1. Partners in Care & the Practice Support Program Shared Care for Patients with COPD/Heart Failure February 28, 2013

2. 2 The Shared Care Committee GOAL: Coordinated, continuous, and comprehensive patient care, from diagnosis through treatment and recuperation.

3. 33 ‣ 1. Improve patient/provider experience. ‣ 2. Improve population health outcomes (wellness). ‣ 3. Demonstrate sustainable per capita costs. ‣ Demonstrate achievable, measurable outcomes. ‣ Address gaps in care. The Triple Aim

4. 4 The Partners in Care (PiC) initiative comprises numerous joint efforts by family (FPs) and specialist physicians (SPs) in regions throughout BC to streamline: ‣ Referral and consult processes. ‣ Shared care planning and re-referral criteria. ‣ Diagnostic standards and communications, telephone advice protocols ‣ And more... Scope of work

5. 5 ‣ The patient’s journey is seamless, with appropriate and timely access and improved outcomes. ‣ Relationships are enhanced. What is success?

6. 66 Partners in Care Teledermatology Practice Support Program Polypharmacy Rapid Access to Psychiatry Youth Transitions

7. 7 Partners in Care Locations Up & RunningPlanned 2013/14 NHA-Northern PiC UNBC IHA -Central Okanagan DoFP -South Okanagan DoFP -Kootenay Boundary DoFP -East Kootenay DoFP -Thompson Region DoFP -Shuswap North Okanagan DoFP VIHA-South Island & Victoria DoFP-Cowichan Valley DoFP FHA-Fraser Northwest DoFP -Surrey North Delta DoFP -Ridge Meadows DoFP VCHA -Providence Health Care -Richmond DoFP -North Shore DoFP -Vancouver DoFP 106

8. 8 Considerations: COPD/Heart Failure Rollout ‣ PiC projects are at various stages in their evolution. ‣ Most PiC projects have priorities identified. ‣ PiC is a great vehicle to support the rollout of the COPD/heart failure module and shared system of care: ‣ Ability to do creative things ‣ Strong relationships with stakeholders (e.g., community- based service providers). ‣ Key for engagement is collaboration and alignment of initiatives ‣ Ensure that initiative is self-sufficient and can be spread easily ‣ Many initiatives (e.g., PSP, PITO, Attachment, Divisions) are competing for resources and people’s time – Need a coordinated approach.

9. 9 Partners in Care Divisions of Family Practice Local DoFP Collaborative Services Committee Regional Health Authority Local Steering Committee Advisory Committee Working Group 1 Working Group 2 Project Governance *Recommended for initiatives with multiple engagements and complexities. Not required for every engagement. Option… COPD/HF

10. For more information Clay Barber – Executive Lead, Shared Care C (250) 984-2500 clay@barbermc.caclay@barbermc.ca Aman Hundal – Lead Partners in Care C (604) 812-3231 ahundal@bcma.bc.caahundal@bcma.bc.ca www.bcma.org