ALBERTA MEDICAL ASSOCIATION PRIMARY CARE SUMMIT WHAT WE HEARD

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1 ALBERTA MEDICAL ASSOCIATION PRIMARY CARE SUMMIT WHAT WE HEARD Corinne Saad February 8, 2013

2 CONTENTS Introduction... 2 Primary health care: What s working... 2 Physician/patient relationship... 2 Team approach... 3 Business model... 3 Information management systems... 3 Access... 4 Primary health care: Where are the gaps?... 4 Access... 4 Communication... 4 Home care... 5 Funding model... 5 Patient registration... 5 Variations in care... 5 Primary health care: The next steps... 5 Enhance coordination and access... 5 Improve connectivity... 6 Promote stability with a new funding model and long-term business plan... 6 Free up resources... 6 Enabling patients to manage their own health... 7 Utilize technology... 7 Expand education... 7 Advocate... 7 Conclusion P a g e

3 INTRODUCTION On Saturday, February 2, the Alberta Medical Association (AMA) held the first in a series of summits discussing primary health care with physicians and patients. About 60 physicians, from the 46 primary care networks (PCNs) across the province, and 30 patients came together to generously provide their input. After a welcome from AMA President Dr. R. Michael Giuffre, Dr. Phillip van der Merwe and Dr. Ann Vaidya set the stage for discussions, describing the evolution of primary care in Alberta over the last 10 years. Dr. van der Merwe detailed how over-worked, disgruntled family physicians lives have been transformed by PCNs: they are now energized by team-based care, where the burden is shared and patients needs are at the center of our work. Dr. Vaidya described the physician s role as that of a professional friend, to address each patient s entire spectrum of needs and help them navigate through their medical home. There is more work to be done, each presenter stressed, to evolve primary health care, smoothing out the process, ensuring that each Albertan has a similarly positive experience: a medical home in their neighborhood, staffed by a team of professionals responsive to the needs of that community, anchored by a doctor, with the patient at the center. Achieving a flexible, responsive model is not possible for one doctor on his or her own but it is a feasible goal for a whole team. As primary care evolves, the AMA is eager to solicit input from patients. Guest speaker, Jim Swaffield from the University of Alberta s School of Business, described the importance of managing expectations determining clearly what the goal should be in primary health care and then agreeing on what Albertans should expect what primary health care can deliver. To further discuss their expectations from primary health care, physicians and patients broke out into smaller groups to answer: 1. What works right now? 2. Where are some of the gaps? 3. What can be done to address those gaps? 4. How can Albertans more effectively manage their own health care? PRIMARY HEALTH CARE: WHAT S WORKING PHYSICIAN/PATIENT RELATIONSHIP The importance, sanctity almost, of the physician/patient relationship came up repeatedly in all groups as the foundation of effective care. For the most part, patients were very appreciative of the relationship that they have with their family physician: My doctor educates me and gives me options. He knows I prefer not to use drugs so he ll advise me and give me choices according to what I want. 2 P a g e

4 For many patients the relationship with other key team members was also significant, particularly if it was a health professional they had to see frequently. It all came down to increased levels of trust within each relationship, but also in the system with comments such as: When I walk into the clinic they know who I am. I might have to wait, but the doctor never rushes me out either. TEAM APPROACH For physicians the team approach not only improves the care they are able to offer their patients and the number of patients they can see in a day, but also improves their own job satisfaction. When the team works effectively, the physician is able to focus on his or her area of expertise, leaving other professionals to theirs, decreasing the overwhelming burden that family physicians had been feeling and enhancing their quality of life. Integral to an efficient team are the individual components: My PCN manager is the quarterback for the system. She looks at the patients needs and shifts services to ensure those needs are met. Patients felt that they are able to see the professional they needed to see the most: that their care is now focused on outcomes with one team member ensuring the coordination. The ideal team was described as flexible and dynamic, meeting patients needs. Registered nurses and nurse practitioners were mentioned as integral members of the PCN team, extending the relationship that physicians and nurses have traditionally had of working side by side in the hospital to the clinic setting. Other professionals discussed were psychologists, dieticians and physiotherapists. Both physicians and patients stressed the advantages of having mental health supports available in clinics. Some patients would like to see more intense supports in that area. Patients were also appreciative of any services, such as pharmacy, X-ray or lab that are co-located in their PCN. BUSINESS MODEL Several physicians expressed pride in the business models that have emerged following conversations on how to build a practice that works. They also talked positively about alternate payment plans and the flexibility of deciding which plan would work most effectively for their practices for instance, one that removes the tyranny of whites of the eyes. The fee-for-service model can be an advantage, some physicians said: physicians can determine the correct blend of services for their communities, with flexibility to manage patients with complex needs. Services might, for example, include education programs (such as smoking cessation) or after care, managed by nurses. INFORMATION MANAGEMENT SYSTEMS In each of the physician groups, Netcare and electronic medical records (EMRs) came up as useful tools. One group described EMRs as essential to good communication between the physician and other team members. Another discussed the role of EMRs in organizing screening and chronic disease management. 3 P a g e

5 ACCESS Many patients talked about improved access: firstly, that they can get appointments more quickly ( Access is terrific. I get an appointment within 24 hours. ); secondly, that they can see whomever they believe they need to see on the team. One patient in particular appreciated being able to see a dietician whenever she needed, without a physician s referral. Some physicians also discussed specialist linkages (with psychiatrists, orthopedic surgeons, cardiologists) as improving access for their patients to that level of care. Navigation of the system, help in accessing the services required, has been improved in many cases: Navigation is the big thing. My nurse navigator is now able to communicate with me through . PRIMARY HEALTH CARE: WHERE ARE THE GAPS? ACCESS While access has improved, all participants still saw access as problematic in some areas, and they defined access on several different levels. As noted above, most patients were happy with access to their family physician, although there was some discussion about older patients reporting difficulties with that. One group also discussed after-hours care and how that could be improved. And some physicians described high staff turnover, which ultimately affects patient access. Rural PCNs need particular attention paid to this issue. A source of much frustration to both patients and physicians was access to specialists. They did not find acceptable the amount of time they had to wait to see specialists. Patients were also unhappy with communication from specialists offices: Am I even on a list? In some cases there were concerns about access to other health professionals: one patient talked about having to go on a waiting list to see the dietician at his PCN. Others were disappointed with access to mental health professionals within their PCN. COMMUNICATION With lack of access to specialists came frustration with communication between offices and with labs as patients waited for results. Silo type of care is how one group described it. Integrated data systems across the spectrum is also a problem, and might go some way to address communication issues, particularly when it comes to access to specialists and lab results. The perceived lack of communication between Alberta Health Services (AHS) and PCNs contributes, it was thought, to a lack of clarity around responsibilities who is delivering which services? and ultimately puts up barriers to services that patients need. Some patients also talked about a lack of communication about PCNs: several weren t sure if the clinic they visit is in fact a PCN; others were unclear about the services they might expect to receive at their PCN. 4 P a g e

6 HOME CARE Similar issues around access and communication emerged repeatedly over the morning with regard to home care. This seemed to be particularly frustrating for many patients and physicians, bogged down in bureaucracy. The suggestion was made that home care should be moved to PCNs. FUNDING MODEL Physicians suggested that there still needs to be a formal funding mechanism put in place that would further enhance the system and improve patient flow. Fee-for-service payment, they said, can reward volume, not quality, of service. And it does not align with both physicians and patients desire to explore alternative methods of consultation. Another group pointed out that per capita funding does not work for some communities, particularly where there are large numbers of people who are homeless, have a mental illness or struggle with addiction issues. And there are problems around funding and staffing models for allied health professionals. Physicians said that remuneration should be based on comprehensive care. Patients recognized the inefficiencies that current funding models create: they talked about a misuse of doctors time when I have to come in for refills of medication. They agreed that appointments for lab results were another example. PATIENT REGISTRATION One group of physicians mentioned that lack of registration for patients can lead to frequent flyer patients, or people falling through the cracks. Formal attachment of patients to PCNs would improve patient care. Patients who see many different physicians at walk-in clinics are provided with band-aid solutions, without a single physician taking responsibility for that patient. VARIATIONS IN CARE While many PCNs work effectively, placing the patient firmly at the center of the business model, others do not. Patients pointed out that those variations in experience should be addressed with specific practice standards. Variations seem to be particularly pronounced in the cases of sole practitioners. PRIMARY HEALTH CARE: THE NEXT STEPS ENHANCE COORDINATION AND ACCESS Patients like the team approach and they want more of it. One physician pointed out: They want us to talk to each other; work together; they want a functional medical home. Patients reiterated that point, expressing a clear desire to have family physicians and specialists communicate and share information more effectively, with reduced barriers between agencies. One physician group suggested that a designated coordinator might be an effective solution. Patients talked about a patient advocate, particularly for seniors as they transition from emergency department, to acute care, to geriatric rehabilitation, back into their homes. 5 P a g e

7 Furthermore, patients would like to have greater input into the services that PCNs offer, particularly additional programs around lifestyle issues: Survey me. Ask me. Co-location of care was seen as key to PCN efficiency even for community services such as supportive housing or home outreach programs addressing the social determinants of health in a more holistic way. The latter implies improved coordination with other provincial government departments, such as Human Services, Justice and Education and potentially with the Federal Government too. Patients also want more effective after-hours care. There were some interesting suggestions of how that might work building on HealthLink to connect patients to a doctor on the phone, a dedicated intake phone line, or just a physician on call. IMPROVE CONNECTIVITY Every group discussed the advantages inherent in using technology more effectively. One patient talked enthusiastically about as a great way simply to book appointments, creating a link directly to her calendar. Other patients took the idea one step further, saying they did not feel that they always need to see their physician an exchange might work instead, particularly around lab results. Physicians in rural communities talked about alternative ways that they might connect with patients, using Skype for example. Balancing all of these discussions, of course, were caveats around privacy. PROMOTE STABILITY WITH A NEW FUNDING MODEL AND LONG-TERM BUSINESS PLAN The funding of each PCN should be dependent on the team working there and the services the team provides. The ideal panel size should be similarly determined. Physicians also discussed the need for long-term business plans, with measurements built in, so that services are analyzed and assessed systematically. One group talked about reducing administration overload. Fundamentally, PCNs need financial and HR stability to build teams and relationships. FREE UP RESOURCES Many of the physicians talked about resources that are used for expensive tests for patients, which may not be necessary. They felt that two things would address this: more effective patient education around testing, and a fully integrated information management system that manages the flow of patients. There was also some discussion about managing expectations: the Generation X population, one group thought, has different expectations than the older generation in terms of the scope of testing available and immediacy. One group of physicians discussed group visits or programs, and how effective those can be for patients and the PCN team. Examples cited were Get Up and Go for seniors in Red Deer, helping them increase their level of activity, or fall prevention programs, again operated through the PCN. Patients also suggested that they could see nurses more often, for immunizations, PAP tests, or surgery follow-up. 6 P a g e

8 ENABLING PATIENTS TO MANAGE THEIR OWN HEALTH Many of the strategies suggested above would enable patients to take better control of their own health ensuring that PCNs are not just seen as clinics for the sick, but as offering resources for maintaining health and managing risk factors such as smoking and weight. Some other specific ideas were: UTILIZE TECHNOLOGY Technology was not just proposed as a means for improved communication, but also as a resource for patients to control their own health. One suggestion was that patients should be able to upload their blood sugar levels, for example, which would have the dual benefit of encouraging them to test their blood regularly and invest in the results. Patients want better access to their medical records, to Netcare, in order to allow them to self-manage their care. And many would like a patient portal: myhealth.alberta. EXPAND EDUCATION Many patients want to know more: Educate me and tell me why. Another patient said: Show me the relationship between risk factors and health, for example, a graph showing the relationship between weight and blood pressure over time. Patients expect physicians to treat the whole person, not just the disease. But they are not anticipating that physicians would do more, rather that other members of the health team, such as nurses, would follow up with more in-depth education. Physicians pointed out that group visits involving other health professionals also provide expanded opportunities for education. So that chronic disease prevention becomes a key focus for the next iteration of PCNs. Patients don t just want more information about their health. Some patients also talked about wanting to better understand costs how much their care is costing the system. ADVOCATE Physicians have the potential to play an important role in bringing together community partners to address social determinants of health and population health in innovative ways suited to individual communities, forging community alliances. An example given was the outdoor gyms in Red Deer, initiated by the PCN but with community organizations joining in. Advocacy, it was suggested, could be taken further: influencing what children are taught in school about health; becoming part of conversations about urban design and how innovative design can promote good health; giving the physician stamp of approval for healthy community initiatives. 7 P a g e

9 CONCLUSION The overall tone of the summit was extremely positive. There is a lot to be celebrated that is working well. One patient talked about feeling embraced by her PCN: the team approach, rooted in solid patient/physician relationships, works well for patients and physicians alike. The challenge now is to take the successes and duplicate them across the province: tailoring unique solutions for each community s needs; ensuring solid business practices and innovative funding models with integrated IT solutions; expanding the team approach in a doctor-led environment, so that prevention, as well as cure, becomes a focus for PCNs. Summit participants described a future where patients don t just turn to their clinic in times of sickness, but as a place to help them maintain good health physical and mental. Patients ended the session with a resounding thank you for being our family doctors. Despite the challenges that still exist, they clearly value the hard work that has taken place over the last 10 years to build PCNs, and look forward to seeing how that work will evolve into PCNs P a g e

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