2020 A Care Odyssey – The Transformation of Primary Care

1. 2020 A Care Odyssey – The Transformation of Primary Care

2. Multimorbidity and Complex Care: Insights from the Bridgepoint Collaboratory for Research and Innovation, Toronto NHS Scotland June 3-4 2014 Renée Lyons, PhDBridgepoint Chair in Complex Chronic Disease ResearchTD Scientific DirectorBridgepoint Collaboratory for Research and Innovation Professor, Dalla Lana School (Faculty) of Public Health and Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto

3. …40,000,000 square kilometers Welcome to Canada… Bigger, not better.

4. Why it is so Hard to Reform Health-Care Policy in Canada “Almost continuously since the late 1990’s, Canadians have pointed to health care as their largest national concern and the issue that should receive the greatest attention from Canada’s Leaders” (2013). Lazar, Lavis, Forest, Church (Editors); McGill-Queen’s University Press Paradigm Freeze

5. Complexity = when chronic disease is difficult to manage • Multimorbidity • Polypharmacy • Functional Impairment • Psycho-social issues (depression, anxiety, stress) • Require input from multiple care providers • Ongoing reliance on health services (formal) and family (informal) • “Complexity involves the intricate entanglement of two or more systems (e.g. body-diseases, family socio-economic status, therapies)” • - Nardi et al. 2007 Characteristics of Complex Chronic Disease Part 1

6. Use of Healthcare Resources Part 1

7. Ontario use data - top 5% Some astounding facts about the top 5%: Number of General Practitioner/Family Physician (GP/FP) visits in one year for top 5%: • Average total GP/FP visits: 5.5 • Outpatient GP/FP visits: 2.2 Number of Specialist visits in one year for top 5%: • Average Specialist total = 18.9 • Outpatient Specialist visits = 3.6 These patients hardly seem on the radar for primary care. - HSPRN, 2014

8. One line of argument: Utilization primarily a function of needs Aging population and rise of multiple chronic illnesses (although utilization rising across all age groups) Another line of argument: Utilization also a function of health system disconnects Fragmented “non-systems” of episodic hospital-centric, curative care poorly equipped to address complex needs The result: costly and inappropriate “default” to hospital and residential care Healthcare Utilization Part 4

9. Robust population approach required to reduce future utilization Part 1

10. How is multimorbidity and complexity defined and measured? • How do we define and measure quality and outcomes? • How do we identify and mitigate risk? • What works, for whom, and under what conditions? • Where do we invest? Key Questions Part 1

11. Part 1

12. Health and Social Care Use Data - Not just an older person’s issue (20-30 years of health and social care) Challenges individuals and families Challenges governments, insurers, and communities Exposes inadequacies in delivery systems Exposes the inadequacies of traditional health research Raises questions about humanity and progress The Research and the Stories Part 1

13. PART 2

14. Bridgepoint Sinai Health System (2015) Part 2

15. Bridgepoint active healthcare Part 2

16. The Collaboratory for Research and Innovation Leading edge research that advances understanding of and action on CCD prevention and care Part 2

17. Health System Improvement & CD Prevention Mental Health Patient Experience & Policy Health Systems Re-engineering Chronic Disease Management & Complex Care Health Services & Policy Epidemiology & Complexity Framework Stroke Rehab Architectural Design & Health Technology & Design Clinical Care Care Giving Mobility Health Gateway Pharmacogenomics Pain COIL Part 2

18. Design Thinking An environment that encourages creative thinking and new approaches Integrates the best of analytical thinking with intuitive thinking PART 3 Part 3

19. “What are the characteristics, needs and experiences of the patient population at Bridgepoint Health?” Phase 1: Framework Phase 2: Data Queries – Indicators of CCD Phase 3: Patients Needs Assessments and Interviews The Bridgepoint Study Part 3

20. Conceptual Framework: Contributors to Complexity Part 3

21. Husband: “She's had MS for 35 years.” Patient: “And it never... The only thing I couldn't do was walk. And it didn't bother me. We built a house. And then all of a sudden this osteomyelitis hit me and my world just crashed. I went right down as low as you go. Not in my mind but in my body.” Add another condition…….. Bridgepoint Study Part 3

22. “You know, the first time I got sick, I was only 33. And my youngest son was only 4. My oldest was not even 12. And we were very new in this country. Language problem, reading problem, neighbours problem. Two times the police came to our house because the children were alone at home. And my husband was with me in the hospital…But family is nice supporting – my husband, my children. Like after everything, still we are doing good. That is one thing.” Coping and Adaptation – Incredible Challenges; Anxiety Bridgepoint Study Part 3

23. “I have a few issues with depression. It's basically because I was in a car accident in 2007 and I lost my daughter…there were 3 of us. There was my wife, my ex-wife. We're separated actually…and we were going home, and we got hit by a drunk driver. And basically that led to a separation with my wife… I was in quite a bit of trouble with the law probably because of my depression, probably because I didn't give a damn about much….I went through rehab for 6, 7 months because when my daughter passed away, I got into sleeping pills really strong, really heavy.” …work loss, inactivity, loneliness and income insecurity Stories about the road to multi-morbidity…. Bridgepoint Study Part 3

24. Young and Mid-Life Adults 1,904 young and mid life adults discharged from Complex Continuing Care (CCC) in Ontario - Utilization and Costs were tracked for 5 Years 50% were in the two lowest income quintiles 54% had 3+ chronic conditions After 5 Years: • 28% were re-admitted • 74% re-admitted to acute care and 94% used the ER • Median # of GP visits: 54 • 48% received homecare services and 22% were placed into Long-term Care • Per Capita Median Public Costs after 5 years: @ least 6x greater than the average Canadian $98,484 Part 3

25. “Complex patients are the norm” in stroke rehabilitative care. “It’s rarely just a stroke. We have to deal with everything they had before – now it has a stroke spin to it…” (FG4) Stroke & the Evidence Base for Multimorbidity Research Question stroke rehabilitation evidence includes adult patients with multimorbidity? Research Approach Knowledge Synthesis Funded by CIHR (ranked #6 of 82) Scored 4.53 for Scientific Merit and 4.62 for Potential Impact • If we don’t have a clear understanding of the patients included in the evidence used to develop practice recommendations, we MAY be faced with a mismatch between the participants used to generate evidence and the patients seen in practice. Part 3

26. Can E-Tools Help Primary Care Patients with Multimorbidities • Communicate better with their • primary care team? • Improve their ability to self • manage? • Use hospitals and emergency • rooms less? • Have a better care experience? • Intervention and control groups will be compared at 3 and 6 month intervals (Fall 2014) • Industry Partner: QoC Health Electronic Patient Reported Outcome Measures Part 3

27. 50% of those volunteers contribute to health services/care 15% Volunteerism & Care Teams of Canadians volunteer Research Purpose Understand and optimize the role of volunteerism in complex care and rehabilitation • Results • Targeted volunteerism can enhance patient experience and support improved outcomes. • To support patient goals, volunteers must be more fully integrated into the care team Part 3

28. Kaiser Permanente – USA – Northern California (Obamacare) Health Links - Province of Ontario Triple Aim – Edmonton, Alberta Complexity Clinics – Bridgepoint Active Healthcare, Canada New Zealand Innovators: Multimorbidity/Complex Care Part 3

29. Health and Social Model of Care Data – appropriate, easily accessed, shared Standard Assessment/Care Plan/Targets/Monitoring Communication - One-stop – care coord./Teams/Skill Mix/Roles Easy Client and Family Engagement – individualized and personable Funding Formula – Accountability must be appropriate! Community facing rehab and acute care Integrated, High Performing Health Services Part 4

30. Foresight and Innovation

31. rlyons@bridgepointhealth.ca www.bridgepointhealth.ca Thank you