Proposal for Consideration. Submitted by: The South Okanagan Similkameen Divisions of Family Practice and the Interior Health Authority

Transcription

1 Service Delivery Model for Quality Medical Care in Residential Care for Interior Health Authority Contracted Residential Care Facilities in Penticton and Summerland Proposal for Consideration Submitted by: The South Okanagan Similkameen Divisions of Family Practice and the Interior Health Authority

2 INTRODUCTION A scan of the literature describing leading practices in the care of the frail elderly in residential care highlights the importance of the role physicians play as part of a multidisciplinary team of health care providers. pivotal in defining, supporting and leading quality of care for this complex population with multiple co-morbidities, including health challenges which impact cognition and behavior, and chronic disease impacts. (Fraser 2010) These challenges highlight the importance of developing a comprehensive model of physician support complex residents in residential care. This proposal outlines the service delivery model for quality medical care in residential care for Interior Health Authority owned and contracted residential care facilities in the Penticton and Summerland health service areas. The service delivery model was designed with intent to meet specific outcomes including (a) the provision of proactive quality medical care for individuals in a residential care setting, (b) establishment of longitudinal and relational attachment of family physician to patient, and (c) ensuring provision of the right care at the right time in the right setting. COMMUNITY DESCRIPTOR This service delivery model covers the Interior Health owned and operated and contracted residential facilities in the Summerland and Penticton health service areas. There are a total of seven (7) facilities with 619 beds. Penticton has 464 beds in five facilities with an estimate of 2.3 admissions per week (120 per year). Summerland has 155 beds in two (2) facilities with 155 beds with an estimate of 1.2 admissions per week (62 per year). BACKGROUND: Current Issues The South Okanagan Residential Care Working Committee reviewed the current state of physician care in residential settings in our communities and the issues raised reflected the current issues identified in the Fraser Proposal with slight additions to point 6 and 7(Fraser 2010). 1. Physicians are often not readily available when a patient deteriorates with a new medical problem. This may lead to the patient being transported to the Emergency Department and increases the potential for an acute care admission. Page 1

3 2. Many patients within Residential Care do not have a current or regular physical assessment either completed or documented, nor do they have complete medication reviews. These two issues contribute to polypharmacy. Polypharmacy is costly to the system, and increases risk of side effects, drug interaction and admission to Emergency Departments or hospitals. 3. The current medical approach for many patients in residential care is episodic rather than proactive in nature leading to patients being subject to inappropriate transfers and medical interventions especially related to end of life issues. 4. The current medical approach/model is unsustainable from the family populations that were associated with the former nursing home model (well elderly) versus a patient population with multiple co-morbidities, complex medication regimes, and end of life symptom management requirements. The model is ineffective and relies mainly on one type of primary care service the family physician. 5. The current medical approach/model is leading to increased quality of care issues, related to inconsistent physician support, lack of standardization and is an unsustainable model from the perspective of the health authorities. 6. There is an increasing inability to recruit and retain family physicians that wish to practice in residential care settings, largely related to the complex and time-consuming nature of the population as well as inadequate compensation. 7. Some Family physicians report difficulties in effectively following residents after admission to residential care. Inefficiency exists that make it difficult for physicians to provide care, such as: rounds and care conferences are not scheduled at convenient times for physicians, staff are not available to inadequate. 8. The physicians caring for these patients often are working in isolation, without benefits of peer support, and new evidence and guidelines pertaining to residential care. Principles The model must: 1. Promote and support longitudinal attachment of a primary care provider to the patient 2. improved access for patients requiring urgent medical assessments within the residential care setting through 24-7 coverage with appropriate compensation. 3. Promote consistency in care provision, including documentation Page 2

4 4. Contain features such as completion and documentation of regular clinical assessments, visits, participation in conference and care planning. 5. Be based in a proactive care approach especially in the areas of chronic disease management, medication management including pharmacy reviews, death reviews, dementia care, advanced care planning and end of life care planning. 6. Incorporate a prevention care approach especially in identifying and addressing clinical issues that will support the prevention of transfers to emergency departments, admissions to hospitals or the need for after hour medical crisis interventions. 7. Promote early transition of an admitted residential care patient in hospital care back to residential care should a patient require hospital admission. 8. Promote full scope family physician practice. 9. Support and encourage MRP role to provide an effective and efficient method for the delivery of comprehensive/high quality care to patients in residential care. 10. Provide physician sustainability incorporating an element of teaching/mentoring medical students, residents and recent graduates. 11. Provide an opportunity for the development and support of the multidisciplinary approach to care that is key to quality in the residential sector. SERVICE DELIVERY MODEL This proposal recommends a model of care that supports longitudinal, relational care by South Okanagan primary care physicians for individuals living in seven residential care facilities in Summerland and Penticton communities. We recommend a two phase approach. Phase 1 is a three prong approach in which the MRP is the key to providing the continuity of care but who is supported by the Doctor of the Day Program for urgent care when required after hours. This approach allows family physicians the ability to provide comprehensive/high quality care to patients in residential care. It also includes a Division Residential Care Medical Coordinator role that will be established to work on developing linkages and network with local systems and processes as well as to identify local gaps in care and services, leading practices and quality improvement opportunities. Page 3

5 Phase 2: The second phase is to expand either the Residential Care Medical Coordinator Position or consider a Health Authority Regional Role if the program is to be expanded throughout the Health Authority. The focus would be to promote best practice and standards, implement clinical quality improvement initiatives that will improve the quality of care for all residents as well as promote educational and continuing professional development opportunities. Additional funding would be required. Phase One Below are the three roles that support this model: I. DIVISION RESIDENTIAL CARE MEDICAL COORDINATOR The Division Residential Care Medical Coordinator is selected and accountable to the South Okanagan Similkameen Division of Family Practice. This coordinator works collaboratively with the SOS Divisional Family Practice Board, the local CSC, the MRP and with the residential care facility staff to improve the quality of care for all residents in Summerland and Penticton facilities. Listed below are the responsibilities of this position for the first six months: Establish linkages and networking with local systems and processes. o Community Most Responsible Physicians (MRPs) o Acute care facilities PRH Emergency Medicine departments Surgical departments o Specialist and resource teams o Collaborative Services Committee (CSC) o Medical Coordinators o IH Geriatric Medical Coordinator o Identification of local gaps in care and services, leading practices and quality improvement opportunities o Visit each site at least quarterly (7 sites total- Summerland and Penticton Communities) o Attend quarterly managers meeting o Collaborate with facility managers and the multidisciplinary teams Page 4

6 These additional responsibilities may be added once the foundation of this program is in place: Develop recruitment and retention initiatives to enhance physician support of the long term care sector for their specific Division Education and Continuing Professional Development for their Division for example: o Development of educational opportunities that enhance General Practitioner knowledge, skill and expertise in the care of the frail elderly and psychogeriatrics in collaboration with the Program Medical Director, academic centres etc. o Optimizing basic scope of care, clinical knowledge of residential care II. GP/MOST RESPONSIBLE PHYSICIAN This role is important in maintaining longitudinal, relational attachment of primary care physicians with their patients. Roles and Responsibilities Admit resident to the residential care facility including an admission history and physical exam life care planning Incorporate a prevention care approach Provide proactive care via 1 regular medical visit per resident every 3 months Complete a physical assessment with documentation, including a complete medication review 1 time per year per resident Attend 1 care conference per resident per year Provide chronic disease management and care as appropriate Provide terminal care as appropriate III. URGENT CARE This model proposes that a back- up system be developed to provide 24-7 urgent response to patients in residential care facilities through a connection with the Penticton Hospital Care Program: Doctor of the Day. It is hoped that all physicians involved in the DoD program will agree to participate in the residential program. The SOS Division will establish a system to ensure coverage should a physician opt out of the residential program. Page 5

7 Currently, Physicians in the Hospital Care Program are required to be on site at Penticton Regional Hospital 5 hours per day, 7 days per week. This time is divided into two shifts 7am-9am and 7pm 10pm. During this time, the DoD physician may be required to leave the Hospital to attend to an urgent matter at one of the residential sites involved in this program. Therefore, the Hospital Care Program will need to be revised to support this new requirement. Roles and Responsibilities Respond to urgent medical calls and provide urgent medical assessments as required by facilities Follow already established care plans and document urgent care provided If MRP is not available, support early transition of hospital admitted residential care patients back to residential care Work with facilities to prevent inappropriate transfers to hospital when appropriate Provide feedback to MRP regarding urgent care provided by requesting facility fax a copy of the notes to MRP Stage 2: Expanding the Program to include Clinical Quality Improvement, This stage requires additional resources to either expand the Division Residential Care Medical Coordinator role or if program will expand regionally a Health Authority Role may be developed. The residential committee will review performance indicator results and make further recommendations. Listed below is an initial outline of additional responsibilities: Clinical Quality Improvement o Promote and monitor best practice standards and standardize best practice for Penticton and Summerland Sites o Guide and review continuous quality improvement performance measurements and recommend improvements o Collaborate with other in evaluating the outcomes of the Residential Physician Care Program o Provide support with medication reviews o Provide support with death reviews o Provide support with critical incident reviews o Identify opportunities for smoothing transition points for individuals in the residential care sector as they transition to/from acute, community and other services streams Page 6

8 QUALITY OF CARE AND SERVICE What changes can we make that will result in improvements? a. Reactive Care Goal: To provide care that meets the clinical needs of patients as they transition to/from acute care and community in a timely manner while ensuring continuity of care that response to the right service and the right time. To include such aspects as: supporting admissions to residential care facilities 7 days a week facilitating transfer to the emergency improving communication regarding the goals of care supporting family understanding of the patients wishes (Advance Directives) ensuring resource intense services are used appropriately for this population reducing inappropriate use of the emergency department, ambulance services and others involved in transferring individuals to the emergency department for services that are within the scope of a community full service family practitioner b. Care of the Acutely Ill Goal: To provide supports to acutely ill patients in residential care to maintain patients in the facility and to support returning residents from acute care in a timely manner. This may include: o clinical assessment that reflect the multidisciplinary team care o enhanced end of life care supports, taking a leading role with families to support Advance Directives and appropriate medical intervention o identifing current practices and systems issues that create barriers and to collaborate with partners to improve these processes and practices Issues identified to date include: Institution of IV therapy Suturing sets available on site Ensuring equipment is accessible Providing medications in a timely manner c. Emergent Proactive Care: Goal: To prevent avoidable admissions to the emergency department. to support the MRP role in providing care for their patients 24-7 in the residential setting by establishing a connection with the DoD Program for urgent care after. Page 7

9 d. Regular Prevention Care Goal: To support the MRP in ensuring appropriate, chronic disease alleviation (symptoms) in the comorbid, frail, elderly population. To develop standards, guidelines and protocols that will provide best medical practice in the appropriate care of chronic diseases in the frail, aging and end-of life population in the residential sector. To ensure regular physical assessment completed, documented and integrated into plans of care. e. Enhanced Clinical Support Goal: To provide enhanced supports to specialty populations within the residential sector, including psychogeriatric, acquired brain injury, neurologic and other populations. Development of clinical skills and leadership to fill the gap related to lack of geriatric psychiatrists, geriatricians and other medical specialty supports to the frail elderly population. PERFORMANCE MEASURES The partners: MoHS, the SOS Division and IHA will collectively agree on measures. How will we know there is improved care? Decreased unnecessary transfers to emergency departments Decreased admissions to acute care Decreased length of stay in the acute care Increased number of individuals supported in their complex care homes during their last days of life, rather than admissions to acute care Increased continuity of care for unattached patients Decreased in medication costs with focused attention on the challenges with polypharmacy Improved communication family/physician/facility staff Timely, proactive quality care rather than reactive care All patients in residential care facilities in these two communities will have a primary care physician Performance measures to include: Accessibility All patients in residential care facilities to have a primary care physician. (Audit) Page 8

10 Appropriateness Increase in the number of residen appropriate end of life care and medical support for pain management. (RAI) Decrease in the number of unscheduled transfer to Emergency Department. (Utilization statistics) Decrease in the average length of stay of those residents admitted to acute care hospital. (Utilization statistics) Coordination Documented advance care planning on all residents target 90% of al residents. (Chart reviews) Number of staff/family care conferences held in residential care facilities with physician attendance. (Chart Reviews) Safety Decrease in the number of medications per resident. (RAI) Increase the percentage of residential care residents who have had medication review within the last 3-6 months. (RAI, Chart Reviews) Effectiveness Decrease in the number of unscheduled transfers to the emergency department. (Utilization statistics) Decrease in the number of residential care residents admitted to hospital through the emergency department. (utilization statistics) Experience Develop a physician satisfaction survey. (new key measure) ROLE OF OTHER MEDICAL PROVIDERS To collaborate on the development, implementation and support of other medical provider roles that will enhance the timely, quality of care and service to the residential care sector. Such roles may include: Page 9

11 Advanced Practitioner with a specialized body of knowledge in the care of frail elderly population, the geriatric psychiatry population, or the neurologic population. Nurse Practitioner Psychiatrist /Geriatrics Currently involved in care: Pharmacists Wound care nurse Dietitian OT/PT At the moment the model does not indicate who would be the employer of these individuals nor the funding source for these positions. PROMOTING ATTACHMENT The South Okanagan Similkameen Division of Family Program will ensure that all residential complex care patients have a primary care physician. As a Division we will promote full-service community general practitioners that follow their patients throughout their lives and practice in a number of settings. However, should a physician choose to transfer the care the Division will work with the IH Access Coordinator to develop a roster to assign a physician that is similar to the system currently operated in Summerland. PROPOSED FUNDING MODEL Divisional Medical Coordinator for RC This role would be funded by the Division through a Residential Care Service Agreement with the Ministry of Health allocating new funding for this service. The allocation of resource in terms of hours of equivalence would be determined by the Collaborative Services Committee and would in part be based on an agreed upon formula consistent throughout the Province. Proposed allocation is based on the number of RC beds that are Interior Health owned, operated and contracted residential facilities in the Summerland and Penticton health service areas. There are a total of seven (7) facilities with 619 beds, which would result in 7 hours per week. Less than or equal to 300 beds 3.5 hours per week 400 beds to 800 beds 7 hrs per week 800 beds + 8 hrs per week Page 10

12 a) Division Medical Coordinator for 619 bedsi /hour of service provided ii. $35/hr for office overhead while performing Medical Coordinator Role iii. Total 52 days x (7hrsX151.52) =$55, Enhance Physician Roles: MRP & Urgent Response The MRP and Urgent Response roles would be funded by the Division through a Residential Care Service Agreement with the Ministry of Health allocating new funding for this service. The allocation of funding would be a fix bed rate of $350 per year per bed with the understanding that the physicians could also bill through MSP services. The HA would not contribute to these roles. b) Enhance Physician Roles for 619@ $ per year per bed (prorated based on contract duration) i. MRP - $200 per year per bed = $200 x 619=$123,800 ii. Urgent Response - $250 x 365 days=$91,250 iii. Administration:$ iv. Total payment= $216,650 MOST RESPONSIBLE PHYSICIAN In addition, this role would also be funded through MSP Billing. It is anticipated that the estimated MSP billing would be $ for any newly admitted residents as well as a total of $ per resident per year as per billing codes related to routine medical care (i.e. proactive quality care). Please refer to attached MSP Billing Protection MRP in the appendix. URGENT RESPONSE This role would be funded by the Division through a MOU between the MOH and the SOS DivFP as describe above at the rate of $ per day. REFERENCES Adapted from Division of Family Practice Service Delivery Model Residential Care October 26 th, 2010 Proposal for Consideration for a Research Prototyping Model for Quality Medical Care in Residential Care for Health Authority Contracted Residential Care (Fraser Health), Page 11