Primary Care Pathways

Transcription

1 Primary Care Pathways Julia Carter, MD, FCFP Digestive Health SCN Core Committee member Co-chair, Primary Care Pathways Working Group November 30, 2018

2 Presenter Disclosure Presenter: Dr. Julia Carter Relationships that may introduce potential bias and/or conflict of interest: Grants/Research Support: N/A Speakers Bureau/Honoraria: AHS Digestive Health SCN Consulting Fees: N/A Other: N/A

3 Disclosure of Commercial Support This program has received financial support from in the form of an education grant from: Merck Canada, University of Calgary Department of Medicine, Alberta Health Services, Alberta Innovates, Alberta Netcare, College of Licensed Practical Nurses of Alberta, BrightSquid,, Health Quality Council of Alberta, Boehringer-Ingelheim, and the Institute of Health Economics. This program has received NO COMMERCIAL in-kind support. Potential for conflict(s) of interest: Dr. Julia Carter has not received payment from the APCC planning committee. Funds from sponsors are pooled to off-set conference costs.

4 Mitigating Potential Bias The planning committee developed the conference objectives which do not include the discussion of our sponsor s products or services. Sponsorship funds are pooled and are evenly distributed throughout the conference. They do not fund specific speakers. The committee has reviewed the content of the presentations and ensured that content presented is evidence-based and free of undue influence.

5 Can Enhanced Primary Care Pathways Improve Patient Care and Referral Processes in Alberta?

6 The problem: Access to digestive health care

7 Calgary Digestive Health Pathways background Untenable wait times 24 months+ in Calgary Appropriateness Frustrating for primary care providers, specialists, and PATIENTS

8 The proposed solution: Pathways

9 Primary-Specialty Care Integration Primary care pathways for low-risk, high-demand indications Telephone advice (Specialist Link) - same-day phone consultation Electronic advice (Advice Request) - non-urgent consultation through Netcare QuRE

10 Quality Referral Evolution

11 Why pathways? Build capacity to manage common, low-risk conditions in the Medical Home rather than referring to specialty care

12 Pathway development Agreement on pathway conditions that can be managed in the Medical Home Co-development by GI and primary care Knowledge translation

13 Pathway components Evidence-based algorithm to guide diagnosis and management of common, low-risk health conditions Local resources (e.g. PCN supports, Alberta Healthy Living Program) References Patient information resources

14 GI pathway conditions Irritable bowel syndrome Chronic constipation Dyspepsia GERD H. pylori NAFLD Chronic diarrhea More to come

15 Other specialties Endocrinology General Neurology Respirology Rheumatology Others

16 Calgary Process Implementation through Central Access Triage Referral closed sent back for further investigation/management within Medical Home Expedited consultation if no resolution after pathway completion

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19 1. Who should be tested for H. pylori? Patients with dyspepsia symptoms Patients with history of peptic ulcer/upper GI bleed who are contemplating use of NSAIDs or antiplatelets Patients with first degree relative with history of gastric cancer 7. Refer for gastroscopy Yes 2. Alarm features Dyspepsia symptoms plus VBAD (V =vomiting, B =bleeding or anemia, A =abdominal mass, D =dysphagia) or melena Dyspepsia symptoms plus first degree relative with history of gastric cancer No 3. Diagnosis HpSAT or UBT Before testing, patient must be off antibiotics x4 weeks and off PPI at least 3 days Negative Treat according to dyspepsia pathway Positive 6. Treatment failure Proceed to next round of treatment Option to refer to GI after 3 failed treatment attempts 4. Treatment Round 1: CLAMET Quad or BMT Quad Round 2 (if needed): CLAMET Quad or BMT Quad Round 3 (if needed): Levo Amox Round 4 (if needed or refer to GI): Rif-Amox No 5. Confirm eradication HpSAT or UBT at least 4 weeks after finishing treatment Yes, continued symptoms Yes, no symptoms = DONE

20 What do pathways do? For patients Comprehensive, evidence-based care within the patient medical home Local resources Patient information sheets

21 What do pathways do? For patients Decrease unnecessary investigations/ endoscopy Decrease time off work/travel for specialist consultation that may not change outcome/management

22 What do pathways do? For primary care providers Enhance supports in diagnosis and management Suggest local resources Provide references Minimize unnecessary consultations Facilitate necessary consultations (expedited)

23 What do pathways do? For specialists Reduce referrals for conditions that can be managed within the medical home Create capacity for more timely consultation with patients at higher risk Good quality referrals with comprehensive work-up (and without unnecessary testing) Alarm features identified

24 Pathways can be used pre-emptively: To identify alarm features and highlight them on the referral letter To reassure patients without alarm features that they don t need referral and provide them with resources To guide management while awaiting, or instead of GI consultation Example: NAFLD

25 Outcomes of pathway implementation

26 Outcomes - safety Prospective review ( ) 2,240 referrals returned to primary care 15% re-referred to GI for endoscopy 70% were completely normal Only 2% had a clinically significant finding (e.g. esophagitis)

27 Outcomes - access 98% reduction in non-urgent GI wait list (Jan 2016-Dec 2017) August , 86% drop in referrals for NAFLD

28 Outcomes - adoption GI/Hepatology Pathway Downloads November 2017-June 2018 NAFLD pathway introduced Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

29 Outcomes awareness/impact 2018 survey of Calgary family physicians (n= 625) 55% were aware of pathways 78% of these reported pathways changed their clinical practice

30 Specialist Link 1,722 calls to GI Average system savings of $133/call (avoided consultations and ER visits) 89% of family physicians are aware of Specialist Link 73% of these report it changed their practice

31 GI Access Challenges - Alberta

32 Wait times for routine GI consultation Edmonton months Central and South 9-12 months Calgary (CAT) 24+ months

33 DHSCN Pathways Goal Improve access through spread of GI Primary Care Pathways across Alberta

34 Clear Adaptable

35 Safe Local

36 How? Validation (content & format) primary care, specialists and allied health Spread Knowledge translation to primary care providers and allied health professionals Collaborative implementation between GI and primary care Evaluation

37 Locally appropriate Zonal differences Rural/remote Varying triage processes Variable need for formal phone advice system

38 ACFP e-panel survey input Do you see a role for using clinical pathways BEFORE you consider a specialist referral? 2% 11% 87% Yes No Maybe

39 ACFP survey input determine if a specialist referral is even necessary help assure the patient prevents wasted time for the physician and the specialist

40 ACFP survey input 30 Which factors would increase the likelihood of you using clinical care pathways? Co-developed with family physicians Brief Recommended as best practice Very visual Comprehensive Not useful at all

41 Primary care input Central repository Easy access at point of care EMR? Potentially time-consuming Need for patient information resources

42 Specialist input Create capacity/more timely care for higher risk patients Can I/when can I decline a referral? Triage processes vary challenges for community specialists

43 Patient input Quality/timely care is the key Self-management resources Strong communication between providers Satisfaction surveys to come

44 Evaluation plan Patient Experience survey Specialty care wait time Continuity of care Inpatient admissions and ED visits for pathway conditions Improved access to GI for sick/urgent patients Enhanced Patient Experience Improved Patient Outcomes Improved Provider Satisfaction Value for Investment Family physician & specialist satisfaction survey Improved system integration Inappropriate specialty consultations and endoscopy procedures avoided

45 Partnerships Primary care and specialist champions working together Primary care teams dieticians, pharmacists, CDMs, BHCs PCN leadership, improvement facilitators PHCIN, AMA, AIM, TOP

46 Summary Primary care pathways can improve patient care and referral processes Improved care of pathway conditions in the patient s Medical Home Proven safety Decreased unnecessary referrals & endoscopy Improved triage processes

47 November 30, 2018 Thank you!