Coordinating a community-wide approach to enhance residential care

One of the main challenges for patients residential care facilities across the province is getting timely onsite care. Elderly residents often end up being transferred to the emergency department if their physician cannot be reached. Not only are these trips costly to the system, they put vulnerable patients at risk with increased stress and exposure to infection and other illnesses.  

Access to onsite care was just one of the issues facing the nine publicly-funded residential care facilities in the White Rock-South Surrey (WRSS) area. The launch of the residential care prototype in 2011 created the opportunity for the WRSS Division of Family Practice to develop a coordinated, community-wide approach to facility-based medical support. The results have been impressive, with the number of emergency room visits and polypharmacy rates down substantially.

“Several years before the prototype, I’d agreed to become medical director at the facility across the street from my office because I wanted to help a vulnerable population,” explains White Rock-South Surrey residential care physician lead Dr Steve Larigakis. Apart from some sessional and regular fee-for-service payments, the role was voluntary and had to be balanced with a busy practice. Fortunately, Dr Larigakis’ business partner agreed to share the responsibility with him.

Across the region, a patchwork approach to care arose, with varying systems at each facility. What was needed was a coordinated system that enabled physicians to meet both residential patients’ needs and the many other demands on their time.

“When the residential care initiative launched, I was asked whether White Rock-South Surrey physicians would be interested in developing a prototype that focused on creating best practices,” explains Dr Larigakis. “So we held a meeting of all the facility medical directors and unanimously decided that if we worked together, we could improve the situation for everyone.”

Identifying Needs and Creating Solutions
To address the need for onsite care, the medical directors agreed to provide all nine facilities with 24/7 access to a physician by forming a call group. If a facility could not reach its own medical director, staff would call a centralized number to be connected to the on-call physician, who would provide onsite care as needed.  The medical directors also agreed to take on the role of Most Responsible Physician for patients awaiting attachment so they could be more quickly transferred from acute to long term care.

To enhance physicians’ expertise in providing care to the frail elderly population, the prototype included a provision for medical education sessions in which experts would share their knowledge on particular aspects of care and afterward physicians could share successes and troubleshoot solutions for things happening in their own facilities.

The prototype plan created greater physician presence at residential facilities and increased participation in patient care conferences with facility staff, families and patients. Reducing polypharmacy was a key focus of these conferences, which touch on all aspects of patient care.

Building on Success
When the prototype had been underway for four years, the Division undertook an in-depth evaluation process to assess its effectiveness.

Emergency room transfers dropped 45 per cent the first year and had fallen 60 per cent from pre-prototype levels by year two.  On average, polypharmacy rates dropped between 20 to 50 per cent.  Physicians, facility staff, patients and families all reported strong satisfaction with the new system and resulting enhancement in care.

Dr Larigakis credits the prototype’s success to two factors: having the funding to support change and the power of collaboration.

“As physicians, we often work in isolation and the collaboration that’s resulted from the prototype has been so beneficial,” says Dr Larigakis. “Working together to share knowledge and in-facility patient support has led to better continuity of care and we’ve been able to provide it in a way that’s manageable with our schedules. We’re working as a team with facilities and patients, which provides a higher level of satisfaction to all of us.”

Looking forward, White Rock-South Surrey physicians plan to focus on further reducing polypharmacy, expanding the prototype’s reach by inviting the medical directors of the area’s two private residential facilities to join the education sessions and call group, and building the initiative’s sustainability by mentoring new physicians with an interest in frail elderly care.

The GPSC’s residential care initiative is designed to enable physicians to develop local solutions to improve care of patients in residential care services. Since 2011, the initiative was prototyped by five divisions of family practice: Abbotsford, Chilliwack, Prince George, South Okanagan Similkameen, and White Rock-South Surrey. Building on the significant learnings of the prototype communities, in 2015, the GPSC committed up to $12m annually to expand the initiative to residential care patients in more than 90 communities across BC.