Champlain Cvd Prevention Strategic Planning 2013-2016

CHAMPLAIN CVD PREVENTION STRATEGIC PLANNING 2013-2016

EXPERT TASK GROUP RECOMMENDATIONS REPORT

REGIONAL PRIMARY CARE CVD STRATEGY

INTERIM REPORT

JUNE 2012

MEMBERSHIP

TABLE 1: JOINT LEADERSHIP TABLE

TABLE OF CONTENTS

1.0 Backround 4

2.0 Environmental Scan 5

3.0 CCPN Primary Care Initiatives 2007-2012 7

4.0 New Priority Areas For 2013-2016 Identified By Joint Family Health Team Leadership Group 10

5.0 Next Steps 11

Appendix 1 – Profile Of Champlain FHTs 12

Appendix 2: Champlain Family Health Team Survey 13

REGIONAL PRIMARY CARE CVD STRATEGY

INTERIM REPORT

1.0 BACKROUND

The Champlain Cardiovascular Disease Prevention Network (CCPN) has been working with primary care since its inception. Guided by its 2007-2012 Champlain CVD Strategy, the CCPN introduced three programs into the primary care setting: the Improved Delivery of Cardiovascular Care, Champlain Primary Care CVD Prevention and Management Guideline, and the Ottawa Model for Smoking Cessation in Primary Care.

As part of the planning activities for the 2013-2016 Champlain CVD Prevention Strategy, the development of a regional primary care CVD strategy was identified as one of the short-listed priority areas. It was also determined that this work would be focused on collaboration with Family Health Teams.

To help inform the development of its 2013-2016 Champlain CVD Prevention Strategy, CCPN in partnership with the University of Ottawa Heart Institute has established a Joint Family Health Team Leadership Table. The Leadership Table is comprised of the Physician Lead and Executive Director from each of the 22 Family Health Teams in the Champlain region along with senior leaders from CCPN, University of Ottawa Heart Institute, Champlain LHIN, Dept. of Family Medicine at the University of Ottawa, and Elisabeth Bruyère Research Institute.

The purpose of this Leadership Table is to:

·  Develop closer working relationships and innovative ways of working together to address the needs of patients and reduce the burden of CVD.

·  Obtain feedback on the current CCPN program offering in primary care.

·  Identify specific opportunities to collaborate with Family Health Teams to improve the delivery of care for the primary, secondary and tertiary prevention of CVD over the next 3 years.

PLEASE NOTE: This is an interim report outlining the recommendations going forward for CCPN’s current primary care priority initiatives, however, the Leadership Table has identified the development of a “collaborative care” model as a new area for collaboration and the work to develop a recommended model is currently underway. A final report is expected to be ready early this fall.

2.0 ENVIRONMENTAL SCAN

2.1 Provincial Context

Primary Care in Ontario

The Ontario Ministry of Health and Long-term Care (MOHLTC) has worked over the past decade to reform primary care and develop a menu of innovative and attractive compensation models that are aimed at rewarding family physicians for providing comprehensive primary care services to their patients. As a result, Ontario has seen a considerable expansion of interdisciplinary primary care teams comprised of Community Health Centres, Family Health Teams, and Nurse Practitioner-Led Clinics. The figure below provides a snapshot of the transformation.

Figure 1: Transformation of Primary Care in Ontario

Ontario Family Health Teams

Family Health Teams (FHTs) are health care organizations that include a team of family physicians, nurse practitioners, registered nurses, social workers, dietitians, and other professionals who work together to provide health care for their community. They ensure that people receive the care they need in their communities, as each team is set-up based on local health and community needs. They focus on chronic disease management, disease prevention and health promotion, and work with other health care organizations, such as public health units and Community Care Access Centres.[1]. FHTs are a key part of Ontario’s plan to build a stronger health care system through better access to doctors and nurses and reduced wait times for services.

Role of Family Health Teams in Ontario’s Health Action Plan[2]

To improve access to family health care and reduce wait times across the province, the Ontario government has created and expanded new primary care models, including Family Health Teams, Community Health Centres, and Nurse Practitioner-Led Clinics as discussed above, opened 200 Family Health Teams across the province providing care to over 2.7 million Ontarians and expanded the roles of nurses, physician assistants and other practitioners, to name a few.

Family care providers are a natural anchor for patients in the health care system. They are well positioned to help patients navigate the system, particularly patients with multiple complex conditions. The province wants family care providers to spend less time referring a patient and spend more time with their patients. The province will be working with doctors and all health providers to strengthen the role of family health care in our system, it improves patient care, supports a better quality of practice for doctors and reduces the likelihood that patients will be admitted, or readmitted, to hospital, As a result, the province, through the LHINs, will hold the entire health system accountable for substantial progress towards fewer hospital readmissions.

Integrated Vascular Health Blueprint (formerly Ontario Integrated Vascular Health Strategy – OIVHS)

In August 2011, Cardiac Care Network of Ontario, Ontario Stroke Network and Heart and Stroke Foundation of Ontario formed a coalition to facilitate the development of a province-wide vascular health blueprint prioritizing activities common to stroke, cardiac and peripheral vascular disease.

The Blueprint is expected to be released at the end of June 2012 with the implementation work to follow in the fall. One of the first steps will be the formation of Regional Vascular Collaboratives. These are expected to be LHIN based groups that will be able to tailor provincial initiatives to meet the needs and nuances of each LHIN. As well, the Collaboratives will support knowledge exchange with the implementation steering committee, at the local level and between regions.

2.2 The Local Context

Champlain’s 22 Family Health Teams

Since April 2005, 22 FHTs have been created across the Champlain LHIN. Please refer to Appendix 1 for a snapshot of FHTs in the Champlain region. All Family Health Teams have a Physician Lead and Executive Director and Board of Directors. Each team has received funding as part of the MOHLTC for the creation of an intra-disciplinary team of health professionals. The exact staffing model varies across teams in accordance with their size and clinical programs.

Regional FHTs vary in size. They are as small as one physician as is the case with the North Renfrew FHT to teams with 25 or more physicians. All FHTs have at a minimum one nurse practitioner on staff and larger teams have additional health professionals on staff such as a pharmacist, dietician, etc. The number of patients rostered ranges from 4,000 for the small ones to 20,000 for larger teams.

It is important to note that of the 22 FHTs in the region some have been in place since 2005 as part of the first wave of FHT approvals from the MOHLTC. Other teams are newer and may have only begun operations in the last 12-24 months. It is also important to note that all FHTs have an Electronic Medical Records system in place to manage patients’ health information electronically and eliminating duplication of effort during a patient’s visit by providing secure access to standardized information. In addition, FHTs can receive information from hospitals and labs faster, allowing for better coordination of care among health care professionals. Currently there are four different EMRs in use among Champlain FHTs.

Survey of Champlain FHTs

A survey of Champlain FHTs was taken to document characteristics of FHTs, receive feedback on existing CCPN programs, and identify new areas for collaboration. The results of the survey are presented in Appendix 2.

Champlain LHIN

To strengthen and further integrate primary care into local health planning, the Champlain LHIN recently appointed, Dr. Jacques Lemelin as the region’s Primary Care Lead. The introduction of a Primary Care Leads into LHINs has been endorsed by both the MOHLTC and the Ontario Medical Association and is in line with Ontario's Health Care Action Plan’s commitment to bring planning for the full patient journey under the LHINs. Through this collaborative work, local primary care providers can strengthen these partnerships and focus on implementing system initiatives identified locally through extensive community consultation to address local health care challenges.

3.0 CCPN Primary Care Initiatives 2007-2012

To align with the MOHLTC’s primary care direction and given CCPN’s limited resource capacity, the Leadership Table has been narrowed to FHTs at this time. However, as CCPN builds capacity and has a proven best practice in FHTs, other primary care models will be considered. As an example, the Ottawa Model for Smoking Cessation in primary care was originally rolled out to FHTs, however, expansion to CHCs is being proposed as part of the 2013-2016 Champlain CVD Prevention Strategy.

Below is a summary of the three Primary Care Initiatives undertaken from 2007-2012 and recommendations for these initiatives for 2013-2016 CVD Prevention Strategy based on feedback from the pre-meeting survey and kick-off Leadership Table meeting held April 18, 2012.

3.1 IMPROVED DELIVERY OF CARDIOVASCULAR CARE (IDOCC)

The Improved Delivery of Cardiovascular Care (IDOCC) Program was one of the six priority initiatives implemented as part of the 2007-2012 Champlain CVD Strategy. IDOCC was designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices. IDOCC involved Outreach Facilitators working with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk.

The intervention consisted of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices were supported in changing practice behavior by incorporating chronic care model elements. These elements included (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients.

This study has been led by Dr. Clare Liddy. Clinical Investigator, C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute.

Summary of Achievements & Outcomes (March 31, 2012):

Process: 182 physicians in 83 primary care practices participated in IDOCC.

Outcome: Phase 1 Report - June 30, 2011; Phase II Report - June 30, 2012 (pending).

The Phase 1 Report examined changes in practice adherence to cardiovascular care guidelines and patient clinical outcomes for the 26 practices during the two-year intervention timeframe. Data was collected for this analysis via chart audits performed one year prior to the initiation of the study (baseline) and during both intervention years (i.e., intensive and sustainability years). Data collected from

1,601 patient medical charts within the 26 practices were very promising, as there were consistent improvements in quality of care and patient clinical outcomes. Specifically, the most consistent process improvements seen amongst the 26 practices were in the areas of smoking cessation care, chronic kidney disease, and diabetes management, while promising trends in patient clinical outcomes were seen for lipid levels. Although the interim findings are promising, the sample size analyzed in Phase I report is not sufficient to draw any definitive conclusions about this intervention yet. The intervention was completed in March 2012 and is currently in the data collection and analysis phase with a more comprehensive report being released end of June 2012.

Proposed Recommendation(s): Examine methods by which we can build on the IDOCC network in our region. A meeting requested with EBRI in fall 2011 has been scheduled for June 20, 2012.

3.2 CHAMPLAIN CVD PREVENTION AND MANAGEMENT GUIDELINES

Complementing the IDOCC project is the Champlain Primary Care Cardiovascular Disease Prevention and Management Guideline. This desktop resource, developed by more than 45 local specialists and family physicians, provides primary care physicians and health professionals with the latest evidence in preventing and managing heart disease, stroke, diabetes and their associated risk factors (hypertension, cholesterol, chronic kidney, disease, smoking cessation, physical activity, obesity/ weight management). The Guideline is tailored to primary care physicians working in the Champlain region and includes links to relevant local community resources. It is available in two formats – desktop manual and web-based downloadable pdf (idocc.ca).