Primary Health Care Virtual Care Knowledge Exchange ...
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Primary Health Care Virtual Care Knowledge Exchange Webinar Series Hosted by: Primary Health Care Practice Support Program
Transcript of Primary Health Care Virtual Care Knowledge Exchange ...
Primary Health Care Virtual Care Knowledge Exchange Webinar Series
Hosted by: Primary Health Care Practice Support Program
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An initiative of Primary Health Care and Department of Family Practice, Nova Scotia Health
Supporting primary health care providers and teams, fostering a culture of shared learning, quality and safety, and enabling quality care for patients and families.
Practice Support Program
Supporting your patients to live well and manage their chronic conditions
Supporting patients with mild to moderate mental health concerns, pain, and substance use disorders
Enhancing access to primary health care services, virtually and in-person
Focused supports for family physicians
Our Current Areas of Focus:PHCQuality.ca
@PHCQualityPSP
Knowledge Exchange: an approach to sharing knowledge that is acquired through work experiences, successes and challenges; essential to achieve continual learning from experience, and to support the application of learning to improve our work
Primary Health Care Virtual Care Knowledge Exchange Webinar Series
1 Making the Leap to Virtual Care: Moving Beyond the Telephone
Getting Started with Virtual CareSession for Nova Scotia Health PHC Chronic
Disease Management / Wellness Teams
Getting Started with Virtual Care Session for Family Practice Providers / Teams
Beyond the Basics: Enhancing Virtual Care March 10
8:00 – 9:30 am
February 248:00 – 9:30 am
February 108:00 – 9:30 am
January 278:00 – 9:30 am
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Knowledge Exchange: an approach to sharing knowledge that is acquired through work experiences, successes and challenges; essential to achieve continual learning from experience, and to support the application of learning to improve our work
Primary Health Care Virtual Care Knowledge Exchange Webinar Series
The Webinar Series aims to:
Increase readiness of PHC providers and teams to transition to or use virtual care technologies in their practice through the sharing of peer experiences
The Webinar Series will not:
Endorse particular virtual applications
Provide direction on clinical standards related to virtual care (i.e. the right balance of in-person vs virtual)
Provide solutions for system-level challenges, e.g. digital infrastructure; inequities in patient access to technology/internet; remuneration challenges, etc
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Webinar AgendaTopic | Presenter Format• Panelist Presentations / Experience Sharing & Q&A:
• Dr. Tara Kiran, Fidani Chair in Improvement and Innovation and Vice-Chair Quality and Innovation, Department of Family and Community Medicine, University of Toronto
• Dr. Laura Sadler, Family Physician and Assistant Professor, Dalhousie University Department of Family Medicine
• Matt Holland, Manager Planning and Development, Nova Scotia Health Primary Health Care
• Wrap-Up: Resources and Evaluation
• Lecture• Group chat• Experience Sharing• Q&A
Beyond the Basics: Enhancing Virtual Care
WEBINAR 3 March 10, 2021
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Webinar Objectives
• Increase familiarity with advanced and innovative uses of virtual technologies to provide care, including asynchronous care
• Increase understanding of how to improve virtual care through a quality improvement lens • Increase awareness of resources / supports available to improve virtual care
Beyond the Basics: Enhancing Virtual Care
WEBINAR 3 March 10, 2021
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Faculty/Presenter Disclosure
Speaker Name: Lindsay Cormier
Relationships with commercial interests:
• No commercial interests to report
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Disclosure of Commercial Support
This program has not received financial support.
This program has not received in-kind support.
Potential for conflict(s) of interest:
• Not applicable
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Mitigating Potential Bias
• Not Applicable
Welcome to WebEx Events
WebEx Chat
Panelist Presentations
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Faculty/Presenter Disclosure
Speaker Name: Dr. Tara Kiran
Relationships with commercial interests:
• No commercial interests to report
Virtual care–COVID-19 and beyond
Tara Kiran MD, MSc, CCFP, FCFP @tara_kiran
Fidani Chair in Improvement and Innovation and Associate Professor, University of TorontoFamily Physician, St. Michael’s Hospital
Beyond the Basics: Enhancing Virtual Care, March 10 2021 Nova Scotia Health, PHC Practice Support Program
“[T]he groups with the highest care needs, including those older than 65 years and thosewith higher levels of morbidity, maintained relatively higher levels ofcare overall. Virtual care increased markedly for all groups, with relativelysmall differences across patient and physician characteristics…”
Ramping Up Bloghttp://cmajblogs.com/ramping-up-in-person-office-visits-in-primary-care-in-the-aftermath-of-covid-19/
Management of chronic conditions
Type 2 diabetes during COVID-19
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In-person or virtual?
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Disease Severity and/or diagnostic uncertainty
Capacity for virtual self-assessment & management
More virtual care
More regular in-
person visits
The patient view
GTA Stream
Barrie or Newmarket Stream
https://www.dfcm.utoronto.ca/improving-quality-during-covid-19
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In Person Phone Video Email/SMS
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How did you receive care during this time? (Select all that apply)N=5068
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PhoneN=4195
VideoN=260
Email/SMSN=886
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Extremely/SomewhatComfortable
Neither ComfortableNor Uncomfortable
Extremely/SomewhatUncomfortable Missing
When using the Phone/Messaging/Video to discuss your health concerns, howcomfortable were you with the level of privacy and security? (Select one
response)
Less likely to report comfort if:-having trouble making ends meet -born outside of Canada-poor/fair health
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Phone Call Video Email/SMS Other
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After the COVID-19 pandemic is over, which of these care options shouldthe clinic continue to offer? (Select all that apply)
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Less likely to want virtual care option if:-having trouble making ends meet -born outside of Canada-poor/fair health
https://www.cihi.ca/en/commonwealth-fund-survey-2019
E-Survey of physicians associated with the DFCM. 865 responses received (56% response rate). 610 met inclusion
Physicians who used email were more likely to:-be remunerated via capitation, -spend 50% or less of the work week doing office-based primary care, -have a smaller roster size, -have a larger group size-work at a core teaching site**it was not associated with physician age or years in practice**
43% personally used email with patients; additional 21% didn’t use email themselves, but their clinic staff did
Facilitators and barriers to using email
Supporting virtual care
https://cep.health/clinical-products/virtual-care/
In-person or virtual?
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Disease Severity and/or diagnostic uncertainty
Capacity for virtual self-assessment & management
More virtual care
More regular in-
person visits
How can we increase capacity for virtual self-management?
Summary• Virtual care can play an important beyond COVID-
19, especially for management of chronic conditions
• Most patients are comfortable with virtual modes of care and want them to continue
• Most virtual care today is via phone• We need to advance the use of email and/or
secure messaging by supporting physicians (e.g. $, workflow, privacy/security) and patients (e.g. access, skill)
• We need to be patient-centred and equity-oriented in our approach
[email protected]://www.dfcm.utoronto.ca/improving-quality-during-covid-19@tara_kiran
Virtual Care at Dalhousie Family MedicineDr. Laura Sadler, MD, CCFP, FCFP
Disclosures• None!
Who we are• Dalhousie Family Medicine Residency Program-Halifax site
• Spryfield and Mumford Clinics• Collaborative practices, team based• Over 10 000 active patients, 25 Academic Family Physicians• Learners include residents and medical students (among other
disciplines)
Overall Visits
Virtual Care Implementation• March 2020
• Phone visits• Telehealth Zoom Visits
• October 2020• Need for a new way to communicate, patients reaching out• Faculty approved use of HealthMyself/Pomelo as Asynchronous Care• Pomelo/Asynchronous care implemented Jan 2021
Virtual Care at DFM: Phone Visits
• Benefits• No travel• Patient satisfaction• Safer in pandemic
• Drawbacks• Unknown numbers• Dropped calls• No physical exam• Merging calls with learners
Virtual Care at DFM:Video Visits (TH Zoom)
• Benefits• Visually able to see the patient• Can assess some physical exam findings• Learner involvement, direct supervision (waiting room feature)
• Drawbacks• Patient hesitation• Technical difficulties, internet speed, access to internet• Visits often take longer• Administrative burden to book
Visit Ratios
Visit Ratios
Virtual Care at DFM:Aynchronous Care
• Pomelo ‘go live’ 2nd week of Jan 2021• Started with invitations to 3000 patients, about
1/3 have registered• Learning curve!
Initial Experience• Sending lab req/DI req securely to patients• Receiving insurance and other paperwork from patients• Patient initiated questions• Provider initiated discussions
Examples
• ‘Can I safely use Tylenol…’• Phone consult re toe pain, sent a picture to complement visit• Sending lab req/DI req to patients • Confirm/remind medication doses via messaging
Asynchronous Care• Anticipated Benefits
• Reduced no-shows with appointment confirmations• Proper demographics as patients can update themselves (mobile
check-in)• Reduce burden to administrative staff (reducing time on phone,
improve office efficiency)• Patient and Provider satisfaction• Allows for ‘richer’ virtual care• Improve proactive care/wellness initiatives
Quality Improvement• Pilot project to evaluate implementation and usage of
asynchronous care• Outcomes
• uptake/usage• access (3rd available, no shows)• satisfaction (provider/patient)• cost
Access - No Shows
Access – Time to 3rd Available Appointment
Next Steps• Further implement asynchronous care
• Patient registration• Provider usage• Other staff usage
• Quality Improvement/Research• Pilot project on asynchronous care
Questions
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Faculty/Presenter Disclosure
Speaker Name: Matt Holland
Relationships with commercial interests:
• No commercial interests to report
But…what do we do? How do we change?
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Quality Improvement
How do you know if a change is leading to improvement?
Quality improvement: An evidence-based approach to understanding issues,
identifying solutions and putting new ways into practice
Change is hard and there’s lots of it
Step 1: Assess your readiness and capacity
Step 5: Test changes and monitor progress
Step 4: Decide where to improve
Step 2: Form an improvement team
Step 6: Implement and sustain the changes
Step 3: Assess your starting place
Quality Improvement Approach
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What is the problem?
Clinicians and office staff are having to make numerous attempts to reach a patient for a virtual appointment, which often results in a virtual “no-show". The unused appointment slots resulting from no shows means a missed care opportunity for the patient, unutilized time that another patient could have accessed if given the opportunity, and increased appointment demand if the no-show has to be rebooked.
Selecting Change Ideas / Solutions
Reduce the likelihood a call is missed• Reminders (texts, etc.)• Have their email? Put in patient’s calendar.• Clear instructions up front (e.g. patient info sheet)
• Keep ringer on• Phone # will be unknown.
Increase ability to use potential wasted time
• Create a waitlist of patients open to last minute calls in case of no-show/cancelations, and clear from the schedule.
• Have non-appointment work identified ahead of time to tackle during downtime.
Model for ImprovementA simple framework for guiding quality improvement work
Setting an aim | Commitment to improving is reflected by an aim statement
Establishing measures | Collecting data on key outcome, process and balancing measures to determine if there is improvement
Selecting change | Test and implement changes in order to improve
PDSA cycle | Testing a change in a real work setting by planning it, trying it, observing the results, and acting on what is learned
Quality Improvement Approach
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Model for ImprovementA simple framework for guiding quality improvement work
Setting an aim | Commitment to improving is reflected by an aim statement
Quality Improvement Approach
By May 2021, we aim to reducethe number of virtual “no shows” in XYX Practice by 25%.
A good aim statement is similar to a good SMART goal; should answer the following:
What, how much, by when, and for whom?
By June 2021, we aim to reducethe number of unused virtual appointments in Dr. Smith’s schedule by 50%.
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Measurement for Improvement
Quality Improvement Approach
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ImprovementAccountability/
Performance MonitoringClinical Research
Purpose Improvement of care; application of evidence
Comparison between organizations or to a criteria, reassurance, spur for change
Generate evidence or new knowledge
Data Collection
Accept consistent bias in data collection
Statistical adjustments to reduce bias
Design of experiment to reduce bias
Sample Size
Small sequential samples of data
100% of available dataLarge samples so there is enough data for hypothesis testing and generalizing to larger population
Analysis Run charts/Control Charts
NAStatistics for hypothesis testing: T-tests, F-tests, Regression Analysis, etc.
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Improvement StoriesAre you or your team improving virtual care delivery in your practice?
Do you have an improvement story to share?
We would love to hear from you!
Email [email protected]
Questions?
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ResourcesFor you and your team:• Nova Scotia Health Zoom for Healthcare
• PHCQuality.ca: Virtual Care Supports and QI Resources and Tools
• Doctors Nova Scotia: Virtual Care Toolkit and e-Health Privacy and Security Guide
• Canadian Medical Association Virtual Care Playbook
• Centre for Effective Practice: Enhancing Management of Chronic Conditions Using Virtual Care During COVID-19 and Managing Type-2 Diabetes During COVID-19: a guide for primary care providers
• CMAJ Blog: Quality Framework: Considerations for balancing in-person and virtual visits in primary care during COVID-19
• College of Family Physicians of Canada: Virtual Care in the Patient’s Medical Home
For your patients:• Nova Scotia Health Virtual Care
• Canadian Medical Association Virtual Care Guide for Patients
• Canadian Patient Safety Institute virtual care resources for members of the public
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Looking for Support?
Contact us to link to appropriate supports in your area:
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MainPro+ Credits: Virtual Care Knowledge Exchange Webinar Series; Program ID: 193721
This Group Learning program has been certified by the College of Family Physicians of Canada and the Nova Scotia Chapter for up to 4.5 Mainpro+ credits.
Thank you for joining us.Please complete the
post-webinar evaluationPHCQuality.ca
@PHCQualityPSP
