1 Développement d'une équipe interdisciplinaire de santé médicale: l'expérience WDFHTDr. Howard Petroff MD, CCFP (EM), FCFP West Durham Family Health Team Pickering, Ontario Presentation pour L’Association des Médecins Omnipraticiens de Laval le 15 Septembre 2017

2 Linguistic Disclaimer:

3 Dr. Howard Petroff MD, CCFP (EM), FCFPActive Staff, Scarborough and Rouge Hospital, Scarborough, Ontario Active Staff, Mount Sinai Hospital, Toronto, Ontario Courtesy Staff, Lakeridge Health Ajax Pickering Hospital, Ajax, Ontario Assistant Medical Director, Toronto Raptors Basketball Club Disclosures: No active clinical research interests Over the years, I have spoken to a variety of groups and moderated educational sessions on behalf of multiple pharmaceutical companies Our FHT has received various clinical training and program development support from Boehringer, Eli Lilly, Merck, Pfizer, Sanofi amongst others I do not have any individual financial interests/investments in any specific pharmaceutical company (However I don’t know where MD Management is investing my RRSPs)

4 Objectives Recognize the characteristics and attributes of high functioning interdisciplinary teams Demonstrate integration and the leveraging of staff expertise to achieve shared team or program goals  Understand how to identify and develop programs to maximize the skills of your teams.

5

6 Agenda Benefits of Team-Based Primary Care WDFHT Genesis ProgramsBackground and Evolution Programs Experience Challenges and Learnings Q&A

7 Benefits of Team-Based Care

8 Benefits of Team Based CarePatients Increased Accessibility and ‘Touch Points’ within the team Access to multiple providers, CDM programs Increased time with providers Education and self management Increased satisfaction

9 Patients who always/often feel that they are given an opportunity to ask questions about treatment

10 Patients who always/often feel involved in decisions about their care and treatment

11 Patients who always/often feel that they are provided enough time with their Doctor/NP

12 Benefits of Team Based CareIHPs Work to full scope of practice Enhanced Professional Development Opportunities Patient Education and Health Promotion Job Satisfaction MDs Utilization of skills of others to enhance care Increased comprehensive care = Better Care Removes ‘physician centric’ approach to non-critical issues Assistance in achieving targets/metrics Recruitment tool for new graduates

13 Benefits of Team Based CareSystem/Community Increase in Primary Care availability, Decrease in unattached patients Improved Coordination of Care Better utilization of resources

14 WDFHT Genesis

15 West Durham FHT GenesisOntario MOHLTC Initiative to develop Multidisciplinary Health Care Teams WDFHT - Established in 2007 Operational 2008/EMR adopted 2009 Co-located in 2012

16 West Durham FHT GenesisPhysician Group Initially 3 MDs -> currently 14 Patient Roster Growth Growth 5,600 -> 19,000+ Current IHP Complement (FHT) 11.4 FTE (NP, RN, RD, SW, Pharm. D) Administrative Staff

17 Team Characteristics 2 Clinical Sites FHT is a Non-Profit CorporationPhysicians have an APP (no longer FFS) Group Coverage Contractual Obligations After-Hours Coverage CDM Program Development Metric Reporting

18 WDFHT Mission and Vision Guiding principlesTo enhance the quality of a patient's health and well-being through accessible and comprehensive care integrated with community resources, providing the Right Care at the Right Time in the Right Place through a patient-centred care approach. Integrated Model of Care emphasizes: Health promotion and disease prevention Patient education and self-management Early detection and treatment of illness Ongoing supervision and treatment of chronic diseases Complete lifecycle health management from birth through to end of life care

19 Strategic Plan 2015 - 2018 Collaboration & PartnershipDevelop & nurture community partners Collaboration to provide seamless, integrated care Strong people & teams Enhance governance Recruitment & retention of IHPs and physicians Team building & collaboration Ongoing Board training Board orientation Bylaw review Board evaluation Recruitment Leverage technology for enhanced patient care Connect GTA Hospital report manager Chronic disease registries OneID Optimize EMR

20 Program highlights

21 WDFHT Programs, CDM, ServicesComprehensive Primary Care Services Diabetes/Pre-Diabetes Respiratory Health Hypertension Well Women Care Mental Health Cancer Screening Smoking Cessation Immunization Foot Care

22 Program Development Program Development Performed Needs AssessmentEnvironmental Scan Community Resources/Programs Availability and Clinical Value Assessed internal expertise Identified Care Gaps and Skill Development Needs Physician and IHP Champions Determine Process Measures and Outcome Metrics PDSA

23 West Durham Diabetes Clinical GoalsTarget LDL ≤ 2.0 mmol or 50% reduction over baseline Target reached in 75% of patients within 12 months A1C < 7% Target reached in 80% within 12 months BP ≤ 130/80 Target reached in 80% of patients within 12 months Outcome Measures LDL measurement Measurement once per year achieved in 80% of diabetic patients A1C measurement Measurement twice/year in 80% of patients BP measurement Measurement at 6 months in 80% of patients Waist circumference measurement Recording documented in 100% of patients within 12 months Set/Review Self Management Goals 70% of patients to have goals set/reviewed within 12 months Screening Targets for Pre-Diabetes every 3years for patients >40 yrs of age Target is a 10% screening increase for eligible patients within the next 12 months. Process Measures

24 Tailored Interventions in DiabetesPatient Registry List of diabetic patients identifying those not at target EMR Maximize the power of the EMR - queries, consistent coding Care Path Flow Sheet Recall Process Identify patients with no next appointment Identify patients not at target Developed algorithm plan for patients not at target with specialist input and recommendations Plan - lifestyle, self management, medication Medical Support: Education with Community Specialists Connection to Clinical Leaders FHT Quality Improvement Plan Consistency and Sustainability Development of Patient Self Management Programs and Group Education Classes Networking with other FHTs Sharing knowledge, experience and best practices

25 Physician Data ReportsExample of title Report - % Patients with Diabetes Coded Visit

26 HP’s Measures

27 West Durham Adult Immunization StrategyStrong Recommendation from a trusted Healthcare Practitioner Physician/nurses/NPs Receptionists supporting CME Patient Awareness Campaign Educational resources in the clinic Patient Letter mailing Immunization Booth Waiting room posters Process in the Office Minimize barriers to immunizations Develop a process in the office to increase efficiency Prompt vaccine discussions

28 Patient Follow-up

29 Penetration Rates: October/14 – March/15628 Imm 280 Imm Data as of June 2015: N = 7811, N >65 = 2811

30 Keys to Program SuccessEstablish Program Champions – clinical and administrative Leadership support and endorsement Program Flexibility – PDSA changes Staff feedback (eg. Process, materials) prior to and during program implementation Education support – Specialist Leaders Communicate progress Celebrate success

31 Experience

32 Team Experience Leadership and Vision Strong People and TeamsCollaboration and Partnerships Leveraging Technology Governance

33 Leadership and Vision What is the vision? MD EngagementMany Forms of Leadership Nurturing Future Leaders Recognize the needs of different groups/practices/roles within the overall organizations Transparency with decision making Involve Staff in formulating Mission and Vision Change Management

34 Leadership and Team Development 3 phasesHealth Team Effectiveness, GROUPEXPEDIA in Collaboration with University of Calgary, Université Laval, and Queen’s University

35 Strong People and TeamsPhysician Engagement Ongoing Process Physician professional satisfaction Add to MD ‘Tool Kits’/Patient Supports available Pharmacist, Dietician, NP and RN skills, SW, CDM programs Enhancing ‘In-House’ circle of care Benefit to patient care Continuum to Embrace Change Varies

36 Strong People and TeamsRecruitment and Retention of MDs, IHPs, and Staff MDs – Have to be involved for the right reasons IHPs - Job Descriptions to identify competencies both for recruitment and performance reviews Team Culture Attitude is a prime driver Team performance and Patient Centeredness

37 Strong People and TeamsTeam Building to Create a Collective Vision Communication – Regular monthly meetings Training and CME – Foster personal/professional growth Team Activities Celebrating Success – Individual Recognition ‘Bestie Westie’ Integration of Staff has to be a priority for effective function of a Team

38

39 Strong People and TeamsExpectations and Accountabilities If clearly outlined, clinicians understand their roles and are empowered to act with confidence Medical Directives – acknowledges IHP scope of practice Engagement need to be involved in decision making process, feedback from all roles when drafting medical directives, policies, procedures “Consistency of practice creates trust, trust drives collaboration” Team Identity Unified Operations/Shared Logo

40 External Collaboration and PartnershipsWorking With Others Health Care Organizations Hospitals, CCAC, Stroke Network, Community Agencies (DEC, Arthritis Society etc.) Peer Organizations FHTs, AFHTO Industry

41 External Collaboration and PartnershipSources of expertise – governance, program development, clinical guidance Can complement the services provided by your team Helps to break down silos by building a network May need to have a formal agreement/MOU with some groups Improved coordination of care

42 Leveraging TechnologyDecisions are data driven Outcome measures validate clinical practice Drives Quality Improvement EMR Data integrity/Quality consistency of coding/entry Data mining Allows for assessment of trends Customized Templates

43 2015 A1c Testing and Outcomes6 months A1C range

44 A1C >7: Medications Prescribed

45 Leveraging TechnologyExternal Linkages via Technology OLIS, Connecting GTA, Hospital Report Manager Hospital EMR connections Telehealth, eConsults Diagnostic Imaging

46 Enhanced Governance (FHT)Understanding Responsibilities/Accountabilities Formalized Agreements Physician Group (FHO) FHO/Family Health Team FHO/MOHLTC Site Cost Sharing Arrangement Formal Policies Conflict of Interest, Privacy, Code of Conduct, Social Media, Computer and Internet Use

47 Challenges and Learnings

48 Ongoing Challenges MOHLTC FundingChanging Government Priorities Misalignment between Policy, Implementation, and Reality Arbitrary performance based metrics, Health Outcomes etc. Recruitment, Retention, Retirement Lack of Public Accountability Physician Behaviour ‘Changing Clinical Paradigm’

49 Learnings Trust your colleaguesEstablish the ground rules and communicate them Get outside assistance/expertise for change management Be mindful of people’s time Be flexible and willing to change/adapt

50 Learnings Go Slow – Set achievable goalsSMART objectives (Specific, Measurable, Attainable, Realistic, Trackable/Time Based) PDSA - Trial with small group before big roll out Don’t spread yourself too thin

51 Learnings

52 Obstacles are those frightful things you see when you take your eyes off your goal.Henry Ford

53 Merci Beaucoup

54 External References Case Studies: Fostering FHT-Physician TeamworkAFHTO 2017 Healthcare Team Effectiveness Team Leader Development GROUPEXPEDIA, University of Calgary, Université Laval, Queen’s University 2010 The Teaming Project Learning from high-functioning interprofessional primary care teams Department of Family and Community Medicine, University of Toronto 2014 Guide for Dissemination and Implementation of Interprofessional Practice Protocols within Family Health Teams Centre for Effective Practice, DFCM, University of Toronto 2008