Presentation to Select Standing Committee on Health
Thursday, July 17, 2016
· Primary care innovation is crucial if we want to have a sustainable, publicly funded and universally accessible health care system
· Changes are happening that require a rethinking of the dominant primary care business model:
o The way that a new generation of providers wants to work;
o An evolution in the mental model of therapeutice relationship, and;
o The promise of wellness-focused care for bending the healthcare cost curve.
· A relatively small investment of resources in prototyping and testing “Primary Care Home” models that are co-developed by clinicians and citizens, would reduce the number of unattached patients, improve efficiency and satisfaction for family practice providers, and long term sustainability of healthcare in BC.
The Vancouver Citizens Health Initiative Society is an incorporated non-profit organization, dedicated to a sustainable health care system.
Today, the question to which we are responding is: How can we create a cost-effective system of primary and community care built around interdisciplinary teams.
We love this question! It goes to the heart of how primary care is governed, funded, operated, evaluated and how income from the provision of healthcare is distributed. More importantly, the issue speaks to the core of therapeutic relationships – inter-professional respect, scope of practice and the nature of the patient-provider relationship. Our perspective is that there is a generational, technological and cultural shift that we can leverage to rethink how primary care is delivered, with significant sustainability benefits for healthcare in BC.
This presentation introduces our organization, explains our interdisciplinary business model of primary care and then shares our next steps and hopes for healthcare in BC. My goal today is to share a new approach for co-designing models of primary care that address the needs of patients, providers and the public. I’ll also share ways that you can catalyze innovation to solve the increasingly urgent problem of healthcare system sustainability.
Vancouver Citizens Health Initiative (Vancouver CHI) has two main purposes:
· One is to involve citizens in understanding and influencing health care system improvement;
· To co-design, build, operate and evaluate sustainable and universally accessible primary care clinics that some call a Patient’s Medical Home.
Board members include
· Brett Sparks, Talent Specialist in the tech sector – expert on high performing collaborative teams, and experience with the millennial workforce;
· Samiran Lakshman, Crown Counsel – critical perspective, focus on integration of technology to make healthcare fit our lives;
· Trilby Smith, Evaluation Consultant in Health and Community Services Sector – formerly with Michael Smith Foundation for Health Research.
Kyle Pearce is co-founder and operational leader of Vancouver CHI. He is a consultant in the health and social impact sector with a history of business innovations in oral and primary health care, including a dental clinic that has and continues to enable thousands of low income children to access dental care.
Kyle spent 5 years in the world of physician-led primary care innovation – incorporating the first divisions of family practice and leading the provincial prototype phase for A GP for Me. He has also led primary care engagement and research for the Vancouver Division of Family Practice. With his work provincially and in Vancouver, he has engaged over 600 family physicians and thousands of citizens around the question the Committee has posed. Vancouver CHI’s approach comes from listening to both patients and providers as they declare the importance of strong primary care relationships and at the same time many lament how difficult it is to get one in a timely way.
Vancouver Citizens Health Initiative is an unaffiliated organization with set of non-negotiable values that are non-partisan. We believe that:
· A high-quality, universally accessible, and publicly funded Healthcare system is a treasured public good and everyone who participates has a stake in its sustained success;
· Wellness begins with relationships and while we need to treat disease, as a collective enterprise we should be aiming at something higher that addresses what patrons really want;
· Primary care is only one element of wellness. Our frame of reference includes social supports, interpersonal connectedness, exercise, education, housing and food;
· We believe that primary care can and should be transparently and appropriately accountable to patrons, providers and the public interest.
As board members, we are all parents, and want desperately to know that everyone, including our kids, will be able to enjoy the benefits of universally accessible healthcare. Our motto is “Health care for everyone, now and in the future.”
Vancouver Citizens Health Initiative Perspective
• Patrons – our primary focus is on the wellness of people who engage with the health care system in our community. At an individual level, this includes everyone who has ever had contact with the health care system. Right now, the biggest problems from this perspective include:
- too many people don’t have timely access to a family doctor. VCH’s My Health My
Community survey estimates over 170,000 in Vancouver alone don’t have a GP
- if you’re lucky enough to have a family doctor, getting an appointment can take a lot of time. Almost 20% of daytime visits at VGH are for people who have a family doctor for issues that could be treated by primary care
· Providers – patrons need consistent, productive, well-rested healthcare providers, so physician wellness is central to our vision. Right now, most providers take the risk of starting up their own business using a model that is 100 years old, resulting in burnout and low satisfaction levels for physicians. Younger doctors are less likely to be interested in that traditional model, which is why so many patients are being orphaned when their doctor retires.
• Public – includes everyone who has a stake in the success of the collective enterprise of healthcare. This means a system that functions well and is sustainable. Right now, tax-based and out-of-pocket costs are rising for consumers, leaving less discretionary income and lower levels of available funding for other valuable investments in things that keep people well, like income security, housing, education, recreation and healthy food.
Vancouver Citizens Health Initiative Perspective
At the centre of everything we do is wellness – well patrons getting care from well providers in a well-connected and functioning system is our goal.
Changes in society that should drive primary care innovation
Our response to the question of creating a cost-effective system of primary and community care built around interdisciplinary teams is that we need to critically interrogate the assumptions that limit our ability to create new mental models that are more efficient and have better results. Three examples of outmoded thinking include:
· That interdisciplinary care is not financially feasible within FFS. In fact, with the new GPSC incentives, our group – with the advice of 40 clinicians innovation leaders and knowledgeable patients - has developed a model that has nurses, doctors and other providers working in a non-hierarchical team to each’s optimal scope, and provides fair compensation to an extended team that includes a clinical pharmacist, navigation supports and social worker.
· That primary care relationships are about how much time a doctor and patient spend together. The nature of relationships is changing. It’s true that patients want to spend some time with their doctor or NP when they have an appointment, but most would rather skip a second appointment and instead text their pharmacist when a prescription isn’t working or email a member of their interdisciplinary team when symptoms don’t subside. If healthcare can adapt to this, then primary care relationships can strengthen its authoritative role in helping us get and stay as well as we are able.
· That younger docs are lazy and it takes 2 of them to replace one experienced GP. In fact, we have found that many in the new generation of GPs want to work in a qualitatively different way that is collaborative, integrates technology and focuses on prevention. Contrary to this assumption, we believe that if we provide opportunities for younger docs to practice the way they want (and incidentally, the way they are trained), then the system will have enough capacity for everyone to have a family doctor.
In contrast to these pieces of conventional wisdom, Vancouver CHI has involved dozens of providers, experts, researchers and citizens to iterate a flexible platform for innovating in the developments, operation, governance and evaluation of primary care.
The Vancouver CHI Platform for Interdisciplinary Primary Care
The platform for the Vancouver CHI model has been developed through discussions with dozens of of people and organizations including:
- GP residents, recent graduates, and physicians who have been practicing for decades; nurses and pharmacists;
- Ministry of Health senior directors in primary care;
- VCH and Providence primary care physicians;
- Vancouver Division of Family Practice’s Continuity of Care Committee;
- BC College of Family Physicians;
- UBC’s primary care research team – CHSPR. (Vancouver CHI participates on the BC Primary Health Care Research Network’s advisory committee)
- Mid-Main and REACH community health Centres
- Community Health Centres in Ontario
- Pharmacy Leaders of Tomorrow
While we listen to everyone who has an opinion, the model is also the reflection of our values about universal access to a single-tier, publicly funded system.
Features of the model
· Core of the model are teams of one physician working with 2 RNs (could potentially involve NPs if revenue generation is not through FFS);
· Administration and business management is done by non-clinical staff;
· Patient experience typical visit – exam room welcomed by a nurse, who discusses the patron’s wellness plan and any changes, does an assessment, identifies all the issues important to the patient.
· When the physician arrives, nurse inputs information into EMR, allowing unmediated contact between doctor and patron;
· After doctor performs evaluation, diagnoses in collaboration with nurse and patient, and determines a course of treatment, they leave the nurse to complete the visit;
· Medication choices can be supported by clinical pharmacist;
· If patient needs to see a specialist or has a visit to the ED or needs a community-based wellness support program, a navigator helps and ensures that information is incorporated into the patron’s file;
· Patrons can make appointments online if they wish, and have control over their medical record, enabling others to see elements of it;
· Scaled down versions are possible and sustainable within FFS – minimum 2 teams;
· Scaled up versions are more attractive – enable sharing of 24/7 phone calls;
· With a critical mass of teams, we can shift hours, schedule open times in each day, even have a mobile team on rotation to see patients at home, in the hospital, or other settings;
· Evaluation of the model’s operation and impact is crucial:
o to improve the timeliness, quality and experience of care,
o ensure providers are satisfied and have a workplace and processes that are efficient and convenient for them
o And ensure that the primary care clinic is having a positive impact on system costs such as ED visits and hospital readmissions
Overall impact of the model
The platform of the Vancouver CHI model can be adapted to a variety of situations, and will require a high-performing staff team that works using a highly efficient, collaborative and performing approach. The rewards of succeeding and scaling up include:
· Greatly increasing the panel capacity of a family physician and allowing for relationship continuity as clinicians have life events;
· Providing a care team for every patient, and satisfaction for patients and providers;
· Timely access, telephone, email and text connectivity and same-day visits will reduce Emergency Department usage;
· Focusing on wellness and integration with community resources will slow advance of chronic conditions;
· Providers have reasonable compensation, work-life balance, support for professional development and opportunities to influence improvements in systems and workplace culture;
· Evaluation of the extent to which the model and its variations address the interests of patrons, providers and the sustainability of healthcare in BC.
Prototyping the Vancouver CHI model
Vancouver CHI has been in discussions with local recreation service agencies about the benefits of hosting a prototype within a facility that helps clients achieve and maintain wellness.
We have developed a business case so we know what our startup and initial operating costs will be, and what our break-even point is. We know that the model is actually profitable, with excess revenues that can provide incentives for providers, or fund additional clinics.
We have met with FP residents and newly-practicing physicians and experienced leaders in health care improvement to seek feedback, improve and assess the attractiveness of the model. We know that the approach resonates for about 1/3 of younger physicians graduating each year.
With the scalable and adaptable model, we have started to think about how to properly govern and oversee the operation of clinics outside of Vancouver. We think that scaling this – or any other like-minded model - will have a significant impact on patient wellness, the provider workforce and overall healthcare costs.
Building a system of primary and community care built around interdisciplinary teams.
Vancouver Citizens Health Initiative might be one of the first to propose such a model but we hope we’re not the only one. With health care consuming more of our public resource each year, we are certain that other diverse groups with an interest in healthcare access and sustainability will bring their non-clinician-focused approach to the public discussion about this treasured resource.
- Our suggestion is that the Ministry, and its health authority partners should catalyze the creation of a plurality of models that are attractive to the next generation of primary care providers. Public calls for local citizen-driven, led or supported models of primary care could result in the generation of new ideas that bend the cost curve.
- Promising approaches should explore innovative approaches to citizen involvement in co-design, to governance, business models (including staffing, technology, revenue generation, and making it easier for people to access care at the same time that we make it easier for providers to give.
- Eligible respondents would include Divisions of Family Practice, other industry associations, non-profit organizations, and First Nations health organizations. Requirements would be that the models would eventually be self-sustaining in either FFS, Blended or APP funding, and would be evaluated using an expanded triple aim.
- One a model passes a rigorous review, provide interest-free loans or a combination of grants and loans to incent sustainability, with clear cut-off criteria tied to clinic revenues over expenditures and meaningful evaluation measuring the interests of patients, providers and system sustainability;
- As we collectively build expertise, create an oversight body to build capacity of less experienced developers and community groups;
- Provide money outside of the Physician Master Agreement, to incent citizen/clinician co-design, and ensure accountability to the public interest;
- Finally, embrace this as a business challenge and engage the public and providers in reimagining how primary care is delivered, governed, funded and evaluated.
The Vancouver Citizens Health Initiative thanks you for your attention, and looks forward to continuing shared efforts to achieve a sustainable, universally accessible and publicly funded healthcare system in BC.