Integrated Primary Care Teams: A key to transforming local health care
Patients and caregivers tell us their needs are not always being met. They say that their health care providers seem “disconnected” from each other. Patients with complex needs tell us they are confused by all of the agencies and providers in their circle of care. They say they want a “go to” person – someone they trust to help them lead their care. They want one care team, made up of fewer providers coming in and out of their homes. Patients say they don’t always want more services or resources. They want better connected and coordinated care supported by providers with whom they have a relationship.
Providers tell us that they work so hard to provide patient-centred care but feel the system limits how well that can be accomplished.
The Guelph and Area OHT (G&A OHT) is transforming our system to ensure the hard work of providers can more effectively and efficiently address the needs of our patients and caregivers.
Our transformation plan is building on what providers in Guelph and Area already do REALLY well – delivering team-based primary care to patients. Within the Guelph and Area health system there is an established culture of trust-based relationships between providers and organizations that has resulted from leaders committed to working together to deliver collaborative care. The G&A OHT will build on this trust to advance our vision of a fully integrated delivery system of care that meets the needs of ALL of our residents.
As a picture can say a thousand words, a real world example gathered at one of our engagement sessions poignantly captures how a disconnected system ill-serves those who need its care the most.
My husband had advanced liver & kidney disease with uncontrolled ascites…along with many other problems. He could barely walk, could not use his hands, unable to eat, difficulties with toileting and bathing and the list goes on. I cannot comprehend why the many health care providers involved in Ray’s care failed to acknowledge his deteriorating condition and increasing needs. No one was willing to step forward to ensure Ray received the care he needed. There was a lack of teamwork. More than once I stood on the curb outside of the hospital or doctors’ offices, with Ray in a wheelchair and wondered what to do next. One doctor that we saw during one of our many visits to the emergency department stated, “This man needs an Alternate Level of Care.” We never saw that doctor again nor was any action taken.
What do I want? I want care coordinators to actually talk to their patients, to listen to them and to their family members. I want care coordinators to apply established tools so they can identify a patient in need of help. I want them to be able to note when a patient is getting worse. Just looking at Ray it should have been obvious he was in a crisis situation. This does not just apply to care coordinators… but to every care giver in whatever their capacity. It is not the “other guy’s” responsibility. It is the responsibility of everyone. I want team work. I want coordination of care. I want patient-centred care. I accept that Ray died. But I do not accept a health care system that denied him the care he needed and was entitled to.
In the G&A OHT, every person will belong to an ‘Integrated Primary Care Team’ (IPCT)
These teams will deliver all primary care to patients – in-home and in-office, where and when they need it. Care may include psychological and behavioral health care, screening and prevention, wellness and health promotion. IPCTs will support access and social care including transportation, interpretations/language services, accompaniment and advocacy. The needs of caregivers will also be met by IPCTs.
When the needs of the patient exceed the capacity, capability of the IPCT, secondary/specialized providers will be invited to join the patient’s care team. For example, when a patient’s needs require acute care, the acute care providers will become part of the patient’s care team. Similarly, when a patient has in-home care needs beyond the capacity, capability or intensity of the IPCT, providers from the ‘Service Provider Organization” (SPO) will be invited to join the patient’s care team.
In the Guelph and Area OHT, our plan is each IPCT will work with a single SPO that will deliver the full suite of in-home services to all patients attached to the IPCT. Interdisciplinary providers from the Service Provider Organization will work as part of the IPCT as required by patient needs. This will support the development of trust and relationships between providers on the IPCT and will optimize integrated, coordinated, streamlined care.
Each patient will have a “Go-To” person. This is someone they know and trust who will be responsible for ensuring all of the patient’s needs are addressed in a timely and proactive manner. The Go-To person will ensure the patient and their family have all of the information they need to be an active member of their own care team and will ensure members of the care team have the information they need to most effectively and efficiently meet the patients’ needs. The Go-To person will support transitions between settings and optimize the patient and caregiver experience.
In an IPCT, care coordination will be integrated across existing roles of the patient’s care team. Some functions may be best delivered to the patient by the IPCT Social Worker in the primary care team office. Other functions of care coordination may be most ideally provided by the nurse or Personal Support Worker who is visiting in the patient in their home. Other functions of care coordination may be provided by the person’s ”Go-To” person.
Providers on IPCTs will share and contribute to each patient’s care plan and will use digital health technology to optimize timely access to the required care. Patients will have the desired level of access to their own health information.
In summary, IPCTs will streamline and simplify how care is delivered and experienced by centralizing care delivery and accountability and by building a relationship-based care team with and around each patient in the Guelph and Area OHT. This vision is going to require us to transform how we will work within our respective scopes of practice and how we work with each other within and across our organizations. We will work with our providers to design models of care delivery that ensure the functions are distributed in a sustainable and patient-centred manner.