Saturday, August 9, 2014

International Patient and Family Centred Care Conference #6

Providence Health Care – Shared Care Partners for Patients

Like every other health service Providence are looking at an ageing demographic that is threatening to overload their health care system and this has prompted health care funders to understand that there is a need to have activated, engaged patients. Supporting people to self-manage is certainly one way to deal with the challenge but you can’t have activated and engaged patients who are skilled at self-management unless you have a system that supports consumers and our families in self management.

The Canadian health care system is one of the prized assets of their country, they value this and want to maintain it. This has come up in many of the sessions and as I talk to people about our universal health care and the way in which it is being eroded they understand my anger about this.

The Shared Care Committee initially conceived to improve working relationships between primary and specialty care. Very quickly the made the patients voice an important part of the dialogue. It is a joint project between BC Medical Association and Ministry of Health. At the table is also health authorities, and a patient representative. It has spawned a number of projects wich they listed on their slide, an impressive list that makes me want to find out more. Today they are talking about the project of the lower mainland, around Vancouver.

The challenge to involve patients and look at rational service delivery is most difficult in big cities along the 49th parallel as they have a model that is costly, disconnected and specialty –centric. Now, the 49th parallel to me makes my think of a kd lang album and a brewery I found in Vancouver but there is obviously another meaning. 

There are 600 more specialists in Vancouver than family physicians and specialists are not always deployed in the right way, and communication between the two are not always meaningful and patients get lost in the shuffle. So the geography is ripe for improvement in shared care. Sounds a lot like Australian health system.

They want to be able to communicate better, address the access issues that are preventing people from receiving the care they need, to improve patient flow, patient journey. And they want to minimise duplication and inefficiency in the system as it is an issue that is preventing specialists from responding to patient needs. The panel spoke about the benefits of having the Ministry of Health involved and committed to bringing about change. The Ministry also recognises that chronic disease management belongs in the community with the family care provider, not the acute care hospitals. Some hospitals want to get into the business of chronic disease management but this is better placed in the community. So they are very concerned with trying to rebalance the work that is going on between specialities, acute and community based primary care.

The Patient Voices Network in BC is a resource for patient representatives and members of advisory councils. So patients are connected to a broader base. Doctors and those working in the health services are somewhat relieved that the patient representatives do not have an axe to grind.

Patient and provider experience, important to not only engage patients but also health care providers in service redesign. They have three prongs to their work. SLIDE includes cost and one other element I didn't catch but will check out.

They find that it is all too easy to make assumptions about what patients need and what is important to them but to have a patient representative at the table these assumpltions can be unpacked and challenged. For example, the ability to receive a copy of the consultation notes. They want access to this information as they often have the chronic disease for the rest of their life and they want to learn as much as they can about this. But some patients will require more support than others to understand this. And timing of appointments is a big issue as those people who love out of town have difficulty in getting to their early in the morning.

They have guidelines and there is a good slide on this. The first thing they say is: include patients form the beginning and have them as full team members.

They also set out some practical advice about the logistics including providing instruction on how to get to the meeting room, provide refreshments and food and need to check for allergies and sensitivities; provide reimbursement ; think about the time of meetings as many people with chronic conditions have a full time job managing their condition just to get there and some may also need to make arrangements to have time off work.

It was fascinating to hear Robert Levy MD, a respiratory physician, reflect on specialist behaviour. He said that lung, heart, diabetes and kidney team all got together as they realised that they were slow to understand that works for one set of organs may not be helpful to other organs. Their training is very organ specific but their patients have more than one set of organs. I always love hearing this. I know that my body has more than one set of organs. We really need to do something about medical education so that they have a more holistic perspective.

The panel reflected on Successful Initiatives
RACE- RapidAccess to Consultative Expertise. Real time telephone access. It is phone line for family physic and. It is a phone line with a selection of specialty services. In 2010 it started with five services and has grown to 22 services. They take more than 15,000 calls to the line. 78% of calls are answered within 10 minutes and 60% of calls avoid unnecessary consults and 32% of calls avoid unnecessary ED presentations. They have estimated that there is a saving to the system of $200 per call.
They have developed RACE in a box, with 5 page booklet on how to set this up.
RACE calls take about 5 minutes and medication advice, testing advice, affirming the view of the Family Physician. They receive 35% of the usual fee of seeing a patient face to face consult but this will take an hour once they see the patient and then write up the consult. So it does free up resources. 
Acknowledgment of referral – fax back form. This is a great idea as often this is when patients fall into a crevice. I am surprised that the Fax is King. And there was no mention of an electronic solution, shared records.
Notification of admission: So now family physicians are notified that their patients are in hospital. The notification includes an invitation to the FP to participate in the discharge planning process.

Three levels of patient participation: individual, organisations and system
Hang Tough Arthritis Support Group. Arthritis increases your risk of heart disease. And anyone with inflammatory arthritis is at risk, regardless of age and gender. IT is not a benign diseases and we do not need to be protected for the tough messages as we need to know this so we can make decisions around our own care.

Patient Voices Network Framework. Patients as Partners Partnerships Framework looks really interesting. We are currently reviewing the ACT Health Consumer and Carer Participation Framework http://health.act.gov.au/c/health?a=dlpubpoldoc&document=2771so I will definitely be looking at this one more closely.

The slide gives examples of how they contribute. They get a greater understanding of the organisation and the services. They have the positive opportunity to improve the system for others. Many people come to the Network because they experience care that was not a good as it could be and this provides an opportunity t make a difference to others.

A couple of gems from the consumer members of the panel:

We have discovered many of the gaps in the system as we have often fallen through them

What every patient wants is good, safe care in a timely manner

Communication is a theme that emerges across the patient journey: referrals to specials, clarity for patients, consults, support for complex chronic diseases, system acknowledgement of patient realises, hospital communications.

The Patient Voices Network has a series of videos of consumer representatives that you need to watch. Really inspiring!

Another fabulous session that I look forward to sharing with my networks.

Darlene Cox
@darlenecox


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