Pulling It All Together March 6.09


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Marcia Carr Presentation March 6-7 2009

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  • Pulling It All Together March 6.09

    1. 1. "Pulling it All Together: Bridging the Gaps in Primary Care". Marcia Carr (RN,BN,MS,GNC(C),NCA) Clinical Nurse Specialist
    2. 2. Stating the Obvious Reality?
    3. 3. Older Adults <ul><li>Changes associated with “normal aging”, development of chronic diseases, atypical acute presentations, fixed income, increased psychosocial stressors, requires: </li></ul><ul><ul><li>Society’s valuing of aging and older adults </li></ul></ul><ul><ul><li>Specialized knowledge, skills, abilities </li></ul></ul><ul><ul><li>More time to manage care and more services </li></ul></ul><ul><ul><li>More money to provide the time to manage care and services </li></ul></ul><ul><ul><li>More coordination, navigation… </li></ul></ul>
    4. 4. Older Adults <ul><li>Aging population = dramatically increasing numbers needing health services and care </li></ul><ul><ul><li>Out-living their providers </li></ul></ul><ul><ul><li>Current providers not choosing to take on older adult patients = use of walk-in clinics </li></ul></ul><ul><li>Additionally, aging health care providers = fewer to provide the services and the care </li></ul><ul><ul><li>Providers not choosing to acquire geriatric or geriatric psychiatry specialization </li></ul></ul>
    5. 5. A Time to dialogue <ul><li>IHI targets “saving lives” by preventing identified sentinel events and/or care gaps in health care systems </li></ul><ul><li>Vision that primary care be the main partner with the patient that facilitates coordination and navigation for the patient through the health and illness continuum so that the sentinel events and care gaps are not just bridged but eliminated. </li></ul>
    6. 6. Gaps
    7. 7. #1: Communication Every time a patient receives care or services from a different provider, the potential for a sentinel event increases
    8. 8. Communication PATIENT Primary Care Provider Family, Significant Others, community Health Authorities’ Services Social Services Gov’t, Others Components connect to patient but not to each other
    9. 9. #2: Immediate Need Responsive Both patients and systems are in urgent, crisis, rescue mode
    10. 10. Immediate Need <ul><li>Immediate need to address a health or social issue is “driver” behind patient’s contact with primary care provider and/or services </li></ul><ul><li>“Quick fixes”? “Instant gratification”? </li></ul><ul><li>Need for immediate satisfaction or solution? </li></ul><ul><li>Effect and affect on older adults? Caregivers? Services? </li></ul>
    11. 11. #3: Control, In Charge Who should or actually holds the control or is in charge of the patient’s health and illness?
    12. 12. Control, In Charge <ul><li>What actually is patient-centred or patient-focused care? Happening or not? </li></ul><ul><li>Who…primary care physician? primary care provider? Health services? Family? Insurer? OR… </li></ul>
    13. 13. The PATIENT? Are we as health care providers responsible for their health/illness or is the patient?
    14. 14. Bridging or Eliminating the Gaps
    15. 15. Changing the Paradigm <ul><li>Ownership of their health/illness management is the responsibility of the patient to which they are accountable to themselves. </li></ul><ul><li>Adherence to the proposed health/illness management plan by the health care provider is also the patient’s responsibility </li></ul><ul><li>Consider being the “wellness coach” rather than director, dictator or controller of the patient’s care and management. </li></ul>
    16. 16. Motivational Interviewing <ul><li>Specific technique that shifts locus of health/wellness control to the patient </li></ul><ul><li>Behaviour changes are built upon patient’s intersecting levels of self-identified “ conviction” (benefits) and “confidence” (barriers to be overcome) based upon what the patient self selects to be their own health/wellness targets. </li></ul>
    17. 17. What is being done? <ul><li>Health Authorities are currently developing “integrated primary care health networks” </li></ul><ul><ul><li>Primary care providers (Family physicians and nurse practitioners) </li></ul></ul><ul><ul><li>Interdisciplinary HCP teams </li></ul></ul><ul><ul><li>Appropriate care by appropriate provider in a timely manner </li></ul></ul><ul><li>Database = minimum data system (Rai) </li></ul>
    18. 18. Propose PATIENT And Primary Care Providers Family, Significant Others, Community Social Services Gov’t Services Health Authorities’ Services Private Providers Patient and PCP partnership assures centralized communication
    19. 19. Care Transitions <ul><li>Eric Coleman’s work </li></ul><ul><li>4 Pillars </li></ul><ul><ul><li>Personal Health Record </li></ul></ul><ul><ul><li>Medication Reconciliation </li></ul></ul><ul><ul><li>Red Flags </li></ul></ul><ul><ul><li>Follow up </li></ul></ul><ul><li>Care transition coaches are empowering the patient to assure that they do not fall into the care gap. </li></ul>
    20. 20. Propose: PCP Database Central tracking for trending for prevention and services Other Social Issue Mental Emotional Issue Physical Issue Health Age Other palliative chronic management acute curative diagnostic preventive
    21. 21. What is being done? <ul><li>CDM provincial collaboratives, such as </li></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Falls and injury prevention, osteoporosis </li></ul></ul><ul><ul><li>Arthroplasty, fractured hip </li></ul></ul><ul><ul><li>Healthy Heart and diabetes </li></ul></ul><ul><ul><li>TIA, Stroke </li></ul></ul><ul><ul><li>Pathways (mental health) </li></ul></ul><ul><li>Specialized Older Adult Services </li></ul><ul><ul><li>Complex, frail clinics </li></ul></ul><ul><ul><li>Disease or syndrome specific (dementia, falls, OP) </li></ul></ul><ul><ul><li>ACE units, geriatric psych teams and units </li></ul></ul>
    22. 22. What is being done? <ul><li>Care provider collaboratives </li></ul><ul><ul><li>CGA, NICE </li></ul></ul><ul><ul><li>UBC Care of Elders, SFU, U Vic </li></ul></ul><ul><ul><li>BCNAR </li></ul></ul><ul><ul><li>CGNA, GNABC, BCGPA </li></ul></ul><ul><ul><li>ACGNN, GENI </li></ul></ul>
    23. 23. However, … Increasing numbers with fewer providers doing lion’s share of work to bridge gaps
    24. 24. The Here and the Now Time to Dialogue
    25. 25. Thank you [email_address]