1. Coordinated Seniors Care Initiative Completing the Circle of Care: Specialists + PMHs + PCNs
October 29th, 2018

2. A Collaborative Culture of
At the core of SCC’s mandate in the PMA is bringing together GP’s, Specialists and GP’s with a focused practice, along with other health professionals, to improve care for patients.
This is an important area – while GPSC focuses on full service family practice, and Specialist Services addresses core needs of specialist practice – SCC works to bring those together, often around the critical issues of access, coordinating care, and communication between providers.
Relationship-Based Care

3. There are 950,000 Older Adults in BC …
*PPhRR Evaluation Administrative Dataset (includes all people 65+ and service data from BC MOH Client Roster, MSP, PharmaNet, DAD, NACRS, Home and Community Care, Vital Stats, RAI Continuing Care and Home Care)

4. Unnecessary Procedures
The Impact of Uncoordinated Care
Canada ranks 9th out of 11 countries in
the Commonwealth Fund ‘Mirror, Mirror 2017’ report on measures of access, effectiveness, safety, coordination, equity, efficiency and patient-centredness
Complications
Wasteful Spending
Pain
Unnecessary Procedures
Medical Errors

5. What we learned from Frail Seniors Prototypes (Fall 2016)
STRENGTHS
CHALLENGES
Collaboration with HAs and local community partners
Fragmented system of care
Inclusion of patients & caregivers
Inadequate communication re Knowledge Translation, Transitions in Care
Increased awareness of existing resources
Social Determinants of Health Issues: Food, Transportation, inadequate income and shelter = POVERTY
Virtual Care
Inadequate Service Funding:
Inconsistent providers, lack of culturally sensitive care, language barriers
Polypharmacy Risk Reduction
Lack of IM/IT systems integration:
Fragmented Pt Medical Record

6. Critical benefit of Shared Care work
New & improved
relationships achieve
better results for patients
& providers
If we want a more effective, patient centred health system – we have to support front line providers – both physicians and others – to build positive, collegial working relationships.
While we have the Patient Medical Home/Primary Care Network alignment rolling out, we are missing the integration of Specialist care to complete the Coordinated System of Care

7. Completing the Circle of Care
Where we want to go now:
Completing the Circle of Care
Coordination of care for older adults with complex conditions by involving SPs, GP’s with Focused Practice, GPs and other Allied Care Providers.
Alignment with PMHs and PCNs
Focus of this initiative is initially on Seniors due to the complexity of their medical care needs. Support for other patient populations continues through PiC and TiC
Increased awareness of multiple specialist physician involvement in care of complex older adults
Address Unique Coordination Challenges in Each Community by aligning strategies with PCN/PMH supports and resources

8. Specialists + PMH + PCNs =
The vision of a Coordinated System of Care includes:
Relationship-Based Care
Cultural Safety and Humility are embedded
And The Principles of Coordinated Care:
Coordinated System of Care

9. Principles of Coordinated Care
1. Track and Manage all Referrals
2. Support Team-Based Care & Organization of Resources
3. Know & Manage your Patients
4. Enable Access to Continuity of Care Information
5. Provide Collaborative Care Management & Support during transitions in care
6. Measure & Improve Performance on Indicators of these Principles
Track and Manage all Referrals Between Providers to Improve Care Transitions
Develop co-management and transition strategies between providers, patients and family caregivers
Understand referral and consult requirements
Improve access to test and procedure results
Support Team-Based Care and Organization of Resources
Establish roles and responsibilities of the team (patients, family caregivers, Specialist and Family physicians and other providers)
Define how team members communicate responsibilities for patient care with each other
Determine access to resources/team members
Know and Manage your Patients:
Share comprehensive patient clinical data, demographics and health risks between the team
Identify proactive measures for patient populations and mechanism for intervention
Enable Access to Continuity of Care Information
Identify level of engagement with Specialist Physician (consult, episodic or longitudinal care) and other providers; develop ways to communicate this between the team, patients and families
Identify responsibility for medication management (in community & post-hospitalization)
Establish access to patient information by patients and families (patient portal?)
Provide Collaborative Care Management and Support to Patients Moving Between Providers and Services
Create collaborative plans for care that are accessible by providers across care settings
Involve patient and family in self-care responsibilities, provide them with educational tools and access to resources
Measure and Improve Performance on Indicators of these Principles
Monitor achievement of coordinated care principles and measures of clinical outcomes
Measure patient and provider experience to identify opportunities for improvement

10. The Medical Neighbourhood
Specialists are integral to care teams, especially for those with complex conditions
Other health system experiences show benefits of early engagement of specialists in system change
Opportunity for Shared Care/Specialist Services collaboration

11. Coordinated System of Care
Specialized Care Service Program for Complex Older Adults
FACILITIES
PCN
MHSU Clinician
Social Worker
Clinical Rx
Dietitian
O.T.
Nurse
LPN
Patient Medical Homes
RN in Practice
Medical Office Assistant
Clinical Workflow Asst.
Specialists
Valerie
Coordinated System of Care

12. Cross-Initiative Alignment Opportunities

13. Integrate with your existing streams of work
Consider how to leverage former and current streams of work and align them with the Coordinated System of Care

14. How will we Do This?

15. Coordinating Care for Moderately Complex Patients
The Challenge:
Coordinating Care for Moderately Complex Patients
Moderately complex patients often require multiple Specialist physicians to provide consultative, episodic or longitudinal care. The challenge is to effectively coordinate care among all providers for a seamless experience.
Also, for these patients, families are often actively involved in daily care, but not recognized as part of the care team.

16. Align with Patient Medical Homes & Primary Care Networks
The Opportunity:
Align with Patient Medical Homes & Primary Care Networks
The Shared Care Committee is allocating resources for interested communities to better connect Specialist physicians to other providers and family caregivers, to create a Coordinated System of Care for older adults with multiple complex conditions.
There are many opportunities to improve outcomes and the experience of care for these patients, their families and their providers.

17. Who Can Become Involved?
Communities selected for developing PCNs OR communities who have interest in improving care coordination for complex adults.
Supports Offered: 
Project development, project management, physician engagement, and other improvement activities
Community Partnership Coaching
Participation in Provincial Learning Sessions
Principles of Care-based evaluation

18. We’re interested – What are the next steps?
Margaret English, Lead, Shared Care Committee
Participate in a call with the Shared Care team to learn more about initiative objectives and supports available.
Participate in optional pre-EOI coaching session to focus your approach and identify outcomes for your community.
Complete an EOI to outline your proposal and which specialists and stakeholders will be involved.