3. Objectives Describe practice settings Canada, Detroit & Denver and the type of patients that I saw. Describe practice settings Canada, Detroit & Denver and the type of patients that I saw. Present patients of mine in each place and time that benefited from a team approach to their care (particularly chronic diseases) Present patients of mine in each place and time that benefited from a team approach to their care (particularly chronic diseases)

4. London, Ontario (Not England) 1982-1992

5. London, Ontario 1982-1992

7. Medical Care London, Ontario 1982-1992 Fee for service (solo FM practice) Fee for service (solo FM practice) 1500 patients but still a micro-practice (Low overhead and just one staff but could easily see 25 patients a day) 1500 patients but still a micro-practice (Low overhead and just one staff but could easily see 25 patients a day) Young practice but a lot of home bound elderly Young practice but a lot of home bound elderly

8. Type of Teams Promoting Care London, Ontario 1982-1992 Practice staff: + Receptionist was an extension of me. Knew patients well and promoted care. + Receptionist was an extension of me. Knew patients well and promoted care. - No other office staff enabled to take responsibility for prevention or care. - No other office staff enabled to take responsibility for prevention or care. Support of Chronic Disease Management - no disease specific team support in the office. (No educators, counselors etc.) - no disease specific team support in the office. (No educators, counselors etc.)

9. Type of Teams Promoting Care London, Ontario 1982-1992 Support of Chronic Disease Management - no disease specific team support in the office. (No educators, counselors etc.) - no disease specific team support in the office. (No educators, counselors etc.) + wide range of specialty support and services to access many times at no cost to patients. Collegial shared care for every patient with my office as the medical home. Cardiac rehab, nutrition counseling, pulmonary rehab etc. + wide range of specialty support and services to access many times at no cost to patients. Collegial shared care for every patient with my office as the medical home. Cardiac rehab, nutrition counseling, pulmonary rehab etc.

10. Type of Teams Promoting Care London, Ontario 1982-1992 Support of Health Promotion - I was on my own in providing prevention. - I was on my own in providing prevention. + community health education initiatives largely government promoted. Immunizations free and vaccines readily supplied to all practices. + community health education initiatives largely government promoted. Immunizations free and vaccines readily supplied to all practices.

11. Type of Teams Promoting Care London, Ontario 1982-1992 Support of Community Care outside the Office Walls + extensive system of home care support services, mostly without charge. Low turnover so could depend on staff to provide good information on your patient. Government insurance paid a significant premium for house calls. Meals on Wheels available. Public health nurses provided home assessments of new moms and babies. + extensive system of home care support services, mostly without charge. Low turnover so could depend on staff to provide good information on your patient. Government insurance paid a significant premium for house calls. Meals on Wheels available. Public health nurses provided home assessments of new moms and babies.

12. Type of Teams Promoting Care London, Ontario 1982-1992 Special Support: Palliative Care + Many family docs cared for their palliative care patients at home. Special palliative care nursing staff experts in symptoms control. + Many family docs cared for their palliative care patients at home. Special palliative care nursing staff experts in symptoms control. Specialized palliative care unit with some inpatient beds but more importantly physicians and staff who consulted on problems by phone through assessing patients at home. Specialized palliative care unit with some inpatient beds but more importantly physicians and staff who consulted on problems by phone through assessing patients at home. Cancer Center Neuro-Oncologist Pain Specialist available. Cancer Center Neuro-Oncologist Pain Specialist available.

13. Type of Teams Promoting Care London, Ontario 1982-1992 Special Support: Palliative Care - You were in charge and it could be emotionally draining (but more often some of the most “memorable” care you gave.) - You were in charge and it could be emotionally draining (but more often some of the most “memorable” care you gave.) Out in middle of night to sign death certificates Out in middle of night to sign death certificates

14. Journey from the Forest City to the Motor City -1992 Crossing “Borders”

15. Grace Family Practice Center & Residency Team

16. (Weird) Teams in Motown Meet Jack Kevorkian at the Peking House restaurant at lunch time. Palliative care consults with “Dr. Death” Meet Jack Kevorkian at the Peking House restaurant at lunch time. Palliative care consults with “Dr. Death”

17. Journey from the Motor City to the Colorado -1999 Crossing “Borders”

18. Medical Care in Colorado -1999 to

19. Teams in the AFW Clinic Team Huddles helping team based care Team Huddles helping team based care CINA EMR disease management CINA EMR disease management Nutritional Counseling Nutritional Counseling Diabetes teaching Diabetes teaching On-Site behavioral science co-consults and co-management. On-Site behavioral science co-consults and co-management.

20. Conclusions Gave a glimpse of a Canadian primary care practice. Gave a glimpse of a Canadian primary care practice. Described the types of patients seen Described the types of patients seen Gave a glimpse of the strengths and weaknesses of team care in London, Detroit & my current my practice. Gave a glimpse of the strengths and weaknesses of team care in London, Detroit & my current my practice. There is a team member that can help, in the office, in the community and in the bigger health care system. There is a team member that can help, in the office, in the community and in the bigger health care system.