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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
