Our big idea is rethinking primary care clinics
A new approach and business model for primary health care is needed to enable people to see their doctor when they want, have a team to support their health and reduce health system costs. The model being developed by the Vancouver Citizen’s Health Initiative (Vancouver CHI) is based on a unique clinical workflow that means patients get more complete and timely care.
The other side of the coin is thinking about convenience for clinicians: an approach that makes it easy for doctors and nurses to use their most important skills, get pharmaceutical expertise and other clinical information quickly and a team that will help their patients successfully complete their course of treatment once they leave the office.
The main enabler of this model is a cultural shift among younger and experienced family physicians, many of whom want to provide holistic care as part of a team, without operating their own business. Combined with an expanded interdisciplinary team, the model embeds a new culture of care that both clinicians and patients want. It enables longer visits, more efficient use of the physician’s skills, and an expanded team to support wellness beyond the course of treatment. Here's our vision for primary care that works for patients, clinicians and a sustainable system:
A new culture and workflow
Planning a new culture of care frees us up to rethink the way that people and providers interact. Our goal is an approach that:
- Enables people to connect with their doctor's office conveniently, from making online appointments to getting in touch through phone calls or video.
- Attaches patients with a family physician and an extended team that includes a nurse, pharmacist, health system navigator and social worker.
- Provides more time for clinicians to hear all the health issues that matter to patients, and removes the computer from the doctor-patient interaction.
- Considers people's circumstances when designing their medication or course of treatment.
- Supports prevention and upstream interventions to reduce the need for their next visit.
A patient coming to our clinic will have an average visit of 15 minutes:
- Patients will be examined first by a nurse, and a physician will join after vital signs and health issues are presented and discussed;
- The patient, physician and nurse will all participate in a physician examination leading to a diagnosis by the physician;
- A clinical pharmacist can assist in determining optimal medications considering side effects, drug interactions, income and other issues;
- Following the doctor’s diagnosis and determination of treatment, the nurse will offer counselling and follow-up support, adjusted for the patient’s life circumstances;
- Nurses have access to outward-looking staff (social worker and patient navigator) to assist patients with course of treatment challenges and follow-up.
Better Care for Patients, Revenue and Balance for Clinicians
Patients get longer visits and receive more comprehensive care within the clinical setting. Patients also benefit from increased interaction between visits, support for their course of treatment and upstream interventions that focus on wellness rather than disease.
Physicians and other clinicians will earn equivalent revenues to what they would make in a standard practice, without having managerial and oversight responsibilities. Clinicians work collaboratively and have access to an expanded range of expertise and supports. Physicians focus on patient care and share the burden of extended hours and after-hours access.
It's all linked together by a process where we continuously create a collaborative clinical culture, and integrate citizen and patient input while maintaining the highest quality standards.
- Doubles the number of patients who can be attached to a family doctor.
- Reduced use of emergency departments and walk-in clinics due to expanded clinical hours and access.
- Focus on prevention reduces use of health care system.
- Long-term reduction in health care system costs especially for patients with chronic conditions.
- Sustainable within British Columbia's fee for service payment system, without any ongoing subsidy.
How we developed the model:
The core of this model grows from expertise and insight provided by more than 500 family physicians and system experts over four years of leadership of provincial and local health system improvement initiatives. During the prototype phase of A GP for Me, three communities generated several strategies for improving primary care capacity, and attaching patients to family doctors. In Vancouver, we led a process to hear from hundreds of family physicians, Health Authority leaders and thousands of Citizens. We found a few things from an survey of Vancouver family physicians:
- Over 50% of Vancouver family doctors are dissatisfied with the amount of time required for administrative work
- Almost half of Vancouver family doctors find it hard to take a vacation because it's hard to find a replacement
- Less than half of Vancouver family doctors set aside time to see patients for same-day appointments, and stay late to accommodate their patients.
When we listened to their suggestions, we heard that interdisciplinary care, reducing administrative tasks for doctors, and creating practices that are attractive for younger doctors (work-life balance, non-physician business lead) would be important if we are to enable everyone to have a family doctor.
We were also fortunate to be able to test these ideas with citizens, through on-line and in-person engagement. We found that people cherish their relationship with their family doctor, and that 93% of people think everyone should have a GP. We also found that people are interested in team-based care, that over 80% of people want to be able to get same-day appointments, and would see a different doctor or a nurse at their regular practice if that meant avoiding an emergency or walk-in visit.
We were intrigued by some apparent contradictions. For examplehow can we improve timely access for patients while preserving work-life balance for patients? So we dug deeper and started to imagine how each piece of the puzzle could be optimized to support primary care relationships. We found that there is a big game-changer in the way physicians work: it is true that many feel that younger doctors want to work quantitatively fewer hours. However, they also want to work in a qualitatively different way - as part of a team that works collaboratively, integrates patient perspectives, and allows them to focus on providing care, rather than running a business.
In addition, we've been fortunate to get feedback on the details of this model from a smaller group of citizens, clinicians and health system experts. These include:
Dr. Rita McCracken, Family Physician
Dr. Kristi Williams, Family Physician Resident
Dr. Daniel Heffner, Family Physician Resident
Dr. John Millar, Clinical Professor at the School for Population and Public Health at UBC
Aaron Sihota, Pharmacist
Ryan Dirnback, Master of Health Administration
Primary Care Subject Matter Experts
Madeline Boscoe, REACH
Irene Clarence, Mid Main
Cindy King, Valley MedCom
Jim Pawson, Project Manager / Consultant
Michael DeSandoli, Consultant
Geoff Trafford, Consultant
We are grateful for the time and energy that clinicians, experts and citizens have set aside to help make our model stronger, and we invite you to help us, by getting in touch with us here!