Photo Credit - Toronto Star , 2011

1. The Integrated Home-Based Primary Care (IHBPC) Project Dr. Sabrina Akhtar TWFHT Dr. Thuy-Nga Pham SETFHTDr. Mark Nowaczynski House Calls Dr. Samir Sinha UHN/MSH GeriatricsDr. Tracy Smith-Carrier King’s, Western Dipti Purbhoo TC-CCAC Photo Credit - Toronto Star, 2011

2. Rationale for our Collaborative – Why? • 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

3. Background 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 famillecanadien 2013;59(3):237-40.

4. Who are our patients?

5. Integrated Home Based Primary Care Catchment Taddle Creek FHT MSH FHT

6. Patient Site Totals *Totals as of March 26, 2014

7. IHBPC Models of Primary Care 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.

8. Program Objectives – What are we doing? Patient Care Objectives Integrated Care Team Objectives • Provide a comprehensive and integrated approach to patient and client care • Improve transitions in care between acute, primary care and community care settings • Establish a network of specialists to support home-based primary care with recent urban telemedicine expansion • Develop shared understanding of roles, responsibilities and accountabilities between providers • Improve communication among team members and across the continuum of care and organizations • Enhance care management partnerships between primary care and community care providers “Skype in your specialist”

9. What are we measuring?

10. Qualitative Research

11. Interprofessional Team Experience 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

12. Dimensions of IHBPC Service Delivery to Team Members

13. Context of IHBPC Types of Teams 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 CCAC …The introduction of CCAC in house, has streamlined the process which is amazing. 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… 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.

14. Benefits of IHBPC 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 • 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 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… 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.

15. Barriers Administrative Load Travel …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. 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.

16. Facilitators & Barriers of Team Collaboration Variety of Communication Mechanisms (Facilitators) Turf Issues (Barrier) 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 ongoing 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…” Iguess 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.

17. System Wide Gains Thus Far

18. Questions? Tia Pham, MD Tracy Smith-Carrier, PhD Thuynga.pham.utoronto.ca tsmithca@uwo.ca