Download Model of Primary Health Care - Divisions of Family Practice

Saanich Peninsula Primary Health Care Society (SPPHCS)
Model for Primary Health Care
Description of the model
The model of care to be provided by the Saanich Peninsula Primary Health Care
Society will serve a complete range of patients, from healthy to those coping with fraility
and end of life issues.
Figure 1 – Stepped Care Pyramid
The pyramid represents the levels of complexity and severity of health concerns
patients may have. After seeing a new patient and assessing their health concerns and
care needs, the most responsible provider (Family Physician or Nurse Practitioner) will
categorize him or her into a colored care level within the electronic medical record. The
care level chosen will generate a standard general care plan which can then be
individualized with the patient’s input. Care plans for each level incorporate members of
the inter-disciplinary team, self-management and education activities as appropriate for
the level of need. Appendix A outlines the specific health professionals who will provide
services to patients.
Patients move up and down the care levels as their health worsens or improves. For
example, a patient with pre-diabetes would be categorized into the “staying healthy /
getting better” (green) level. They could attend self-management classes for chronic
conditions. These classes include general health topics, such as nutrition, and making
healthy decisions. If they progress into diabetes, they would move into the “low
complexity health concerns” (yellow) level. Their care plan would be modified to include
self-management strategy classes specific to diabetes and a referral to the diabetic
specialized team. If the same patient was not able to manage their diabetes and their
blood glucose levels were unstable, they would progress to the “moderate complexity
health concerns” (amber) level and could be referred to home care nursing for closer
monitoring, a pharmacist for review of medications and / or a dietician for individual
coaching. Once their blood sugar stabilized, they would move back down to the “low
complexity health concerns” level.
If a patient’s needs are not being met by a standard care plan, any team member may
initiative “collaborative care planning” where the inter-disciplinary group will meet to
develop an individualized shared care plan with input from each relevant discipline as
well as the patient and family.
The interdisciplinary safety net – Figure 2
The model of care can also be depicted as a safety net being held by many care
providers to show the network of support offered to the patient to meet their goals for
care. The patient is at the centre with multiple providers intersecting to deliver care.
Figure 2 shows a generic image..
Figure 2 – Interdisciplinary safety net
The inner circle depicts services that may be offered by each discipline within the
centres, the second circle are services provided outside the centres via Island Health or
private care providers. The services outside the inner two circles are provided by
volunteer and non-profit organizations in the community. Appendix B depicts three
different colored nets with detailed examples of services that may be offered in and
outside the clinic by each discipline. The three colors of safety nets correspond to the
colors in the pyramid; for example, the green net shows the network of team members
and services for people in the “staying healthy / getting better” category.
Connection between sites of care and health care providers
Interdisciplinary Collaboration
When patients become “attached” to the Network, they will agree to be cared for by an
interdisciplinary team which may also include students and residents. They will be
assigned a Most Responsible Provider (MRP), who may be a Family Physician (FP) or
a Nurse Practitioner (NP), as funding allows. Their MRP will oversee their treatment
plan and ensure the requirements for complex care are met. However, they could at any
time be seen by another Family Physician or member of the team who will know their
health history and care plan.
In a visit to the clinic, patients will be greeted by a Medical Office Assistant (MOA), who
may take vital signs and / or assist with changing into a gown. For many visits, patients
will then only see the FP or NP. Other times, they may first be seen by a Registered
Nurse (RN) to take a history or do a preliminary assessment. The findings of this
assessment will be communicated to the FP or NP, who will see the patient next and
plan for treatment. Afterwards, the RN may see the patient again for teaching and make
a plan for follow up via phone or in person visit. Other visits, the patients may see the
RN for a procedure (wound care, injections) and have a minimal interaction with the FP
or NP.
Other care providers, such as social workers, pharmacists and counselors may be
added to clinic staff and incorporated into the model of care as funding becomes
available. To avoid duplication and utilize existing services, there will be a close working
relationship between the Network and the interdisciplinary team members who are
employed by Island Health. Individual Island Health Long Term Case Coordinators will
be assigned to each clinic, to facilitate shared care planning for home-bound and
complex patients. The Network and Island Health will continue to collaborate to develop
innovative ways to work together towards the common goal of patient-centered care.
Specialist teams from within Island Health, such as Geriatric and Diabetic Educators will
be accessible as well, at certain days of the week or month.
Appendix A - Detailed Stepped Care Model
Appendix B – Detailed Interdisciplinary safety nets
Registered
Nurse / Licenced
Practical Nurse
Immunizations,
wound care
Education,
injections,
wound care,
procedures,
Education, cognitive
Assess need assessment
and assist
with access
Resource
Navigator
Keep up to
date on
community
resources
Education,
including around
alternative
therapies & OTC
meds, access to
funding,
consultation
Education re:
specific prescribed
meds,
Pharmacist
flu shots
Post surgery
/ injury
adaptation
Social
Worker
Discharge
planning
Education,
Accessing financial
resources, housing, Education,
allergies
counseling, family
conflict
1st Nations, Seniors:
MRP Oversees care,
medical treatment
MRP, Education planning, goals of
care
Patient
MRP Oversees care,
medical treatment
planning, goals of
care, group visits
Hospital
care
Medical
Office
Assistant
Nurse
Practitioner
Family
Physician
Mobility
assessment,
education re: selfmanagement
Education,
Return to work Pt into room,
ht, wt, VS,
planning
billing, clerical,
referrals
Occupational
Therapist
Dietician
Post surgical,
strengthening
rehab, pain
management
Physiotherapist
Registered
Nurse / Licenced
Practical Nurse
Social
Worker
Discharge
planning
Home care
nursing, Case
coordination
Resource
Navigator
Navigation,
accessing services,
housing, assist with
treatment / housing
decision making
Symptom
check in
Identify gaps in
resources and
challenges with
access
Follow up
with access
Dietician
Modified textures,
increased /
decreased calorie
diets, IBD
Education
re: diets
1st Nations, Seniors:
Nurse
specific to
MRP Oversees care,
condition
medical treatment Practitioner
MRP, Education
Patient
Med review,
education for
complex meds
Education re:
specific prescribed
meds
Pharmacist
Functional
assessment
flu shots
Adaptation
needs for ADLs,
cognitive
assessment
Occupational
Therapist
Registered
Nurse / Licenced
Practical Nurse
Home Care Nursing,
Case Coordination,
symptom
management
Resource
Navigator
Communication
with HCN
Liaise with HCC &
family – ensure all
resources accessed
as needed
Blister pack meds,
education re: opiods
Pt into room,
ht, wt, VS,
billing, clerical,
referrals
Family
Physician
Neurologic,
musculoskeletal,
cardiorespiratory
conditions
Physiotherapist
Social
Worker
Discharge
planning,
family supportc
Dietician
Modified textures,
education re: food
& fluid at end of life
Decision making
support,
bereavement
1st Nations, Seniors: Nurse
MRP Oversees care,
medical treatment Practitioner
planning, symptom management,
goals of care, home visits
MRP
Patient
Pharmacist
Occupational
Therapist
Mobility
assessment, falls
prevention,
education re:
pacing
Hospital
care,
home /
facility
visits as
needed
Medical
Office
Assistant
Symptom
management
collaboration
Energy conservation
adaptations
MRP Oversees care,
medical treatment
planning, goals of
care, group visits
planning, goals of
care
Pt into room,
ht, wt, VS,
billing, clerical,
referrals
Medical
Office
Assistant
MRP Oversees care,
medical treatment
planning, symptom
management, goals of
care
Hospital
Family
care,
Palliative Physician
care unit,
facilities, home visits
Pain management,
education,
strengthening
Physiotherapist