Providing the best possible care to elderly people in residential care facilities presents a variety of challenges. Enabling good communication and consistent care between health care providers is key—continuity of care is vital to maintaining the health of these vulnerable patients. When doctors in Prince George set out to find solutions for the residential care challenges facing their community, they chose to address responsive continuity of care first, before moving on to solve issues relating to polypharmacy and emergency room transfers.

Fostering Continuity of Care
Staff at Prince George’s six residential care facilities had been finding it difficult to arrange for physicians to visit —a problem faced by care facilities in other communities around the province. At the same time, the number of patients taking multiple medications (polypharmacy) was on the rise, along with the number of facility residents being transferred to the emergency department for medical care.

Efforts to improve care in residential facilities began in 2010, one year after the 2009 establishment of the Prince George Division of Family Practice.  “Our first goal was to increase physician presence at residential facilities,” says Dr Ian Schokking, Residential Care Lead for the Prince George Division.  To address the growing need for round-the-clock access to on-site care in facilities, the Residential Care Call Group was created —a group of interested physicians available to provide care 24 hours a day.

“Prince George was then chosen as a prototype community for the 2013 residential complex care plan, funded by the Ministry of Health. We wanted to ensure continuity of care for frail seniors, whether they were in daycare, hospital, or a residential facility,” explains Dr Schokking. “At every step, we were determined to put the best needs of patients first, and that meant 24/365 access to on-site care.”

As residential care lead for the Division, Dr Schokking acts as a coach and liaison between physicians and facilities, to ensure the needs of both are being met.  The philosophy was to build on the full-service longitudinal care culture in Prince George by strengthening the relationships amongst physicians, facility staff and resident’s families with the ultimate goal of supporting as many of our colleagues to provide responsive longitudinal care to residential care residents.

For two years, sessional payments were provided to physicians who attended each residential care facility once on the weekends. This acted as the nidus for our long term care call group: physicians with interest and increased experience in residential care who were willing to assume primary care for residents from out of town, or whose physicians were not up for providing adequate continuity. This evolved into a separate call group which backs-up physicians during the week and provides weekend coverage to unburden the inpatient call groups.

There are 14 physicians in the long term care call group, each of whom is responsible for at least four patients in the facilities they serve. This means that between 75% and 80% of residential patients are cared for by a call group member. The remainder continue to receive longitudinal care from their regular family physician.  Because call group members are also regular family physicians, at least 50% of patients are cared for by their regular family physician that has longitudinal cradle-to-grave relationships with residents and their families.

“It makes a positive difference when physicians really know not only the patients, but their families, the facilities and their staff,” says Dr Schokking. “It creates a team where everyone is working together to achieve the same objective.”

Changing Care Needs
“The reality is, residential care is changing,” says Dr Schokking.  “In the past, residents typically lived in facilities for three to five years. Now, the average length of stay in our community is less than a year. Folks are living longer and by the time they come to us, most have complex health conditions so the care they need is different.  For most, residential care is palliative and it’s in the patient’s best interests to approach it that way.”

Ensuring that patients are on the right medications (and that those medications interact well with each other) is an important factor in helping make patients comfortable. When a patient enters a residential care facility, all medications he or she may be taking are reviewed during an intake consultation. Medication reviews are also conducted at annual care conferences, when all those involved in a patient’s residential care come together to review their needs.

“Seniors often see many medical professionals and can have multiple prescriptions,” explains Dr Schokking. “We’re looking at the whole picture – do they still need the medication, how do their medications interact, is there a better option?”

Following this increased focus on patients’ decreasing medication needs as they become frail, polypharmacy rates have decreased, and in-person medication reviews are happening more frequently.

Other positive effects of the Prince George program include an increase in the number of frail seniors who have access to a primary care provider, and a decrease in the number of residents being transferred to the emergency room for care. The majority of those who do visit the emergency department have first been assessed by a physician at their residential facility, and need diagnostics or treatment that cannot be provided at a care home (such as X-rays).

Looking forward, Prince George physicians are now strengthening the culture of continuity of care in their community, supporting facility staff and physicians in providing the best possible care to seniors living in residential care facilities.

The GPSC’s residential care initiative is designed to enable physicians to develop local solutions to improve care of patients in residential care services. Since 2011, the initiative was prototyped by five divisions of family practice: Abbotsford, Chilliwack, Prince George, South Okanagan Similkameen, and White Rock-South Surrey. Building on the significant learnings of the prototype communities, in 2015, the GPSC committed up to $12m annually to expand the initiative to residential care patients in more than 90 communities across BC.