Innovative model contributes to healthier patients, more satisfied care team and better accountability for care dollars spent.
Patients of the Byron-based London Family Health Group are reaping the benefits of family medicine practiced in a new way. It’s called Shared Care, a team-based approach that involves allied health professionals working with family doctors as key care team members.
The London Shared Care Pilot Initiative (SCPI) is one of six similar projects in Ontario formed in 2007 with funding from the Ontario Ministry of Health and Long-Term Care. The model is similar to a Family Health Team, but differs in governance structure. Drs. Cathy Faulds, Pam Smith and Kirk Hamilton lead the London pilot supported by social worker Paula Shea, registered nurse Mary-Ellen Chalmers and registered practical nurse Cheryl Montgomery. Certified management accountant Anne Dennerley was hired to manage the pilot’s finances and human resources. She has developed a system of accountability to the Ministry, tracking chronic disease and prevention outcomes enabled by pilot-funded programs.
If needed, patients in Faulds’, Smith’s and Hamilton’s practices get medical, mental health and social services, in addition to acute and preventative health care. Shared Care is well suited to managing many chronic conditions. For example, one patient, Marilyn, was obese. Faulds arranged a special consultation for her with nurse Chalmers. Chalmers then helped Marilyn decide to lose weight. She developed a weight-loss program with Marilyn and will monitor her progress over time. Another patient, Mary, was struggling with bipolar disorder and trying to cope with her nine-year-old son’s angry outbursts. Rather than refer her to a behavior specialist who she’d likely have to wait weeks to see, Smith introduced Mary to social worker Paula Shea. Within days, Shea began counseling Mary at the family practice office and helped her find an anger management program for her son.
Family doctors and allied health professionals on Shared Care teams develop programs together and tailor them to patient needs. Doctors lead management decisions concerning patient care, but allied health professionals - who include dieticians, physiotherapists and pharmacists as well as nurses and social workers - enhance care through regular health checks, education and counseling. “We take the time to listen and motivate patients,” Chalmers says, adding this kind of contact is an extremely rewarding part of the job.
Allied health professionals working for the London SCPI meet many patient needs right in the family doctor’s office. Smith says, “It’s a place where patients are comfortable.” Patients become part of the team, too. Val, a heavy smoker with Chronic Obstructive Pulmonary Disease (COPD) has joined the London pilot’s stop-smoking program and says, “I’m very determined now to improve my health thanks to a team that always listens to me and shows they care.”
Shared Care provides family doctors with more time to treat patients with acute illnesses and injuries, as well as patients who don’t belong to a family practice. Faulds, Smith and Hamilton have also extended their practices to include home and hospital palliative care, pain management and more baby deliveries, especially for mothers who need intense pre and post-natal support. Hamilton says, “Quite simply, Shared Care has made me a better doctor.”
The Shared Care model supports Ontario’s plan to combat chronic disease at the family practice level and embraces the concept of holistic, rather than disease-specific, care. Ultimately, Shared Care reduces the burden on hospitals and ERs. Faulds says, “When people with chronic conditions like diabetes manage their health well at the primary care level, they’re less likely to suffer heart attacks, strokes and other complications, all requiring expensive hospital care.”
The London Shared Care Pilot is funded until June 2009. The team hopes for renewed Ontario government funding to continue delivering excellent comprehensive primary care through Shared Care.
For more information, contact Cathy Faulds, London Family Health Group Shared Care Pilot Initiative at 519-473-4394.