Primary health care is about a team of health care providers working in harmony for the good of the patient, the family, and themselves. It is clearly accepted that not everything tried will work, and that ongoing change is inevitable. It is about enabling the right health care provider to provide the right care at the right time to enhance patient-centred care.
Saskatchewan physicians recognize that the province is unique and that different regions, municipalities, towns, and villages are also unique – and so are the health care needs. The current cookie-cutter, one-size-fits-all approach to primary health care is not always appropriate. Saskatchewan requires a multidisciplinary collaborative primary health care framework based on flexibility, adaptability, and ingenuity.
“Primary health care redesign offers opportunities to try new things in team-based patient care, and measure the results. Only then can we focus on providing optimum patient care in each circumstance,” said Dr. Fourie. “In all arrangements with other health care providers however, every patient must be connected to a physician or physician group. This is essential for patient- and family-first care.”
For the presentation this morning, Dr. Fourie has lined up three physician leaders who truly demonstrate the endless possibilities that exist in primary health care redesign. Each in different ways has successfully turned perceived obstacles into patient-centred opportunities in primary health care delivery and this morning they share those experiences.
Dr. Lise Morin from Arcola describes how through strong community involvement and a focus on physician work-life balance they developed a centre of excellence that delivers clinical services, acute care and ER services to patients in six rural municipalities and two towns. The communities saw the need for well-rested doctors, so they took over the administrative side of health care and provided the clinical infrastructure thus allowing physicians to focus on patient care. “I want to be able to spend the necessary time with each patient,” says Dr. Morin. “By removing administrative pressures off of the physicians, we are able to deliver primary health care services through a team of providers. The end result is that patients, physicians, and other team members are happier.”
To achieve success these physicians first had to overcome preconceived notions in the communities. They really worked hard at explaining to the communities that it is not acceptable for any physician to work 24/7. They also convinced the communities that physicians don’t have to live in a community to provide stable sustainable care in that community. Finally, they had to convince communities that they would need to be the ones to step up and make this change happen. Once this occurred, they were well on their way.
The goal was to build on the ‘wheel’ or ‘hub and spoke’ approach to service delivery. “We provide clinical assessments at the spokes and offer acute care when required at the centre of care in Arcola,” says Dr. Morin. “We don’t let doctors work in isolation.”
What makes the model unique is that it focuses on well-being and balance for all. “What we came up with was a philosophy of happy patient, happy practice, and happy physician.” The corporation concept allows incoming physicians, especially new grads, a seamless adjustment into practice where they can focus on patients immediately and learn at an acceptable pace, without the immediate burden of having to take on the business side of practice. This allows for continuity of patient care. Sharing of patients and their information across the care team is also unique. The concept of ownership has been removed. “We manage patients - we don’t own them.”
Success in creating an innovative compensation model is also noteworthy. Since each physician is compensated through alternative payment from the corporation there is a set workload expectation for each provider and there is set compensation for that. However, if a physician does more than that set threshold they are compensated accordingly. “If a physician works more, then they receive more. This helps maintain physician motivation.”
Despite success, Dr. Morin maintains that there are huge opportunities available to further improve patient first care and provider satisfaction. “If we had access to health region and government resources it would make such a difference. If we could come to mutually beneficial arrangements to share health care providers more efficiently for diabetic services, or administrative personel for evaluation and assessment that would be huge. If we could hire and manage a nurse practitioner and define his or her role according to our needs and compatibility, and still access government funding, that would further improve care.”
Still, Dr. Morin sees much promise in the future. What would be on her immediate wish list? “We’ve built the model based on flexibility. If we have a certain number of physicians then we can expand care to any community within a one hour radius of our centre. When we have fewer physicians, then we retract services accordingly. Ideally, we’d like to maintain a roster of 3-4 physicians in Arcola working with the lone physicians in Carlyle and Redvers. This would allow for optimum patient-centred care while maintaining a one in four ER rotation.”
Next, Dr. H. Schalk Van Der Merwe described how, in Moosomin, physicians identified service deficiencies in the surrounding area and took it upon themselves to find a solution. The result has been a physician led primary health care model with a stable complement of seven physicians providing services to 18,000 patients in five surrounding communities. “Physician retention has been very good and has allowed us to deliver ongoing services to patients involving other care providers when appropriate,” says Dr. Van Der Merwe. In contrast to the Arcola example, Moosomin physicians take ownership of all clinic management and remain on a fee-for-service payment structure.
Dr. Werner Oberholzer then spoke of the Rural West Primary Care Team centred in Radville. Dr. Oberholzer described how two physicians are able to serve 7000 patients in four communities. Conducting a needs assessment with community input and measuring outcomes has been vital to success. “Instead of telling patients what we were going to provide, we asked each community what they needed,” Dr. Oberholzer explained. “Then as a team we designed a way to accommodate those needs with measurable targets for success.”
By enabling team members to function to full capacity within their respective disciplines, the model creates team commitment and interdisciplinary collaboration. The use of personal assistants to coordinate the care originating from the healthcare providers and allied healthcare professionals enables the physician to provide care in a rural remote region with numerous care centres.
What makes their model unique according to Dr. Oberholzer is the EMR capability to accommodate all the healthcare professionals so that all members work within the same patient charts on the EMR, and that each team member’s opinion is valued and considered to provide timely, high quality and affordable care. “We have incorporated pharmacy, home care, dietitians, and facility nursing staff working together to provide the best, guideline-based care,” says Oberholzer. “This helps create transparency and safety within the common record.” The basic EMR had to be adapted over a number of months to function adequately, and much time was spent in accomplishing this. The health region also had to be lobbied and convinced that the primary care team members could and should all work within the same patient record, and traditional models of service delivery and charting/record keeping had to be changed to improve function. There were numerous forms and paper requests that had to scanned and mapped to change to the electronic format, and the time taken to do this was excessive.
Another obstacle at the beginning according to Dr. Oberholzer was that there was no set model or approach to build the team. When the team was originally formed, the payment model was restricted to contract payment, but this was overcome by taking a sessional fee and blending with a fee-for-service model. This allowed Dr. Oberholzer access to health region resources.
Even though the model is working well, Dr. Oberholzer notes that there are still restrictions placed on team members, either by the regional health authority or the labor unions that restricts some team members from functioning at full capacity. “Change is always a concern, and some practices or practice routines are difficult to change,” says Dr. Oberholzer.
Aside from that, the one addition that would make the model work even better would be another physician to take some of the load off of providing 24/7 emergency room coverage 365 days a year. “A bit of relief would be welcome,” Dr. Oberholzer humbly states.
“These three non-traditional primary health care examples demonstrate that it is possible to deliver patient-centred care in a team environment in many different ways,” Dr. Fourie proudly stated before encouraging delegates to participate in breakout sessions to discuss the possibilities and what they believe are essential components for any primary health care site.
If current provincial restrictions on the traditional primary health care model are removed, the opportunities for success in primary health care redesign are almost limitless, and physicians need to be ready to act.
“Physicians must be ready to participate in primary health care redesign opportunities when they arise so our voices continue to be heard,” stated Dr. Fourie. “The initial examples of primary health care redesign, whether physician, community, or health region driven, should be innovative with as much flexibility in team-based care as possible, and with precise measures in place so we can demonstrate success.”
From the SMA News Digest, Winter 2011 - Article by Scott Donaldson, Director of Communications
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