1. CLARITY FROM CHAOS: MULTIPLE INITIATIVES, ONE GOAL
Dr. Brad Bahler
February 24, 2018

2. Presenter: Dr. Brad Bahler
Presenter Disclosure
Presenter: Dr. Brad Bahler
Relationships that may introduce potential bias and/or conflict of interest:
No relationships to declare.
This slide must be visually presented to the audience AND verbalized by the speaker.

3. Feel like this some days?

4. It Started with a Vision…
SEPTEMBER 2011 A Vision for Canada Family Practice – The Patient’s Medical Home

5. Following the Threads…to a New Blue Sky World for Providers…for Patients
What if being a primary care doctor meant…
Work-life balance for us and our teams, team based care, coordination of services, effective exchange of information, managing care together – across the system, payment that allows us to focus on our work and provide care in efficient and new ways, better outcomes and satisfaction for our patients
We have the potential to get there if we follow and pull the threads together….

6. A structured process to realize the vision

7. The Golden Thread… Continuity
All steps lead move us toward continuity. Continuity is thread that binds all elements of the Patient’s Medical Home

8. What are the parts, how do they weave together….
Continuity

9. CPAR – Central Patient Attachment Registry
Opportunity to clarify attachment and record in patient chart and registry
Increased understanding of overlap through reports back to clinics
Increase information back to practices from other health care services
I know who my doctor is and he knows who I am
I value the trusting relationship we have
Wherever I go in the health system other providers know who my family physician is

10. CII – Community Information Integration
The goal is to share useful information into Netcare – from PC and Community SC
Bidirectional information flow is desired future
All integrated health systems have PC data available!!
The specialist at the hospital, she knew exactly what I had talked to my family doctor about
What a relief not to have had to repeat my story to her… for both of us!

11. ASaP – Alberta Screening and Prevention
Supporting providers and teams to screen using standardized protocols
Target - patients who do not present for screening care
Harness power of EMR’s
Harness the power of the Team
I didn’t know that at 50 I should get a mammogram every 2 years. My doctors office called me and got me set up to go for my first one.
Since then, life got busy so I totally forgot that over 2 years went by! That’s when I got the call from my doctor’s office to remind me. Somehow she knew I was due and called me! I’m so thankful they watch out for me.

12. PaCT - Patients Collaborating with Teams
I was diagnosed with diabetes a few years ago. It’s been so hard. I try to do what I am told, but there are so many reasons it is hard
The last time I was in, the nurse met with me and asked me how I was really feeling, what I wanted. We made a care plan together. I feel like I can rely on my team
Many stakeholders in partnership with patients helping to steer the program
Reach those patients who need care the most, and shift the conversation from, “What’s the matter?” to “What matters to you?”
Transform the team’s role in care planning

13. Access / AIM, HQCA Reports
I don’t know what’s going on at my doctor’s office but lately it’s so easy to get an appointment when I need it
I am not sure what is happening but there is a different feel at my clinic
My doctor was talking to me about the medical home and asking about why I needed to use the emergency room for care
Focus on improving access by helping clinics develop a thirst for improvement
Improve access to appointments by making small operational changes at a clinic level
HQCA reports provide valuable data so you can understand what is happening with your patients and plan improvements

14. Physician Remuneration – New models of payment (BCM), and changes to the old
It’s so cool because now my doctor can me or sometimes he calls me – I don’t have to go in!
When I had a chest infection the nurse saw me, she works as a team with my doctor
I appreciate the changes and how my team is trying different things to meet my needs
New models being tried - BCM which open the doors to different types of care
Pts. are affiliated via documented agreement between them and the provider
Changes to the SOMB can also enhance the ability to “work differently” and maximize team use

15. PLN – Physician Leadership Network (Champions)
My clinic was closed for an hour one week so my team could learn together, one of my nurses told me that my doctor helps other clinics as well
I thought doctors just took care of people but I guess they also help each other and the whole system
Designed by physicians for physicians and their teams
Provides essential tools to encourage, and lead effective system transformation towards the Patient’s Medical Home and Integration

16. Primary Healthcare Integration Network
Mom was in hospital - when she went home I knew exactly who to call if we needed help
We got a call from her doctor’s office that week, they knew all about her stay and made an appointment for us
We had an appointment with her specialist already made when we left the hospital – and I knew what to do on discharge
Focusing on transitions of care in our health care system
Works closely with patient/family advisors, AHS zones, provincial programs, PCNs, Primary Care Alliance, other SCNs, AH and academic partners
Working on helping providers fill the gaps they see in transitions of care

17. PCN Governance Framework
My doctor belongs to something called a PCN and it’s pretty interesting because I can get services like seeing a dietician really easily. It was so simple to figure out and all the information went back to my doctor and the team back at my clinic
Zone-wide service plans – become a hub of service delivery
Alignment of services within zones leading to better access and easier navigation for Albertans
Shared administrative services
Leadership for transformation

18. Primary Healthcare Integration Network
CII
CPAR
(Panel ID)
Continuity CPG
PaCT
Access (AIM)
PLN / Champions
PCN Governance
HQCA Reports
ASaP
Physician
Remuneration
Primary Healthcare Integration Network
Threads creating a structure for Continuity...
Continuity

19. Program restructuring
TOP – QI, Panel & Cont, Organized Evidence Based Care
PMP – Governance & Leadership
AIM – Access & QI
PCN PMO – Enabler – PCN supports
AI3 – Care Coordination
AHS Provincial Portfolio – PCN Supports, Leadership and Capacity
Integrated Programs