1. 1 February 20, 2015 Ken Becotte, Executive Director Chilliwack Division of Family Practice Sarah Metcalfe, Program Developer Fraser Health Older Adult Program PCSC Primary Care Seniors ClinicChilliwack Improving Access through Integration PictureBC

2. 2  The speakers do not have any affiliations to disclose

3. 3 Introduction  Chilliwack Primary Care Seniors Clinic (PCSC)  Key part of Integrated Health Networks (IHN)/ Integrated Primary and Community Care (IPCC)  Innovative partnership co-operated by Fraser Health and Chilliwack Division of Family Practice

4. 4 Context  Fraser East (Chilliwack, Agassiz-Harrison, Hope)  Target population: frail seniors  Few specialized geriatric services

5. 5 Issue  Collaborative working group, comprehensive needs assessment and patient journey mapping  Scarcity of specialized resources  Barriers to access  Low dementia prevalence rates (diagnosis)

6. 6 Intervention  Innovative “one-stop shop” clinical model  Comprehensive primary care geriatric assessments  Additional support of nursing and specialists  Key objective: to improve access, coordination and integration of specialized geriatric care

7. 7 PCSC Clinical Service Model

8. 8 Service Philosophy  Integrated and provided collaboratively between interdisciplinary team members  Patients and family actively participate in the development of the Health Improvement Plan  Enhance geriatric knowledge, skills, and competencies for the interdisciplinary team in the community to support patients and their families

9. 9 Clinic Features  Operates 1.5 days per week  Referrals from multiple sources  GP and NP services  Specialist services  Registered nurse  Mental health clinician Primary Care Seniors Clinic entrance (Chilliwack General Hospital)

10. 10 Governance Model  Joint Steering Committee  Defines and makes recommendations on evaluation, sustainability, evolution/growth, resource allocation, and operational decisions that require escalation to that level  Oversees the well-being of the Clinic; responsible for problem solving  Resource requests go through formal channels for both FH and the CDoFP board

11. 11 Measurement & Evaluation  Patient and family/caregiver satisfaction questionnaire  Quarterly metrics and operations reporting  Pre/post analysis of acute care utilization

12. 12 Highlights Satisfaction Questionnaire Operations Reporting Acute Care Utilization Majority agreed: PCSC took concerns seriously and “all of the services I needed right now” were available 1,474 patient visits (as of Jan 29, 2015) Pre/post analysis of ED and acute admissions 82% very or mostly satisfied with experience Year-over-year increases in volume PCSC patients with ED visit declined 76% to 73% Skills and knowledge of SSC staff met or exceeded expectations 391 unique patients (as of Nov 6, 2014) PCSC patients with acute admission decline from 46% to 41% Patient feedback included QI ideas for PCSC services Majority patients from Chilliwack; others from ~7 surrounding communities Average number of acute admissions per patient decrease from 0.91 to 0.72

13. 13 Key Learnings  Multiple partners  three systems of EMR  Ongoing engagement  Space allocation and capacity for growth  Dynamic decision-making  Sustained on collaboration and resource inputs from many partners

14. 14 Thank you  Ken Becotte Executive Director Chilliwack Division of Family Practice kbecotte@divisionsbc.ca  Sarah Metcalfe Program Developer Older Adult Program Fraser Health Authority sarah.metcalfe@fraserhealth.ca PictureBC