Like many communities around BC, the South Okanagan region has faced significant challenges in meeting the medical needs of seniors in residential care.  A significant reason for this trend is that while the number of seniors continues to grow, the number of physicians with practices that focus on residential care is declining.  

The physicians of the South Okanagan Similkameen (SOS) Division of Family Practice decided to take an innovative approach to ensuring these seniors get the best patient care. With funding support from the Ministry of Health and BC Divisions Innovation Funding (and later by the General Practice Services Committee), the physician team received funding to become one of five prototypes to build and put in a place a plan to enhance care for seniors in residential care. Over three years, they have made significant strides.  The number of proactive physician visits to patients in the facilities has gone up significantly, while the number of emergency department visits has dropped. And, physician participation in patient care conferences has increased dramatically.
 
“Collaboration has been the key to our success,” says Dr Bob Mack, one of two SOS residential care medical coordinators. “Everyone involved –physicians, facilities and patients– was experiencing frustrations with residential care services. By sharing our perspectives and working together to develop solutions, we’ve already seen great improvements and have laid the foundation to continue that trend.”

Opportunities for Improvement
The first step in their plan of action was to gather critical pieces of information so that the team clearly understood the challenges they faced. Dr Mack and his fellow medical coordinator, Dr Mark Lawrie and QI Coordinator Arlene Herman, connected with SOS physicians, Penticton Hospital emergency department personnel, MOAs, facility staff, and patients and their families to assess needs and hurdles to care.

Here is what they found: seniors in residential care were over-reliant on emergency department visits for matters that could be handled at the facility.  However, residential care staff cited difficulty in reaching patients’ physicians for non-urgent care and had come to rely on the emergency department for non-acute matters. While MOAs did receive fax requests for physicians to attend their patients in facilities, there often wasn’t enough information to assess urgency.

When they looked into why physicians weren’t more present they learned some interesting things. It became clear there were two very different situations in the communities that comprise the SOS region. Summerland has two facilities that are located just 100 metres apart. On average, Summerland physicians had 12 residential patients, six in each facility. This proximity and historical culture led to Summerland physicians typically visiting residential care patients on a monthly basis. In contrast, Penticton’s residential patients were spread across five facilities in different parts of the city. The area’s 40 physicians also averaged 12 residential care patients each but they were spread across Penticton with only one or two in each facility, which made regular proactive care difficult and resulted in visits being mostly in response to acute situations. Possibly due to their infrequent attendance, physicians didn’t feel they were part of the team at the facilities and were prevented from optimizing on-site care due to a lack of available tools such as suture kits.

Collaborative Solutions
The Division created three quality improvement working groups, Communication, Care Conferencing and Palliative Care, to explore different aspects of the care mix.

“There was a clear need for better communication between physicians and facilities,” says Arlene Herman, SOS project lead. “One of the first things we have done is to pilot a communication tool called the SBAR (Situation-Background-Assessment-Recommendation) which we adapted to our needs.”

SBAR is a tool that promotes efficient and accurate communication between physicians and facility staff by effectively and reliably sharing patient information. It communicates the urgency level to physicians and generates timely and appropriate responses

“This tool is used when requesting a visit or further instruction from the physician about a patient. Now, physicians can more accurately assess patient needs and it has dramatically improved their response time. It has proved to be very successful in our pilot ; Interior Health adopted our form as a template,” says Herman.

Most Responsible Physicians became eligible for $200 per year for every patient they saw twice or more in six months at the facility.  This additional funding was designed to support proactive visits to residents including medication reviews and end of life discussions.  In addition it compensates physicians for the extra travel time and the additional time it takes to treat patients with complex care needs. As well, facilities now stock supplies such as the requested suture kits to help physicians provide more in-house support.  

“Our physicians feel a deep responsibility to their patients and there is a strong desire to remain their patients’ physician when they move to a residential facility,” says Dr Mack.  “Logistically, that can be a challenge but making visits more efficient and effective has led to an increase in proactive visits. While we didn’t measure the baseline number of visits before the prototype began, there was a 58 percent increase in proactive visits since the first reporting period and almost certainly a far higher increase from the baseline.”

To reduce emergency department visits for acute after-hours care, SOS negotiated the extension of the hospital’s Doctor of the Day jurisdiction to include residential facilities. The Doctor of the Day receives $250 for the added responsibility. With this additional coverage, the number of emergency department visits dropped 25 percent in the 13 months after the prototype began. Also, the gap between emergency visits and hospital admissions decreased, providing evidence that those patients sent to the emergency room were more suited to hospital care.

Physicians have also become more frequent participants in patient care conferences, which bring together everyone who supports a patient at a facility to discuss health changes, medications and forecasted needs, including palliative care. Before the prototype, physicians rarely attended, at least partly because the conferences often conflicted with their practice schedules. Now, they are held when the physician can attend, completed within 20 minutes, and result in a solid care plan more than 90 percent of the time. MRP attendance has increased 175 percent.

Looking Forward
SOS’ prototype has shown clear improvements in residential care and in the satisfaction of everyone involved. Dr Mack believes there are still opportunities for further improvement.

“We’re now at a place where we can take a deeper look at polypharmacy,” he says. “We also believe greater efficiencies and better care can be had if we are able to ‘cluster’ care.  This would entail having a small number of physicians in each facility, each caring for a larger number of residents. That is a long term goal but working together, I’m sure we can achieve it.”

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.