Barcelona

1
Primary care renewal
as the springboard to a high-quality, sustainable
public health system
Workshop B3
INTERNATIONAL FORUM ON QUALITY AND SAFETY IN
HEALTH CARE
Barcelona April 18, 2007
2
Workshop objectives

• Drawing upon the BC experience
• Better understand the critical relationships
  within your health system
• Determine what factors to consider when
  establishing incentives for improved primary care
• Examine supports necessary for achieving improved
  primary care
• Determine the applicability of the approach to
  your situation

3
Workshop team

• Valerie Tregillus, BC Ministry of Health
• Dr Bill Cavers, General Practice Services
  Committee
• Judy Huska, Northern Health
• Dr Andrew Sear, General Practitioner
• Dr Dan MacCarthy, BC Medical Association
• Dr Chris Rauscher, Vancouver Coastal Health
• Paddy OReilly, IMPACT BC, Healthy Heart Society
• Liza Kallstrom, BC Medical Association

4
Workshop agenda
5
A pragmatic approach
Valerie Tregillus Executive Director, Primary
Health Care Medical Services Division BC Ministry
of Health Email Valerie.Tregillus_at_gov.bc.ca
6
Stages of transformation

• Results from collaboratives
• Patients as partners
• Partnerships and supportive environments
• Physician agreements
• Administrative data tell a story
• Charter brings it all together

7
The BC context
8
The BC context

• 4.2 million people
• 948,191 km2 approximately 2xSpain
• Publicly funded, universal health system
• Federal Canada Health Act, administered at the
  Provincial level
• 5 regional and 1 provincial health authorities
  with global budgets
• Separate physician administration at provincial
  level
• Primary care based in fee-for-service GP offices,
  often solo, few nurses
• Ministry, medical association, health authority
  and non-government organization relationships are
  key

9
The vision for the BC health system
10
Building primary care around the needs of
individuals
Stay Healthy
Get Better
Individuals
Involves maintaining health and wellness from
birth through end of life
Involves getting better after experiencing an
illness or injury
Manage Disease and Disability
Cope with End of Life
Involves remaining stable and successfully
managing a long-term condition
Involves preparing for death with dignity
11
Health status the good news

• 88 of adults rate their overall health as good
  to excellent
• Cardiovascular disease rates in BC are the lowest
  in Canada
• Life expectancy in BC is the best in North
  America-among the best in the world
• Men 79.2 - best in the
  world
• Women 85.2 - sixth place

12
BC population health status 2005/6
1 to 3 Chronic
Conditions
32
4 to 6 Chronic
Possible Chronic
Conditions
Condition
2
17
7 Chronic Conditions
0.2
Non-Users
15
Acute Condition(s)
34
Possible Chronic Condition 1 medical
diagnosis 1 Chronic Conditions 2 or more
medical diagnoses Source Medical Services
Division
13
Costs are weighted towards those with chronic
conditions
620,313
2005/6
14
Shifting age demographic
Age groups with highest prevalence of chronic
diseases
15
Growth over the next 25 years for those with 1
chronic condition
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The improvement journey in BC

• Video may be viewed online at www.impactBC.ca

17
Primary Health Care Charter for BC

• The Charter sets the direction, targets and
  outcomes to support the creation of a strong,
  sustainable, accessible and effective primary
  health care system in BC

17
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Common themes

• Establish regional practice support teams
• Provide local learning sessions with follow-up
  action periods
• Implement integrated health networks in a
  staged or phased approach
• Realign secondary and tertiary services
• Build supports for patients as partners
• Provide technology to support critical primary
  health care functions
• Ensure a supportive policy environment

19
Integrating services around the needs of patients
Family Practice
Hospital ER Specialists Mental Health Home and
Community Care
Non-formal health system community resources
20
An emphasis on chronic disease management

21
Priority populations for PHC
Cardiovascular
Mental Health
Hypertension Diabetes Mellitus Ischemic Heart
Disease Congestive Heart Failure Cerebrovascular
Disease Chronic Renal Failure Disorders of Lipid
Metabolism
Depression
Musculoskeletal
Osteoarthritis fractures related to
osteoporosis Lower back pain
Other focus areas
Respiratory
Aboriginal Frail Elderly End of Life Care Complex
patients Maternity Care Dementia
Asthma Chronic Obstructive Pulmonary
Disease Acute Lower Respiratory Tract Infection
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Co-morbidities management

• Problem
• Complexity of combinations of disease potentially
  involving the prescription of multiple
  medications and the increasing need for planning
  and care coordination
• Example Initiatives
• Complex care incentive, conferencing fee
• Specialist compensation for shared care
• Alignment of services

23
Shifting a complex system

• BC government makes primary care a priority with
  substantial investment
• Partnershipsmultiple stakeholders
• Directionthe Primary Care Charter aligned with
  leadership and improvement
• Patients as partners
• Physician engagement
• Health authority implementation in partnership
• Integrated healthcare networks

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Creating an Engagement culture a RISQy Business
Dr. Bill Cavers BC Medical Association
Co-Chair, GP Services Committee Email
wcavers_at_shaw.ca
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RISQy Business

• Relationships
• Incentives
• Supports
• Quality

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Relationship Tensions Loop

• Mandating responsibility
• Funding challenges

• Confrontation
• Lack of trust

?

• Limited relationships with
• Health Authorities
• Community Services
• Other GPs/Providers

• Little contact with GPs
• Poor understanding
• Inadequate funding
• Few successes

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Building a trusting Relationship

• Needs of both sides must be met
• Establishment of joint committees
• Clinical Guidelines Protocol Committee
• Joint Utilization Committee
• Joint Utilization Committee
• Tariff Committee
• Strategic grants to facilitate the change
  process
• To BCMA Diabetes Collaborative, Frail Elderly
  Initiative
• To College of Physicians Surgeons Self-Audit
  Module
• To College of Family Physicians Patient
  Self-Management Training
• To Faculty of Medicine PDA Guideline Support

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Building a trusting Relationship

• GP visits are the real measure in primary care
• Government realized this reality

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The Eureka! moment

• Discussions at ideological level NO Interest
• Discussions on needs of patients REAL interest
• GP Services Committee Aligning discussion with
  funding

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Incentives

• Buy what you want - funders providers agreed
  on expenditures
• Targeted Funding
• Targeted incentive payments for GPs over 4 years
• Wide engagement 85 of 4,000 GPs expected to
  participate
• Ongoing funding increased sustainability
• Chronic Conditions
• Existing conditions CHF, DM, HTN flowsheets
  One-time CDM bonus
• Commitment to address additional conditions
• Complex care fee
• Patient Management Conference Fees
• Patient Complex Care Clinical Action Plan Fees
• Obstetrical care bonus/Maternity Care Network
• Prevention (5 of targeted funding 2007)
• Mental Health Depression/Anxiety

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Supports IM/IT Clinical

• Clinical Information Systems must be
• Secure/Confidential Interoperable Supportive of
  workflow, NOT the reverse User friendly
  Inclusive of Clinical decision support
• Financially supported large benefits to system
• Clinical Supports
• Nurses, psychologists, pharmacists, social
  workers, dieticians, Community RNs
  (Home/Palliative Care) aligned with GPs
• CME Modules for both GPs and Patients.Frail
  patients, CDM
• Practice Redesign
• CDM, Advanced Access, Group visits/DIGMAs, CBT,
  IT, Patient Self-Management
• GP Networks - locums
• Mutual Support Community-Located,
  Clinically-Focused
• Planned/Shared Locum-Hood

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Supports - Change Management

• Funding for Professional Quality Improvement Days
  (PQIDS), Practice Support Program (PSP)
• Meetings in each of 5 Health Authorities PQIDs
  1,000 GPs
• PSP includes Medical Office Assistants currently
  gt600 enrolled
• Funding/Support for Change Management
• Practice redesign CDM, Advanced Access, Patient
  Self-Management Group Visits/Touches
• Implementation of IM/IT

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Quality loop
Quality Care
Measurement
Professional Satisfaction
Feedback
Professional Development
34
Quality

• Some is not a number soon is not a time
• Dr. Don Berwick
• Practice information is powerful
• International data is nice
• National data is fine
• Provincial data is good
• Local data is better
• Personal data is best Dr. Art Macgregor
• Without data, you are the owner of a fairly
  hollow pride

35
Quality

• Care gap 45 of diabetes patients treated to
  guidelines in BC (for A1C)
• 70 tested for A1C among GPs who billed incentive
• 31 tested for A1C among GPs who didnt bill
  incentive
• Patient registries
• Total number of patients with a condition in a
  practice
• of patients treated optimally in a practice
• Quality Improvement collaboratives
• CHF patients on B-Blockers
• A1C tests for DM patients
• Physician Mini-Profiles to include Quality
  feedback

36
Quality
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Results from the CHF Collaborative
What was achieved in the CHF Collaborative?
100
Closing congress
Start of collaborative
75

Percentage
50
25
24
21
22
15
4
Had specific self-management goals for diuretics
Patients who
Had documented ejection fraction
Established self-management goals
Were on ACE-I / ARB
Were on B-Blockers
Making BIG changes video may be viewed at
http//www.heartbc.ca/pro/collaboratives/chf/bigch
anges.htm
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Quality
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Quality

• Measurement and feedback ? professional
  development
• Brings back cycle of continuous education and
  excellence that brought doctors into medicine in
  the first place
• Professional development component of quality
  improvement
• Brings back collegiality and sense of community
  of the profession
• Results in professional satisfaction

40
Use of heart failure medications for CHF grows
41
Number of physicians involved in QI initiatives
accelerates
4,430 GPs in BC at March 31, 2006
42
QI efforts lead to 32 drop in ASMR
43
Conclusion

• BCs primary care approach is unique
• Targets mainstream fee-for-service GPs
• Voluntary
• no rostering, no capitation, no hoops
• Based on CDM business case
• Results
• improved patient outcomes, and
• reduced health care costs
• Sustainability of health system

44
Approaches towards integration of services
Judy Huska Executive Director Health Services
Integration Northern Health Email
judy.huska_at_northernhealth.ca
45
The story of Jake
46
Transforming BCs health system
patients receiving optimal medical diabetes
primary care 2002/03

• Achieving optimal diabetes care requires
  significant and complex changes across the
  healthcare delivery system

Ministry of Health data for people Using MSP
and Pharmacare
47
Northern Healths Community Collaboratives

• The Collaborative Vision
• Participants working together to learn and
  implement an innovative organizational approach
  to chronic disease prevention and management.
  The approach is population-based and creates
  practical, supportive, evidence-based
  interactions between informed, activated patients
  and a prepared, proactive practice team.
• Identify best practice clinical practice
  guidelines
• Look at gap in care
• Set targets for improvement
• Redesigning the system

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Investment in practice and system change

• Outcome-based quality improvement model
• 7 sites
• 33 family physicians and over 70 providers
• Multidisciplinary planning and service delivery
  teams
• Spread to 16 communities, 168 physicians
• Introduction of change management tools
• PDSAs
• Five As Self-Management
• CDM Toolkit

49
Achievements in redesign

• Clinical practice changes
• increased use of clinical guidelines
• increased recall and proactive care
• introduction of open access
• use of group visits or DIGMAs
• support for self-management and prevention.
• Local PHC system changes
• increased use of interdisciplinary teams
• expanded scope of practice
• increased use of tele-diagnostics
• increased use of technology based decision
  support
• Connection with communities

50
Improved adherence with blood pressure guideline
Achievements in patient care - BP
Better blood pressure results/outcomes
51
Improved adherence with A1C guideline
Achievements in patient care A1C
Better A1C Results/Outcomes
52
EMR 40,000 patients data
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Chronic Disease Management
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Lessons learned

• Its all about relationships
• Outcome-driven change rather than blueprint
  driven change
• Physician leaders are critical to success
• Money matters
• Changes in individual clinical practice cant be
  sustained without the support of system changes
• Successful change management requires dedicated
  resources and effective tools

55
And

• Quality patient care requires team work.
• Patient-focused care reduces or eliminates
  program silos
• Clear clinical guidelines and opportunities for
  measurement and monitoring success encourages and
  supports clinical change
• Technology is contagious EMR is critical
• Patient as partner is a new paradigm
• Communities need and want to be involved in
  primary health care change

56

• NO SERVICE HERE? LETS FIX THAT!
• Mackenzie Mammogram Experience
• Mammography screening only available at least 2
  hours drive away

AIM Women between the ages of 50-70 to have the
opportunity for a screening mammography exam in
their own community

• STUDY
• Clinic was booked to full capacity prior to
  start
• Waiting list established and the majority of
  cancellations filled
• Clinic extended to accommodate requests
• BEFORE 10 of eligible women in Mackenzie
  screened
• AFTER 65 screened
• STILL WORK TO DO!

• DO
• Identify all women age 50-70 years old
• Mailed leaflets with clinic information and
  toll-free phone number
• Advertised clinic in local media, doctor and
  hospital waiting rooms, community centres
• Poster displays in the clinic waiting room

• ACT
• Measures taken to optimize the Mackenzie clinic
  were a success and will be repeated annually
• BC Cancer Agency asked to increase number of
  days of the Mackenzie clinic and/or consider
  visiting Mackenzie twice/year.

57
Care North (primary health care) infrastructure
58
Spread and new focuses

• Community Collaborative expanded to 8 more
  communities
• Frail Elderly Collaborative Integrated Health
  Networks
• Aboriginal Health Collaborative partnership
  with FNIHB, aboriginal communities
• Asthma mini-collaborative
• Chronic kidney disease mini-collaborative
• Hypertension and cardiovascular disease
• Industry/HA/physician partnerships
• Introduction of Nurse Practitioners
• Quality and Outcomes Framework Scorecard 32
  physicians, 40,000 patients

59
Whats changed for Jake?

• Proactive, holistic rather than reactive care
• Consistent, coordinated evidence based care
• Information management recall, data extremes,
  sharing data across providers
• Depression addressed
• One-stop shopping group visits
• Jake is involved in his own care
• Prevention flow sheet hearts_at_work employer
• Improved health outcomes possibly avoid
  amputation, MI
• Supportive environment in his community access
  to healthy foods and walking trails

60
A Physicians perspective
Dr Andrew Sear General Practitioner Quesnel,
BC Email andrew.sear_at_northernhealthcare.ca
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My town

• Quesnel BC
• 28,000 people
• 18 GPs
• Solo
• 5 groups

62
Why our GPs might consider change

• Because it makes sense financially
• Because it will improve his/her satisfaction
• Because it is easy to do
• Because it will improve outcomes for the patient
• Because someone is watching
• Because it will help achieve guideline care

63
Working in partnership mode

• Coordinator/facilitator must have credibility
  with doctors
• Believes in what she/he is facilitating
• Can make it easy for them to try the change
• Is knowledgeable in primary care
• Works well with people - inspirational
• Four point plan approach
• Present the financial support
• Present the evidence
• Bring the doctor who has tried it and his success
  graphs
• There will be ongoing support and follow-up

64
A simple four-step plan

• Preliminary (lunch) meetings with the facilitator
• Overview (short and concise) and handout package
• Follow up with the GP who takes lead
• Arrange for monthly meetings to provide help for
  redesign
• Access financial supports
• Help to access grants, incentive payments for
  flow sheet, Sessional fees for attending learning
  sessions
• Develop concise plan for redesign using CDM
  toolkit
• Sign up for toolkit (provide toolkit user guide)
• Flag charts
• Work on baseline data registry
• Use key measures reports for recall
• Provide toolkit support education (IT will come)
• Provide a phone and online resource list

65
What we learned

• Its all about building relationships and trust
• Need to be flexible and accommodating in
  physician schedule and needs
• Doing PDSAs together that report success is
  vital
• Data and measurement speak volumes competition
  is a motivator
• Base the work on the evidence
• Were in this together
• Focus on a population that you want to improve
  e.g. cardiovascular, CKD, frail elderly,
  aboriginal health, mental health and addictions,
• Use IHI and other learning opportunities

66
What we learned

• Use 5 As (Ask, Ask.)
• Find a GP champion in the community
• Credible with other physicians
• Has graphs to demonstrate
• Works under same fee schedule
• Willing to share his/her success
• Involve the Medical Office Manager key to
  success
• Do not INSIST on change ASSIST with the change
  even the smallest changes

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We now help each other
Quesnel Doctors Join To Help Each Other In
Decision Support. Example of Monthly Comparisons
68
Quesnel Doctors Join To Help Each Other In
Decision Support. Example of Monthly Comparisons
69
Quesnel Doctors Join To Help Each Other In
Decision Support. Example of Monthly Comparisons
70
Quesnel Doctors Join To Help Each Other In
Decision Support. Example of Monthly Comparisons
71
Quesnel Doctors Join To Help Each Other In
Decision Support. Example of Monthly Comparisons
72
Town hall meeting and discussion
Dr Dan MacCarthy, Director Professional
Relations BC Medical Association Email
dmaccarthy_at_bcma.bc.ca Dr Chris
Rauscher Physician Lead Chronic Disease
Management Vancouver Coastal Health Email
Chris.Rauscher_at_vch.ca
73
Reinforcing key lessons
Valerie Tregillus Executive Director, Primary
Health Care Medical Services Division BC Ministry
of Health Email Valerie.Tregillus_at_gov.bc.ca
74
Thank you
Paddy OReilly CEO, Healthy Heart Society of
BC Director, IMPACT BC 1 604 742
1772 pmo_at_healthyheart.bc.ca