"Pulling it All Together: Bridging "Pulling it All Together: Bridging the Gaps in Primary Care".the Gaps in Primary Care".

Marcia Carr Marcia Carr (RN,BN,MS,GNC(C),NCA)(RN,BN,MS,GNC(C),NCA)

Clinical Nurse SpecialistClinical Nurse Specialist

Stating the Obvious Reality?Stating the Obvious Reality?

Older AdultsOlder Adults

Changes associated with “normal aging”, Changes associated with “normal aging”, development of chronic diseases, atypical acute development of chronic diseases, atypical acute presentations, fixed income, increased presentations, fixed income, increased psychosocial stressors, requires:psychosocial stressors, requires:– Society’s valuing of aging and older adultsSociety’s valuing of aging and older adults– Specialized knowledge, skills, abilities Specialized knowledge, skills, abilities – More time to manage care and more servicesMore time to manage care and more services– More money to provide the time to manage care and More money to provide the time to manage care and

servicesservices– More coordination, navigation…More coordination, navigation…

Older AdultsOlder Adults

Aging population = dramatically increasing Aging population = dramatically increasing numbers needing health services and carenumbers needing health services and care– Out-living their providersOut-living their providers– Current providers not choosing to take on Current providers not choosing to take on

older adult patients = use of walk-in clinicsolder adult patients = use of walk-in clinics

Additionally, aging health care providers = Additionally, aging health care providers = fewer to provide the services and the carefewer to provide the services and the care– Providers not choosing to acquire geriatric or Providers not choosing to acquire geriatric or

geriatric psychiatry specializationgeriatric psychiatry specialization

A Time to dialogueA Time to dialogue

IHI targets “saving lives” by preventing IHI targets “saving lives” by preventing identified sentinel events and/or care gaps identified sentinel events and/or care gaps in health care in health care systemssystems

Vision that primary care be the main Vision that primary care be the main partner with the patient that facilitates partner with the patient that facilitates coordination and navigation for the patient coordination and navigation for the patient through the health and illness continuum through the health and illness continuum so that the sentinel events and care gaps so that the sentinel events and care gaps are not just bridged but eliminated.are not just bridged but eliminated.

GapsGaps

#1: Communication#1: Communication

Every time a patient receives care Every time a patient receives care or services from a different or services from a different provider, the potential for a provider, the potential for a sentinel event increasessentinel event increases

CommunicationCommunication

PATIENT

Primary CareProvider

Family,SignificantOthers, community

HealthAuthorities’Services

SocialServices

Gov’t,Others

Components connect to patient but not to each other

#2: Immediate Need #2: Immediate Need ResponsiveResponsive

Both patients and systems Both patients and systems are in urgent, crisis, rescue are in urgent, crisis, rescue

modemode

Immediate NeedImmediate Need

Immediate need to address a health or Immediate need to address a health or social issue is “driver” behind patient’s social issue is “driver” behind patient’s contact with primary care provider and/or contact with primary care provider and/or servicesservices““Quick fixes”? “Instant gratification”?Quick fixes”? “Instant gratification”?Need for immediate satisfaction or Need for immediate satisfaction or solution?solution?Effect and affect on older adults? Effect and affect on older adults? Caregivers? Services?Caregivers? Services?

#3: Control, #3: Control, In ChargeIn Charge

Who should or actually holds the Who should or actually holds the control or is in charge of the control or is in charge of the patient’s health and illness?patient’s health and illness?

Control, In ChargeControl, In Charge

What actually is patient-centred or patient-What actually is patient-centred or patient-focused care? Happening or not?focused care? Happening or not?

Who…primary care physician? primary Who…primary care physician? primary care provider? Health services? Family? care provider? Health services? Family? Insurer? OR…Insurer? OR…

The PATIENT?The PATIENT?Are we as health care providers Are we as health care providers

responsible for their health/illness responsible for their health/illness or is the patient?or is the patient?

Bridging or Eliminating the GapsBridging or Eliminating the Gaps

Changing the ParadigmChanging the Paradigm

Ownership of their health/illness management is Ownership of their health/illness management is the responsibility of the patient to which they are the responsibility of the patient to which they are accountable to themselves.accountable to themselves.

Adherence to the proposed health/illness Adherence to the proposed health/illness management plan by the health care provider is management plan by the health care provider is also the patient’s responsibilityalso the patient’s responsibility

Consider being the “wellness coach” rather than Consider being the “wellness coach” rather than director, dictator or controller of the patient’s director, dictator or controller of the patient’s care and management. care and management.

Motivational InterviewingMotivational Interviewing

Specific technique that shifts locus of Specific technique that shifts locus of health/wellness control to the patienthealth/wellness control to the patient

Behaviour changes are built upon patient’s Behaviour changes are built upon patient’s intersecting levels of self-identified intersecting levels of self-identified ““conviction” (benefits) and “confidence” conviction” (benefits) and “confidence” (barriers to be overcome)(barriers to be overcome) based upon based upon what the patient self selects to be their what the patient self selects to be their own health/wellness targets.own health/wellness targets.

What is being done?What is being done?

Health Authorities are currently developing Health Authorities are currently developing “integrated primary care health networks”“integrated primary care health networks”– Primary care providers (Family physicians and Primary care providers (Family physicians and

nurse practitioners)nurse practitioners)– Interdisciplinary HCP teamsInterdisciplinary HCP teams– Appropriate care by appropriate provider in a Appropriate care by appropriate provider in a

timely mannertimely manner

Database = minimum data system (Rai)Database = minimum data system (Rai)

ProposePropose

PATIENT AndPrimary CareProviders

Family, SignificantOthers, Community

Social Services

Gov’tServices

Health Authorities’Services

Private Providers

Patient and PCP partnership assures centralized communication

Care TransitionsCare Transitions

Eric Coleman’s workEric Coleman’s work4 Pillars4 Pillars

1.1. Personal Health RecordPersonal Health Record2.2. Medication ReconciliationMedication Reconciliation3.3. Red FlagsRed Flags4.4. Follow upFollow up

Care transition coaches are empowering the Care transition coaches are empowering the patient to assure that they do not fall into patient to assure that they do not fall into the care gap.the care gap.

Propose: PCP DatabasePropose: PCP DatabaseAgeAge preventivepreventive diagnosticdiagnostic acute acute

curativecurativechronic chronic managementmanagement

palliativepalliative OtherOther

HealthHealth

PhysicalPhysical

IssueIssue

MentalMental

EmotionalEmotional

IssueIssue

SocialSocial

IssueIssue

OtherOther

Central tracking for trending for prevention and services

What is being done?What is being done?

CDM provincial collaboratives, such as CDM provincial collaboratives, such as – Dementia Dementia – Falls and injury prevention, osteoporosisFalls and injury prevention, osteoporosis– Arthroplasty, fractured hipArthroplasty, fractured hip– Healthy Heart and diabetesHealthy Heart and diabetes– TIA, StrokeTIA, Stroke– Pathways (mental health)Pathways (mental health)

Specialized Older Adult ServicesSpecialized Older Adult Services– Complex, frail clinicsComplex, frail clinics– Disease or syndrome specific (dementia, falls, OP)Disease or syndrome specific (dementia, falls, OP)– ACE units, geriatric psych teams and unitsACE units, geriatric psych teams and units

What is being done?What is being done?

Care provider collaborativesCare provider collaboratives– CGA, NICECGA, NICE– UBC Care of Elders, SFU, U VicUBC Care of Elders, SFU, U Vic– BCNARBCNAR– CGNA, GNABC, BCGPACGNA, GNABC, BCGPA– ACGNN, GENIACGNN, GENI

However, …However, …

Increasing numbers with fewer Increasing numbers with fewer providers doing lion’s share of providers doing lion’s share of

work to bridge gapswork to bridge gaps

The Here and the NowThe Here and the Now

Time to DialogueTime to Dialogue

Thank youThank you

Marcia.carr@fraserhealth.caMarcia.carr@fraserhealth.ca