It Takes a Team
Using an Inter-professional
Clinic(IMPACT PLUS) to treat Complex
Patients (Toronto, Ontario)
Dr. Pauline Pariser, Co-lead, Taddle Creek Family Health Team
Dr. Howard Abrams, Head, Division of General Internal Medicine,
University Health Network
Dr. Nadiya Sunderji, Staff Psychiatrist, St. Joseph’s Health Centre.
Ms. Brandi Grozell, Nurse Practitioner, Taddle Creek FHT
OBJECTIVES
After hearing this presentation participants will:
‹Describe the scope of and evidence for this initiative
‹Analyze the conditions for success implementing this clinic
‹Apply key processes in the design of this intervention
‹Select key features in scaling this model to a local setting
What it is
• Interprofessional Model of Practice for
Aging and Complex Treatment
• A comprehensive model of:
– Assessment
– Care
– Mentorship and training
Interprofessional problem solving
Including primary care providers, CCAC
worker, pharmacist, RNs, NPs, social
workers, physiotherapist, OT, dieticians,
trainees PLUS consulting general internist
& psychiatrist
Sunnybrook Health Sciences Centre
Psychiatrist
Internist
Relevance of Psychiatric Input
• Literature cites examples of the confluence
of complex chronic illness with concurrent
psychiatric co-morbidities
• Addresses challenge of sorting out organic
vs. psychosocial etiology in real time
• Introduces theories and concepts related to
illness behavior
• Supports group process of team
Scope
‰Patients with complex co-morbidities
represent 1-4% of the population but
account for 30-60% of health care costs
‰They account for 59% of
57 million deaths worldwide
and 46% of global burden of
disease WHO: Preventing
Chronic Diseases: A vital
investment 2005.
The Problem/Opportunity
Broader patterns
• 65+ age group is the fastest growing segment
of Canadian population
• More than 50% of Canadian adults and 81%
of seniors in the community have a chronic
health condition
• Patients 65+ require treatment for 6.5 chronic
illnesses, on average
• Seniors consume largest proportion of health
care resources
• "Frail
older patients – unlike younger persons
in the health care system or even well elders –
require complex care. Most frail older patients
have multiple chronic illnesses. Optimum care
cannot be achieved by following the paradigm
of ongoing traditional health care, which
emphasizes disease and cure. Because no
one health care professional can possibly
have all of the specialized skills required to
implement such a model of health care
delivery, interdisciplinary team care has
evolved.”
– Dyer et al. Frail Older Patient Care by Interdisciplinary Teams.
Gerontology & Geriatrics Education 2004;24(2): 51-62.
Empirical Evidence:
Traditionally these patients are managed by
serial specialist consultations using singledisease models, inadequate in addressing
reinforcing medical conditions, medication
interactions, lifestyle factors or co-morbid
psychosocial determinants
“Heart-sink” patients typically
overwhelm provider who can only
manage 1-2 health issues per visit
Typical Patient
Multiple
doctors
Mental health
issues
Multiple
medications
Poor coping
skills
Inactive
Low income
Limited
adherence
Poor social
support
Involvement of increasing number of medical
specialists and increasing amount of
diagnostic tests
What is the optimal
management of multiple
chronic conditions?
• Unknown
• Single provider cannot do it adequately
• Inter-professional approach may be the
answer
Plan: Bridges Funding to
measure a range of outcomes
using this model with Family
Health Teams
Multiple chronic diseases:
the care challenge
• Clinical Practice Guidelines (CPGs) have a
single disease focus
• CPGs often conflict with each other and
between diseases
• Reliance on single disease CPGs for care
of patient with multiple co-morbidities =
near total medicalization of patient’s life
The multi-problem patient likely
increases the need for:
• A more effective primary care medical home with “wholeperson” knowledge of the patient and clearer accountability
for the totality of care.
• Primary care clinicians able to integrate input from multiple
specialties/agencies into a coherent, patient-centered
treatment plan.
• Greater sharing (interactive communication*) of care
planning and care management between primary and
specialty care.
• Clinical care management services integrated with primary
care.
• High quality referrals, consultations, shared care, and
transitions.
* Foy et al. Ann Int Med 2010; 152:247-258
Patient
on
Screen
Doctor
HCP
learner
Resident
Internist
Nurse/NP
Psychiatrist
Dietician
Pharmacist
CCAC
worker
Social Worker
Physio
The IMPACT PlUS patient
• Inclusion criteria
– aged 65+ or
– 5 or more long term medications
– 3 or more chronic disease requiring monitoring
and treatment OR 2 chronic diseases when one
is frequently unstable
IMPACT PLUS patient
– minimum of 1 functional ADL limitation
– not home-bound or institutionalized
– patient and/or caregiver is willing and able
to deliberate with a team
– patient and/or caregiver are motivated to
take action to improve patient’s health
status and patient is
emotionally/cognitively/socially equipped to
do so
Clinic Process:
• Case particulars disseminated ahead of time
with key questions identified by referring PCP
• 1 team member designated as facilitator
• Case “unpacked” by PCP other than referring
PCP
The IMPACT protocol
Patient Selection & Invitation
Document. & Debrief
Group Discussion 1
Team Deliberation
Patient Welcome & Initial Patient Interview
HCP Assessments
Group Discussion 2
Group Discussion 1
• Referring practitioner provides background
info:
– Brief history
– Recent events
– Current issues/concerns
– Patient’s support systems
– Rationale for bringing patient to IMPACT
• Appointment facilitator identified
Intended outcomes
• Reduction in Emergency room visits
• Reduction in the burden of care:
•Reduction in hospital admissions
Intended outcomes
For patients: Medication management,
comprehensive assessment to address issues in
depth, real-time problem solving avoiding multiple
referrals, caregiver involvement, feeling valued
For HC providers: Comprehensive chart review,
reduction in office visits, enhanced resources to
serve patient, clarity in direction and strategies
moving forward
Intended outcomes continued
For the team:
1)Modeling of synergistic problemsolving for all health care providers
2)Building interdisciplinary collaboration
The DELUXE model of Collaboration
1)Real-time knowledge transfer
Necessary Conditions for
Implementation
Mutually respectful working
relationships among team
members characterized by:
¾ Nonhierarchical relationships
¾ M.D. a participating member of the team
¾ Communication to enhance understanding of
each other’s roles and of the case to be
discussed
¾ Facilitated interaction
¾Sharing a non-authoritative stance of expertise
Multidisciplinary
vs
Interprofessional
Communication is generally one-toone or in report format one-to group
Communication is among team,
fluid and a work in progress
Scope of practice tends to be
narrow
Scope of practice embraces broad
range of skills within profession
and between professions
Limited knowledge of
scope of practice of other
disciplines
Physician-centric: M.D.
directs discussion
Patient/family goal-setting is done
independently by professionals
rather than through collaboration
Team members understand
educational backgrounds,
areas of expertise, and
pertinent roles of one
another
Patient-centric: Patient
needs direct discussion
Patient/family goal-setting,
planning and implementation
undertaken in integrated manner
by all team members
Necessary
Conditions
™ Clarity regarding referral process
™ Time allotment: 2 hours per patient
with most of the team members present
™ Clinics need to be pre-scheduled
™ Technology: Portable EMR, video
camera, CCTV
™ Clarity regarding process of the clinic
™Large meeting room & exam room
Challenges
Time factor:
• Investing in time now for returns later
• Time management: getting through
the appt.
Confidence factor:
• For team members - volunteering to interview, to
share their opinions openly
• For M.D.s - typically these are patients who
overwhelm providers so showing less than optimal
care takes courage
IMPACT: Challenges
• Implementation
– Patients may not have the financial,
cognitive, or practical ability to put team’s
recommendations into practice
– Organize rx. plan that does not overwhelm
PCP
• Information transfer
– Patient documentation
– Satisfying professional obligations
– Maintaining communication
Scalability
✜ Need a champion(s) of the model, provide regular
updates, show evidence
✜ Pre-schedule team members - everyone
booked out ahead of time
✜ Regular meeting time to encourage
consistency
✜ Search EMR for patients with 3-5 co-morbid
conditions and/or on >5 meds
✜ Find creative ways to support PCP to present cases
Scalability
• Consider team-based consultation clinic to local
Primary Care Providers, similar to Regional
Diabetes Clinics
• Stay tuned for tool kit once findings from
Bridges research project documented
• Currently video “It takes a team”- demonstration
DVD of actual clinic in process
Scalability
For more information:
Contact: Dr. Pauline Pariser
[email protected]