"Building More Connected Primary Care: Improving Connections between Primary Care and Community Care, Specialists and Hospitals for Timely and Appropriate Care"

Although strong, well connected primary care results in better health outcomes and health equity at a lower cost, most family physicians in Ontario, Canada are not supported by teams and have variable connections to other system sectors resulting in variable access and quality of care. A continuous relationship with a family physician and primary care team facilitates access to timely care, appropriate preventive care, reduced acute care utilization and costs, reduced mortality and more satisfied patients. This was further confirmed during the COVID 19 pandemic when patients who were attached to primary care teams had superior care for both COVID and non-COVID health issues. Together with patients, families, family physicians and all health care sectors, we co-created and evaluated efficient models of connecting family physicians to: specialists for just in time advice, virtual and in-person consults; to interprofessional teams tailored to the needs of their practices and to navigation services tailored to primary care. These models were co-designed with family physicians and continue to evolve based on their evolving needs: SCOPE (Seamless Care Optimizing the Patient Experience) connects primary care providers (PCPs) in the community to real-time supports through a single point of access, Co-designed with local PCPS, SCOPE improves access to an interprofessional team who can help with urgent medical consultations, diagnostic imaging, curated home and community care, mental health, and navigation of other services available in the hospital or in the community. TIP (Telemedicine IMPACT PLUS) TIP (Telemedicine IMPACT Plus) provides rapid access to case consultation by a virtual team of health care professionals to enable proactive health and social care for patients living with multi-morbidity. The case conference involves the patient/caregivers, family physician and TIP RN along with the consulting team that consists of: Psychiatrist, Internist, Pharmacist, Social Worker, Home Care Coordinator, Dietitian and others as required. The purpose of this consultation is to coordinate care and derive new solutions for addressing chronic conditions. A dedicated TIP nurse facilitator prepares the case, facilitates the consultation with one of 12 available teams, summarizes a coordinated care plan and coordinates the patient’s circle of care. Building interprofessional primary care teams based on family physician patient roster needs relies on nourishing foundational relationships with local PCPs to help identify gaps in care, engaging PCPS in continuous program improvement and developing partnerships with key stakeholders: leadership from the anchor hospital and their specialist groups, home and community care and community organizations. Joint implementation is based on the value proposition that all sectors win when care is appropriately triaged and managed in the community. When combined, connected and integrated into primary care practices, these initiatives build the Patient Medical Home, with the PCP at the centre of care, support to more effectively co-manage patients using existing resources more efficiently mapped to patient needs. These initiatives support relationship-based navigation, the underpinning of team-based primary care essential to improving system navigation for timely access to needs-based care. The target audience: patients, families, interprofessional primary care providers, specialists, home care and community providers, and hospitals.

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