Complex Care Management Project

Rapid Fire Session B6 Reaching Out: Proactive Approaches to Primary Care

Hello from Vancouver’s North Shore! • Dr. Joanne Larsen, Family Physician, Practice Management

Working Group Chair

• Candace Travis, Practice Support Program Coordinator, Vancouver Coastal Health

• Claire Doherty, Project Lead, North Shore Division of Family Practice

Disclosure

Nothing to disclose.

Aims

•Strengthen patient-physician relationship

•Improve office efficiency

Context •Working Group funded by A GP for Me

•Partners: • Practice Support Program – Vancouver Coastal Health

• North Shore Division of Family Practice

Complex Care Incentive Fees

•14033 for patients with 2+ chronic diseases

•14075 for patients with frailty level 6 or 7

Strategies •Created chronic disease registries

•Implemented process to recall patients

•Set reminders for incentive fee due dates

Process

Baseline data Registries Visits and

billings Sustainability

Results

Indicator Maximum Average

Newly identified complex care patients 76 14

Increase in complex care and chronic disease management billings

$13,860 $5,623

Increase in accuracy of patient registries

52% 13%

Lessons Learned

•Every practice was different

•Different “aha” moments

•Staff engagement

Challenges

•Time commitment

•Reluctance to change

•Technical difficulties

•Sustainability

Feedback Loop

•Assumptions

•Quotes

Next Steps • Patient Medical Home and Primary Care Home

• Other patient populations

Thank you for listening!

Any questions?

For more information, contact:

Claire Doherty, Project Lead, North Shore Division of Family Practice

cdoherty@divisionsbc.ca