SHAPING YOUR FUTURE DR. BRAD BAHLER PROVINCIAL MEDICAL DIRECTOR - - PowerPoint PPT Presentation

SHAPING YOUR FUTURE

• DR. BRAD BAHLER

PROVINCIAL MEDICAL DIRECTOR PCN EVOLUTION, AMA ACTT, CHAIR OF THE PRIMARY CARE ALLIANCE

LOOKING BACK TO LOOK FORWARD - PRACTICE IN SYLVAN LAKE – CIRCA 2003/2004

• Family Medicine Sylvan Lake - Hospital Medicine in Red Deer
• Obstetrics
• Long T

erm Care + Palliative Care

• Rural ER Locums
• Clinical T

eaching Site Coordinator Medical Students and Residents

• My panel size at that time was 1750

Utilization by Attachment to a Family Doctor (probability of being in the top 5%)

Continuity vs. Cost by Clinical Risk Group

Mortality by Continuity of Care

EVERY SYSTEM IS DESIGNED PERFECTLY TO YIELD THE RESULTS IT GETS . . .

Primary Care Networks QI/Practice Improvement Personal Agency Practice Facilitation T eam

Primary Care Networks QI/Practice Improvement Personal Agency Practice Facilitation T eam

PRIMARY CARE NETWORKS IN ALBERTA

• Become Board Chair of Wolf Creek Primary Care

Network

• Started to experiment with different types of team

members and different roles and responsibilities – both clinical and non-clinical

• CDM Nurse, Panel Manager (MOA role), MH therapist,

MH liaison, Social Work, Improvement Facilitator, Dietician, Foot Care, Senior’s nurse, Pharmacist, Kinesiology, Home Care liaison, Public Health Integration

• Exposed leaders to quality improvement, practice

facilitation, supported physicians to make changes

• Networked physicians behind a common call to action and

started to combat isolation

PRIMARY CARE NETWORKS

• Clinical resources
• Practice Facilitation
• Connection to Health

Neighbourhood

Patie ient nt’s ’s Medic dical al Home me Healt alth h Nee eeds of

• f the

he Commu mmunity y & Populat pulatio ion Strong

• ng

Partnersh rships & s & Trans nsitions ions o

• f

Care re Accou

• unt

ntabl able & e & Effec ectiv ive G e Gov

• ver

erna nanc nce

SCALING UP PATIENT’S MEDICAL HOME IMPLEMENTATION;

SCALING UP PRIMARY CARE TRANSFORMATION:

majority

Shifting in thinking at all levels

Policymakers, decision makers, leaders in the profession, frontline change agents

Early, visible win

Focused efforts on team-based, chronic disease management

Mass customization

Greater investment into a workforce equipped to support the early majority

OLD PARADIGM

• VS. NEW

“ The Old Paradigm”

• Single physician
• One visit at a time (responsible

for that visit only)

• Focus is acute and episodic
• No measurement
• Guidelines
• Outcomes
• Value (accountability)
• High return visit rates
• Low continuity of care
• Follow up sporadic

“The New Paradigm”

• Physician and T

eam

• Responsible for patient

panel/caseload (population)

• Focus on:
• continuity
• optimizing visits
• Same day access
• Screening and surveillance
• Chronic disease management
• Measures of process and
• utcomes
• Integration with specialty

programs/medical specialists (service agreements)

• Information systems and

technology to support

NOTHING IN THIS WORLD COMES FOR FREE

KEY POINTS – HOW TO MAKE IT WORK

• The Non-Clinical staff are JUST AS IF NOT MORE important to the success of

implementing PCNs and team based care models (improvement facilitation and panel managers)

• Be prepared that you will need to adjust your initial plans in terms of what your staff will

do and what role they will fill (continuous improvement mindset)

• Implement roles in a staged fashion whenever possible
• This will be a paradigm shift for many practices and leaders must engage, engage, engage!

KEY POINTS – HOW TO MAKE IT WORK

• Know the problem you are trying to solve and the outcomes you are looking for, but

allow for maximum flexibility on the how (tight-loose-tight)

• Provincial frameworks are very helpful to draw the “lines in the sand” around the

problems and the outcomes, less useful in the “how” of implementation

• Provincial Primary Care organizations must be on the same page
• A true partnership between the health authority (AHS in Alberta) and PCNs essential

KEY POINTS – HOW TO MAKE IT WORK

• You need strong change management supports do not underestimate – but the goal is

to train clinics to be self sufficient – we call this training the trainer

• Governance is important and all leaders should have training
• Leadership is absolutely critical – create space to share and learn and find a way to

support leaders with administrative support and mentorship

• Include patient advisors at all levels of design and from the start

CAPACITY TO ENGAGE AND SPREAD CHANGE

Phy hysi sici cian C n Cham hampi pions/

• ns/Leader

Leaders 57 57 152 152 230 230

10 10

34 34

455 455 476 476

2012 2013 2014 2016 2017 2018 2015

REMEMBER TO HAVE FUN!

WHAT A TEAM COULD DO . . .

• Sinusitis, URTI, Influenza, UTI, STI screening, treatment and

counselling, vaginosis, PAP testing

• 12 week prenatal, 1,6 week post-natal
• Warts, lesion treatment (LN2)
• Long T

erm Care Management

• Care Planning (CDM Care Plans), Advanced Care Planning

(GOC)

• Active Case Management (High Needs – First Contact)
• Post-hospital reviews and chart updates
• New patient reviews and updates
• Home

Visits

• HTN management, Medication Review, Opioid / Benzo

Tapering, Anti-coagulation starts, Chronic Pain Reviews/Management, De-prescribing

• Comprehensive geriatric assessments, Trails A+B, (DMED

screening), MMSE, MOCA, family interviews and liaison work

• All screening of every kind at every visit
• COPD management, Diabetes management, Smoking cessation,

Weight loss

• Hyperlipidemia management, dietary consulting (IBS, picky

eaters (kids), pregnancy, weight)

• Insurance form completion
• Mild-Mod, Mod-Severe MH supports, Social Support Navigation