Kootenay Boundary Division Leadership Report
In 2014-15 the Kootenay Boundary Division of Family Practice has had tangible impact in 20 projects currently in progress. Our work within the provincial A GP for Me initiative has begun in earnest; the Rural Residency Program arrived in July; we’ve supported clinics, communities and incoming GPs in recruiting 7 new doctors to the region; we’re seeing Telehealth improve patient care; Child and Youth Mental Health Substance Use connect GPs, Specialists, Allied Health, patients and their communities, and much, much more.
The success in our project work reflects the strength with which Division members have embraced system transformation in alignment with leaders at the highest levels in British Columbia. In March 2015, Deputy Minister Stephen Brown published three health care policy papers outlining the new vision for our Health Care System. British Columbia will join other leading jurisdictions across the western world in implementing truly collaborative Inter-Professional Team-Based Primary Care, to address the growing challenges in chronic disease management, mental illness, the aging population, system sustainability and patient/provider experience of care.
It is our work over the coming years to breathe life into this transformation at the local level, and target it at priority issues of Kootenay Boundary practitioners, many of which are captured in the Division Tree. GPs and NPs have an unprecedented opportunity to work collaboratively with our health care providers in IH and community to implement a system of team based primary care in Kootenay Boundary that consequentially addresses the triple aim of improved patient and provider experience of care, improved population health and more efficient use of financial resources.
In the coming year, we will seek external advice, as well as draw on the expertise of Practitioners in our midst already on this path, and bring this knowledge to bear on how we implement team based care to best effect in Kootenay Boundary. We will continue to build the critical skills that are foundational for grassroots, collaborative, consensus based change, as shown in the diagram you see here – emotional, intellectual, process and operational. (Think of this graphic as analog to the CanMEDS Physician Competency Framework, applied to Practitioner leadership in change management.)
Thanks to the efforts of our Board, members and project teams since the launch of the Division four years ago, we have the organizational strength to embrace this process. Over this same time frame, our work and the work of our partners has dramatically improved relationships in all sectors of the health care system in KB, creating the foundation for real change.
The gauntlet has been thrown down. It is our opportunity to pick it up and along with our health care and community partners, lead the future of primary healthcare in Kootenay Boundary. The result will be a stronger health care system, better outcomes for patients, and richer, more satisfying careers for physicians.
Dr. Lee MacKay, Dr. Martha Wilson,
Executive Director Andrew Earnshaw
Regional Continuing Professional Development (CPD)
We are very excited to be ushering the KBCPD program into its fifth year with some new faces and a new focus for 2015-16.
Over the past four years we have created strong communication around CPD in the region with our regional calendar, newsletter and regional steering committee. We have made connections at the health authority and provincial level and had several opportunities to pilot CPD designed for rural settings. Each year we support/deliver over 100 CPD events across Kootenay Boundary.
Some highlights from this past year include:
Coming for this CPD year:
There have been some important changes in the KB medical community in the last few years. Selkirk College now offers the first Rural Pre-Med Program. The UBC Southern Medical Program is now in its fifth year in KB and the UBC Family Practice Residency Program is now in its first year. Team-based care is becoming a bigger part of our health care system and we are strengthening connections with the regional nurse and allied health educators. Moving forward we envision creating a Regional Campus with inter-professional learning happening across all the stages of medical education, including practicing GPs.
Another focus this year will be using data to drive learning. We will be supporting the first steps of quality improvement through EMR data analysis. We have seen excellent examples from other communities reviewing EMR information with a quality lens resulting insignificant impacts on patient outcomes and creating a culture of discussion and quality improvement.
With Jaime and Erin moving on, our regional CPD program would like to welcome and introduce our new project manager. Sylvain Turgeon will be an asset to our program as Project Manager with a Master’s in Education from Universite du Quebec and years of experience in adult learning, project management, technology and professional development.
I’ll conclude with thanks to the CPD leads (some new, some not so new) for our KB communities:
GF: Jen Dressler
Kaslo: Isabelle Anne Fontaine
New Denver: Chuck Burkholder
Castlegar: Josee Lesperance
Naksup: Norm Lea
Nelson: Dharma McBride, Anne-Marie Baribeau, Mike Vance, Rob Kobayashi, Megan Kennedy
Trail: Melissa Ringer, Janet Fisher
Regional Medical Educators
In late 2014 the Kootenay Boundary was chosen as the 18th UBC Family Medicine Residency training site and is one of eight rural sites for the program. Dr. Willa Henry, Director for the Family Medicine Postgraduate Program at UBC said, “The Kootenay Boundary is already a recognized medical academic teaching centre with a well-established Clinical Clerkship Program that currently trains four medical students completely for their third year. For many years, the area’s physicians have shown a dedication and enthusiasm for training future physicians with strong support from Interior Health. So, it was an easy decision to choose the Kootenay Boundary as a site for our Rural Family Medicine Residency Program.”
With region-wide support through early 2015, a strong syllabus was developed by the local Rural Residency Program team and four applicants were accepted. Dr. Alana Benes, Dr. Gabe Krahn, Dr. Gretchen Snyman and Dr. Mark Szynkaruk, pictured here with 2015/16 ICC students, arrived in Kootenay Boundary at the beginning of July 2015 to start the program.
Many thanks to the communities, physicians and Interior Health representatives across Kootenay Boundary who have so enthusiastically embraced the development of a new teaching site in our region.
In 2014 we concluded our pilot application of the objective data dashboard in EMRs. Dr. Jeanette Boyd and project manager Selena Davis made a well-received presentation of the results at the eHealth 2014 conference in Vancouver. We are now working with the physician data collaborative to bring a polypharmacy pilot application of their physician-owned EMR data aggregator to an Osler clinic in the KB. As well as working on another regional EMR data quality initiative through the small group learning sessions funded by the GPSCs PSP technology group.
The Division developed and launched a recruitment marketing plan in early 2015 with new marketing materials and an updated website – kbdoctors.ca. As an exhibitor at May’s RECC conference in Penticton we developed a list of over 40 new contacts interested in hearing more about practicing medicine in our region, including many residents and students who will be graduating within the next few years.
Recognizing how important community involvement is in successful recruitment, through late 2014 to date we have been working with the Lower Columbia Community Development Team Society to create a welcome program which ensures timely and organized follow-up and support of residents and doctors considering or coming to practice in the Trail/Rossland/Fruitvale area. Our work with the LCCDTS is forming the basis for similar programs in other communities around the Kootenay Boundary, with meetings scheduled in Nelson for Fall 2015.
So far this year, Nine new doctors have moved to the Kootenay Boundary and the Division has been actively supporting clinics, communities and arriving recruited physicians. We have also been working with a number of members on succession planning as they move towards retirement.
In late 2015 and through 2016 we will:
Thanks to all those members who have been involved in developing the Division’s recruitment program.
PATIENT CENTRED FAMILY PRACTICE
A GP For Me
The provincial goals of the A GP for Me initiative are strengthening the physician-patient relationship, improving access to family physicians, especially for vulnerable patients, and increasing the capacity of BC’s primary health care system.
The KB Division was approved for $650,000 of A GP for Me implementation funding in July 2014 and has since implemented the following five strategies:
About 78 Division members are actively involved in our A GP for Me work, from the board to the steering committee, recruitment & retention advisory group, being supported in recruitment or succession planning, working with a practice coach (Division and/or PSP), being supported with IPCC processes or a social worker or being referred unattached patients through the Hotline.
We are working collaboratively with our partners, KB communities, Interior Health and PSP, to effectively accomplish our A GP for Me work.
The IPCC Optimization Strategy is designed to optimize the existing Integrated Primary and Community Care (IPCC) program. Through strengthening team-based care approaches, the initiative aims to improve care for complex patients and increase capacity of family doctors.
KB clinics that would benefit from optimization resources were identified and clinic coaching plans created, resulting in gains in the areas of streamlining chronic disease management, improved patient selection, flow and recalling. Six 6 GPs at clinics in Nelson, Rossland and Castlegar have been supported; and the use of the IPCC program in other KB clinics has been initiated.
To further enhance optimization opportunities, a former PITO practice automation coach was recruited to the project team to assist GPs and MOAs in tracking and improving work flow via their EMR. Strong collaborative relationships between GPs-IHA-IPCC and Divisions of Family Practice have been built through the optimization strategy serving as a solid and essential foundation to improve outcomes.
The aim of this initiative is to establish an innovative and sustainable team-based care model in fee-for-service group practices through the integration of a social worker to support patients with multiple needs. We have established one social worker in a Nelson group practice. We have provided time-limited wage subsidies and coaching support to facilitate the successful integration of the social worker in the practice. Referral patterns and billings associated with the social worker’s care provision align with our developed business model and project towards a fully sustainable model. The program will continue until end of March 2016.
“The addition of a social worker to our clinic is of great value for our patients and for us care providers. We are still monitoring for sustainability but the benefits to patients and to us as providers is unquestionable,” says Dr. Lee MacKay.
Improved Practice Efficiency
The Improved Practice Efficiency Strategy targets enhancing practice efficiency and utilization of community resources and services. Working collaboratively with the Practice Support Program (PSP), practice coaching program as well as an open practice improvement coaching approach, the initiative has focussed on increasing the capacity of family physicians to care for more patients, improve clinic efficiency and enhance work-life balance. Practice efficiency advances have been realized through both coaching approaches.
PSP’s whole clinic Practice Coaching with GPs, NPs, MOAs and allied health professionals has generated practice improvements at a system level for the clinics so far involved. The Open Practice Coaching approach has focused on improvements that individual GPs have highlighted as priorities in their particular practices. PSP and the Division have created a collaborative coaching team and have engaged 11 GPs across Kootenay Boundary with an additional seven slated for the fall 2015.
Three other notable achievements include: implementation of a regional billing workshops with Dr. Cathy Clelland in October 2014; addition of a former PITO practice automation coach to support EMR efficiency; gathering of PSP, IHA and Division leaders from the East and West Kootenay to plan the future of PSP service delivery in the region. The ongoing focus of the project is on monitoring and evaluating project outcomes.
A GP for Me Hotline
As part of our A GP for Me work, Kootenay Boundary Division of Family Practice has created the ‘A GP for Me Hotline’ – a matching mechanism to connect patients without a family doctor with GPs who are willing to accept new patients. Due to the very limited GP capacity in Kootenay Boundary area at this time, referrals to the Hotline have been limited to hospital and primary health centre (PHC) emergency departments and mental health services.
The KB A GP for Me Hotline went live on April 13, 2015. As of Monday June 29th, 2015 (10 weeks live) the Hotline has:
The hotline will continue to operate through 2015/16, focusing on attaching patients coming through the aforementioned referral sources.
Working with IHA, our second successful NP4BC (Nurse Practitioners for British Columbia) application resulted in the employment of nurse practitioner Donna Gibbons. Donna started in the fall of 2014 in the New Denver/Slocan area supporting complex care patients.
Our NP4BC success is furthering the Division’s team-based care project, putting into practice different models that address current primary care challenges. We’d also like to acknowledge a number of our members who are independently and successfully exploring the employment of nurse practitioners and other allied health practitioners to improve efficiencies and offer multiple ‘in-clinic’ care options to their patients.
CARE OF COMPLEX PATIENTS
The Kootenay Boundary Chronic Pain tool launched in late 2014 promoting a multidisciplinary approach aimed at integrating physical therapies, medical interventions and cognitive and complementary therapies. The database of resources launched in 2014 has been developed further and now includes over 80 resources to help patients and doctors with this complex issue. The database is available online at kbdivision.org/chronicpaintool and on the community resource site kb.fetchbc.ca. It has been promoted through the media with articles in the Nelson Star and Trail Times.
Polypharmacy and Residential Care
Our work in advancing the polypharmacy goal of improving care and the quality of life for the frail elderly continued this year within facilities and received a substantial boost in focus and attention through the GPSC residential care incentive program.
The GPSC’s residential care initiative is a new program designed to address the downward trend in the number of physicians providing services to seniors in residential care by enabling physicians to develop local solutions to improve care of patients in residential care services. The initiative supports five best practices for residential care that should reduce unnecessary ER transfers, improve patient, family, and provider satisfaction and hopefully reduce costs.
In early 2015, Kootenay Boundary Division Executive Director Andrew Earnshaw sat on a provincial steering committee for this incentive and championed the integration of robust medication review into the standards for incentive payments. The Division will receive funding to implement local solutions for continuing to improve residential care through 2015/16.
In 2015, Dr. Lilli Kerby continued to represent family doctors for the Palliative Care project. Following a presentation to the Collaborative Services Committee (Division/IH table) by Elisabeth Antifeau (IHA Practice Lead, Community Care, Special Populations, Community Integrated Health Services), a workshop on palliative care education was held with Kalein Hospice, Kalso Hospice and the Columbia Basin Trust. A partnership was then formed with IH (Elisabeth Antifeau) and Division (Dr. Kerby and Dr. Fisher) representation. Modelled on a program developed by the Victoria hospice society [http://www.victoriahospice.org/health-professionals/courses], the new group are creating local palliative care CPD sessions that will bring leading practice standards in team-based palliative care to the region in 2016.
In November the winter of 20145, IH hosted a cross community all day workshop on access and care transitions in Kootenay Boundary. Flowing from this workshop, GPs and the 4 IH portfolios of acute, community, residential and allied agreed to focus on system reform of discharge planning for frail seniors from KBRH. A new working group was formed with many members of the previous frail seniors committee. The groups firt meeting was an all day workshop with Dr. David Kuhl focusing on the importance of relationship based care. The group is to reconvenereconvene’s in the fall to develop goals and priorities for 2016 from this foundation.
SOCIAL DETERMINANTS OF HEALTH
Poverty Intervention ToolThe successful launch of the Poverty Intervention Tool locally and throughout BC was followed with rounds at KLH. In Nelson, Dr. Lee MacKay presented on the importance of considering social determinants of health in patient consults and outlined ways to use the KB Poverty Intervention Tool.
In early 2015 our Division was approached by Pacific Blue Cross who were impressed by our work with the Poverty Intervention Tool and suggested developing a partnership to further the Social Determinants of Health agenda. As a result of these conversations, a province wide meeting has been planned for Fall 2015. We’re excited to be part of this wider initiative and to explore how the Kootenay Boundary can contribute to advancing this issue.
Enhancing team skills, providing timely clinical access to specialists for patient care and building collaborative care between primary care teams and specialists have been the focal areas for Kootenay Boundary Shared Care Psychiatry.
Team skills across the region for 270 participants have been enhanced through the Responsive Behaviours in Seniors rounds with Dr. Trevor Janz and psychiatrists Cletus Okonkwo and Richard Magee since starting in September 2014. The monthly sessions have participation from family physicians, residential care, home health, mental health and acute care teams. Session will be continuing in September 2015 under the CPD banner with coordination support from Interior Health. Our model is being adopted across Interior Health providing local teams the opportunity to discuss local cases.
The Shared Care team continued to support and expand the monthly collaborative care sessions between psychiatrists and family physicians. These sessions, initiated in Castlegar by Dr. Sharman Naicker, now take place in Kaslo, Nelson, Salmo, and the Boundary with Dr. Bassingthwaighte, Dr. Magee and Dr. Naicker. A specialized child and youth collaborative care session was also piloted this past year with Dr. Iyiola.
This funding round concludes our current work with psychiatry. Most activities under this project will be sustained in the future through our CPD program. Our thanks to the hard working groups who pioneered these new partnerships for primary care teams and psychiatrists.
Child/Youth Mental Health
The Shared Care Child & Youth Mental Health Substance Use Collaborative has focused on three goals this year:
We launched the first local web resource for families and practitioners to link all child and youth mental health care services for the region in one place – www.kootenayfamilyplace.org/kbsearchlight. The impact – quick and easy access to the most current resource information for families and practitioners and improved referral processes and relationships between stakeholders.
27 GPs completing the CYMH PSP module through 2014/15 as well as critical reviews of wait lists and tests of change and complex cases at the committee level have improved collaborative approaches, increased support for the patient/family and strengthened provider relationships. Together these have contributed to increasing timely integrated access and wrap-around care for children, youth and families in Kootenay Boundary.
Through 2015/16, the Local Action Team will be engaged in a service redesign exercise with the goal of piloting a prototype in Kootenay Boundary aimed at increasing our understanding of and explore solutions for barriers to wrap around care, such as privacy and information sharing between organizations. We will also work on developing local/regional protocols to support children/youth who have been victims of sexual abuse or violence, and continue to engage and coordinate a multi-sectoral speaker series to provide meaningful community based CYMHSU education for teachers, students and parents.
After being chosen as a pilot site, 2014/15 saw the development of the Kootenay Boundary Pathways website – an amazing web-based resources that facilitates real-time, efficient, optimal patient referrals to specialists, clinics and selected additional healthcare services. An administrator has been hired and all KB specialists have provided detailed information and referral requirements for the website.
Alongside up to date info on local specialists including access to the lower mainland’s database (with Kelowna coming soon), Pathways includes hundreds of vetted clinical, and patient resources. Practitioners can also directly access the new KB Fetch community health listings website that provides a massive database of community health resources, also accessible to patients at kb.fetchbc.ca.
KB Pathways launched in June 2015 and will continue to be developed and updated with new resources through 2015. “I’m very impressed with KB Pathways, I have the site open regularly during clinic to use the calculators, patient resources and forms.” – Dr. Chuck Burkholder
Last year also saw the launch of the Kootenay Boundary Rapid Access to Consultative Expertise (RACE) phone advice line. Initially providing clinical access to psychiatrists for quick consultations to enhance physicians’ ability to better support patients in their clinics, the line now has three specialities.
The monthly calls from over 11 clinics have prevented ER admissions, unnecessary referrals for consults and were used to confirm care management plans and medications. RACE is looking forward to expanding in 2015 with more specialties as well as providing instant access through a smartphone app.
The RACE service continued development will be supported under a proposed new Shared Care project focus on tele-medicine.
Regional Diabetes Care
The Shared Care Regional Diabetes Project ran between April 2014 and March 2015. The goals of the project were to: develop relationships between care providers within Kootenay Boundary; introduce enhanced skills to primary health care practitioners; increase awareness of diabetes resources/ best practices; and develop priorities for diabetes care, including solutions to help build and sustain the delivery of optimal interdisciplinary diabetes care in the Kootenay Boundary.
The committee successfully met the first three goals by organizing and hosting a multidisciplinary Diabetes conference in January, 2015 with over 80 attendees including GPs, specialists, pharmacists, nurses, dieticians, and Interior Health staff. Providers agreed that as a result of the conference they are more aware of resources that are available for patients with diabetes as well as best practices. Additionally, they indicated that they have shared something they learned at the conference with a colleague, further spreading knowledge of diabetes resources and best practices among care providers. This increased awareness has also changed practice patterns among care providers, such as using the diabetes education centre and the dieticians in town.
The committee addressed the fourth goal by co-authoring and sharing a discussion paper regarding physician involvement in sustainable diabetes care. Specifically, the paper highlighted funding structures that could potentially make it more sustainable for physicians to participate in providing comprehensive and team-based care for patients living with diabetes. This is seen as a first step towards ensuring GP involvement in any model of interdisciplinary care that is developed in the future.
As a result of the collaborative work of the committee, changes have been made toward improving historical and geographical challenges in the Kootenay Boundary region. Together, these accomplishments have readied the Division to move into the next planned phase of developmental work. Some potential future opportunities identified by the regional diabetes committee for a future project or initiative to consider include:
Maternity – Child
Patient care has been the key focus for the Mat/child project under Shared Care projects in the past year. Over 62 hours of driving on Kootenay Boundary roads and $2,100 in travel costs for families were saved in 15 initial virtual appointments by the launch of tele-maternity in 2014. Sharing care between family physicians and their primary maternity care providers, the tele-maternity service is changing the way we offer care in our region.
Five rural clinics have been introduced to the video conferencing service, and three maternity care locations – Nelson, Trail and Penticton – have paired up with family physicians to support these patients at home. Nothing can compare to seeing a pregnant mom and her four-year-old daughter smiling after not having to drive for four hours to see their care provider.
This pilot in-office video conferencing service has laid the groundwork for increasing the number of specialities available for remote consultation in the coming year and inspired the expansion of virtual maternity care to obstetricians.
The Regional Perinatal Advisory Committee, co-lead by Dr. Trudi Toews and Dr. Raz Moola, has met regularly throughout 2014 / 15 to continue their collaboration bringing forward issues, sharing key information, and creating a venue for joint planning for maternity services in the Kootenay Boundary.
Other key accomplishments for this year include: providing physicians with a preferred practice guideline for high BMI patient care; working with Interior Health in developing a region-wide process for the same patients; providing a learning session by Dr. Jeanette Boyd for first trimester care at the Rossland medical conference with 60 participants.
Testing a model of team-based care, both the Family Obstetrics Clinic in Trail and Apple Tree Clinic in Nelson have hired lactation consultants to provide feeding clinics. Over 114 moms and babes have been seen in Trail, and 138 in Nelson providing feeding guidance and peer support between moms.
In January the committee hosted an engagement on perinatal mental health leading to this collaborative team’s next key focal area for the coming year.