
Receptionist
• Retirement Plans???
SHARED RESPONSIBILITY??
Patient
Provider
System