The Art of Integrating Several Teams into ONE
Enhanced Interdisciplinary Team
Accelerating Primary Care Conference
November 6, 2015
Joe Kwan, Extended Team Manager
Yolanda Martens-Van Hilst, Program Manager, Service Delivery
CALGARY FOOTHILLS
Faculty/Presenter Disclosure
• Faculty: Joe Kwan & Yolanda Martens-Van Hilst
• No relationships with commercial interests:
–
–
–
–
Grants/Research Support: No
Speakers Bureau/Honoraria: No
Consulting Fees: No
Other: No
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Objectives
• Be aware of the philosophy and principles that lead to
the creation of a primary care Extended Health Team
• Describe different team models and adapt them to your
environment
• Identify challenges and a model to help predict possible
solutions
• Understand the importance of building partnerships
between primary and tertiary care
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Patient Centred Primary Care Model
Core team
Physician
Behavioural Health Consultant (BHC)
Health Management Nurse
Pharmacist
Dietitian
Clinic Staff
Extended team
Family physicians
(with specialty interest)
Nurse
Pharmacist
Kinesiologist
Occupational Therapist
Social Worker
Dietitian
Psychologist
BHC
Physiotherapist
Specialty Linkages
Enhanced team
Physiotherapist
Chiropractor
Psychologist
Home Care
Public Health
PCN Pop Health Resources
System
Community Resources
Education Resources
Workplace Resources
Social Services Resources
Acute Care
Long Term Care
Specialty
Our Challenge
• Improving access and care for patients with complex
health needs through care coordination between
primary care and specialty care
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Our Resources
• 5 Focus Teams with Strong Specialty Linkages
– Chronic Pain Management ↔ AHS Calgary Chronic Pain Center
– Navigation ↔ Various AHS transition services
– Medical MSK Management ↔ AHS Division of Rheumatology
– Gastroenterology ↔ AHS Division of GI
– Mental Health ↔ AHS Adult Psychiatry
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Our Programs’ Origins
• Silo care
• Commonalities in the program
• Multi – disciplinary approach
• Consultation model
• Specialty focused programs
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Relationship
struggles
Common Patient
Mood depression
Decrease of
Function
Struggle with
self-management
Diagnosis
unknown unclear
Pain
Safety Concerns
Employment
compromised
Increased Risk factors
No drive to
achieve goals
Significant mental
health challenges
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Challenges
• Referrals to each program became increasingly
complex as Medical Home improved care to better
manage patients with support from each of these
programs
• Became increasingly challenging to provide a holistic
approach utilizing a biopsychosocial model to deliver
effective patient care with limited resources
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Our Goal
• Provide comprehensive interdisciplinary team-based
patient care
– Collaboration between programs to provide
enhanced care
– Adaptation to the need of primary care service
– Collaborative care model within the team, the
medical home and specialty partners
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Extended Health Team Model
Gastroenterology
Medical MSK
Navigation
Chronic Pain
Mental Health
Our Dilemma
• HOW to align several programs/teams into one comprehensive
interdisciplinary team?
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How did we reach our goal?
• Invested in interdisciplinary team approach
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Our Team Development
• Innovation - develop vision / philosophy
• Time to plan for program development
• Time to achieve professional confidence and maturity
• Team alignment - challenge with continued change & shifting care
• Education - adaptation
• Communication and interpretation of messages
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Our Team Development
• Evolution of team moving away from consult model
• Baseline knowledge of each team member
• Nurturing environment for change


Team will need to feel empowered to be part of the decision
of change
Trust between team members and partnership are crucial
• Sharing learning influences others
• External partnership
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Our Team Function
• Holistic Approach – Chronic disease management
• Build on existing relationship of medical home
• Roles are integrated for continuation of care
• All members are case managers
• Comfort skills are often challenged and supported that
allows maximum level of scope of practice
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Our Team Function
• Not have to be the expert /specialist
• Need to be comfortable with change and shifting care
• Transition support – mending relationships
• Use online and utilize existing resources
• Build partnerships
– Shared mental health
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Our Findings
• Good team work needs time & maintenance
• Effective team needs a safe, fostering and innovative
environment
• Team needs empowerment to lead projects and changes to
improve care delivery
• Continues reflection of team work, care provision and outcome
data is needed to evaluate the progress of care and team work
• Over the last four years, there has been increased success in
team collaboration and enhanced care in our Extended Health
Team
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Our Findings
• Complex care can be offered through support of
teams. This will need ongoing investment in team
and allow the evolution of team work to happen
naturally
• Continue relationship building within the organization
and outside will support positive team work and result
in improved patient care
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How do you know your team works well?
How would you measure?
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Are the goals and objectives of the team clearly
understood and accepted by all members?
Mean
Min
Max
5.5
4
7
6
6
6
MDT (n=14)
4.9
2
7
Overall (n=22)
5.2
2
7
Physician (n=2)
Support staff and admin
(n=6)
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Are team members open and honest, or are there
hidden agendas? Are members free to be candid?
Mean
Min
Max
Physician (n=2)
6.5
6
7
Support staff /admin (n=6)
5.8
5
6
MDT (n=14)
5.6
4
7
Overall (n=22)
5.8
4
7
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Do members support each other, even when someone
makes a mistake? Do members help each other?
Mean
Min
Max
6.5
6
7
6
5
7
MDT (n=14)
6.3
5
7
Overall (n=22)
6.2
5
7
Physician (n=2)
Support staff /admin (n=6)
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Physician Feedback
The Extended Health Team aims to act as an extension
of the family physician's office, working closely with the
medical home. How do you find the current level of
collaboration offered by Extended Health Team? (n=208)
I would like less
collaboration
2%
Current collaboration I would like more
is sufficient
collaboration
80%
18%
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Physician Feedback
Thinking about the communication you have received from
the Extended Health Team over the past year, please
indicate your satisfaction with the following: (208)
Very
satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
Timeliness of
communication (n=202)
33%
57%
8%
3%
0%
Clarity of information
(n=202)
33%
58%
8%
1%
0%
Amount of information
(n=201)
31%
59%
9%
2%
0%
Layout of information
(n=202)
26%
61%
12%
2%
0%
Patient Feedback
How would you rate your overall experience with the
Extended Health Team program? (n=51)
Good, 24%
Very Good,
33%
Excellent,
43%
Fair, 0%
Poor, 0%
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Patient Feedback
Which health care professionals did you see during this
program? Check all that apply. If you’re not sure who you saw,
please record their name. (n=54)
Doctor
Nurse
Dietitian
Occupational Therapist
Pharmacist
Mental Health Consultant/…
Kinesiologist
Physiotherapist
Social worker/ Community…
81%
28%
13%
13%
24%
9%
43%
48%
59%
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Patient Feedback
5. Do you feel that your providers
listened and respected you as a partner
in care? (n=53)
6. Did the providers explain things in a
way you could understand? (n=52)
7. Do you feel you had enough
involvement in decisions made about
your care? (n=53)
Often, 8%
Always, 91%
Sometimes, 2%
Often, 19%
Often, 17%
Always, 81%
Always, 83%
Patient Feedback
What specific aspects of your care were most
helpful and why?
 The multiple health professionals I saw at the
same appointment
 Tools were provided and I had to practice hard to
breakdown specifics so that they worked for me
 Assessment, explained my condition, this gave me
peace of mind
 Just everyone taking the time to listen and making
suggestions on what to try
 The explanations of my problems and getting to the
point of accepting of how to deal with ongoing pain
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Questions
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