Pillar I: Patient-Centred Care  Caregivers must be patient-focused and provide services that are responsive to their feelings, preferences and expectations.  Patients, families and personal caregivers should be listened to and respected as active partners in the care decisions.

Pillar l: Patient-Centred Care  Self-managed care encouraged and supported as part of care plans.  Access to inform and care beyond traditional visits ( , website, teleconferences)  Patient participation and feedback (patient surveys re patient experience/patient advisory councils)

Pillar II: Personal Family Physician: MRP  By 2015, 95% of people in each community in Canada should have a personal family physician  By 2020, every person in Canada should have a person family physician  By 2022, every person in Canada should have a personal family physician whose practice serves as the Patient’s Medical Home  Each patient in a Patient’s Medical Home should be registered to the practice of his or her personal family physician

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Pillar III: Team-based Care/Provider Networks  The patient’s personal family doctor and nurse should form the core team with physician assistants, pharmacists, psychologists, social workers, physio/OT, and dietitians, as needed. Family Health Teams Health Links  Family physicians with specialized skills and other specialists should be part of the Patient’s Medical Home to provide timely access to a broad range of primary and access to consulting services.  The Patient’s Medical Home may be a solo or group practice

Pillar III: Team-based Care  The patient’s personal family doctor and nurse should form the core team with physician assistants, pharmacists, psychologists, social workers, physio/OT, and dietitians, as needed. Family Health Teams Health Links  Family physicians with specialized skills and other specialists should be part of the Patient’s Medical Home to provide timely access to a broad range of primary and access to consulting services. Family Physicians with special interests  The Patient’s Medical Home may be a solo or group practice.

Family Physicians with Special Interests  Addiction Medicine Family Practice Anesthesia Child and Adolescent Health Chronic Pain Developmental Disabilities Emergency Medicine Global Health Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine  Addiction Medicine Family Practice Anesthesia Child and Adolescent Health Chronic Pain Developmental Disabilities Emergency Medicine Global Health Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine Addiction Medicine Family Practice Anesthesia Child and Adolescent Health Chronic Pain Developmental Disabilities Emergency Medicine Global Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine Addiction Medicine Family Practice Anesthesia Child and Adolescent Health Chronic Pain Developmental Disabilities Emergency Medicine Global Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine Incorporated as part of FHTs or Health Links

Pillar III: Team-based Care/Provider Networks  On-site shared care model to support consultations and continuity of care. Mental Health shared-care models Palliative care  Teams maybe geographically located or networked locally or remotely

Pillar III: Team-based Care/Provider Networks  On-site shared care model to support consultations and continuity of care. Mental Health shared-care models Palliative care  Teams maybe geographically located or networked locally or remotely Family Health Teams Health Links

Fred – the high user Fred is 66 and lives alone. He has 24 different conditions, and has been in and out of hospitals for much of the year, including a lengthy stay in acute care, complex continuing care, rehabilitation, and homecare. He also had 3 ER visits. Fred has seen 16 doctors. The cost of his care was over $900,000 in one year.

Background Rationale  High Users  1% of the users account for approximately 40% of Ontario’s health care costs ($15.2 Billion)  Seniors –The Grey Tsunami approaches  Is the system sustainable? –2013  Health care consumes >40% of provincial budget –2030  Health care will consume >80% of provincial budget

Health Links, South East LHIN ** after feedback from Webinar and Primary Health Care Council

What does a Health Link look like?

Health Links, South East LHIN

Voluntary participation in a Health Link FHO FHT NP Led Clinic CHC

Health Link FHO FHT NP Led Clinic CHC Hospital CCAC VON Community Care for Seniors Mental Health Support Network Mental Health Services Addictions Centre Public Health Health Collaborative

Health Link Criteria 1. 1.Population > 50,000, organized around natural health service utilization patterns Health care providers/organizations involved in the care of the high use/high need population cohort (primary care, hospital, specialists, CCAC, community service providers) Member providers must show a high degree of collaboration (including and signing written agreements formalizing their participation in the Health Link) Member providers agree to identify and track the high use/high needs population cohort (some assistance can be provided) Collaborating providers include minimum of 65% of primary care providers in the region.

Fewer days “on call” Coordinated Quality Improvement Potential Benefits of Joining a Health Link Access to inter-professional providers Patient and Community Focus Even for those not practicing in inter-disciplinary teams. (FHOs, FHNs, FHGs, and solo physicians) New resources for the cluster Not diluting current resources of FHTs/CHCs Community-wide projects Avoids duplication of work (surveys, data analysis, etc) Makes it easy for many providers to participate Possibility of sharing on-call services with a larger pool of providers/groups Only where it “makes sense” Specific target populations (i.e. palliative patients) Activities can be directed by community and population needs Patient-centred care For example: Cluster groups could share a data analyst to support QI work

Potential Outcomes  Increased communication  Improved Transitions in Care  Collaborative Quality Improvement projects  Increased efficiencies (reduced waste)  Improved patient outcomes –Seniors –High Users  Improved patient and provider satisfaction

Pillar III: Team-base Care/Provider Networks  The patient’s personal family doctor and nurse should form the core team with physician assistants, pharmacists, psychologists, social workers, physio/ot, and dietitians, as needed.  Roles and responsibilities should be clearly defined and leadership and support roles for clinical, governance and administrative responsibilities may vary and be determined by the practice.

Pillar III: Team-base Care/Provider Networks  Health system support (funding) to support all members of the team  Each professional to have appropriate liability protection  Ongoing research to evaluate the effectiveness of teams carried out in Patients’ Medical Homes

Pillar IV: Timely Access/Coordination of referrals  24/7/365 access to medical advice, provision of care or direction to needed care.  Advanced access/same day scheduling strategies  Coverage for patient’s family physician

Access at the Belleville Queen’s FHO   Advanced Access – –Patients choose any appointment they want in the next 2 weeks   Group fit-ins – –Pods of 3-4 doctors – –Within building – –Across FHO (3 sites)   FHO Access Committee – –Peak times / Holidays “fit in doc” – –After-hours   Health Link opportunity – –Shared city-wide after-hours clinic

Pillar IV: Timely Access/Coordination of Referrals Process for patient feedback re access, appointments and referrals Process for patient feedback re access, appointments and referrals Annual patient surveys  Appropriate panel size to ensure access Discussions with MOHLTC & OMA  Practice should reflect the needs of the community, workload of the providers and patient safety Linkages to broader healthcare system to ensure access to services and coordination of care Linkages to broader healthcare system to ensure access to services and coordination of care eReferrals Single-intake referrals (ortho) (Health Links

Pillar V: Comprehensive Scope of Services  Family physician and team collaboratively provide comprehensive range of services for people of all ages, including management of undifferentiated illness and complex medical presentations.  Services meet the public health needs of the patients and practice population.  Priority is to deliver evidence-base care for illness and injury prevention and health promotion at each visit

Pillar V: Comprehensive Scope of Services  Health care system supports the Patient’s Medical Home to ensure key role in the management and coordination of care for patients with chronic diseases, including mental illnesses  The health effects of the social determinates of health (poverty, job loss, culture, gender, and homelessness are taken into consideration

Two sets of directions for a banking firm O Imagine telling your organization that the international market represents a huge opportunity for growth. OR O Tell them that the management team assessed the opportunity in other markets and believes the business can accelerate growth by entering the European market and by establishing a direct presence with offices in three countries. Let them know that you plan to invest to enter these markets, as well as the specific business results you expect to see (for example, 7.5% of revenues coming from European markets in two years). Then, clearly identify the team you want leading the effort, and ask them to come back with a detailed business plan

OCFP Leadership "Be willing to make decisions. That's the most important quality in a good leader." General George S. Patton

Pillar V: Comprehensive care O In 2004, Family Medicine in Canada, Vision for the Future2 recommended that the core curriculum for all family medicine residents include maternity care (including intrapartum obstetrics), emergency medicine, palliative care, mental health care, and care of the elderly O PLUS

Definition of “Comprehensive Care” Primary Health Care of the Provincial Co-ordinating Committee for Community and Academic Health Sciences Centre Relations’ (PCCCAR) list of mandatory functions for primary care: O 1. Health assessment. O 2. Clinical evidence-based illness prevention and health promotion. O 3. Appropriate interventions for episodic illness and injury. O 4. Primary reproductive care. O 5. Early detection and initial and ongoing treatment of chronic illnesses. O 6. Care for the majority of illnesses (in conjunction with other specialists, as needed).

Definition of Comprehensive Care O 7. Education and support for self-care. O 8. Support for in-home, long-term care facility, and hospital care. O 9. Arrangements for 24-hour, seven-days-a-week response. O 10. Service coordination and referral. O 11. Maintenance of a comprehensive client health record for each rostered consumer in the primary health care agency. O 12. Advocacy. O 13. Primary mental health care, including psychosocial counselling. O 14. Coordination and access to rehabilitation. O 15. Support for people with a terminal illness.

Sustainable ?

My practice prior to July 2007 Medical Secretary RN Accountant Patients Hospitals LHIN CCAC London Community Professional organizations UWO FHG Call system Jenn Tom and Kelly Jenn Tom Kelly

Challenge = Opportunity

Why I love going to work!

Comprehensive Care O Family Physicians with special interests are those family doctors with traditional comprehensive continuing care family practices who act as the personal physicians for their patients and whose practices include one or more areas of special interest as integrated parts of the broad scope of services they provide. O Family physicians with focused practices are those family doctors with a commitment to one or more specific clinical areas as major part-time or full-time components of their practices.

Special Interest and Focused Practice O As of June 1, 2012, programs have been approved in the following areas: O Addiction Medicine Family Practice Anesthesia Child and Adolescent Health Chronic Pain Developmental Disabilities Emergency Medicine Global Health Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine Addiction Medicine Family Practice Anesthesia Child and Adolescent Health Chronic Pain Developmental Disabilities Emergency Medicine Global Health Health Care of the Elderly Hospital Medicine Maternity and Newborn Care Mental Health Occupational Medicine Palliative Care Prison Health Respiratory Medicine Sport and Exercise Medicine

Facilitators Triple-C Competency Based Curriculum O Focus based practice/ special interest based Practice O Team based care : Can the team develop internal ways to encourage comprehensive care without compromising continuity of care? O Payment plans : Capitation models O On call groups O Open or same day access (I like the term reasonable access) O Educational modules that are case based O Specialist support for primary care scope How do we make sure there are opportunities to be comprehensive practitioners?

Barriers O Huge, if not impossible knowledge base expected = Generalist O Lack of system coordination O PAPERWORK O The EMR....”I do not type” O The lack of specialists, the lack of tests, the lack of help in your office/department setting O The meetings, the lack of input to a problem O The complexity of the patients, the aging population O The lack of family doctors O The walk in clinics, the emergency rooms, the hospitals, the government O The accountability looming in the not too distant future O The pay...the lack of pay....the inequality of pay....the pay for not working.....the fee for service....the lack of on-call pay......the inequality of on call pay.....the little pay for teaching.... O Etc....you get the hint...we can complain about anything!