VCHA  Urban  Primary  Care  Clinic  Review  Fall  2013  External  Reviewer  Report  December  2013              Prepared  by:  Dr.  Garey  Mazowita  Head,  Family  and  Community  Medicine,  Providence  Healthcare  &    Vicki  Farrally  Praxis  Management        Final,  January  22,  2014    Section  One:  Background  and  Approach    1.1  Background  • Vancouver  Coastal  Health  (VCH)  is  conducting  a  review  of  its  six  Urban  Primary  Care  (UPC)  Clinics  to  assist  in  determining  the  future  direction  for  its  primary  health  care  services,  including  which  “high-­‐needs”  populations  should  be  served  by  these  clinics  and  the  right  service  model  within  the  context  of  available  funding.    • Six  UPC  Clinics  are  included  in  this  Review:  Evergreen,  Ravensong,  Pacific  Spirit,  South,  and  Pine  Street  Clinics,  each  owned  and  operated  by  VCH,  and  the  Mid  Main  Community  Health  Center,  a  non-­‐profit  society  receiving  partial  funding  from  VCH.    This  review  is  intended  to  provide  the  opportunity  to  revitalize  and  better  support  these  clinics,  consistent  with  the  provinces’  ambitious  agenda  for  a  more  integrated  and  interdisciplinary  primary  health  sector.    • VCH  operates  a  number  of  similar  clinics  in  the  inner  city  and  funds  the  REACH  Community  Health  Center.    It  is  understood  these  may  be  the  subject  of  a  separate  review.  Several  other  primary  care  services,  such  as  Primary  Care  Outreach  Teams,  are  not  funded  by  VCH’s  Community  Division  and  so  are  outside  of  the  scope  of  the  review.      1.2  Approach  • Two  external  reviewers,  Dr.  Garey  Mazowita  (Head,  Family  and  Community  Medicine,  Providence  Healthcare)  and  Vicki  Farrally,  a  health  system  consultant,  (the  reviewers)  were  invited  to  participate  the  review  process  to  provide  an  independent  perspective.    Specifically,  we  were  asked  to  conduct  a  set  of  interviews  with  senior  administrative  and  clinical  representatives  from  each  UPC  Clinic  and  with  several  community  stakeholders  and  provide  VCH  with  a  summary  of  our  observations  and  conclusions  and  a  brief  set  of  recommendations.        • VCH  provided  orientation  materials,  including  descriptions  of  each  clinic;  a  recently  completed  analysis  of  panel  size,  workload,  and  complexity  data  for  each  site  and  the  program  as  a  whole;  and  a  questionnaire  completed  by  each  to  describe  its  role,  functioning,  and  current  challenges.        • We  met  with  VCHA  representatives  twice  to  review  these  materials,  consider  their  observations,  and  explore  their  preliminary  thoughts  as  to  potential  opportunities  for  change  and  improvement  across  the  UPC  Clinics.    • The  interviews  were  conducted  in  a  single  day,  each  less  than  an  hour  in  duration.  Because  of  this  limited  time,  each  UPC  Clinic  was  invited  to  summarize  their  completed  questionnaire,  highlight  areas  they  wished  to  emphasize,  and  add  any  additional  information  they  felt  would  be  useful.    Community    2  stakeholders  were  asked  about  their  knowledge  of  the  role  of  the  UPC  Clinics  and  their  services  and  queried  as  to  their  perception  of  the  utility  and  relevance  of  these  clinics  to  their  respective  organization.      •  •Despite  the  brevity  of  the  interviews  they  were  viewed  as  having  been  very  productive,  with  respondents  being  forthright  in  outlining  their  key  issues  and  responding  to  questions.    We  are  cognizant  of  the  limitations  of  brief  subjective  interviews  and  anecdotal  comments  so  have  focused  the  majority  of  our  comments  on  the  key  themes  that  emerged  repeatedly  during  the  interviews.      We  note  that  the  UPC  Clinics  serve  a  relatively  small,  albeit  important,  proportion  of  Vancouver’s  population,  since  the  majority  of  primary  care  is  provided  by  private  fee-­‐for-­‐service  (FFS)  physician  practices.  Given  this,  one  reviewer  attended  the  November  2013  meeting  of  the  Inter-­‐divisional  Collaborative  Services  Committee,  at  which  the  Co-­‐Chairs  tabled  the  issue  of  the  management  of  high-­‐high-­‐need  patients  for  general  discussion,  a  summary  of  which  is  included  in  the  following  section.    Section  Two:  What  We  Heard  -­‐  Key  Observations    2.1  Interviews      A.  Program  and  Service  Model    • VCH’s  six  UPC  Clinics  were  established  at  different  times  between  the  1960s  through  to  the  mid  2000s.    Although  the  precipitating  factors  were  different  for  each  clinic,  the  overriding  purpose  was  to  improve  access  to  primary  health  care  for  populations  recognized  as  not  being  well  served  by  traditional  FFS  primary  care.    Each  clinic  focuses  on  a  different  population  segment  or  target  group,  each  with  unique  health  and  social  care  needs,  as  described  in  more  detail  in  the  following  section.      • The  most  recent  clinics  were  established  specifically  to  demonstrate  new  models  of  multidisciplinary  primary  health  care,  a  key  objective  of  the  2000-­‐2006  Primary  Health  Care  Transition  Fund  (PHCTF).    However,  with  the  end  of  the  PHCTF  funding  stream,  the  province’s  primary  care  policy  shifted  to  strengthening  traditional  private  practice.    The  2006  negotiated  agreement  between  the  government  and  the  British  Columbia  Medical  Association  (BCMA)  formalized  the  General  Practice  Service  Committee,  establishing  its  mandate  to  improve  the  existing  primary  care  system  rather  than  adopting  new  structural  changes,  such  as  community  health  centers  with  salaried  family  physicians  (Cavers,  et  al.,  2010)1.                                                                                                                1  Cavers, W.J., Tregillus, V.H., Micco,A., & Hollander, M. J. (2010). Transforming family practice in British Columbia: the GeneralPractice Services Committee. Canadian Family Physician, 56(12), 1318-1321.    3  Consequently,  further  development  and  expansion  of  interdisciplinary  clinics  and  non-­‐fee-­‐for-­‐service  (FFS)  physician  payment  models  was  largely  abandoned.    Existing  clinics  were  maintained,  possibly  because  the  majority  of  their  operating  budgets  are  physician  payments  from  the  provincial  Alternative  Payment  Funding  Program  (APP)  and  can’t  be  reallocated  to  other  purposes.  Some  clinics  also  benefited  from  new  nurse  practitioner  (NP)  positions  and  funding  made  available  by  the  provincial  Nurse  Practitioner  Program.  However,  in  the  absence  of  provincial  policy  support  for  interdisciplinary  models,  the  UPC  Clinics  have  had  little  scrutiny  or  additional  resources  in  the  last  decade.  •  •Give  this,  it  is  not  surprising  that  we  heard  little  during  the  interviews  to  suggest  that  the  six  UPC  Clinics  operate  as  a  cohesive  and  coordinated  program,  for  example  with  a  common  vision  or  a  defined  team  or  service  delivery  model.  There  is  no  overall  strategic  plan  setting  out  the  program’s  goals  and  objectives  and  clinics  do  not  share  common  operating  policies  and  procedures  or  collaborate  on  processes  such  as  professional  development  or  education.    •We  were  told  that  VCH  has  not  regularly  monitored  service  utilization  metrics  (e.g.  referrals,  new  cases,  closed  cases,  etc.),  nor  has  quality  and  outcome  evaluation  been  conducted.  We  also  heard  that  internal  quality  assurance  processes,  such  as  routine  chart  review,  rounds,  professional  education,  etc.  have  not  been  put  in  place.      •A  first  step  in  most  program  evaluations  is  the  assessment  of  fidelity  against  a  defined  program  or  service  model,  its  operation  within  defined  parameters,  and  its  results,  i.e.  structure,  process,  and  outcomes.    We  saw  no  evidence  of  documented  program  model  and  so  we  are  unable  to  comment  on  the  extent  to  which  the  UPC  Clinics,  individually  or  as  a  group,  align  with  VCH  expectations.      B.  Interdisciplinary  Team/Professional  Practice  • The  composition  of  the  clinical  teams  varies  from  clinic  to  clinic,  seemingly  based  mostly  on  whatever  resources  became  available  over  a  number  of  years  rather  than  reflecting  a  specific  service  model  intended  to  meet  the  health  needs  of  a  specific  target  population.      • Although  described  as  interdisciplinary  clinics,  we  observed  that  the  majority  of  providers  are  physicians,  paid  on  sessions,  clinical  service  contracts  or  salary  through  the  provincial  APP.    Although  most  clinics  also  have  a  registered  nurse  (RN)  and  in  some  cases  a  NP,  counselor,  and/or  part  time  pharmacist,  the  ratio  of  physicians  to  other  providers  is  much  higher  than  one  would  expect  in  an  interdisciplinary  community  clinic  serving  a  high-­‐need  clients.    • There  were  several  reports  of  vacated  RN  and  NP  positions  not  being  filled  for  long  periods  of  time  due  to  budget  restraints.  Where  the  vacated  position  represented  the  sole  non-­‐physician  provider,  this  delay  virtually  eliminated  that    4  team’s  “interdisciplinary”  aspect.  We  also  heard  that  in  some  clinics,  the  respective  roles  and  responsibilities  for  NPs,  RNs,  and  other  providers  have  not  been  clarified  and  this  has  led  to  confusion  and  practice  inefficiencies.    •  •  •  •  •  •We  heard  that  the  overhead  payment  associated  with  each  APP  physician  FTE  has  been  eroded  over  time  and  this  reduction  in  medical  office  assistant  (MoA)  support  is  perceived  to  contribute  to  inefficiencies  and  suboptimal  patient  care.    Some  physicians  also  expressed  frustration  with  their  lack  of  control  over  how  this  MoA  support  is  determined  and  managed.  These  observations  suggest  that  many  UPC  Clinic  physicians  practice  more  as  independent  primary  providers  than  as  members  of  an  interdisciplinary  collaborative  team.  As  well,  many  provide  clinical  services  likely  better  managed  by  a  RN  or  counselor  and  assume  administrative  work,  such  as  data  entry  and  file  management,  more  efficiently  handled  by  a  support  staff.      Although  we  noted  recently  increased  physician  administrative  leadership,  we  observed  little  evidence  of  organized  physician  clinical  leadership  on  key  policy  and  practice  issues,  either  within  individual  clinics  or  across  the  program  as  a  whole.    Several  physicians  commented  they  have  little  opportunity  to  provide  input  to  or  influence  clinic  policy  or  operational  decisions.  Coupled  with  the  aforementioned  absence  of  formal  quality  improvement  processes  or  an  established  professional  development  agenda,  this  gives  us  concern.      In  the  case  of  NPs,  we  heard  that  despite  widely  recognized  sensitivities  associated  with  introducing  NPs  into  existing  teams,  in  some  cases  the  physicians  were  not  consulted  or  included  in  the  hiring  process.    We  also  heard  that  there  had  been  little  work  devoted  to  articulating  their  new  roles  and  responsibilities  or  establishing  appropriate  working  relationships.  This  is  seen  to  have  led  to  professional  conflict  and  even  resignations.  Clearly  the  potential  associated  with  adding  new  NPs  to  these  teams  has  not  been  optimized.  Clinic  respondents  also  noted  the  staffing  levels  in  such  small  clinics  is  a  major  barrier  to  providing  the  24/7  access  required  by  many  high-­‐need  clients,  although  VCH  advised  they  have  worked  with  the  clinics  to  develop  an  on-­‐call  roster  of  physicians  or  NPs  to  respond  to  patient’s  calls  after  regular  hours.    In  conclusion,  we  observed  a  lack  of  what  may  be  best  described  as  the  overarching  “culture  of  care”  that  is  essential  to  fostering  patient  access,  creating  team  ethos,  and  providing  mutual  support  for  all  staff.    From  the  VCH  perspective,  we  saw  little  to  suggest  a  participatory  management  style  that  would  encourage  the  clinics  to  be  invested  in  providing  effective  and  efficient  patient  care  or  providers  to  feel  they  “have  a  voice”  in  the  design  or  operation  of  the  UPC  Clinic  program.        5  C.  Target  Population  • We  heard  that  each  clinic  services  a  different  high-­‐needs  target  population  recognized  as  not  being  well  served  by  traditional  private  practice:  • The  South  Clinic  reported  serving  predominately  refugees  and  new  immigrants,  many  of  whom  do  not  speak  English  and  have  recently  arrived  in  Canada  with  “delayed”  primary  health  care  needs.  Many  of  its  female  clients  are  culturally  unable  to  be  seen  by  male  physician  and  so  the  clinic  has  assumed  a  major  role  in  reproductive  health;  • Pacific  Spirit  CHC  reported  accepting  an  increasing  number  of  referrals  of  patients  residing  in  residential  care  facilities  and  homebound,  frail  elderly,  and  palliative  care  patients,  many  referred  by  private  physicians  who  no  longer  are  willing  to  manage  their  complexity  of  care  or  provide  the  outreach  service  to  home  and  facilities;    • Evergreen  and  Ravensong  reported  providing  comprehensive  primary  care  to  marginalized  people  with  complex  care  issues,  the  majority  with  serious  mental  illness  and/or  addiction  issues;    • Pine  Street  Clinic  has  focused  on  the  needs  of  at-­‐high-­‐need  youth  and  young  adults  from  across  the  city  since  the  1960s  and  also  provides  urgent  primary  care  services  for  uninsured  individuals;  and  • Mid  Main  has  a  large  population  of  low-­‐income  seniors,  young  families,  and  new  immigrants  living  in  that  community  and  like  Pacific  Spirit,  reports  increasing  number  of  residential  care  patients.      • VCH  communicated  to  us  their  preference  to  focus  the  UPC  Clinics  on  “the  most  vulnerable”,  estimated  as  5%  of  the  Vancouver  population.    We  also  noted  that  a  number  of  need-­‐descriptors  were  used  interchangeably  throughout  our  discussions  with  VCH,  e.g.,  medically  complex,  high-­‐high-­‐need,  high-­‐needs,  high-­‐users,  frequent-­‐users,  unattached,  orphan,  under-­‐served,  etc.    On  the  other  hand,  the  UPC  Clinics  described  their  clients  by  population  segments,  i.e.  new  immigrants,  marginalized  people,  people  with  mental  health  and  addictions  problems,  frail  elderly,  and  street  youth,  etc.,  not  by  the  need-­‐descriptors,  with  the  understanding  that  these  populations  have  high-­‐needs.      • This  simple  difference  in  how  the  target  population  is  described  reflects  the  current  confusion  about  clinic  purpose,  focus,  and  role  and  thus  patient  eligibility.    VCH  advised  us  that  initiatives  to  refocus  the  UPC  Clinics  on  vulnerable  and  more  medically  complex  patients  were  introduced  in  2009.  Several  clinic  respondents  expressed  confusion  with  this  direction,  believing  they  are  already  serving  high-­‐needs  patients  who  otherwise  would  go  without  primary  care  or  use  more  expensive  services  such  as  emergency  departments.  They  acknowledge  that  not  all  patients  are  high-­‐need  all  of  the  time,  but  suggest  they  already  have  discharged  most  of  those  suitable  for  regular  FFS  practice.            6  •  •  •  •  •We  also  heard  that  the  clinics  recently  were  directed  to  identify  their  lower  complexity  patients  and  transfer  them  into  FFS  practices  and  to  develop  a  “flow  through”  policy,  i.e.  a  process  by  which  patients  initially  accepted  on  the  basis  of  their  need  for  intensive  or  interdisciplinary  care  are  referred  to  FFS  practices  as  they  stabilize.  This  direction  has  met  with  considerable  resistance,  clinics  perceiving  it  as  contradicting  a  core  principle  of  family  medicine,  i.e.  continuity  of  care,  and  at  odds  with  the  current  focus  on  increasing  patient  attachment,  especially  for  high-­‐need  patients.    Importantly,  it  is  seen  to  substantively  change  the  overall  and  long-­‐term  mandate  of  the  UPC  Clinics  from  providing  better  access  to  longitudinal  comprehensive  primary  health  care  for  underserved  populations  to  triage  and  brief  transitional  care.      Respondents  asked  the  very  real  question  of  where  these  “transitioned”  patients  will  receive  their  longitudinal  primary  care  in  future.    It  is  widely  recognized  that  few  private  practices  are  accepting  new  patients  and  virtually  none  currently  have  the  additional  resources,  staff  and  expertise  to  manage  patients  with  complex  and  intertwined  health  and  social  needs.  The  assumption  that  high-­‐needs,  often-­‐chaotic  patients,  who  bounce  in  and  out  of  acute  care  and  have  a  long  history  of  failure  to  engage  with  or  “attach”  to  a  regular  primary  care  provider,  can  be  successfully  transitioned  and  attached  to  family  practice  was  frankly  challenged.  We  agree  that  expecting  private  practices  to  absorb  and  maintain  potentially  unstable  and  high-­‐needs  patients  without  additional  support  is  unrealistic.  As  well,  we  understand  that  each  UPC  Clinic  must  make  its  own  arrangements  with  private  practices  to  transfer  lower-­‐acuity  patients  and  presumably  also  make  arrangements  for  these  patients  to  return  if  their  relationship  with  the  private  physician  fails  (we  note  that  most  private  practices  respect  patient  choice  in  the  selection  of  a  provider,  and  so  “assignment”  of  patients  is  unlikely  to  be  seen  as  acceptable).  This  burden  on  individual  UPC  Clinics  also  appears  unrealistic.    We  were  advised  that  early  in  2013,  VCH  introduced  a  centralized  screening  and  referral  process  for  its  CHCs  and  clinics,  operated  by  Home  and  Community  Care.    During  out  interviews,  every  clinic  described  this  new  system,  which  relies  on  voice  mail  messaging  and  call-­‐back,  as  slow  and  unresponsive.    In  addition,  there  were  reports  of  considerable  confusion  about  its  purpose.    VCH  staff  suggested  the  system  is  intended  to  make  the  UPC  clinics  more  visible  and  accessible  to  emergency  departments  and  family  practice.    However,  all  of  the  clinic  respondents  interviewed  advised  us  that  the  new  system  is  widely  perceived  to  be  the  sole  referral  mechanism  to  the  UPC  Clinics  and  rather  than  expediting  appropriate  referrals,  has  virtually  eliminated  all  new  referrals.        7  •  •Representatives  from  Vancouver’s  emergency  departments  (ED)  indicated  that  they  have  little  awareness  of  the  UPC  clinics  and  don’t  consider  them  as  a  resource.    However,  a  respondent  from  associated  with  MH&A  services  reported  on  a  recent  review  of  40  emergency  department-­‐identified  “familiar  faces”  (previously  known  as  frequent  fliers  or  high  users)  identified  as  mental  health  and  substance  use  clients  and  rated  low  acuity  for  the  purpose  of  that  ED  visit.    Three-­‐quarters  of  these  patients  reportedly  had  an  open  file  with  a  VCH  community  health  centre  offering  primary  care,  although  not  necessarily  with  a  UPC  given  the  majority  resided  in  the  Downtown  Eastside.  Importantly,  the  ED  patient  review  highlights  that  the  primary  care  needs  of  people  with  serious  mental  illness  may  not  be  adequately  met  even  when  they  are  registered  with  a  primary  care  clinic  or  a  fee-­‐for-­‐service  primary  care  provider.  This  gap  needs  to  be  better  understood.  Although  the  ED  representatives  expressed  interest  in  having  a  basic  primary  care  resource  more  available  for  “familiar  faces”,  they  also  suggested  that  it  would  need  to  be  located  close  to  the  emergency  department  and  be  open  24/7,  given  their  experience  that  many  of  these  patients  are  unable  or  unwilling  to  follow-­‐through  on  referrals,  even  where  these  services  are  merely  across  the  street.  They  also  commented  on  the  reality  that  although  many  of  their  “frequent  faces”  make  what  are  generally  seen  as  “unnecessary”  visits,  these  often  require  very  little  time  and  don’t  necessarily  contribute  to  ED  congestion.    2.2  Review  of  Data  Analysis  • VCH  conducted  an  extensive  analysis  of  UPC  Clinic  physician  shadow  billing  data  to  determine  panel  size,  attachment,  and  complexity.    VCH  reports  that  the  findings  reveal  a  mismatch  between  the  capacity  at  some  clinics  and  the  demand  and  needs  of  those  patients  currently  accessing  the  services,  as  follows:  • Panel  size  40  to  78%  of  target  of  1250  per  physician  FTE  • Attachment  20  to  40%  higher  than  provincial  average  • Complexity  86  to  122%,  against  a  target  of  125%  • Approximately  40%  of  UPC  clinics  considered  highly  complex/vulnerable.    • These  findings  suggest  unrealistically  low  panel  sizes  for  clinics  and  individual  providers,  even  given  a  high-­‐need  caseload.    At  the  same  time,  complexity  measures  suggest  a  lower  level  than  would  be  anticipated  for  this  type  of  program.  VCH  suggests  these  findings  indicate  clinic  inefficiency  and  low  provider  productivity,  noting  they  are  relatively  consistent  across  clinics  and  even  providers  and  have  not  increased  since  2010  despite  direction  to  the  clinics  to  serve  the  more  vulnerable  and  medically  complex  population.    • Although  the  magnitude  and  the  consistency  of  the  findings  of  the  VCH’s  analysis  of  the  UPC  Clinics  clearly  is  worrisome  and  as  such  cannot  be  disregarded,  we  have  reservations  about  the  use  of  shadow  billing  data  and  the  metrics  examined.    Although  we  agree  these  findings  are  of  concern  and  warrant  further    8  investigation,  we  do  not  view  them  as  necessarily  diagnostic.  Rather,  we  suggest  they  be  interpreted  cautiously  and  within  the  context  of  the  observations  provided  from  the  interview  process.    Our  concerns  are  as  follows:    a) Shadow  Billing  Data  • We  have  reservations  about  the  use  of  APP  physician  shadow  billing  data  and  in  particular,  its  use  in  the  comparison  of  APP  and  FFS  provider  performance.    There  is  good  reason  [and  research]  to  suggest  that  in  the  absence  of  the  payment  incentive  enjoyed  by  FFS  physicians,  APP  shadow  billings  routinely  and  significantly  underreport  actual  physician  activity,  making  comparisons  with  FFS  practice  less  meaningful.    •  MSP  billing  codes  are  limited  to  activities  and  procedures  agreed  to  by  government  and  the  BCMA.    In  2006,  BC  introduced  incentive  payments  for  FFS  practices  in  recognition  that  caring  for  high-­‐needs  patients  requires  additional  time  and  often  involves  non-­‐billable  activities,  such  as  counseling,  case  conferences,  support  to  families,  system  navigation,  etc.    APP  physicians  providing  these  same  services  cannot  bill  these  incentive  fees  and  these  activities  cannot  be  recorded  using  MSP  billing  codes,  serving  to  underreport  APP  physician  activity.  b) Panel  Size  • The  policy  context  within  which  the  Ministry  of  Health  established  1250  as  a  target  for  APP  physician  panel  size  is  not  known.  We  have  reservations  that  this  target  may  no  longer  be  appropriate  for  the  UPC  Clinic  environment  and  suggest  more  consideration  be  given  to  how  to  best  measure  panel  size  and  establish  targets  for  physicians  working  in  interdisciplinary  teams,  a  topic  of  current  interest  across  the  country.      •We  also  have  reservations  that  comparing  panel  size  across  APP  and  FFS  practices  is  not  meaningful  without  taking  numerous  factors  into  consideration.    This  is  not  to  suggest  that  APP  productivity  is  not  a  concern  or  that  it  should  not  be  maximized  and  monitored,  only  that  it  should  be  done  within  a  specific  policy  and  operational  context.    •Muldoon  et  al.  (2012)2,  having  had  experience  in  the  development  of  new  interdisciplinary  primary  health  care  models  in  Ontario,  suggest  that  before  panel  size  be  used  as  an  accountability  measures  for  individual  physicians  or  practices,  its  relationship  to  quality  and  outcomes  at  the  individual  and  population  level  and  the  contextual  factors  that  affect  it  must  be  understood.                                                                                                                      2  Muldoon,  L.,  Dahroug,  E,  S.,  Russell,  G.,  Hogg,  W.,  Ward,  N.  How  many  patients  should  a  family  physician  have?  factors  to  consider  in  answering  a  deceptively  simple  question.  Healthcare  Policy  Vol.7  No.4,  2012.      9  •Relevant  contextual  factors  for  VCH’s  UPC  Clinics  identified  during  our  interviews  included:  composition  of  the  interdisciplinary  team;  roles  and  responsibilities  of  different  types  of  providers;  scope  of  practice;  ratio  of  physicians  to  other  providers;  clinical  administrative  support  levels;  availability  of  information  technology  supports  for  clinical  care;  building  space  and  equipment.  •The  unique  characteristics  of  the  target  population  also  influence  establishment  of  panel  targets,  e.g.  medical  complexity,  ESL/translation  needs,  demand  for  out-­‐reach  and  home  care,  etc.  We  also  note  that  most  CHCs  require  physicians  to  be  involved  in  clinical  leadership  and  mentorship,  program  and  policy  development,  community  prevention,  etc.,  all  of  which  need  to  be  taken  into  consideration  when  developing  realistic  panel  targets.    •Alberta's  new  interdisciplinary  Family  Care  Clinics  (FCC),  developed  to  serve  their  highest-­‐need  populations,  are  considering  whether  to  measure  by  physician  FTE  or  by  the  interdisciplinary  team  FTE’s.  As  of  the  spring  of  2013,  the  fully  interdisciplinary  FCC  teams  were  operating  with  panels  of  about  800  patients  per  physician  full  time  equivalent.          c) Complexity  • We  understand  that  ACGs  and  RUBS  are  calculated  to  individuals  using  available  diagnostic  information  derived  from  outpatient  or  ambulatory  physician  visit  claims  records,  encounter  records,  inpatient  hospital  claims,  and  computerized  discharge  abstracts.  A  patient  is  assigned  to  a  single  ACG  based  on  the  diagnoses  assigned  by  all  clinicians  seeing  them  during  all  contacts.    Therefore,  to  receive  a  high  RUB  score,  a  patient  needs  to  have  engaged  with  these  health  services.    We  think  more  consideration  needs  to  be  given  to  the  use  of  this  metric  with  the  high-­‐need  population  given  they  frequently  are  recognized  as  being  underserved.    d) Value  • Our  final  concern  in  this  regard  is  the  absence  of  a  “value”  perspective  in  these  analyses.    While  we  recognize  efficiency  and  productivity  are  important,  quality  and  outcomes  at  the  individual  and  population  level  also  are  important  considerations  (Muldoon  et  al.  Ibid),  such  as  better  access,  improved  clinical  outcomes,  and  more  appropriate  utilization,  such  as  reduced  avoidable  emergency  department  visits.  The  current  analysis  does  not  address  these  broader  questions.    2.3  Interdivisional  Collaborative  Services  Committee  • The  management  of  high-­‐needs  patients  was  tabled  for  general  discussion  at  the  November  2013  Interdivisional  Collaborative  Services  Committee  (CSC)  by  the  Co-­‐Chairs,  Dr.  Dean  Brown  and  Carol  Park,  VCH.        10  •  •The  existing  UPC  Clinics  were  noted  to  be  limited  to  the  Vancouver  area.  On  the  North  Shore,  local  physicians  and  VCH  staff  have  collaborated  to  develop  a  high-­‐needs  clinic,  which  accepts  patients  in  need  of  urgent  care  and  endeavors  to  connect  them  with  regular  practices  for  ongoing  primary  care.  Richmond  and  Powel  River  currently  do  not  have  dedicated  services  for  high-­‐needs  patients.      The  CSC  agreed  that  there  is  limited  knowledge  about  the  high-­‐needs  patient  population  and  developing  a  better  understanding  of  the  size,  location  and  needs  of  this  population  should  be  the  first  priority.  It  was  noted  that  the  CSC’s  current  Attachment  Initiative  work  may  help  to  answer  some  of  these  questions  but  at  the  same  time,  not  all  unattached  patients  are  necessarily  high-­‐need.  There  was  agreement  that  the  high-­‐needs  group,  however  ultimately  defined,  is  not  easily  served  in  a  traditional  practice  environment  and  new  solutions  are  needed.      A  number  of  cautions  were  expressed.    First,  it  was  suggested  a  single  solution  or  model  might  not  sufficiently  take  into  consideration  the  differences  across  communities,  physicians,  and  patients.  For  example,  smaller  communities  might  not  have  sufficient  number  of  high-­‐needs  patients  to  warrant  a  separate  service  and  yet  still  need  to  have  some  type  of  additional  support,  while  for  some  patients,  a  state  of  “high-­‐need”  may  be  transitory  and  so  the  capacity  to  add  interim  support  to  regular  primary  care  might  be  a  better  solution  than  relegating  those  patients  to  a  dedicated  program.    Consideration  of  a  “laddered”  response  was  suggested,  based  on  community,  physician,  and  patient  need.    Examples  discussed  included:  a  transition  clinic  (North  Shore  Model)  operated  by  physicians  with  the  support  of  VCH;  additional  support  provided  to  a  practice  with  a  handful  of  high-­‐needs  clients;  a  formal  arrangement  with  VCH  to  provide  comprehensive  support  to  a  practice  choosing  to  manage  a  large  number  of  high-­‐needs  patients;  and  the  dedicated  clinic  model  (e.g.  VCH  UPC  Clinics).      It  was  noted  that  previous  inquiries  or  requests  for  alternative  funding  arrangements  to  provide  more  flexible  support  for  high-­‐needs  patients,  such  as  APP  sessions,  have  not  met  with  success.    The  discussion  concluded  with  the  following  observations:  • The  term  “high-­‐need”  needs  to  be  defined.  i.e.  who,  where,  and  what  do  they  need  and  how  can  they  be  best  served.  • This  work  might  overlap  with  the  Attachment  Initiative,  although  not  all  unattached  patients  are  necessarily  high-­‐needs.    • “High-­‐needs”  for  some  patients  may  be  a  transitory  state;  consideration  needs  to  be  given  to  how  services  can  be  developed  to  support  these  individuals  when  required,  rather  than  assigning  them  permanently  to  more  intensive  services.        ••••  11  ••Solutions  to  serving  high-­‐needs  patients  need  to  reflect  local  realities  and  reflect  a  gradient  of  service  intensity.      Specific  solutions  should  be  developed  in  collaboration  with  VCH.    Our  Conclusions    VCH’s  review  of  the  UPC  Clinics  is  not  a  simple  project.    Rather,  it  involves  a  number  of  complex  considerations  and  challenges,  including  understanding  the  history  and  the  current  state  of  six  diverse  clinics,  diagnosing  and  rectifying  longstanding  operational  and  management  issues,  determining  VCH’s  future  PHC  role  in  the  context  of  the  new  provincial  community  integration  agenda  and  the  Interdivisional  CSC,  contributing  to  reducing  avoidable  ED  and  acute  utilization,  and  meeting  VCH’s  current  budget  targets.    Although  all  of  these  issues  are  intertwined,  for  purposes  of  clarity  we  have  distilled  our  conclusions  in  to  four  themes,  as  follows:  1. Current  management    2. Implementation  of  major  changes  to  program  mandate  and  role    3. Collaboration  with  the  Interdivisional  CSC  4. Policy  and  research  considerations    1. In  regard  to  the  current  management  of  the  UPC  Clinic  Program:  • The  UPC  Clinic  managers,  physicians,  NPs  and  RNs  expressed  a  strong  commitment  to  serving  high-­‐needs  and  vulnerable  populations  and  want  the  resources  and  supports  required  to  do  a  good  job.  • However,  the  program  appears  to  have  been  undermanaged  for  many  years,  only  recently  beginning  to  receive  the  attention  required  to  optimize  its  resources.  In  particular,  there  has  been  a  long-­‐standing  absence  of  physician  clinical  leadership.  • Specifically,  we  understand  there  is  no  overall  program  strategy,  plan  or  service  model  for  the  program  as  a  whole.    As  well,  operating  policies,  procedures,  and  standards  are  not  shared  across  clinics  and  explicit  outcome  expectations  and  critical  success  factors  have  not  been  established.    Each  of  the  six  clinics  operates  in  relative  isolation  from  each  other.      • Despite  the  external  perception  of  robust  interdisciplinary  teams,  the  long-­‐term  reliance  on  APP  as  the  majority  source  of  clinic  funding  have  left  these  teams  with  a  much  higher  ratio  of  physicians  compared  to  other  types  of  providers  typically  included  in  a  team  focusing  on  a  high-­‐needs  population.    We  think  that  this  imbalance  is  contributing  to  some  of  the  recently  identified  inefficiencies  and  productivity  concerns.    • We  also  observed  considerable  confusion  and  frustration  on  the  part  of  both  managers  and  providers,  which  we  attribute  to  the  lack  of  clarity  around  program  operation  and  expectations.      • Regardless  of  the  ultimate  focus  of  these  clinics,  they  need  a  more  formalized  management  structure  and  process,  including  a  documented  plan,  service    12  model  and  strategy,  and  increased  attention  to  important  internal  processes,  such  as  quality  improvement  and  professional  education.    Once  these  plans  and  expectations  have  been  agreed  and  documented,  managers  and  all  providers  should  be  held  accountable  for  ensuring  their  implementation.    2. In  regard  to  implementation  of  program  changes:    • VCH  needs  to  be  much  clearer  as  to  the  purpose  of  the  UPC  program  as  a  whole  in  advance  of  making  policy  decisions  intended  to  change  or  reduce  clinic  numbers  or  role/function,  i.e.  what  are  the  goals,  objectives  and  critical  success  factors  and  where  will  a  redesigned  program  fit  within  the  overall  continuum  of  primary  health  care.  • Key  is  determining  the  appropriate  population  for  the  intensity  of  care  the  UPC  Clinics  potentially  can  deliver.  As  illustrated  in  Figure  1,  about  5%  of  the  population  is  known  to  have  the  highest  health  needs.  For  example,  in  BC  Reid  et  al  (2003)3  used  health  service  utilization  data  to  describe  the  top  5%  of  users.    This  group  consumed  a  disproportionate  amount  of  physician  and  hospital  services  (about  30%  of  each  in  2002)  and  was  characterized  by  a  significant  burden  of  morbidity,  with  over  80%  having  at  least  six  different  morbidities.  These  individuals  also  were  much  more  likely  to  have  both  major  acute  and  chronic  diagnoses  and  psychosocial  co-­‐morbidities  and  chronic  medical  conditions.  • Another  15%  or  so  of  the  population,  many  of  whom  have  complex  care  needs  or  multiple  health  and  social  issues,  are  recognized  not  to  be  well-­‐served  by  traditional  physician  practice.  However,  recent  enhancements  introduced  by  the  General  Practice  Service  Committee  (GPSC)  to  encourage  full-­‐service  family  practice  and  improve  the  management  of  chronic  disease,  complex  care,  and  mental  health  are  beginning  to  blur  the  line  between  this  group  and  the  80%  of  the  population  generally  thought  to  be  well  served  by  traditionally  fee-­‐for-­‐service.      a. The  Highest  Need  5%:    • As  observed  above,  VCH  has  directed  the  UPC  Clinics  to  serve  the  “most  vulnerable  and  medically  complex  5%”,  presumably  with  the  intent  of  reducing  demand  on  EDs  and  other  intensive  acute  care  services.  However,  we  observed  considerable  confusion  between  VCH  and  the  UPC  Clinics  as  to  who  exactly  is  considered  to  be  included  in  the  5%,  with  most  UPC  Clinics  working  under  the  belief  that  they  are  in  fact  already  serving  high-­‐needs  patients.    As  noted  above,  this  confusion  needs  to  be  resolved.  • The  challenges  of  efficiently  and  effectively  addressing  the  needs  of  the  5%  are  well  documented  and  consequently,  refocusing  the  UPC  Clinics  on  this  population  requires  not  only  policy  direction  from  VCH,  but  introduction  of  a  wide  range  of  program  changes  and  supports,  such  as                                                                                                                  3  Reid,  R.,  Evans,  R.,  Barer,  S.,  Sheps,  S.  Kerluke,  K.,  McGrail,  K.,  Hertzman,  C.,  Pagliccia,  N.  Conspicuous  consumption:  characterizing  high  users  of  physician  services  in  one  Canadian  province.  J  Health  Serv  Res  Policy.  2003  Oct;8(4):215-­‐24.    13  admission  criteria4  to  ensure  appropriate  intake,  reconfigured  professional  teams  providing  a  more  appropriate  provider  mix  and  skills  (especially  community  psychiatry),  sufficient  capacity  to  provide  outreach  and  extended  hour  coverage,  close  interface  with  other  community  services,  real-­‐time  information  transfer  between  clinics  and  hospitals,  and  formal  shared-­‐care  or  referral  protocols  with  EDs.        b. The  High  Need  15%:    • The  15%  includes,  although  is  not  necessarily  limited  to,  the  population  segments  currently  being  served  by  the  UPC  Clinics,  e.g.  people  marginalized  due  to  poverty,  mental  health  or  addictions  issues,  or  with  complex  and  multiple  comorbidities,  the  frail,  the  disabled,  street  youth,  and  refugees  and  new  immigrants  (not  to  suggest  that  the  clinics  do  not  also  serve  a  proportion  of  the  5%).  However,  for  the  reasons  discussed  above,  i.e.  absence  of  monitoring  and  evaluation  and  management  and  operating  concerns,  we  are  unable  to  comment  as  to  how  well  the  UPC  Clinics  currently  fulfill  this  role.  • The  critical  issue  for  the  individuals  commonly  included  in  the  15%  is  time  –  their  complex  interplay  of  multiple  health  and  social  issues  generally  require  more  provider  time,  in  terms  of  both  duration  and  frequency  of  visits,  than  most  FFS  practices  can  afford.    Their  primary  health  care  needs  are  often  best  met  by  interdisciplinary  teams  that  include  physicians  and/or  NPs  as  well  as  RNs,  counselors,  social  workers  translators,  pharmacists,  etc.  • Providers  serving  this  group  also  often  need  specialized  skills,  especially  in  behaviorally-­‐oriented  interventions  such  as  cognitive  behavioral  therapies  for  anxiety  and  depression;  self-­‐care  education  for  chronic  disease  such  as  diabetes  and  COPD;  and  understanding  of  cross  cultural  health  service  issues,  etc.    • There  is  good  evidence  to  suggest  that  by  ensuring  the  complex  needs  of  these  individuals  are  met  with  regular,  appropriate,  and  continuous  primary  care  they  can  avoid  slipping  into  the  highest-­‐need  5%.  • As  noted  above,  during  the  past  few  years  GPSC  has  introduced  a  number  of  practice  supports  to  encourage  better  care  for  this  population.    These  include  a  comprehensive  program  of  clinical  guidelines,  practice  supports,  and  incentive  payments,  as  well  as  integrated  interdisciplinary  initiatives  beginning  to  be  introduced  by  Divisions  of  Family  Practice.    • Together  these  enhancements  to  traditional  family  practice  are  establishing  an  environment  that  encourages  and  enables  more  intensive  high-­‐quality  care  for  people  with  chronic  disease,  mental  health,  and  complex  care  needs.    The  circles  crossing  the  boundaries  between  the  80%  and  15%  in  Figure  One  below  are  intended  to  depict  this  shift.                                                                                                                    4  For  illustration:  3  or  more  acute  hospitalizations  in  proceeding  14  months,  3  or  more  chronic  diseases/conditions,  and  8  or  more  medications.    14  •••However,  as  the  Interdivisional  CSC  observed,  this  is  a  slow  process  and  few  family  practices  are  yet  able  to  absorb  and  sustain  large  numbers  of  high-­‐need  patients  without  additional  resources,  staff,  and  training.      As  well,  many  of  the  important  key  levers,  such  as  alternatives  to  or  augmentation  of  FFS  payment  models  and  initiatives  to  better  link/integrate  family  practice  and  health  authority  programs  and  providers,  still  are  in  their  infancy.    Clearly  the  impact  of  any  significant  change  to  the  role  or  number  of  UPC  Clinics  needs  to  be  thoroughly  explored  and  understood  and  realistic  alternatives  put  into  place  in  advance  of  making  such  changes  so  as  to  avoid  creating  a  “treatment  gap”  between  VCH  services  and  FFS  primary  care  practice.    There  will  be  no  gain  if  this  “in  between  group”  fails  to  access  needed  primary  care.    3. In  regard  to  collaboration  with  the  Interdivisional  CSC:  • The  Interdivisional  CSC  has  expressed  interest  in  better  understanding  the  scope  and  nature  of  the  high-­‐need  population  and  considering  the  resources  and  supports  needed  to  assume  the  care  of  high-­‐needs  patients,  including  what  a  care-­‐continuum  eventually  could  entail.    • Although  unlikely  to  be  a  quick  process,  given  government’s  current  community  integration  agenda  and  expansion  of  interdisciplinary  practice  into  physician  offices,  it  is  essential  that  this  issue  be  considered  within  this  joint  context.    4. In  regard  to  policy  and  research  considerations:  • In  considering  changes  to  the  current  UPC  Clinics,  VCH  needs  to  take  into  account  the  increasing  international  recognition  of  the  value  of  interdisciplinary  teams  in  meeting  the  needs  of  high-­‐needs  clients  as  well  as  the  rapidly  aging  population.  The  World  Health  Organization  recently  acknowledged  that  40  years  of  research  has  confirmed  the  value  of  interdisciplinary  care  to  good  clinical  outcomes  (WHO,  2010)5.    • Although  consolidation  of  some  clinics  may  help  to  address  some  of  VCH’s  immediate  concerns,  i.e.  inadequate  building  infrastructure,  small  clinic  size,  and  inappropriate  team  composition,  the  optics  appear  contrary  to  the  government’s  current  integration  and  interdisciplinary  care  agendas.      • Consolidation  also  is  likely  to  reduce  access  to  primary  care  for  many  high-­‐needs  patients  and  will  eliminate  the  opportunity  to  customize  individual  clinics  to  meet  individual  community  needs.  A  large  group  of  patients  is  likely  to  be  affected,  yet  it  private  practice  alternatives  are  not  reliably  in  place.  • Importantly,  VCH’s  community  clinics  offer  the  sole  community-­‐based  opportunity  for  employment  in  multidisciplinary  primary  health  care                                                                                                                  5  World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. RetrievedNovember 2, 2013, from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf    15  •teams.    This  is  particularly  important  for  NPs  who  represent  a  valuable  resource  trained  specifically  for  primary  care  but  who  are  underutilized  and  underemployed  in  BC,  largely  due  to  the  lack  of  employment  opportunities  in  precisely  such  settings  (MSFHR,  2013)6  Finally,  in  light  of  these  policy  considerations,  the  optics  of  undertaking  significant  change  to  the  handful  of  interdisciplinary  clinics  already  serving  primarily  marginalized  high-­‐needs  populations  and  their  redirection  to  largely  inaccessible  private  practice  may  be  difficult  to  address.                                                                                                                    6  Michael  Smith  Foundations  for  Health  Research.  (2013).  The  Utilization  and  Impact  of  Nurse  Practitioners  and  Physician  Assistants:  A  Research  Synthesis.  Retrieved  November  18,  2013,  from  http://www.msfhr.org/sites/default/files/Utilization_of_Nurse_Practitioners_and_Physician_Assistants.pdf      16  Figure OneLevels of Population Health Need5% populationHighest-needsrequiring assertivespecialized careE.g. unstable,chaotic,unpredictable,history ofmultiple ED/acute admissions,multiple chronicdisease15% populationHigh-needs, requiring continuous andintegrated primary health and socialcareE.g. frail, at-risk youth, peoplemarginalized due to poverty, addiction,mental health, refugees and newimmigrants, multiple chronic diseaseand complex care requirementsChronicdiseasemanagementComplex andpalliative careMental illnesscare80% PopulationUsual primary care practice / full service family practice        17    Our  Recommendations    1. Develop  more  clarity  as  to  the  “problem”  to  be  solved  by  the  UPC  Clinics  in  advance  of  making  policy  decisions  intended  to  change  or  reduce  their  number  or  current  role,  i.e.  establish  the  program’s  purpose  and  critical  success  factors,  and  take  steps  to  develop  a  coherent  overall  program,  including:  • Target  population;  • Service  eligibility  criteria  and  screening  tools;  • An  interdisciplinary  team  model  appropriate  to  the  health  needs  of  the  population  to  be  served;  • Program  policies,  processes  and  procedures  and  standards  aimed  to  improve  the  appropriateness,  quality,  and  accountability  of  the  service  provided/patient  care;    • Regular  performance  reporting  based  on  an  appropriate  set  of  metrics;  and    • Clarity  as  to  how  the  primary  health  care  needs  of  clients  no  longer  served  by  these  clinics  will  be  addressed  within  the  broader  primary  care  community.      2. Consistent  with  the  provincial  Community  Integration  agenda,  consider  strengthening  and  diversifying  the  current  UPC  Clinic  interdisciplinary  teams  by  integrating  additional  RNs,  mental  health  and  addiction  counselors,  social  workers,  etc.  from  other  VCH  community  programs.  This  also  would  contribute  to  improving  physician  efficiency  and  increase  clinic  capacity.    This  new  focus  on  truly  interdisciplinary  teams  will  require:  • Clear  definition  of  provider  roles  and  responsibilities;  • Investment  in  developing  and  supporting  collaborative  interdisciplinary  teams  (i.e.  not  merely  co-­‐location  of  providers);  and  • Establishment  of  clinical  physician  leadership  support  for  physicians.      3. Working  within  the  context  of  the  Interdivisional  Collaborative  Services  Committee,  develop  a  medium  to  long-­‐term  plan  (three-­‐  to  five  year)  for  the  management  of  all  high-­‐need  patients  that  includes  CSC  jointly-­‐developed  solutions  to  maximize  opportunities  for  physician  practices  to  increase  their  ability  to  appropriately  meet  the  needs  of  some  yet  to  be  determined  proportion  of  those  patients.      18