RRTs Leading Innovation and Health System Transformation: Best Care Program
ASTHMA RESEARCH GROUP INC. (ARGI) PRIMARY CARE INNOVATION COLLABORATIVE (PCIC) MELISSA FISK RRT, CRE, RPSGT MADONNA FERRONE, RRT/CRE The Best Care Program in Primary Care (since 2003) The Best Care Asthma Program ✓Windsor - Essex Asthma Strategy Network Pilot ✓Community Asthma Demonstration Project (2003-2006) ✓Primary Care Asthma Program (2006-present) (22 sites – all models) for COPD ✓Best Care COPD RCT (4 FHTs) 2011 - 2013 Chronic ✓Best Care COPD Program 2014 – present (7 FHTs – 22 sites all models) Disease ✓Feasibility Assessment SW LHIN – Spread to Brockton FHT 2018 ✓SWLHIN funded 2019-2020 spread and scale to all sub-LHIN regions Management ✓Proposal now is for a demonstration of LHIN to LHIN spread as the in Primary care basis to assess a provincial roll-out plan
Heart Failure and Atrial Fibrillation ✓HF Pilot 2016 to present / Program 2017 to present General Business Concept: Provide a patient-centred cost effective program that decreases acute services utilization
Move care upstream to Primary Care to prevent disease progression and exacerbations leading to acute care utilization Spread and scale with a peer-to-peer model Ensure program value with robust evaluation Build primary care infrastructure to complement and extend existing transitional programs
ACUTE CARE HOSPITALIZATION PRIMARY CARE TRANSITIONAL Integrated CARE Disease Connecting Care Management to Home
Extraordinary PRIMARY CARE Care COMMUNITY CARE ✓Led by primary care practitioners in the Patients’ Medical Home ✓Evidence-based & standardized across all sites (Fidelity / adaptability) ✓Team-based care (proactive) ✓Supports collaborative self-management (Wagner model) Improved ✓Peer-to-Peer (solutions created & spread by primary care) → Self- propagating Health ✓High quality evidence of efficacy and effectiveness Outcomes ✓Efficacy - Randomized controlled trial: 38% reduction in total hospitalizations. (1) ✓Effectiveness – CQA program n >1,000 patients. 47% fewer hospitalizations p<0.001 and Lower ✓Dramatic improvements in quality of life (1) ✓Treat 1,000 COPD patients in Best Care COPD avoid 100 Cost hospitalizations (scaled to improve system performance)
✓Strong business case (Deterministic Markov economic model)
1) M. Ferrone, C. Licskai and The Primary Care Innovation Collaborative. The impact of integrated disease management in high-risk COPD patients in primary care. npj Primary Care Respiratory Medicine (2019) 29:8 ; https://doi.org/10.1038/s41533-019-0119-9 The Components of the Best Care Program in Primary Care
Patient Apps Portfolio Care Model Effective Peer to Peer Includes HF, DM, HT Integrated Disease Spread, Scale, Provider Management Sustainability Electronic Medical Tools Continuous Quality Shared Resources / Record Patient Apps Assurance Program Program Development breathe for Asthma and COPD
Certified Respiratory Physician Educator Network Evidence-Based Program Advisory (95% RRT’s) Local Adaptation of Standards Group Standards (Delphi Evidence Network Panel) Evaluation Program Specific Team Randomized The Primary Care Controlled Trials Innovation Collaborative
Health Economic Analysis (Markov Model)
The Care Model - Integrated Disease Management
• Patient + Certified Respiratory Educator/RRT + Primary Care Physician/NP
• Evidence Based Standardized Intervention • Case Management • Education (collaborative self-management) • Skills training The Clinic Work Flow
Designed to work in a primary care practice (7,500 patient encounters, > 300 physicians) CRE/RRT seeing 5-7 patients per day Need 5 - 7 minutes of the PCP’s time per patient Patient leaves with all elements of evidence based care (Diagnosis, Rx, education, action plan, case management) Medical Directives (communicating dx, Pre/post spirometry, dispensing samples) Follow up 3 visits/year 1 (progressive – do not discharge) Delivering Evidence-Based Care in Every Encounter (Measured)
Expert - Certified Respiratory Educators/RRTs Patients that have achieved self-efficacy Patients trust the synergy in the team (measured – Dr. Sibbald) Physician co-management Program Standards Integrated IT – Standardized Care and Performance Metrics across all sites (measuring what we value) High Performing Health Team
CRE/RRT + MD/NP + Patient + Other (Case Management) CRE/RRT Network MD Advisory Group Primary Care Innovation Collaborative (7 FHT’s) Evaluation Team – Western University. Professor of Health System Innovation Digital Team – (LHIN2, eHO, eHealth Innovation) Erie St. Clair (LHIN 1) – All Regions
Best Care Program
Lambton
Rural Kent
Chatham City Centre
22 sites with 120 MD’s. Windsor
Tecumseh Lakeshore Amherstburg LaSalle
Essex South Shore SWLHIN (LHIN 2) Q1/Q2 2019-2020 Spread and Scale
Best Care Program
Readiness Assessment
Contacted Grey Bruce Contact Pending
Not interested at this time
Huron Perth - 56 sites with 250+ MD’s. - 23 sites adapting Best Care Projected 2020 - 88 sites and
Oxford 423 physicians
London Middlesex
Elgin City of London
1673/1653 Richmond St 215 Fanshawe Park Rd 1807 Wonderland Rd Best Care Program 1135 Adelaide St 240 Victoria St Readiness Assessment 499/701/825 Oxford St 825 Richmond St 295 Saskatoon St 1634 Hyde Park Rd 450 Central Ave Contacted 140 Oxford St London FHT (3) 240 Wharncliffe Rd 612 Colborne St LIHC Contact Pending London TV FHT (8) SOAHAC 204 Hamilton Rd 640/747 Hyde Park Rd 190 Wortley Rd Not interested at this time 130 Thompson Rd 460 Springbank Dr
440 Boler Rd 551 Knights Hill Rd Health Zone NP Clinic Nixon 1051 Wonderland Rd 395 Southdale Rd 575 Bradley Ave London Lambeth FHO
2519 Main St Champlain – All Regions
26 sites – Ottawa Community Lung Health Program & Lanark Renfrew Lung Health Program
Western Champlain
Eastern Ottawa
Central Ottawa Eastern Champlain
Western Ottawa
Western Champlain South East – All Regions
Lanark, Leeds & Grenville
Smith Falls NP-Led CHC Smith Falls NP-Led CHC Merrickville CHC
Rural Frontenac, Lennox Rural & Addington Hastings Perth CHC 6 sites – Lanark Renfrew Lung Country Roads CHC - Westport Country Roads CHC - Portland Health Program
Kingston
Quinte