Providence Health Care (BC)

  • Sandra Barr, Program Director, Heart Centre, Providence Health Care, Vancouver, British Columbia
  • Margot Wilson, Project Director, Chronic Disease Management, Providence Health Care, Vancouver, British Columbia

Collaborative Management of Patients with Chronic, Complex Co-morbid Conditions

Patients with complex chronic conditions often navigate multiple care interfaces and can experience fragmented care and poor outcomes. The increasing challenge of chronic disease management (CDM) presents opportunities for creative, collaborative and innovative solutions. Conceptually, the locus of chronic disease care belongs in the realm of primary care from a continuity of care and economic perspective, with episodic specialist treatment (Starfield, 2003). As care systems become more complex, coordination of services across primary, secondary, and tertiary care has become fragmented (Kvamme, Olesen, & Samuelson, 2001).  Currently there is a lack of alignment and interface between specialists and primary care. Issues around accessibility, role clarity, and communication all impact the care experience, patient outcomes and per capita cost.

The shared care model provides opportunity for patients to be cared for by specialists while at the same time maintaining the benefit of continuity of care from their family physicians (FPs) (Smith, Allwright, & O'Dowd, 2008). The literature is inconclusive on the effectiveness of interventions for shared care (Smith et al., 2007). In particular, the use of specialist telephone advice to avoid unnecessary face-to-face consultation has not been extensively studied. Publications on physician telephone advice are limited and generally report on a single speciality area. In general the literature reports telephone advice as an accessible, effective and useful model of care that facilitates knowledge transfer. (Karari et al., 2011), (Waldura, Neff, & Goldschmidt, 2011), (Carr, Lhussier, & Wilcockson, 2008).

This intervention project is the initiation of a telephone advice line to facilitate FPs’ access to specialist’s advice. The Rapid Access to Consultative Expertise (RACE) advice line was launched at Providence Health Care (PHC) in June 2010 based on the encouraging results from a PHC pilot project where FPs could page a cardiologist (Lear et al., 2010). RACE allows FPs to call one number, choose from a selection of 10 specialities and speak to the specialist usually within a few minutes. The RACE line is available Monday to Friday from 0800 -1700 to support FPs during office hours. RACE is an innovative strategy to enhance patient care. For traditional referrals, patients often wait months to see a specialist although minor advice may be all that is needed. The RACE call provides an educational interaction with an opportunity for knowledge transfer.

The development of the RACE prototype has been a shared care collaboration between FPs and specialists. A formal summative evaluation is being conducted and includes qualitative interviews, focus groups and quantitative surveys. Early results and anecdotal feedback, reported here, indicate that RACE contributes to knowledge transfer, has the potential to decrease unnecessary consults and ER visits, and provides “just in time” advice for FPs to care for their patients, often while the patient is still in the office. Both specialists and FPs have embraced the advice line as shown by the request from FPs for additional services and by the request from specialists who wish to participate in the service. Survey results demonstrated high user satisfaction; all FPs would use the service again and over 90% of FPs would recommend the RACE line to their colleagues. RACE was viewed as an excellent resource for FPs – allowing practical and specific advice and transforming how FPs seek assistance. Results show 78% of calls are returned within 10 minutes, 80% of calls are less than 15 minutes in length and initial findings on resource utilization show a 62% reduction in face to face consult and a 32% reduction in emergency department visits.

The goal of RACE is to develop a prototype that is scalable provincially. To date, several health authorities have expressed interest in pursuing this model of care. Physicians from across the Vancouver Coastal Health region, both specialists and FPs have been engaged in the process of developing and trialling the prototype. Potentially, all health authorities could develop a RACE advice line to enhance access to care.

With a view to achieving progress guided by the Institute for Healthcare Improvement “Triple Aim” (Institute for Healthcare Improvement, 2009) principles which strive for simultaneous improvement in:

  • the health of the population
  • the care experience of the patient and health professional
  • the per capita cost

RACE:

  • Enhances the care experience by providing just in time educational advice for the FPs. Patient experience is enhanced as they receive information while at their appointment instead of waiting to see a specialist and consults may be avoided thus avoiding redundant travel and time off. 
  • Improves population health by improving timely access to appropriate care. 
  • Controls per capita cost of healthcare avoiding unnecessary consults or emergency department visits. 

Given the early feedback from physicians who have used RACE, this initiative should be spread across the province and tailored to the local context.