By Dr Sarah Cook and Dr Ewan Affleck
Yellowknife, the capital of the Northwest Territories, is home to an ethnically diverse population of 22,000 people. Historically, outpatient primary health care services in Yellowknife have been provided by four distinct private clinics. Residents of Yellowknife experienced many of the same primary care constraints seen elsewhere in Canada: excessive wait times, limited access to family physicians, poor continuity of care, limited options for after-hours service, and fractured information systems.
In 2012 a project was launched to reform the Yellowknife Primary Health Care Clinic service. The clinics were physically consolidated into two spaces and expected to function as a unified service with a single electronic medical record (EMR) system. While the initial task of the working committee—documenting deficiencies in the service—was simple enough, establishing a coherent approach to address service shortfalls was more daunting. Although the desire was to establish a means of carefully measuring primary care service improvement over time, quantitative clinic-based reform tools were not readily available. As a result, the committee decided that the College of Family Physicians of Canada’s Patient’s Medical Home (PMH) model could not only serve as a model for service improvement, but could also be converted into a scoring tool to evaluate the function of the Yellowknife Primary Health Care Clinic service.
The 10 core goals of the PMH are designed to serve as a model for ongoing practice assessment and quality improvement. Each core goal has recommendations that outline a coherent approach to establishing effective, patient-centred, high-quality primary health care. These recommendations were adapted to the Yellowknife Primary Health Care Clinic environment and served as the foundational directives for service reform.
Using a grading system (see the Benchmark Grading Scale in Table 1 below), the performance of the Yellowknife Primary Health Care Clinic service was rated for how often it met each of the project recommendations. This rating served as a benchmark of the current state of clinic function and for project evaluation over time. The initial score of the Yellowknife Primary Care Clinic service was 39%.
Project interventions were then established for each of the PMH recommendations. Once the benchmark grading was completed, the project interventions began to be implemented in a serial and iterative manner as a series of Plan-Do-Study-Act cycles. Principle among the project’s early successes (the project is ongoing) have been the establishment of provider panels, the establishment of coherent team-based care, the development of service analytics, and the integration of team coordinators. Subsequent scoring of clinic function based on the grading scale has demonstrated significant service improvement, with an overall score of 52% in April 2015 and 69% in April 2016.
In the initial 2013 benchmarking exercise, the score for the recommendation of having every patient assigned to a family doctor was 20%. The intervention chosen to address this was to create panels. Initially a panel size was set at 1,200 patients per full-time equivalent family doctor, which was loosely based on averages in similar practice settings. Empanelment followed a defined process. The score for patient assignment improved to 60% by 2015. Since then, we have increased panel sizes to 1,375 based on actual capacity, and we expect an even higher score for this measure on the next benchmarking exercise. The new panel size was calculated using the following formula: Panel size capacity = (Provider encounters per day X Provider days per year)/Average encounters per patient per year.
We now have a plan to gradually increase panel sizes to be able to empanel every resident of Yellowknife while maintaining near-current provider resources. This will involve a number of innovations aimed to:
- Decrease the number of patient encounters per year by:
- Improving continuity
- Lowering encounter return rate
- Eliminating unnecessary visits (eg, sick notes, prescription refills)
- Increase the number of patient encounters per day by:
- Exploring alternatives to traditional encounters (eg, messaging, telephone follow-ups)
- Increasing the responsibilities of team members by maximizing scope
- Decreasing no-show rates
Empanelment shifts the focus from individual one-on-one encounters to providing care for and increasing the health of a population. It also facilitates the use of data analytics to proactively manage the health of patient panels. This work is under way with diabetes and renal analytics projects through the creation of registries and implementation of flags in the EMR system to ensure these populations are receiving optimal care.
The PMH goal of team-based care led to another area of significant change in practice style. Teams of physicians, nurse practitioners, licensed practical nurses, and clinical assistants were formed. Nurse practitioners were given a “load balancing” role on teams; though they were not empanelled themselves, they contributed to the overall capacity of provider encounters per day. The benchmarking score for team-based care increased to 57% in 2015 from 28% in 2013.
Access to services, continuity of care, and the establishment of highly functioning teams continue to present challenges as we hone our PMH; however, we are confident that we are on a path that is improving the patient-centredness and quality of care we provide to the residents of Yellowknife.