1. Pillar VI : Continuity of Care, Relationships, Information  Care should be provided continuously over time.  Should foster continuity of relationships between patients and each of their caregivers.  Should ensure continuity of care for their patients in different health care setting

2. Pillar VI Continuity of care, relationships and information  Should advocate on behalf of patients to ensure continuity of care throughout the healthcare system.  Should serve as the hub that ensures coordination and continuity of information related to all medical care the patients receive throughout the system.

3. Pillar VII: Maintenance of the EMR  By 2020, all family physicians in Canada should be using EMRs.  System supports, including funding to support transition from paper records must be in place to enable the practices to introduce and maintain EMRs.  Process for approving vendors must be centralized, include the end users and must provide practices with selection choices.

4. Pillar VII: Maintenance of EMRs  EMRs must include: –. –Appropriate standards for recording and following patient care in the primary care setting; e-prescribing; clinical decision support programs; e-referral and consultation tools; advanced access e- scheduling programs, and systems that support teaching, research, evaluation, and CQI.

5.   http://prezi.com/uetlw7eniy76/ocfp-retreat- jan-25-2012- goel/?auth_key=95f2f67f5902c8b7d019ac0a0 292a297e18606e4&kw=view- uetlw7eniy76&rc=ref-4028582 http://prezi.com/uetlw7eniy76/ocfp-retreat- jan-25-2012- goel/?auth_key=95f2f67f5902c8b7d019ac0a0 292a297e18606e4&kw=view- uetlw7eniy76&rc=ref-4028582

6. Pillar VIII: Training and Research Site  Supported and identified by medical and other health professional school as prime locations for experiential training of their students and residents.  Should teach and model their core defining elements: Patient-centred care, teams/networks, EMRs, timely access to appointments, comprehensive and continuing are, management of undifferentiated and complex problems, coordination of care, practice-base research and CQI.

7. Pillar VIII: Site for Teaching and Research  Provide a training environment for family medicine residents that models and enables residents to achieve the objectives of the Triple C Competency-based Family Medicine Curriculum, the Four Principles of Family Medicine and the CanMEDs Family Medicine (CanMEDS-FM) Roles.  Identified as optimum sites for the training experiences for residents in all medical specialities

8. Pillar VIII: Site for Teaching and Research  Sufficient funding and resources to ensure teaching faculty and faculty requirements are met by every teaching site.  Should encourage and support physicians and other healthcare professionals, students and residents to participate in research in the practice.  Function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services.

9. Pillar VIII: Site for Teaching and Research  Competitions for research grants relevant to primary care and family practice should be supported.  Family physicians and other healthcare professionals in the Patient’s Medical Home practices should be encouraged and supported to compete aggressively for research grants to study the effectiveness of the services they provide.

10. Pillar IX: Evaluation/Continuous Quality Improvement  Should establish CQI programs to evaluate the quality and cost effectiveness of the services they provide and the satisfaction of their patients and providers.  Indicators should be developed to help guide the CQI activities, based on the objectives, goals and PMH recommendations and other published quality indicators.  Clinical guidelines to address the complexity of patients (co-morbidities and complex medical presentations)

11. Pillar IX: Evaluation and CQI  All members of the team including trainees and patients should participate in CQI activities  Annual national multi-stakeholder forums should be held to monitor and evaluate the effectiveness of Patient’s Medical Homes across Canada

12. Pillar IX: Evaluation/ Continuous Quality Improvement O Should establish CQI programs to evaluate the quality and cost effectiveness of the services they provide and the satisfaction of their patients and providers. O Indicators should be developed to help guide the CQI activities, based on the objectives, goals and PMH recommendations and other published quality indicators. O Clinical guidelines to address the complexity of patients (co-morbidities and complex medical presentations) O RED = Opportunity for the OCFP/CCFP O Green = expectation of medical home directly

13. Pillar IX: Evaluation and CQI O All members of the team including trainees and patients should participate in CQI activities O Annual national multi-stakeholder forums should be held to monitor and evaluate the effectiveness of Patient’s Medical Homes across Canada Red = Areas that OCFP/CCFP should have a role

14. Quality Improvement O What it is not…….it is not used for professional accountability. Not all physicians trust this O It is designed to help us evaluate what we do as physicians and improve the care we deliver to patients. We measure: 1. outcome measures (HbA1C, LDL, pneumococcal vaccine rate increased) 2. process measures (examining feet, taking blood pressures, counselling re smoking cessation) 3. balance measures (system outcomes) 4. patient/provider satisfaction evaluations

15. Why Bother with all this? Standardization of patient visits with evidence based care Opportunity to improve the physician and AHP job satisfaction System redesign with cost saving rewards O Evaluation of outcome targets leading to improvement of patient outcomes O “Running on time” “Schedule planning = more time for administration, teaching, research… O Professional satisfaction=meaning and purpose…. O Fewer unnecessary visits/tests, team care with AHP, fewer ER visits, fewer hospitalizations, home deaths

16. Chronic Disease Programs

17. Results www.HQOntario.ca Percent of patients over 40 years of age who are current/former smokers and have been screened for referral to spirometry using the Canadian Lung Health Test. LFHT Learning Community n=4 PROCESS MEASURE: 98% patients screened 43% required spirometry OUTCOME MEASURE: Case finding for the COPD Roster 2009  47 patients 2011  66 patients 17% with spirometry had COPD

18. Results Percent of COPD Patients who report a COPD related visit to the emergency department or hospital admission over the course of QIIP. HQO

19. Results Decrease in patient MRC grades.

21.  Figure 2: After Hours Clinic visits by patients of PCP, calculated per 1000 pts as physician’s panel size changed significantly over the course of the study. Open access booking resulted in a 16.8% relative reduction in after hours clinic visits. Weekday after hours clinic visits decreased by 10.5%.

24. Facilitators O Quality coach and education O EMR O Data management O Remuneration to offset increased costs O Staff in FHT O Development of a quality culture across the health care system (hospital, LTC and community) O See the “wins” Celebrate them O OCFP !!!!

25. Barriers to QI O EMR – data extraction O Knowledge in Quality Improvement O Who decides on outcomes? O What are we to measure? Measurements at the practice level or the system level or accountability? O Staff: Data management, nursing, administration O Time –to evaluate, train staff, develop programs, do education O Financial remuneration – lack of O Financial penalties – fear of O Attitude/buy in ”How does this help me deliver improved care?”

26. Willingness to change As stated in PHAROS, June 2010 by Justin Palmore,.. “I fervently believe that everyone is worthy to serve the suffering. It is not a matter of worth, it is a matter of heart, a matter of passion, and as this picture so candidly portrays, a matter of willingness to progress----- to progress in a way that best serves the human condition, in every aspect.”

27. Pillar X: Governance/Administration  Governance, administrative and management roles and responsibilities should clearly be defined and supported in each Patient’s Medical Home.  The persons responsible for governance, administration and management roles may differ from practice to practice and should be determined at the practice level.  Leadership Development programs should be offered to individuals taking on governance, administration and management roles.

28. Pillar X: Governance/Management  Sufficient system funding must be available to support the clinical, teaching, research and administrative roles of all members of the Patient’s Medical Home  Blended payment models should be introduced in all provinces/territories as the preferred option for remunerating family physicians in practice functioning as Patients’ Medical Homes.