Patient Attachment is Vital for Sustained Virtual Care

sanderson-150pxIn a previous article on virtual care in the Fall of 2019, I described how Kaiser Permanente had achieved significant value with their virtual care deployment.  KP has one common digital electronic record for each of its 12.2 million patients.  This electronic record is accessible across all the geographic regional centres that comprise KP.  Information for patients’ VIRTUAL CARE interactions with KP providers is captured in this shared electronic health record. Almost 70% of all KP patients have signed up to use their KP.ORG Virtual Care capabilities.  Important to the success of KP’s virtual program, every client patient upon enrollment with KP is attached to their local primary care physician and clinic.

As Canada emerges from the pandemic, there is significant discussion on how to  sustain and expand virtual care engagements that are enthusiastically embraced by the public. Many of these virtual episodes while having immediate, positive impact, the episodic data was not being captured and returned to the patient’s medical / health home. Important that patients and their families know their primary care giver, have sustained relationship and thus expanding their medical history with their medical / health home.

What are the benefits of patient attachment and paneling?

  • Attachment is the basis of patient-centred care and promotes continuity of care. It helps physicians and care teams engage with patients on a one-on-one basis to understand their needs and preferences. As attachment evolves, it can move beyond simple acknowledgement of the doctor-patient relationship to become the basis for agreement between the patient and their physician, helping patients understand the benefits of attachment and defining the reasonable expectations and responsibilities of both parties.
  • Attachment provides the foundation for panel management in primary care. Panel management is a structured process for monitoring the care needs of patients on the panel and proactively offering them care such as screening, testing or other services. Attachment thus forms the basis for performance measurement and quality improvement by establishing the patient population for which each physician and clinic is responsible.
  • Attachment and paneling benefits accrued to patients: When patients have a longitudinal relationship with a single-family physician, this results in better access, better quality of care, and reduced overall health care system utilization and costs.
  • Attachment and paneling benefits accrued to care providers: When providers have knowledge of patients’ comprehensive medical information it results in better handoffs, better communication, and less duplication of care.
  • Attachment and paneling benefits public health insurers: Enabling step on journey to blended capitation model.  The potential for fee-for-service innovations, such as higher fee codes that recognize continuity (when seeing one’s own patient panel) and lower fees for turnstile, episodic walk-in care.
  • Attachment and paneling benefits chronic disease management: the development of community and/or jurisdictional chronic disease registries would be a natural next step enabled by the attachment and panel registry.  “ Researchers have shown that satisfaction with the interpersonal quality of the patient-provider relationship is significantly associated with adherence to treatment in diabetes”. [i]

Case Study: Alberta Central Patient Attachment Registry (CPAR) and Patient Paneling

[i]The Central Patient Attachment Registry (CPAR) is a key enabler for continuity of care which focuses on improving Albertans’ health through stronger ongoing relationships with their family physician/nurse practitioner (FP/NP) and team, increased information sharing, and enhanced care coordination.

CPAR works together with the Community Integration Initiative (CII) to provide essential technology supports for the three core dimensions of continuity. This registry will serve as the foundation to reporting, refitting physician compensation, supporting increased information continuity, and advanced predictive analytics of the Alberta patient population.   Figure 1 illustrates the integration and management of the CPAR Registry within the CII Architecture.   Figure 2 highlights CPAR registry as an extension to Netcare’s Provincial Community Health Information repository.

The CPAR Repository enables continuity of care for Alberta’s community patients in three ways:

  • Relational Continuity: When patients have a longitudinal relationship with a single-family physician, results are better access, better quality of care and reduced overall health care system utilization and costs.
  • Informational Continuity: When providers have access to patients’ comprehensive medical information it results in better handoffs, better communication and less duplication of care.
  • Management Continuity: When the care patients receive from different providers is connected in a coherent way, results are more effective management of chronic conditions and health problems.

Figure 1
figure1

Figure 2
figure2

Challenges for Alberta’s CPAR

Denis Protti, uVIC professor, provided feedback to the Alberta Medical Association Board in March 2017 for their IMIT Strategy Development on specific challenges with the CPAR Program for Alberta:  

  • Culture Change – For the CPAR to be truly effective, a culture change needs to occur within this province where all recognize that they are all responsible for the success and failure of the program.  Many parts of the health care system work within silos and are focused on their one area of interest.
  • Voluntary participation – One of the biggest challenges will be convincing community-based care providers to participate in CPAR.  Currently, participation is voluntary.  Strong leadership, a good communication plan, an effective and responsive change management process, and effective incentives that will assure physicians can see the value in participating will be required.
  • Extra Workload – There will be extra resources required to participate in this work, and that needs to be acknowledged and supported. 

CHIA/ ITAC Awards honoring CII & CPAR Program

On behalf of Orion Health and the Ministry of Health, I delivered acceptance speech for the CII and CPAR Program at the CHIA/ITAC Awards in June, 2018 award banquet in Vancouver.   In 2020, the Alberta Premiere’s award acknowledged the excellence of the CII and CPAR Program, similar to acknowledgment a generation earlier for Netcare EHR . The primary goal of CII and CPAR is to improve continuity of care across Alberta’s health system through better access by providers and their patients to primary care and community health information. To achieve this goal, the CII and CPAR Program has implemented a solution to collect patient data from physician offices and other community-based clinics and make it available to other healthcare providers through Alberta Netcare, Alberta’s provincial electronic health record. The information will also serve as a key asset in health analytics for quality improvement, population health assessment and health system planning.

The Alberta Ministry of Health has worked in focused collaboration with the Alberta Medical Association (AMA), the College of Physicians and Surgeons of Alberta (CPSA), the Alberta Health Quality Council (HQCA), early adopter clinics and PCNs to lay the foundation for innovative, far-reaching initiatives including CII and CPAR.   Vendors who played vital role in the development and sustained operation and deployment of CII and CPAR Program:  Orion Health, Telus Health, QHR, Micro Quest and CGI.

Other jurisdictions and their approaches to patient attachment:

NHS: Choice Framework[i]: Adults in NHS jurisdiction can:

  • choose which GP practice you register with
  • ask to see a particular doctor or nurse at the GP practice.
  • Upon Selecting, a practice must make every effort to meet your preferences to see the doctor or nurse you have asked for, although there are some occasions when this might not be possible, as outlined below. Individual may wish to register with a GP practice that is not close to home but is more convenient for you to access. However, you might not be able to access all out-of-hours services or be able to have a home visit if you live outside of the practice’s boundaries. We recommend you discuss this with the GP practice before registering. Individual may also wish to access primary care services digitally.
  • Digital-first primary care is an exciting innovation in general practice delivery which will mean that all patients will have the right to web and video consultations by April 2021.

Manitoba MyHT:  “My Health Teams (MyHTs, formerly primary care networks) represented a most novel and complex initiative. These entailed contractual agreements among an RHA, fee-for-service clinics, and other partners to collaboratively plan and provide coordinated services to patients within a geographic area. Each MyHT received resources to augment services, typically by hiring allied health providers to be shared among clinics. To participate, fee-for-service clinics had to commit to the “attachment deliverable,” which required each MyHT to collectively attach 2000 new patients.”[ii]

Summary 

Canadians enjoy the freedom to move around this great country, and the power of choice.   There is need for public education on the benefits accrued for maintaining a long-standing relationship with their medical/health home. The COVID pandemic combined with virtual care, provides the catalyst to revise the long-standing practices of always requiring an in-person care appointment.   At the same time, choosing wisely instructs patients to not only embracing convenience of virtual care, but to ensure they are enabling sustained continuity of care.   Our health leaders must learn lessons from telehealth introduction two decades ago, importance of integrating virtual remote access service, not simply operating as a stand-alone service.

“Champions may initiate improvement, but it depends on top level organizational leaders to create an institutional culture ready to accept change and to spearhead the spread of particular improvements.”[iii]

[i] “The Patient-Provider Relationship: Attachment Theory and Adherence to Treatment in Diabetes”; (Am J Psychiatry 2001; 158:29–35
[ii] Central Patient Attachment Registry – Panels
https://www.albertanetcare.ca/learningcentre/CPAR-Panels.htm

[iii] ANHIX ‘Community Information Integration’,  September 13, 2017

[iv] E&Y ‘Review of Connect Care, Alberta Netcare and MyHealth Records report’, March, 2020

[v] NHS Choice Framework
https://www.gov.uk/government/publications/the-nhs-choice-framework/the-nhs-choice-framework-what-choices-are-available-to-me-in-the-nhs

[vii] Manitoba’s MyHealth Teams https://www.cfp.ca/content/cfp/65/9/e397.full.pdf

[vii] Thomas Bodenheimer, The Science of Spread: How Innovations in Care become the norm.    California Healthcare Foundation; September 2007