Building Primary Care Homes: Enhancing Healthcare in Northern BC

1. THIS NEW HOUSEHOW NORTHERN HEALTH STAFF AND PHYSICIANS ARE BUILDING PRIMARY CARE HOMES TO IMPROVE CAREBC QUALITY FORUMFebruary 25, 2016

2. History of the Work • Over 8 years ago Northern Health started the journey towards a more integrated system of care, with strong Primary Care as the cornerstone of the system and clear connections to specialized and specialist services. • A number of consultations and streams of work to improve care for seniors and other people with complex needs. These include but are not limited to: • Northern Health’s Primary Health Care Strategy - Care North (2008) • Prince George Division established 2009 – collaboration started • Understanding Our System Work • Uptake of electronic medical records by physicians in Northern BC • Aging well in Northern and Rural Communities (2008) • Development of 2009 -15 Northern Health vision and strategic plans • Seniors Consultation and Action Plan 2014

3. Strategic Plan “Northern Health is known for our strong primary health care system. People experience seamless and coordinated service. The Primary Care Home is the foundation for multidisciplinary health care and helps people navigate across services.” Northern Health Strategic Plan 2009-2015

4. Objective of the Work A Primary Care Home is the place where people • establish long-term relationship with a primary care provider and inter-professional team, • receive seamless, coordinated, and longitudinal care • are supported in managing their own health In Northern Health, the Primary Care Home is embedded in a Healthy Community. Health promotion and prevention is an integral part of the work

5. Primary Care Home

6. Primary Care Home Goal 3 – Team Based Care A Patient’s Primary Care Home will offer its patients a broad scope of services carried out by teams or networks of providers, including each patient’s personal family physician working together with peer physicians, nurses, and others.

7. Primary Care Home Goal 5 – Comprehensive Care A Patient’s Primary Care Home will provide each of its patients with a comprehensive scope of family practice services that also meets population and public health needs.

8. Primary Care Home Goal 6 – Continuity A Patient’s Primary Care Home will provide continuity of care, relationships, and information for its patients.

9. Primary Care Home Goal 7 – EMR A Patient’s Primary Care Home will maintain electronic medical records (EMRs) for its patients.

10. Partnership and Collaboration

11. Northern Health Idealized System of Services

13. Inter-professional Team Members & Functions • Members (not all teams will have all members) • Primary Care Physician / Nurse Practitioner • Primary Care Nurse • Mental Health Clinician • Rehab Professionals • Pharmacists, Dieticians, other • Roles • Case Finding • Care Planning • Care Coordination / Monitoring

14. Current State

15. Inter-professional Team Example

16. Small Community Example

17. Interprofessional Team Formation – Phase 1

18. Interprofessional Team Formation – Phase 2

19. Interprofessional Team Formation – Phase 3

20. Interprofessional Team Formation – Phase 4

21. Work in Progress • Supporting people through change • Workforce Transition • Leadership Structure • Front-line staff team assignments • Work process redesign • Documentation (options) • Logistics

22. Logistics – Team Location

23. What are staff saying - Challenges • Loss of identity • Loss of team members / connections • Stressful environment with so much change • Is this a business model or a model of care? • Transition (transformation) is difficult and takes a long time • Change affects people (in a negative way)

24. What are staff saying - Opportunities • Chance to participate in change for better care • Challenge the system • Small teams encourage team development • Keep the big picture in mind (don’t sweat the small stuff)

25. Key Messages • Objective is to provide better care, particularly for patients with complex needs • Never too early to meaningfully engage medical staff • Structure change is insufficient – care process changes are essential • Change – significant, emergent, at all levels, needs to be supported • The system is complex and this work is hard • PARTNERSHIP!

26. QUESTIONS?