Community Navigation and Access Project RFP Response

The Integrated Home-Based Primary Care (IHBPC) Project

Dr. Sabrina Akhtar TWFHTDr. Thuy-Nga Pham SETFHTDr. Mark Nowaczynski House CallsDr. Samir Sinha UHN/MSH GeriatricsDr. Tracy Smith-Carrier Kings, WesternDipti Purbhoo TC-CCAC

Photo Credit - Toronto Star, 2011Tia to start1Rationale for our Collaborative Why?93% of Canadians aged 65 and older live at home, > 100,000 of them are homeboundSince 2000, five English systematic reviews published on home-based primary care with conflicting results on mortality, functional status and health care use and costs

Source: Stall et al, 20th IAGG WORLD CONGRESS OF GERONTOLOGY AND GERIATRICS 2013

22Background3FEATUREHOME-BASED PRIMARY CAREOUTREACH HOME VISITSFunctional ModelOngoing comprehensive primary care in the homeHome-based multidimensionalGeriatric assessmentsCare FocusComplex and interrelatedchronic disease management and social care issuesNeeds assessmentsTime CourseOngoingConsultation with possible limitedfollow-upPersonnelPrimary care providerledinterprofessional teamsVaried, but typically nursingand allied health professionalsGoals of CareImprove access to primary careAssess needs and develop careplanSource: Stall N, Nowaczynski M, Sinha SK. Back to the future: home-based primary care for older homebound Canadians: part 1: where we are now. Canadian family physician Medecin de famille canadien 2013;59(3):237-40. Who are our patients?4

Taddle Creek FHTMSH FHTIntegrated Home Based Primary Care Catchment

Samir5Patient Site Totals6SiteCurrent TotalMount Sinai Hospital25SMH31SETFHT61Sunnybrook57Taddle Creek62TWH73SPRINT425*TOTAL734*Totals as of March 26, 2014IHBPC Models of Primary CareFHT Model:Family Health Teams taking care of homebound patients that benefit from an interprofessional team delivery model (FPs, NPs, SW, OTs, Pharmacists)

CSS Model (SPRINT House Calls Model):Primary Care Team (3 FPs, 1 NP, 2 OTs, 1 PT, 1 SW, 1 Team Coordinator etc.) embedded in a Community Support Services AgencyEarly Analyses show 67% Die at Home Rate, and 14% and 29% lower hospital readmission rates at 30 and 90 days.

Emerging CHC/Hospital/CCAC Models:In development! One of the FHT graduating PGY3 Care of the Elderly Fellows has joined a West End CCAC interprofessional team in providing IHBPC.

77Program Objectives What are we doing?8Provide a comprehensive and integrated approach to patient and client care

Improve transitions in care between acute, primary care and community care settings

Establish a network of specialists to support home-based primary care with recent urban telemedicine expansion Patient Care ObjectivesIntegrated Care Team ObjectivesDevelop shared understanding of roles, responsibilities and accountabilities between providers Improve communication among team members and across the continuum of care and organizations

Enhance care management partnerships between primary care and community care providers

Skype in your specialistWhat are we measuring?99Qualitative Research

10Interprofessional Team ExperienceExploredTeam members experiences providing IHBPC services vis--vis providing usual careThe key characteristics of successful team functioning within the IHBPC environmentThe facilitators of effective IHBPC service delivery Areas of improvement (barriers)

Analysis InformationGrounded theory methodologySample = 7 sites (6 FHTs + 1 IHBPC CSS team) in Toronto - winter of 2013Purposive sampling approach (Patton, 2002) by team member role

Team Members (n=17)CCAC Care coordinators Social WorkersPhysiciansOccupational TherapistsPhysician AssistantNurse Practitioners & NursesPharmacists11Dimensions of IHBPC Service Delivery to Team Members12

There are a significant number of seniors who cant access their family doctors office for a variety of reasons: Cant access transportationDementia and cognitive impairmentsCant sit in an office and wait for hours Mental health

CCACThe introduction of CCAC in house, has streamlined the process which is amazing.

Now, I would say my role is more of a team player. I am letting our nurse leader take more of the leadership of this & coordination role. So for me it is easier.

Well the doctor is the leadI mean we all have rolesBut there has to be somebody in charge of all of that, because if we all had control it would be not doable for anybody

Its, from what I can tell, its all through our physician assistant. So shes sort of the quarterback & she gathers all of us together & whoever she needs help with, & then she helps carry out the plan.

The Population & Necessity of the Service and CCAC Involvement Types of TeamsContext of IHBPC13Benefits of IHBPC(I)t is making it easier because you can visually understand what their needs are:you can tell if they are taking their medicationsyou can tell if they have safety issuesthe extent of their dementia becomes more rapidly obvious to youyou can see where they keep their medications and can tell whether they can take their medications as you prescribeddo they have dexterity issues with the blister packs, can they read the pills bottles, do they have somebody to administer themare they living in a second floor bedroom & they cant access food on the main floor or a bathroom on the main floor & they are living on the 2nd floorSo you can address multiple issues quickly, so from that respect I find it easier to create a care plan that works for the patient.

I love the population and I think that we are stemming some emergency visits although that remains to be born out, thats a difficult thing to measure as we all know. But based on the kind of presentations, and the phone calls we get from their providers, and the treatments that were giving, I think that probably were deferring visits

I went out to see this guy last week and I could see something was brewing on his foot so I could deal with it before he went to emergency, you know?

Thats the one major change, that they can actually manage their care through us now without having to access emergency department services on every occasion.

Benefits of the Context of Home

Sense that IHBPC Defers Hospital Visits14BarriersAfter seeing the patient theres a lot of kind of paper work & stuff that needs to be attended to, you know, youre not seeing people with colds, you know.

One of the biggest barriers would be how far away the doctor or the person has to drive, right. It really should be no longer than 15 minutes, because than thats a half hour for the drive, not including wherever you have to park.

Administrative LoadTravel15Facilitators & Barriers of Team CollaborationUsing our computers and our blackberries, which everything goes into the clients fileWe are not missing anything using the interdisciplinary approach.

We also have biweekly meetings where we sit down & discuss new referrals, we discuss current cases, issues, good stories, bad stories, & housekeeping

The weekly rounds seem to be the venue where things are discussed. I know theres also some email correspondence that I have been part of as well around plans & they are sort of an on going dialogue.

We use a program called One Note for our patient charting. If a patient has passed away or needs urgent attention usually that warrants a phone call to another team member or at the very least an email. Communication folder is just a Hey I just wanted to give you the heads up about this

I guess one of the other challengeswas that some of our physicians are not as embracing of a nurse going out to see their patients, or not their nurse going out to see their patient. I find that one of the very frustrating things, that theres this protectionism of my practice attitude, & we really have to move away from that. We need to remember its the patient thats at the center of what we do, not the physician or the physicians views. And thats a challenge. Its a challenge I have had in complex continuing care, its a challenge being out here.

Variety of Communication Mechanisms (Facilitators)Turf Issues (Barrier)16System Wide Gains Thus Far171718

Tia Pham, MDTracy Smith-Carrier, PhDThuynga.pham.utoronto.catsmithca@uwo.ca Questions?