Becoming Measurably Better in Primary Care · Becoming Measurably Better in Primary Care Dr. Tobias...

Becoming Measurably Better in Primary Care

Dr. Tobias Gelber

Lisa Cook, PhD

Faculty/Presenter Disclosure

• Faculty: Tobias Gelber & Lisa Cook

• Relationships with commercial interests: – Grants/Research Support: Not applicable

– Speakers Bureau/Honoraria: Not applicable

– Consulting Fees: Not applicable

– Other: Not applicable

CFPC COI Template - Slide 1

Chinook PCN There are approximately

134 physicians/26 clinics participating, providing care to over 160,000 regional residents.

PCN 2.0 Evolution

Image borrowed from PCN Evolution Portal (http://www.pcnevolution.ca/Pages/default.aspx) accessed January 27, 2015.

Measurement TNA

Measurement

Clinic Visits

Panel Pts

Medical Home

No Show

Another Medical Home

TNA

Medical Home Panel

Pt

Emergency Department

Clinic Open Clinic Closed

External Pt

TNA

Measurement

Clinic Visits

Panel Pts

Medical Home

No Show

Another Medical Home

TNA

Emergency Department

Medical Home Open

Medical Home Closed

Medical Home Panel

Pt External Pt

TNA

Measurement

Clinic Visits

Panel Pts

Medical Home

No Show

Another Medical Home

TNA

Emergency Department

Medical Home Open

Medical Home Closed

Medical Home Panel

Pt External Pt

TNA

Measurement

Clinic Visits

Panel Pts

Medical Home

No Show

Another Medical Home

TNA

Emergency Department

Medical Home Open?

Medical Home Panel

Pt External Pt

TNA

Measurement

Measuring for the sake of measuring is not practical

Cannot measure everything

How Do You Become Measurably Better?

Why? Consequences? Show Value

Measurement in our PCN

AHS Data

Measurement in our PCN

Measurement in our PCN

Why? Consequences?

Utilization Greater understanding of our patient population

Utilization Decisions are not evidence-based

Measurement in our PCN

Why? Consequences?

Utilization Greater understanding of our patient population

Utilization Decisions are not evidence-based

ER & Admission Identify high users and long time users

ER & Admission Continued inappropriate usage

Measurement in our PCN

Why? Consequences?

Utilization Greater understanding of our patient population

Utilization Decisions are not evidence-based

ER & Admission Identify high users and long time users

ER & Admission Continued inappropriate usage

Laboratory & Diagnostic Imaging Identify redundant tests and over-investigation

Laboratory & Diagnostic Imaging Adverse effect on patients (unnecessary tests, etc), and sub-optimal medical treatment.

Measurement in our PCN

Why? Consequences?

Utilization Greater understanding of our patient population

Utilization Decisions are not evidence-based

ER & Admission Identify high users and long time users

ER & Admission Continued inappropriate usage

Laboratory & Diagnostic Imaging Identify redundant tests and over-investigation

Laboratory & Diagnostic Imaging Adverse effect on patients (unnecessary tests, etc), and sub-optimal medical treatment. . Specialty & Primary

Care Visits Further our understanding of attachment

Specialty & Primary Care Visits Inappropriate paneling

Measurement in our PCN

Why? Consequences?

Utilization Greater understanding of our patient population

Utilization Decisions are not evidence-based

ER & Admission Identify high users and long time users

ER & Admission Continued inappropriate usage

Laboratory & Diagnostic Imaging Identify redundant tests and over-investigation

Laboratory & Diagnostic Imaging Adverse effect on patients (unnecessary tests, etc), and sub-optimal medical treatment. . Specialty & Primary Care Visits

Further our understanding of attachment

Specialty & Primary Care Visits Inappropriate paneling

Home Care & Addictions Mental Health Identify the users

Home Care & Addictions Mental Health Appropriate usage can avoid hospitalization

Measurement in our PCN

Why? Consequences?

Utilization Greater understanding of our patient population

Utilization Decisions are not evidence-based

ER & Admission Identify high users and long time users

ER & Admission Continued inappropriate usage

Laboratory & Diagnostic Imaging Identify redundant tests and over-investigation

Laboratory & Diagnostic Imaging Adverse effect on patients (unnecessary tests, etc), and sub-optimal medical treatment. . Specialty & Primary Care Visits

Further our understanding of attachment

Specialty & Primary Care Visits Inappropriate paneling

Home Care & Addictions Mental Health Identify the users

Home Care & Addictions Mental Health Appropriate usage can avoid hospitalization

Costing Impact the PCN services

Costing Continued resource expenditure

Measurement in our PCN

Need Something….

Need Something….

Secure

Need Something….

Secure

Need Something….

Secure

Timely

To Show Value

Central Data Repository Web Based System

Chinook PCN

Chinook PCN

Telus Health

Medical Homes/AHS Programs

Central Data Repository

Panel

Who is the Most Responsible

Provider?

Standardized Patient Attachment & Detachment Process

Individualized Posters for Each Clinic

Distributed Postcards to Patients

Automatic Patient Identification Process

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

NoWait Medical Clinic

Central Data Repository

NoWait Medical Clinic

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Central Data Repository

Our Journey Continues…

Our Mission: To deliver exemplary, evidence-based and timely patient-centered primary

health care