comprehensive and continuous care in a collaborative care

Transcription

Comprehensive and Continuous Care in a Collaborative Team Environment:
Challenges for the 21st Century in Family Medicine and for Hospitals
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COMPREHENSIVE AND CONTINUOUS CARE
IN A
COLLABORATIVE CARE ENVIRONMENT
CHALLENGES FOR 21ST CENTURY FAMILY MEDICINE AND HOSPITALS
Contact:
M. Janet Kasperski, RN, MHSc, CHE
Chief Executive Officer
THE ONTARIO COLLEGE OF FAMILY PHYSICIANS
357 Bay Street, Mezzanine
Toronto, Ontario M5H 2T7
Tel: (416) 867-9646 • Fax: (416) 867-9990
Email: [email protected] • Website: www.ocfp.on.ca
May 5, 2008
-1Challenges for the 21st Century in Family Medicine and for Hospitals
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INDEX
1.0 Key Facts...................................................................................................................................3
2.0 Introduction... ..........................................................................................................................6
3.0 Challenges and Potential Solutions ......................................................................................10
3.1 Hospital Based Respect for Family Physicians ...............................................................10
3.2 Respect from Other Members of the Medical Staff.........................................................10
3.3 Admission and Discharge Policies ....................................................................................10
3.4 The Hospitalist Model – anchored in Family Medicine or Focused Scopes
of Practice ..........................................................................................................................11
3.5 Emergency Department and Obstetrics ...........................................................................12
3.6 Hospital Restructuring and Re-engineering/Hospital Mergers......................................13
3.7 Workload Implications ......................................................................................................13
3.8 Remuneration for Hospital-Based Care ..........................................................................14
3.9 Training for Medical Students, Family Medicine Residents and CPD for
Practicing Family Physicians ...........................................................................................14
4.0 Major Strategies to Engage in Hospital-Based Care ..........................................................15
5.0 Summary ................................................................................................................................17
6.0 Appendix
Listening to the Voices of Family Physicians .....................................................................18
7.0 Key Papers on Continuity of Care ......................................................................................24
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Family physicians are ribbons
that tie
everything together.
We walk through
The health and life journey
with our patients
from birth to death.
Dr. L. P.
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1.0 Key Facts
1. 2003 CFPC conducted a Decima Poll
• 81% of Canadians rated their family physicians participation in their hospital care
as important
• 97% believed it was important that a discharge summary be sent to their family
doctor
• 93% of patients cared for by their family physicians while in hospital were
satisfied with their care
2. National Physician Survey
•
2004 – 35% of physician practice time was spent in hospital-based activities
nationally compared with 33% in Ontario
2007 – 43% of physicians nationally provided inpatient care compared with 33% in
Ontario.
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3. Commonwealth Fund 2005 (Report on Canadian Physicians based on the six
country survey)
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95% of family doctors report that they often or sometimes experience long wait
times for their patients to see a consultant
80% report long wait times for diagnostic tests
94% report long wait time for selective surgical procedures or hospital care
79% report difficulties getting appropriate home care when needed
95% of family doctors have patients in their practices with multiple chronic
problems. Only 55% of them feel well-prepared to provide optimum care
89% have patients with mental health problems and only 40% feel well-prepared
to provide optimum care
69% have palliative care patients and only 33% feel well-prepared to provide
optimum care
46% of family doctors report that their patients experience problems because care
was not well coordinated across multiple sites or providers
Only 3% report that they receive a discharge report in less than 48 hours when
their patient is discharged from hospital. 16% report waiting more than 30 days
and 9% report that they rarely receive a report.
40% report having patients who acquired an infection while in hospital.
4. Cancer Quality Council of Ontario
Findings from focus groups, comprised of cancer patients, conducted summer 2007
by the Cancer Quality Council of Ontario, included:
- Very little interaction with family physician after referral to specialist
- It was unclear who was responsible for communicating results to them
- Test results not always available at family physician visit; test results go
missing so patients carried copies of records/test results from one healthcare professional to another to avoid delays
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There was more likely to be breakdowns in communication if tests were
performed in different locations (hospitals, cities, etc.)
Significant delays in getting a diagnosis without family physician
5. Ottawa Study
The safety of patients is compromised when family physicians are not involved in the
care of inpatients and especially when discharge information is not made readily
available to the family physician. 30% of all patients discharged from the medical
unit were re-admitted within thirty days, mostly because medication management was
not undertaken as a shared responsibility between the discharging physician and the
family doctor.
6. OCFP Research
Many family physicians have withdrawn from the provision of hospital-based
care. Their valid reasons fall into two broad categories; namely, overwhelming
workload in their community-based practices and dissatisfaction with the roles
assigned to them in the hospital environment. Some family physicians describe the
hospital environment as “hostile” to family medicine and report feeling stressed by
conditions that reduce their level of confidence in their abilities to provide acute
inpatient care.
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2.0 Introduction
The father of family medicine in Canada, Dr. Ian McWhinney described the relationship
between a family doctor and his or her patients as a “covenant” as opposed to a “contact”.
A contract states that one will do this much and no more; whereas, a covenant implies that
the family doctor will do anything and everything to assist his or her patients. It is this
covenant that underpins the trusting patient-physician relationship that is central to the
specialty of family medicine. It is also the central tenet of an effective and efficient
healthcare system, resulting in better health outcomes at less cost. Over the course of time,
mutual trust and respect builds as family physicians deliver continuous and comprehensive
care for his or her patients and their family members. Continuity of care in family
medicine is referred to as the ability of patients to access healthcare from and through the
same family doctor over the course of time from “cradle to grave”. Continuity of care is
almost inseparable from comprehensive care. The former implies the ability to access
one’s own physicians; the later implies that the family physician is able to provide and/or
access a wide range of health services to respond to patient’s needs over the course of
time.
Family medicine has been undergoing a transformation that is challenging how we deliver
continuous and comprehensive care. Building upon the “patient-centred” model of care,
family physicians are incorporating health promotion and prevention at all points in the
care continuum to assist our patients to become and remain as healthy as possible, as long
as possible. This model of care includes partnering with patients to empower them to make
decisions about their own care, as well as actively supporting them to manage their own
health. Given the complexity of care in our community-based practices, family physicians
are increasingly adopting an integrated and interprofessional approach to patient-centred,
proactive care. The redesigned system is anchored in the principles of collaborative care
which includes family physicians working in an inter-professional team with nurses and
other healthcare providers including sharing care with other specialists.
The challenge that family physicians and their patients face is the maintenance of the
trusting patient-physician relationship, central to family medicine and crucial to insuring
continuity and comprehensiveness of care, in a team-based environment. Research clearly
demonstrates the value Canadians place on the trusting relationship with their family
physicians. That relationship affects their assessment of the quality of care in the rest of
the system. Patients who have a family doctor rate every part of the system much more
positively than do “orphaned patients”. Keeping the trusting patient-physician relationship
as the foundation of our healthcare system should be an important goal for all of us.
Evidence suggests that continuity and comprehensiveness of care improves preventive
care, enhances adherence to therapy, increases patient and physician satisfaction and
improves the health status of our patients and the outcomes of chronic disease
management. Tests and referrals to specialist consultants are reduced and emergency
department and, subsequent admissions to hospitals, are reduced in the presence of strong
primary care system anchored in the primacy of the patient-physician relationship.
A number of forces have combined to make access to competent, continuous and
comprehensive care more difficult for many patients in Ontario. The increasing number of
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“orphan” patients, the evident gaps in the quality of care especially in the arena of chronic
disease prevention and management, the increased number of adverse events in hospitals
and the high rates of readmission are all too obvious indicators of the lack of continuity
and comprehensiveness in the system. Many family physicians have withdrawn from
hospital-based services and no longer deliver care to their own inpatients and/or have
withdrawn from intrapartum care and emergency medicine. Increased fragmentation has
occurred as a result of the development of problem-specific clinics (memory clinics,
secondary stroke prevention clinics, anticoagulation clinics, etc). Walk-in clinics and
Hospitalists programs originally were organized as band-aid solutions: however, they have
become the norm and have further reduced the ability of family doctor to promote
continuity and comprehensiveness of care for their own patients. Those individuals who
are unfortunate enough not to have a family doctor at all are reduced to having access to
episodic care only.
While the term “continuity of care” is often used to imply relational continuity (i.e. the
ongoing patient-physician relationship), it also implies both informational and
management continuity. Informational continuity (i.e. the availability of information to
assist in the management of patients) can be supported by information technology but
there is nothing that can replace the input of the family doctor into the care plan for an
inpatient or into the discharge plan of that same patient to ensure safe transfer back to
community. Management continuity means that there is a consistent and coherent
approach to management that responds quickly to the patients’ changing needs. The lack
of a consistent approach in a fragmented system and lack of involvement of family doctor
when care is delivered in other parts of the system interferes with the ability of the family
doctor to work with his/her own patients to plan and manage optimum care.
Continuity and comprehensive care implies 24/7/365 responsibility for care; however, this
does not mean that the individual physician needs to deliver all the care that a patient
requires. While patients benefit greatly by having the majority of care delivered by the
same physician, maintaining this level of continuity/comprehensiveness is almost
impossible today. As a result, the vast majority of family physicians are working in group
practices. As more family physicians develop special areas of interest and focused scopes
of practice, we need to have in place organizational structures to integrate physicians in a
co-ordinated practice environment. The OCFP has also been actively supporting sharedcare collaborations to link family physicians with specialist consultants and team-based
interprofessional collaborative practices including nurses, dieticians, social workers,
pharmacists etc. As we build organizational structures such as Family Health Teams and
other models of interprofessional care in the community, the “Seven C’s” need to be taken
into account.
The Seven Characteristics of Continuity of Care
Contact – regular access to a consistent family doctor and consistent team members
Collaboration – patient and family physician participation in planning
Communication – accurate collection and timely transfer of patient data, care plan
Co-ordination – delineation of roles and responsibilities amongst the team members
Convenience – minimizing travel; avoiding repeats of basic patient data
Consistence – patient data and care plan agreed upon and shared various providers
Contingency – readiness to respond to questions and acute care needs.
Adapted from an article by Dr. H. Jay Biem - Canadian Journal of CME, November 2004
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Governments all across Canada are promoting system changes that are felt to result in
positive health outcomes for the population and will serve as the foundation for a
sustainable healthcare system. Currently, over one third of our health dollars are spent on
the hospital sector; however, in any given month, the
sector deals with less than 1% of the population.
25% of the public report that they are perfectly
healthy; another 50% experience symptoms but selfmanage their care; of the 25% that seek care, 24%
are cared for by family doctors and other
community-based service providers. Advances in
technology and medication mean that hospital stays
are shorter and shorter, and in many cases can now
be avoided completely for problems previously
requiring hospital care. As our population ages, even
more care will take place outside hospital walls. Expansion of primary care and
community-based services is simply good planning; however, as we concentrate on the
development of strong community-based primary care systems, in some settings, planning
for the involvement of the primary care team members in inpatient care has been
somewhat neglected.
It is a sad state of affairs to see the withdrawal of family doctors from the hospital bedside.
Traditionally, inpatients have benefited greatly from the active participation of their family
doctor in their care. The bond of trust that develops over time deepens when the family
doctor is present during a hospital admission. This is the time when the patient is sickest
and most vulnerable. Their family is most often in need of support as well. In addition to
the hundreds of thousands of patients who do not have a family doctor, many patients are
admitted to hospitals in the absence of their own family physician.
Hospitalists have been described as “an appropriate step in the evolution of healthcare”. It
should be noted that the OCFP makes a distinction between family physicians who do
inpatient care and “hospitalists”. Family physicians who are part of a family practice
partnership and/or a community-based system of care and provide inpatient care to their
own patients and other family physicians’ patients are distinct from hospitalists who are
part of a hospital-based system of care. Hospitalists provide inpatient care and refer back
to the community; whereas, family physicians who provide inpatient care are part of
system that transcends the walls of the hospital. The commitment to the ongoing care of
patients in the community separates the two groups. Patients would argue that hospitalists
are a band-aid solution and not a cure, since these physicians face significant problems in
dealing with orphaned patients due of lack of knowledge about the patient and lack of
trusting relationship. The patient’s own family doctor should function as the Most
Responsible Physician or work in collaboration with the most appropriate consultant. The
two models of care will provide a level of care that cannot be matched by Hospitalist or
any other model of family physician substitution.
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Patients, families and family physicians:
at the heart of the healthcare system
- 10 Challenges for the 21st Century in Family Medicine and for Hospitals
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3.0 Challenges and Potential Solutions
3.1 Hospital-based Respect for Family Physicians
Hospitals in rural and smaller communities value family physicians and are
entirely dependent upon family doctors for the provision of medical care.
Hospitals in large communities and especially, in academic health centres, have
varying degrees of respect for the role that family physicians play. Moreover,
patients are admitted to a variety of hospitals in these communities and regions.
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All hospitals should have a policy on privileges that recognizes and
supports family physicians to provide as much care as possible for
their own patients in the local hospital(s) of their choice.
All other hospitals should permit the development of a system for
encouraging family physicians to receive privileges to carry out
appropriate roles in the care of their patients while in hospital and
especially to provide and receive information on the admission and
discharge of their patients. LHINs should consider LHIN-wide
privileges for family physicians.
3.2 Respect from the Other Members of the Medical Staff
Medical students, family medicine residents and practicing family physicians
report that the “just-a-GP” mentality is still alive and well within many
hospitals.
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All physicians, and especially physicians in leadership roles, need to
demonstrate respect for the important roles that family physicians play
in the care of their own patients. Processes need to be in place to make
family physicians feel welcome at the hospital, and hospitals need to
demonstrate that family physicians are valued for the knowledge they
have about the patient, respected for their contributions to inpatient
care and recognized as key members of the patient care team.
In addition, family physicians need to be informed of changes in
policies and procedures, included in the development of effective
communication systems, and supported in their roles by appropriate
consultant back-up, especially during the after hour period when
patients may require urgent intervention.
3.3 Admission and Discharge Policies
Many patients are admitted to hospital without any information being sought
from or provided by the family doctor. The physicians assigned the Most
Responsible Physician (MRP) role for an individual patient frequently fail to
inform the family doctor of the admission nor do they consult with the family
physician to ensure a clear understand of all of the patients health problems and
their care regimen.
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The official hand-over of the responsibilities from one MRP to another during
hospitalization requires the sharing of information; however, the discharge from
hospital most often takes place in the absence of a formal turn over of
responsibilities to the family physician and frequently without any information
sharing.
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Hospitals should develop a policy to ensure that the family doctor is
contacted and provides essential information within 24 hours of
admission.
On discharge, a formal transfer of care, including information sharing
should occur between the hospital-based MRP and the family doctor.
This is best accomplished by having the family doctor as an integral
part of the care team while the patient is in hospital.
3.4 The Hospitalist Models – Anchored in Family Medicine or Focused Scopes
of Practice
Some hospitals have actively supported family physicians to maintain privileges
and to care for their own patients. The Hospitalist Program in these hospitals
includes family doctors who are willing to provide care for “orphaned patients”,
in addition to their own patients or may have full-time Hospitalists providing
care for “orphaned patients”. The combination of providing family doctors with
support to look after their own patients and a formal program of Hospitalist
caring for the “orphan patients” seems to be a factor in retaining family
physicians in the provision of inpatient care.
Other hospitals have required physicians to participate in the Hospitalist
Program and if they refused, their privileges were withdrawn. In these hospitals,
the patients of physicians who withdrew from the hospital are deemed
“orphaned” and add to the list of patients admitted without a family doctor.
In many hospitals, the creation of full-time Hospitalist positions has drawn
family physicians away from broad scope of practicing family medicine
creating “orphaned patients” amongst these physicians’ former patients. The
lack of capacity in the community to provide broad-based family medicine
places pressure, not only on the Hospitalist program but also on the emergency
department. Key to the Emergency Wait-time strategy is increased capacity in
family practices.
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All hospitals should actively encourage every family physician in their
community/region to maintain (or re-establish) privileges and care for
their own patients. Hospitals should recognize that the patient’s own
family doctor is the preferred member of the care team and Hospitalists
should be assigned to a patient only if the patient does not have a family
doctor.
Family physicians who choose to work as a Hospitalist should be
encouraged and supported to practice in the community and to work as
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Hospitalists proportionately to their available practice time to increase
capacity in the community amongst broad scope of practice physicians.
Community based family physicians and hospitalists alike should be
supported to be active participants in the patient’s care team and included
in all committees that address patient care issues.
Consideration should be given to the role of a “hospital co-ordinator”
whose responsibility is to ensure liaison occurs between the hospital
inpatients units and community based family doctors and between
hospitalists and family physicians.
Since Hospitalists are expected to develop higher levels of knowledge
and skills in regards to inpatient care, their role as mentor/coach and
CME/CPD resources for family physicians seeking further education and
support in inpatient care should be developed and supported provincially
and locally.
3.5 Emergency Departments and Obstetrics
In rural and small hospitals, family physicians provide 24/7 care throughout the
hospital including the emergency department and the obstetrical unit.
Frequently, they do so without the medical back up from the rest of the system.
In addition, most hospitals are experiencing problems in staffing specialty
departments such as emergency and obstetrics. In 2006, the closure of larger
hospitals was imminent and family doctors were encouraged to return to
practice to provide 3 to 4 shifts per month in their local emergency department
to ensure adequate coverage (The Primer in Emergency Medicine for Family
Physicians program).
Many family physicians have dropped intrapartum care from their basket of
services. Reports of these units being viewed as “hostile” environments need to
be addressed. High volume obstetricians are on the verge of retiring and, while
more midwives are being trained, their low volume practices will not replace
retiring obstetricians. Obstetrical units can expect to have the same problems
with coverage in the very near future as emergency departments are
experienced.
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Hospitals in rural and smaller communities should be supported
regionally and provincially by systems that provide adequate back-up
from emergentologists and other critical care specialists including
anaesthetists and obstetricians (see OCFP’s proposal to support family
physicians in emergency medicine).
Larger hospitals should develop systems of supports to encourage family
physicians in their communities to participate in the emergency
department rotations. Many of the factors related to the rural and small
communities also need to be taken into account; however, respect for
their contributions to the ED and the hospital in general needs to be built
into the strategy.
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Hospital obstetrical units need to develop strategies to encourage family
physicians to participate in the care of their own obstetrical patients
including intrapartum care (see OCFP’s Babies Can’t Wait
recommendations).
3.6 Hospitals Restructuring and Re-engineering/Hospital Mergers
The hospital restructuring that occurred in 1990s had a major impact on family
practices in every community in the province. The impact of bed closures,
accompanied by the drive for efficiencies and reduced health human resources
within hospitals especially in the outpatient’s arenas, has negatively impacted
on family practices. Family physicians are now responsible for more complex
patients in their practices without the community-based resources to address the
identified problems. While FHTs are replacing some of the lost services that
were readily available in hospital outpatient departments, the number of patients
served within FHTs is very limited compared with the needs in communities
throughout the province.
Hospital mergers have also impacted on family medicine. With the loss of fullservice hospitals, patients tend to be admitted to a variety of hospitals, making it
difficult for family doctors to connect with every admitted patient.
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As LHINs, and the hospitals reporting to them, begin to address
changes in programs within hospitals (and within the CCACs and the
community services sector), the impact on family practices needs to
be given due and thorough consideration. Planning for a growing and
aging population needs to consider the supports needed for family
practices.
The majority of care for patients with chronic diseases is delivered by
family doctors. The system enhancements in the area of chronic
disease prevention and management need to be implemented with this
thought in mind.
Communication systems need to be employed to ensure that family
doctors can provide input to patient care and can communicate with
their patients while they are in hospital.
3.7 Workload Implications
Managing complex care in their offices, in the patients’ home, in long term care
facilities and in the hospital has proven to be a major cause of burnout for
family doctors. Hospitals need to take into account these competing demands
when trying to engage family physicians. In turn, family physicians often fail to
work together to plan for group involvement with their local hospitals that may
reduce the burden on the individual physician.
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Demands for committee work and other hospital based administrative
responsibilities need to take into account the competing demands
placed on family doctors.
Finding ways to support family doctors to provide clinical care in the
hospital should be the major thrust of engagement activities.
Innovative ways to provide family doctors with input into decisions
and to keep them informed of changes should be developed, out of
respect for their other time commitment.
In turn, family physicians should organize themselves into practice
groups and/or networks of an appropriate size to share responsibilities
and the workload associated with the provision of hospital-based care
(see North York General Hospital Network of Networks model).
3.8 Remuneration for Hospital Based Care
Family physicians who provide hospital-based care express concerns regarding
hospital-based incentives. The MRP funding envelope may be insufficient to
provide an incentive for family doctors to take on this role and the supportive
care funding barely compensates for the cost of hospital parking in the larger
hospitals. HOCC funding helps to provide on call income; however, in rural
communities, the physician is frequently on call for a variety of services but can
only receive HOCC for one activity. Moreover, the HOCC funds depend on the
number of staff. If a community loses a physician, funding is reduced. The
remaining physicians, under these circumstances, are required to work more
frequently to provide adequate coverage throughout the hospital and the
community. Working harder and more frequently for reduced income is,
needless to say, a major disincentive.
•
OMA, OHA and the Ministry need to review all funding available to
family physicians proving hospital-based services to ensure that
appropriate remuneration is available and the incentives are aligned
with the responsibilities for patient care in hospitals.
3.9 Training for Medical Students, Family Medicine Residents and CPD for
Practicing Family Physicians.
Medical students are frequently unaware of the roles that family physicians play
in hospital-based care. Family medicine residents report that they feel
unprepared to provide care in hospital, especially emergency and obstetrical
care. Practicing family physicians are made to feel that inpatient care is so
complicated that their patients require the care of other specialists.
•
Medical schools should increase the exposure of medical students to
family doctors who can act as role models. Medical students should be
provided with opportunities to engage with family physicians who
competently provide care in hospitals and throughout the community.
The culture within medical schools should support medical students to
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recognize the importance that patients attach to the role of the family
doctor and celebrate the contributions that family physicians make in
our healthcare system.
The CFPC’s accreditation standards should require all academic
Departments of Family Medicine to provide family medicine residents
with multiple opportunities to acquire acute care skills needed for both
rural and urban hospital care including experiences in delivering
inpatient, obstetrical and emergency care. The training for hospitalbased care should be delivered, wherever possible, by family doctors
modeling the roles that family doctors play in the system, as a
condition of full program accreditation.
PGY3 programs and re-entry programs should be available to
practicing family physicians to develop specific skills in hospitalbased care required in their community.
The OCFP and the University CME Departments should be funded to
provide accredited CME/CPD programs to support knowledge and
skill acquisition related to all aspects of hospital-based care.
4.0 Major Strategies to Engage Family Physicians in Hospital-based
Care
Hospitals have an opportunity to address the issues related to decreasing
participation of family physicians in hospital-based care; however, they will be
unsuccessful unless family physicians are aware of how important is it to their
patients and the healthcare system in general that they provide hospital-based care.
Family physicians need to hear these messages:
1. Every hospitalized patient needs to have their own family physician
participating in their care, whenever possible. For those patients who
do not have a family doctor, a Hospitalist with family medicine
training should be made available to them.
2. Appropriate communications will be maintained between hospitals
and family doctors including timely notification of their patients upon
admission, the progress of their patients during the admission and
effective discharge information prior to or, at a minimum, within 24
hours of discharge.
3. Family physicians will be represented in the hospital and LHIN
committees whenever policies are developed that affect their patients
and their practices.
4. Hospitals will recognize the important roles that family physicians
play in the following areas of practice:
o Continuity of care
Inpatient hospital care should be considered an integral part of a
patient’s continuum of care that includes office-based care; home
care, rehabilitation and long term care provided by
interdisciplinary teams with family physicians in clinical
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leadership roles.
o Coordination of care
Upon discharge, patients should continue to be cared for by their
own family physician. If they do not have a family physician, they
should be supported in finding a community family physician for
their ongoing care.
o Efficient use of resources
Since patients are now enrolled with their family doctor and
family physicians are the custodian of patients’ medical
information, they are in the ideal position to manage the patient’s
use of effective hospital and healthcare resources. This should be
reflected in policy, for example the e-health strategy provincially
and in each LHIN.
o Patient advocacy
In ensuring continuity of care and in understanding patients’
wishes regarding their own care, the family physician plays a key
advocacy role for both the patient and his or her family.
5. In providing hospital-based care, family physicians will be supported
in delivering care and will reap the following benefits:
o Access to specialists
Interactions with colleagues enhance patient management and
outcomes for family doctors and other specialists.
o Maintenance and enhancement of knowledge and skills
Hospital rounds, formal CPD/CME and re-entry programs provide
opportunities to maintain and enhance knowledge, skills and
confidence.
o Stimulating Environment
The hospital environment decreases the danger of isolation in the
healthcare system and promotes collegiality and team building
skills.
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5.0 Summary
In addressing the interactions between family physicians and their local hospitals and
the Ontario Hospital Association, the following questions will be addressed:
1. Does the scoring in the hospital report card include a measure of how
engaged family physicians are in the care of patients at the hospital?
2. Does hospital accreditation clearly include indicators to measure and
evaluate the structures, processes and outcomes associated with the effective
engagement of family physicians in the care of hospitalized patients? Does
the accreditation process include a review of information sharing between
hospitals and community-based family physicians?
3. Are family physicians included in strategic planning exercises and is the
impact of changes on family practices taken into consideration?
4. Are family physicians included on the Board of the Ontario Hospital
Association (OHA) and does the OHA have a Working Group looking at
hospital/family practice interfaces, as well as, how to engage family
physicians in hospital-based care?
5. Has OHA (or any of the hospitals) thought about establishing Patient
Registries to begin the process of identifying and address the issues that
arise for patients without family doctors?
6. Does OHA have a list organized by LHIN boundaries of hospitals of
comparable size and program mix?
7. Would OHA consider promoting Family Physician Week in Ontario in same
way that Nurses’ Week is promoted?
8. Will the OHA join with the OCFP to address the education needs of
practicing family physicians as key to supporting their re-entry to inpatient
care?
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6.0 Appendix
Listening to the Voices of Family Physicians
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Listening to the Voices of Family Physicians
There are several administrators who maintain that effective system designs can
provide the elements of continuity of care over time and across locations
without the necessity of maintaining the trusting patient-physician relationship.
I believe that this is incorrect and will remain incorrect for a very long time.
Healthcare and relationships are too complex to be managed by our continued
predation for specialization.
I will give you today’s example. I am on the inpatient service at the moment
and one of patients is from my own practice – a woman with multiple severe
co-morbidities of CHF, COPD, DM, renal insufficiency, morbid obesity ……
you get the picture. I admitted her because of her intractable heart failure.
Today, I saw her and, based on immediate first impressions, it was evident to
me she was worsening. Reviewing the notes from yesterday, she had been
converted to oral lasix. Although conventional, the change was based on
parameters that did not take into account several nuances that were immediately
apparent to me as soon as I saw her. WE CANNOT DESIGN A SYSTEM
THAT SUBSTITUTES FOR THAT LONG TERM RELATIONSHIP AND
RESULTANT TACIT KNOWLEDGE.
I recognize we cannot be everywhere --- however, I believe that, if we provide
care to a reasonable size roster of patients, with appropriate supports to our
population needs, there remains no substitute for that family physician role.
Dr. E.
I am fortunate that I live in an environment where a broad scope of practice and
continuity of care are expected and feasible. I am not a saint and that is what is
required for this environment where it makes no sense to have full-time
emergency physicians, hospitalists, office-based physicians, full-time
anaesthestologists etc. Because rural practice is so unique and seems daunting
to others, we are having a difficult time recruiting. (Our ER hourly rate isn’t
great and does not compete with the “near north in cottage county” adding to
our problems).
Has family medicine giving up on broad scope of practice and continuity of
care? What will separate us from NPs if we don’t follow our patients and
provide care outside of the office? How will we provide care in rural
communities if family physicians are not capable of delivering comprehensive
and continuing care throughout the system?
Dr. G.
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I think the rural situation is different. Docs in most suburban and urban
communities have walked away from hospital inpatient care, ER, OBS, long
term care and most unfortunately, end-of-life care and also into focused areas of
practice for some valid and some not-so-valid reasons and I won’t repeat all of
the reasons for this happening. Most who have done so were struggling daily
just to keep up. Running harder and harder with a sense of not meeting
expectations weighs heavily on all of us.
Dr. N.
In the urban reality, care tends to be physically located in the family doctor’s
office where the physician develops a long-term relationship with the patient.
The physician maintains personal contact over time and directs and collates
visits to “elsewhere”, as well as the care delivered by other allied healthcare
professionals. The family practice is where the patient’s records and care plans
are centred. The Americans would call this the patients’ “medical home”. My
biggest question and concern is how to maintain this core relationship with my
patients with the advent of the allied health team, whose help is invaluable in
providing care for patients with complex chronic problems. We are being asked
to take on more and more intense areas of care. Should we also provide care in
the hospital? Yes. Are we able to do so? Not really.
Dr. N.
I already have 2200 rostered patients in my FHT, they are asking us to take on
200 extra patients to reduce the 10,000 people in our community who do not
have a family doctor. I can’t do it and feel, in fact, that to do the job expected,
even with lots of other allied healthcare professionals working with me, that I
should say good-bye to about 700 of my current patients. We cannot berate
family doctors for not working in the ER, inpatients units etc. nor should we set
up expectations that are unrealistic in urban centres. Until we have enough
family doctors to reasonable cover rational patient rosters, we all face a
challenge in maintaining the patient-physician relationship in a climate where
the answer that seems to be pushed upon us is a team of allied healthcare
professionals where it is tempting to give over even more visits to others and
lose the thread of personal contact. The challenge is to work out a collaborative
system where this continuity of relationship does not suffer.
Dr. N.
I left my hospital where I had been a nurse before I went to medical school. I
watched nursing care deteriorate before my eyes. My last patient experience
convinced me that my license was at risk so I left. My patient was admitted
with severe gastro. They gave her bag after bag of IV fluid. On day one, I was
pleased to see that there was plenty of urine. On day two, the level and the
colour of the urine was the same. I thought it was an unusual coincidence. On
day three, the level was same and I knew something was wrong. My patient
with congestion heart disease had not had her urine bag emptied in the previous
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two days. What was there was three days old. They were drowning her. I asked
about intake and output flow sheets. They told me they were too busy to keep
track. I quit the hospital.
Dr. N.
The hospital has a new computer system. As a family doctor, I am not allowed
to access my patients’ charts any more. They treat us like “friendly visitors”.
Why would I bother to go there? The disrespect for family doctor is a major
barrier for us and our patients – and remember, they are our patients. Patients
don’t refer to us as “my doctor” for nothing.
Dr. K.
My urban reality: I work largely out of my office. If I have an in-patient at my
primary hospital, (closest to my office) I will leave my home at 7:30am to do
supportive visits, unless it’s a new baby, who is then directly under my care.
There are three hospitals in town with some sub-specialization. With the bed
situation, I have no or little control which hospital my patient will be admitted
to, and of course, another hospital may be more appropriate for the problem. I
pay $600+ a year for parking at this hospital. Going to the other hospitals
regularly would mean a huge time commitment, even if done in rotation.
Colleagues have frankly said, “hospitals are a loss leader and you are crazy to
go.” As well, GPs cannot admit directly, but need admission under a consultant
(unless maternity or newborn). I do go because I “translate” for my patients
what is happening, what is planned and diagnosis, etc, which they frequently
are not aware of and I do get a better idea of what is actually happening,
although my voice (despite talking to residents, writing in the chart) is not
infrequently ignored. I also go to try and develop at least a passing
acquaintance and relationship with consultants. I attend Grand Medical rounds
and Family Practice rounds 2 days a week after seeing any in-patients. I gave
up assisting in surgeries when laparoscopic surgery came in and I found myself
3rd in line, just standing, scrubbed behind the resident and clerk. I do not have
the ER skills for a tertiary hospital nor the time.
Back at the office, I start at 8:30am with seeing about 30-35 patients a day of a
2200 patient roster with at least 2 hours of “paper time” stolen from lunch, or
spent at the end of the day. My practice has grown old with me, so lots of
chronic care. I have put in fair effort on my EMR with stamps, reminders, etc to
ensure I am hitting the main parts of screening, prevention, and appropriate
monitoring of e.g. diabetes but am running most of the day as it is a general
practice with lots of well babies and prenatals which also means keeping on
with current management here. My FHO group of 23 docs has largely walked
away from long-term care as almost all of our nursing homes have a medical
director, with or without a NP assistant, who often works part-time office/parttime nursing home or has retired to doing only nursing home care. In the past, I
would be visiting my long-term patients over lunch and in the evenings and
over a very wide geographic area. Unsatisfying, rushed care and in the end,
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untenable. This is my most guilt-inducing constriction of services, but after
many 45 minutes drives from one end of the city to another, to see one patient, I
finally decided that it was just as important to occasionally have supper with
my family.
Yes, one could share by setting up rotations, but then I would not be seeing my
own patients most of the time either.
I currently have 2 palliative care patients very near the end of life. I do at least
weekly house calls and telephone support and will commit to long drives for
them. I take after-hour call about 2 days over a month covering about 50,000
patients and these are busy days.
I think this is descriptive of most family docs care in town, and I probably do
more hospital visits than most.
Dr. N.
You can’t pay me enough to do more. I am drowning now.
Dr. W.
Most hospitals in this country could not function without family physician.
Sadly, large urban hospitals and Academic Health Science Centres seem to be
happy to function without them. The hook is that a large proportion of FM
residents gets their training in those institutions and quickly learns that there is
no place for them in hospitals. They then set up their office in a community and
have no formal linkages with their local hospital to the detriment of their
patients. I believe this tendency needs to be reversed and having a well
organized primary care system with appropriate administrative support will
certainly help us to get there.
Dr. L.
How many family physicians would be willing to return to hospital service even if
the environment was appropriate? What skill set is required for the competent
management of today’s hospital patients? What courses would be needed to
improve their knowledge, skills and, mostly importantly, their confidence? Family
physicians that only do a little hospital-based care lose some of their confidence
and eventually stop because it is too stressful. Perhaps, if primary care was better
co-coordinated, the care of the patients of a group of family doctors could be
provided amongst the group rather than by each physician making a daily trek to
the hospital to see their own patients.
Dr. L
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I have listened to some very loud voiced opinions of “comprehensive care”,
meaning the physician providing all the different forms of care themselves.
Having trained recently and realizing that we are trained in a model of
interdisciplinary care with a team based patient-centred approach as opposed to an
individual paternalistic approach, I recognize the great benefits of being able to
admit that one person can never provide the quality of care of a team, and it is a
fallacy of pride to think that we can be providing top quality in all areas without
help from very well trained healthcare professionals.
Comprehensive care, to myself being trained in an interdisciplinary setting, places
a great emphasis on the patient-physician relationship and the continuity is a huge
part of quality of care. The physician acts as the ribbon that ties everything
together. We walk through the health and life journey with our patient from birth
to death. This does not mean we personally do every single part of their
management, but it does mean we are involved, and we circle them with the best
possible support and care team that we can.
I worry about a very black and white definition of comprehensive care because
the implementation of “comprehensive care” will change according to the
resources, location and population served, etc. A tick system in which those with
the most ticks are deemed to be providing comprehensive care is very limiting in
my view and may be too simplistic to capture the complexity of it all.
Dr.L-P
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7.0 Key Papers on Continuity of Care
1. Continuity & Comprehensiveness of Care: Primary Care Toolkit for Family
Physicians by the College of Family Physicians of Canada
http://toolkit.cfpc.ca/en/continuity-of-care/index.php
2. Promoting continuity of care should be integral to any health care system by
Drs. Walter Rosser and Karen Schultz
http://www.cmaj.ca/cgi/reprint/177/11/1385
3. Implementation Strategies: Protecting Trust in the Patient-Physician
Relationship by the Ontario College of Family Physicians
http://www.ocfp.on.ca/English/OCFP/Communications/Publications/default.asp?s=1
4. Continuity of Care in Family Practice, Part 1: Dimensions of Continuity by
Dr. B. K. Hennen published in the Journal of Family Practice Vol.2, No.5,
1975
5. Continuity of Care by Dr. B.K. Hennen
6. Defusing the Confusion: Concepts and Measures of Continuity of Healthcare.
Canadian Health Services Research Foundation, Robert Reid et. al. March
2002

comprehensive and continuous care in a collaborative care

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