Primary Health Care Developer
Much time had already been spent as a PHC Developer in building relationships with the team and attempting to establish trust over the previous year (September 2011 to November 2012). Formal monthly meetings were held with the entire team which included physicians, MOAs and the clinic office manager. These meetings were accompanied by impromptu ‘hallway’ chats mid-week with individual team members. It was the PHC Developer’s task to present the physicians and team with a predetermined outline of tasks which included:
- Working with the electronic medical record system (entering patient chart information, tracking specific health issues (especially chronic diseases),
- Holding group medical visits
- Implementing modules addressing specific aspects of work within the clinic including office access and efficiency, health literacy, self-management planning, chronic disease management etc.
The expectation of the clinic team was to implement the work as it was presented to them. The process was tracked through quality improvement measurement indicators.
The team’s response to the delivery of this work was half-hearted enthusiasm at best. There was no sustainability in the processes undertaken. Although the physicians were presented with a ‘menu’ of projects they could choose to participate in, there was little enthusiasm and they looked upon it as make-work in a world where they were already constantly pressed for time.
It’s also important to note the format of the activities were formal in structure with the expectation to implement them as specified with little flexibility. However, ‘one size does not fit all’ as will be explained next.
Group Medical Visits
One of the projects undertaken was a group medical visit (GMV) for diabetic patients. The theory behind the group visits is that one-on-one physician visits take place in a group setting. The physician interviews each patient as he would in the clinic and discuss lab results and encourage questions from everyone in the room. There is strict confidentiality with consents signed in the beginning of the set of sessions. Benefits of the GMV are as follows: all patients present benefit from the information made available; questions come up that may not in an individual clinic visit; the physician saves time by seeing more patients in a ninety minute session than he could in the clinic in the same amount of time. In theory, patients are also able to see a physician sooner in the group than if they had to wait for an appointment in the clinic. As well, the physician only has to answer a question or deliver a piece of information to the group once. There are also the benefits of the patients understanding they are not alone in dealing with their disease and the socializing with others and the insight that is gained through group involvement. These are only a few of the benefits of the group style visit.
Four monthly sessions were held; fewer patients attended each subsequent session until there was only one patient attending along with one physician, two clinic clerks and the PSC. It was apparent this was not an efficient use of time and more importantly, the patients were not finding value in the GMVs. Post-session evaluations indicated general satisfaction with the visits, however, the numbers attending further GMVs did not reflect this. Informal chats with patients outside of the clinic proved dissatisfaction with the GMV format; the patients voiced their desire to be given chronic education rather than a ‘check-up’ in front of everyone.
During the team debrief, the following conclusions for poor attendance were determined: patients in this particular clinic did not have to wait longer than one day to see their physician for a private clinic visit so there was no advantage for them in attending the group medical clinic from a scheduling point of view; our community members value education during the visits more than having one-on-one visits in front of a group of people – this in particular worked against the GMV concept as our community of less than seven hundred people felt uncomfortable discussing personal problems in front of people they may bump into downtown.
The sessions were discontinued with the expectation of revisiting the group format in the future, after having tailored a visit format to suit the patients of our community and what was important to them. The fact that the team will be adapting the formal structure of the GMV to fit the needs of our specific community is key; the team is building flexibility into much of what they do in order to deliver health care in a community-specific way. We were changing from a pre-packaged, directive style of health care delivery to one that matched the needs of the community.
Transition to Practice Support Coach
Near the end of 2012 there was a change in job title and description from PHC Developer to Practice Support Coach. The focus of this role was to be entirely on the physician’s practice. The PSCs in the province were enrolled in a coaching program through Dartmouth Institute and for the next year our coaching skills within a health care context were developed while we practiced our new skills with our teams in the clinics.
Even though a working relationship had already been established with the clinic team, there was still further progress to be made. This was a long term coaching relationship and as such, more effort was required to create a deeper trust between the team and the coach. As establishing a basis of trust is imperative in the beginning of a regular coach/client relationship, so too was this important to the longer term coaching relationship with the practice team.
Meeting Spaces Impact Engagement
Shorter and more frequent formal meetings were planned and we began a schedule of weekly fifteen minute meetings prior to the clinic opening every Thursday morning. In this way, we were able to check in frequently and ask each other questions and problem solve on a consistent basis. It also created a culture of accountability since each person on the team understood the action items would be reviewed by their peers weekly. The meetings were held in the clinic manager’s office instead of the usual larger conference room which made a surprising difference in the engagement of the team members. For instance, medical office assistants (MOAs) were often very quiet and did not contribute to the discussion often. In the smaller, more ‘informal’ setting of the smaller office situated inside the clinic, everyone began to voice their thoughts and ideas. It was not long before the meeting atmosphere became much more relaxed and congenial. The original fifteen minute weekly meetings turned into one hour long meetings, even though there was an attempt to be very intentional around effective meeting skills and respecting everyone’s time by ending at the specified time; the team did not want to end after only fifteen minutes so were allowed continue. Unless there was an emergency, everyone chose to continue.
Whole Team Contribution
Through the coaching approach, the MOAs felt less pressure to ‘perform’ and also less stress to make continuous improvement. By experiencing the empowerment coaching brought to the clinic, the MOAs began to be interested in expanding their roles; instead of only entering the arrival of patients into the daybook and scheduling future appointments, an MOA now takes the patient into the exam room and takes point of care measurements which are then entered into the patient’s EMR database. The measurements are ones used to track BMI and BP and at the same time, the MOA can have a relaxed, informal discussion with the patient on how they are doing and perhaps take the opportunity to build a self-management plan with them. These interactions help the patients to feel they are receiving improved quality of care while at the same time allowing the clinic to gather measurement data in an efficient manner; everyone works to their individual scope of practice.
Primary Care Homes
Home isn’t where our house is, but wherever we are understood. Christian Morgenstern
An important primary health care theme is to promote health improvement as the co-responsibility of the patient health care delivery team or Primary Care Home.
‘A medical home is a patient-centred medical care setting where: 1) patients have a personal family physician who provides and directs their medical care; 2) care is for the patient as a whole; 3) care is coordinated, continuous and comprehensive with patients having access to an inter-professional team; 4) there is enhanced access for appointments; 5) the practice includes well-supported information technology, including an electronic medical record; 6) remuneration supports the model of care; and 7) quality improvement and patient safety are key objectives.’
The Primary Care Home gives greater responsibility of one’s well-being back to the patient. In our facility, this is done in part through self-management planning, particularly in people with chronic disease conditions.