Divisions of Family Practice

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Divisions of Family Practice

Provincial Round Table Report

Thursday, June 12, 2014

Vancouver, BC

October 29, 2014

Provincial Round TableReport

Meeting summary

200+ participants
9 speakers
16 GPSC host-staff pairs
4 breakout sessions
31 questions/topics
256 separate table talks
106 pages of notes
8 main themes
= 1 bright future for
primary care in BC / The June 2014 Provincial Round Table brought together over 200 participants — the largest event in the history of the Divisions of Family Practice — for a day full of strategic conversations, exchange of ideas, and relationship building. Representatives included physicians and executive directors or coordinators from community divisions, the Ministry of Health, Doctors of BC, the General Practice Services Committee (GPSC), health authorities, and the Divisions of Family Practice provincial team.The day began with a landmark welcome speech from the Honourable Terry Lake, the first Minister of Health to attend a Divisions of Family Practice Round Table.
The day was structured as a series of small-table discussions, in four breakout sessions, between division members and GPSC and health authority representatives. Pairs of GPSC hosts and provincial team staff moved from table to table to guide up to six conversations (each lasting from 10-15 minutes) on a specific question or topic during the first three breakouts. The breakout sessions and conversation topics included:
Breakout 1: Modelling primary care for the future

What does practice composition look like in the primary care model of the future?
What scope of services should primary care deliver in the future?
How can funding models facilitate what we want to deliver in primary care?
What are the roles and the strategies of primary care providers to help patients access services to stay as healthy as possible in the community?

Breakout 2: GPSC strategic directions, and GPSC and Divisions of Family Practice engagement

For input into the GPSC’s strategic planning process, what is the best way for the GPSC to engage with divisions; how can it populate a visioning task group; and what topics in primary care do we need more information on?
Following the recommendations in the Understanding and Improving Two-Way Engagementreport,how do divisions want the GPSC to more actively participate with them?

Breakout 3: Emergingtopicson supporting divisions and their work

Maturation of divisions
Infrastructure funding model review
Impact of A GP for Me on divisions
GPSC and divisions – strengthening our relationship
CSC model review
Future of practice management/support
Future research – what are the questions we need to ask?
Specialists in primary care

Breakout 4: Presentations on“Hot Topics” by divisions and partners

Physician recruitment and retention: practice coverage, locum coverage, process mapping
Technology: Pathways, Physician Data Collaborative, UpToDate
Community-based system of health, residential care, inhospital care
Rural perspectives
Alignment with or impact of other initiatives and programs: NP4BC,A GP for Me, Practice Support Program (PSP) and PSP-Technology Group

Part 1 of this report distills the important themes from all the conversations throughout the day and speakers’ remarks.
Part 2 consolidates the feedback on each conversation topic in the breakout sessions. The report captures the diverse views among all participants. It does not present consensus or decisions, or policy directions of Doctors of BC or the Ministry of Health.
Next steps:
The divisions and the GPSC appreciated the opportunity at this Round Table to directly engage and share their ideas and hopes for the future of primary care in BC. The GPSC has been building on these important conversationssince the Round Table. As of October 2014, these next steps are underway:

The GPSC is continuing to implement the recommendations in the Understanding and Improving Two-Way Engagement report. [The report was sent again to all divisions, and it is also available on the Divisions website.]
As part of its strategic directions process, the GPSC is committed to understanding effective primary care models.Over the fall, the GPSC isundertaking a literature and jurisdictional review, which will be shared with the committee as it is developed.The GPSC co-chairs have agreed to look at setting a strategic direction early in 2015. This will include discussions with divisions and physicians in identifying what primary care could look like in BC.

A planning group will be formed to start organizing the next Round Table (in spring 2015), where divisions and the GPSC will continue working together on realizing a common vision for primary care and determining what it will take to make it happen, supports needed, and barriers to overcome.

Part 1 – Important themes

Opening remarks
Georgia Bekiou introduced herself in her new role as Executive Lead, General Practice Services Committee, stating that one of the goals of the conference was to strengthen BC’s “primary care family” by reinforcing the relationship between the GPSC and Divisions of Family Practice. Serving as the event’s host she introduced each speaker.
Welcome from the Ministry of Health
The first BC Minister of Health to attend a Divisions of Family Practice Round Table event, the Honourable Terry Lake, praised the success of the collaborative approach to health care showcased by the Divisions of Family Practice. He emphasized the initiative’s central role in guiding the improvement of our health care system to help drive attachment, inspire more effective collaboration, and remain relevant as the medical profession evolves alongside societal values.
Welcome from Doctors of BC
Dr. Bill Cavers, Doctors of BC President, remarked on the incredible progress of the Divisions of Family Practice - six years ago the initiative didn’t exist and now it’s the “cultural norm” with 90% of BC physicians having the opportunity to be engaged in a local division. Dr. Cavers outlined Doctors of BC’s three priorities: physician professionalism, specialist engagement, and physicians as leaders in a time of technological change.
Strategic priorities and areas of alignment
Doctors of BC CEO Allan Seckel identified the Divisions of Family Practice initiative as a perfect model of collaboration and one that can be used in Doctors of BC’s next goal: improving specialist engagement. Speaking about “Strategic Priorities and Areas of Alignment”, Allan outlined the benefits of providing strategic guidance and empowering local decision making and leadership for becoming a profession of influence. He also emphasized the importance of embracing the diversity within the Divisions of Family Practice, describing the initiative as “a little bit messy, a little bit scary,
but extremely beautiful.”
Linkage with Ministry of Health priority areas
Stephen Brown, Deputy Minister of the Ministry of Health and pioneer of collaborative health care in BC, reminisced about the early days, describing how the collaborative programs rose from rocky beginnings to become an innovative and nationally renowned model of health care. Stating the Ministry’s desire “to leverage further what [local divisions] have achieved,” he asked members to keep combining their community knowledge, innovative spirit, and commitment to quality care by continuing to come up with creative service ideas that benefit patients. He also encouraged them to engage in “disruptive innovation” to help create meaningful change. He pledged that the Ministry will work with the divisions to make these ideas work within the system.
Framing the day
Dr. Shelley Ross, GPSC CoChair – Doctors of BC,and Mark Armitage, GPSC Co-Chair – Ministry of Health, spoke about the impressive scope of the Divisions of Family Practice initiative, its impact on primary care in BC, and the collaborative spirit fostered between community divisions and their health authorities. Shelley mentioned the importance
of having three Executive Lead positions filled (Georgia Bekiou for the GPSC, Yvonne Taylor for Divisions of Family Practice, and Graham Taylor for Quality Improvement and Practice Support) and that the GPSC is now able to move forward strategically and thoughtfully.
Community divisions were identified as being the proving ground where the Triple Aim and theories of improving care are put into practice. In taking responsibility for their communities’ needs, divisions throughout BC are changing the face of health care by taking a leadership role and creating locally focused care solutions that have implications outside their communities. They emphasized the GPSC’s desire to improve its communication and engagement with local divisions.
GPSC strategic directions
Dr. Peter Barnsdale,
GPSC – Doctors of BC, praised the Divisions of Family Practice for having “turned around the GP experience.” The initiative has enabled GPs across BC to perform better at work, make a difference in their communities, and influence the structure of the health care system. He emphasized that the GPSC is committed to engaging in more robust two-way communication with local divisions and that this event marked the beginning of a stronger relationship between divisions and the GPSC.
Closing remarks
GPSC Executive Lead
Georgia Bekiou introduced Dr. Brenda Hefford, new Executive Director, Practice Support and Quality. They remarked on the increasing size and scope of the Divisions of Family Practice initiative and on the potential divisionmembers have to improve primary care in BC. / Part 1 consolidates the main themes from all the table talks in the four breakout sessions and speakers’ presentations.
Table talk themes
The main themes that emerged from across the small-table conversations include support for and suggested actionsto:

Support team-based care
Adopt the patient medical home
Shift toward a community-based system of health
Develop flexible funding models
Accommodate flexible practice models
Recognize and support rural practice
Increase the GP’s role in health promotion, prevention, and health education
Use technologymore

Support team-based care
Participants reinforced that movement to team-based care is necessary and inevitable. It could be a co-located or virtual team.
We need to look for the best collaborative primary care models worldwide, and what makes them work. A model needs to be defined concretely enough to enable diverse care providers to practice together as a team, and that includes supportive funding models, better communication, and shared understanding of each other’s roles and responsibilities around scope of practice.
The composition of interdisciplinary teams should be based on patient needs and community needs. The team may change its composition, but a constant is the GP. Successful team-based care depends on relationships, and patients need to be connecting with the same person.
The role of the GP in team-based careis unclear. Team-based care is challenging the current model of the physician as the captain of the ship: for example, other professionals could also play this role.
As complexity of patient care increases, team-based care should increase. GPs don’t want to focus only on complex care;care should be shared among a group of professionals. The issue will be to manage the continuity of care for the patient, as the patient may experience fragmented care if too many people are involved.
Adopt the patient medical home
Health care is still not patient-centred: care should be where the patient is. Put the patient in the middle, start with what they need, and coordinate care across disciplines (e.g., physician, nurse practitioner, allied health) and care environments (e.g., hospital, acute, community-based).
No matter what door patients enter, channel them back to longitudinal care. We need to maintain the GP-patient relationship to ensure longitudinal care. The medical home provides solid attachment in a convenient way.
The GP is accountable and has a critical role in the complete care of the patient.You can’t dilute the role of the GP.
Traditional practice models are failing populations with barriers to access (e.g., seniors, those with mental health and addictions issues, homeless). Care for vulnerable populations needs better coordination and accessibility.
Shift toward a community-based system of health
We need to shift toward community-centred care, to remove silos and provide seamless care among primary, acute, and community care. Link to the community as the centre in the medical home model. Look at and understand the community as a whole, including barriers and strengths. Provide all-inclusive community care, including social services, to wrap services around the patient.
Partner with other community agencies, not only the health authority (e.g., healthy community partnership model in Fraser Health). Bring together the right groups of organizations, collaborate on a common goal, leverage strengths, and build on existing work of local governments, parks and recreation, and community organizations.
Divisions can take on an integrator role: talk to the municipality about what needs to change, and figure out how to get organized in community to get to action.Physicians need to be leaders in their communities. CSCs need community representatives at the table.
Access to care needs to be available outside of a doctor working 9-5 in an office. Provide services at different times and locations to access care. Embed allied health provider supports in the community (e.g., physiotherapists in rec centres).
A resource navigator or integrated care coordinator (e.g., nurse
or social worker) is needed who can help patients connect to appropriate services in the community at the appropriate time. This role is critical to support physicians with access points for patients, and to facilitate patients effectively moving through system. GPs are not aware of all the community resources available nor have time to find services. But who is going to pay for and sustain navigation?
Develop flexible funding models
Funding models should not drive the care of patients. We need to align “what we value” with “what we pay for.” It should be the best care supported by a funding model rather than funding model driving care.
Begin with defining the practice model, then the funding model follows. New funding models are needed for team-based care and medical home that take into account funding allied health professionals and accommodating such roles as navigator, family support, and home care. There should be funding for teams to manage care. Provide incentives to doctors for working in a team?Doctors need better infrastructure support for multidisciplinary care (e.g., overhead costs). The fee structure has fragmented primary care to more specific activities; we need to incent the full spectrum of care. Give every GP the option to access base funding to support longitudinal care. Attach the funding to the patient.
Funding poses a real challenge to creating workable practice models — there needs to be flexibility based on patient needs.
We need to not work to the fee: we can tell who the good billers are but not who is providing good care. The current model incents “fast” medicine — it does not reward quality, it rewards quick. If a doctor wants to provide quality, s/he pays for it with lifestyle.
Funding models that are too complicated are a barrier. The current billing system is not efficient, and billing processes and codes need to be simplified. It takes too much time and administration, and disrupts workflow, when doctors want to focus on care.
Prototype new funding models. We need to test blended models that include fee for service and Alternative Payments Program (APP), with support from the Ministry of Health for prototyping. Consider using all funding models concurrently. Use divisions to test blended models and reduce barriers (especially to inclusion of nurse practitioners). Divisions could test two models in one community, with test sites reporting and sharing with each other. Pilots need to be in a “bubble” so that patients are within one system and the pilots are operational for at least three to five years so there is commitment.
Ensure sustainability. Funding programs need to be longitudinal, not one-off or time-limited. There is current funding for innovative pilot projects (e.g., Shared Care), but it’s not ongoing. There are concerns about taking part in pilot programs because what happens when funding stops? Change and adaptation takes time; funding dies before we see the effects.
Accommodate flexible practice models
Physicians should be able to choose where to practice and how. Depending on lifestyle and age, physicians may want to practice differently. New physicians have different expectations; they prefer group practices to solo practices to ensure work-life balance. Those that are new to practice are shifting it. As doctors age, they also may want to adjust their practice.
Physicians are being asked to move out of their comfort zones, but it is challenging to consider other models of care because it means a possible loss of income in the short term, while a more sustainable model is built for the future.
Recognize and support rural practice
Recognize how rural and urban settings differ for health care delivery, access, and the role of a GP in the patient journey.
Transportation issues, including both critical care transport and general travel to appointments, are a key issue in rural communities. A lot of travel time for rural physicians isn’t compensated.
Rethink service delivery for rural communities: what do patients travel to and what travels to the patient? How can we replicate a full suite of services in novel ways? It is difficult to get specialists to small communities, and services are not based on a community’s identified needs. Engage specialist groups to see it as their responsibility as a group for a more coordinated approach to rural care (more than one specialist is more sustainable).
Expectations of qualifications have increased. Physicians with advanced skills in rural areas need to be privileged in a way so they stay (competency based not currency based). Credentialing is one of the biggest threats to care in rural areas.
Rural communities have different needs. For example, at the Round Table, discussions are around primary care, but in rural communities there is no distinction between people providing primary care and acute — the same doctors do both. Would it be possible for all participants at Round Tables to help brainstorm solutions to help rural communities?
Increase the GP’s role in health promotion, prevention, and health education
Shift from an illness model to a wellness model. Don’t only reward for treating illness. Increase resources and support for health promotion, prevention, and early intervention.
GPs play a key role in facilitating patient education. Health education should be strengthened to promote self-care, healthy eating, active lifestyles, etc. Shift patient expectations of care from cure to prevention, and encourage them to take ownership of their health. Increase support for patient education and self-management for patients to be partners in their health care.
Move away from one patient/one problem at a time in a practice. Bundle services for a cohort of patients with the same condition (e.g., group medical visits for people with diabetes) so patients can network, provide peer support, and learn from each other. And make it work within the fee structure.
There is a role for divisions in community education and physician engagement with the community as a whole to increase people’s understanding of how the system works. Develop public education around primary care and the importance of attachment for better integration, awareness, and appropriate use of health services.
Develop better recognition of the social determinants of health so care is more holistic and coordinated. How do we encourage working upstream? For example, divisions impacting public policy and educating physicians about opportunities for people to stay healthy in the community (physical activity, green space, healthy foods, etc.). It’s hard to affect changes in behavior that are driven by bigger system issues.
Use technologymore
Information management is part of the scope of primary care. We need integrated information systems to support practice (includingvirtual primary care networks and medical homes); provide realtime data to manage care;and access patient resources.
We need coordinated electronic medical records (EMRs) to ensure physicians have access to comprehensive, coordinated patient data, and more interoperability between physicians, hospitals, labs, etc.
We need more integration of information technology support and office support; ongoing support for technology and business systems; and meaningful use of technology driven by GPs.
PSP and PSP-Technology Groupneed to ensure all PSP modules are embedded into EMRs; develop a policy on data in the EMRs; support EMR user groups and communities of practice; and provide training with data draws to influence quality improvement and reflective practice.
The Physicians Data Collaborative is a vehicle for supporting physicians to use the EMR to inform their practice. Division members have a wealth of data on their EMRs, and the Physicians Data Collaborative is developing a platform so that they can use the anonymized aggregate data in a meaningful way.
Pathways will be very helpful. Can the health authority and Ministry help bring it more quickly? Can it be expanded to include community resources? Can access be extended beyond GPs and specialists to allied health and others who support us (e.g., hospitalists)?

Part 2 – Table talk summaries