1. THIS NEW HOUSE HOW NORTHERN HEALTH STAFF AND PHYSICIANS ARE BUILDING PRIMARY CARE HOMES TO IMPROVE CARE BC QUALITY FORUM February 25, 2016
Dr. Garry Knoll
Family Physician
Lead Physician
Prince George Division of Family Practice
Suzanne Campbell
Director, Community Services
Prince George
Northern Health
Michael McMillan
Chief Operating Officer
Northern Interior HSDA

2. History of the Work
Over 8 years ago Northern Health started the journey towards a more integrated system of care, with strong Primary Care as the cornerstone of the system and clear connections to specialized and specialist services.
A number of consultations and streams of work to improve care for seniors and other people with complex needs. These include but are not limited to:
Northern Health’s Primary Health Care Strategy - Care North (2008)
Prince George Division established 2009 – collaboration started
Understanding Our System Work
Uptake of electronic medical records by physicians in Northern BC
Aging well in Northern and Rural Communities (2008)
Development of Northern Health vision and strategic plans
Seniors Consultation and Action Plan 2014

3. Strategic Plan
“Northern Health is known for our strong primary health care system. People experience seamless and coordinated service. The Primary Care Home is the foundation for multidisciplinary health care and helps people navigate across services.” Northern Health Strategic Plan

4. Objective of the Work A Primary Care Home is the place where people
establish long-term relationship with a primary care provider and inter-professional team,
receive seamless, coordinated, and longitudinal care
are supported in managing their own health
In Northern Health, the Primary Care Home is embedded in a Healthy Community. Health promotion and prevention is an integral part of the work

5. Primary Care Home

6. Primary Care Home Goal 3 – Team Based Care
A Patient’s Primary Care Home will offer its patients a broad scope of services carried out by teams or networks of providers, including each patient’s personal family physician working together with peer physicians, nurses, and others.

7. Primary Care Home Goal 5 – Comprehensive Care
A Patient’s Primary Care Home will provide each of its patients with a comprehensive scope of family practice services that also meets population and public health needs.

8. Primary Care Home Goal 6 – Continuity
A Patient’s Primary Care Home will provide continuity of care, relationships, and information for its patients.

9. Primary Care Home
Goal 7 – EMR A Patient’s Primary Care Home will maintain electronic medical records (EMRs) for its patients.

10. Partnership and Collaboration

11. Northern Health Idealized System of Services

13. Inter-professional Team Members & Functions
Members (not all teams will have all members)
Primary Care Physician / Nurse Practitioner
Primary Care Nurse
Mental Health Clinician
Rehab Professionals
Pharmacists, Dieticians, other
Roles
Case Finding
Care Planning
Care Coordination / Monitoring

14. Current State

15. Inter-professional Team Example

16. Small Community Example

17. Interprofessional Team Formation – Phase 1

18. Interprofessional Team Formation – Phase 2

19. Interprofessional Team Formation – Phase 3

20. Interprofessional Team Formation – Phase 4

21. Work in Progress Supporting people through change Workforce Transition
Leadership Structure
Front-line staff team assignments
Work process redesign
Documentation (options)
Logistics

22. Logistics – Team Location

23. What are staff saying - Challenges
Loss of identity
Loss of team members / connections
Stressful environment with so much change
Is this a business model or a model of care?
Transition (transformation) is difficult and takes a long time
Change affects people (in a negative way)

24. What are staff saying - Opportunities
Chance to participate in change for better care
Challenge the system
Small teams encourage team development
Keep the big picture in mind (don’t sweat the small stuff)

25. Key Messages
Objective is to provide better care, particularly for patients with complex needs
Never too early to meaningfully engage medical staff
Structure change is insufficient – care process changes are essential
Change – significant, emergent, at all levels, needs to be supported
The system is complex and this work is hard
PARTNERSHIP!

26. QUESTIONS?