When a patient in residential care needs medical attention, facility staff need to connect with a physician as quickly as possible which often proved difficult. Staff in Chilliwack residential care facilities had identified this as a significant problem, so when the Chilliwack Division of Family Practice formed in 2010, solving this issue was one of their key priorities. With the residential care initiative, Chilliwack’s family doctors were able to focus on creating a solution that was specifically designed to meet the needs of patients in their community.
“As a medical director of a care facility, I saw the impacts of the uncoordinated, reactive care system we had in place,” says Dr Ralph Jones, Lead Physician on the Board of the Chilliwack Division of Family Practice and the Division’s first Residential Care Coordinator. “There was an appetite for improvement from everyone involved but the multiple demands on physicians’ time can be all-consuming. The GPSC’s support gave us the resources to drive change.”
Creating Clear Goals
As the first step in charting a new course, the Division’s board struck a residential care committee, stewarded by Dr Jones. Together, committee members identified three goals for their program:
- Reducing the number of patients transferred to the hospital’s emergency department;
- Decreasing polypharmacy, where patients take more than nine medications; and
- Clustering physicians, where a small number of physicians support most of the patients in particular care homes, rather than having many physicians with one or two patients in each facility.
Clustering was the Key
While reducing emergency department transfers and polypharmacy are common residential care goals across the province, for Chilliwack these were seen as benefits that would come, in part, as a result of increasing physicians’ presence at the facilities. Having more patients in a care home not only makes visits more practical for doctors, it creates a familiarity with staff and can lead to more proactive care.
“Clustering isn’t easy,” admits Dr Jones. “The patient mix is always changing and physicians are used to caring for their own patients. Of course, when you only have one patient it’s hard to justify leaving your busy practice, especially during the day. We worked hard to show people that clustering is in everyone’s best interests.”
Under the leadership of Dr Gordon Enns, the Division’s second Residential Care Coordinator, the Chilliwack team focused on clustering at two of the area’s seven facilities. As a result of these efforts, the number of physicians supporting patients at those facilities has dropped from 45 to 25, with each family doctor now caring for an average of seven or eight patients.
“We wanted everyone to be enthusiastic about this change, so we sought out physicians that were the right fit,” says Dr Jones. “We asked the facilities’ nurses which doctors they would most like to have working with them and then we approached those folks about signing on – more than 80% said yes.”
Physicians, the facilities’ nurses, and patients are happy with the results. With family doctors on site more, not only do a higher number of acute needs get addressed at the residential facility, there is also more proactive care. Taken together, this approach has achieved Chilliwack’s goal of reducing emergency department transfers.
Expanding Success Region-Wide
Movement towards clustering at Chilliwack’s five remaining facilities is already underway. Looking ahead, Dr Jones sees an increased focus on polypharmacy.
“There’s been some reduction but we believe it can further improve if we more actively drive that part of the program,” he says. “To be successful, we must actively manage the process, provide physicians with tools to help them and ensure there is appropriate compensation. The residential care initiative will provide us with the ability to do that.”
Medication reviews are already part of annual patient care conferences, where patients and all those involved in their care come together to review the patient’s health status and plan for the future. The Chilliwack Division is increasing its focus on reducing polypharmacy with education sessions for physicians and support in building medication reviews into proactive 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.