Family Practice Teams: Professional Role Identity

1. Family Practice Teams: Professional Role Identity Introduction to the session Overview of the literature Marie-Dominique Beaulieu And Associates

2. Primary Care RenewalLessons to Learn We would like to express our thanks to Health Canada for its support related to this FMF Session and its ongoing support related to the work of The College of Family Physicians of Canada in Primary Care.

3. Why This Session at FMF 2007? Increasing focus on primary care at the CFPC Establishment of Advisory Committee on Primary Care Renewal Creation and maintenance of Primary Care Toolkit at www.toolkit.cfpc.ca Increasing interest in the roles of nurses working with family physicians in primary care / family practice Increasing need to focus on process in primary care / family practice, e.g. access to care, continuity of care and quality of care (performance)

4. Objectives of FMF Session What do we know about the effectiveness of team work in primary care and FP-nurse collaboration? How to define collaborative practice ? What is the evidence that it works in PC? What have we learned so far about success factors?

5. Plan of the session Overview of Interprofessional Collaboration in Primary Care Optimizing the Family Practice Nurse role in family practice settings (C Todd) FPN and FPs working together to improve: Continuity of care (J. Brewer/A. Alsaffar) Access to care (R. Wedel/C. Todd) Quality of care (D. Gelhorn/A. Kowalski) Conclusion

7. Collaborative practice �Collaborative practice is an inter-professional process for communication and decision-making that enables the separate and shared knowledge and skills of care providers to synergistically influence client/patient care provided.� � Ontario College of Family Physicians 2000 Collaboration within a team can be described as a continuum of professional autonomy. Collaborating in a team is not a static process: it evolves with the needs of the patients/community and with the shared experiences/expertise of the team members.Collaboration within a team can be described as a continuum of professional autonomy. Collaborating in a team is not a static process: it evolves with the needs of the patients/community and with the shared experiences/expertise of the team members.

8. Seven Components of Collaboration Responsibility and accountability Co-ordination Communication Co-operation Assertiveness Autonomy Mutual trust and respect

9. Research on Interdisciplinary Teams in Primary Care Most of the evidence comes from research on ��integrated�� care for specific clients ��Team work�� is part of the intervention but poorly defined or conceptualized. A handful of studies have looked at the impact on health outcomes Few studies on primary care in family practice settings, but some interesting ones ...

10. Nurses and Family Physicians Working Together in Primary Care Evaluation and triage (Lattimer et al 1998, Thompson et al 1999, Reveley 1998) Management of acute problems (Butler &Rees 2001, Shum et al 2000, Caldows et al. 2006) Follow-up of chronic problems (Lyons 2005,Evans et al 2005, Keanaly 2004)

11. Effectiveness of Primary Care Teams In a study of 68 PC health care teams (and 568 members), Poulton and West showed that team process was an independent predictor of team effectiveness while team structure (size, tenure, budget) was not associated with outcome. � Poulton BC, West MA, J Interprofessional Care,1999 Effectiveness defined as : Team work Organisational efficiency Health care practices (no CPGs Patient Centeredness Effectiveness defined as : Team work Organisational efficiency Health care practices (no CPGs Patient Centeredness

12. Effectiveness of Primary Care Teams in General Practice In an observational study of a random sample of 60 general practices in the UK, team process - as measured by the Team Climate Inventory - was an independent predictor of increased access to care as perceived by patients and of diabetes control (Hba1c) � Campbell SM et al, BMJ 2001 Douglas Roblin, in USA, reported similar results in a study of the redesigh of work in PC teams in the Kaiser Permanente in Georgia in a communication et the Academy for Health Services research and Health Policy in Washington in 2002.Douglas Roblin, in USA, reported similar results in a study of the redesigh of work in PC teams in the Kaiser Permanente in Georgia in a communication et the Academy for Health Services research and Health Policy in Washington in 2002.

13. Who are the Canadian Family Physicians and Nurses Working in Primary Care? Of primary care providers in Canada: GPs: 140 per 100,000 inhabitants RNs: 790 per 100,00 inhabitants (40% in PC) NPs: 878 in 2004. 25% of FPs work in solo practices 46% in inner cities 19% in remote areas 13% of FPs reported working closely with NPs and 43.6% with FP nurses � from NPS 2007

14. FPs working with nurses*

15. The Canadian Scene: Experiences Supported by the PHCTF 47 initiatives Health Care Renewal in New Brunswick Five community health centres / interdisciplinary teams Newfoundland and Labrador Primary Health Care Initiative Eight interprofessional PHC teams Family Medicine Groups in Qu�bec Ontario: 100 new practices (FHG, FHN, FHT) The Manitoba PHCTF Initiative Saskatchewan: 17 PHC teams British Columbia PHCTF Initiative 92 practice models implemented

16. What barriers to expect?What levers to mobilize? Determinants of effective collaboration and team work: Systemic determinants Cultural, professional, educational Organisational determinants Organizational philosophy and structure, administrative support, team resources, communication mechanisms Interactional determinants

17. Systemic Determinants of Collaboration Liability issues Scopes of practice Professional regulation policies: variability across provinces and territories Remuneration of professionals and funding schemes for primary care: fee-for service is not a facilitator. Training issues Human resources Current Canadian context of shortage of human resources is an asset and a barrier

18. Examples of Organisational Factors That Foster Collaboration Team meetings in which goals are discussed Patient-centeredness: assessing practice needs Formalization of protocols Statutory meetings Leadership Access to expertise in collaboration /shared professional education Enjeu 1 : la collaboration n��tant pas Enjeu 1 : la collaboration n��tant pas

19. Interactional Determinants of Collaboration Willingness to collaborate Trust Level of trust based on perception of competence and on the knowledge of the other profession�s field Mutual respect Capacity to discuss role identities and to clarify responsibilities

20. The Challenges Facing PC Teams Integration of the nursing and the medical models: evolving scopes of practice Making team care visible to patients Relationships with specialized care teams

21. In summary What we mean by team work varies considerably There is evidence suggesting that ��Primary Care Teams�� are associated with better outcomes in general practice settings No magic bullet: team effectiveness depends on the ��quality�� of team processes and the support it receives Teams operate in systems: all the actual knowledge we have on team work is very �context sensitive� Better outcomes : chronic diseases and continuity, accessibility, satisfaction Unanswered questionsBetter outcomes : chronic diseases and continuity, accessibility, satisfaction Unanswered questions

22. Primary Care Toolkit www.toolkit.cfpc.ca

24. Nova Scotia Advisory Committee on primary health care renewal states �� �The core team would include the family physician, family practice nurse, pharmacist, nurse practitioner, social worker, dietician, the appropriate health providers and midwife.�

25. What we knew��. Family practice nursing � not new Ontario family practice nursing group No contact with any FP nurses in NS Nothing in the literature

26. Our Journey of Discovery Received grant through the NS Department of Health Nursing Strategy Program Strategic Planning Day - Feb 2004

27. Project Goals Determine the current role of FP/PHC nurses in Nova Scotia Identify common issues, concerns and challenges Establish links with FP/PHC nurses for further networking

28. Methods RN�s identified from CRNNS 2004 registration Limitations of identifying target group 112 questionnaires mailed out 61 returned 41 met the criteria for participating in the survey (45% response rate) 30/41 respondents agreed to participate in a telephone interview (22 were contacted) Ethics approval by CDHA

29. Survey Key themes of collaboration, scope of practice, patient education, triage, documentation and continuity of care Demographics Concerns and challenges - published in June issue of the Canadian Nurse Journal

30. Collaboration

31. Triage: Reasons for Contacting the Nurse 100 % Reassurance and support 100% Clarification of physicians advice 98% Advice and health teaching 90% Medication clarification 87 % Test results 85% Urgent calls 78% of nurses indicated response-time-to-call was within 30-60 min

32. Continuity of Care 85% believe they have an active role in providing continuity of care 66% are asked to follow-up on patients when the physician is away 71% are contacted by other health care providers when the physician is not available

33. Concerns and Challenges

34. Infrastructure Isolation and limited networking Need for more FP/PHC nurses Difficulty taking time from practice to attend educational sessions Leadership and support for the role of the FP/PHC nurse

35. Education/ Scope of Practice Need for a clear definition or understanding of scope of practice Lack of understanding of the role Continuing education needs Continuing education funding Lack of awareness and sharing of resources and tools

36. Remuneration Lack of adequate benefits and job security Underpaid when compared to unionized nurses Unable to bill the provincial medical insurance program for nursing services Too much time on non-nursing services

37. Networking (chat line) NS Family Practice Nurses Website (www.cdha.nshealth.ca/programsandservices/familypracticenurses/index.html) Educational Conferences Publications/Presentations Round Table Discussion - Nov 2006 Progress

38. Other things happening in NS � Capital Health Professional Practice Nursing Council Nursing in Your Family Practice Program Educational Program for FP nurses Family Practice Nurses Association of NS

39. National Collaboration College of Family Physicians of Canada Canadian Nurses Association Ontario Family Practice Nurses Networking with FP nurses nationally

40. �If the millions of nurses in a thousand different places articulate the same ideas and convictions about primary health care, and come together as one force, they could be a powerhouse for change.� (Mahler,1985)

41. References Todd, C., Howlett, M., MacKay, M., & Lawson, B. (2007, June) Family Practice/Primary Health Care Nurses in Nova Scotia, Canadian Nurse, p 23

42. Questions or Comments?

43. Continuity of Care in the Family Practice Setting John Brewer & Ann Alsaffar

44. Pedroage 74 Sister with Colon Cancer, age 70 Father died with Colon Cancer, age 75 Mother with Type 2 Diabetes Fatigue for 3 months Recent blood tests at walk-in clinic OTC Meds Poor dietary habits Smoker Bp156/ 84 25 pound weight gain (BMI 34) Random blood sugar 15.6, urinalysis , 2 + sugar, (rest normal) High cholesterol (LDL 4.3 , HDL < 1 , Total 6.52)

45. Pedro�s �To do List�Who does What? Doctor Nurse Dietary Counseling for diabetes, cholesterol and weight loss Prescription Writing Medication Counseling/ Compliance Monitoring Discussions of non-pharmacologic options , if any Referral to Diabetic Nurse Educator Exercise Prescription Ophthalmologist referral Chiropodist/Podiatry referral Gastroenterology referral for colonoscopy Repeat office visits for BP and sugar and weight monitoring Patient notification and �fast track� triage when FOBT is positive

46. The Physician�s Perspective Do I want to be a Quarterback? Do I want to be an Orchestra Conductor?

47. The Nurse�s Perspective Do I want a traditional Role? Do I prefer a team approach?

48. The Patient�s Perspective Comfort level in seeing the same doctor and/or nurse ������ Continuity of care impacts on improved quality of care, on the reduction of errors, and on reducing costs.

49. How Do We Ensure Continuity for Pedro? Relational continuity Informational Continuity Managerial Continuity

50. Key Factors for Success Team Building CME Consider Teaching , Community Outreach and Research to be Multidisciplinary Team Building exercises Infrastructure (space) Governance Job descriptions Time for meetings Feedback , open and honest Proper Charting!!! $$$$

51. Challenges Changing practices (walk-in clinics , less focus on in-patient care, obstetrical care, etc. Increasing 3rd party care (�the Doc must do it�) Liability (?) Current physician payment schemes Time

52. Access to Care in the Family Practice Setting Rob Wedel & Carol Todd

53. Access and Family Practice Teams Pedro, a 74 yr old man in your practice, has a sister who is recently diagnosed with colon cancer. �Hmm, its been a few years. Maybe its time I see my family doctor.� Pedro is lucky. He has a family doctor. Many Canadians do not. Their doctor has retired, moved away, limited their practice. They use the ER and walk-in clinics when they have to, even tho they would prefer their own personal family doctor. Continuity and followup is sporadic, chronic diseases are not addressed. �Re-visit rates are high, as is cost to the system.

54. Pedro calls his doctor�s office and gets an appointment 34 days later (average time to next available appointment in Alberta). Once there, he sits in a �standing room only� waiting room for over an hour. Access and Family Practice Teams

55. Does Pedro have an Access Problem?

57. Finally, Pedro gets in to see the doctor�..  Pedro comes into the office for his 15 minute appt with Dr. L. Dr. L quickly does a blood pressure measurement revealing a significantly high result. Dr. L searches for Pedros� most recent lab work in his medical record. Dr. L thinks he made a referral to the diabetes program in the past, but did not have time to look for any notations. Pedro has had high blood pressure, elevated cholesterol, and is overweight, all of which have been noted for the past 20 years. Dr. L only finds pieces of the information, and in frustration, schedules another visit for Pedro in three weeks. Pedro books his next appointment on his way out the door.

59. Despite all our best efforts, using our traditional medical model, and the resources currently available to us, we have been singularly ineffective in meeting targets and providing �guideline level care�. �These quality problems occur typically not because of failure of good will, knowledge, effort or resources directed to health care, but because of fundamental shortcomings in the way care is organized� �Crossing the Quality Chasm Report, US Inst of Med 2004 Access and Family Practice Teams

60. Could Pedro gain better access using a more organized collaborative, team based approach to care?

61. Pedro�s 2nd Visit Assessment (physical, social, emotional, cultural) Physical (BP, pulse, waist circumference, BMI) Preventative Health (immunizations) Flow Sheets - Hypertension and Diabetes (CFPC Toolkit) Pedro returns for 2nd visit Assessment ( physical, social and emotional ) being sensitive to of any cultural needs � for example language, reading level, any impairments ( hearing, vision) Social � financial concerns ( drug plan), support at home Includes vital signs BP, pulse, BMI, waist circumference, medication review, EMR � review the last visit notes and update preventive health list � noting Pedro needs an updated Td, has not had pneumovax and flu immunization ( if medical directive in place � give immunizations ) High Bp � CFPC toolkit start evidence based flow sheet for hypertension ( complete Framingham risk assessment tool, review life style �focusing Pedro�s diet, smoking, and exercise and identify health education needs Identify diagnostic tests needed � U/A , EKG FP � focus on reviewing lab and diagnostic results, more detailed physical assessment, medication management FP, FPN and Pedro discuss plan of care FP would review diagnosis of diabetes, hypertension and high cholesterol order Colonoscopy Referral to DEC, ophthalmology, Pedro returns for 2nd visit Assessment ( physical, social and emotional ) being sensitive to of any cultural needs � for example language, reading level, any impairments ( hearing, vision) Social � financial concerns ( drug plan), support at home Includes vital signs BP, pulse, BMI, waist circumference, medication review, EMR � review the last visit notes and update preventive health list � noting Pedro needs an updated Td, has not had pneumovax and flu immunization ( if medical directive in place � give immunizations ) High Bp � CFPC toolkit start evidence based flow sheet for hypertension ( complete Framingham risk assessment tool, review life style �focusing Pedro�s diet, smoking, and exercise and identify health education needs Identify diagnostic tests needed � U/A , EKG FP � focus on reviewing lab and diagnostic results, more detailed physical assessment, medication management FP, FPN and Pedro discuss plan of care FP would review diagnosis of diabetes, hypertension and high cholesterol order Colonoscopy Referral to DEC, ophthalmology,

62. FP and FPN Collaborative Care Health Education (survival diet, self-blood sugar testing, hypoglycemia, diagnostic tests) Triage Advocacy / Navigator Health Education- possibly after identifying educational needs � arrange for Pedro to rtc to meet with nurse for education re survival diet, glucose testing, while waiting to be seen DEC Triage � letting Pedro know how to contact the nurse ( telephone, appt, walk-in ) For example � Pedro may call with questions about his colonoscopy. It may be a question the nurse would have to discuss with the FP � which medications to take with bowel prep. I may need to d/w FP and than let Pedro know It may be something I can help with at the time or perhaps facilitate a timely appt if required based on nursing assessment In our clinic of approx 2000 pts on our team I would have qpprox 100 telephone calls pre month ( could be anything form prenatal to end of life concern Strategies � generally encourage pts to come in for test results and prescription refills Will be doing some research to try and determine the top 10 reasons for telephone calls Emir- gives us the patient information almost immediately � no need to take time to get paper records Advocacy /Liaison A lot of this care is provided through follow up telephone calls with the nurse being the liaison Linking Pedro to community resources ( dietician, meals on wheels, foot care, diabetes association ) Liaison with pharmacist � possibly blister packaging, home care, social worker, mental health Health Education- possibly after identifying educational needs � arrange for Pedro to rtc to meet with nurse for education re survival diet, glucose testing, while waiting to be seen DEC Triage � letting Pedro know how to contact the nurse ( telephone, appt, walk-in ) For example � Pedro may call with questions about his colonoscopy. It may be a question the nurse would have to discuss with the FP � which medications to take with bowel prep. I may need to d/w FP and than let Pedro know It may be something I can help with at the time or perhaps facilitate a timely appt if required based on nursing assessment In our clinic of approx 2000 pts on our team I would have qpprox 100 telephone calls pre month ( could be anything form prenatal to end of life concern Strategies � generally encourage pts to come in for test results and prescription refills Will be doing some research to try and determine the top 10 reasons for telephone calls Emir- gives us the patient information almost immediately � no need to take time to get paper records Advocacy /Liaison A lot of this care is provided through follow up telephone calls with the nurse being the liaison Linking Pedro to community resources ( dietician, meals on wheels, foot care, diabetes association ) Liaison with pharmacist � possibly blister packaging, home care, social worker, mental health

63. Days to Third Next Available Appointment: Taber Clinic

64. ER Visits for Asthma in Taber

65. Clear roles within the team are the key. Protocols and directives pre-planned and embedded into daily practice improve reliability and outcomes. The EMR is an essential component for team communication, decision supports, patient management, and measurements that guide improvement changes. Team meetings with common goals understood by all (�The people that do the work must change the work.�) Education in team building, and CPD around roles and responsibilities is essential. Knowing each other and understanding each others� roles builds confidence and trust within the team. Strong teams promote consistent and reliable care, every time, on time. Access and Family Practice Teams

66. Taber Health Project Satisfaction Health providers are significantly happier with: Communication flow and information sharing The amount of time communicating with patients and other providers about care Ability to impact patient health behaviors Their autonomy in the performance of their jobs Current work situation Improved job satisfaction expressed by several disciplines Patient and Community satisfaction remained high.

67. �Without access there is no quality.� Dr. Jonathan Perlin, MD, Under Secretary for Health

68. Questions or Comments?

69. Quality of CareWorking together to make it better Attaining clinical and practice targets Don Gelhorn

70. QUALITY STRUCTURE PROCESS OUTCOME What is quality? The World Organization of Family Doctors, WONCA, defines quality as �the best healthcare outcome that is possible given available resources and that is consistent with patient preferences�. My primary care practice is in a small, relatively isolated community serving 4000 people. The available resources in Hudson Bay are different than those in a large urban practice such as that Alex will describe in his presentation. Yet we will see how similar in many ways our primary teams function. Most of us would agree that quality has three dimensions: structure, process and outcome. STRUCTURE is the framework in which we practice, and includes the education of the professionals, and the facilities in which we practice. Fortunately, for us in Canada, the structural component of quality is well developed. Today we can focus on the other two dimensions: the PROCESS of medical care; for example, was the treatment received by the patient for his MI consistent with the most current treatment guidelines? Are screening programs in place and implemented for patients at risk? Secondly, the OUTCOME of our health care. Did people get better? Was the disease or disability reduced? The Saskatchewan Health Quality Council would define the process of providing quality health care �as doing the right thing at the right time in the right way for the right person and having the best possible outcome�. However, measuring quality in family medicine and showing improvements by utilizing primary health care teams remains at an early stage of development in Canada. For most of us, when we start into quality improvement projects, it is quite an eye-opener to find out that our performance measurements aren�t as good as we anticipated. What is quality? The World Organization of Family Doctors, WONCA, defines quality as �the best healthcare outcome that is possible given available resources and that is consistent with patient preferences�. My primary care practice is in a small, relatively isolated community serving 4000 people. The available resources in Hudson Bay are different than those in a large urban practice such as that Alex will describe in his presentation. Yet we will see how similar in many ways our primary teams function. Most of us would agree that quality has three dimensions: structure, process and outcome. STRUCTURE is the framework in which we practice, and includes the education of the professionals, and the facilities in which we practice. Fortunately, for us in Canada, the structural component of quality is well developed. Today we can focus on the other two dimensions: the PROCESS of medical care; for example, was the treatment received by the patient for his MI consistent with the most current treatment guidelines? Are screening programs in place and implemented for patients at risk? Secondly, the OUTCOME of our health care. Did people get better? Was the disease or disability reduced? The Saskatchewan Health Quality Council would define the process of providing quality health care �as doing the right thing at the right time in the right way for the right person and having the best possible outcome�. However, measuring quality in family medicine and showing improvements by utilizing primary health care teams remains at an early stage of development in Canada. For most of us, when we start into quality improvement projects, it is quite an eye-opener to find out that our performance measurements aren�t as good as we anticipated.

71. However, measuring quality in family medicine and showing improvements by utilizing primary health care teams remains at an early stage of development in Canada. For most of us, when we start into quality improvement projects, it is quite an eye-opener to find out that our performance measurements aren�t as good as we anticipated. In Hudson Bay we are involved in a chronic disease management project for Type II Diabetes and Coronary Artery Disease. In the Diabetes project, the targets are blood pressures less than 130/80, hgb A1C�s less than 7%, total cholesterol /HDL ratios less than 4, the monitoring of microalbumin levels, and medication treatment with ASA, a statin, and an ACE. However, measuring quality in family medicine and showing improvements by utilizing primary health care teams remains at an early stage of development in Canada. For most of us, when we start into quality improvement projects, it is quite an eye-opener to find out that our performance measurements aren�t as good as we anticipated. In Hudson Bay we are involved in a chronic disease management project for Type II Diabetes and Coronary Artery Disease. In the Diabetes project, the targets are blood pressures less than 130/80, hgb A1C�s less than 7%, total cholesterol /HDL ratios less than 4, the monitoring of microalbumin levels, and medication treatment with ASA, a statin, and an ACE.

72. For coronary artery disease we target smoking, blood pressure less than 140/90, cholesterol /HDL ratios less than 4 and treatment with ASA, an ACE inhibitor, a beta-blocker and a statin. Both projects have measurement tools for referral to diabetic education or cardiac rehab programs. Our core team in chronic disease involves physicians, nurse practitioner and diabetic educator and dietician. As you can see we have made slow steady improvement in our measurement values. Are we as good as we can be? Definitely not, but we are initiating change and improving results and therefore hopefully improving the quality of our care. For coronary artery disease we target smoking, blood pressure less than 140/90, cholesterol /HDL ratios less than 4 and treatment with ASA, an ACE inhibitor, a beta-blocker and a statin. Both projects have measurement tools for referral to diabetic education or cardiac rehab programs. Our core team in chronic disease involves physicians, nurse practitioner and diabetic educator and dietician. As you can see we have made slow steady improvement in our measurement values. Are we as good as we can be? Definitely not, but we are initiating change and improving results and therefore hopefully improving the quality of our care.

73. Back to Pedro Trust Access Comprehensiveness Continuity Caring demeanor Communication But for Pedro, who is diabetic, and may have carcinoma of the colon, his measurement of quality may be something different. I would suspect that what Pedro considers to be quality care would be based on things like trust, access, comprehensiveness, continuity, and a caring demeanor and an ability to communicate. Firstly, Pedro wants to have trust in his healthcare providers - trust they will be knowledgeable, that they will be accessible and that they will treat him with respect. He will want to have input into decision-making, and be reassured that processes are in place to enable accurate communication between all members of his team. He will expect that when he is having trouble with his blood sugars that someone on the team will be able to help him adjust his insulin dose. If he is having trouble with his colostomy after he has had surgery that he can get access to a member of the team to try and sort out the problem. If he needs emergency care and hospitalization will help be available? And when he does, is the information from that patient encounter readily accessible to other members of the team when he is next seen at the clinic? Is everyone aware of the treatment changes and complications that Pedro has experienced? In our model we have one common chart, which is not an electronic medical record, but is used by the physicians and the nurse practitioner. This ensures that we are able to easily communicate with one another. All the pertinent data is readily available. Pedro would know that although I may be his principle care provider, I can not be available to him 24 hours a day 7 days a week, but someone on our team will be. He would know that every patient encounter will be documented in his chart and be available to me as his principle care provider. As his physician, my role is to coordinate his care among the specialists he might see, the investigations that he might receive and his treatment. We have designed and implemented a common referral sheet to simplify the consult process among all of the various disciplines. We communicate with one another by email, fax and phone as well as face to face. Because Pedro sees other individuals on the team, there is an informal internal audit process that is ongoing in our practice so that if one of us has missed or overlooked some aspect of care then it is likely that one of my colleagues will pick up on this and ask about it. It is this coordination, this access, and this continuity, throughout his care that is important to Pedro in evaluating quality of care. In our primary care site we have utilized patient satisfaction surveys. It is one way to assess our strengths and weaknesses in meeting our patient�s needs.But for Pedro, who is diabetic, and may have carcinoma of the colon, his measurement of quality may be something different. I would suspect that what Pedro considers to be quality care would be based on things like trust, access, comprehensiveness, continuity, and a caring demeanor and an ability to communicate. Firstly, Pedro wants to have trust in his healthcare providers - trust they will be knowledgeable, that they will be accessible and that they will treat him with respect. He will want to have input into decision-making, and be reassured that processes are in place to enable accurate communication between all members of his team. He will expect that when he is having trouble with his blood sugars that someone on the team will be able to help him adjust his insulin dose. If he is having trouble with his colostomy after he has had surgery that he can get access to a member of the team to try and sort out the problem. If he needs emergency care and hospitalization will help be available? And when he does, is the information from that patient encounter readily accessible to other members of the team when he is next seen at the clinic? Is everyone aware of the treatment changes and complications that Pedro has experienced? In our model we have one common chart, which is not an electronic medical record, but is used by the physicians and the nurse practitioner. This ensures that we are able to easily communicate with one another. All the pertinent data is readily available. Pedro would know that although I may be his principle care provider, I can not be available to him 24 hours a day 7 days a week, but someone on our team will be. He would know that every patient encounter will be documented in his chart and be available to me as his principle care provider. As his physician, my role is to coordinate his care among the specialists he might see, the investigations that he might receive and his treatment. We have designed and implemented a common referral sheet to simplify the consult process among all of the various disciplines. We communicate with one another by email, fax and phone as well as face to face. Because Pedro sees other individuals on the team, there is an informal internal audit process that is ongoing in our practice so that if one of us has missed or overlooked some aspect of care then it is likely that one of my colleagues will pick up on this and ask about it. It is this coordination, this access, and this continuity, throughout his care that is important to Pedro in evaluating quality of care. In our primary care site we have utilized patient satisfaction surveys. It is one way to assess our strengths and weaknesses in meeting our patient�s needs.

74. Access Demand vs. Supply Be willing to attempt change Adjust appointment scheduling Make small fine tuning changes until it works Rob and Carol have spoken earlier about access. I must admit that I was skeptical when we first launched into a quality improvement project to assess access to our clinic. We are a small group of three physicians and one nurse practitioner, the only group in town, and we provide all the on call services. Our patients are quite readily seen in our clinic or in the outpatient department. It was interesting to find that like most medical practices the demands for patient services follow a pattern that is consistent throughout Canada, North America and Europe. Demand is highest at the beginning of the week on Mondays, tapers down by Wednesday, and starts to pick up on Thursday and Friday in preparation for the weekend. Accordingly, we made some minor adjustments in the supply side of the equation by not scheduling meetings on Mondays and leaving more spaces available for people needing to be seen urgently. We leave open spaces for same day appointments not only for the doctor on call but for all of us in the practice. These small changes have balanced our demand and supply, and, in doing so, we have improved our access.Rob and Carol have spoken earlier about access. I must admit that I was skeptical when we first launched into a quality improvement project to assess access to our clinic. We are a small group of three physicians and one nurse practitioner, the only group in town, and we provide all the on call services. Our patients are quite readily seen in our clinic or in the outpatient department. It was interesting to find that like most medical practices the demands for patient services follow a pattern that is consistent throughout Canada, North America and Europe. Demand is highest at the beginning of the week on Mondays, tapers down by Wednesday, and starts to pick up on Thursday and Friday in preparation for the weekend. Accordingly, we made some minor adjustments in the supply side of the equation by not scheduling meetings on Mondays and leaving more spaces available for people needing to be seen urgently. We leave open spaces for same day appointments not only for the doctor on call but for all of us in the practice. These small changes have balanced our demand and supply, and, in doing so, we have improved our access.

75. Community Involvement Interagency Committee An umbrella organization Identifies community issues and needs Leadership Team Sets long and short term goals Provider Team Program and project implementation Other facets that are important in improving quality in family medicine include strengthening the role of disease prevention, health promotion and increasing individual and community involvement in program development and planning. The main determinants of health are factors that are outside of the traditional boundaries of medicine. Therefore it is important and imperative that we link health services to other community initiatives such as recreation and self help groups as well as human services such as social services, justice, education and housing authorities. To encompass these ideals, one must expand the concept of team to include other individuals and professionals from the community. In our community we have an Interagency Committee with representation from Public Health, RCMP, local schools, social service agencies, chronic and acute facility, clergy and community citizens. This committee meets every two months as the umbrella organization to identify community issues and needs. We have a Leadership Team that distills these issues and needs into long and short term goals. And thirdly we have a Provider Team that sets up the programs and projects to help achieve the goals. Other facets that are important in improving quality in family medicine include strengthening the role of disease prevention, health promotion and increasing individual and community involvement in program development and planning. The main determinants of health are factors that are outside of the traditional boundaries of medicine. Therefore it is important and imperative that we link health services to other community initiatives such as recreation and self help groups as well as human services such as social services, justice, education and housing authorities. To encompass these ideals, one must expand the concept of team to include other individuals and professionals from the community. In our community we have an Interagency Committee with representation from Public Health, RCMP, local schools, social service agencies, chronic and acute facility, clergy and community citizens. This committee meets every two months as the umbrella organization to identify community issues and needs. We have a Leadership Team that distills these issues and needs into long and short term goals. And thirdly we have a Provider Team that sets up the programs and projects to help achieve the goals.

76. Community Programming Diabetes monitoring clinics Wellness clinics for seniors Youth and mental health projects Tobacco initiatives P.A.R.T.Y. KIDSPORT Drug education and awareness programming Living Well with Chronic Disease TM Program As physicians, we believe that family doctors have roles to play in promoting healthy public policy. Examples of new programs introduced to address the identified community needs in areas of health promotion and prevention include women�s wellness initiatives, tobacco initiatives, diabetes monitoring clinics, wellness clinics for seniors, books for babies, a bike safety program, youth wellness and mental health projects, P.A.R.T.Y - preventing alcohol related trauma in youth, In Motion Kids Sports program and an interagency drug education and awareness subcommittee which has launched initiatives around drug education for parents and families. As physicians, we believe that family doctors have roles to play in promoting healthy public policy. Examples of new programs introduced to address the identified community needs in areas of health promotion and prevention include women�s wellness initiatives, tobacco initiatives, diabetes monitoring clinics, wellness clinics for seniors, books for babies, a bike safety program, youth wellness and mental health projects, P.A.R.T.Y - preventing alcohol related trauma in youth, In Motion Kids Sports program and an interagency drug education and awareness subcommittee which has launched initiatives around drug education for parents and families.

77. Tangible Benefits for physicians Reduction in on-call demands Community preventative health initiatives Distribution of work load Enhanced role as educators As physicians, our perception of providing quality care for our patients, is partially tied to the satisfaction we feel in our work environment. The tangible benefits of working in interdisciplinary teams for the physicians in our practice have been several. There has been a reduction in on call demands because of the assistance of the nurse practitioner. It has allowed us to become more involved in community preventative health initiatives. It has allowed us to function as a team and therefore distribute the workload. It has enhanced our role as educators and we do believe it has improved continuity and comprehensiveness of patient care.As physicians, our perception of providing quality care for our patients, is partially tied to the satisfaction we feel in our work environment. The tangible benefits of working in interdisciplinary teams for the physicians in our practice have been several. There has been a reduction in on call demands because of the assistance of the nurse practitioner. It has allowed us to become more involved in community preventative health initiatives. It has allowed us to function as a team and therefore distribute the workload. It has enhanced our role as educators and we do believe it has improved continuity and comprehensiveness of patient care.

78. Secrets to Success Communication, collaboration, continuity and comprehensive care are the words all of us in the CFPC have heard over and over again, for good reason, they truly do define Quality in primary care.Communication, collaboration, continuity and comprehensive care are the words all of us in the CFPC have heard over and over again, for good reason, they truly do define Quality in primary care.

79. Quality Collaborative Practice Lessons from an Urban Primary Care Centre: a Nurse Practitioner�s Perspective Alex Kowalski

80. Presentation Outline The Team The Scenario Quality indicators Have we made a difference? The principle objectives of this presentation is highlight the success and challenges in providing �quality� collaborative primary care in a relatively new and large urban centre The principle objectives of this presentation is highlight the success and challenges in providing �quality� collaborative primary care in a relatively new and large urban centre

81. The Team Who are we? ACCESS River East, a publicly funded urban centre providing more than 90,000 residents of northeastern Winnipeg with a access to health and social services. ARE provides a wide range of services, including a primary care clinic, mental health services, midwifery, dietician, audiologist, speech language pathology, home care, child and family services, children�s special services, and coordination, community engagement and development, community mental health services, employment supports for persons with disabilities/vocational rehabilitation, employment and income assistance, public health, seniors health resource team and supported living. - The Primary care clinic team includes 4 physicians (family medicine, internal medicine), 3 family practice nurse practitioners and 4 primary care nurses. These team members collaboratively provide care in what could best described as a group family practice to many of the area residents. �ACCESS River East, a publicly funded urban centre providing more than 90,000 residents of northeastern Winnipeg with a access to health and social services. ARE provides a wide range of services, including a primary care clinic, mental health services, midwifery, dietician, audiologist, speech language pathology, home care, child and family services, children�s special services, and coordination, community engagement and development, community mental health services, employment supports for persons with disabilities/vocational rehabilitation, employment and income assistance, public health, seniors health resource team and supported living. - The Primary care clinic team includes 4 physicians (family medicine, internal medicine), 3 family practice nurse practitioners and 4 primary care nurses. These team members collaboratively provide care in what could best described as a group family practice to many of the area residents. �

82. The Scenario Key points: Role of the Nurse Practitioner Integrated health care for Pedro Our work is different and yet complimentary To summarize the role of NP at ARE It�s a RN with an expanded scope of practice ability to asses, treat & refer ideally suited for collaborative practice model May engage in primary, acute, and /or chronic care settings - From the perspective of a primary care nurse practitioner Pedro would have likely been referred to me by homecare or perhaps directly from the community and possibly identified as a high risk individual without consistent medical care. - My role would include, doing initial and ongoing assessments, history& physical, identify risks, problems, initiating further workup and initiating treatment and monitoring outcomes. Typically I would assume the role as primary provider. Pedro would likely have the opportunity to be referred to our dietician, nurse run diabetes clinic, hypertension clinics or perhaps to a member of mental health/ shared care program. If complex or resistant problems are identified that require the specialized knowledge of a physician, a consultation may be initiated formally or as simply as a conversation in the hallway. Key point-By bringing together health care professionals with different yet complimentary knowledge and skills, the quality to the patient is often perceived through an increase in accessibility to patient services. � I get to see my doctor (or Nurse practitioner) when I need to� To summarize the role of NP at ARE It�s a RN with an expanded scope of practice ability to asses, treat & refer ideally suited for collaborative practice model May engage in primary, acute, and /or chronic care settings - From the perspective of a primary care nurse practitioner Pedro would have likely been referred to me by homecare or perhaps directly from the community and possibly identified as a high risk individual without consistent medical care. - My role would include, doing initial and ongoing assessments, history& physical, identify risks, problems, initiating further workup and initiating treatment and monitoring outcomes. Typically I would assume the role as primary provider. Pedro would likely have the opportunity to be referred to our dietician, nurse run diabetes clinic, hypertension clinics or perhaps to a member of mental health/ shared care program. If complex or resistant problems are identified that require the specialized knowledge of a physician, a consultation may be initiated formally or as simply as a conversation in the hallway. Key point-By bringing together health care professionals with different yet complimentary knowledge and skills, the quality to the patient is often perceived through an increase in accessibility to patient services. � I get to see my doctor (or Nurse practitioner) when I need to�

83. Research on the NP Role in Primary Health Care Spitzer WO et al. ( NEJM 1974;290:251-256) Conclusions: �NPs can provide first contact primary clinical care safely and effectively, with as much satisfaction to patients as a family physicians.� �NPs can provide a major increase in total quantity of clinical service, without a reduction in quality� Is my role really useful? A little research in support of collaborative NP practice in primary care, fortunately it�s not all bad. Over 25 years ago in Ontario, Spitzer and colleagues concluded that �.. This study provided evidence that NPs have a viable role in improving quality accessibility to primary care services Is my role really useful? A little research in support of collaborative NP practice in primary care, fortunately it�s not all bad. Over 25 years ago in Ontario, Spitzer and colleagues concluded that �.. This study provided evidence that NPs have a viable role in improving quality accessibility to primary care services

84. Quality Indicators What are quality indicators and to Whom? Quality to patient Quality to the provider What do quality indicators mean ? In simply stated they are laundry list of expectations:What does the patient expect of their provider. What would a physician or NP be expected to do, given patients with certain ailments . These commonly involve chronic disease management concerns? Using this list, we can tell how providers �measure up� in terms of providing quality care. What do quality indicators mean ? In simply stated they are laundry list of expectations:What does the patient expect of their provider. What would a physician or NP be expected to do, given patients with certain ailments . These commonly involve chronic disease management concerns? Using this list, we can tell how providers �measure up� in terms of providing quality care.

85. Quality for the Patient How do we measure up to our patient? Is it all just a popularity contest? What�s really important to the patient? Although there is a general distaste to open public forums like ratemd.com some interesting perspective can be found. Not dissimilarly, when patients such as Pedro were petitioned for feedback at ARE re: their perception of the quality of care received , positive comments often mentioned terms such as �respectful�,� caring� and �takes the time to listen�. What they did not like was the perception of being hurried. Key point � The few studies that have been conducted regarding quality indicators suggest that patients consider respect, caring, and communication to be key aspects of health care quality. In some cases these components,were more important than the relief of pain or disability itself. Unfortunately this often clashes with providers perception that technical ability equates to quality. �Is it all just a popularity contest? What�s really important to the patient? Although there is a general distaste to open public forums like ratemd.com some interesting perspective can be found. Not dissimilarly, when patients such as Pedro were petitioned for feedback at ARE re: their perception of the quality of care received , positive comments often mentioned terms such as �respectful�,� caring� and �takes the time to listen�. What they did not like was the perception of being hurried. Key point � The few studies that have been conducted regarding quality indicators suggest that patients consider respect, caring, and communication to be key aspects of health care quality. In some cases these components,were more important than the relief of pain or disability itself. Unfortunately this often clashes with providers perception that technical ability equates to quality. �

86. Quality to the Provider This slide shows a table From Dr Alan Katz paper by Manitoba Centre for Health policy � titled Using Administrative Data to Develop Indicators of Quality in Family Practice Not unlike Don�s experience it highlights how poorly we really do and how much we can improve. There is clear opportunity makes improvements on a collaborative basis. In my world, chronic disease management such as diabetes, hypertension, COPD, and mental health are all shared collaboratively among our various clinic providers and at least in our small part of the world, collaboration seems gets us further than competition. At least monthly formally, or daily informally we get together to discuss difficult cases and decide who might benefit from a uniquely skilled colleague and ultimately how this may help the community through decreased hospital re-admission. Specific examples of chronic disease management initiatives at ARE include DM, HTN, COPD clinics and Depression, Anxiety groups. Satellite teen clinics and satellite family practice clinics in particularly underserved regions of the community. Even resource consuming episodic disease management concerns such wound or IV antibiotic reassessments are referred from local ER to our clinic for follow-up. We have made some initial clinic attempts at measuring outcomes looking a specific and measurable quality indicators, using flow sheet based tools that mimic the work done by Alan Katz. This evaluation of our service remains an ongoing project. Key point - Collaborative practice naturally lends its self to chronic disease management . Quality is often perceived by measured outcomes, such as, improvement in specific indicators of chronic disease management, patient mortality/morbidity rates, and hospital readmissions. This slide shows a table From Dr Alan Katz paper by Manitoba Centre for Health policy � titled Using Administrative Data to Develop Indicators of Quality in Family Practice Not unlike Don�s experience it highlights how poorly we really do and how much we can improve. There is clear opportunity makes improvements on a collaborative basis. In my world, chronic disease management such as diabetes, hypertension, COPD, and mental health are all shared collaboratively among our various clinic providers and at least in our small part of the world, collaboration seems gets us further than competition. At least monthly formally, or daily informally we get together to discuss difficult cases and decide who might benefit from a uniquely skilled colleague and ultimately how this may help the community through decreased hospital re-admission. Specific examples of chronic disease management initiatives at ARE include DM, HTN, COPD clinics and Depression, Anxiety groups. Satellite teen clinics and satellite family practice clinics in particularly underserved regions of the community. Even resource consuming episodic disease management concerns such wound or IV antibiotic reassessments are referred from local ER to our clinic for follow-up. We have made some initial clinic attempts at measuring outcomes looking a specific and measurable quality indicators, using flow sheet based tools that mimic the work done by Alan Katz. This evaluation of our service remains an ongoing project. Key point - Collaborative practice naturally lends its self to chronic disease management . Quality is often perceived by measured outcomes, such as, improvement in specific indicators of chronic disease management, patient mortality/morbidity rates, and hospital readmissions.

87. Goals: Have We Made a Difference? Goals: To improve access to primary care services for community To promote continuity of care between hospital, the primary care provider and the home To reduce hospital readmission To provide additional health resource to clients and families Although the data collection is ongoing our initial impressions are, that in the very least the patients seems happier with greater accessibility to primary care. The strengths and advantages of our collaborative model in primary care lie in timeliness of care and continuity of care. Clients are seen within days of hospital discharge or same day based on the urgency of the case. There is timely monitoring of lab work, drug therapy and referrals to specialists and other services. 3) Because the provider communicates with home care case coordinators in the hospital and community, with Day Hospital nurses, GPAT and Public Trustee, there is continuity in the process of managing a client�s case. 4)Because of frequent and regular contact with these clients, acute exacerbations and episodic illnesses are identified early and treated in a timely fashion in the home rather than in hospital or urgent care. From the provider�s perspective we feel that we are meeting reasonable expectations re: quality indicators but frankly the jury is till out and only time will tell if this collaborative primary model has made a significant difference in our communities overall health. Certainly in areas where considerable collaborative effort has been focused such as diabetes we are seeing specific indicators such a HbA1C, BP measurement and LDL levels improving. Key point � Again Collaborative practice naturally lends its self to chronic disease management . Quality is often perceived by measured outcomes, such as chronic disease management, patient mortality/morbidity rates, and hospital readmissions. Although the data collection is ongoing our initial impressions are, that in the very least the patients seems happier with greater accessibility to primary care. The strengths and advantages of our collaborative model in primary care lie in timeliness of care and continuity of care. Clients are seen within days of hospital discharge or same day based on the urgency of the case. There is timely monitoring of lab work, drug therapy and referrals to specialists and other services. 3) Because the provider communicates with home care case coordinators in the hospital and community, with Day Hospital nurses, GPAT and Public Trustee, there is continuity in the process of managing a client�s case. 4)Because of frequent and regular contact with these clients, acute exacerbations and episodic illnesses are identified early and treated in a timely fashion in the home rather than in hospital or urgent care. From the provider�s perspective we feel that we are meeting reasonable expectations re: quality indicators but frankly the jury is till out and only time will tell if this collaborative primary model has made a significant difference in our communities overall health. Certainly in areas where considerable collaborative effort has been focused such as diabetes we are seeing specific indicators such a HbA1C, BP measurement and LDL levels improving. Key point � Again Collaborative practice naturally lends its self to chronic disease management . Quality is often perceived by measured outcomes, such as chronic disease management, patient mortality/morbidity rates, and hospital readmissions.

88. Conclusion: Lessons in �Quality� Primary Health Care Primary Health Care should: - be integrated and inter-sectoral - emphasize health promotion - address the main health problems within a community from the community perspective - depend on a diversity of trained workers functioning as a multi-disciplinary team In conclusion, the collaborative practice model fits well in implementing the principles of primary health care. As part of a collaborative team of diversified health providers, it�s my impression we can provide improved �quality� to primary care for individuals patients and groups in the clinic, community, and hospital.In conclusion, the collaborative practice model fits well in implementing the principles of primary health care. As part of a collaborative team of diversified health providers, it�s my impression we can provide improved �quality� to primary care for individuals patients and groups in the clinic, community, and hospital.

89. Primary Care RenewalLessons to Learn