Calgary Foothills Primary Care Network · Provide MDT with current and evidence-based education to support patient care. Support MDT to provide high quality care. 14 pharmacists have

Calgary Foothills Primary Care Network

(Go live date July 1 2006)

Annual Report

Sections 1 & 2

Version 9.0

For the period

April 1, 2013 to March 31, 2014

To be submitted to the PCI Program Management Office no later than July 1, 2014

2013-14 Annual Report sections 1 & 2 version 9.0 {PCN Name} 2

SECTION 1

Summary of PCN Highlights (2-3 paragraphs) Calgary Foothills Primary Care Network (CFPCN) continued to build on a strong group of core programs

during the 2013-2014 fiscal year.

New program highlights included the emergency department referral pilot, in which appropriate patients

were referred from the Foothills Medical Centre Emergency Department to the CFPCN After Hours Clinic.

The initiative was first introduced during the flooding of the Bow and Elbow rivers in June 2103, before a

pilot was held during a non-crisis period, from December 2013 to March 2014. The pilot was a success and

the program will be continued indefinitely.

In June 2013 the geriatric psychiatry program built on the on the success of the Extended Team’s Navigation

stream by introducing a one-time psychiatric assessment, while Population Health programming was

boosted with the October 2013 addition of Craving ChangeTM, a free, four-class workshop for adults who

struggle with their choices around eating. Throughout the year there was also a strong focus on helping

physicians to implement quality improvement initiatives in their practices.

Period Overview (5 pages or less)

Name of priority initiative: After Hours Care

Elements Planned Achievement Status* Status Explanation**

After Hours

Clinic (AHC)

Provide support for patients when family

physician offices are closed on evenings,

weekends and statutory holidays.

Ongoing 9,832 patients were seen at AHC

this fiscal year (14% increase from

FY 12/13).

Continuity

Clinic

Increase ability to provide same day access

for primary care issues during the day when

family physicians are not available.

Ongoing 783 patients were seen at the

Continuity Clinic this fiscal year

(71% in average number of patients

seen per month from FY 12/13).

Partnership

with Health

Link

Triage patients to the After Hours Clinic and

available physician through Health Link.

Ongoing Health Link Alberta triaged 49,719

Calgary Foothills PCN (CFPCN)-

related calls (1% decrease from FY

12/13).

Physician On

Call

Provide on-call support to patients after

hours, through Health Link triage.

Ongoing Health Link referred 59 patient calls

this fiscal year to the physician

available by phone after hours

(45% decrease from FY 12/13).

Name of priority initiative: Chronic Disease Management


Crowfoot

Primary Care

Centre

Provide primary care services for complex

patients who may be difficult to attach; clinic

has multidisciplinary team (MDT) for

patients with chronic disease.

Ongoing 932 patients with complex conditions

are currently attached to the clinic

and benefiting from enhanced MDT

care (6.8% decrease from FY

12/13).

MDT

Provide comprehensive team-based care in

the medical home to assist in chronic

disease management.

Support physicians and team to increase

their capacity of diabetes care, through a

Diabetes Outreach Educator (DOE).

Provide MDT with current and evidence-

based education to support patient care.

Support MDT to provide high quality care.

Ongoing

On

target

Ongoing

Ongoing

As of March 2014, 96.3% of

physicians with a family practice had

at least one team member in the

medical home (99.6% in FY 12/13).

Teams consisting of pharmacists,

health management nurses and

dietitians had 20,532 patient

interactions (9.4% decrease from FY

12/13).

DOE received 62 referrals. 71% of

patients (n=21) saw an improvement

in HbA1c following treatment.

Additional education and resource

support provided to MDT.

A resource library provides MDT

with remote access to evidenced-

based information and patient

handouts.

4 MDT educational seminars were

held, with +/- 55 attendees at each

session.

14 pharmacists have prescribing

privileges (13 in FY 12/13), 14

pharmacists have their Certified

Diabetes Educator (CDE) (9 in FY


Provide member physicians with evidence-

based information. Partnership with

University of Alberta (Best Practice Support

Visits).

On

target

12/13), and 5 health management

nurses have their CDE (4 in FY

12/13).

46 physicians received a Best

Practice Support Visit education

session during the fiscal year. The

topic of these sessions was

Dyslipidemia & New US Guidelines.

Name of priority initiative: Clinic Innovations


Calgary PCN

Managed

Clinics

Exploring a variety of models to support

physicians to optimize the medical home

and support the recruitment and retention of

family physicians.

Ongoing 4 Primary Care Centres (PCCs)

operating: Crowfoot PCC, Cochrane

PCC, Foothills PCC, and Riley Park

PCC. Each PCC also supports PCN

programs which increase access to

primary health care.

Extended

Team

Increase the ability of the medical home to

provide comprehensive care for patients

with complex issues, and link medical

homes with specialty care: Chronic pain

stream, Medical MSK stream, GI stream,

and Navigation stream.

Ongoing

Ongoing

On

target

Ongoing

Chronic Pain Stream: Received 346

referrals this fiscal year. Patients

demonstrated improvements in pain

intensity, severity and self-reported

depression symptoms.

Medical MSK Stream: Received 184

referrals for non-inflammatory and

non-surgical concerns in multiple

joints.

GI Stream: Received 193 referrals

from AHS Central Access and

Triage for patients with dyspepsia,

gastro esophageal reflux disorder,

and Irritable Bowel Syndrome.

Navigation stream: 376 patients

were referred regarding falls,

cognitive screening, function and

safety, and community resources.

Information

Technology

Support all member physicians to have

completed their PIAs and encourage EMR

uptake.

Facilitate signing of the CFPCN Data

Sharing Agreement to allow member to

share data in a secure manner with their

Physician Corporation.

Facilitate the use of online resource (Up-To-

Date) for physicians, staff and CFPCN allied

health professionals.

Communicate information about health

promotion, AHS services and CFPCN

information to patients via Health Unlimited

Television (HUTV).

Ongoing

Ongoing

Ongoing

Complet

ed

All members have completed PIAs.

83% of physicians use an EMR

(69% in FY 12/13). 84% of

physicians use Netcare (85% in FY

12/13).

76% of member physicians have

signed the DSA as of March 2014

(81% in FY 12/13).

48, 849 Up-To-Date topic views

(26% decrease from FY 12/13).

The four CFPCN Primary Care

Centres and Riley Park Maternity

Clinic received HUTV monitors in

patient waiting areas.


Liaisons Liaisons meet with physicians on a regular

basis in order to provide regular PCN

updates and father physician feedback.

Liaisons received practice facilitation

training from Towards Optimized Practice.

Support clinics in screening activity (Alberta

Screening and Prevention- ASaP).

Support clinics in Alberta AIM (Access

Improvement Measurement) collaboratives.

Partner with AHS Calgary Zone and Health

Quality Council of Alberta (HQCA) to

support physicians to receive data on their

patient panels.

Support physicians to engage in quality

improvement initiatives in their practices.

Ongoing

Complet

ed

Complet

ed

Ongoing

Ongoing

Ongoing

Member physicians met with their

liaisons an average of 5.3 times over

the fiscal year (4.8 in FY 12/13).

Liaison confidence in overall

facilitation skills, knowledge

increased by 177%.

Liaisons received training from TOP

to facilitate ASaP processes.

Over the fiscal year, 16 physicians

have enrolled with ASaP.

Two clinics participated in AIM this

fiscal year (33 physicians). One

clinic completed the initiative; time to

third next available appointment

decreased by 75%.

Liaisons facilitated the signing of

HQCA data sharing agreements.

62% of full member physicians

received HQCA physician-level

reports (53% in FY 12/13).

146 physicians participated in

liaison-facilitated practice

enrichment projects. Projects were

related to treatment (47%), efficiency

(28%), understanding patient panel

(24%), screening and prevention

(22%), access (15%) and continuity

(2%).

Program

Promotion &

Education

Provide family physicians, staff and team

ongoing education opportunities to support

uptake of PCN services and programs.

Ongoing

Four CME events were held with

392 physicians, clinic staff and MDT

in attendance.

New Grad

(New)

Provide new family physicians the

opportunity to experience a variety of

practice settings in primary care with

financial and mentoring support.

On

target

4 new physicians positioned in the

four CFPCN Primary Care Centres.

In the Cochrane PCC, 128 patients

were attached to the clinic as part of

a New Grad panel.

Primary

Health Care

Service

Delivery

Model (New)

Provide a primary health care service

delivery model to support medical homes by

coordinating care in the community and

enhancing team.

On

target

The Cochrane PCC has been

identified as the initial Community

Hub site, to be implemented in fall

2014.

Name of priority initiative: In-Hospital Care


In-Hospital

Care

Enhanced Hospital Discharge– transitioning

discharges from Foothills Medical Centre

(FMC) to the community.

Seamless Care – identification of

pharmacists’ concerns at discharge

Ongoing

Ongoing

2,316 packages have been sent to

member physicians (58% of

discharges).

10 pharmacist-to-pharmacist

referrals for CFPCN patients (56%

decrease from FY 12/13).


Name of priority initiative: Mental Health


Access to

Psychiatry

Offer tele-psychiatry consultations with a

psychiatrist for Calgary Foothills PCN

physicians.

Offer Adult Psychiatric Assessment

service available to Calgary Foothills PCN

physicians.

Ongoing

Ongoing

Tele-psychiatry provided 32 consults

(10% increase from FY 12/13) to 20

different physicians.

Psychiatrist received 394 referrals,

concerning topics such as diagnostic

assessment, depression/mood, and

anxiety.

Behavioural

Health

Consultants

Behavioural health consultants work

alongside physicians to address mental

health concerns in the medical home, as

part of the MDT.

Ongoing 91% of physicians with a family

practice have a behavioural health

consultant (of those who requested

one). BHCs saw approximately

11,954 patients (24% increase from

FY 12/13).

Name of priority initiative: Population Health


Cochrane: Teen

Health

Provide sexual and reproductive health

care and education for young adults in the

Cochrane area.

Ongoing 3 patients have used this program.

The small number is believed to be

due to lack of publicity. The program

will continue in the FY 14/15 year.

Ask a Dietitian

Increase access to registered dietitians by

offering “Ask a Dietitian” group

appointments.

Ongoing 95 people attended a group

appointment (6% increase from FY

12/13).

Pediatric Kids in

Care (PKIC)

PKIC is a joint program with Pediatricians,

Calgary Child & Youth Services and

Calgary Foothills PCN.

Ongoing

10 children from the Child Protective

Services were attached to a family

physician.

Tobacco

Cessation

Program

Support patients to quit tobacco use

through a comprehensive program of four

classes, including education, group

support and access to medications.

Ongoing

326 referrals were made (11%

decrease from FY 12/13), 31%

registered (61% in FY 12/13) and

88% of registrants attended the first

class (51% in FY 12/13). After three

months, 50% of those contacted

(n=36) reported they had quit (37%

in FY 12/13).

Craving

ChangeTM

(New)

Workshops focused on helping patients

understand their eating patterns and

develop a healthier relationship with food.

Ongoing 67 registrations, 88% attended first

class. Overall patients reported a

positive change in their ability to

cope with their cravings.

Unattached

Patient Registry

Manage the pan-PCN Registry in order to

help connect unattached patients with

family physicians.

Ongoing The website/registry received 6,257

registrations from CFPCN (33%

increase from FY 12/13).

Walking

Program

Promote physical activity in the

community by supporting a walking

program.

Connect patients with physicians in an

informal setting while promoting physical

activity through Walk with Doc program.

Ongoing

Ongoing

12 new participants this fiscal year,

for a total of 226 registrants (5%


10 session were held, attended by a

total of 119 walkers.


TrymGym Promote physical activity by subsidizing

the TrymGym program (partnership with

University of Calgary).

Ongoing 126 Calgary Foothills PCN patients

participated (same in FY 12/13).

Name of priority initiative: Seniors Health


Pan PCN Long

Term Care

Availability

Group

A Pan-PCN service for residents in long

term care, where physicians provide after-

hours coverage on weekdays and

weekends.

Ongoing 61 physicians (39 from CFPCN)

cover 28 LTC facilities. 5,302 calls

received (8% increase from FY

12/13).

Nurse

Practitioner

program

Provide a nurse practitioner at Bethany

Cochrane to increase access and improve

coordination.

Ongoing

The nurse practitioner continues to

provide care to Calgary Foothills

PCN patients.

Seniors

Outreach

Provide education events to seniors in the

community.

On

target

Five events have been held, with

103 participants in total.

Senior Primary

Care Service

(Now known as Navigation Team; merged

with extended team)

Ongoing See Extended Team.

Restricted Grants & Central Allocation Key Activities: (E.g. Evaluation, IT, etc…)

Activities Planned Achievement Status* Status Explanation**

Atrial

Fibrillation Pilot

Restricted grant funded by Boehringer-

Ingelheim (Canada) Ltd., to identify high

risk patients and reduce preventable

strokes.

Deferred Project being considered at level of

Calgary Zone Primary Care Action

Plan (CZPCAP). Further action

pending CZPCAP decision.

Enhanced

Participation in

Cancer

Screening

(EPICS)

Restricted grant funded by Alberta Cancer

Prevention Legacy Fund (ACPLF), testing

impact of improved clinic processes,

electronic registries and EMRs on cancer

screening.

Ongoing This fiscal year, Calgary Foothills

PCN has been an active partner in

implementing phase 2 of the study.

Specialist

Linkages

Specialists Linkage funding discontinued.

We provide tele-consult programs to

continue the linkage.

Connect member physicians and teams

with specialty through “lunch and learn”

educational opportunities in member

clinics.

Ongoing

Ongoing

Tele-programs include: psychiatry,

cardiology, orthopedics,

rheumatology, chronic pain, GI, ENT

(new), geriatric psych (new),

hematology (new), perinatal psych

(new).

26 sessions were held: 13 Chronic

Pain, 7 MSK, 5 Geriatric Psychiatry,

and 1 Endocrinology (diabetes).

*Completed, On-going, On Target, Delayed, Deferred or Discontinued

**Briefly describe achievements or explain delays, deferrals or discontinuations.


SECTION 2: EVALUATION

Objective 1: To increase the proportion of residents with ready access to

primary care

1.1 Comment on any key achievements by the PCN toward increasing

access to primary care in the past year.

ATTACHMENT Many Calgary Foothills PCN family physicians attach people to their medical homes. Patient

attachment to a medical home helps improve patient care and population health, and is

supported by the College of Family Physicians of Canada (2009). As of March 31, 2014, there

were 361,464 people paneled to Calgary Foothills PCN, an increase of 2,077 people (0.58%)

from last fiscal year.

The PCN has developed PCN-specific web registry processes to connect people who request

a family physician to family physicians who are building their practice.

Web Registry Calgary Foothills PCN operates and manages a Calgary Zone pan-PCN Web Registry to

coordinate patient connections to family physicians. The Web Registry is an online data

collection tool designed to connect people who do not have a family doctor to a physician in

their surrounding community on a first come, first served basis. People who are looking for a

family physician may register online at www.needadoctorcalgaryandarea.ca or by calling

Health Link Alberta. This is an example of how PCNs are collaborating to improve patient

access to primary care services.

During the period of April 1, 2013 to March 31, 2014, the Need-a-Doctor website received

17,794 registrations from the Calgary Zone area (a 50.5% increase from FY 12/13), which

may be due to simplification of the registration process which occurred in April 2013.

This fiscal year, Calgary Foothills PCN received 6,257 registrations from the PCN

catchment area (a 50% increase from FY 12/13).

The PCN provided 4,482 patient names to family physicians in the community from the Web

Registry (a 165% increase from FY 12/13). When patients were contacted, some no longer

required attachment to a family physician.

The average wait time before connection was 119 days (a 33% increase from FY 12/13).

As of March 31, 2014, a total of 4,370 patients were attached to a medical home from the

web registry.

2,748 were attached to family physicians in member clinics (13% increase from FY 11/12.

Comparison for FY 12/13 is not available).

1,622 were attached to Crowfoot Primary Care Centre. (18% decrease from FY 11/12.

Comparison to FY 12/13 is not available).

Prioritizing Attachment for Patients with High Needs Calgary Foothills PCN monitors and prioritizes attachment to Crowfoot Primary Care Centre for

people with high needs such as people discharged from hospital without a family physician,

pregnant women, and people with chronic disease. Crowfoot Primary Care Centre is a PCN-

http://www.needadoctorcalgaryandarea.ca/


managed clinic with a mandate to attach high needs patients. The PCN has developed PCN-

specific processes to support connecting people who need or request a family physician.

In addition to the Web Registry, patients were also attached from the following sources:

49 from Foothills Medical Centre

5 from Peter Lougheed Hospital

24 children (and their biological families and/or foster families) from Pediatric Kids in Care

60 from After Hours Clinic

92 from other sources such as community physicians and retirement homes.

51 from Riley Park Maternity Clinic

New grad program The New Grad Program was developed in July 2013 to allow new family physicians to

experience a variety of practice settings in primary care with financial and mentoring support.

This program provides support and additional time as the new grads continue to develop their

expertise and make their career choices. The program was piloted with 4 new graduates in the

PCN Primary Care Centres (PCCs) this fiscal year.

In the Cochrane Primary Care Centre, 128 patients were attached to a new grad panel. In

the other PCCs, New Grads see patients from clinic physician panels. The additional

provider practicing in the clinic increases the number of patients who can be seen each

day.

Feedback from New Grads following each rotation (n=7) indicates that there is room for

improvement with regards to patient variety and opportunities for diverse practice

experiences. The program continues to be developed in order to meet New Grad needs.

Further evaluation is underway to assess patient satisfaction and impact on access.

AFTER HOURS Calgary Foothills PCN operates, in partnership with Health Link Alberta, an After Hours Clinic

and Physician On-call Service (in Calgary and Cochrane) to increase access to primary care

for patients of member physicians and unattached people living in the PCN catchment area.

The objective is to provide primary care support (the issue needs to be seen within four – 24

hours) for patients when physician members’ offices are closed, and when physicians do not

capacity for same-day access.

The After Hours Clinic provides primary care from 5 p.m. – 9 p.m. during the week and 10 a.m.

– 4 p.m. on weekends and statutory holidays. Referrals are received from Health Link Alberta

and directly from member physicians. The Physician On-call service provides after hours

advice from 9 p.m. – 8 a.m. during the week and 4 p.m. – 10 a.m. on weekends and statutory

holidays. Referrals are received through Health Link Alberta.

Health Link Alberta Referrals Over the fiscal year, Health Link Alberta received 49,719 Calgary Foothills PCN-related

calls (average of 4,143 calls per month), which is a one per cent decrease from the previous

fiscal year (50,109 in FY 12/13).

Of these calls, 95% were made by attached patients and five per cent were made by

unattached patients, which is the same as the previous fiscal year.


Sixteen per cent of these Calgary Foothills PCN-related Health Link calls were triaged to

the After Hours Clinic over the fiscal year, to a total of 7,963 calls (17% in FY 12/13).

Consistent leading categories of health concerns referred to the After Hours Clinic included

pediatric cough/hoarseness/stridor (5%); abnormal urination (5%); adult cough/hoarseness

(5%), and sore throat (5%).

After Hours Clinic Approximately 9,832 patients were seen at the After Hours Clinic over this fiscal year (8,628

in FY 12/13, a 14% increase).

On average, 82% of referred patients were seen (73% in FY 12/13). Some of the reasons

patients did not come to the clinic after being referred were: staff are unable to reach

patients; patients prefer to wait and see their family physician; or patients report feeling

better.

1.8% of total Calgary Foothills PCN patients seen were unattached (2% in FY 12/13). These

patients were subsequently referred to the Crowfoot Primary Care Centre to be attached.

Direct physician referrals accounted for about 23% of all patients seen in the clinic (24% in

FY 12/13).

During the fiscal year, the clinic operated close to capacity: on average, 73% of possible

appointments were booked (69% in FY 12/13).

From November 2012 – February 2014, Mosaic and Calgary Foothills PCN harmonized

Health Link Alberta referral algorithms to provide patient-centered choice of location. The

patient’s medical home received a visit report regardless of which PCN After Hours Clinic

the visit occurred in. Mosaic PCN closed their clinic in February 2014, and in order to

continue to provide access to convenient after hours care, Calgary Foothills PCN has

maintained availability for Mosaic patients. Health Link Alberta continues to offer patients

the option of being seen at the Calgary Foothills PCN clinic.

Attached and unattached patients from Mosaic accounted for approximately 4% of the

patients seen (2.5% in FY 12/13).

A brief anonymous survey was conducted with patients at the After Hours Clinic in October

2013 and March 2014. This survey has been conducted six times over the past three fiscal

years. All patients are asked to complete a single-question survey indicating where they would

have gone for medical help if the After Hours Clinic was not available.

On average, the findings suggest that the After Hours Clinic diverted at least 37% of patients

from emergency rooms and urgent care centres during this fiscal year. This finding is

roughly consistent with the previous year (41% in FY 12/13).


Chart: Patients’ choice for medical help if the After Hours Clinic was not available,

October 2013 and March 2014 (n=156)

Continuity Clinic The Continuity Clinic is a service offered by Calgary Foothills PCN since November 2012, which

provides patients with access to a primary care team (physician, nurse practitioner and

pharmacist) when their family physician is unexpectedly absent or absent during a planned

vacation and does not have a locum or call group to cover. Absent physicians keep their clinics

open and staffed in order to take patient calls, and staff refer patients to the Continuity Clinic if

appropriate. The clinic is available Monday to Friday from 1:00-5:00pm.

Over the fiscal year, 783 patients were seen at the Continuity Clinic (average of 65 per

month, a 71% increase from FY 12/13).

A survey of physicians who used Continuity Clinic was administered to understand their

experiences (n=8). Five respondents (63%) would consider using the clinic again (100% in

FY 12/13, n=7) and six respondents (75%) would recommend it to colleagues.

In the annual physician survey, 42% of physicians foresee using the service in the future

(44% in FY 12/13). In the comments, many physicians noted that they have cross-coverage

within their clinics and therefore have no need of the service. Some noted that the costs to

keep their clinic open and the administration requirements to coordinate patients are

burdensome.

A brief anonymous survey was conducted with patients at the Continuity Clinic (n=15). The

findings suggest that the Continuity Clinic diverted at least 20% of patients from emergency

rooms and urgent care centres.

93% of surveyed patients are very satisfied with the service (n=15)

In order to improve efficiency, the Continuity Clinic and After Hours Clinic were merged on April

1st, 2014 now called Access 365. The services provided remain the same, but access to the

After Hours component is enhanced through extended hours. Reporting for the 2014-15 fiscal

year will reflect the combined structure of this clinic.

PHYSICIAN ON-CALL SERVICES

Physician On-call Service

35%37%

20%

6%

0%

10%

20%

30%

40%

50%

Walk-in clinic UCC or ER Wait to see GP Stay home


The Physician On-call service provides on-call support to patients in the Calgary Foothills PCN

catchment area once the After Hours Clinic closes: 9 p.m. – 8 a.m. during the week and 4 p.m.

– 10 a.m. on weekends and statutory holidays. Referrals are received through Health Link

Alberta.

During the fiscal year, 59 calls were referred to the Physician On-call service by Health Link

Alberta. This is a 45% decrease in referrals from the previous fiscal year. Health Link

Alberta suggests that referrals may be in decline because not all PCNs in the Calgary Zone

have an on-call service, and thus this option may not be top-of-mind for Health Link nurses.

Calgary Foothills PCN and Health Link are working to better understand this trend.

Chart: On-Call Referrals from Health Link, 2011/12 – 2013/14

The top categories of health concerns referred to the on-call physician included: non-trauma

eye concerns (5%); medication reaction (5%); vaginal bleeding and abnormal cramping

(3%); and visual disturbance and loss (3%).

The most common recommended action by the physician on call was to follow up with a

family physician (39%; 43% in FY 12/13). Recommendations to proceed to the ER or Urgent

Care Centre (29% of recommendations) are fairly consistent with the previous fiscal year

(26% of recommendations).

275

107

59

0

50

100

150

200

250

300

2011/12 2012/13 2013/14


Chart: Recommendation by on-call physicians, 2011/12 – 2013/14

Pan PCN Long Term Care (LTC) On-call Service Calgary Foothills PCN manages and coordinates a Pan PCN LTC On-call service with Calgary

West Central PCN for residents of 28 long term care facilities in the city of Calgary. The service

increases efficiencies by providing one telephone number (for each call group) to LTC facilities,

increasing the continuity of the support with one week interval coverage (two physicians on call

for the city, one for the north and one for the south) and decreasing physician travel time.

Physicians are supported to attend the LTC site when appropriate, which is particularly

important because on-site assessment can reduce unnecessary patient transfers to

emergency.

As of March 31, 2014, the LTC on-call service consists of 61 physicians across Calgary

Foothills PCN (39), Calgary West Central PCN (20), South Calgary PCN (1) and Mosaic

PCN (1) in 28 long term care facilities throughout Calgary. This represents a decrease of

one physician from March 2013.

Approximately 5,746 calls were received in this fiscal year (8% increase from 5,302 in FY

12/13).

7% of patients were sent directly to emergency following a call (7% in FY 12/13)

2% of patients were visited following a call (3% in FY 12/13)

Following a visit, 16% of patients were transferred to emergency (21% in FY 12/13)

ACCESS TO COMPREHENSIVE OBSTETRICAL CARE AND

DELIVERY

Riley Park Maternity Clinic Riley Park Maternity Clinic provides perinatal care for women of the greater Calgary area

(including CFPCN and non-CFPCN patients) who wish to deliver at Foothills Medical

Centre. Services are provided for attached and unattached patients.

41%

19%

33%

4%

43%

28%26%

4%

39%

28% 29%

4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Family physician Self Care ER or Urgent Care After Hours Clinic

2011-12 2012-13 2013-14


This fiscal year, there were 39,474 appointments (an average of 3,290 per month) at Riley

Park Maternity Clinic. This is a 14% increase from the previous fiscal year.

Riley Park Maternity Clinic received 3,109 referrals.

2074 women were early referrals at 10-12 weeks (9% increase from FY 12/13). This

accounts for 67% of referrals (68% in FY 12/13).

668 were late referrals at 30 weeks (17% increase from FY 12/13). This accounts for 21%

of referrals (21% in FY 12/13)

33 were shared care referrals at 36 weeks (120% increase from FY 12/13). This accounts

for 1% of referrals (1% in FY 12/13).

334 patients self-referred to the clinic (15% increase from FY 12/13). This accounts for 11%

of referrals (10% in FY 12/13).

Riley Park Maternity Clinic physicians attended 2,910 deliveries this past fiscal year,

averaging 242 per month (a 0.1% decrease from FY 12/13).

95% of physicians who responded to the annual survey (n=227) are satisfied with the

services provided by Riley Park Maternity clinic (93% in FY 12/13). 95% indicated that

patients are being seen in a timely manner once referred (88% in FY 12/13).

Nurse Practitioners work alongside physicians increasing access to low risk maternity care.

Nurse practitioners had 1651 appointments with patients (29% decrease from FY 12/13). This decline is due to a decrease in nurse practitioner FTE in the clinic.

Of total clinic visits, 96% were with physicians (93% in FY 12/13) and 4% were with

nurse practitioners.

A lactation consultant and maternity-focused shared mental health care psychologist are co-

located in the Riley Park Maternity Clinic. These care providers link directly with patients, low-

risk maternity physicians and family physicians.

This fiscal year, the lactation consultant provided 3,740 visits (11% increase from FY

12/13).

In September 2013, a survey was administered to patients at Riley Park Maternity Clinic to

ascertain their experience and satisfaction with their care (n=113). The results will help the

PCN understand the patient experience and highlights areas for improvement.

On a scale of 0-10, patients rated their care 8.6 on average.

96% of surveyed patients felt they were treated with courtesy and respect by health care

professionals.

95% of surveyed patients felt they were appropriately involved in decisions about their care.

86% of surveyed patients were satisfied with the wait for their appointment.

86% of surveyed patients felt they had an acceptable wait in the waiting room and 85% had

an acceptable wait in the exam room.

86% of surveyed patients felt providers listened carefully and explained things in a way

patients could understand.

In September 2013, the Medical Home task group for the pan-PCN/AHS Calgary Zone Primary

Care Action Plan Secretariat developed an initiative to improve access for breastfeeding

support. In Calgary, mothers with breastfeeding concerns often have long waits to see

providers; this initiative created new partnerships between Low Risk Maternity family

physicians and Public Health. As part of this process, mothers see family physicians in Riley


Park Maternity for non-complex concerns (e.g., frenotomies), thereby shortening wait times and

freeing the time of family physician lactation consultants for complex issues.

In Calgary Foothills PCN, Riley Park Maternity Clinic saw 35 patients for frenotomies and

other non-complex breastfeeding issues during this fiscal year.

Patients seen at Riley Park Maternity Centre were surveyed following their appointment.

Some patients may have been seen in the 2014-15 fiscal year.

85% of patients waited three days or less for their appointment, and 100% were satisfied

with this wait (n=39).

97% of patients were satisfied with the services provided in the clinic (n=39). At three weeks

follow up, 93% agreed that the experience helped them meet their breastfeeding goals, and

100% agreed the visit helped keep them and their babies healthy. (n=15)

At three weeks after their appointment, 100% of patients were still breastfeeding their

babies (27% partially supplementing with formula) (n=15).

Health care providers and staff who are involved in this process across the PCNs (n=42) were also surveyed:

87% felt adequately prepared to participate in the referral process.

64% found the referrals were simple and straightforward to make.

71% found the process helped streamline care for their clients/patients.

88% felt the process prevents adverse outcomes related to breastfeeding.

79% felt their patients received the service they needed in a timely manner.

88% felt their patients received high quality care.

67% felt their patients received exactly the care they needed.

Respondent suggestions and comments will be used to help improve the referral process

following the pilot.

Following the success of the pilot, this partnership and process will continue. Further report to

follow.

PCN-MANAGED MEDICAL HOMES (PRIMARY CARE CENTRES) Calgary Foothills PCN is exploring a variety of models of PCN-managed primary care centres,

to optimize the medical home and support the recruitment and retention of family physicians.

Each primary care centre also supports PCN-specific programs which increase access to

primary health care. The fundamental principles of the medical home1 which guide the PCN-

managed clinics are:

1) Everyone should have access to a family practice/primary care setting that they can call

their medical home.

2) Everyone should expect the medical home to be patient-centred and provide team-based,

collaborative, comprehensive and continuous care.

3) The care should be supported by an electronic medical record to facilitate quality

improvement and evaluation.

A brief description of PCN-managed clinics is listed below:

Crowfoot Primary Care Centre provides primary care services for unattached patients with

high needs in the PCN catchment area. This site is a single point of contact for other health

care providers who have identified a patient in need of a medical home. Hospitals,


outpatient clinics, home care nurses, social services, low risk maternity clinic, and other

services, fax in a referral form and clinic staff will contact the patient within 24 hours (M-F)

to attach the patient and book an appointment. The clinic has a multidisciplinary team of

healthcare professionals focused on increasing access to primary care for patients with

complex chronic disease and helping these patients manage their health conditions.

932 patients with complex conditions are currently attached to the clinic and benefiting from

the enhanced multidisciplinary team care (a 6.8% decrease from FY 12/13).

This decrease is attributed to 2 CDM physicians reviewing their patient panel in 2013 and

moving stable CDM patients out into the community.

Crowfoot Primary Care Centre builds medical home capacity by providing a location for new

medical graduates or physicians starting a family practice in Calgary. Physicians build their

patient panel in a supportive environment with a physician mentor, multidisciplinary team and

access to an electronic medical records (EMR) system. Once physicians’ panels are full,

Calgary Foothills PCN assists physicians in moving out into the community. This initiative

increases the proportion of people with ready access to primary care and supports new

physicians setting up in Calgary.

Over this fiscal year, 2219 patients were attached to family physicians building a practice

in the clinic and then moved to the community with their physician (47.5% increase from FY

12/13).

The clinic has 3,517 patients who are attached to a family physician within the clinic as of

March 2014, of which 2,233 patients are waiting to be transferred to a family physician

building a practice in the clinic or community.

There is an Extended Team that operates out of the Crowfoot Primary Care Centre which

services the whole PCN. The extended team is an extension of the medical home team, which

works closely with specialist partners to increase access of team care for patients with complex

issues. The extended team has four streams: Muscular Skeletal, Gastro-intestinal (GI), Chronic

Pain and Navigation. (For more information please see objective 3.1).

This site also provides centralized access to health promotion education; AHS Living Well

education programs and CFPCN-specific health education sessions such as Tobacco

Cessation, Ask a Dietitian and Craving ChangeTM group appointments are offered from this

site.

Foothills Primary Care Centre was developed to provide access to a multidisciplinary team for all family physicians practicing in the Foothills Professional building. This centre is piloting the efficiencies and processes required when providing centralized multidisciplinary team care from a medical home hub, versus a co-located team. The clinic has also facilitated semi-retired physicians to continue to provide care to a full panel of patients. Starting in January 2014, Foothills PCC started the AIM collaborative where 2 out of the 5 sessions are completed; see Quality Improvement under Objective 3 for more details. During the year, this site went through an EMR transition from MD Practice Solutions to Wolf.

Riley Park Primary Care Centre provides a setting for member family physicians seeking to join a medical home. The PCN opened the centre at a time when the cost of operating a family practice was prohibitive for many new and transitioning family physicians. The site also houses two PCN clinic-programs, the After Hours Clinic and Continuity Clinic. This site provides centralized access to health promotion education: AHS Living Well programs and


PCN-specific health education sessions such as Tobacco Cessation, Ask a Dietitian and Craving ChangeTM group appointments are offered from this site.

Cochrane Primary Care Centre joined physicians in three family physician offices in one medical home to optimize multidisciplinary team care by increasing efficiencies and opportunities for team work. This site provides centralized access to health promotion education, including partnering with AHS Public Health to provide a Teen Health Clinic for the young people of Cochrane and offering PCN specific health education sessions such as Tobacco Cessation and Ask a Dietitian group appointments on site. Cochrane PCC has also been selected as the initial “Community Hub” site for the primary health care service delivery model; see Primary Health Care Service Delivery Model under Objective 3 for more details.

LINKING MEMBER PHYSICIANS IN CALGARY FOOTHILLS PCN Calgary Foothills PCN uses a number of methods such as the PCN website, PCN publications,

weekly email, annual board of directors’ visits, regular liaison visits and health education events

to communicate with physician members, patients and people in the catchment area to facilitate

PCN objectives and access to primary care.

Calgary Foothills PCN Communications The Calgary Foothills PCN website is designed to increase patient and provider knowledge

of PCN services. Visits to the website increased by 15,559 visits compared to last fiscal

year for a total of 97,141 visits. This fiscal year, 22% of visitors to the site used a mobile

device (up from 15% last fiscal year). Over the fiscal year, two surveys were administered

to gain feedback from PCN members, MDT, staff and patients regarding the CFPCN

website. This information will be used to help guide redevelopment of the website in the

future.

Calgary Foothills PCN began rebranding in fall 2013. It aims to give the organization a

warmer, more approachable feel.

Physician Member Engagement Liaisons are trained facilitators who visit member physicians in their offices on a regular basis

to support access to primary care programs and integration of multidisciplinary teams in the

medical home.

Member physicians (308 of whom have a liaison) had a total of 1,640 visits with liaisons

over the fiscal year. On average, each physician met with their liaison 5.3 times (4.8 in FY

12/13).

Physicians meet with a board member on an annual basis in the spring and summer (not

aligned with fiscal year). This year, 83% of eligible members attended or sent a proxy for the

annual general meeting.

Objective 2: To provide coordinated 24 hour, 7-day-per-week management of

access to appropriate primary care services

2.1 Has the PCN implemented any new strategy in the past year to provide

after hours coverage (beyond 9:00 am to 5:00 pm Monday to Friday) for

its practice population.

Yes


2.2 If the answer to Q. 2.1 is “Yes,” what are key achievements by the PCN

in provision of coordinated 24 hour, 7-day-per-week management of

access to appropriate primary care services?

See ED referral strategy in Objective 4.1

Objective 3: To increase the emphasis on health promotion, disease and injury

prevention, care of the medically complex patient, and care of

patients with chronic disease

3.1 What are key achievements, in the past year, by the PCN in the areas

of health promotion, disease and injury prevention, care of the medically

complex patient, and care of patients with chronic disease?

CFPCN PRIMARY HEALTH CARE SERVICE DELIVERY MODEL Calgary Foothills PCN has designed a primary health care service delivery model to meet the

future demands of primary care such as the development of Family Care Clinics, the Alberta

Primary Health Care Strategy, and PCN Evolution. The service delivery model is designed to

align with provincial developments and support medical homes while leveraging the strengths

of the PCN.

The model consists of two features, a service delivery structure and team-based care

components. The service delivery structure is best described as a hub and spoke structure.

There are three levels in the hub and spoke structure: the Medical Home, the Community Hub,

and the PCN Neighbourhood.

A key feature of the service delivery structure is expanding circles of team-based care

surrounding the patient with a Core Team, Enhanced Team and Extended team. Care is

integrated between levels through defined roles, responsibilities and care pathways. Care is

also supported with information flow between levels as appropriate and always back to the

Medical Home.

The Cochrane Primary Care Centre has been identified as the initial Community Hub site, to

be implemented in fall 2014.

Figure: Primary Health Care Service Delivery Model


POPULATION HEALTH – UNDERSTANDING THE PCN

POPULATION

Health Quality Council of Alberta (HQCA) – PCN Patients In March 2014, HQCA released the report “Primary Healthcare Measurement Initiative”, their

analysis of administrative data to understand the impact of primary care networks on Alberta’s

healthcare system.

HQCA determined that:

1) Physician attachment substantially impacts healthcare service resource utilization. Overall, patients who consistently see the same family physician over a period of time utilize less acute care services (emergency department visits and hospitalizations).

2) Acute care services decreased in most patient populations after the patients’ involvement with a PCN, while visits to family physicians increased.

3) Conclusions about the performance of individual PCNs should not be drawn based only on a comparison of healthcare service utilization of their patients. There are differences between PCNs that cannot be controlled and accounted for with the currently available province-wide data.

4) Conclusions about the impact of PCNs should not be drawn based on a comparison of PCN and non-PCN patients. These two populations differ substantially on characteristics known to influence utilization of healthcare services: age, gender, burden of illness and physician attachment.

They conclude that province-wide data is currently insufficient to effectively measure the overall

performance and quality of primary healthcare in Alberta.

In 2013, Calgary Foothills PCN received a report from HQCA on the demographics, health

status and health system utilization of its panel, with comparisons to the Calgary Zone and the

province. These outcomes are based on data from the 2011-12 fiscal year.


In general, patients attached to Calgary Foothills PCN physicians are very similar to those

within the Zone and Alberta. Calgary Foothills PCN patients are slightly older and more female,

are more highly attached to a physician and business arrangement (e.g. clinic), have slightly

more hypertension, and have slightly more visits per year with specialists; they are less healthy

by clinical risk group, and they have slightly fewer visits to the ER in general and for GP-

sensitive conditions.

Table: CFPCN patient characteristics (HQCA, 2011-12 administrative data)

Indicator CFPCN Calgary

Zone Alberta

% Female 53% 52% 50%

% Aged 40-90 years 51% 47% 46%

% in Clinical Risk Group #1 “Healthy - no major conditions” 47% 48% 52%

Mean degree of attachment to a physician 69% 64% 57%

Mean degree of attachment to a business arrangement 73% 69% 62%

Percent with hypertension 14% 13% 13%

Percent with diabetes 5% 5% 5%

Percent with depressive and/or other psychoses 7% 7% 7%

Percent with acute stress and anxiety diagnoses 4% 4% 4%

Average visits per year with GP

(This number has steadily increased since 2007-08)

4.8

(4.3 in 07-

08)

4.9

(4.3 in

07-08)

4.6

(3.9 in

07-08)

Average visits per year with specialists 1.6 1.5 1.3

Average visits per year in ER 0.2 0.3 0.5

Average visits per year to ER that are for GP Sensitive

Conditions 0.03 0.05 0.12

HQCA also provided information about where Calgary Foothills PCN patients live and the local

catchment area population, based on data from the 2011/12 fiscal year:

Calgary Foothills PCN has 323,798 patients. Of these, 64% live in the 13 postal codes

which make up the catchment area. 36% of CFPCN patients live outside the catchment

area.

359,358 people live in the catchment area. Of this total population, 57% are attached to

Calgary Foothills PCN physicians. 43% of the people who live in this area do not have a

Calgary Foothills PCN physician. Calgary Foothills PCN is working further with HQCA to

better understand this population and its needs.

Unattached Patient Registry Calgary Foothills PCN uses the Unattached Patient Registry to increase the understanding of

the unattached patient population in the Calgary Foothills PCN catchment area. The PCN

plans to use this information to guide program development.

62% of registrants were female.

When asked how they heard about the service, 44% of registrants reported they learned

about it through an internet search (37% in FY 12/13), 13% had learned about it at a clinic

(17% in FY 12/13), and 14% had heard through Health Link.


33% of registrants had been without a family physician for two years or more (35% in FY

12/13); 30% had gone without for less than six months (31% in FY 12/13).

When asked why they did not have a family physician, the top three reasons given are: new

to the area (39%), physician either moved, closed practice or retired (23%) and couldn’t

find a physician (14%).

The most common issues are: anxiety (14%), depression (11%) and high blood pressure

(9%). This marks a shift from FY 12/13 when the most common problems were sleep

issues, anxiety and depression.

HEALTH PROMOTION IN THE PCN

Seniors Outreach This initiative seeks to educate seniors in the community about health topics through events

held in the Calgary Foothills PCN catchment area.

Over the fiscal year, five events have been held, presented by multidisciplinary team

members (dietitian, occupational therapist, social work) and Heart and Stroke foundation

representatives. Topics covered community resources, healthy eating, aids to daily living

and preventing heart attack and stroke.

A total of 103 participants attended the five presentations.

Participant evaluations indicate that the presentations were well-received, and made

attendees more aware of health risks and available resources.

The PCN is connecting with community group leaders (e.g. at community associations and

church groups) to explore challenges when reaching out to this population.

Ask a Dietitian Calgary Foothills PCN increased access to dietitians through the Ask a Dietitian program. Ask

a Dietitian is a group appointment for the patient with general nutrition questions. Patients may

be referred by member physicians or patients may self-refer to the appointment.

95 people attended an Ask a Dietitian group appointment this fiscal year (a 6% increase

from FY 12/13).

The most common reasons for coming to the group appointment were weight

loss/management, healthy eating, and high cholesterol.

The majority of participants (93%; 92% in FY 12/13) found their understanding of healthy

eating improved by taking the class, 91% (94% in FY 12/13) were confident they could set

goals, and 89% (92% in FY 12/13) felt they could make changes around their

eating/nutrition.

TrymGym Calgary Foothills PCN works in partnership with the University of Calgary to offer an accredited

weight management program called “TrymGym”. The program runs twice per semester for

eight weeks and consists of three parts: a behavioural change component, nutritional education

and a physical activity program with optional pre and post measurements taken during each

session. Six separate sessions were held over the fiscal year. Results from the optional

measurements indicate the program helps participants take an active role in their own health.


A total of 187 people participated in TrymGym (a 2.2% increase from FY 12/13); of which

126 were Calgary Foothills PCN patients (same in FY 12/13).

PCN participants are asked to complete a survey following their TrymGym session (n=62).

52% rated their physicians’ recommendation as a high influence on their decision to attend

(66% in FY 12/13), and 72% rated the $200 discount as a high influence (84% in FY 12/13).

60% heard about the program through Calgary Foothills PCN (physician, MDT, CFPCN

advertisement, website) (63% in FY 12/13).

The following table outlines changes in participant outcomes for weight, BMI, Sit and reach, 6-

min walk, and waist circumference, for the six sessions of TrymGym held between April 1, 2013

and March 31, 2014.

Table: Changes in participant outcomes

% Increase/Decrease

Weight (kg) BMI Sit and

Reach (cm)

6 min

walk (m)

Waist

Circumference (cm)

Total (n=187) -2.3% -2.1% 16.7% 8.2% -2.9%

Tobacco Cessation Calgary Foothills PCN offers a comprehensive program, four classes per session, which

includes education, group support and access to medications for people interested in tobacco

cessation. Calgary Foothills PCN then follows up with participants at one week, two weeks,

one month, three months, six months and one year to offer support and track their cessation

progress.

Evaluation of the program consists of the self-reported data from patient referral to the last

follow-up period (attendance to at least one class triggers the follow-up calls). Patients reached

at each follow-up period were not mutually exclusive; some patients were only reached once,

while others were reached in more than one follow-up period. Therefore, results are susceptible

to bias and must be interpreted with caution.

Referrals have declined by 11% since the previous fiscal year, as has attendance in the

first class by 25%. The PCN is working on a communication strategy and exploring the

characteristics of this tobacco-using population.

Quit rates are comparable to the last fiscal year; 50% self-reported quitting at the 3-month

follow-up (37% in FY 12/13) and 28% reported reduced use (34% in FY 12/13).

Table: Tobacco Cessation program patient referrals, 1st class attendance and follow-

ups contacted

13/14 12/13 11/12

Referrals 326 390 753

1st class registered 110 (31%) 239 (61%) 346 (46%)

Decline registration 240 (69%) 151 (39%) 407 (54%)

1st class attended 97 (88%) 121 (51%) 270 (78%)

1 month follow up calls – Reached 32 (34%) 62 (36%) 100 (40%)

3 month follow up calls – Reached 36 (37%) 83 (44%) 94 (37%)

6 month follow up calls – Reached 36 (34%)* 80 (39%)* 89 (34%)*

12 month follow up calls – Reached 42 (31%)* 99 (38%)* 126 (39%)*


Notes:

1) *Denotes program activity during the current fiscal year, but follow-up calls may be from referrals in previous fiscal year.

2) Percentage is of participants reached for a follow-up call.

Table: Tobacco Cessation participant quit rates over time

1 Month Follow up 3 Month Follow up 6 Month Follow

up

12 Month

Follow up

13/14

(n=32)

12/13

(n=62)

13/14

(n=36)

12/13

(n=83)

13/14

(n=36)

12/13

(n=80)

13/14

(n=42)

12/13

(n=99)

Quit 31% 35% 50% 37% 39% 31% 40% 31%

Reduced use 44% 47% 28% 34% 33% 28% 36% 16%

No change 25% 18% 22% 29% 28% 41% 24% 53%

Notes: Percentage is of participants reached for a follow-up call.

Walking Program Calgary Foothills PCN operates a peer led Walking program that seeks to promote healthy

lifestyles and active living within a safe and social environment. Approximately 30 participants

walk regularly either at Northhill Mall, or at Confederation Park.

There are 226 registered participants, 12 of whom were newly registered in 2013/14 (5%


Walk with a Doc Calgary Foothills PCN has licensed the “Walk with a Doc” program, which was piloted in spring

of 2012 and formally launched to occur once per month beginning in March, 2013. Up to 20

registered walkers are invited to attend “Walk with a Doc” where a PCN physician provides a

10-15 minute talk on a health related topic and then walks with the participants.

During the fiscal year, 10 sessions were held, attended by a total of 119 walkers.

Enhanced Participation in Cancer Screening (EPICS) This fiscal year Calgary Foothills PCN has been an active partner in implementing EPICS II.

Alberta has low screening rates for cancer (breast cancer 55%, cervical cancer 65% and

colorectal cancer ~60%). EPICS II set out to improve cancer screening rates through two

approaches; panel linkages and process redesign. Whilst longer term data is required to

accurately assess the impact of this program, there is some initial evidence that cancer

screening uptake has increased within the study population.


The chart below shows percentage of patient records with documented cancer screening status

before and after process redesign with repeated measures at 9 and 12 months sampling 50

patient records.

Craving ChangeTM

Craving ChangeTM started in October 2013. It is a free, four-class workshop for adults who

struggle with their choices around eating. The workshop focuses on helping patients determine

why they eat the way they do and learn new ways of thinking and behaving to develop a

healthier relationship with food. Craving ChangeTM is open to patients who are at least 18 years

old and who are attached to a member physician. This program is offered at two different

locations, Crowfoot and Riley Park Primary Care Centres.

6 series of classes have been held

67 people registered; 88% of registrants attended the first class and, of those, 73%

attended the final class.

Feedback from participants (n=45) indicates that the classes are very well-received.

Respondents found the information is useful for daily life (98% agree), and the class taught

them something new about their choices around eating (100% agree).

Participants also complete the Eating Self-Efficacy Scale questionnaire at their first session,

at the end of the class, and again in 6 months’ time. Self-efficacy describes confidence in

coping ability in a specific situation. Patients self-rate their self-efficacy on a scale of 1-7 for a

variety of situations (high scores indicate poor eating self-efficacy).

Data is currently available for the baseline and 4-week measures. 40 participants completed

the survey at both baseline and 4 weeks.

75% had an improvement in their self-efficacy score.

The table below shows that following the four-week class, average self-efficacy scores

decreased. The biggest improvement is for self-efficacy related to negative affect (problematic

eating when experiencing negative emotions).

Table: Change in eating self-efficacy for Craving Change patients

Baseline

(n=59)

4 Weeks

(n=45)

Negative Affect 4.85 3.83

Socially Acceptable Circumstances 4.80 4.20

Overall score 4.82 4.00


QUALITY IMPROVEMENT

During this fiscal year, Calgary Foothills PCN has paid special attention to

supporting quality improvement in a sustainable and measureable way, and our

physician members are embracing quality enhancement initiatives in their

practices.

In the annual physician survey, physicians indicated their involvement in quality

improvement:

80% of physicians have participated in quality improvement work in their practice (42% in

FY 12/13).

Of the above, 93% found this work useful or moderately useful (73% in FY 12/13).

66% of physicians report having systems in their office for measuring quality (25% in FY

12/13).

Panel management is one area where physicians are improving their practices. This approach

to primary care uses information on a group of patients to improve the care and clinical

outcomes of those patients within the primary care practice. This approach changes the focus

from reacting to the ad hoc needs of individual patients to proactive management of a practice’s

patient panel.

In the annual physician survey, respondents indicated their use of panel

management strategies:

74% of physicians have identified a population of patients on their panel (e.g. patients with

diabetes).

Of the above, 76% also have integrated MDT protocols to manage those patients.

76% of physicians have systems in place for patient recall.

70% of physicians are confident that they could pull an accurate patient list.

Quality improvement activity by physician members can be both independent and PCN-

facilitated (“Practice Enrichment”).

Independent quality improvement

Many physicians engage in non-facilitated quality improvement activities, which Calgary

Foothills PCN does not systematically track nor report on.

The PCN supports physicians to engage in quality improvement by facilitating the signing of

HQCA data sharing agreements with individual physician members. HQCA provides physician

panel reports that include data on patient demographics, comorbidities and health system use,

with comparisons to PCN and Calgary Zone averages. Physicians may choose to review their

HQCA report with their liaison, which can help them to understand their panel and identify

quality improvement opportunities.

165 physicians (62% of full members) received an HQCA report this fiscal year (53% in FY

12/13).

25 physicians reviewed the report with their liaison.

In the annual physician survey, the majority of physicians who received an HQCA report

learned something about their panel (82%; 76% in FY 12/13). 51% applied this new panel


information to their practice (32% in FY 12/13), and of those, 85% felt they were successful

in making changes (75% in FY 12/13).

Practice Enrichment

The practice enrichment initiative supports medical homes as they develop, test and adopt

quality improvement strategies to improve patient care and/or efficiencies. In 2012, Calgary

Foothills PCN partnered with Toward Optimized Practice (TOP), and together created

reference materials regarding quality improvement and guidelines for panel-based care. TOP

experts provided training in quality improvement practice facilitation to CFPCN liaisons.

Following a successful pilot with four physicians, the initiative was expanded to the entire

physician membership in the spring of 2013. The projects reported here are facilitated by

liaisons, including projects generated by member physicians and provincial quality

improvement initiatives (AIM and ASaP).

146 (55% of full member physicians) have been involved with projects over the year.

87 projects have been developed, of which 31 (36%) are complete.

The majority of projects are led by a single physician, although 22% of projects involve a

group of doctors or are clinic-wide.

The projects completed this fiscal year were on average four months long.

Projects touch upon several themes (note, many projects cover more than one theme):

o Panel management (92% of projects)

Treatment (47%)

Understanding patient panel (24%)

Screening & Prevention (22%)

o Clinic processes (45% of projects)

Efficiency (28%)

Access (15%)

Continuity (2%)

Included among these projects are two provincial quality improvement initiatives which are

facilitated by liaisons:

Alberta Screening and Prevention (ASaP) supports physicians and NPs in offering

screening to patients. In the fall of 2013, Calgary Foothills PCN liaisons received training

from TOP to facilitate the processes of panel identification, chart review, and improving

screening in clinics. These projects are captured under the practice enrichment themes of

Screening & Prevention and Understanding patient panel. Over the fiscal year, 16

physicians have enrolled with ASaP.

Alberta AIM (Access Improvement Measurement) helps physicians, specialists and

healthcare teams see their patients sooner and reduce wait times while patients are at their

appointment. It uses a collaborative learning model where teams work together with others

to test new models of service delivery and share best practices. AIM projects are captured

under the practice enrichment themes of Access and Efficiency. One clinic (18 physicians)

completed the AIM initiative during the fiscal year, and one clinic (up to 15 physicians)

started the AIM initiative.

In order to illustrate the variety of projects that physicians undertake, six completed projects

are highlighted below.


1) Properly prepare patients for visits

In order to reduce errors in patient preparation (e.g. shoes not removed for a foot

examination or temperature not taken), this physician began daily huddles with staff to

discuss the patients booked that day. The staff and physician found it improved office

workflow and team relationships, and patients are seen faster. Before beginning

huddles, there were 10 errors in a week of measurement; 2 months later, only 1 error

was recorded in a week.

“Everything runs so much smoother and faster. It's easier to communicate with the

doctors, and satisfy the patients.” – Clinic staff

2) Increase screening for cancer

This physician called all female patients who had not had a pap test in >3 years to book

them for an annual physical. At the appointment, she also checked whether the patient was

due for mammogram and colon cancer screening. By reviewing billing codes, she identified

approximately 500 patients who qualified for pap tests, of whom 29 were overdue and not

already booked. Fifteen were booked for an appointment; two had low-grade abnormal

results and several other patients had not been seen in a number of years. Fourteen

patients could not be reached, were not patients of the physician, or refused an

appointment. This process also helped the physician identify patients who were no longer

part of her panel, and patients missing from her annual physical reminder call list.

3) Eliminate fax and phone prescription refills

This clinic created a new policy so that patients would be seen for all refills. Pharmacies

and patients were informed of the new policy, and in order to ensure patient access for

refills, protected appointments were created in the schedule. Staff and physicians feel

that time is spent more efficiently now and they are providing better patient care.

Pharmacy refill requests declined from 60 in the month prior, to three requests six

months later.

Chart: Pharmacy Refill Requests

4) Understand panel makeup and build panel to appropriate size

This new physician is currently building her practice. With her liaison, she reviewed her

current patient panel to understand their demographics and health needs. She also

calculated her appropriate panel size based on the number of appointment slots per day,

days worked in a year, and average number of times patients visit per year. The target

Median

0

10

20

30

40

50

60

Sept Oct Nov Dec Jan Feb Mar

# R

equ

ests POLICY CHANGE


panel size was determined to be 1400, and she will build toward this number over the

coming year with the characteristics and needs of her panel in mind.

5) Convert Atrial Fibrillation (AF) patients to new medication

This physician switched patients with AF from Warfarin to new oral anticoagulants, in

order to take advantage of new Blue Cross coverage guidelines. These new

medications do not require patients to do regular INR testing. Patients who did not need

to be on Warfarin and were out-of-range for their INR were offered appointments with a

PCN pharmacist and prescribed the new medication. By reviewing the physician’s AF

patient registry and cross-referencing with the EMR, 24 patients were identified; after

two months, 16 patients were switched to Rivaroxaban or Dabigatran and eight patients

were not. Staff, MDT and the physician found this project improved patient quality of life

and reduced staff workload.

“It was a learning experience that made me think about other ways to assist our

patients.” – Clinic nurse

6) Improve patient access and clinic efficiency

This clinic (eighteen physicians) completed the AIM initiative, which is an approximately

year-long process that involves using the PDSA approach to set goals and measure

changes regarding access, efficiency and clinical care. The initiative also includes

learning sessions and teleconferences with AIM faculty and other participating clinics.

After 10 months, the clinic saw 75% and 78% improvements in wait for the third next

available short and long appointments, respectively.

Table: Improvement in access by third next available (TNA) appointment:

November 2012 September 2013 Improvement in Access

TNA Short

Appointment 8 days 2 days 75% decrease in wait time

TNA Long

Appointment 32 days 7 days 78% decrease in wait time

After completing a project, physicians, MDT and clinic staff are asked to provide feedback on

their experience; 31 projects are complete.

94% of surveyed physicians, staff and MDT found that the quality improvement project was

a positive experience overall.

78% of physician respondents had no previous experience leading quality improvement in

a primary care setting.

88% of physician respondents anticipate doing another quality improvement project in the

next year.

Participant comments are displayed in the table below.


Table: Practice Enrichment participant feedback

Physicians (n=19, from 13 projects)

MDT & Clinic Staff

(n=16, from 11 projects)

Benefits

Improved patient care/treatment

Clinic efficiency: staff workload, workflow,

organization

Improved patient health outcomes and/or

quality of life

Improved team (staff, physicians, MDT)

relationships

Patient coordination

Increased patient motivation for self-

management

Improved knowledge of CFPCN resources

Clinic efficiency: staff

workload, workflow,

organization

Improved patient health

outcomes and/or quality of

life

Patient satisfaction

Improved knowledge of

patient care/treatment

Improved clinic

communication, team work

Challenges

Difficult to coordinate team members

Difficult to recruit and motivate patients to

participate

Difficult to assess change with small

amounts of data

Projects can be time-consuming

Difficult to recruit and

motivate patients to

participate

Difficult to advance project

with high clinic staff

turnover

Difficult to pull data from

EMR

Health education Calgary Foothills PCN coordinates health education events to provide physicians, staff and

multidisciplinary team the opportunity to come together and learn about health issues and are

provided with updates on Calgary Foothills PCN programs, and activities.

Over the fiscal year, four CFPCN CME events have been held, covering:

o Community resources available for patients and managing difficult situations (129 attendees)

o Health Quality Council of Alberta physician reports (18 attendees) o PCN program referral processes (149 attendees) o Depression (96 attendees). A small group collaborative was also offered to

physicians who attended this CME to further discuss depression management (5 physician attendees).

The majority of participants who submitted evaluations for the CMEs (n=148) found the

presenters knowledgeable (96%), and presentations relevant (95%) and well-organized

(97%).

As of October 2013, physicians, MDT and staff now have the opportunity to view video

recordings of selected CME presentations on the CFPCN website.

Other education opportunities open to physicians, MDT and staff included:

o Hypertension in pregnancy lecture for Riley Park Maternity Clinic (41 attendees) o Behaviour change presentation by Dr. Michael Vallis (50 attendees)

INFORMATION MANAGEMENT AND TECHNOLOGY


Electronic Health Records Calgary Foothills PCN encourages the uptake of electronic medical records (EMR) and Netcare

applications.

A review of member physician technology uptake in August 2013 showed that 84% of

member clinics use Netcare (85% in FY 12/13). In the annual physician survey, 75% report

that they use Netcare as a regular part of their practice.

According to the review of technology, 77% of members are using EMR to chart and an

additional 6% are using a combination of EMR and paper (69% report using an EMR in FY

12/13).

69% of respondents to the Annual Physician Survey who use EMR consider it important to

use/develop standardized data input (coding) and/or templates (63% in FY 12/13).

Data Sharing Agreement In addition, a Data Sharing Agreement (DSA) with physician members and the Physician

Corporation has been developed and implemented to support future data collection and

reporting.

The DSA supports member physicians to share data in a secure manner when the

Physician Corporation and Calgary Foothills PCN participate in evaluation and reporting

with larger health care systems and design programs to best serve members and their

patients. 75.6% of member physicians have signed the DSA as of March 2014 (81% in FY

12/13, a 5.4% decrease). This decrease can be attributed to new physicians joining the

PCN (approx. 30), who have not yet signed. Also, a few physicians who had signed the

DSA but are no longer with the PCN.

Up-To-Date The PCN facilitates the use of an electronic medical resource, Up-To-Date, for physicians, staff

and Calgary Foothills PCN allied health professionals with an organizational license accessed

through the PCN web site.

Over the fiscal year, there were 48, 849 Up-To-Date topic views (a 26% decrease from FY

12/13). The previous fiscal year increase was due to a log-in error which allowed non-PCN

users to access Up-To-Date. This has now been resolved.

HUTV This year, Calgary Foothills PCN introduced Health Unlimited Television (HUTV) monitors in

patient waiting areas at PCN Primary Care Centres and Riley Park Maternity Clinic. The

televisions show health information, news, AHS services and PCN programs.

A survey of patients at two clinics (n=81) shows that about half of patients watch the

television during their wait. The vast majority either find the television interesting and that it

helps to pass the time, or are neutral.

A survey of front-end staff working at the five clinics (n=11) shows that, in general, the

televisions are not distracting or irritating for the staff.

SUPPORTING THE CARE OF THE COMPLEX PATIENT

The Extended Team


The extended team is an interdisciplinary team of health professionals consisting of specialists,

family physicians with a specialty interest, nurses, pharmacists, dietitian, occupational

therapists, community support worker, social worker, behavioral health consultant, kinesiologist

and physiotherapy. This team is an extension of the medical home and increases the ability of

the medical home to provide comprehensive care. The team acts a link between the medical

home and specialty care to provide seamless and integrated care to patients with complex

issues.

The main reasons for referral are assistance with diagnosis or when the patient is experiencing

difficulties managing their conditions. The additional team capacity, working with the medical

home, allows for intensive attention to self-management skills and more time to address issues

such as mental health aspects which may be contributing to the complexity. There are four

streams in the extended team; Chronic Pain, Gastrointestinal (GI), Medical Musculoskeletal

(MSK), and Navigation.

Chronic Pain Stream The Calgary Foothills PCN Chronic Pain stream was developed in partnership with the Calgary

Chronic Pain Centre. The Chronic Pain stream has group and individual appointments tailored

to the patient’s self-management skills.

The PCN Chronic Pain stream received 346 referrals this fiscal year (9% increase from 316

referrals in FY 12/13).

o 70% of patients were female (no change from last fiscal year)

o Age ranges between 18 – 39 (22 % vs 20% last fiscal year), 40 – 59 (51% vs 45% last

fiscal year) and 60 – 100 (27 % vs 35% last fiscal year)

o The top five diagnoses were: low back pain (23%), fibromyalgia (15%), migraine & headache (11%), depression (11%), and shoulder pain (7%). In the previous fiscal year, top diagnoses were back pain (23%), neck and shoulder pain (22%), non-surgical osteoarthritis (19%), fibromyalgia syndrome (15%) and neuropathic pain (10%).

Patients fill out a survey evaluating their group appointment (Explain Pain, Pacing, Life

Changes and Core & Cardio) (n=216)

o 93% felt they received support by attending the class

o 92% felt they could ask the questions that are important to them

o 95% felt the class time was just right to allow for the information presented

o 76% felt the group discussion was helpful

o 88% felt the resources and handouts were helpful

Patients are asked to complete a Brief Pain Index (BPI) and Patient Health Questionnaire 9

(PHQ9) at their initial visit (baseline), at midway somewhere between three to six months and

when transitioning back at approximately nine months to their family physician. The BPI is a

validated tool designed to measure pain intensity and the extent to which pain interferes in

activities of daily living. The PHQ9 is a nine-question validated tool to assist in the diagnosis of

depression. The following table and chart outline the results of the measures:


Table: Clinical measures for Chronic Pain patients

Fiscal year Baseline Midway Transition

Pain Severity 2013-14 6.70 (n=334) 5.55 (n=140) 4.86 (n=82)

2012-13 6.18 (n=257) 5.07(n=86) 4.35 (n=45)

Pain

Interference

2013-14 6.67 (n=337) 5.70 (n=138) 4.59 (n=89)

2012-13 6.80 (n=265) 5.51 (n=90) 4.60 (n=49)

PHQ9 2013-14 12.51 (n=264) 11.32 (n=148) 8.18 (n=94)

2012-13 12.73 (n=231) 11.74 (n=82) 7.9 (n=48)

Charts: Severity of depression among Chronic Pain patients at baseline and transition

The SF-12v2 tool is a 12-item questionnaire tool that is used to measure patient quality of life.

Patients treated in the Chronic Pain stream complete a SF-12v2 on their initial visit for

treatment, which provides a baseline for the patient, at the midway stage of their treatment and

finally at the end of their treatment.

Over the course of treatment, it is noticeable that both the Mental Component Score (MCS)

and Physical Component Score (PCS) increase in value, indicating that the overall health and

quality of life of the patient population does improve through the treatment. Unfortunately, it has

not been possible to ascertain the minimum difference in PCS and MCS values that represents

a statistically significance difference to the health of the patient population over time.

Table: SF12 Scores for Chronic Pain patients

Values Baseline

(n=387)

Midway

(n=104)

Transitio

n (n=71)

Average of Mental Component

Score 28.81 29.33 31.78

Average of Physical Component

Score 41.02 42.85 43.35

18%

26%57%

Baseline (n=264)

No/Minimalsymptoms

Minordepression

Moderate/Majordepression

46%

27%

27%

Transition (n=94)

No/Minimalsymptoms

Minordepression

Moderate/Major depression


In 2014, the Calgary Foothills PCN’s annual physician survey indicated:

75% of physicians have referred to the chronic pain stream (82% in 2013)

Of those that have referred, 71% feel the program has helped their patients manage their

health concerns (73% in 2013)

GI Stream Since May 2012, the PCN, in partnership with the Division of Gastroenterology, is working to

improve access for patients with dyspepsia, gastro esophageal reflux disorder (GERD), and

Irritable Bowel Syndrome (IBS). Calgary Foothills PCN patients who would normally wait almost

two years for an appointment are directed to the PCN for a group appointment. Member

physicians are also able to refer directly to the extended team by referring to GI through the

AHS central triage referral and indicating Nurse Navigator on the referral form. Many patients

only need one group appointment, but individual follow up appointments are booked if required.

The GI stream received 193 referrals this fiscal year

o 59% of patients were female

o Age ranges between 18 – 39 (29%), 40 – 59 (42%) and 60 – 79 (31%)

o 49% of patients were referred for GERD, 47% for dyspepsia and 4% for IBS.

In the Calgary Foothills PCN’s annual physician survey, results showed that

40% of physicians have referred to the program (an increase from 32% last year)


health concerns (88% in FY 12/13)

Patients complete an evaluation of their experience at the GI clinic (n=229)

100% were satisfied with the outcome of their appointment

100% felt they received the support they required to address their health concerns

Patient comments indicate that they appreciate learning strategies to manage their

symptoms, the opportunity to access specialists, and discussion with their peers.

SF-12s were collected from two different patient groups, those attending the GI clinic and those

who are receiving no treatment creating our control group. GI patients filled out a questionnaire

on their initial visit. Their follow-up questionnaire was conducted via phone, since these patients

are discharged fairly quickly after their initial treatment.

Note that the treatment group at baseline has higher quality of life than the control group, which

may be due to random error. At transition, the treatment group shows improvement in both

MCS and PCS, whilst the control group remains fairly constant in their physical component

score and actually decreases in mental component score.


Table: SF12 Scores for GI patients

Control Treatment

Baseline

(n=103)

Transition

(n=38)

Baseline

(n=241)

Transition

(n=158)

Average Mental Component Score 42.02 40.49 48.21 51.77

Average Physical Component

Score 45.29 46.79 46.10 49.11

Medical MSK Stream Calgary Foothills PCN partnered with the Division of Rheumatology to address the long wait

lists for adult patients with non-inflammatory and non-surgical concerns in multiple joints.

Initially, referrals from Calgary Foothills PCN member physicians were received in Central

Access and Triage (CAT). Since the Division of Rheumatology no longer takes referrals for

non-inflammatory issues member physicians directly refer to the extended team. Patients are

booked into individual appointments.

The PCN Medical MSK stream received 184 referrals (40% decrease from 308 referrals FY

12/13). This is significantly less than the previous fiscal year as the stream was not

accepting new referrals for approximately 4 months during the fiscal year while they

addressed operational challenges during the transition to a direct referral process.

o 80% of patients were female (79% FY 12/13)

o Age ranges between 18 – 39 (21 % vs 19% FY12/13), 40 – 59 (43% vs 44% FY12/13) and 60 – 100 (36% vs 37% FY12/13)

o The top five reasons for referral were osteoarthritis (18%), arthralgia & poly-arthralgia (18 %), back pain (10%), fibromyalgia (7%) and shoulder pain (3%). In the FY 12/13 the top four referral reasons were osteoarthritis, fibromyalgia syndrome, poly-arthralgia, and degenerative disc disease.

In 2014 the Calgary Foothills PCN’s annual physician survey indicated:

59% of physicians have referred to the program (58% referred in FY 12/13)


health concerns (up from 47% in FY 12/13)

Navigation Stream The Navigation stream provides a comprehensive assessment and resources for patients with

cognitive impairment, risk of falls, coping with a life transition or needing a home safety

assessment. This team acts like the eyes and ears of the medical home when they do a home

assessment and gather information not possible to be obtained in a typical physician office visit.

Patients may also be seen at the clinic located at Crowfoot Primary Care Centre or in the

patient’s medical home. A geriatric psychiatrist and geriatrician provide specialist support to

this stream.

The Navigation team received 376 referrals this fiscal year (3% decrease from 386 referrals

in FY 12/13).

o 76% of patients were female (69% in FY 12/13)


o Age ranges between 18 – 49 (6% vs 7% in FY 12/13), 50 – 69 (18% vs 17% in FY 12/13) and 70 – 100 (75% vs 76% in FY 12/13).

o The top five reasons for referral were functional screen (28%), cognitive assessment (23%), home assessment/safety screen (9%), fall assessment (8%) and dementia (6%). The top four reasons for referrals in FY 12/13 were function/safety/ home assessment (53%), falls screen (31%), cognitive screen (8%) and community resources (13%).

In 2014 the Calgary Foothills PCN’s annual physician survey indicated:

o 71% of physicians have referred to the Navigation stream (78% referred in FY 12/13)

o Of those that have referred, 83% feel the program has helped their patients manage their health concerns (up from 71% in FY 12/13).

In 2014, Calgary Foothills PCN received an HQCA report on the demographics, health

status and health system utilization of patients seen by the Navigation team in 2012-13,

with comparisons to CFPCN and Calgary Zone. The outcomes are based on data from

2011-12, and therefore reflect patients’ health during the year before referral to the team.

Navigation team patients are generally more complex and less healthy than the average CFPCN patient population (see table below).

Table: Navigation patient characteristics (HQCA, 2011-12 administrative data)

Indicator Navigatio

n CFPCN

% Female 67% 53%

% Aged 70-90 years 70% 8.5%

% in Clinical Risk Group #1 “Healthy - no major

conditions” 9% 47%

% in Clinical Risk Group #6 “Significant chronic

disease in multiple organ systems” 38% 6%

Mean degree of attachment to a physician 69% 69%

Mean degree of attachment to a business

arrangement 73% 73%

Percent with hypertension 52% 14%

Percent with diabetes 22% 5%

Percent with depressive and/or other psychoses 15% 7%

Percent with Alzheimer’s disease and other

dementias 15% 1%

Average visits per year with GP 10.9 4.8

Average visits per year with specialists 4.4 1.6

Average visits per year in ER 0.7 0.2

Average visits per year to ER that are for GP

Sensitive Conditions 0.04 0.03

Geriatric Psychiatric Consultation As part of our Navigation stream, our geriatric psychiatrist offers a one-time psychiatry

assessment (now offering follow up in the 2014-15 fiscal year). This service started in June of

2013.


This service received 76 referrals.

o 74% of patients were female.

o Age ranges between 50 - 59 (1%), 60 – 69 (13%), 70 – 79 (37%) and 80 – 100 (49%).

o The top five reasons for referral were assessment (48%), cognitive assessment (17%), mood/anxiety/memory (15%), dementia (6%), and depression (4%).

MENTAL HEALTH

Prioritizing mental health services

In the annual physician survey, 50% of physicians agreed that CFPCN has improved their

ability to coordinate mental health services.

Previous physician surveys have established that Behavioural Health Consultants are

highly valued by physicians. In this year’s survey, 65% of physicians indicated that other

CFPCN services (beyond BHCs) have improved their ability to care for patients with mental

health conditions.

In October 2013, the Mental Health task group for the pan-PCN/AHS Calgary Zone Primary

Care Action Plan Secretariat held a “Mental Health Summit”. This collaborative huddle

between Primary Care and AHS Mental health was a structured opportunity to consider the

current state of mental health demand and services and in that context, to look for synergies

and establish new directions.

o Approximately 80 representatives from AHS, community partner groups and Calgary area PCNs attended, including CFPCN leadership and three member physicians.

o The task group will focus on establishing a psychiatric liaison service, increasing medical home capacity to manage mental health issues, and emphasis on prevention.

Adult Psychiatry Assessment Access to psychiatry was identified as an issue in a mental health needs assessment

conducted with member physicians November 2010. As a result, Calgary Foothills PCN

partnered with a psychiatrist to assist family physicians in assessing and diagnosing patients

with mental health concerns. The psychiatrist does not provide case management for any of

the patients.

There were 394 referrals to the psychiatrist from 122 PCN member physicians, and 214

consultations were completed. The number of referrals has increased by 58% and

consultations by 89% since FY 12/13.

In this fiscal year, of the 214 consultations completed, the most common reasons for referral

were: diagnostic assessment (35%); depression/mood (29%); anxiety (14%) and the most

common resulting diagnoses were personality disorders (27%); adjustment disorder (21%);

generalized anxiety disorder (21%).

Of the 180 referrals not completed, the most common reasons were that the booking clerk

was unable to reach the patient (63%) and patient declined (28%).


Objective 4: To improve coordination and integration with other health care

services, including secondary, tertiary, and long-term care through

specialty care linkages to primary care

4.1 Comment on any key achievements by the PCN, in the past year, to

improve coordination and integration with other health care services,

including secondary, tertiary, and long-term care through specialty care

linkages to primary care.

Emergency Department Referral Strategy During the flood of the Bow and Elbow rivers in late June 2013, Calgary Foothills PCN

partnered with emergency departments and Health Link Alberta to support the needs of

patients who were often displaced and facing stressors to their health. The After Hours Clinic

expanded its hours and accepted a greater range of patient referrals from Health Link Alberta,

as well as patients diverted from emergency departments.

27 patients were referred to the After Hours Clinic from an emergency department during

the flood period.

During this period, After Hours Clinic patients were surveyed (n=36). 97% felt their needs

were met, noting the fast access, friendly staff and high quality of care at the clinic.

The clinic saw a 56% increase in referrals during this period, compared to July 2012.

One of the recommendations out of the flood surge was to have an emergency department

(ED) surge protocol in place for any future disaster management planning or periods in which

there was extraordinary increases in ED demand. An improvement team was struck comprised

of AHS Primary Care Managers and leadership from Foothills Medical Centre (FMC) and

Calgary Foothills PCN to develop a pilot project between FMC ED and the CFPCN After Hours

Clinic. This initiative aimed to ensure that patients receive care from the right provider at the

right time, by referring appropriate patients from the ED to the After Hours Clinic. In order to

test the success of this process, the pilot was held during a non-crisis period over December

2013 – March 2014. As the process was found to be successful, it will be continued indefinitely

as a referral partnership beyond the pilot.

From December 23rd – March 31st, 109 referrals were made from FMC ED to the After

Hours Clinic. Of these, 87 (80%) were seen.

Further evaluation will include: a patient survey to determine patient satisfaction with this

process; a provider survey regarding referral processes; and analysis of safety.

HOSPITAL DISCHARGE – TRANSITIONING BACK TO THE

MEDICAL HOME

Enhanced Hospital Discharge The Enhanced Hospital Discharge targets the Calgary Foothills PCN patient population

discharged from medical and specialty units at Foothills Medical Centre (FMC) who are being

discharged back to the family physician in the community. The enhanced discharge coordinator

identifies the patients using the hospital information system and within 24-48 hours of

discharge, a subset of the clinical chart will be extracted and faxed to the family physician. In

addition, the coordinator identifies patients who do not have a family physician and fall within


the Calgary Foothills PCN catchment area, and offers them a referral to Crowfoot Primary Care

Centre for attachment to a family physician.

At the project’s inception in September 2011, the objective was to facilitate transition to the

community following a hospitalization. The assumption was that when family physicians receive

timely, in-depth reports, the post-hospitalization transition will be smooth as evidenced by a

decrease in hospital readmissions and emergency room visits. The program has been well

received by Calgary Foothills PCN physicians and the project has grown from Cardiology (units

81, 82) and to include Neurology (units 100, 101, 111, 112) as well as units 36, 37, 46 and 47.

Over the fiscal year, 2,316 packages were sent (58% of discharges). Since May 2013,

program output has fallen by half due to unanticipated and unavoidable staffing reductions.

Additional staff were hired in March 2014, and consistent output is expected to return to

normal for the following fiscal year.

13 patients were referred to the Crowfoot Primary Care Centre to be attached, all during

the first two quarters; attachment will recommence as the program capacity increases in

April 2014.

In the annual physician survey, 69% of physicians who use the program reported that they

found the information useful for managing patient concerns at the first office appointment

post-discharge (80% in FY 12/13).

A request has been made to HQCA for information about health system utilization by

patients whose discharge report was sent to their family physician as part of this program.

Seamless Care Calgary Foothills PCN has implemented a Seamless Care pilot project with the in-hospital

pharmacists at three large hospitals in the Calgary area to improve patient outcomes and

reduce hospital readmissions within Calgary Foothills PCN’s catchment area. A referral system

has been created between the AHS – Calgary Zone inpatient pharmacists and the PCN

pharmacists to identify any pharmacist concerns at discharge. The PCN pharmacists then

provide the information to the medical home.

During the fiscal year there were 10 pharmacist to pharmacist referrals (a 56% decrease

from 23 referrals in FY 12/13). Half of the patients (50%) were referred from the Rocky View

General Hospital (a 20% decrease from FY 12/13), and 70% were for non-urgent concerns

(an 11% increase from FY 12/13).

30% of patients were 76 years and over (52% in FY 12/13, a 22% decrease). In addition,

70% of patients were female (52% last fiscal year, an 18% increase).

The most common listed reasons for referral were: medication reconciliation being the most

frequent reason for referral (50%), followed by lab work required (40%), cognitive

impairment (40%) and other potential issues (40%).

PCN leadership is in discussion with in-hospital pharmacy leadership to determine viability of

program.

LINKAGES WITH SPECIALTY

Lunch and Learn Education Opportunities with Specialists


Specialists who work in partnership with the Extended Team streams (Chronic Pain, MSK and

Navigation team) as well as an endocrinologist are available for lunch-and-learn sessions with

family physicians in their offices. These informal presentations are tailored to family physician

interest, and often include patient case studies and general discussion of diagnosis and

management.

26 sessions were held over the fiscal year:

o 13 Chronic Pain o 7 MSK o 5 Geriatric Psychiatrist o 1 Endocrinology (diabetes)

Lunch and Learn participants are generally very satisfied with the presentations; 100% of

participants who filled out evaluations (n=50) agreed that the sessions were of excellent

quality.

Pediatric Kids in Care (PKIC) PKIC is a joint program with pediatricians, Calgary and Area Child and Youth Services and the

Calgary Foothills PCN. The goal of the program is to ensure access to primary care services

to children who come into the care of Child Protective Services. The children are attached to

a family physician in Crowfoot Primary Care Centre.

This fiscal year, 24 children (and their biological families and/or foster families) were

attached to a physician.

Calgary Foothills PCN led the Calgary Zone Primary Care Action Plan committee to expand

the partnership to the Calgary Zone.

Telephone Consults Calgary Foothills PCN has developed several telephone consultation partnerships with

specialists. This service is growing, especially among the family physicians starting a practice.

In the annual physician survey, respondents indicated their preferences for tele-consult

process and satisfaction with the service:

o 57% of physicians are satisfied with the current system of consulting via telephone. 18% of physicians would prefer to use email, and 17% would like to use both email and phone for consults.

o 46% of physicians are satisfied with the current timing of interactions. 15% would prefer to have set times for all tele-consults, and 33% would like to have more times available.

o 58% of physicians indicated they find the tele-consults extremely or very useful, and another 20% find them moderately useful.


Table: Summary of telephone consults

Consult Number of Reported (by

specialist) Consults Completed Action Following Consult

Tele-psychiatry 32 100% were managed in medical home

following consult

Tele-cardiology 17 (23 FY 12/13) 100 were managed in medical home

following consult (87% in FY 12/13)

Tele-orthopedics 125 (128 FY 12/13) 98% were managed in medical home


Tele-rheumatology 50 (32 FY 12/13) 100% were managed in medical home


Tele-chronic pain 12 (13 in FY 12/13) 100% were managed in medical home


Tele-GI

Data not available at time of

report

(50 FY 12/13)

Data not available at time of report

(68% were managed in medical home

following consult in FY 12/13)

Tele-ENT (new) Data not available at time of

report Data not available at time of report

Tele- geriatric

psych (new) 4

100% were managed in medical home

following consult

Tele-hematology

(new) 28 referrals and 27 completed


following consult

Tele-perinatal

psych (new) 1


following consult

LONG TERM CARE

Nurse Practitioner at Bethany Cochrane Since 2007, a Calgary Foothills PCN nurse practitioner has worked within the Bethany

Cochrane long-term care facility. The goal of the nurse practitioner is to increase access to

primary health care for residents, increase communication between physicians and family

members, and improve coordination of primary health care services with long term care. In

addition, this role emphasizes the importance of health promotion, illness and injury prevention,

chronic disease management and treatment of acute illness.

The PCN continues to work with Bethany Cochrane to evaluate the impact of this additional

resource. No data is available at this time.

4.2 Comment on any types of structures and activities which have been

developed in the past year to link your PCN with other health care

services.

See Objective 4.1

4.3 How have these structures and activities led to active collaboration,

improved informational continuity, or facilitated referral and feedback

between your PCN and other health care services in the past year?


See Objective 4.1

Objective 5: To facilitate the greater use of multidisciplinary teams to provide

comprehensive primary care

5.1 What percentage of the core family physicians in the PCN currently

used the services of an interdisciplinary / multidisciplinary primary care

team in the past year?

As of March 31st, 2014, 96.3% of physicians with a family practice had

at least one team member in the medical home. This is a decrease of

3.3% from the previous fiscal year (99.6%).

Of the physicians who have a family practice and have requested a team member:

o 96% have a health management nurse (79% in FY 12/13)

o 91% have a behavioral health consultant (88% in FY 12/13)

o 99% have a pharmacist (99% in FY 12/13)

o 100% have a AHS diabetes educator (92% in FY 12/13)

o 100% have a respiratory educator (100% in FY 12/13).

5.2

Comment on any key achievements by the PCN, in the past year, in the

use of interdisciplinary/ multidisciplinary teams to provide comprehensive

primary care.

BUILDING SKILL SETS AND COMPETENCIES

Facilitation Facilitating health behaviour change was a focus for the multidisciplinary

teams (MDT) over the summer and fall of 2013. Learning opportunities

included a workshop by psychologist and motivational interviewing expert

Dr. Michael Vallis, a presentation by Dr. Richard Ward, and role playing

activities.

The MDT completed a survey in August and again in October (n=27)

to assess the effect of these activities.

o The general attitude towards facilitation among the MDT

was very positive both before and after. In October, fewer

respondents agreed that facilitation is appreciated by

patients, compared to August (97% vs. 85%). o Overall, MDT knowledge and competence with facilitation

principles and techniques is good; on a scale of 1-5, MDT rated themselves 4.0 for facilitation knowledge, 3.8 for facilitation competence. These outcomes are marginally improved from before the facilitation focus. Expressing empathy continues to be the area of greatest strength.


o Use of facilitation techniques has increased in group

settings. In August, 50% of respondents used the

techniques all or most of the time, compared to 69% in

October.

o Use of facilitation techniques has declined in one-on-one

interactions. In August, 92% of respondents used the

techniques all or most of the time, compared to 81% in

October. This may be due to MDT responding more

accurately to the question following their education in

facilitation or using the technique when most appropriate.

Chart: Extent of facilitation technique use by providers

Team education Multidisciplinary team members meet three weeks each month, and

receive ongoing education as part of these meetings. This education

includes team presentations, profession-specific education, and

general education.

Multidisciplinary team educational seminars were held quarterly: o Chronic pain, presented by AHS chronic pain program o Obesity management, presented by AHS bariatric

program o Cognitive decline and assessment tools o Academic detailing on dyslipidemia guidelines

Three additional diabetes education opportunities were provided to

the multidisciplinary team over the fiscal year, presented by DHCC

(Diabetes, Hypertension and Cholesterol Centre). These sessions

covered education for diabetes at basic, intermediate and advanced

levels.

Education opportunities are provided in joint extended team and core

team education days. One of the focus areas was chronic pain. In

order to assess the impact of this education, a retrospective survey

was completed by MDT to assess their comfort managing chronic pain

patients before any education opportunities were available (2009) and

currently (September 2013).

30% 36%60%

77%20%33%

32% 4%

0%

20%

40%

60%

80%

100%

Group

(Aug)

Group

(Oct)

One-on-one

(Aug)

One-on-one

(Oct)

Most of the time All of the time


o 73% of surveyed MDT report having accessed three or more chronic pain education opportunities (n=34)

o 53% of surveyed MDT (n=34) rate their current comfort level managing chronic pain patients as “good” or “excellent”, compared to 3% prior to CFPCN education. They note that the education has improved their knowledge about pain and ability to offer/suggest resources, help patients set realistic goals and provide better care overall.

In addition, the PCN supports the multidisciplinary team through the

Hub Resource Library. This is a comprehensive SharePoint database

for health professionals to access updated, evidenced-based

information and patient handouts. All multidisciplinary team members

have access to the Hub Resource Library from any computer. A new

search function allows people to quickly find what they are looking for.

Examples of some of the folder topics are: anticoagulation, dementia,

diabetes, exercise, nutrition, mental health, and pain and weight

management. Each folder is reviewed annually by a team member

who has expertise in that area. New articles, handouts, and guidelines

are uploaded on a regular basis.

CERTIFICATION OF MULTIDISCIPLINARY TEAM

MEMBERS As of March 31, 2014, 14 out of 16 PCN pharmacists have prescribing

privileges (up from thirteen pharmacists in FY 12/13) and of the two

pharmacists remaining, one is in the process and the other is awaiting

results. Fourteen out of 16 pharmacists have their Certified Diabetes

Educator (CDE) qualifications (up from nine in FY 12/13). Five out of 15

health management nurses have their CDE (up from four in FY 12/13).

MEASURING TEAM WORK IN THE MEDICAL HOME The core team in the medical home consists of the behavioural health

consultant (BHC), pharmacist and health management nurse. The

success of this team in the medical home may be measured by access,

communication, and patient health outcomes.

Access BHCs report approximately 11,954* patients seen (a 24.4% increase

from FY 12/13)

Health management nurses had approximately 9,728** patient

interactions (a 5.7% decrease from FY 12/13)

Pharmacists had approximately 9,400** patient interactions (a 11.3%

decrease from FY 12/13)

Dietitians had approximately 1,404** patient interactions.

*Note: 8 months data extrapolated into 12 months for above

statistics. Data provided by Alberta Health Services.


**Note: 3 months data extrapolated into 12 months for above

statistics

The decrease in patient interactions can be attributed to the transition

of roles into internal CFPCN roles which include the extended team

and pharmacist outreach programs. Also, there has been an increase

in educational opportunities physicians and the team itself.

Multidisciplinary team activities include direct patient care and indirect

patient care. Complete patient assessment, monitoring or follow up

processes, information questions and group patient activities all make up

direct patient care. Academic detailing, non-scheduled and scheduled

team meetings, head office work and education and travel time between

clinics make up indirect patient care.

The health management nurses report 55.5% of their time is spent on

direct patient activities (61.2% in FY 12/13)

The pharmacists report 58.5% of their time is spent on direct patient

activities (58.7% in FY 12/13)

Table: Third next available appointment for MDT

Team

member Range (days) Average (days) Median (days)

13-14 12-13 13-14 12-13 13-14 12-13

Health

Management

Nurses

0 - 105 1 - 105 15.3 20.0 7 18.5

Pharmacists 0 - 77 0 - 56 13.3 13.3 7 12

BHCs 0 - 112 0 - 63 22.7 21.3 21 18

Integration and effectiveness In an MDT survey, respondents reported on integration in the medical

home (n=39):

At the clinics where they spend the most amount of time:

o 100% of team members report that they have informal access to physicians, e.g. through hallway consults (90% in FY 12/13).

o 14% meet with physicians at a regular time to review patients, plan care, etc. (18% in FY 12/13).

o 47% meet with physicians in a liaison-scheduled multidisciplinary team meeting (41% in FY 12/13).

o 29% report that their clinics have identified patient populations and developed integrated interdisciplinary guidelines to manage these populations (29% in FY 12/13).

85% of team members have full access to charts at all of their clinics.


In a survey assessing effectiveness in clinics (n=39), MDT indicated performance on 17 characteristics, on a scale of 1-7.

The average score across each of the elements of effectiveness was

5.7. The highest scores were given for support (6.0) and atmosphere

(6.0) among teams; the lowest scores were for evaluation (4.9) and

procedures (5.2).

Patient Health Outcomes In an attempt to document the impact of multidisciplinary care,

pharmacists have recorded a spreadsheet of patient health outcomes in

at least one physician office. The pharmacist’s collect baseline data at

their initial assessment appointment and follow-up data during regular

subsequent appointments.

The following table shows change in chronic disease outcomes for

patients who were not treated to target at baseline. For example, of the

diabetes patients not at-target at their baseline assessment, 18% were

at-target at their follow up assessment.

Table: Chronic disease outcomes for pharmacist not at-target

patients after follow up

FY 13/14 FY 12/13

Diabetes 114 out of 605 (18%)

were treated to target at

follow up

11 out of 72 patients (15%)


follow up

Hypertension 345 out of 1,023 (34%)


follow up

51 out of 149 patients

(34%) were treated to

target at follow up

Dyslipidemia 100 out of 495 (20%)


follow up

18 out of 100 patients

(18%) were treated to

target at follow up

Note: All patients who had a follow up assessment in the relevant fiscal

year are included, which may include patients who had their baseline

assessment in a previous fiscal year.

MDT INITIATIVES IN THE MEDICAL HOME

Best Practice Support Visits In the fall of 2013, Calgary Foothills PCN pharmacists partnered with Dr.

Michael Allan, family doctor and Associate Professor at the University of

Alberta's Department of Family Medicine, to offer Best Practice Support

Visits. Best Practice Support Visits are a variation of academic detailing,

involving a short presentation to physicians and their team on current,

evidence-based, unbiased and practical information on a variety of new

drugs, topics and interventions. The clinic pharmacist will be offering eight


presentations throughout the year, and physicians can receive 0.5 CME

credits for each presentation.

Forty-six physicians received a BPSV education session during the

fiscal year, of which four were informal hallway presentations. The

topic of these sessions was Dyslipidemia & New US Guidelines.

100% of physicians who provided feedback (n=35) agreed that the

sessions were relevant to family medicine and free of bias, that the

presenters were well-informed, and that the information will be useful

for patient care.

Diabetes Outreach The Diabetes Outreach Program was developed in the fall of 2013 as an

extension of the medical home, and works collaboratively with physicians

and MDT members to increase capacity of diabetes care. The team is

comprised of a Diabetes Outreach Educator (RN) who can provide care,

seamless support and linkages to specialty care. The Diabetes Outreach

Educator also supports the medical home with complex diabetes patients

with identified needs through intensive short-term clinical management,

consultative support through patient case reviews/problem solving and

mentoring of multidisciplinary teams.

The program has a strong focus on patient self-management and an

individual care plan is developed with the patient, Diabetes Outreach

Educator and family physician. If a patient requires more intensive

diabetes management and follow up, the Diabetes Outreach Educator

can link to specialty care by facilitating a referral to Diabetes

Hypertension Cholesterol Centre with the family physician's consent.

The DOE accepts referrals from physicians and MDT for consults and

one-on-one visits with diabetes patients. o Received 62 referrals, of 68% were seen in a one-on-one

visit and 32% were consults with MDT. o Patients were on average 60 years old, and 55% were

male. o HbA1c values were collected for 21 patients (34%) after

the initial appointment/consult: 15 patients had improved HbA1c scores, 1 patient

had no change, and 5 patients worsened. Average change in HbA1c was -0.8.

The DOE also provides additional education and resource support to

MDT around diabetes care. A baseline assessment of MDT

competence and experience with diabetes management was

completed in fall 2013; this survey will be repeated in the spring of

2014 in order to determine the impact of the DOE in this role.

Group appointments in the medical home Several MDT offer group appointments to patients on issues such as

weight management and checking blood pressure monitors; data


collection and analysis for these groups is currently underway. Data is

currently available for a metabolic syndrome class.

In partnership with the AHS Living Well program, a health

management nurse and Living Well dietitian provide group classes to

patients with metabolic syndrome in a medical home. o 7 Metabolic Syndrome classes have been offered over the

fiscal year, with 44 attendees. o 13 participants filled out an evaluation of the class. By

attending the class, patients improved their understanding of healthy eating, risk factors for heart disease and blood sugar control. Patients are also more confident that they can set and reach healthy eating and other lifestyle goals.

SUMMARY Calgary Foothills PCN distributes an annual survey to physician

members. Physician responses help the PCN better understand levels

of provider satisfaction and guide program development. In the 2014

annual physician survey, 227 physicians (69% response rate) completed

the survey.

Chart: Overall satisfaction with Calgary Foothills PCN, 2010/11 –

2013/14

5.3 Highlight your outcome focused achievements of your Priority Initiatives in this section

if you had not previously listed them under PCI objectives.

95% 94% 95% 93%

0%

20%

40%

60%

80%

100%

FY 10/11 FY 11/12 FY 12/13 FY 13/14

% Satisfied &Very Satisfied

Documents

Calgary Foothills Primary Care Network · Provide MDT with current and evidence-based education to support patient care. Support MDT to provide high quality care. 14 pharmacists have