PROJECT UPDATES Inside this issue
Improved Care for COPD
Specialists in Princeton
Showcasing Shared Care project in Orlando
Shared Care project designed to improve care for patients with acute exacerbation (AE) of COPD has been chosen to present at an upcoming Institute of Healthcare Improvement (IHI) conference in Orlando, Florida. This national forum unites thousands of health care leaders, visionaries and frontline practitioners from around the world. Dr. Shannon Walker will present the results of the South Okanagan Similkameen (SOS) AECOPD Transition in Care project in a poster presentation. This forum will provide the opportunity
to showcase the 3-month trial of the AECOPD pathway and the AECOPD preprinted orders. Dr. Murali Venkataraman and Terrie Crawford from the SOS Division of Family Practice, Dr. Elizabeth Watters from the SOS Shared Care Steering Committee, and Aman Handal, provincial Shared Care initiative lead will also be travelling to Florida. They will answer questions about the project, and be on the lookout for new ideas. (For more information about improvements to COPD care in the South Okanagan Similkameen please see page 2).
Terrie Crawford (left), Dr. Shannon Walker and Dr. Elizabeth Watters are part of a team heading to Orlando to showcase AECOPD project.
WHAT IS SHARED CARE? The Shared Care Committee (SCC) is a joint committee of the BC Medical Association and the BC Ministry of Health that is working to improve health outcomes and the patient journey through the health care system. SOS Shared Care projects are funded by the SCC and directed by a local steering committee (pictured left). Project funds are administered by the SOS Division of Family Practice.
Local Projects: Past: SOS Shared Care Steering Committee: (from left) Dr. Brian Forzley, Carol Stathers, Tracy St. Claire, Lori Motluk, Dr. Elizabeth Watters, Dr. Marius Snyman, Terrie Crawford, Ida Keller and Dr. Shannon Walker (missing from photo: Dr. Glen Burgoyne and Susan Brown)
Referral acknowledgments, Patient self-management tools
Present: AECOPD Transitions in Care, Maternity Care, Princeton Access to Specialist Care Planned: Emergency Transitions
South Okanagan Similkameen
Breaking the cycle: AECOPD project aims to reduce patient readmissions “As doctors, we saw COPD patients going back and forth to the emergency department, and not getting the right support to manage their care effectively at home” — Dr. Brent Harrold
Shared Care project has introduced significant changes to the way patients with Acute Exacerbation (AE) of COPD receive care. Now when patients with AECOPD enter the hospital they receive: COPD education, standardized medical treatment, patient follow-up in home and by phone, timely family physician follow-up and involvement in community respiratory programs.
An interdisciplinary team of 15 healthcare providers, including Drs. Brent Harrold, Shannon Walker, and Glen Burgoyne, developed this care model for AECOPD patients. “We tried to design protocols that
Drs. Brent Harrold and Shannon Walker review Jack Swoboda’s patient information in Emergency.
were quick and efficient so it wasn’t making hordes of extra work,” says Dr. Harrold. One tool designed to improve efficiency is the new pre-printed order set, which includes a referral function, contains information on recommended medications and can double as a prescription at any pharmacy. “We’ve had pretty good support getting pre-printed orders filled out by emergency physicians but it’s still a challenge in a busy shift to pull out extra forms,” adds Harrold. Working with family physicians is also key to successful patient outcomes: “The research we looked at during the project showed that if a patient is going to experience complications, it is often around the two week mark,”
says Dr. Burgoyne. “The care pathway helps us more predictably make sure we are connecting with our patients in that vulnerable time.” Results from the 3-month trial (from March to May 2013) indicated potential gaps in AECOPD case identification. To assist with this case identification, the working group has recommended increased use of respiratory therapy (RT) resources. Interior Health is currently investigating ways to provide additional resources, including having RTs help with COPD education and rural outreach. Further evaluation is planned to help assess long-term impacts of the pathway on patient outcomes once data is made available.
Family physicians to get better tools to help their patients manage COPD Family physicians will soon have better
tools to assist in the care of patients with COPD in their offices. The tools, which will relate to COPD diagnosis, treatment, patient education and referrals, are expected to be ready to trial in the new year. A small group of physicians led by Drs. Johan Boshoff, Perold Louw, Glen Burgoyne and Shannon Walker are developing a COPD EMR (Electronic Medical Record) template in Med
Access. The information in this template could be replicated in any office, whether paper-based or electronic. Respiratory therapists from the South Okanagan are also developing a single respiratory referral form (replacing several forms currently in circulation). In response to physician requests, they are also writing a short COPD handout for patients that can be printed from an EMR in a doctor’s office.
This South Okanagan Similkameen project is part of the Integrated Practice Support Initiative (IPSI), a partnership of the Physician Information Technology Office (PITO), Practice Support Program (PSP), and the Divisions of Family Practice initiative. If you wish to have access to these tools or would like more infomation, please contact Tracy St. Claire, the Shared Care Project Manager: email@example.com. 2
Carol Stathers joins the Shared Care team at the SOS Division of Family Practice as the project coordinator for maternity care. Carol is a familiar face in the Okanagan health care system working as a nurse educator for chronic disease self-management at Interior Health, and as Interior Liaison for Patients as Partners Patient Voices Network with ImpactBC.
Care providers invited to share information on maternity care A pregnant mother in the South Okanagan Similkameen can access prenatal care in so many different ways. She can be referred by a family doctor, by public health or self-refer to a maternity clinic, a specialist or to a midwife. How she finds care also depends on whether she lives in town or in a rural area. A new Shared Care maternity project aims to bring representatives from all these various areas of maternity care together to clarify roles and improve information flow. Carol Stathers, who is leading the project, hopes that by coming together at one table, stakeholders in maternity care can ask questions such as: What are we doing that’s working? How could it be easier to share information, and work with other care providers?
“There’s such good work being done here that we’d like to get the various care providers together to listen, to collaborate, and to look for improvements that could benefit mothers to be,” says Stathers. Stakeholder engagement is underway with maternity clinic doctors, obstetricians, paediatricians, referring physicians, midwives, IH administration, public health, perinatal community social workers, aboriginal representatives, mental health and substance use workers, doulas, child birth educators and patients. WANT TO GET INVOLVED? If you have a special interest in materity care and want to become involved in the project, please contact Carol Stathers: firstname.lastname@example.org.
Princeton physicians team up with Penticton specialists Patients in the town of Princeton will soon have better access to specialist care
Expanded specialist outreach clinics
in Princeton will start in the new year and are intended to provide patientcentred care to this rural area. At the first clinic, on Jan.15th, Dr. Shannon Walker will offer respirology care. She hopes to be accompanied by a respiratory therapist who can provide spirometry and self-management education to patients. A second clinic on general nephrology as well as general internal medicine (GIM) cases is planned for Feb. 19th with Dr. Brian Forzley. The GIM cases could include whatever is needed, but areas of interest include most aspects of endocrinology (diabetes, thyroid, adrenal, electrolyte, calcium disorders), hematology and cardiology.
Both Walker and Forzley have offered to host a lunchtime Continuing Medical Education component on clinic days. The Princeton Access project is funded by the Shared Care committee and is intended, in part, to improve support for Princeton family doctors: Ella Monro, Devinder Sandu, Evaristus Idanwekhai and Colleen Black. Three of these doctors are new to the community. The project also aims to develop a comprehensive list of Penticton specialists and their sub-specialties for use by all family physicians in the South Okanagan. Outreach clinics in Princeton will continue with paediatrics, psychiatry, cardiology and mental health and substance use.
Dr. Brian Forzley is teaming up with other physicians to provide better specialist care for patients living in Princeton.
All outreach clinics will be evaluated to ensure that the experience is positive for specialists, Princeton family doctors, other health care providers and their patients.
Front page photos:
(Top left) Drs. Brent Harrold and Shannon Walker with patient Jack Swoboda (Top middle) Dr. Brian Forzley (Top right) Dr. Elizabeth Watters (left) with MOAs Colleen Tew and Candace Gerk (seated) 3
Report card on SOS Shared Care: Evaluating our progress Two years ago, the first SOS Shared
Care project was funded as a single project under the banner of the SOS Division of Family Practice. A recently completed evaluation report sheds light on valuable lessons learned during this time, before SOS family and specialist physicians embarked on more projects in the region. The original SOS Shared Care project focused on five areas designed to improve family physician/specialist partnerships while coordinating patient care. These areas were: referrals/e-referrals, consultation processes, medications, shared care plans and continuity of care, and end of life management. The project included family physicians along with chronic disease specialists. The Shared Care project began in Jan. 2011 and was scheduled to be completed by Dec. 2011. Very soon into the project, it was realized that the focus of the project was too broad to be completed in this short time frame. The work narrowed to focus on the use of referral acknowledgments. In the evaluation report, 89% of family physicians and their MOAs said it was helpful to receive a referral acknowledgment. The use of referral acknowledgments lets patients know that a referral was received, helps predict wait
times, and clarifies which office would contact them for appointments. SOS Shared Care work also focused on patient self-management tools (Personal Health Records and Medication Bags). Improvement efforts in the area of shared care and continuity of care were limited to one speciality – renal care. “This evaluation represents two years of work, and we’ve learned many valuable lessons from it,” says Terrie Crawford, SOS Division executive lead and first Shared Care project lead. “It’s vital to have the right people at the table to define the issues and to develop, test and revise new processes and tools so changes are relevant and sustainable. We know that this process takes time.” Building on lessons learned, both provincially and regionally, large Shared Care projects have since been broken into smaller focused projects. This focus fosters a more efficient and effective environment for people to come together to collaborate on innovative health care solutions. Shared Care work in the region has revealed that the best way to promote health care improvements, collaboration and communication is to work on each project as a shortterm initiative.
Report highlights the benefits of referral acknowledgments “When I’m with a patient, and I can see a referral acknowledgment in the chart, it’s reassuring for both of us. It completes the communication loop.” — Dr. Elizabeth Watters
Family physician Elizabeth Watters (left) and MOAs Colleen Tew and Candace Gerk (seated) look over a referral acknowledgment in use at the physician’s office. 89% of family physicians and their MOAs reported that it was helpful to know that a referral was received by a specialist.
For more information about stories in this issue: Contact members of the SOS Division/Shared Care Project Team
From left: Terrie Crawford, Tracy St. Claire, Ida Keller and Carol Stathers
Terrie Crawford SOS Division of Family Practice Executive Lead tel: 778 476 5628 email: email@example.com
Tracy St. Claire Shared Care Project Manager tel: 778 476 5694 email: firstname.lastname@example.org
Ida Keller Shared Care Project Assistant tel: 778 476 5896 email: email@example.com
Carol Stathers Shared Care Maternity Care Coordinator tel: 778 476 5694 email: firstname.lastname@example.org 4
South Okanagan Similkameen Division of Family Practice Shared Care project updates