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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