Physician Referral to Self Management Program

Bethina AbrahamsSabrina Kang

Practice Support Program

Practice Support Program

GP Practice Team

Patient Care

Integrated Community Collaborative: What is it?

• Chronic Disease Management (CDM) Module– CDM: Registry, Recall, Guideline Based Care,

Flowsheets– Patient Self-Management– Group Visits

Primary Health Care Network Strategic Direction

A patient-centered, primary care-drivenintegrated health care system

Improve health outcomes and quality of life

Improve patient access to primary health care

Improve patient experience with primary health care

Improve provider experience in primary health care

Decrease the average annual cost per patient

VISION:

GOALS:

Alignment with BC Primary Care Charter and VCH Continuums & Population Health Strategies

CDM+ Pathway

•Learn about the concept and the new culture

•Learn tools/skills to help implement•Meet your peers with similar interests•Develop an action plan

•

•Share experiences and data(good & bad) w peers•Refine skills/tools & learnings•Learn new clinical concepts•Learn new tools/skills•Troubleshoot issues•Update action plan

•Try initial implementation•Debrief & problem solve w practice staff

•Use your data to inform changes•Troubleshoot issues w Support Team •Use the Support Team to remove barriers to change

Prework

Month 0

Ongoing

LS = Learning Session AP = Action Period

LS1 AP1 LS2 AP2 LS3 AP3 LS4 AP4 LS5 AP5 LS6 AP6 LS7 AP7 LS8

Month 12-18

Tips for Support Teams –It’s all about the Action Periods• Build relationships with each practice that will

last beyond the module’s end• Emphasize hands on in-practice support• Help practices to obtain, understand and use their data.• Help practices share their stories and data at LSs• Help generate ideas. • Remove barriers.

Building relationships

Integrated Community Collaborative: Goals

• Proactive, planned chronic disease management

• Link practices to existing resources • Identify barriers to accessing patient

resources• Assess gaps in resources• Support the development of needed

resources through community partnerships

Purpose of Evaluation

• To determine if the mode of delivery of self management resource information impacts GP referrals

Evaluation Questions

• Do GPs who receive the information on self management resources indicate they are aware of which self management resources are available to their patients with chronic diseases?

Evaluation Questions

• Do the number of referrals to self management resources increase after resource presentations and resource list handouts or only resource list handouts?

Methods

• Surveys at learning session after GPs have viewed various self management resource presentations

• 51 GPs were surveyed

Findings: Resources Presented at Learning Sessions and

Included on Handouts• If the physician was already aware of the

resource, there was an increase in referrals after the presentation

• If the physician was not aware of the resource, there was less uptake of the resource without added supports (e.g. Provision of referral materials)

Findings: Resources Included on Handouts Only

• Less utilization than with resources presented during learning sessions

• Web-based resources and telephone supports made up the majority of resources used

Preferred Format to Learn About Self Management Resources

61 54

38

0

20

40

60

80

100

Perc

enta

ge o

f GPs

Presentations Emails Handouts

Barriers to Referring Patients to Self Management Resources

76

54

02468

10

Num

ber o

f GPs

PatientMotivation

Distance toResources

Language MOA needsmore

Communityknowledge

Lessons Learned

• Support that simplifies and speeds up the referral process is needed

• Resources need to be presented multiple times in different forms

Next Steps

Compilation and Presentation of

Resources

Organization into Electronic Algorithm

Patient Accessible Lists and Pamphlets

Address Gaps in Services

Acknowledgements• Carole Gillam, Executive Director of Primary

Health Care Initiatives, VCH• Carol Park, Director of Primary Care Integration,

VCH• Dr. James Lai, Dr. Vincent Tang, Dr. Alex She

for leading the Integrated Community Collaborative

• Marina Niks, Kerri Abramson, and Bryn Sadownik for their evaluation project advice