Concurrent session II: Interprofessional practice, integration, and coordination

Friday, March 10, 11:00 am – 12:00 pm
Salon D
Chair: Chad Dickie

Coordination of primary and oncology care in five Canadian provinces: A CanIMPACT study

Presenting author: Mary McBride, BC Cancer Agency

Co-authors: Patti A. Groome, Marcy Winget, Li Jiang, Aisha Lofters, Rahim Moineddin, Kathleen Decker, Cynthia Kendell, Monika Krzyzanowska, Dongdong Li, Nicole Mittmann, Geoff Porter, Donna Turner, Robin Urquhart, Yang Zhang, Eva Grunfeld

Background: Primary care is increasingly recognized as a key component of cancer control. Using population-based data in five Canadian provinces, the Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT) examined the intersection and variation of primary and oncology care across the diagnosis, treatment, and survivorship phases of care, and the impact of sociodemographic, clinical, and healthcare factors on care.

Methods: Female breast cancer patients diagnosed from 2004/7 to 2010/11/12 in BC, AB, MB, ON, and NS were included. Standard provincial datasets were created using linked registry, clinical, and administrative data. Common approaches were applied to address research questions relating to primary care involvement in the screening, treatment, and post-treatment phases of care.

Results: The percentage of patients diagnosed with a screen-detected breast cancer varied from 25 to 40 percent across provinces; both intra- and inter-province geographic variability was identified. Higher primary care physician (PCP) continuity of care (i.e. regular and frequent care) was associated with increased screening rates and screen-detection in the pre-diagnosis phase. More than 75% of patients visited their PCPs two or more times in the six months prior to diagnosis, except for NS, for which 62% of patients had two or more PCP visits in that time period. More than 80% of patients had at least one PCP visit during breast cancer adjuvant treatment, in BC, MB, ON, and NS. We observed higher PCP continuity of care in the survivorship phase of care compared to pre-diagnosis in BC, MB, and ON. However, PCP contact decreased over time during breast cancer survivorship.

Conclusions: PCPs were involved throughout the breast cancer care continuum, but their level of involvement varied across care phases and by province. Outcomes for vulnerable populations (rural, older, low income, and immigrant populations) will be examined next. These results will be combined with qualitative research to identify an intervention that addresses observed key barriers to quality coordinated care for cancer patients. The intervention will be tested in the latter part of the CanIMPACT study. This work directly addresses healthcare system performance, quality of care, innovation, and the spread of improved care in Canada.

Transforming primary health care: A three-way partnership of health authority, physicians, and communities

Presenting author: Martha MacLeod, University of Northern British Columbia

Co-authors: Neil Hanlon, Trish Reay, Dave Snadden, Cathy Ulrich, Fraser Bell, Kelly Gunn

Objectives: BC’s Northern Health Authority (NH), in partnership with physicians and communities, is reshaping primary care and community services. Objectives are to describe the NH Idealized System of Care, specifically the Primary Care Home, key change processes, outcomes, and lessons learned in undertaking and scaling up long-term, transformative, whole system change.

Methods: An integrated knowledge translation approach was taken through a longitudinal study of the processes through which NH engaged in transformative change regionally and in multiple communities. Evolution of the NH Model and the processes of change were examined over four years through 250 in-depth qualitative interviews with regional and community leaders, NH staff, nurses, and physicians, along with documents (planning documents, meeting minutes and NHA evaluation results). Interviews and documents were thematically analyzed, and themes were brought back to NH and community members for further discussion and input.

Results: Instead of creating additional primary healthcare services and networks, Northern Health, with its physician and community partners, are fundamentally restructuring the way in which primary care, mental health and addictions, public health and home and community care services are provided across northern BC. A clearly articulated, enduring end-in-view, of patient and community-centred health services embedded in healthy communities and serving the needs of northern peoples, has been embraced by the NH Board, communities and northern physicians. This common vision, coupled with active development of trusting relationships and actions, have enabled fundamentally disruptive process and structural changes to be undertaken in a strategic, yet organic manner. Although the changes have not been without controversy and challenge, transformed structures and services continue to be scaled across northern BC.

Conclusion: Through a long-term vision and common commitment to fundamental health system transformation, NH and its physician and community partners have been able to break down barriers to innovation. Early results show some impacts on the improvement of population health, positive patient and provider experience, and no escalation in NH costs.

Knowing patients and improving coordination in the primary care home

Presenting author: Erin Wilson, University of Northern British Columbia

Co-author: Martha MacLeod

Objectives: In the implementation of the Primary Care Home model in British Columbia, many teams are not co-located, nor do they share an electronic medical record with primary care providers (PCPs). There has been little attention in the literature or in practice to the type of information that is important for team members to share or transfer in this context, in order to optimize continuity and coordination in team-based primary care. The objective is to examine current practices to identify how processes of sharing information influences delivery and experiences of team-based primary care.

Methods: This interpretive study incorporates interviews with seven patients, and 16 PCPs and interprofessional team members. Thirty-seven patient-provider encounters were observed over a five-month period during early implementation of Primary Care Homes. Interpretive analysis allowed for detailed descriptions of patient and provider experiences to identify and highlight the effect of practices on patient care and experiences.

Results: PCPs in this study understand patients’ preferences, goals, existing supports and resources. This understanding influences decision-making about which patients may require interprofessional team-based care, and when it is required. Three types of situations were identified that prompt PCPs to request involvement of the interprofessional team. Although the PCPs have in-depth knowledge about patients, varying amounts of information were shared based on the situation prompting team involvement. Interprofessional team members frequently met patients without knowing important pieces of information about the patient. These gaps between PCPs and interprofessional team members knowing patients can disrupt the ability of interprofessional team members to establish rapport, deliver effective, coordinated care, and provide a positive experience for the patient.

Conclusion: The information that is important for interprofessional team members to know about patients is frequently not conveyed by PCPs. Improved understanding in this area can help improve continuity and coordination of care, as well as patient experience of interprofessional primary care teams.

Primary care transformation in BC: The role of the nurse practitioner

Presenting author: Natasha Prodan-Bhalla, BC Nurse Practitioner Association

Co-authors: Minna Miller, Fiona Hutchison, Lorine Scott

High performing primary care is the cornerstone of an efficient health care system. While decades of effort, resources and planning have been spent on primary care reform in an attempt to create a more responsive health care system in B.C., a primary care crisis remains. To date, primary care reform has included the family physician as the centre and cornerstone, however it is imperative that other models are also considered and implemented as approximately 15% of British Columbians are still without a primary care provider.

B.C. Nurse Practitioners propose a new model for primary health care that builds on the Patient Medical Home and Primary Care Home models while integrating nurse practitioners in multidisciplinary teams with shared governance and care that is “wrapped around” the patient. The aim of this paper is to describe an innovative, cost effective, holistic framework for primary care transformation centred on care that is truly inter-professional, team based, comprehensive and longitudinal with quality measurements focused on population and equity health outcomes. Integral to the model is engagement of the community at all stages of implementation and shared governance among health authorities, providers, patients and communities.

In this presentation we will review our paper, along with examples of programs that have been successful implementing this innovative approach to care and discuss the importance of having a sustainable, cohesive, collaborative provincial approach to primary care reform.