A BUSINESS PLAN FOR COMMUNITY PAEDIATRIC SERVICE DELIVERY IN CALGARY

A BUSINESS PLAN FOR COMMUNITY PAEDIATRIC SERVICE DELIVERY IN CALGARY “Building Communities of Practice in Paediatric Care” Final Report JUNE, 2009 ...
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A BUSINESS PLAN FOR COMMUNITY PAEDIATRIC SERVICE DELIVERY IN CALGARY “Building Communities of Practice in Paediatric Care”

Final Report

JUNE, 2009

Prepared for: The Department of PaediatricsDivision of Community Paediatrics & Child & Women’s Health and Specialized Clinical Services of the Alberta Health Services, Calgary Health Region By: Petra O’Connell, BSc., MHSA Belfield Resources Inc

TABLE OF CONTENTS Acknowledgements Executive Summary 1.0

INTRODUCTION & PURPOSE

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2.0

INFORMATION SOURCES

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3.0

THE NEED FOR CHANGE: A REVIEW OF THE LITERATURE 3.1 The Evolving Role of the Community Paediatrician 3.2 Factors Influencing Future Community Paediatric Practice 3.3 Implications for Future Community Paediatric Practice 3.4 An Overview of National and International Concepts & Models

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COMMUNITY PAEDIATRICIANS IN CALGARY & SOUTHERN ALBERTA 4.1 Calgary Community Paediatricians 4.2 Paediatricians in Southern Alberta Centres

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THE STATUS OF PAEDIATRIC HEALTH IN CALGARY & ALBERTA

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6.0

GAPS & CHALLENGES IN COMMUNITY PAEDIATRIC CARE 6.1 A Changing Patient Profile 6.2 Lack of an Integrated Whole System Approach 6.3 The Community Paediatrician Workforce 6.4 Teaching & Research 6.5 Challenges for Model Design

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7.0

STRENGTHS & OPPORTUNITIES 7.1 Practice Enablers 7.2 Other Community Based Programs 7.3 Private Real Estate Opportunities

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8.0

CONCLUSIONS & RECOMMENDATIONS 8.1 Conclusions 8.2 Recommendations

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9.0

BUSINESS PLAN 9.1 Vision 9.2 Assumptions 9.3 Strategic Directions 9.4 Budget 9.5 Implementation Plan 9.6 Measures of Success

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10.0

REFERENCES

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APPENDICES A. Informants B. Overview of National/International Concepts & Models

Acknowledgements

The author thanks all informants for their time and thoughtful contributions. Many thanks to the community paediatricians who participated in planning sessions and surveys which contributed enormously to the author’s understanding of the issues and potential opportunities for community practice. Special thanks to Dr. Neil Cooper and Dr. Stephan Wainer for their leadership and commitment and to Dr. Francois Belanger and Toni Macdonald for their guidance and feedback.

Building Communities of Practice in Paediatric Care

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Executive Summary Background: The number of community paediatricians in Calgary and other southern Alberta centres has remained relatively constant for more than a decade despite a significant growth in the paediatric population, the expansion of medical student and residency programs at the University of Calgary and recent increases in community paediatrician fee-for-service rates. Over the next eight years approximately 34 new FTEs of community paediatricians will be required in Calgary for replacement and projected growth. This equates to 89% of the current Calgary community paediatrician workforce. New strategies will be required to meet this target. In the summer of 2008 the Calgary Health Region’s Department of Paediatrics and the Child & Women’s Health and Specialized Clinical Services portfolio contracted a Consultant from Belfield Resources to work with the Division of Community Paediatrics, led by Dr. Neil Cooper and Dr. Stephan Wainer to produce a business plan that will revive and strengthen community paediatric practice in Calgary. The first section of this report presents an overview of Community Paediatrics based on a review of the international literature and consultations with paediatric experts and health service providers in Canada. It covers definitions, the evolving roles of community paediatricians, and strategies and models that have been proposed or adopted by other countries and Canadian regions The next section of the report focuses on community paediatric services in Calgary and southern Alberta. It describes actual paediatrician activity as well as important child and adolescent trends in Alberta identified in the 2005 Alberta Health and Wellness Child Health Surveillance Report that will impact on community paediatrician services. The section concludes with an overview of local challenges and opportunities in community paediatrics that were identified by community paediatricians, paediatric hospitalists, residents, families, family physicians and other paediatric health and community service providers. The final section of the report provides a detailed description of the proposed business plan including a four year implementation plan. Environmental Scan Highlights: ¾ The definition of community paediatrics has evolved from a limited definition of providing medical care (assessment and consultation) to newborns, children and adolescents in a private office or out-patient setting to being a sub-specialty that recognizes the child’s community as a major health determinant (Haggarty,1995). ¾

Implications of this definition for community paediatricians include: - a broader and more comprehensive scope of practice along the continuum of care (health promotion/harm reduction; comprehensive/holistic assessment; early intervention; ongoing management of complex chronic health problems; and child advocacy); - a philosophy of holistic care of the child and family that requires effective communication with other professionals, coordination of care and support from multiple child health disciplines and child care groups; - special orientation on developmental/behavioral paediatrics, child protection and

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advocacy, early intervention and parenting approaches; - Broader paediatrician teaching curriculum ; - a unique opportunity to advance knowledge and inform understanding on the health and social risks of children and youth through participation in research. ¾ Key drivers of future community paediatric practice include: (1) Changing patterns in paediatric morbidity and mortality; (2) Greater need for integrated/collaborative interdisciplinary teams in the community; (3) Technological capabilities for more effective and efficient data management, communication and remote consultation; (4) Shifts in paediatrician workforce and practice trends that reflect a higher percentage of female paediatricians and preference for work-life balance. ¾ At this time there is no best-practice model or approach in Community Paediatrics that is based on formative evaluation results. It is generally recognized that a successful model must be responsive to the local needs of the population it serves and to the specific capacity of the system from which it operates. Emerging concepts and themes include: o The need for integrated/collaborative models of care or managed networks for children with complex and long standing problems; o

The importance of horizontal, vertical and longitudinal integration to optimize child health

o

The recognition of the need for integrated multi-disciplinary teams that support care in the community (either co-located or via a network);

o

A greater shift to providing care closer to home and whenever possible outside hospital, based on the principle ‘localize where possible, centralize where necessary’.

o

Enabling tools and processes including referral processes; clinically safe care pathway/protocols; use of collaborative management or shared care processes (e.g. mental health/paediatrician).

o

The use of Nurse Practitioners and other health professionals to administer treatments for routine ailments to enable paediatricians to practice “intuitive medicine”.

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Enhanced uptake of information and communication technology; and

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More innovative and comprehensive paediatric residency training programs

The Need for Change Major challenges identified by community paediatricians in Calgary include:

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Most are over the age of 50 years old and at least 20% plan to retire within the next 5-8 years. Work-life balance is a constant challenge.

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Most Calgary paediatricians (75%) lease their office space and 64% practice in solo or small group practices. This limits both practice and cost efficiencies. Small practices are also associated with professional isolation.

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Based on actual Calgary community paediatrician referral data and provincial child health survey findings, community paediatricians are seeing a higher percentage of children and youth with complex and multiple health problems. Key growth areas include low birth weight infants, congenital anomalies and associated developmental delays, mental health problems (e.g. Attention Deficit Disorder and Depression), Asthma, Sexually transmitted infections and sports related injuries.

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The Calgary Physician Workforce Plan Forecast for 2008-2017 projects the need to recruit 34 FTEs of community paediatricians over the next eight years to replace the existing workforce and support the city’s growing paediatric population (projected to grow by 16% by 2020).

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Lack of an integrated whole system approach that supports child and family health care needs in the community. Deficiencies include: - absence of a consistent referral process between family physicians and community paediatricians and other paediatric sub-specialists; - community paediatrics in Calgary does not have a clearly defined identity. The variable scope of practice among community paediatricians presents a potential for overlap between primary and secondary/consultant care); - insufficient community resources (e.g. system navigators/connectors) and services of allied health professionals for community paediatricians to refer patients for developmental screening assessments, mental health treatment, and treatment of more common childhood maladies (e.g. diarrhea; constipation, headaches, and query or afebrile seizures). -the growing cultural and socio-economic diversity of Calgary’s population presents new challenges for community paediatrician services including the need for more culturally sensitive prevention and care approaches. -consequences include inappropriate /unnecessary referrals to ACH tertiary level programs and prolonged waiting times in various clinics (e.g. Gastrointestinal, Neurology, Child Development, Mental Health);

The 19 general paediatricians serving communities in southern Alberta centres outside of Calgary practice as regional general paediatricians and are responsible for hospital inpatient care, outpatient care, emergency care, neonatal and newborn care in addition to community practice. The majority operate in solo or small group practices of two. A minimum of two additional FTEs is required to safely meet paediatric care needs. Challenges and issues reported include: the consistent need for additional locums to safely cover on-call paediatrician requirements;

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a growing paediatric population in most areas; a growing shortage of family physicians which creates pressures for more primary care delivery by paediatricians; chronic difficulty in attracting new recruits in part due to too few medical residency assignments in these centres. an increasing prevalence of children and youth presenting with complex mental and behavioral health concerns and influx of immigrants calls for mores supports from other health professionals (e.g. therapists, social workers, diversity services).

The Opportunities to Support Change There are local and provincial initiatives underway that can inform and potentially support or leverage a new model for Community Paediatrics. (1) Technological Enablers including the implementation of a common Electronic Health Record Medical technology within the next two years; access to the health region’s Virtual Private Network; and broad implementation of desktop videoconferencing technology. (2) Transition to a single flexible Standard Referral Process and Form (the Medical Access Service Project) to standardize and improve the referral process between family physicians and specialists across the health system. (3) The Alberta Access Improvement Measures Project (AIM), a provincial initiative that assists community based physicians and their teams with strategies to improve patient access, office efficiencies and clinical care delivery. (4) The provincial Primary Care Initiative involves the formation of a joint venture between a not-for-profit company of participating family physicians and the local health region to improve the delivery of primary care across Alberta. (5) The Chronic Disease Management Program for Adults is predicated on strong linkages with primary care physicians, supports of other allied health professionals for high risk/complex patients, and the provision of self-management and personal support programs. (6) The health region’s Healthy Living portfolio produces and promotes evidence-based health promotion tools and education services in all areas that target healthy lifestyles in children and parents. (7) Private real estate opportunities in Calgary could potentially support larger physician group practices at more reasonable cost. Recommended Calgary Model of Community Paediatric Care The final section of the report describes a business plan for the implementation of strategic directions intended to: (1) Improve Access to Community Paediatricians: ¾ Development and adoption of a new scope of community paediatric service that emphasizes secondary level and consultative paediatric health care; ¾ Improve referral processes through participation in the Medical Access Project as member of the Department of Paediatrics;

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Participation in the Alberta AIM Program.

(2) Improve Community Practice Efficiencies and Effectiveness: ¾ Formation of a Calgary Community Paediatrician Not-For-Profit Company (NPC) for potential membership by all community paediatricians. Benefits to member paediatricians, patients, medical students/residents and the system are described. ¾ Paediatrician Practice Consolidation to form larger group practices as leases expire. ¾ Participation in the Alberta AIM Program (3) Improve Allied Health Professional Support: ¾ Implementation of the Medical Access referral/triage process should reduce wait times for patients referred by community paediatricians for assessment and treatment at ACH in the short term. ¾ As larger group practices emerge, consideration should be given to co-locate or arrange planned clinic visits by allied health professionals (e.g. dietitian, psychologist, rehabilitation therapist) employed by Child Health, AHS for specific services based on demonstrated service referral patterns. ¾ Recruitment of a Paediatric Nurse Practitioner to extend paediatric health care capacity in the community. Potential roles could include neonatal follow-up care, health promotion and harm reduction and/or child behavior assessment and management. (4) Build capacity for Health Promotion & Chronic Disease/Harm Prevention ¾ Participation in a Pilot Project with the Calgary Healthy Living portfolio to enable more structured health promotion in the community paediatrician’s office setting. Scope of service could include health risk screening measures and education. (5) Build Paediatric Care Capacity in the Community ¾ Recruitment of a Paediatric Systems Navigator/Liaison ¾ Participation in AIM & Medical Access Projects ¾ Paediatrician participation in the CANREACH mental health training on evidencebased psychotherapies for children and adolescents. ¾ Establish Specialist Linkages with Primary Care Networks (e.g. Foothills and Mosaic) that focus on specific paediatric health issues. (6) Teaching & Research ¾ Establishment of a Paediatric Student/Resident Placement Coordinator to coordinate the placement of all medical students and residents seeking training experience in Calgary and other Alberta centres. ¾ Participation in research coordinated and supported by research institutes such as the Alberta Children’s Hospital Research Institute for Child and Maternal Health. The business plan describes guiding principles, planning and budget assumptions, a four year implementation plan and budget, and anticipated short term and mid term outcomes (measures of success). Projected key outcomes include: an increase in community paediatrician services in Calgary, improved continuity of care across the health care continuum (primary, secondary, tertiary/quaternary level services), and a net reduction in paediatric health service waiting times. Projected costs for this model consist of one time costs of approximately $150,000 and an annual operating expenditure of between approximately $260,000 and $340,000 for allied health professional support.

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INTRODUCTION & PURPOSE Within the Calgary region of Alberta Health Services, the Department of Paediatrics delivers comprehensive clinical care across all aspects of the paediatric care continuum and paediatric tertiary level care for southern Alberta (a catchment area of approximately 1.8 million). The majority of acute clinical services for children and adolescents are provided at the Alberta Children’s Hospital (ACH) and the Peter Lougheed Centre (PLC). Paediatric inpatient and outpatient services are now being planned for the new South Calgary hospital site which is slated to open in 2011. The Department also provides physician coverage for the medical Level III nursery at the Foothills Hospital and Level II nurseries at both the PLC and Rockyview (RGH) Hospitals. Department members also provide a variety of outreach services to Calgary and other southern Alberta communities as part of an ongoing commitment to provide care closer to home. The number of children and youth in southern Alberta continues to grow at a significant rate. There are currently over 300,000 children and adolescents In Calgary alone, the population is expected to increase by almost 16% in 2020.1 This will have significant impact on paediatric health services when one also considers in parallel, the increasing demands on neonatal services (for pre-maturity), the increasing incidence and prevalence of child mental and neuro-developmental problems (ADHD, autism, cerebral palsy, spina bifida) and the increasing prevalence of disabling and long-term conditions (asthma, obesity) and their long term impacts on the system. An increasingly diverse population of families both in terms of ethnic and socioeconomic profiles will also intensify the need for the examination and care of children and youth who are more vulnerable to poor health or abuse. The Faculty of Medicine at the University of Calgary is expanding the number of medical students to 180 in 2009 from 150 in 2008. Over the longer term the number will increase to 240. Residency programs in Paediatrics will also correspondingly expand to accommodate two more residents per year in each of the paediatric sub-specialty areas. Students and residents will require placement in community paediatrician offices at various points throughout their training to satisfy curriculum requirements in community based practice. Community paediatricians in Calgary and other southern Alberta regions are largely responsible for consultant or secondary level care involving a broad range of physical, behavioral, or social problems affecting children and youth; the primary coordination of care of children with complex (profound or severe developmental or functional disabilities typically associated with congenital anomalies or traumatic injury) or multiplesystem health problems and also support families through anticipatory guidance, parenting approaches and referral to other specialist and child care service providers when indicated . The number of community paediatricians in Calgary, and other southern Alberta health regions has remained relatively constant over the past decade or more despite growing paediatric populations. There are fewer full time equivalent community paediatricians in Calgary today than there were 10 years ago when the population was only 650,000 compared to today’s population of over one million. The situation in Calgary is becoming

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Population Projections for Alberta and its Health Regions-2006-2035. Alberta Health & Wellness Public Health Surveillance and Environmental Health. March 2007.

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critical as approximately 20% of the community paediatrician workforce is expecting to retire over the next 5-8 years. Innovative strategies will be required to attract new recruits given the growing competition for paediatrician hospitalists and sub-specialist positions, an increasingly female workforce who desire more flexible working arrangements, and the broad presentation of patient and family needs that call for more community based supports particularly for earlier assessment and management interventions for developmental and behavioral problems. In 2008 the CHR’s Department of Paediatrics in conjunction with the Child & Women’s Health and Specialized Clinical Services portfolio contracted Belfield Resources Inc to: (1) Conduct an environmental scan to determine the need for a new model of care for community paediatrics and identify potential models of care based on literature findings and consultations with representatives from other jurisdictions. (2) Develop a business plan for a new model of care for community paediatrics in Calgary based on the findings of the environmental scan.

2.0

INFORMATION SOURCES The environmental scan and business plan are based on the following information sources: •

A review of the published literature on community paediatrics and practice models. The majority of citations were located in Paediatrics (American Academy of Paediatrics), the Journal of Paediatrics and Child Health (Royal Australian College of Physicians) and position papers by the Royal College of Paediatrics and Child Health of the UK. Few citations were located in the Canadian Medical Association Journal.



Canadian reports on demographic trends among Canadian paediatricians and the proceedings of the Canadian conference on Child Health in the 21st Century- The Role of the Paediatrician in an Inter-professional Environment held in November 2006 (Sponsored by the Canadian Association of Paediatric Health Centres, the Canadian Paediatric Society, Health Canada, Paediatric Chairs of Canada, Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada).



Annual reports of the CHR’s Department of Paediatrics (2008) and Division of Community Medicine. Results of the 2005 survey of members of the Division of Community Paediatrics and notes from a retreat held by the Division in November 2007.



The Provincial Service Optimization Review-Final Report, Alberta Health and Wellness, 2008.



A review of health service utilization rates and trends for child and adolescent health problems reported in the 2005 Alberta Health and Wellness Child Health Surveillance Report.

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A review of 2007/08 ACH and PLC emergency visit data classified as nonurgent/urgent in order to identify those health problems that are more appropriate for assessment and treatment by a member of a paediatric care team based in the community.



A review of 2006/2008 ACH Specialty Clinic utilization data. in order to determine the magnitude of potential health problems that could be managed by an appropriately resourced community paediatrician.



Interviews with 36 (88%) Calgary community paediatricians Thirty-six community paediatricians (88%) participated in interviews with the Consultant were interviewed on the following: ¾ current roles in the areas of clinical care (newborn, child, youth), education, research and child health advocacy ¾ shifts or trends in the types of patients seen and services required ¾ challenges/gaps with respect to services and supports for community-based, family-centred and responsive health care delivery by a paediatrician ¾ current office lease arrangements and future career plans ¾ interest in participation in a new community paediatric service delivery model in the Calgary health region in follow up to a planning retreat held by the membership in November, 2007.



Telephone interviews with 14 out of 19 (73.4%) general paediatricians in David Thompson (4), Palliser (6), Chinook (3) and Canmore (1) about: ¾ current roles and responsibilities ¾ shifts or trends in the types of patients seen and/or services required ¾ challenges/gaps with respect to services and supports required to sustain paediatrician service delivery in their respective health region ¾ opportunities for improvement that would enhance their capacity to provide quality child/youth health care in their respective health region (including existing relationship with ACH programs and services)



Interviews with representatives from other Canadian jurisdictions (Vancouver, Edmonton, Ottawa, Toronto and Sydney, Nova Scotia) regarding general/community paediatric service arrangements.



Consultation with the Executive Director of the Canadian Paediatric Society regarding the Society’s position on the envisioned role of the community paediatrician in Canada in the future.



Consultations with sub-specialists and other health professionals from Child and Adolescent Mental Health, Neurosciences, Cardiology, and Gastro-enterology regarding their relationship with community paediatricians and opportunities for improving child health delivery in the community.



Representatives from the ACH Complex Care team, ACH Paediatric Hospitalists, Paediatric Home Care, Regional School Health, Specialty Clinical Services, Transition Planning, the paediatric unit at Peter Lougheed Hospital, SACYHN Partner organizations (Calgary and area school boards the United Way, Child and Family Services Authority) and Aboriginal Health were consulted regarding their

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relationships with community paediatricians and perspectives on ways to improve the delivery of child health services in the community.

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Consultation with regional representatives responsible for the Primary Care Networks, Community Health Centres Partnerships & Services, Chief Medical Office, and Corporate Real Estate about potential opportunities for creating new partnerships with primary care and community health initiatives.



Consultations with Family Physician representatives from the Community Division of Family Medicine



Meetings were held with Calgary Paediatric Residents and ACH Hospitalists to discuss their interest and issues regarding community paediatric practice.



A focus group was held with the Family Liaison Council of the Family Resource Centre at the Alberta Children Hospital to hear from parents about their experiences with child health services in the community and how community based services could be improved to support family-centred care. Telephone interviews were conducted with five parents of children with complex health care needs to learn about their experience with the paediatric health care system in Calgary and to identify potential areas for improvement.



Consultations with representatives from the private sector to determine potential future real estate opportunities for more cost efficient practice arrangements based in the community.



An informal survey of Calgary community paediatrician patient case-mix to determine patient and family-centred support requirements and capacity for future patient referrals.

THE NEED FOR CHANGE : REVIEW OF THE LITERATURE 3.1

The Evolving Role of the Community Paediatrician ¾ A sub-specialty that recognizes the child’s “community” as a major health determinant Traditionally, community paediatrics has been associated with newborn, child, and adolescent health care assessments and consultation by a paediatrician in a private office, hospital, emergency department or out-patient care setting. The paediatrician would refer more complex or acute health problems to a specific paediatric sub-specialist depending on the nature of the problem. Paediatric practices in the United States are generally regarded as primary care practices where the paediatrician is responsible for well child health care (American Academy of Paediatrics, 2005). In contrast, paediatricians in Britain, Australia and New Zealand perform as consultants and the primary care of well children is provided by the family doctor (Menahem, 1984; RCPCH, 2002). In Canada, many paediatricians have a mixed practice, consisting of primary care and consultant care (Klein, 1985; Pollett, 1983). Local paediatric practices are

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largely driven by physician capacity serving the catchment area, e.g. the number of paediatricians and the number of family physicians who are comfortable caring for children relative to the number of children and youth residing in the area. However, community paediatrics, a term coined by Robert Haggarty (1995), goes well beyond this limited definition which focuses merely on medical care. Community paediatrics is now widely accepted as a sub-specialty that has evolved in response to the ‘new morbidity’ in paediatrics that recognizes that the community in which a child lives is a major determinant of his/her health (e.g. environmental and social processes in addition to biological factors). In 1999, the American Academy of Paediatrics produced the following definition of community paediatrics:

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-

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Community paediatrics encompasses the following principles: A perspective that enlarges the paediatricians’ focus from one child to all children in the community; A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly on the health and functioning of children; Clinical practice and public health principles are directed toward providing health care to a given child and promoting the health of all children within the context of the family, school and the community; Collaboration with other professionals, agencies and parents to use a community’s resources to achieve optimal accessibility, appropriateness and quality of services for all children, and to advocate especially for those who lack access to care because of social or economic conditions or their special care needs. The implications of this definition include: ¾ A broader and more comprehensive scope of practice & interactions with many providers on behalf of the child/family The American Academy of Paediatrics definition implies a broader and more comprehensive scope of practice for community paediatricians along the continuum of care, e.g. health promotion/injury/disease prevention (aimed at both the child and family), more comprehensive/holistic assessment of psycho-social status in addition to physical, medical and functional health status, early intervention, the ongoing management of chronic and complex health problems, and child advocacy. It also implies increased specialization and knowledge in developmental, developmental-behavioral and child protection paediatrics; population health/health promotion; as well as interactions with providers in more diverse settings including schools, daycares, aboriginal health centres, child protection services, and refugee/immigrant agencies. ¾ A philosophy of holistic care of the child and family that requires effective communication with other professionals, coordination of care

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practices and support from multiple child health disciplines and child care groups. The Royal College of Paediatrics and Child Health (RCPCH) in the UK describes a commitment of community paediatricians “to a philosophy of holistic care of the child and family and to the imperatives of effective communication between professionals, improving the co-ordination of children’s care, cooperating in management and, increasingly in multidisciplinary service planning. This convergence of perspective needs to be combined with a convergence in practice so that the full complement of expertise can be brought together in the interests of the child population.”2 The RCPCH recognizes the roles of community paediatricians to include: o the comprehensive assessment and management of health care of children with multiple or chronic and complex health problems; o coordinating the child’s care across the health care system o empowering parents on health promotion (e.g. childhood obesity) o child protection services (physical/sexual abuse) o medical support for adoption panels; o teaching and training of future paediatricians and family physicians; o supporting education of other health professionals; o a growing role in management of behavioral, learning and mental health disorders (e.g. ADHD); o health policy development; o planning/developing and implementing community initiatives based on specific community health needs and services identified through research ¾

Special orientation on developmental/behavioral paediatrics , child protection and advocacy, early intervention and parenting approaches Menahem (1984) concluded that the community consultant paediatrician in Australia is sought by family physicians, obstetricians and other specialists and parents: (1) as a physician who is specifically knowledgeable and interested in the child; (2) as a person who will listen and support the family (understands and practices the principles of family-centred care); and (3) as someone who will serve as the child’s advocate Paediatricians are developmentally oriented and trained to focus on the early detection, prevention, treatment and the management of behavioral, physical, social and developmental problems which may affect children. They serve a natural role as caring, objective child professionals with whom parents can discuss child-rearing and parenting approaches in the promotion of physical, emotional and social health and well-being (Ginsburg, 2007). The report, What Adults Know About Child Development- An Albertan Benchmark Survey (Alberta Centre for Child,

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Royal College of Paediatrics and Child Health. Strengthening the Care of Children in the Community, 2002.

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Family & Community Research, 2008) reported that doctors or paediatricians were the most widely-used resource for child development information among Calgary parents (92.8%) and Alberta parents (91.6%), regardless of where respondents lived. ¾

Paediatric colleges and associations are calling for changes to paediatric training curriculum (American Academy of Paediatrics, 2000): o Emphasis on neuro-developmental, behavioral and genetic issues in addition to in-depth knowledge on normal development; o Core competencies in bio-psychosocial and developmental problems such as early family adjustment difficulties and school failure that adversely affect child and adolescent health; o Core competencies in adolescent health o Health promotion and changes in lifestyles which may be more effective in affecting child morbidity and mortality; o Effective complex and chronic disease management strategies; o Skill development in team approaches to care, consultative liaison, clinical outcomes, evidence-based clinical decision making, critical pathways, system navigation, and information systems. o Adequate experience in community based settings that provide good grounding on system processes and working interfaces across the continuum of health care (primary through tertiary/quaternary) and across child care sectors (health, education, child and family social services).

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Community paediatricians are in a unique position to advance knowledge and inform understanding in health and social risks of children and youth through participation in research (Duggan et al, 2005) which can be described by the following three streams : o

o

o

longitudinal epidemiologic research to trace the determinants and consequences of health status across the life span which will inform health policy; observational and experimental clinical research to assess the effectiveness of health care interventions and ensure quality of care; and health services research to guide the development of systems of care that ensure service accessibility, integration, equity, and efficiency

Implications include: educational opportunities that build community paediatrics research capacity, the creation of and participation in collaborative research networks involving academic and community paediatricians, and the necessary infrastructure required for research design, data collection and analysis, and the dissemination of information. 3.2

Factors Influencing Future Community Paediatric Practice Experts cite the following factors as key drivers of future community paediatric practice (Leslie et al, 2000): ¾ Changing Patterns in Paediatric Morbidity and Mortality:

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Factors that will impact on morbidity and mortality patterns are attributed to a combination of changing disease patterns, technological advances and sociodemographic trends among children and families. Key areas include: o

Molecular advances in genetics and biology (used for the diagnosis of debilitating diseases or the prevention of adult-onset diseases) will require that paediatricians have a better understanding of the uses, limitations and ethical implications of these tools and play a greater role in counseling families.

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Premature and low birth weight infants including children born with congenital anomalies will continue to require paediatrician care.

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Intentional/unintentional injuries will likely continue to be the major reason for death among children and youth over the age of one year. calling for more preventative measures(Grant et al, 2002).

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Exposure to environmental hazards increases the risk of cancer, hypertension and stroke, and neurodegenerative disease.

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Behavioral and developmental consequences of inappropriate prenatal care and experience (e.g. Fetal Alcohol Syndrome);

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Increasing prevalence of moderate to severe chronic conditions (developmental, physical, mental, and learning). Over the past four decades there has been an overall decline in hospitalization of children for injuries, respiratory conditions and other acute conditions (Halfon et al 2007). In contrast, there has been a 10-14% increase in chronic health problems in children. Five of the most frequent chronic conditions among children now include asthma, recurrent otitis media, adolescent depression, attention deficit hyperactivity disorder (ADHD) and developmental disabilities (such as mental retardation and cerebral palsy). Mental health problems affect anywhere from 15-20+% of children/youth. There is also a greater appreciation of the role and impact of developmental health problems on learning and language. It is estimated that 10%-17% of the school aged population have some type of learning disability. ADHD is more commonly recognized among school aged children and a growing percentage of children are developing more severe developmental-behavioral pathology and require more intensive therapy. One study estimated the rate of significant behavioral pathology in children aged 9-17 years at 9% to 13%. In the United States the 2003 National Survey of Children’s Health recorded that among pre-schoolers, 5.8% had speech problems and 3.2 % had developmental delays (Halfon et al, 2007).

o

Childhood obesity rates have doubled and predispose the child to heart disease, hypertension, and diabetes.

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Children with very severe disabilities and complex multi-system problems are surviving longer and they and their parents have higher expectations. Many need a range of specialist services both for

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long term medical care planning and acute events such as infections or seizures. Management of nutrition has become a very important consideration for many of these children. o

Scientific and technological advances in medical and surgical care result in more survivors of previously fatal conditions such as prematurity, organ failure and childhood cancer. Over 95% of children with severe chronic conditions survive into adulthood. Some of these children are permanently dependent on complex medical interventions and many experience serious developmental or emotional morbidity. Therefore, paediatricians must address the long term complications of pre-maturity and childhood illness as well as the unique developmental and behavioral needs of these children as they transition into adulthood.

o

Adolescent health needs will continue in response to: - the prevalence of high-risk behaviors (early sexual activity, substance abuse, violent behavior, deaths secondary to unintentional injuries, teen pregnancies) - trends in adolescent health behaviors that serve as precursors for adverse health outcomes such as obesity, eating disorders, smoking and substance abuse will require preventive health efforts.

o

The impacts of increasing cultural and ethnic and socio-economic diversity in urban and rural communities on health status and utilization of health services will continue to pose major challenges on the delivery of paediatric health services.

¾ The Need for Integrated/Collaborative Interdisciplinary Teams based in the Community The increasing prevalence of multi-faceted and chronic conditions among children and youth calls for alliances with or extended networks of a variety of health professionals and service providers for health promotion/prevention, early screening/identification, more timely interventions, case management, system navigation and chronic care management. The reasons given for engaging in an integrated interdisciplinary practice include: o o o o o

capacity for larger numbers of patients who require frequent visits; the capacity to perform multiple procedures on the same day; greater triaging capacity interacting with a variety of service agencies on behalf of the child and family improves recognition of specific child and family needs (education, counseling etc.) particularly for children with complex, chronic or debilitating conditions.

In 2006, the Canadian Medical Association consulted with 4000 paediatricians on collaboration between specialists, sub-specialists and family physicians and heard that lack of collaboration ultimately results in inadequate consultation letters/information, inappropriate referrals, a

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general breakdown in communication, inappropriate use of health professional expertise which ultimately extend wait times, thereby limiting or denying patient access to specialty care.3 The inclusion of other allied health professionals is also important given the increasing prevalence of patients who present with developmental, behavioral and mental health concerns as well as those lifestyle behaviors that pose long term health risks (e.g. obesity, eating disorders, and poor nutrition). They are drawn into the patient’s care plan as the patient’s situation evolves. As in the case of adults with chronic disorders (diabetes, asthma and arthritis) children also require multidisciplinary team management. Yet most children are managed exclusively by primary care physicians or paediatricians. Nurses can improve the quality and efficiency of care delivery through patient education, ensuring compliance with treatment, collecting data on quality of care and patient outcomes including satisfaction, case management and assisting patients/families with system navigation to access care and services. Paediatric nurse practitioners in the United States have a major responsibility for providing direct patient care with a strong focus on primary care. They typically work in urban areas in a variety of settings including hospitals, clinics, private practices, day cares, juvenile detention centres, and school and community clinics. Here in Canada nurse practitioners frequently form collaborative working relationships with physicians to serve underserved areas (Dicenso, 2008). Future opportunities for more collaboration with community paediatricians include health promotion activities; educational activities for families, patients and staff; case management coordination; and longitudinal follow-up of children with chronic illness or following premature birth. Consistent and timely access to paediatric and adolescent psychiatrists, behavioral and developmental paediatricians and other mental health workers will continue to present major challenges for community paediatricians unless measures are taken to increase the workforce in these areas. In the meantime it will be important to identify and implement strategies that optimize linkages with these groups. More importantly, patients and families also benefit from the care of a team as each expert can more effectively address each problem or concern as it arises. This opportunity should not be exclusive to costly tertiary care settings. ¾ Technological Capabilities for Data Management, Communication and Consultation Computerized office management systems, implementation of the Electronic Medical Record, the use of internet to enhance communication and other 3

Cited in Child health in the 21st century-the role of the paediatrician in an inter-professional environment. Conference Proceedings and Recommendations. November 17-18, 2006. Canada.

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computer advances that help improve and monitor the quality of care will become the standard in all practices. These technologies will also enable training and education (web or e-based learning) as well as facilitate data management and analysis for research. Telemedicine (advanced videoconferencing and e-based) applications will enable the relay of visual and physiologic measurements from patients to offsite experts for more timely management and consultation. Web-based video-conferencing can facilitate more timely and real time consultation with child/youth service providers across settings and regions. ¾ Trends in the Physician Workforce and Practice Canadian Medical Association data indicates that the total number of paediatricians in Canada remained relatively constant between 2006-2008 (Peachey, 2008). In Alberta the rate of increase in the number of paediatricians during this time period did not keep pace with the rate of paediatric population growth. Consistent with physician workforce trends in other countries, particularly the United Kingdom, there are a number of factors at play that seriously threaten the future supply of community paediatricians across Canada. Innovative measures will need to be taken in the short term. An Aging Workforce: 69.6% of the current paediatrician workforce in Canada (n=2247) are 45 years and over and 41% are over the age of 55 years. Only 7% are under the age of 35 years. As of January 2008, there were a total of 259 paediatricians (community and sub-specialist) in Alberta. The 2005 Canadian Paediatric Survey indicated that many paediatricians plan to work fewer hours in the upcoming years, with 11% planning retirement in 2010. The Gender Factor: - The medical profession in Canada is becoming increasingly female. Women today make up the majority of physicians in the under 35 age group (2007 National Physician Survey)4. - The 2005 Canadian Paediatric Society Survey 4 indicated that 75% of paediatric residents were female, two thirds reported that they planned to work in an academic centre, 10% planned to work in a community office and 11% wanted to work in smaller communities of less than 100,000 people. Over one third (36%) want to do subspecialty care while 22% want to do consultant care and only 5% are interested in doing primary care. One-third of residents want to do international work. When asked about their priorities 50% of residents rated location as the top priority followed by lifestyle at 49%.

4

College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, 2008. National Physicians Survey. http://www.nationalphysiciansurvey.ca/nps/home-e.asp

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- On average female physicians work fewer hours a week than male counterparts. Female physicians are more inclined to participate in jobshare arrangements or have office hours that reflect other priorities and interests. Younger female family physicians work fewer hours than their male counterparts although working hours of females and males between the ages of 45 and 54 are the same. Practice Trends - 27% of Canadian doctors have reduced their weekly work hours over the past two years and 35% plan to do so in the next 2 years. Nationally, 13% of physicians plan to reduce their scope of practice. - Most Canadian physicians belong to a medical group (46%) or interprofessional practice (24%). Solo physician practices account for 27% of all practices nationally and only 18% in Alberta. - 58% of family physician/general practitioners either limit the number of new patients they see or do not take new patients at all. - Depending on the data source, 41% to 80% of family physicians in Canada provide primary child and adolescent health care. Moreover, paediatric medicine is more often practiced by female family physicians, younger family physicians, rural family physicians, and family physicians working in group practices. - Paediatricians are caring for more children with complex care needs but are more apt to provide primary care in larger urban centres. - Weekly paediatrician activity in 2007 was identified as 52.5 hours (compared to 50.40 hours in 2004). Most of the additional time was spent in indirect patient care activities. Acuity indices (e.g. hours of direct patient care while on call) indicated an increase in acuity. - Fewer paediatricians are working in the community and even fewer are working in communities with less than 100,000 people. More paediatricians are being attracted into paediatric sub-specialty areas and the hospitalist paediatrician role which continues to proliferate in Canadian urban centres. - Paediatricians reported difficulties accessing primary care physicians and allied health professionals (e.g. social workers, psychologists and dietitians). The majority (58%) also had difficulties accessing paediatric sub specialists. - The 2005 Canadian Paediatric Society survey indicated one half of Canadian paediatricians are doing some primary care, almost two-thirds provide consultant care, one-third provide subspecialty care and two-thirds were involved in hospital services. - In Canada there is an increasing shift from fee-for-service to other remuneration methods, particularly blended models that recognize the

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diverse roles and responsibilities of paediatricians (2007 National Physician Survey). 3.3

Implications for Future Community Paediatrician Practice The implications for future community paediatrician practice can be summarized as: ¾ The need for increased specialization and knowledge in developmental, behavioral, psycho-social issues and child protection paediatrics; ¾ More emphasis in training and practice in behavioral paediatrics, child psychiatry, disability, epilepsy management, learning disorders and on personal, family and social complications of chronic illness; ¾ More collaborative interface with more diverse settings including schools, daycares, aboriginal health services, public health/community health centres in addition to primary care physicians and paediatric sub-specialists ; ¾ Systems thinking or understanding on how to navigate different systems that address various aspects of child health (health promotion/disease prevention, acute care treatment, chronic illness management); ¾ Greater participation in integrated inter-disciplinary teams and in shared care models. Success will depend on a clear delineation of roles and responsibilities of each team member including legal provisos and a governance structure. ¾ The need for effective communication skills and strategies for interprofessional collaboration. ¾

Change management processes for the effective use of electronic communication and information/data management technologies for clinical care/consultation, education and research and effective team dynamics;

¾ The need for the development of tools e.g. clinical care pathways that standardize the management of chronic conditions based on best practice evidence across primary, secondary and tertiary care levels. ¾ The need for effective strategies for transitioning children with chronic and complex medical and mental health conditions (e.g. ADHD) to adult services in the community. ¾ Attention to continuous practice improvement and evidence based practice ¾ More student/resident training opportunities that focus on “community practice” and provide experience on population health issues in properly resourced community environments that promote family-centered principles, support the management of chronic/complex care, and

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children/youth/families who are particularly at high risk or vulnerable for poor health. ¾ Participation in community health research and evidence based practice in community paediatrics. ¾ Remuneration methods that properly recognize the diverse range of responsibilities (e.g. for roles in case management, advocacy or provider of comprehensive chronic care). ¾ More innovative and flexible work arrangements that will attract and retain paediatricians in the sub-specialty of Community Paediatrics. 3.4

An Overview of National and International Concepts & Models At this time there is no particular model or approach that can claim the designation of “best-practice” based on any formative evaluation results. Successful health service delivery models effectively and efficiently address the specific needs of the population(s) served within the parameters of a particular system (e.g. professional and physical capacity). Therefore, any model needs to be responsive to the local needs of the population it serves and the specific capacity of the system from which it operates. Many paediatric associations, colleges and societies around the world are examining paediatrician roles and practices in order to improve access to paediatric care in the community. In May, 2009 The Canadian Pediatric Society issued a position statement on a model of paediatrics for the evolving health care environment in Canada (Canadian Pediatric Society 2009-01). Central features include: - The priority for paediatricians should be the delivery of comprehensive consulting care, regardless of the location or nature of their practice; - Paediatricians should be able to provide ongoing comprehensive care to children and youth with complex medical needs both in the community and when hospitalization is needed. - Paediatricians should where possible, give preference to collaborative medical practice, including working with other professionals such as family physicians, psychologists, social workers and nurses. - Governments should ensure that there are appropriate numbers of all child and youth health professionals to meet the needs and to participate in teams. Appendix B provides an overview of relevant initiatives and models relating to community paediatrician service delivery in Alberta, Canada, the United Kingdom, the United States and other countries. Major themes and concepts that emerge include: o The need for integrated/collaborative models of care or managed networks for children with complex and long standing problems; o

A model/system that is focused on patient need rather than patient crisis;

o

The importance of horizontal, vertical and longitudinal integration to

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optimize child health (e.g. the inclusion of prevention and health promotion programs; formal partnerships across medical, public health, education and social service sectors; and optimize health trajectories around developmentally sensitive transitions across the child’s life)

4.0

o

The recognition of the need for integrated multi-disciplinary teams that support care in the community (either co-located or via a network);

o

A greater shift to providing care closer to home and whenever possible outside hospital, based on the principle ‘localize where possible, centralize where necessary’.

o

The need for enabling tools and processes including referral processes that span the paediatric care continuum; development of clinically safe care pathway/protocols; use of collaborative management or shared care processes (e.g. mental health/paediatrician).

o

The use of Nurse Practitioners and other health professionals to administer treatments for routine ailments to enable paediatricians to practice “intuitive medicine” to help diagnose and treat patients presenting with complex and complicated conditions;

o

Enhanced uptake of information and communication technology; and

o

Recognition of the need for more innovative and comprehensive paediatric residency and family medicine training programs

Community Paediatricians in Calgary & Southern Alberta 4.1

Calgary Community Paediatricians

The Department of Paediatrics -Division of Community Paediatrics in Calgary is comprised of 38 full time equivalent community based paediatricians. Community Practice Profile: The following table provides an overview of current Calgary community paediatrician practice profiles: Profile Indicator

Number (%)

Total Number (full and part-time) Demographic Profile

41 Female: 21 (51%) Male: 20 (49%) 55% are over the age of 50 years and 17% are over the age of 60 years. Only 4 (10%) are under the age of 35 years and are also female.

Practice Size: Solo practice

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8 (20.5%) (Two work as part of two larger family physician/specialist practices. One practices outside of a formal office setting in the community.)

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Profile Indicator

Number (%)

Two person group practice Three person group practice Four person group practice Five person group practice Seven member group practice Other Practice Location: NW Quadrant NE Quadrant SW Quadrant SE Quadrant Okotoks Office Arrangements: -Ownership - Rental arrangements with existing landlords - 5 year lease arrangements -Works out of space owned by PCN or other community agencies -Unknown Lease Renewal Dates: 2009 2010 2011 2012 2013

4 (20.5%) 3 (23%) 1 (10%) 1 (13%) 1 (18%) 2 are currently working in ACH programs. 14 (36%) 7 (18%) 15 (38%) 1 (2.5%) 2 (5.0%) 3 (8%) 3 (10%) 29 (74%) 3 (8%) 1 (2.5%) 1 (2.5%) NW 6 (15%) (2 in NE and 4 in NW) 3 (8%) NE 13 (33%) (12 in SW and 1 in SE) 6 (15%) (3 in NW and 3 in SW)

Primary vs. Secondary/Consultant Care: All community paediatricians in Calgary currently provide consultant (secondary care) and complex primary care to children/youth with complex and chronic medical, mental, behavioral, developmental or functional issues. In support of family-centered care, most paediatricians also attend to the health care needs of siblings of patients with complex care needs which may include healthy children. Many reported that they continue to serve as the primary care physician for some healthy children who became patients when the paediatrician was first establishing their practice or saw them as premature newborns. Many of these patients are now adolescents. Patient Case Mix: A survey of community paediatrician referrals over a one week period in January of 20095 indicated that:

5



An average number of 12 patients were seen each day (includes new referrals and follow-up consults) by each paediatrician.



62% of patients seen received ongoing care from the paediatrician; approximately 7% of children were seen for well child care, e.g. sibling of a child who has complex care requirements or for premature infant (who could potentially be seen by family physicians).



60% of patients seen had multiple medical diagnoses

15 Community Paediatricians responded across all quadrants for a 40.5% response rate.

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The most frequent diagnoses cited were: ADHD (12%), Prematurity, Asthma, Emotional Disturbances, Developmental Delay, Autism, Constipation, Feeding Difficulties/Failure to Thrive and Speech and Language Delays



Approximately 30% of patients required referral to publicly funded services, those most frequently identified included: Access Mental Health, Developmental Clinic, Rehabilitation Therapies (Speech, OT, and PT), Dietician, Cardiology, Neurology, Ophthalmology and Surgery, Gastrointestinal Services and ENT. Approximately 10% of patients were referred to private health care services, most notably for Psychology, Physio-therapy, Family Therapy and Counseling.



Paediatricians noted that the actual number of referrals does not reflect the true need as paediatricians will not refer patients to services when they feel that it is too troublesome for the family (difficult for them to go to ACH or unaffordable) or because of lengthy waits for ACH services, or because of a “lost teaching opportunity”, e.g. patient/family is motivated at the time of the visit to receive education.

The case mix observed is consistent with that found in other larger observational research studies. A paediatric case mix observational study conducted in the UK district of Northampton in 1998 identified that the five commonest cases presenting to community paediatriacians were: speech delays, behavioral difficulties, global developmental delays, autism and difficulties with school attendance including ADHD (Holmes, 2002). Diverse Practice Interests: In addition to seeing patients in their community practices, most paediatricians also engage in other child health service settings, teaching and advocacy roles. Hospital Care: Ten paediatricians (24%) currently provide hospitalist coverage at the Alberta Children’s Hospital and six paediatricians (14.6%) provide paediatric on call and preceptor coverage for family medicine residents on the Paediatric Unit at Peter Lougheed Hospital. Newborn Care: Fifteen paediatricians (36.6%) provide normal newborn care at PLC and RGH, while six paediatricians provide care at the Level 2 special care nurseries and one paediatrician provides care in the Level 3 Special Care Nursery at FMC. Home Care Responsibility: As of December, 2008 there were 181 active clients receiving Paediatric Home Care services in Calgary. Of these 176 were under the care (primary responsibility: 132, shared responsibility: 44) of a community paediatrician. Specialty ACH and Child & Adolescent Mental Health Clinics/Services: Eighteen (44%) community paediatricians provide coverage in the following outpatient clinics at ACH and Child & Adolescent Mental Health Programs: Head Shape Clinic Asthma Clinic Seizure Clinic Vascular Birth Clinic Neuromotor Clinic Cleft Palate Clinic Hemophilia Clinic Child Abuse/Sexual Abuse Service Palliative Care Developmental Paediatric Clinic Hearing Clinic Oncology Clinic

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Behavior Clinic Fetal Alcohol Syndrome (FAS) Collaborative Mental Health

June, 2009

COPE (Community Outreach in Pediatrics/Psychiatry and Education)

Two community paediatricians provide paediatric consultant services in Sports Medicine and Paediatric Obesity in the community. Community Paediatric Urgent Assessment Program: In 2008 the Calgary Health Region implemented this program to expedite urgent paediatric medical consultations by community paediatricians of children with urgent/acute medical concerns that do not require hospitalization or acute sub-specialty care. Children are seen within 72 hours of referral from the Emergency Department. The majority (N=28 or 68%) of community paediatricians participate in this program. Outreach Services/Advocacy: Eleven community paediatricians (27%) offer paediatric care and advocate on behalf of various high risk or vulnerable child/youth groups through outreach service agreements with the Calgary Health Region. These include: -

Kids in Care (A partnership of Calgary & Area Child & Family Services Authority (CFSA) and the Calgary Health Region Department of Paediatrics, Division of Community Paediatrics to ensure that all children coming into the care of the CFSA receive a full assessment of health and developmental issues by a community paediatrician followed by necessary intervention and follow-up care by appropriate developmental and child health programs and services.

-

High Risk Adolescent Clinic: A partnership involving Hull Child & Family Services, Calgary & Area Child & Family Services Authority and the Calgary Health Region Department of Paediatrics, Division of Community Paediatrics whereby a community paediatrician provides supportive, non-judgmental, confidential, and comprehensive assessment to adolescents who are in secure treatment at Hull Child & Family Services (through the Protection of Children in Prostitution or brought to the facility by CFSA.

-

One World Child Development Centre: A partnership involving the Calgary Urban Project Society (CUPS) and the Calgary Health Region Department of Paediatrics, Division of Community Paediatrics. CUPS/One World offers a variety of programs and services for at-risk families and their children including a paediatric clinic at CUPS and an early intervention education centre at the One World Child Development Centre. The community paediatrician provides medical assessment and diagnosis services to these children, many of whom are severely disabled (e.g. Autism, FAS, and seizures). These families are of very low income and very few are able to see a family physician on a regular basis. The physician here works with a team of consultants including teachers, speech therapists, occupational therapist and physio-therapists.

-

Siksika General Paediatric Clinic: A partnership involving the Siksika Nation and the Calgary Health Region Department of Paediatrics, Division of Community Paediatrics. A community paediatrician provides paediatric care to the children and youth on the Siksika Nation reserve located 100 km east of Calgary two days per week in order to provide care closer to home. The paediatrician also supports the Health & Wellness staff through education and capacity building initiatives.

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-

June, 2009

Stony Health Centre General Paediatric Clinic: A partnership involving the Stoney Nakoda Health Centre and the Calgary Health Region Department of Paediatrics, Division of Community Paediatrics. A community paediatrician provides paediatric care to children and youth of the Stoney Nation in Morley one day per week. The paediatrician also works closely with other members employed at the Stoney Health Centre providing education and building capacity.

Teaching: Most paediatricians (N=33, 80%) hold clinical appointments with the Faculty of Medicine of the University of Calgary. Paediatricians employed in group practices tend to serve as preceptors for medical students, family medicine residents, paediatric residents and international medical graduates. In contrast, few solo practice paediatricians can engage in student/resident education due to space and time constraints. Community Based Research: To date there has been little opportunity for community paediatricians to participate in research largely due to an absence of supporting research infrastructure (e.g. electronic medical records/data collection, research supports (design, methodology, data analysis) from University research institutes, insufficient space for research activity, and unavailable paediatrician time. 4.2

Paediatricians in Southern Alberta Centres

There are 19 paediatricians outside of Calgary as follows: - 7 in Red Deer (former David Thompson) - 4 in Lethbridge, (former Chinook Health Region) - 5 in Medicine Hat (former Palliser Health Region - 1 in Brooks and (former Palliser Health Region) - 2 in Canmore) (former rural Calgary Health Region) Paediatricians in Red Deer, Lethbridge and Medicine Hat are responsible for hospital inpatient care, emergency care, Level II Neonatal Nursery and newborn care in addition to their community practices. The size of paediatric/adolescent populations in these areas are: Chinook (44,000), in Palliser (27,000), and David Thompson (approximately 74,000). Practice Arrangements: With the exception of one large group practice in Red Deer, most paediatricians in southern Alberta practice alone or with one other partner. This limits efficiencies in operating a practice and the ability to consult more broadly with peers on patients who present with complex conditions. Solo practices: 7 (Brooks (1), Medicine Hat (3), Lethbridge (2) and Red Deer (1)). Group Practice of 2: 3 (Canmore, Medicine Hat and Lethbridge) Group practice of 6: 1 (Red Deer) Consistent with other centres, the demographic profile is characterized by an aging workforce and a growing number of female paediatricians (currently at 9 or 47%). Quality of work life balance is becoming increasingly challenging, particularly for smaller practices. Almost all paediatricians highlighted the need for additional locums to adequately cover hospital on-call requirements. Until recently paediatricians from Calgary and other parts of Canada were providing on-call relief. In the absence of

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attracting new paediatrician recruits into these centres, there is urgency, particularly in Lethbridge for new sources of on-call relief support. Role Description: Paediatricians in Red Deer, Brookes, Lethbridge and Medicine Hat described themselves as regional general paediatricians who are responsible for newborn care, hospital-based paediatric care (emergency and paediatric ward) and outpatient/community consultant (secondary level) paediatric care. Primary care is typically the responsibility of family physicians. However, a growing number of families, particularly in Medicine Hat do not have a family physician and consequently paediatricians there are increasingly attending to primary care needs. Several paediatricians identified having specific experience in sub-specialty areas of neonatology, child development/mental health, paediatric respirology, and diabetes management. One paediatrician in the Palliser Health Region (Brookes) is involved through an outreach agreement (SACYHN) with the Healthy Minds/Healthy Children program that contributes to the development of internet web-based educational programs on children’s mental health topics. Another tentative outreach agreement is planned for one of the paediatricians in Medicine Hat to provide a paediatric diabetes management clinic commencing in 2009. Paediatricians in southern Alberta indicated that their involvement in medical student and family paediatric residency training (Years 2-4) has been negligible. They feel that this undermines the potential for attracting future paediatricians to practice in smaller centres in southern and central Alberta. Significant efforts are underway to recruit new paediatrician resources through the International Medical Graduate Program but assistance is required from Calgary or Edmonton to complete the three month clinical assessment period required for certification/licensure One paediatrician indicated that the Canmore and Banff hospital on-call stipend was discontinued a year ago so paediatricians are no longer providing on- call coverage in those hospitals. Another paediatrician in Lethbridge acknowledged that she discontinued providing on-call coverage because of the growing work-life imbalance. Paediatricians in Lethbridge and Medicine Hat/Brookes identified a dire need for locum coverage and the desire to attract more paediatric residents in order to sustain the workforce. All paediatricians interviewed praised the caliber of outreach consultation services offered by Calgary paediatric sub-specialists. Most were very satisfied with relationships with and quality of ACH specialty clinic services. However, long wait times in excess of a year were noted in the case of GI and Neurology. Referral processes were questioned. It was also noted that while these clinics provide exceptional multidisciplinary assessment services, families are left to pursue actual treatment for their children in their home communities which often is not available. Like Calgary, community based paediatric treatment services outside of limited school health programs are not generally available in other southern Alberta centres. Most paediatricians identified seeing more children over time with behavioral and or mental health problems. Community based paediatric mental health, behavioral therapy, rehabilitation therapist, nurse education, social work, psychologist and dietitian services were all identified as requisites for good child health outcomes. Paediatricians typically

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aided by receptionist support are not equipped to provide multidisciplinary support that is frequently required by children with complex and chronic health problems. The influx of immigrants in some areas (e.g. Brookes) has raised the need for more diversity service supports including translation/interpretation and culturally appropriate health delivery approaches. The establishment of Primary Care Networks to date has not produced any significant linkages with paediatrician services in the community. 5.0

THE STATUS OF PAEDIATRIC HEALTH IN CALGARY & ALBERTA Understanding the current status of health among children and adolescents is necessary to inform future service delivery. The 2005 Alberta Health and Wellness Child Health Surveillance Report provides important child and adolescent health trends in Alberta and by health region. Highlights include the following: Health Determinants In 2000, 15.4% of Alberta children lived in low-income families (compared with 11.9% among all Albertans). Of children living in female lone parent families, 34.3% were low income. While there are proportionately fewer low income families in Alberta than in Canada, the depth of poverty is greater in Alberta. This is important as children living in poverty are at increased risk of poor physical health during childhood and of poor physical, cognitive and emotional functioning in adulthood. (World Health Organization, 2003). -

More than 1% of Alberta children are abused and neglected each year. The infant and toddler age group (0-2 years) had the highest rate (20 per 1,000) or 6,880 children. Rates among First Nations children are higher. Rates are higher in Palliser and Chinook health regions compared to rates of other health regions.

-

In 2000/01 29% of Alberta children were overweight. The highest rates were observed in children aged 2 to 11 years where overweight rates ranged between 28% and 41%. Rates have been increasing steadily since surveyed in 1994/95.

-

Alcohol consumption is widespread among Alberta youth (56.4%) of students in grades 7 through 12 reported drinking in the previous year. AADAC reported that 1 in 4 students in grades 11 and 12 are at risk of hazardous and harmful alcohol use (AADAC, 2003).

-

Alcohol consumption during pregnancy occurs in 4.0% among general population and 10.7% among teenage mothers. Rates in Palliser, Chinook, David Thompson, and Northern Lights were significantly higher than those of other health regions. This is significant in that alcohol consumption during pregnancy can result in growth restriction and functional impairment, miscarriage, fetal alcohol syndrome and cognitive or behavioral abnormalities.

-

More than 50% of Alberta teen mothers smoked during pregnancy from 2000 to 2002. The rate of smoking during pregnancy was higher than the provincial average in Palliser and David Thompson health regions. Smoking during pregnancy increases the risk of restricted intrauterine growth, decreased birth weight, pre-term birth, still birth and infant death.

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Health Status The low birth weight rate (less than 2500 grams) in the Calgary region (7.1 per 100 live births or 3,025 low birth weight babies) was higher than the provincial average in 2002-2004 (6.3 per 100 live births) and higher than in Canada (5.9 per 100 live births). Many of these babies were born to women in their forties. This is important as low birth weight babies often have fetal, neonatal and long-term implications including physical, cognitive, behavioral and educational impairments and fetal and infant mortality. -

Congenital Anomalies (developmental disorders identified prior to, at, or after birth, including malformations, deformations, disruptions, and dysplasias) are a leading cause of fetal/infant death and an important cause of morbidity and longterm disability. The rate of congenital anomalies was higher in the Calgary region than the provincial rate (37.1) in 2001 to 2003 with a rate of 46.7 or 1,934 cases. Rates are highest among women over the age of 39 years.

-

In 2002/03 11.5% Alberta children (16,282) aged 0-3 years showed delayed motor and social development. About 10.7% of children aged 4-5 years or 7,063 had delayed receptive vocabulary (based on Peabody Picture Vocabulary Test) for their age (cognitively delayed) which could result in difficulties in school entry.

-

Between 2001 and 2003, 22,963 children between the ages of 10 and 14 were diagnosed with Attention Deficit Disorder (ADD) in Alberta for a rate of 33.4 out of every 1000 children. Calgary region rates are higher than the provincial rates. ADD is the most common neurobehavioral disorder of childhood and is often seen in association with other mental disorders including conduct disorder, depression, and anxiety disorders. It is three to four times more common in males. First Nations children are more likely to be diagnosed with ADD than non-First Nation s children between the ages of 1 and 9 years.

-

Anxiety and neurotic disorders ( includes separation anxiety, social phobia, generalized anxiety disorder, obsessive compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and panic disorder) are most common among 15-17 year old children, where rates are double that of children aged 10-14 years. Post-pubertal girls are more likely to be affected than boys. In 2003, there were 41.6 (per 1000 children) or 17,193 children aged 15 to 17 years in Alberta diagnosed with anxiety and neurotic disorders and more First Nations children were diagnosed than non-First Nations children (49.0 vs. 41.1 per 1000 children).

-

Depression is widespread among Canadian youth. Depression diagnoses increase dramatically with age during childhood. It is more common in adolescents and in girls. The highest rate occurring among 15 to 17 year olds is 32.2 (per thousand children) or 13,329 children. Chinook (11.0), Calgary (10.3 or 8,094) and David Thompson (10.3) regions reported higher rates than the provincial average (9.9). Childhood depression is a significant risk factor for depression in adulthood. Depression requires medical attention and is fairly responsive to psychotherapy.

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-

In 2003, Calgary had the highest rate of childhood asthma in the province at 75.9 per 1,000 children or 59,894. Asthma is the most common medical disorder of childhood. It is more common in pre-pubertal boys and post-pubertal girls and appears more frequently in children living in urban areas. Therapy focuses on avoiding triggers, treating the acute attack and trying to reduce lung inflammation.

-

Between 1998 and 2002, there was a small but significant increase in the rate of diabetes (Type I and Type II) among Alberta children from 2.0 (in 1998) to 2.4 (1,861 in 2002). Long term complications associated with childhood diabetes include cardiovascular disease and stroke, high blood pressure, kidney disease, nervous system disorders, eye disease, and increased susceptibility to infection. Chinook (2.7) and David Thompson (2.7) had higher rates than the province (2.3).

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Regarding sexual health, in 2004, the rate of newly reported cases of Chlamydia was more than 8 times higher in girls (237.5 per 100,000) than in boys (27.5). Chlamydia infection rates increased in both adults and children in Canada and Alberta between 1998 and 2002 and Alberta rates were consistently higher than the national average. One percent of 17 year olds were diagnosed with Chlamydia between 2002 and 2004. Between 2002 and 2004 the incidence rate of childhood Chlamydia in Alberta was 130.4 per 100,000 children. Between 2002 and 2004, 121.8 out of 100,000 17 year olds acquired gonorrhea. Gonorrhea is also more common among girls (new cases of 30.8 per 100,000 in 2004) than boys (7.6).

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Injuries are the leading cause of mortality for children age 1-19 years. Motor vehicle collisions are the major cause of injury death in all age groups. Motor vehicle collisions and suicide are more common in the teenage years while suffocation and drowning are major causes of injury death for infants and preschoolers. More boys die from injury than girls. Complications of medical care and unintentional falls are the leading causes of hospitalization for injury. Sports-related injuries are a common cause of hospitalization for school aged children and appear to be rising while adolescents become increasingly likely to be hospitalized for motor vehicle collisions or for deliberate self-harming behavior. This area offers tremendous opportunities for prevention through proven public health measures including the use of seatbelts, helmets, and childproof medicine bottles.

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Child mortality in Alberta is low with 407 deaths in 2003 (52.6 per 100,000). The mortality rate is highest in infants at 609.8 per 100,000 between 1998 and 2003. Perinatal conditions, congenital anomalies, and transport accidents are the leading causes of child mortality in Alberta.

Health Service Utilization (Based on the 2005 Child Health Surveillance Report) ¾

Immunization: In 2003, 86.2% of one year olds were up to date on their immunizations for diphtheria, pertussis, tetanus, polio and Hib compared with 78% of two year olds. During the same period 90.3% of two year olds were up to date on their measles, mumps and rubella immunizations. Over 90% of two year

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olds were up to date on their measles, mumps and rubella immunizations in 2003. ¾

Hospitalization rates: Between 2001 and 2003 child hospitalization rates in the Calgary and Capital Health regions were the lowest in Alberta for a rate of 3.0 per 100 children. The top two reasons for hospital visits in Alberta in 2003 were perinatal conditions (e.g. slow growth, prematurity, respiratory distress) and respiratory disorders (asthma, bronchitis, pneumonia, tonsils). These accounted for 47% of all childhood hospitalizations in 2003 in Alberta. Injuries and digestive disorders accounted for another 17.5%. Leading causes by age in 2003 and 2007/08 in Calgary were as follows:

Infants under 12 mos. 2003 2008 Perinatal Perinatal

Pres-school aged 2003 2008 Resp Resp Disorders Disorders

5 to 9 years 2003 2008 Resp Injury & Disorder Poison

Congenital abnormal

Congenital abnorm

Digestive disorders

Ears Nose Throat

Injury & Poison

Resp. dis.

Resp Disorders

Resp Disorders

Digestive disorders

Digest. Dis

Digest.

10-14 years 2003 2008 Injury Digest. & disord. Poison Resp. Injury Dis. & poison Digest. Mental dis. disord.

15-17 years 2003 2008 Injury Mental & disord poison Mental Injury disord. & poison Digest. Digest disord. disord.

Hospitalization rates due to respiratory disorders and for pregnancy and childbirth were notably higher in First Nations children compared with non-First Nations children while hospitalization rates for peri-natal conditions was higher in non First Nations children. ¾ Emergency Room Use: Between 2001 and 2003 emergency room visits by children ranged from 20.9 (per 100 children) in the Calgary health region (165,064 patients) to 50.6 in the Peace Country health region (56,739 patients). Emergency visit rates are highest among children under the age of 5 years (e.g. 41.1 per 100 children aged 1 to 4 and 31.5 per 100 children under 1 year). The rate for 15 to 17 year olds was higher than those aged 5 to 14 years. While visits among First Nations children were higher across all age groups, the most marked was among infants where the rate was 50.7 per 100 First Nations children compared with 30.1 per non-First Nations children. Leading causes for emergency visits by age in 2003 and 2007/08 in Calgary were as follows: Age 0-17 years 2003 Injuries Symptoms Respiratory diseases

2008 Injuries & Poisonings Respiratory diseases Symptoms not elsewhere classified.

Under 5 Years 2003 Acute respiratory infections

2008 Respiratory diseases Injury & poisonings Symptoms not elsewhere classified

6-17 Years 2003 Injuries

2008 Injury & poisonings Symptoms not elsewhere classified Respiratory diseases

In general, emergency visits for dislocations, sprains, strains and fractures become more common as children get older while visits due to respiratory infections and otitis media and other diseases of the middle ear and mastoid are less common.

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In 2007/08 only 12.9% (N=7909) of total emergency visits (N=61,357) in the Calgary Health Region were triaged as requiring resuscitation or emergent. The most frequently cited main diagnosis among those classified as urgent, less urgent and non-urgent were: - acute upper respiratory infections of multiple and unspecified sites - open wound of head - viral infection of unspecified site - fracture of forearm - other and unspecified injuries of the head ¾ Physician Office Visits: Almost every Alberta child under the age of one saw a physician between 2001 and 2003 (96.7 per 100 children; 109,501). In 2003, 327,550 girls visited physician’s offices in Alberta for a rate of 86.9 (per 100 girls) while the rate for boys was 85.1 (337,009). The highest rate occurred in the Calgary Health Region where 88.0 out of every 100 children visited a physician between 2001 and 2003 (695,005 children). The Calgary Health Region also had the highest number of visits per patient in that time period at 5.0. The top leading causes for physician office visits in 2003 in Alberta were acute respiratory infections (16.6%), symptoms (10.5%), development (6.7%) and diseases of the ear and mastoid process (6.4%). Leading causes by age were: -Infants: (1) Development (36.5%), (2) Symptoms (14.7%), and (3) acute respiratory infections (10.4%). -Children aged 1 to 17: (1) acute respiratory infections -Children aged 1 to 9 year olds: (2) symptoms and (3) diseases of the ear and mastoid process -For 10 to 17 year olds: (2) symptoms were the second leading cause. Neurotic disorders, personality disorders and other non-psychotic mental disorders, and sprains and strains of joints and muscles were the next leading causes. The data did not differentiate between family physician and paediatrician visits. Data was limited to primary diagnosis and represents only those patients seeking care and does not include referrals.

6.0

GAPS & CHALLENGES IN COMMUNITY PAEDIATRIC CARE

Informants identified the following challenges in caring for the paediatric/adolescent population in Calgary: 6.1

A Changing Patient Profile: Characteristics of the paediatric population in Calgary that challenge the delivery of community based care include: ¾ A growing population of children and adolescents. There are currently about 315,000 6children and youth aged 0-19 years residing in the Calgary Health Region. This population is expected to reach 367,000 by 2020, an increase of 16%. The paediatric populations are also

6

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expected to grow in the Palliser (14%), Chinook (6%) and David Thompson (11%) health region over the same time period. ¾ An increasing number of premature and low birth weight babies and infants born with congenital abnormalities due in part to population growth, advances in fertility technology and women choosing to give birth later in life. ¾ The increasing prevalence of chronic illnesses in children including asthma, diabetes and other illnesses associated with unhealthy lifestyles including childhood obesity, poor diet and inactivity. Ongoing monitoring, care by a multi-disciplinary team and patient/family self-management education identified by best practice chronic disease management models are required. Evidence based health promotion measures need to be broadly implemented across primary care and community paediatrician settings. ¾ Calgary and Southern Alberta community paediatricians reported an increasing trend in the presentation of patients with behavioral and mental health problems. This is consistent with various studies that report that psychiatric illnesses affect 13 to 22% of Canadian children (Globe and Mail, November 22). All expressed concerns over insufficient resources in the community (e.g. psychologists, child psychiatrists, mental health therapists, social workers) to provide time sensitive psychosocial assessments, early intervention and therapy. Many noted that the parents of these children/youth also required supports including family counseling, parent coping strategies, and in many cases therapy for their own mental illness. ¾ Calgary’s diverse communities and a surge in the number of new immigrants in other southern Alberta communities will require culturally sensitive care approaches and resources. 6.2

Lack of an Integrated Whole System Approach ¾ Other jurisdictions are working on implementing child and adolescent health service delivery models based on the right place…right time premise which encompasses a range of environments for service delivery including the home, the community, the local community hospital and the regional/specialty hospital that distributes resources across the care continuum. British Columbia is taking this further by adopting a model that integrates services across health, school and social service sectors. In Calgary there is no universal community based model for comprehensive assessment and care of children and youth who require periodic and ongoing care for chronic, debilitating, multiplesystem and or complex health problems. o

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Primary Care Networks in Calgary and Southern Alberta with the possible exception of the Rural Calgary PCN in Okotoks have not established formal linkages with community paediatricians for

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paediatric service delivery or capacity building in the community. They have not designated any resources or supports for child health in the community.

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o

There is no defined or consistent referral process between family physicians and paediatricians in the system at this time. Calgary informants identified that referral patterns are influenced or affected by the following: - the anticipated amount of physician time required to deal with the suspected problem; - the nature of the problem, e.g. patients tend to be referred to different paediatricians depending on the type of health problem. - established relationships between family physicians and paediatricians - prolonged wait times for certain diagnoses e.g. ADHD patients; - the variability in scope of practice among community paediatricians, e.g. some practice more primary care than others and some see healthy siblings of chronically ill patients (in support of family-centered care); some do not see patients with certain health problems - community paediatricians are not linked to other services or resources; - concerns in some cases that primary care of the patient will be unnecessarily assumed by the community paediatrician (e.g. patient loss) - growing pressures on community paediatrician consultant services as the number of family physicians continues to decline. Family physicians that leave the city are referring their paediatric patients for well child health to paediatricians.

o

Children/youth who require assessment or treatment by a health professional other than by a family physician or paediatrician are typically referred to a tertiary/quaternary level specialty clinic at the Alberta Children’s Hospital regardless of the severity or complexity of the child’s condition or to Access Mental Health in the case of a suspected mental health issue. However, ACH clinics are neither designed nor resourced to attend to the needs of all children/youth in need of an assessment or treatment by a particular health discipline such a rehabilitation therapist or a psychologist. Consequently, parents must privately pay for these services if they are not eligible for school based health services. Many simply cannot afford this option.

o

There are some paediatric focused programs located outside of ACH. Examples include the Community Paediatric Dietitian Service and Pre-School Speech Language Services Program. While these services are valuable they present limitations for timely or early assessment and intervention due to limited resources or program design/intent. For example, Community Paediatric Dietitian Service is open to referrals from a broad base including family physicians, public health nurses and paediatricians. This can result in longer

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waits for service, uncertainty in terms of referral status and brief report summaries that are not necessarily meaningful or useful to the practitioner in the ongoing care of the patient. Referral to paediatric rehabilitation services (pre-school and school aged) is currently restricted to parents (for pre-school services) and educators and parents (for-school aged services). While this model is one excellent way of ensuring child and family focused care, it does potentially preclude paediatrician involvement and advocacy on behalf of their patient. Paediatricians are trained to identify potential developmental problems in speech and gross and fine motor function as part of their comprehensive assessment of the child/youth and are likely to identify or anticipate problems earlier than parents. Timely referral and responsive access to paediatric services is particularly crucial in paediatric health care given the relatively short developmental trajectory. Early identification and treatment are key to ensuring optimum health and quality of life outcomes over the long term. One notable exception is the Community Paediatric Asthma Service which partners certified asthma educators (CAE) with family physicians and paediatricians to provide education and follow-up to children with asthma and their families in their physician’s offices or community clinics located in each of the city’s quadrants. In addition to helping patients manage their asthma more successfully, the model enables real time consultation and problem solving with the patient’s physician. The tendency has been to create targeted programs and initiatives that focus on the needs of a particular high risk group in response to unmet needs in the community as identified by a particular advocacy group or service provider. The list of these initiatives continues to grow and includes the Kids in Care Program (a partnership involving Health and Child & Family Services), the Complex Kids Program and the Collaborative Care Programs (Child & Adolescent Mental Health), the COPE (Community Outreach in Paediatrics/Psychiatry and Education) Program for children assessed with emotional and behavioral problems that impact learning in school (a partnership involving Calgary school boards, the Health Region and Calgary & Area Child and Family Services. The key limitations of these programs are capacity and limited reach. For example, the COPE Program at this time can only accommodate a limited number of elementary school aged children. The current system is not effectively or efficiently designed for early assessment and treatment of infants, children and youth who present with mild/moderate health or developmental issues which potentially could lead to life-long learning deficits, a compromised quality of life and chronic health problems in adulthood.

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¾ Community paediatricians, paediatric sub-specialists, educators, Child & Family Services and parents identified a general lack of health resources in the community for the assessment, early intervention and ongoing management of children with health issues. Specific services identified included: mental health services, child development assessment/intervention, psychological testing and therapy, health promotion education, and paediatric rehabilitation services (Speech Language Pathology, Occupational Therapy and Physical Therapy). The only recourse for paediatricians and family physicians is to refer patients to ACH for assessment and or treatment. This can pose a significant challenge if the child does not meet the referral criteria for a specific ambulatory clinic or service at the hospital. ¾ Many community paediatricians identified insufficient resources in the community for the assessment and treatment of developmental delays in infants and pre-school aged children. Many of these children do not have a clear diagnosis for eligibility to one of the ACH specialty clinics for treatment. While pre-school aged children and families have access to a Preschool Speech Language Services program and school aged children have access to limited rehabilitation services through the school system, e.g. the Student Health Partnership Program, current rehabilitation personnel resources are insufficient to help children optimize their functional potential. ¾ Many paediatricians and parents expressed concerns regarding the transitioning of complex patients (e.g. those with cerebral palsy and other severe developmental disabilities) and patients with mental health disorders e.g. ADHD to family physicians upon reaching adulthood. Finding family physicians that are willing to accept them into their care continues to be problematic. As a result paediatricians will continue to care for patients, particularly those with developmental delays into their early twenties. Earlier connections with family physicians need to be established prior to transitioning of care. ¾ Paediatricians, educators, allied health professionals, representatives from Child & Family Services and parents identified the need for professional ‘Connectors’ or ‘Navigators’ similar to the Family Liaison Worker position (COPE Program) with a good working knowledge of all child and family services and programs in the system who can function as case managers across the child sectors of health, education and child and family services and over time as the child transitions from pre-school to school to adult chronological phases. These individuals who are typically Social Workers by training have a good understanding of the broad and varied needs of families of children with complex health and developmental issues over time as children transition to adulthood. ¾ Paediatricians from Calgary and Southern Alberta expressed concerns over increasing wait times for patients to be seen by sub-specialists,

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those most notably being Neurology Clinic, Gastrointestinal Clinic and Mental Health services. ¾ ACH Program sub-specialists confirmed that a significant percentage of referrals from community physicians do not require tertiary level services/resources and would be more appropriately managed in the community by paediatrician supported by allied health professionals and potentially some sub-specialists (e.g. paediatric cardiologists) (e.g. for more timely and appropriate developmental screening, assessments, patient/family education and surveillance). This would result in more appropriate referrals to tertiary and quaternary level services and may also reduce unnecessary emergency /urgent care visits in the Emergency department. Examples included referrals to GI Clinic for assessment/treatment of diarrhea and constipation; referrals to Neurology for headaches query seizures, afebrile seizures, and migraines; and referrals to the Cardiology Clinic for unspecified heart murmur. A review of ACH ambulatory data during the period of June 2006 through May 2008 confirmed that a significant number of children and youth could have been potentially seen and managed in the community if appropriate referral processes and community based resources were in place: ƒ

28% (N=1,094) of Cardiology Clinic visits were for an unspecified cardiac murmur

ƒ

34% (N=972) of Gastrointestinal Clinic visits were for unspecified abdominal pain, constipation and feeding difficulties/mismanagement.

ƒ

GI Clinic data from September 28th through October 28th, 2008 revealed that Level 2 and Level 3 referrals, which could be handled by a community paediatrician with proper resources was 43 or 51% of total referrals for Levels 1 though 3. Referral sources included: 28% - out of region, 44% - family physician vs. 14%-paediatrician, and 28%- walk-inclinic. (Note: As of February 2009, there were 30 referrals per week of which 6.6 (22%) were being redirected to community paediatricians from GI Clinic. The majority were for constipation).

ƒ

The December, 2008 GI-CQI Audit update showed that there were 83 Level 1 patients waiting to be seen at the GI Clinic, in contrast to 254 Level 2 patients and 174 patients waiting to be seen. Wait times for Level 2 patients had increased from 9 to 12 months while Level 3 patients were waiting up to 13 months from 10 months in July.

ƒ

37% (N=1039) of Neurology Clinic visits were for query seizures, afebrile seizures, headaches, and migraines.

ƒ

Neurology Clinic data from December, 2007 through February, 2008 showed that 41 % of all referrals were for query seizures/afebrile seizures and that 33% of these referrals were from a family physician. Another

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22% of all referrals were for headaches of which 58% were referred by family physicians. ƒ

¾

Community paediatricians and sub-specialists pointed out that tertiary/quaternary services at ACH do not distinguish between referrals from family physicians and community paediatricians. This results in a level of redundancy in the assessment/diagnostic process. Many community paediatricians also work in ACH Clinics where they consequently re-assess a referred patient on behalf of another colleague paediatrician. This may also contribute to unnecessary reassessment by a paediatrician and delayed patient access to the sub-specialists or other members of the multi-disciplinary team. Other specialty paediatric programs/clinics such as Toronto Sick Kids only accept referrals from paediatricians. Leaders from Child and Adolescent Mental Health Services confirmed an overwhelming lack of community based mental health services to support children, adolescents and their families. Presently, Mental Health is helping about 3% of the paediatric population with mental health conditions in Calgary, far short of the 14-22% who need help. Furthermore, it is not known whether those with the greatest needs are being served. The Student Health Partnership in Mental Health Program (a partnership involving Child and Adolescent Mental Health and the Calgary Rockyview School Board) offers mental health services to students from ECS through Grade 12 who have mild to moderate mental health needs. Services include individual therapy, group therapy, and whole classroom interventions and involve the student, their parents, teachers and aides. In 2007 the Program reported that 75% (26,499) students requiring emotional/behavioral supports were not being provided for7. The Division of Child and Adolescent Mental Health recently implemented several improvements to the Access Mental Health referral process: designating single contact person exclusively for the community paediatricians; o immediate and direct contact with the paediatrician if the service recommended by Access Mental Health differs from the service requested by the referring paediatrician; o accepting letters of referral as replacement for completing the current referral form and accepting telephone consent from a patient’s paediatrician for a patient self-referral for mental health service. o direct telephone consultation with a Child/Adolescent Psychiatrist will now be accommodated as is reasonably possible. However these initiatives do not address the fundamental need for more mental health services based in the community including child and o

7

Calgary Rockyview Student Health Partnership Program. Estimating unmet health needs for students in the Calgary Rockyview Student Health Partnership service delivery area. February, 2007

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adolescent psychiatrists, mental and behavioral therapists for children and adolescents, psychologists and family therapists and family liaison workers This will continue to be a major challenge in the system due to the chronic shortage of these professionals. Therefore, capacity building among community family physicians and paediatricians on evidence based assessment and psycho-therapy interventions will be essential in order to proactively and effectively manage children and adolescents with common mental health problems including ADHD, Depression and Anxiety. Capacity building initiatives in mental health include:

¾

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Child and Adolescent Shared Mental Health Care A mental health/psychiatric team works directly with the primary care provider (family physician or paediatrician) to address mental health concerns in children and adolescents in the primary care provider’s office. This collaborative model is designed to increase capacity in the areas of identification, assessment, treatment, and referral of children with mental health concerns.



Training on evidence-based psycho-therapies for children and adolescents with ADHD Disruptive Disorders, Depression, Anxiety and Post Traumatic Stress Disorders. Training includes key skills including coping strategies, problem solving, parenting, family communication and cognitive restructuring. World renowned Dr. Peter Jensen from the REACH Institute (The Resource for Advancing Children’s Health) at Columbia University and his team have developed training modules and manuals specifically targeted at community family physicians and paediatricians.



The Healthy Minds Healthy Children accredited online continuing professional development program is another program that is currently offered to health professionals in Alberta to build capacity in the delivery of children’s mental health services and facilitate inter-professional dialogue and collaboration.

Members from the Paediatric Rehab Collaborative Practice Committee (a committee of representatives from paediatric community rehabilitation services and ACH established in 2008 to collaboratively plan and coordinate rehabilitative care for children and families across the Calgary health region) identified that relative to adult rehabilitation services based in the community, with the exception of region funded services at Calgary Youth Physio there are no publicly funded rehabilitation services for children and adolescents in the community outside of the school system. The majority of rehabilitation service funding for children is through the Alberta Education’s Program Unit Funding (PUF) which is designated for preschoolers with severe disability/delay for educational services and supports for a maximum of three years and for school aged children through the School Health Partnership program, which focuses on optimizing the learning experience of the student. Neither program addresses the rehabilitation

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needs nor potential for children who are mildly or moderately disabled/delayed but whose learning capacity is not negatively impacted. The school system is also ill equipped to rehabilitate students as identified in the following findings of the 2007 Report by The Calgary Rocky View Student Health Partnership : 41% (7,213) students requiring Speech Language services were not provided for. 45% (2,394) students requiring Occupational Therapy services were not provided for. 86% (4,525) students requiring Physical Therapy services were not provided for. 78% (2,061) students requiring Audiology services were not being provided for. Parent focus groups identified a general lack of rehabilitation services, particularly for children with mild to moderate developmental delays and disabilities. They also indicated that rehabilitation services seem to be more focused on assessment and less so on therapy. Health professionals and parents raised the need for more group therapy and the feasibility of employing more rehabilitation assistants to carry out therapeutic interventions as prescribed and under the guidance of rehabilitation professional. ¾ Child Development Services at ACH :Developmental Clinic, Preschool Autism/Coordinated Community Services, Preschool Treatment Program and the Early Intervention Program are designed for children with Autism Spectrum Disorders or multiple and severe/complex developmental delays/disorders in need of a tertiary multi-disciplinary team for assessment and diagnosis. These services also focus more on infants and pre-school aged children and typically provide assessments and recommendations for interventions for caregivers. Paediatricians felt that there are inadequate resources in the community to support these recommendations, which could be viewed as an ethical issue. Some also raised the possibility of duplication of assessment efforts by child development and mental health services. Child Development and Child and Adolescent Mental Health Services should review and streamline assessment processes to prevent unnecessary duplication. ¾ Parents and community paediatricians identified the need to improve timeliness of patient care information transfer across the system, specifically from tertiary care to community paediatricians. Parents did not feel that it was appropriate for them to be the messenger of the care/services they received at ACH to their paediatrician. Paediatricians also expressed frustration over the poor legibility of faxed patient summaries from the ACH emergency department, which typically necessitates follow-up telephone inquiries. ¾ Family physicians identified the need for timely and consistent information from community paediatricians about their patients and

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needing to be “kept in the loop” prior to transitioning the patient back to the family physician. ¾ Family physicians who work in the northeast quadrant of Calgary (Mosaic PCN) indicated significant health care challenges in these communities. They tend to have the highest concentration of individuals with substance addictions, mental health issues, obesity levels, teenage pregnancies and premature/low weight births. This is also borne out in Calgary health region health status reports. They identified the need for more Paediatrician support specifically in the areas of high risk Newborn Care (e.g. premature and low birth weight infants), the treatment of Childhood Obesity, and the assessment and treatment of children presenting with mental health, behavioral and learning problems. ¾ Family physicians from the Mosaic PCN identified that socio-economic and language barriers make it difficult for many parents in these neighborhoods to go to a Paediatrician’s office in other parts of the city. “You need to bring the service to them…”The cultural diversity in these communities also calls for more culturally sensitive prevention and care approaches. More grassroots measures are required to determine more effective ways of providing health care preventative and treatment interventions in these communities. 6.3

The Community Paediatrician Workforce 6.3.1 Calgary: The current community paediatrician workforce of 38 FTEs in Calgary is insufficient to support the city’s growing paediatric population, the new South Calgary Health Campus scheduled to open in 2011, projected growth in activity at Peter Lougheed Centre (16%) and the planned increase in medical student and paediatric resident placements. The Physician Workforce Plan Forecast for 2008-2017 which is based on a comprehensive modeling approach projects the need to recruit about 34 FTEs of community paediatricians over the next eight years based on the following: - 15.6 FTE to replace the existing workforce - 10.5 FTEs additional recruits for patient population growth 8.0 FTEs additional recruits for SHC and PLC The current ratio of 1 paediatrician for 8289 (based on 315,000 children and adolescents in Calgary) is much less than that found in the United States where ratios range from 1:1040 to 4280 depending on the State but is comparable with that of Australia (1:8,400). The difference can be explained by the fact that paediatricians in the United States practice more primary care whereas paediatricians in Australia practice as consultants. However, more community paediatricians in Australia are part of community based multi-disciplinary child health teams, e.g. Polyclinics, and hence are better supported in the community. Over the next five years an increasing number of Calgary paediatricians will assume more part time positions and several will likely retire or provide temporary coverage when colleagues are away. Many are not interested in renewing their current lease arrangements and are looking for more flexible work

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arrangements. Those who currently own buildings are not interested in relocating. By 2010 there will be at least 8 paediatricians who would be interested in a new practice arrangement. Attracting new paediatrician recruits to the community will pose a daunting challenge unless creative strategies that include building communities of paediatric practice are implemented. Between 1998 and 2008 only 6 (14%) of 42 paediatric resident graduates chose to practice as community paediatricians in Calgary and 3 (50%) of these occurred in 1998. The Hospitalist model at ACH presents another competing career path for paediatric residents to follow. Since 1999, nine (21%) paediatric resident graduates have chosen to work as hospital based paediatricians. There are currently 24.5 FTE Hospitalists working in Calgary. Ten (10) hospitalists also practice in the community. There is tremendous potential to attract more hospitalists to practice part-time in the community provided more flexible practice arrangements are available to them. Hospitalists and residents identified that the inherent reward of community practice is the ability to provide comprehensive and ongoing care of children who have complex and chronic care needs and their families. Community practice offers the opportunity to establish relationships with patients and families unlike hospital care which is episodic in nature. However, they also observed that working as part of the ‘hospital’ team of professionals is important for optimum patient care and practice capacity across all members. Patients and families have immediate access to a team of professionals and other resources in hospital. As one resident put it, “You don’t need to look for resources for your patients in the hospital…everything is there…so you can practice medicine. It was scary in the community…I didn’t know where to look for resources/supports for my patients or their families.” “How do you navigate such a fragmented system on behalf of your patients?” According to community paediatricians, paediatric residents and hospitalists, successful recruitment and retention of paediatricians into the community will depend on: -

The availability of larger group practice office settings. This is important from a number of standpoints. i) In order to create effective paediatric care networks in the community, paediatricians need to work together to build capacity for optimum family and patient -centered care through mentorship of junior partners and dialogue and consultation with one another. Paediatricians in solo practices and paediatric residents remarked on the disadvantages including professional isolation associated with smaller practices. ii) Larger practices enable more flexible working arrangements for teaching, research and outreach commitments and other interests. It is also more reassuring for families to see colleagues from the same practice should the need arise. More flexible working arrangements are considered to be necessary for work-life balance, particularly among

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female paediatricians. It is important to note that of the 40 paediatric residents at the University of Calgary, 31 (77.5%) are female and 9 (22.5%) are male. iii) Larger practices would be more conducive to attracting hospitalists to work part time in the community and facilitate transitioning their practice into the community over time. Some hospitalists expressed interest in working occasionally or part time in the community but felt that the present environment did not present this opportunity. iv) Larger practices offer greater economies of scale for more efficient operations and lower overhead costs. All paediatricians identified unused clinic space at various times throughout the work week. Ideally, physician scheduling based on a larger available pool that would draw from community paediatrician and hospitalist streams would optimize use of office space and reduce relative overhead costs. -

The ability to consult with other specialists and health disciplines in a timely manner (closer to real time) on behalf of their patients to ensure optimal patient care. This is important to build “communities of practice”. Examples include nurse practitioners, nurses, psychologists, dietitians, child psychiatrists, rehabilitation therapists.

-

The quality of the community training experience for medical students and paediatric residents is greatly compromised by the overall lack of sufficient paediatric exam room space, the absence of other health professionals and the lack of a coordinated placement function. Many paediatricians are unable to engage in teaching due to space restraints. Resident placement requires that the resident have access to an exam room. This will quickly become a critical issue as the number of medical students will increase from 150 in 2008 to 180 in 2009 and up to 240 students in the longer term. In response to this the number of paediatric resident placements across the sub-specialties and general paediatrics will also increase. Currently, there is no central coordination function to ensure the most appropriate placement of students and residents in community practices. The random and haphazard approach of leaving it up to the individual continues to frustrate many paediatricians.

-

All paediaticians highlighted the need to optimize business operating efficiencies.

-

Calgary based community paediatricians expressed mixed opinions on remuneration. Some are satisfied with current fee-for-service, others see the need for a blended model that recognizes time for teaching, research, inter-professional consultations and other activities that are not recognized by the fee-for-service-schedule.

6.3.2

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The paediatrician workforce shortage is even more dire in Chinook and David Thompson health regions where paediatrician/population ratios are 1:11,000 and 1:10,570 respectively. Paediatricians are stretched to the maximum in order meet hospital on-call and office practice responsibilities. They are actively seeking locum relief from outside jurisdictions with little success. They have identified the need for more support from the Universities of Calgary and Alberta for paediatric resident placements (e.g. Years 2 and 3) as one strategy to attract new recruits. This may require some flexible arrangement whereby residents with family would be able to return home for weekends, if desired. Larger urban centres could also assist with the assessment of Immigrant Medical Graduates candidates for location in southern Alberta centres upon completion. 6.4

Teaching & Research Paediatricians and paediatric residents felt that the teaching experience in the community is far from optimal. There is no consistent opportunity to develop skills in team approaches to care for complex and chronic disease management; consultative liaison with sub-specialists, system navigation, or patient/family health promotion education. There is no adequate experience offered on system processes and working interfaces across the continuum of care and across child care sectors or on the potential of telehealth applications and applicable information systems. In addition to medical students and paediatric residents, community practice settings could offer a rich and varied learning environment for students in potentially all other health professions. At this time there are no tangible supports for community research such as presence of a collaborative research network with the university or its affiliated research institutes or infrastructure for research design, data collection and analysis.

6.5

Challenges for Model Design All community paediaticians supported the concept of an integrated multidisciplinary model of paediatric care based in the community that will enable more timely and comprehensive patient assessments, create opportunities for inter-professional and intra-sectoral consultation and professional capacity building; facilitate more treatment and patient/family education in the community and create a vibrant environment for teaching students and residents in medicine and potentially other health disciplines and research. All community paediatricians also desire equal access to any enhancements or resources, regardless of their practice location, to avoid a two tier system of quality for their patients At this time not all paediatricians are interested in relocating their practices following conclusion of leases and others are not inclined to sell their buildings. The majority support larger group practices that include the co-location of other health disciplines, family medicine and potentially other interested paediatric sub-specialist (e.g. Psychiatry, Cardiology etc.) Others raised the possibility of connecting with other health disciplines

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and sub-specialists through purposefully designed virtual networks. These networks could also potentially link with Primary Care Networks. This option however, does not address the need for more space for student/resident teaching and does not replace some of the advantages of a larger group practice as previously described. Paediatricians are concerned about loss of autonomy associated with any governance structure that includes a non-member partner, e.g. health region. All identified the need to participate in the recruitment of staff and establishment of office functions. Hospitalists sought clarity regarding billing practices and contribution towards overhead costs, medical leadership, work flexibility and medical-legal issues. The vast majority of paediatricians identified a preference for working in the northwest and southwest quadrants. Informants from the allied health professions who are employed in ACH programs raised concerns regarding the feasibility of new resources to support Paediatric Centres in the community in view of chronic workforce shortages that exist across most disciplines. They also felt that a reallocation of staff from ACH programs was not realistic given existing wait times for tertiary/quaternary services. However, anecdotal opinion from a number of informants suggests that there may be some merit to review current assessment practices across some programs to minimize unnecessary duplication and excessive service. Real estate opportunities within the existing Calgary health care facility inventory are not available to support large physician group practices in the community. Plans are virtually completed for all pending health centres which are designed for public health and primary health care service delivery. Pending future funding there may be space at the Richmond Road Diagnostic & treatment Centre in phases 3 through 5 for primary care and other health services.

7.0

STRENGTHS & OPPORTUNITIES

There are a number of initiatives that will potentially enhance the delivery of paediatrician services in the community and there are also other community based programs and models that have been implemented in Calgary that offer a potential framework for action or opportunities for future collaboration. These are described as follows: 7.1 ¾

¾

Practice Enablers: 7.1.1 Technology The majority if not all community paediatricians will be supported by a common Electronic Medical Record technology within the next two years through support from the provincial Physician Office Support Program. The provincial government will cover 70% of the cost. Some community paediatricians have access to the health region’s network (Virtual Private Network) enabling direct access to patient X-ray data, SCM,

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Alberta Wellnet and all other secure region websites. A few paediatricians have access to the region’s computer systems by means of a secure sign in system and a key fob. ¾

Desktop videoconference technology is currently being installed in three paediatrician practices as test-sites as part of an Alberta Children’s Hospital Foundation project “Supporting Family Centered Care through Technology”. Learnings from the implementation will be used to determine future roll-out to other paediatrician offices across southern Alberta. Potential uses identified by paediatricians included: - case conference discharge planning on complex patients transitioning from ACH back to the community; - participation in mental health and child development case conferences; - participation in patient discussions with Child & Family Services Authority; - participation in team conferences involving representative of the child’s care team across sectors; - a scheduled consultative service with Paediatric Mental Health and/or Developmental specialties; - attendance at paediatric grand rounds, child & adolescent rounds, developmental paediatric/community paediatric rounds and other off-site educational opportunities. - observation and consultation of sub-specialist expertise for capacity building Broader implementation of the technology would enable greater opportunities for consultation among paediatricians across southern Alberta that requires observation or for didactic education to fulfill CME requirements. 7.1.2 Patient Access Improvement Initiatives In Calgary, The Department of Medicine’s Innovation Fund has supported the development of a single flexible Standard Referral Form to improve the referral process between family physicians and involved specialties (the Medical Access Service Project). This new process effectively replaces many existing separate forms and increases the ease of making referrals for family physicians while ensuring that specialties get the minimum information they require to adequately triage patient referrals. To date the Departments of Medicine, Family Medicine, Cardiac Sciences, Rural Medicine, Psychiatry and the Tom Baker Cancer Centre have participated in the Project. The Project has successfully reduced wait times for more urgent patients, improved the accuracy of referral information and enhanced communication among specialists and urban and rural primary care physicians. The Department of Paediatrics is currently considering participating in this initiative. This should be extended to include community paediatricians. Funding will be required for a part time (e.g. 0.1 FTE) Project Coordinator to work with all paediatric clinics, the Medical Access Service Project Team.

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The Alberta Access Improvement Measures Project (AIM) is a provincial8 initiative that assists community based physicians (family physicians and specialists) and their teams focus on access, efficiency and clinical care improvements. Participants are introduced to an improvement process and a set of principles that effectively reduces or eliminates wait times and delays for patients and physician clinics. Physicians and their teams participate in six collaborative learning sessions (11 days over 13 months) on strategies to: o improve access/reduce appointment delays; o improve the efficiency of the operational/office team (ensuring teams members optimize their capabilities (determining the right team); o improve the effectiveness of the clinical team (explore the planned care model and how to improve clinical care); o improve clinical outcomes (impact of the above changes) o sustain the change (maintaining momentum; sustaining the improvement Community clinics establish service agreements with referring physicians that identify the range of services that will be provided and when the patient will be returned to the referring physician (e.g. defines/clarifies the scope of service). Service agreements also identify any specific area of patient interest/specialty in order that primary care physicians can make the most informed/appropriate and efficient referral. Physicians and clinics learn to track outcome measures on a routine basis in order to assess real change in service/practice. Identified project goals include: o improved access o improved efficiency o improved clinical care outcomes o improved patient satisfaction o improved clinician and staff satisfaction o decreased cost Physicians and their teams receive assistance on designing, implementing, measuring results and sustaining action plans to improve the efficiency and effectiveness of their office/clinic operations. Compensation of participating family physicians and their team members has been covered by the Primary Care Network initiative. 7.1.3 Southern Alberta Child and Youth Health Network(SACYHN) SACYHN is a dynamic voluntary collaboration among individuals and organizations concerned with the health and well being of all children, youth and families. It was formed in 2001 and membership includes parents, regional authorities, ministries and provincial agencies, universities and the not-for-profit sector. The membership’s vision is for optimal health and well-being for children, youth and families through the Network’s collective strengths (expertise and resources). SACYHN continues to promote and advance the health and wellbeing of children, youth and families through a variety of initiatives and programs including Outreach services (for care close to home), Family Resource Centre, 8

Involves Alberta Health and Wellness, Alberta Health Services, Primary Care Initiative, Toward Optimized Practice, and the Alberta Medical Association.

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Child and Youth Advisory Council, Whole School Mental Health initiative, Children with Complex Needs Program and Health Promotion initiatives such as the Prevention of Childhood Obesity. SACYHN can provide community paediatricians a unique and valuable connection to other child/youth service organizations and partners to plan and implement services/initiatives in the community that will benefit child health and well-being across the system. 7.1.4 Paediatric Community Service Models The Community Paediatric Asthma Service which partners certified asthma educators (CAE) with family physicians and paediatricians was designed and implemented in 2005 to provide education and follow-up to children with asthma and their families in their physician’s offices or community clinics located in each of the city’s quadrants. In addition to helping patients manage their asthma more successfully, the model enables real time consultation and problem solving with the patient’s physician. This service delivery model could be used for other service applications depending on projected requirements across paediatrician practices. The Community Paediatric Dietitian Service currently employs a total of 1.5 FTEs registered dietitians at ACH, South Calgary Health Centre and two community centres in the NW and NE quadrants to provide patient assessment and counseling for children and adolescents for concerns regarding growth, adequate nutritional intake or infant feeding. Referrals are broadly accepted from all health professionals. Wait times on average are four to six weeks. 7.2

Other Community Based Programs Multi-disciplinary teams currently deliver primary care and chronic care management services to adults and seniors in the community. 7.2.1

Primary Care Networks (PCNs)

The provincial Primary Care Initiative9 involves the formation of a joint venture between a not-for-profit company of participating family physicians and the local health region to improve the delivery of primary care across Alberta. PCNs aim to improve the delivery of primary health care services through: o Integration (a group of physicians and the RHA deliver specific primary care services) o Capacity (increase the use of existing resources and facilities) o Access (improve patient entry into the system) o Innovation (find new and improved ways to provide health care to the patient population) Key business plan objectives include: increased access to primary care services; increased emphasis on health promotion and disease/harm prevention; care of medically complex patients and patients with chronic diseases; improved

9

PCNs originated as a result of a Master Agreement (2003) between the Alberta Medical Association, Alberta Health and Wellness and provincial regional health authorities.

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integration and coordination across the health care service continuum; and greater use of multi-disciplinary teams. PCNs provide a broad range of direct health care services to patients (e.g. basic ambulatory care and follow-up, care of complex problems and follow-up, psychological counseling, screening/chronic disease prevention, family planning/pregnancy counseling, well-child care, obstetrical care, palliative care, geriatric care, care of chronically ill patients, minor surgery, primary in-patient care in hospitals and long term care facilities, rehabilitative care, information management and population health). Other services are provided through special linkages with PCNs. These include: 24/7 management of access to appropriate health care; access to laboratory and diagnostic imaging; coordination of home care, coordination of emergency room services, coordination of long term care, coordination of secondary care, coordination of public health and the provision of services for unattached patients. Actual services depend on the determined primary care priorities of the local community. Each PCN has a business plan that addresses specific requirements by the government: participants, service delivery plan, legal provisions, governance, organizational structure, risk assessment, a three-year operational plan, a financial plan and a communications plan. The province’s Primary Care Initiative provides funding for Change Management (business planning and preparations for operations); Per Capita Grants based on the patient population in the PCN area and Capacity Building Grants may also be paid based on the PCN’s efforts to increase the number of patients seen per year. Outcome evaluation is a condition of the arrangement. Funding for specialist services is also available (e.g. Specialist Linkages) as a capacity building opportunity. There are seven PCNs in the Calgary Health Region catchment area. Approximately 70% of family physicians in the Calgary region are participating (S. Crichton, personal communications, February, 2009). These are: (1)

Calgary Rural Primary Care Network (2006) - (101 physician members in 23+ clinics).

(2)

South Calgary Primary Care Network (2006) (72 physicians in 20 clinics and 22.0 FTE staff. The network is bounded by Anderson Road, Deerfoot Trail and 114 Ave. S, east by 52nd St., west by 37th St. W and south by the City of Calgary boundary.

(3)

Calgary Foothills Primary Care Network (2006) (110 physicians in NW Calgary and Cochrane).

(4)

Calgary West Central Primary Care Network (2006) (about 215 physicians in Calgary West Central area).

(5)

Highland Primary Care Network (2007) (25 physicians in 10 clinics

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serving 22,800 in Airdrie, Balzac, Beiseker, Carstairs, Cremona, Crossfield, Didsbury, Irricana, Kathryn, Madden). (6)

Mosaic Primary Care Network (2008) (75 physicians in 31 clinics) in Northeast Calgary.

(7)

Bow Valley Primary Care Network will soon go live. It will be comprised of 29 physicians and will implement programs to increase physician capacity and serve the needs of the Bow Corridor population.

To date, PCNs have largely focused on adult health needs including chronic disease management, mental health, low risk obstetrics clinics (through a specialist linkage with an Ob-Gyn specialist) and senior’s health. They are supported by varied teams of health professionals (e.g. nurses, social workers, dietitians, kinesiologists, psychologists, nurse practitioners, pharmacists, behavioral health consultants, physical therapists) based on the health needs of the catchment population. Other supports can include: -

-

-

Primary Care Coordinators to improve patient flow and work efficiency. Discharge Coordinators responsible for coordinating and transferring patient information and scheduling follow-up appointments with family physicians for attached and unattached patients. Office supports and Information Management and Technology to improve office efficiency, improve accuracy of patient information and improve the referral process. PCN Navigators to link patients with appropriate services across the system.

There are a few paediatric initiatives underway or in planning including: two weekly paediatric clinics in the Okotoks Health and Wellness Centre for child development (run by paediatricians) (a Calgary Rural PCN initiative); Childhood Obesity Prevention (South Calgary PCN), and preliminary plans for Childhood Obesity Prevention and potential telephone consultations with a Paediatrician through a specialist linkage arrangement (Mosaic PCN). Several of the PCNs are now refreshing their three year business plans. Master Agreements will be reviewed in 2011 and renewal will depend on evaluation results and outcomes regarding integration, capacity, access, and innovation. There may be some future opportunities for linkages with community paediatricians across all PCNs in the future. Examples of services might include: telephone paediatric consultations for attached and unattached patients, specific paediatric mental health consults for ADHD or other behavioral/learning issues, shared care/capacity building on normal child development clinical pathways, or shared care strategies for children who require complex or chronic disease/disorder management to ensure ongoing engagement of the family physician the child’s care and effective transitioning of care upon graduation to adulthood. 7.2.2 Health Care Centres: Offer a range of primary care, urgent care and public health (including immunization and well-child clinics) programs and

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services across the health region as listed below. There may be potential opportunities at Sheldon M Chumir Centre, East Calgary Health Centre and South Calgary Health Centre for integration with community paediatrician services through specialist linkages to support co-located PCN services at those centres clinics. - Sheldon M Chumir Health Centre - South Calgary Health Centre - East Calgary Health Centre (proposed for construction) - Cochrane Community Health Centre - Airdrie Community Health Centre - Okotoks Health & Wellness Centre - Richmond Road Diagnostic & Treatment Centre 7.2.3 Chronic Disease Management in Adults: The Chronic Disease Management Program was implemented in Calgary 2002 for adults and seniors with various chronic illnesses. The program continues to evolve and improve through initiatives that: -

-

Provide chronic disease nursing support to PCN family physicians Increase family physician access to specialty clinic staff for high risk/complex patients Improves provider communication and monitoring of care across the continuum by means of an electronic Chronic Disease Management Information System; Provides self-management and personal support programs to patients in community facilities.

Recent program additions include: Transitioning Adolescents with a Chronic Condition. The CDM Program and the Adolescent Transition Program will offer a Living Well Program for adolescents and chronic disease nurses in family physician offices. The Living Well Program is now piloting the Row Your Own Boat Self-management program to adolescents (aged 15 to 25 years) in Edmonton and Calgary. The program is also being offered to parents of youth with chronic conditions as a pilot in Calgary. Complex Chronic Disease Management Clinic: The CCDMC was launched in March 2008 at the Peter Lougheed Hospital to decrease exacerbations of chronic conditions and readmissions through intensive disease management by hospitalists, internists and family physicians. The goal is to provide integrated care for patients with multiple co-morbidities and other special needs. Patients are also assessed and treated by an interdisciplinary team including nurses, pharmacists, physical therapists, respiratory therapists, social workers and dietitians. In 2009 it is anticipated that complex clinics will be established in community settings for referral by family physicians and other community care providers. There is work underway to expand this program to include transitioning adolescents aged 15-25 years who have complex medical and mental health issues. A paediatrician who specializes in Adolescent Medicine and a clinical nurse specialist will augment the Clinic. Youth Health Program at the Child Development Centre: This program provides consultation services to health providers working with youth with complex

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medical issues. The program targets youth aged 11 years and older who have a chronic medical illness and adherence to treatment problems, special health care needs, complex undiagnosed conditions, adolescents with interpersonal or family crises, challenged by health risk behaviors or may have dropped out of the school system and wish to reintegrate. The program also facilitates transitioning from the paediatric to the adult health care delivery system. 7.2.4 Healthy Living, Public Health: The health region’s Healthy Living portfolio is responsible for population health promotion. It produces various evidence-based health promotion tools and resources and education services in the areas of injury prevention, parenting, mental health promotion, childhood obesity /healthy growth, and other areas that target healthy behaviors in children and parents. These resources have recently been disseminated to PCN physician members. Community paediatricians should be another key stakeholder group included in planning future child health promotion initiatives. 7.3

Private Real Estate Opportunities: LifeMark Health, Canada’s largest full service provider of integrated rehabilitation services and patient care products currently operates 16 facilities in communities across Calgary. The organization has potential real estate opportunity to provide clinic space for group practices through a rental agreement. Other services including appointment scheduling could be arranged if desired. Aetes Health Care, a division of CBI Health is a privately owned Canadian company with head offices in Calgary. The company has been providing Home Health Care support services and child and family services since 1971. It is an accredited member of the Alberta Association for Children and Families. Child and family services include home care, services for persons with developmental disabilities, child care, foster care, transportation, parenting skills education and support. It has operations in Alberta, Ontario and most recently in British Columbia. Aetes could potentially offer more of a turn-key operation that would include facilities and an interdisciplinary health care team working with paediatricians to support the health care needs of children and their families in the community.

8.0

CONCLUSIONS & RECOMMENDATIONS 8.1

CONCLUSIONS

(1) Approximately 34 new FTEs of community paediatricians will be required over the next eight years in Calgary for replacement and projected growth in response to paediatric population growth expectations, an evolving paediatric patient profile (more infants with congenital anomalies/complex medical system issues, mental and behavioral health issues, impacts of unhealthy lifestyle choices) and the significant increase in the number of medical students in family medicine and paediatric residents planned by the Faculty of Medicine, University of Calgary. (2) Both Lethbridge and Red Deer require 2 new general paediatrician recruits at this time based on paediatrician/paediatric population ratios and projected paediatric population growth rates to ensure timely access in the community and ensure safe

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coverage for regional hospital paediatric services (e.g. newborn, emergency, and inpatient). (3) Community Paediatrics in Calgary does not have a clearly established identity in the broader system. Over the past decade the roles of community paediatricians have evolved out of necessity in reaction to the needs of the tertiary care system (e.g. the implementation of the Hospitalist model, creation of Urgent Response rosters etc) rather than developing to support the health needs of children and families in the community. (4) The service delivery model for child and youth health services in Calgary is presently not designed nor resourced to deliver the right care in the right place at the right time. As a result a significant number of children are being seen in tertiary level clinics at ACH for ailments that are more appropriately attended to in the community by adequately resourced paediatricians. Parents and paediatricians experience disconnects between community and hospital services in terms of information flow and potential for duplication of assessment. Responsibilities for well child care involving family physicians and community paediatricians is unclear and inconsistent. Implications include the need for clear delineation of scope of service, improved referral processes, the development of tools (e.g. clinical protocols and pathways) to ensure standard and consistent practice across the care continuum, and improved access to allied health care professionals either through co-location in community settings or through a network that supports improved access, information flow and communication. (5) A community practice model that promotes more real-time collaboration and consultation with colleagues and other health discipline professionals; provide a more stimulating teaching experience for students and residents; enable work-life balance and greater flexibility to pursue teaching and education opportunities, research and skill development in specific areas of interest; and optimize business efficiencies will be required to attract new and retain current community paediatricians. (6) The evolving paediatric patient profile calls for communities of practice in paediatric care that supports responsive delivery of multi-disciplinary care ; incorporates strategies for capacity building among family physicians and paediatricians; creates opportunities for more universal and targeted health promotion strategies; and coordinates family support across the system. (7) While province-wide initiatives such as the Primary Care Network initiative have been implemented to ultimately improve patient access to family physicians in all Alberta communities there has been no corresponding provincial strategy or designated funding to improve capacity or access to community paediatrician services. 8.2

RECOMMENDATIONS

(1) Develop and implement a new model of community practice in paediatric care in Calgary that:

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¾

provides comprehensive paediatric secondary level (consultant) assessment and ongoing management of children with complex developmental, multiple system and mental health problems in the community based on family-centered care principles based in the community

¾

advocates for child healthcare needs, particularly for those infants, children and youth who are medically vulnerable.

¾

promotes collaboration and integration across the child and youth care continuum to ensure earlier health problem identification and intervention and successful transitioning to primary care service providers;

¾ ¾

supports families of children and youth with complex health problems provides medical students and residents with a rich and comprehensive learning experience in community based paediatric care that includes but is not limited to health promotion/population health, early childhood development, prevention of injury and maltreatment, child advocacy and culturally appropriate approaches, working as a member of a multi-disciplinary team in the community

¾

supports more innovative group office settings in response to the need for more dynamic, flexible and cost efficient paediatrician practice arrangements

¾

builds knowledge and understanding of paediatric care through community physician capacity building initiatives and participation in community based research

(2)

Evaluate the new model of community practice in paediatric care to determine potential for broader replication in the province.

(3)

Develop and implement strategies in the short term that increase paediatrician capacity across southern Alberta including expanded use of technology for consultations and education, more support for International Medical Graduate assessments from large urban centres including Calgary, and implement mandatory paediatric residency placements in smaller urban and rural centres.

BUSINESS PLAN FOR NEW MODEL OF COMMUNITY PAEDIATRIC CARE 9.1

VISION

Consistent with Alberta Health Services’ Mission to provide a patient-focused health system that is accessible and sustainable to all Albertans, the Calgary Division of Community Paediatrics proposes to create and sustain a model of community paediatric care guided by the following: Vision: To create “communities of practice in paediatric care” that deliver integrated comprehensive care to children, youth and their families in the community. Mission: To improve access to and coordination of child health care in Calgary communities by community paediatricians and allied health

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professionals who specialize in child development and complex health care management. Goals: 1. Children, youth and families receive timely, appropriate and consistent child health care services based in the community. 2.

Care will be provided by a team of Paediatric health care professionals through coordination, collaboration and consultation.

3.

To deliver seamless and integrated care across the child health

continuum: (primary care ↔ community paediatric care ↔ ACH tertiary/quaternary paediatric care) through consistently applied standards of practice, patient referral/transitioning processes and system navigation support.

4.

To build and retain a sufficient supply of community paediatricians through the creation of attractive practice arrangements that enable flexible work schedules, work -life balance and collaborative interprofessional practice.

5.

To serve a key role in advocating on behalf of all children and youth, and particularly the vulnerable including those at risk for poor health outcomes.

6.

To build system capacity in the area of child and youth health care though purposeful linkages and collaborative initiatives with family physicians, public health, school health, population health promotion, child and family services and tertiary child heath care providers.

7.

To provide a rich teaching environment and experience for future community paediatricians and family physicians, and potentially other students in the paediatric health care professions.

8.

To participate in research opportunities to advance knowledge in child health care and improve practice in community paediatrics.

Guiding Principles: ¾

Community paediatricians will continue to independently operate and manage their practices in the community.

¾

Collaboration, transparency and respect will underpin all planning and implementation activities.

¾

Care will be promoted and delivered within the context of the child’s family, school and community environments.

¾

Care will be centered around the needs of the child and family.

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¾

Parents/guardians will be empowered through health promotion education and anticipatory guidance.

¾

Technology including electronic health record, telehealth, and information storage/retrieval technology will be promoted and consistently employed to ensure optimal patient/family care.

¾

Clinical practice and health promotion interventions will be based on the best available evidence and comply with national and provincial adopted guidelines, positions and consensus statements.

¾

Implementation of effective and efficient information transfer and communication at all interfaces of the child’s care continuum will be emphasized.

¾

Community paediatricians will be encouraged and have the opportunity to participate in a broad spectrum of issues and initiatives involving child/youth health and well-being.

9.2

Assumptions

The identification and implementation of specific strategies and initiatives are based on the following assumptions: (1)

Where appropriate and possible, existing regional and provincial initiatives will be used to leverage changes in community paediatric practice. This will reduce/eliminate unnecessary duplication of effort and additional expenditure. More importantly, this will also help to standardize processes and practices across the system, ensuring better outcomes for patients, their families and community health care team members.

(2)

Implementation of service changes will be reasonably gradual to allow for evaluation to inform and ensure successful changes.

(3)

Successful implementation and adoption of new service delivery structures and processes will require special attention to change management supports and strategies.

(4)

As learned from other practice change models (e.g. Primary Care Network Initiative), participation by 100% of community paediatricians in all initiatives can not be reasonably assumed, at least over the short term. As benefits are realized over time, it is anticipated that more community paediatricians will join.

(5)

The physical co-location of allied health professionals in community paediatrician group practices (the formation of community paediatric practice teams) will be reviewed and considered following the implementation and evaluation of changes in paediatric service referral/access processes.

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(6)

The Department of Paediatrics and the University of Calgary, Faculty of Medicine will proactively collaborate on developing and implementing strategies that improve the coordination of student/resident placements in the community.

(7)

The ACH Quality Improvement Team will track paediatrician patient referrals over time by service and discipline and monitor productivity workload measures in order to accurately inform the need for additional paediatric allied health professional resources to support community paediatricians.

9.3

Strategic Directions

Over the next several years the Division of Community Paediatrics with the support of partners including Child Health Alberta Health Services (Calgary Health Region), the Alberta Medical Association, The University of Calgary, Faculty of Medicine and provincial initiatives including the Medical Access Project and Alberta Access Improvement Program will engage in the following strategies and initiatives towards the establishment of communities of paediatric practice in Calgary. 9.3.1

Improve Patient Access to Community Paediatricians

Several strategies will be implemented over the short term in order to ensure that paediatric patients and their families are seen by the paediatrician in the community at the most appropriate time. These strategies include: (1) Development and adoption of a new scope of community paediatric service that emphasizes secondary level and consultative paediatric health care. The following scope of service has been tabled with the Division’s membership for ratification. This scope more effectively complements well child health care provided by family physicians; recognizes the need for ongoing communication and or interaction with primary care providers that will ultimately result in smoother transition at the time of adulthood; and will optimize community paediatrician knowledge and skill-sets in child development assessment, treatment and advocacy roles. It also serves to ensure more consistent practice among paediatricians, which is important to parents, families and other healthcare providers across the child health continuum. Proposed Scope of Service: Calgary Community Paediatric Care Centres will: ¾

Provide comprehensive secondary level care to children and adolescents from birth to eighteen years, and occasionally for developmentally delayed youth over the age of 18 years depending on the nature of their health circumstances. Care will be provided by community paediatricians supported by a network of allied health professionals specifically trained in paediatric/adolescent health care.

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Patients will receive their ongoing primary care from their family physician. Specifically, paediatric care centres will: - Provide comprehensive assessment, diagnosis and treatment of a broad range of physical, developmental, behavioral, mental and social problems which can affect infants, children and adolescents; - Manage the ongoing health care of children/youth with complex and/or acute or chronic multi-system/multi-organ health problems. This includes periodic assessment of personal, family and social complications; patient and family-centered care planning; instructions on self-management strategies; and support with end-of-life care; - Oversee the health and development of newborn infants presenting with a broad variety of serious health problems (e.g. significant pre-maturity, respiratory distress, malformation or congenital anomaly); - Manage and/or coordinate mental health and behavioral disorders (including evaluation and diagnosis, patient and family counseling, treatment options, consultation/referral to other child development and mental health specialists and resources when indicated); - Promote healthy lifestyles through individualized or group child/family education where appropriate and life skill development and evaluation; - Coordinate patient/family care needs across the community (including health, school and Child & Family Services) with the assistance of a system navigator; - Provide consulting services to family physicians, Paediatric Home Care health care providers and other child health and service providers in the community; - Manage urgent and non-urgent referrals from ACH Clinics and Calgary hospital emergency departments. - Refer to tertiary/quaternary health services and paediatric sub-specialists when indicated; - Transition the management of care to adult services in a timely manner for patient and family and through close collaboration with the patient’s family physician. Patient referral will be required. ¾

Teach medical students, Paediatric Residents, Family Medicine Residents and other disciplines on the delivery of child and adolescent health in a community setting.

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¾

Advocate for system improvements in child and adolescent health through collaboration with other child and youth service providers including health, education, Child & Family Services and their respective government ministries.

¾

Engage in relevant community based research that is supported and funded by the Canadian Society of Paediatricians, the University of Calgary, Mount Royal College, Southern Alberta Institute of Technology or other Canadian research institute. Communication of this scope of service will be incorporated into the Medical Access Project directory described below. This will ensure broad dissemination (2) Participation through the Department of Paediatrics in the Medical Access Project The Department of Paediatrics will participate in the Medical Access Service Project (Department of Medicine). This will effectively produce a single, standard flexible referral process and form and a central access and triage service for the referral of children across the health system. This should ultimately reduce waiting times and promote more effective use of clinic office personnel. Referral information requirements will be standardized across all paediatric subspecialties, including community paediatrics. This process should include all paediatric, child development and child and adolescent mental health service areas. Community paediatricians will be able to refer patients to ACH clinics and programs for more specific requests (e.g. assessment by a particular allied health professional, 2nd opinion of a physician, confirmation of a diagnosis, recommendation for treatment/management, telephone consultation, patient education etc.) This should reduce unnecessary duplication of physician assessments or unnecessary team assessments and improve wait times. Paediatric sub-specialists at ACH will be able to refer patients directly to community paediatricians for preliminary paediatric assessment and follow-up, provided that community paediatricians in turn have timely access to other allied health professionals for assessment, treatment and education as indicated. This should reduce wait times for tertiary services at ACH, most notably in Neurology, Gastro-enterology and Nephrology. It is anticipated that the Department of Paediatrics will provide funds for a parttime Project Coordinator (e.g. 0.1FTE) to facilitate the identification and collection of information for the duration of the project. (3) Participation in the Alberta AIM Program Community paediatrician representatives initially from two group practices and their office staff will participate in the Alberta AIM Program in order to identify and implement specific strategies that improve patient access to community paediatricians through more efficient office practices and better use of all office personnel. The program should also help inform whether follow-up care is required by a Paediatrician or can be safely delivered by the patient’s family physician.

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It is anticipated that more timely access to community paediatrician services will likely result in fewer non-urgent and potentially urgent visits to the emergency department, and consequently eliminate the need for the current urgent patient roster among paediatricians. Funding will be required to compensate paediatricians and their staff for direct time attending six one-day learning sessions over a 13 month period. Project funds may be available to cover this. 9.3.2

Improve Community Practice Efficiencies and Effectiveness

Children and their families, community paediatricians and ultimately the system will benefit from the following proposed initiatives: (1) Formation of a Calgary Community Paediatrician Not-For-Profit Company Incorporate→Improve→Transform Calgary community paediatricians will have the opportunity to join a professional not-for-profit company (NPC) for an annual tax-deductible eligible fee. The company will be managed by a Board of Directors comprised of NPC physician members. Similar to other Alberta Medical Association Practice Management Program models 10 (e.g. currently used by Primary Care Networks), NPC physician members will:

10

-

Retain control over decision-making with respect to individual patient care and services provided in their clinics;

-

The Physician NPC Board of Directors will be responsible for the day to day operations of the company;

-

The Physician NPC is an entity created in addition to current relationships, and therefore, current working relationships should not be impacted by the Physician NPC, e.g. partnerships and/or relationships within current physician offices are not impacted with the formation of an NPC.

-

The Physician NPC can: o carry forward a percentage of its revenue (total billings) as an operating reserve, therefore the surplus is not taxable to physician members o purchase assets with no accrued benefit or tax liability being allocated to the participating physician members of the NPC

-

The Physician NPC is responsible for entering into contracts with third parties to enable the membership to provide services detailed in the business plan;

Taken from the Discussion paper, Practice Management Program…working with physicians, for physicians. November, 2005.

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-

Physicians will be protected from liability arising from contracts between Physician NPC and third parties by a statutory corporate shield;

-

Fiduciary duties create a responsibility on the part of each physician who sits on the Physician NPC Board of Directors to act in the best interest of the physician NPC.

-

Articles of Association of Physician NPC will establish the procedure for becoming a participating physician.

A Service Agreement will establish termination provisions for service contracts. Membership will offer the following opportunities and benefits: -

A net reduction in overhead costs through the sharing of support staff costs (e.g. Office Receptionist, Billing Clerk, Business Manager) across a larger employer pool;

-

Enable the hire of new support personnel through annual membership fees and cost savings achieved in other areas, e.g. IT support for ongoing maintenance and linkage of EMR with other information systems in the health region and province;

-

Create a casual staff pool for more flexible coverage;

-

Lower supply and maintenance contract costs through volume purchasing;

-

Increase work flexibility among paediatricians;

-

Ensure greater consistency and efficiencies in business and billing practices;

Patients, Paediatric Residents/Students and the System will benefit from: -

Greater likelihood of attracting ACH hospitalists and graduating paediatric residents to work in the community;

-

Potentially a single point of contact for patient referrals, arranging teaching preceptorships, researchers, and other child service representatives.

-

A larger pool for student/resident/clinical clerk placements including Longitudinal Clinic experience.

-

Better resourced paediatricians.

(2) Practice Consolidation

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Commencing in 2010/11 there will be an opportunity for approximately eight (8) paediatricians whose leases expire to potentially join forces with new community paediatrician recruits (Hospitalists and/or recent graduates) to form larger group practices in the northwest quadrant, near the UCMC campus and in the northeast quadrant. This will enable greater work flexibility among the group, reduce individual overhead costs, provide mentoring of new recruits, and ensure uninterrupted patient coverage. This arrangement should also provide a more equitable allocation of overhead costs among physicians based on actual clinic attendance (e.g. you pay for the time you use the facility). A larger patient setting will also provide a larger base for teaching and research opportunities. In 2012/13 other paediatrician practices will be able to consider consolidation. Eventually it is hoped that large group practices of 10 or more community paediatricians will replace most solo and dual practices in Calgary. Larger practices will also have the advantage of providing a critical mass of patients necessary for the effective co-location or planned visitation by other allied child health professionals, also in short supply. The Physician Office System Program will also facilitate easier practice consolidation across practices, as paediatricians will likely opt to install electronic health record products from the same vendor. The POSP Program will continue to support paediatricians with limited IT support following system installation and connectivity. Together the Medical Access Service Project and the upcoming Electronic Medical Record should greatly enhance and standardize communication across family physicians, community paediatricians and paediatric sub-specialists at the Alberta Children’s Hospital. (3) Participation in the Alberta AIM Program Participation in the Alberta AIM Program commencing in the Fall of 2009 will provide community paediatricians with strategies to optimize effective and efficient use of all office personnel both professional and non-professional. 9.3.3 Creation of Integrated Multi-disciplinary Care Teams Over the next 12 months, implementation of an improved referral and central access/triage process involving all paediatric programs should reduce wait times for patients referred by community paediatricians for assessment and treatment by sub-specialists and allied health professionals in child health (e.g. dietitians, rehabilitation therapists, psychologists) at ACH. Referral patterns and workload measures will be monitored to determine actual service demands by discipline and service type (e.g. assessment, diagnosis, treatment, education) and to identify any other issues or barriers that may impact the delivery of care in a timely manner. Within the next 18-24 months, as more community paediatrician group practices consolidate, consideration will be given to co-locate or arrange planned clinic visits by allied health professionals employed by Child Health, AHS for specific services based on identified utilization patterns.

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It is envisioned that over the next three or four years, these larger group practices will be able to efficiently and reasonably support the co-location or visitation of allied child health professionals (e.g. dietitians, rehabilitation therapists, psychologists) as demonstrated by patient referral patterns. Consideration should be given to the recruitment of a Paediatric Nurse Practitioner registered in the child stream of practice (as per the College & Association of Registered Nurses of Alberta- Nurse Practitioner Competencies, September 2005) to extend paediatric health care capacity in the community. Potential roles could include: (1)

Neonatal Care providing close and consistent assessment/monitoring of premature/low birth weight infants over the first 12-18 months following delivery and monitoring newborns and/or provide well baby follow-up care in hospital of unassigned infants following delivery. The latter alone would potentially free up over 5000 community paediatrician hours in a year.

(2)

Health Promotion and Prevention of Illness, Injury and Complications. This individual could work closely with family physicians and families in the Northeast Calgary quadrant providing culturally and evidence based screening and education for populations at risk and population based harm-reduction strategies.

(3)

Child behavior assessment and management. Given the significant number of referrals of children presenting with behavior or learning problems, this could be another important area for consultation with physicians, psychiatrists, pharmacists and school liaisons on behalf of the child and family.

The incumbent would be hired by and responsible to the Department of Paediatrics. He (she) could also have student placement teaching responsibilities to support the University of Alberta Nurse Practitioner program and participate in community child health research. 9.3.4 Health Promotion & Primary Chronic Disease/Harm Prevention Community paediatrician clinics present a unique setting for health promotion and chronic disease/harm prevention targeting children and youth and their families/parent. As reported earlier, parents mostly seek guidance and advice regarding health matters from their paediatricians and family physicians. However, today this “teaching moment” remains relatively untapped with the exception of child asthma education. (1) The Healthy Living portfolio has expressed interest in planning and others as appropriate to create an innovative opportunity for health promotion in the doctor’s office or other community based setting. Topics could include healthy parenting education; healthy child/youth weight promotion, healthy feeding relationship, adolescent sexual health promotion, healthy teen pregnancy, child injury prevention and potentially many others that affect children with complex health and care needs. The scope of this service could potentially include health

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risk screening measures in addition to education. User friendly tools for paediatricians, children/youth and parents/guardians and public health nurse educator resources would be provided through the Healthy Living Portfolio for the duration of the Pilot. Thereafter, continuation or expansion of the program would depend on program evaluation results. (2) The Southern Alberta Child and Youth Health Network’s Family Resource Centre is another important resource that will be consulted to address patient/family health education and support resource requirements in paediatrician offices. 9.3.5 Build Paediatric Care Capacity in the Community There are several initiatives that would build capacity in community child health. (1) Recruitment of a Paediatric Systems Navigator/Liaison This position would be responsible for assisting the families of children with complex health care needs to access or connect in a more timely and informed manner with appropriate child and adolescent programs and services in the community, education sector and Child & Family services. Families would be referred by Paediatrician offices. The Navigator would advocate on behalf of the family and also arrange for Diversity and Translation Services as indicated. The Navigator would complete or assist parents with the completion of necessary forms. A dedicated resource person for this activity will also ultimately help inform the system as to where the greatest needs and gaps exist for parents in the system. He/she could provide health care planners and health promotion educators valuable insights on what family/child resource/information needs and engagement strategies. (2) AIM & Medical Access Projects Both of these initiatives will create additional community paediatrician capacity in the system through improved referral and practice efficiencies and ensuring more appropriate use of paediatrician services for direct patient care. (3) Mental Health Training on Evidence –based Psychotherapies for Children and Adolescents A core group of interested community paediatricians will enroll and participate in the four day Accredited Continuing Medical Education CANREACH mental health training session on evidence-based psycho-therapies for children and adolescents with ADHD Disruptive Disorders, Depression, Anxiety and Post Traumatic Stress Disorders. Training will include the development of key skills on coping strategies, problem solving, parenting, family communication and cognitive restructuring. Paediatricians will receive direct support from expert psychiatrist educators over a minimum period of six months. Supports and tools are designed to complement the paediatrician’s typical patient routine encounter. This is the first comprehensive evidence-based practical strategy designed to mesh with the existing practice of community paediatricians. Furthermore the curriculum has been designed specifically for use in supporting community-based children's mental health. (4) Primary Care Network Specialist Linkages

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Both Foothills and Mosaic Primary Care Networks have expressed preliminary interest in establishing potential specialist linkages with community paediatricians in the near future that focus on identified paediatric health issues in NW and NE communities served by those two networks. 9.3.6 Medical Student and Resident Teaching Plans are underway to implement a mandatory residency rotation in centres outside of Calgary (e.g. Lethbridge, Medicine Hat, Red Deer) for second and third year Paediatric Residents. In Calgary, support is required to organize and coordinate all placements regarding Medical Students and Paediatric Residents, particularly given the increasing numbers that are planned by the University of Calgary. The University of Calgary, Faculty of Medicine should provide funding for a Paediatric Student/Resident Placement Coordinator to coordinate the placement of all medical students and residents seeking training experience in the community. This should include Calgary as well as other centres in Alberta. The Calgary Community Paediatrician Not-For Profit Company can potentially serve as the primary point of contact for arranging placements among its member paediatricians. The company will produce a roster of paediatricians that will provide placement opportunities including Longitudinal Clinic experience during the course of the year. Numbers should improve as more practices consolidate over time and secure larger premises. 9.3.7 Research At this time there is little capacity or opportunity for Calgary community paediatricians to engage in research. There is no infrastructure to support the collection of data or other research activities. In the future, the Electronic Medical Record will potentially provide a reliable source for patient data. In the meantime community based research study will require more proactive involvement and initiation from researchers (e.g. Research Institutes such as the Institute of Child and Maternal Research). 9.4

Budget 9.4.1 Assumptions: (1)

Year 1 commences in April, 2009.

(2)

Assessment of referrals to/demands on allied health professional services at ACH will be undertaken by the DSRT Program as part of its existing mandate and resource base.

(3)

All costs associated with the establishment and annual renewal of the Calgary Community Paediatrician Not-For-Profit Company will be assumed (100%) by physician members.

(4)

Costs associated with current community paediatrician practices (e.g. office/business management, reception/booking, billing, nursing office practice, HER Information Technology support, web-site development) will be included as paediatrician overhead costs.

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(5)

Funding sources for salaries of the Paediatric System Navigator and potentially co-located allied health disciplines in the future (e.g. Clinical Dietitian, Psychologist/Behavior Therapist, Rehab therapists etc.) required for assessment, treatment and patient/family education will need to be determined.

(6)

Partial leveraging of salaries (e.g. up to 0.2 FTE each) for the Paediatric Nurse Practitioner, Clinical Dietitian, Psychology and Rehabilitation Therapist positions may be reallocated from existing staffing levels following ACH workload reviews. This would reduce the proposed annual operating budget by $83,600.

(7)

Resource requirements are based on supporting the current paediatrician contingent (approximately 38 FTEs), the number of patient referrals and referral processes. Evaluation of actual referrals and system capacity in Year 1 will determine need to augment these resources.

(8)

Non-physician salaries include an annual 5% increase for inflation and benefits as per current contract.

(9)

The Department of Paediatrics/University of Calgary, Faculty of Medicine will assume costs for the arrangement and coordination of medical student/resident placements in community paediatrician offices.

(10)

Initiatives including AIM Project, EHR implementation, Medical Access Services Project, Health Promotion/Healthy Living Pilot will provide resources to support implementation.

(11)

The Physician Lead position currently funded by ARP funding (0.2 FTE) will continue through the fiscal year of 2009/10.

9.4.2 Projected Costs Cost Area Year 1 Year 2 Physician Lead, Model of Community Paediatric Care Paediatric System Navigator

FTE/$ 0.2 FTE

FTE/$

0.5 FTE $37,000

1.0 FTE $74,000

Laptop/office furnishings for Navigator AIM Physician/Team training costs

$3,500

Quality Improvement

$2,500

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$43,500

Year 3

Year 4

FTE/$

FTE/$

Notes 2009/10 Approved Physician ARP

1.0 FTE $74,000

1.0 FTE $74,000

Social Worker I or equivalent. Consistent with PCN rates/qualifications

Based on 2 physicians, 2 clerical/reception, 2 business managers, 2 nurses. NB: May be covered by AIM Project. Review of 3 month workload involving ACH Scheduler/data

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Cost Area

June, 2009

Year 1

Year 2

Year 3

Year 4

FTE/$

FTE/$

FTE/$

FTE/$

Notes

Workload Assessment Project Paediatric Nurse Practitioner

retriever and analysis by QI Coordinator 0.5 FTE $65,000

1.0 FTE $130,000

1.0 FTE(1) $130,000

This position may be augmented by NPs at PLC or SHC (e.g. half day clinic for newborns unattached to a family physician).

Laptop/furnishings Paediatric Clinical Dietitian

$3,500 0.5 FTE $43,000

0.5 FTE $43,000

0.5 FTE(1) $43,000

Paediatric Psychologist Paediatric Rehab Therapist

0.5 FTE $56,000 0.2 FTE $18,000

0.5 FTE $56,000 0.4 FTE $36,000

0.5 FTE(1) $56,000 0.4 FTE(1) $36,000

If required following evaluation. (May be augmented through existing Community Paediatrician capacity) If required following evaluation If required following evaluation (SLT, OT) Funding will be covered by Department of Paediatric (0.1 FTE Project Coordinator). Dissemination/communication and update of information will be funded by Medical Access Services Project. Assumes successful Pilot. Assumes teaching to 4 CPs. Includes 4 days of physician time. Funding will be provided through Healthy Living. Funding will be provided through SACYHN.

Redesign and implement new paediatric referral/triage service

CANREACH Mental Health Training Health Promotion Pilot Family Resource Centre Health Promotion materials Student/Resident Placement Coordinator Evaluation

sub-total Total

$66,000

$2000

$2000

$2000

$2000

0.2 FTE $12,000

0.2 FTE $12,000

0.2 FTE $12,000

0.2 FTE $12,000

$10,000

$10,000

$15,000

$110,500 $110,500

$349,500 $362,900

$368,000 $403,100

Part time position to be funded by University of Calgary, Faculty of Medicine. Evaluation design, data collection/analysis and reporting (DSRT)

$353,000(2) $405,650

Includes annual 5% inflation factor on salaries. (1) These positions may be reduced by up to 0.2FTE through leveraging from existing resource capacity. (2) Potential reduction of $83,600 through leveraging from existing staffing.

One time costs: Evaluation: Quality Improvement: Mental Health Training: AIM Training Costs:

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$35,000 $2,500 $66,000 $43,000

(DSRT in kind) (Quality Improvement in kind) (CME funding) (AIM Project Funding)

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Equipment/furnishings: sub-total:

June, 2009

$7,000 $153,500

Annual operating costs in Year 3+: $257,400- $341,000 (AHS) (excludes inflation) $12,000 (University of Calgary, Faculty of Medicine) 9.5

Implementation Plan The roll out of key implementation activities is anticipated as follows: Key Activity

Responsibility

Tentative Timeline

Calgary Community Paediatrician Business Incorporation Meet with legal counsel to review model Physician Lead, Model of April 09 option templates including benefits and Community Paediatric Care limitations of each. Provide presentation to Division of Physician Lead/Legal May 09 Community Paediatricians/determine interest counsel Select legal structure template. Physician lead to facilitate May 09 Define Terms of Agreement, legal or Physician lead/legal May 09-March 10 registered name of the NPC, entry/exit of counsel to facilitate physicians, termination provisions, GST status etc. Redesign and Implement System-wide Referral Process Recruit Project Coordinator To be determined. Apr 09 Consult with all paediatric sub-specialty clinic Project Coordinator/ April 09-July 09 teams & community paediatrics Physician Lead for Community Paediatricians Develop referral form and accompanying Project Coordinator/Project December 2009 information/eligibility requirements for each working teams paediatric sub-specialty and community paediatrics. Review and revise as necessary Launch new referral process/communication Project Manager, Medical January 2010 plan Access Service Project Evaluation of new process Project Manager, Medical spring 2010 Access Service Project Assess Interim Redirection of Referrals to CPs from Tertiary Clinics (GI, Neurology, Nephrology) Monitor waiting times for clinic visits ACH Outpatient QI team April 09- June 09 Monitor CP referrals for paediatric allied ACH Outpatient QI Team Apr-June 2009 health professionals (assess workload demands, patient wait times for service). Review, revise and reassess Sept-Nov 2009 Determine need & feasibility of relocation to Department of Commence in 2010 the community. Paediatrics/Division of (depends on progress of Community Paediatrics practice consolidation across the city). Implementation of Electronic Medical Record System in Community Paediatric Offices Establish CP Working Group & Review Physician Lead, Model of April 09 Committees Community Paediatric Care Identify high level business requirements Working group/POSP May 09 /technical requirements/work flow Project Mentor requirements Vendor evaluation based on specifications Working group/POSP Fall 2009 Project Mentor Develop detailed Implementation plan for Working group/POSP Fall 2009

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Key Activity paediatric pilot group Trial EMR vendor & select final vendor Implement (Install, train and test) Post Implementation activities (maintenance contracts, infrastructure & process documents) Access Improvement Measures Project Community paediatric team training/implementation (initial teams) Additional paediatric team training /implementation Health Promotion Pilot Project Present Healthy Living program opportunities to CPs at monthly meeting of CPs Consultation involving CPs and HL managers (Pre-school and school aged focus areas) to identify project priorities and strategies that target specific paediatric care populations and parents/families. Identify specific desired outcomes. Develop health promotion strategies as indicated by needs assessment Develop implementation plan

Implement strategies Develop evaluation framework

June, 2009

Responsibility Project Mentor Working group/POSP Project Mentor POSP Implementation Team POSP Operations team

Winter 2009 Fall- Winter 2010 Spring 2011

AIM Project Facilitator/2 CP Teams AIM Project Facilitator/ new CP Teams

October09-September 10

Healthy Living Director

May 09

Healthy Living Manager /Physician Lead Model of Community Paediatric Care

June 09

Healthy Living Manager

Summer 09

Healthy Living Manager /Physician Lead Model of Community Paediatric Care Healthy Living Manager/team Healthy Living Portfolio Evaluator

Fall 09

Identify ongoing health promotion plan based on evaluation results Medical Student/Resident Placement Coordination Collaborate with the University of Calgary, Physician Lead Model of Faculty of Medicine on development of a Community Paediatric position description and determination of Care/Head, Department of placement coordination process Paediatrics Recruit/implement position Allied Health Professionals Develop position description for Paediatric Physician Lead Model of System Navigator Community Paediatric Care & Rep (s) from Department of Paediatrics Recruit individual to commence winter 2009 To be determined. Develop position description for Paediatric Physician Lead Model of Nurse Practitioner Community Paediatric Care & Rep (s) from Department of Paediatrics Recruit individual to commence in Apr/10 Study referrals to allied health professionals ACH QI team by paediatricians including wait times to determine need for additional capacity. Confirm need & feasibility of relocation to the AHS-Child & Women’s

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Tentative Timeline

2010-2011

Fall 09 Fall 10

Summer 2009

Fall 2009 Fall 2009

Winter 2009 Fall 2009

April 2010 Winter 2009

Commence in 2010 (will

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Key Activity

June, 2009

Responsibility

community.

Health/Department of Paediatrics

Recruit additional resources or reallocate to community as identified. Evaluation Develop Evaluation Framework (including outcomes, indicators, data elements and processes for data collection)

Department of Paediatrics

Produce preliminary and final reports. Revise community paediatric model based on results

9.6

Physician Lead, Model of Community Paediatrics /DSRT Lead/Dept of Paediatrics Lead DSRT Department of Paediatrics/Division of Community Paediatrics

Tentative Timeline depend on progress of practice consolidation across the city). Commence in 2010.

Spring 2009

2010 and 2011. 2010 and 2011.

Measures of Success Anticipated key outcomes include: Short term (within 2 years): ¾ Reduced waiting times for patients to be seen by Community Paediatricians and ACH sub-specialists ¾ Reduction in number of urgent referrals to paediatricians. ¾ More efficient clinic processes. ¾ Increased proportion of paediatrician and allied health professional time for paediatric direct patient care. ¾ More cost efficient clinic practices for community paediatricians that enable the hire of other required practice supports, e.g. IT support etc. ¾ Improved continuity of care across health sector (primary, secondary, tertiary/quaternary) ¾ Increased patient, physician (family physician, community paediatrician, and paediatric sub-specialist) and student/resident satisfaction. ¾ More hospitalists choosing to provide coverage in the community ¾ Increased ability and confidence among community paediatricians to treat and manage children/youth with mental health problems (e.g. ADHD, anxiety, depression. ¾ Fewer referrals to Access Mental Health from paediatricians. ¾ Fewer emergency referrals for paediatric mental health related complications. ¾ Greater consistency of services across community paediatric care centres. ¾ Improved patient transitioning across the continuum of care (primary Mid Term (within 3-5 years) ¾ Over time, more paediatric residents choose to specialize in community paediatrics. ¾ Improved information flow across system following implementation of EMR. ¾ Attract new paediatricians to join the not-for-profit corporation. ¾ Begin to see a net increase in the total number of community paediatricians working in Calgary.

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10.0

June, 2009

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Burto OM. Community Access to Child Health (CATCH) Program: A model for supporting community paediatricians. Paediatrics. 2003, Sep; 112(3):735-37. Calgary Rockyview Student Health Partnership Program. Estimating unmet health needs for students in the Calgary Rockyview Student Health Partnership service delivery area. February, 2007. Canadian Association of Paediatric Health Centres, Canadian Paediatric Society, Health Canada, Paediatric Chairs of Canada, Public Health Agency of Canada, Society of Obstetricians and Gynecologists of Canada. Child health in the 21st century-the role of the paediatrician in an inter-professional environment. Conference Proceedings and Recommendations. November 17-18, 2006. Canada. Canadian Medical Association, Canadian Paediatric Society, College of Family Physicians of Canada (2007). Canada’s Child and Youth Health Charter. www.ourchildren.ca Canadian Paediatric Society. Planning a healthy future for Canada’s children and youth: Report of the 1999-2000 Paediatrician Resource Planning Survey. Ottawa: Canadian Paediatric Society, 2001. Canadian Pediatric Society. Position Statement (CPS 2009-01): A model of paediatrics: rethinking health care for children and youth. Paediatric Child Health. 2009; 14(5):319-325. Canadian Paediatric Society. Are we doing enough? A status report on Canadian public policy and child and youth health. 2nd edition. Ottawa: Canadian Paediatric Society, 2007. Chantler C. Paediatrics and the new National Health Service. Archives of Disease in Childhood. 1990; 65:357-60. College and Association of Registered Nurses of Alberta (CARNA). Nurse practitioner streams of Practice (2008) and Nurse Practitioner Competencies (2005). http://www.nurses.ab.ca College of Family Physicians of Canada, the Canadian Medical Association and the Royal College of Physicians and Surgeons. The 2004 National Physician Survey. Canadian Family Physician. 2006, March ;( 52):393-95. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, 2008. National Physicians Survey. http://www.nationalphysiciansurvey.ca/nps/home-e.asp Communities of Practice. http://en.wikipedia.org/wiki/communities-of-practice Cooper N., O’Connell P. and Wainer S. Calgary Community Paediatrics Diagnostic Survey. January 2009. Dicenso A. Roles, research and resilience: the evolution of advanced practice nursing. Canadian Nurse. 2008, Nov: 37-40. Didcock E, Polnay L. Pioneers, paediatricians and public health: the evolution of community child health services in Clifton, Nottingham- 1983-1999. Public Health. 2001: 115:412-17.

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Duggan A, Jarvis J, Derauf DC et al. The essential role of research in community paediatrics. Paediatrics. 2005, April; 115(4): 1195-1201. Ettelt S, Nolte E, Mays N et al. Healthcare outside hospitals: accessing generalist and specialist care in eight countries. 2006. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Feldman W, Milner R, Punthakee N. Canadian paediatricians: demographic characteristics, perceptions on training and continuing medical education. CMA Journal. 1980 ;( 123):185-89. Filler G and Piedboeuf B. Variability of paediatric academic workforce in Canada. Submitted for publication to Canadian Medical Association Journal. 2008 Fine A and Mayer R. Beyond referral: paediatric care linkages to improve developmental health. The Common Wealth Fund. Health Policy, Health Reform and Performance Improvement. 2006 Fletcher M. Collaborative Care: a necessary evolution. MD Pulse 2008:40-43. Garfunkel LC, Sideling DE, Rezet B et al. Achieving consensus on competency in community paediatrics. Paediatrics. 2005, April; 115(4):1167-71. Gill JM, Dary JA. Community paediatricians collaborate with hospitalists to build a ward service. Paediatric Annals. 2003, Dec; 32(12):791-96. Ginsburg KR. American Academy of Paediatrics Committee on Psychosocial Aspects of Child and Family Health. The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Paediatrics. 2007; 119(1):182-91. Goldfield S. Community paediatrics and children’s health: an idea whose time has come. Commentary. Journal of Paediatrics and Child Health 2006; 42: 309-10. Goodfriend M, Bryant T, Livingood W et al. A model for training paediatricians to expand mental health services in the community practice setting. Clinical Paediatrics. 2006 ;( 45):649-54. Goulston KJ and Dent OF. Trends in the specialist workforce in paediatrics in Australia: 198197. Journal of Paediatric Child Health. 2000; 36:306-12. Grant P, Skinner HG, Fleming LE et al. Influence of a structured encounter form on documentation for community paediatricians. Southern Medical Journal. 2002; 95(9):1026-31. Haggerty RJ. Child health 2000: new paediatrics in the changing environment of children’s needs in the 21st century. Paediatrics. 1995; 96(4): 804-12. Haggerty RJ and Aligne CA. Community paediatrics: the Rochester story. Paediatrics. 2005, April; 115(4):1136-38. Halfon N, DuPlessis H, Inkela S. Transforming the US child health system. Health Affairs. 2007, March/April; 26(2): 315-30.

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Hewson PH, Anderson PK, Dinney AH et al. A 12 month profile of community paediatric consultations in the Barwon Region. Journal pf Paediatrics and Child Health. 1999; 35:16-22. Hewson PH, Anderson PK, Dinney AH et al. The evolving role of community based general paediatricians: the Barwon experience. Journal of Paediatrics and Child Health. 1999; 35: 2327. Holmes NR and Bhrolchain CM. Case mix presenting to paediatricians in a UK district (1998). Public Health 2002; 116:179-83. Imison C, Naylor C, and Maybin J. Under one roof-will polyclinics deliver integrated care? Kings Fund 2008, London. 42 p. Kean WJ. Cuba’s system of maternal health and early childhood development: lessons for Canada. CMAJ. 2009, Feb: 314-16. Klein M. Child health care in Canada. Can. Fam Physician 1985, May; 31:955-67. Kushnir T and Cohen AH. Positive and negative work characteristics associated with burnout among primary care paediatricians. Paediatrics International (Japan Paediatric Society). 2008; 50(4):546-51. Lakhani M, Baker M and Field S. The future direction of general practice- A report for the Royal College of General Practitioners. 2007. London 45 p. Leslie L, Rappo P, Abelson H et al. Final report of the FOPE II paediatric generalists of the future workshop. Paediatrics. 2000, Nov: 106(5):1199-1223. Lynch M. Community paediatrics: role of physicians and organizations. Paediatrics. 2003; 112:732-34. Marcer H, Finley F and Baverstock A. ADHD and transition to adult services-the experience of community paediatricians. Community Child Health in Child Care, Health and Development. Blackwell Publishing Ltd. 2008; 34(5):564-66. McLennan JD and Sheenan D. Where do young children in specialty care come from? A preliminary investigation of the role of primary care physicians. J.Can Acad Child Adolescent Psychiatry. 2008, Feb; 17(1):20-25. McManus P, Fox H, Limb S et al. Promising approaches for strengthening the interface between primary and specialty paediatric care. A federal expert work group on paediatric subspecialty capacity. Maternal and Child Health Policy Research Center. Washington DC. March, 2006. www.mchpolicy.org Menahem S. The role of the consultant paediatrician in community paediatrics-an Australian perspective. Journal of Developmental and Behavioral Paediatrics. 1984, June; 5(3): 135-38. Minkovitz CS, Chandra A, Solomon B et al. Community paediatrics: gender differences in perspectives of residents. Ambulatory Paediatrics. 2006, Nov-Dec; 6(6): 226-31. Minkovitz C, Grason H, Aliza B et al. Evolution of the community access to child health program (CATCH). Paediatrics. 1999, June; 103(6):1384-93.

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Oberklaid F. Community child health in Australia. The road ahead. Commentary. Journal of Paediatrics and Child Health 2006; 42: 229-30 O’Brodovich H. Addressing the national shortage of paediatricians. About Kids Health News. Hospital for Sick Kids, Toronto. http://wwwaboutkidshealth.ca/news/address-the-nationalshortage-of-paediatricians.aspx Palfrey JS, Hametz P, Grasa H et al. Educating the next generation of paediatricians in urban health care: the Anee E. Dyson Community Training Initiative. Academic Medicine. 2004, Dec.; 79(12): 1184-91. Pan RJ, Littlefield D, Valladdid S et al. Building healthier communities for children and families: applying asset- based community development for community paediatrics. Paediatrics. 2005, Apr; 115(4): 1185-87. Peachey D. Demographics and Compensation. A Report to the Executive Committee Section of Paediatrics of the Ontario Medical Association. September, 2008. Health Intelligence Inc.

Pferfferle SG. Paediatrician perspectives on children’s access to mental health services: consequences and potential solutions. Admin. Policy Mental Health. 2007(34): 25-34. Pollett GL, Shah CP and McConnan JK. Comparison of consultant paediatricians in an Ontario community with their provincial counterparts. Can Fam. Physician. 1983, April; 29:799-802. Rezet B, Risko W, Blaschko GS. Competency in community paediatrics: consensus statement of the Dyson Initiative Curriculum Committee. Paediatrics. 2005, Apr; 115(4):1172-83. Royal Australian College of Physicians, Paediatrics and Child Health Division. In the interest of children- a statement of principles for paediatric services in Australia. A National Health Policy for children and Young People (The Health of Young Australians). May 2003. Royal College of Paediatrics and Child Health. The next ten years-educating paediatricians for new roles in the 21st century. January 2002, UK. www.rcpch.ac.uk Royal College of Paediatrics and Child Health... Modeling the future I-a consultation paper on the future of children’s health services. 2007, UK www.rcpch.ac.uk Royal College of Paediatrics and Child Health. Modeling the future II 2008, Aug UK www.rcpch.ac.uk Royal College of Physicians, Royal College of General Practitioners, Royal College of Paediatrics and Child Health. Teams without walls-the value of medical innovation and leadership. 2008 13 p. Royal College of Paediatrics and Child Health. Training paediatricians of the future. 2005, UK www.rcpch.ac.uk Royal College of Paediatrics and Child Health. Working together for children: College strategy 2003-2008. UK www.rcpch.ac.uk

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Royal College of Paediatrics and Child Health. Strengthening the care of children in the community. A review of community child health in 2001. Report 2002, February. UK www.rcpch.ac.uk Royal College of Physicians and Surgeons of Canada, Canadian Medical Association and the College of Family Physicians of Canada. A concentrated focus on medical services: a summary report of the 2007 National Physician Survey (NPS). June, 2008 www.nationalphysiciansurvey.ca Royal College of Physicians and Surgeons of Canada, Canadian Medical Association and the College of Family Physicians of Canada. Summary report of the 2004 National Physician Survey (NPS). Canadian Family Physician. 2006, Mar; 52:393-95. Sanders LM, Robinson TN, Forster LQ et al. Evidence-based community paediatrics: building a bridge from bedside to neighborhood. Paediatrics. 2005, Apr; 115(4):1142-47. Shipley LJ, Stelzner SM, Alter Zenni E et al. Teaching community paediatrics to paediatric residents: strategic approaches and successful models for education in community health and child advocacy. Paediatrics. 2005, April; 115(4):1150-57. Skellern C. Community paediatrics in transition. Commentary. Journal of Paediatrics and Child Health 2006; 42: 302-03. Smith AS and McDowell M. Community paediatrics: soft science or firm foundations? Journal of Paediatrics and Child Health 2006; 42:297-301. Solomon BS, Minkovitz CS, Mettrick JE et al. Training in community paediatrics: a national survey of program directors. Ambulatory Paediatrics. 2004, Nov-Dec; 4(6): 476-81. Stoever J. Collaborate, don’t compete, say family physicians and paediatricians. Annals of Family Medicine. 2006, Nov.; 4(6): 567-68. Toronto Sick Kids Community Paediatrics. 2008, Toronto. http://www.sickkids.ca/paediatricmedicine Vimpani G. Pragmatism and idealism in community child health. Commentary. Journal of Paediatrics and Child Health 2006; 42: 306-08. Visser HK. Paediatrics in the Netherlands: challenges for today and tomorrow. Archives of Diseases in Childhood. 1993; 69:251-55. Wigg N. Growth and development are fundamental dynamics for paediatrics. Commentary. Journal of Paediatrics and Child Health 2006; 42:304-05. Willms J. The prevalence of vulnerable children. In J Willms (ed). Vulnerable children: findings from Canada’s National Longitudinal Survey of Children and Youth. 2002, The University of Alberta Press, Edmonton, Alberta. 45-69. Young L. The perspective of the community paediatrician. Paediatrics. 1996, Dec; 98(6):125558.

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APPENDICES A.

INFORMANTS

Calgary Community Paediatricians Dr. Brian Kelly Dr. Susan Aitken Dr. Vicki Kendrick Dr. Starr Cardwell Dr. Christopher Lever Dr. Neil Cooper Dr. Jennifer MacPherson Dr. Kate Culman Dr. Donald Markowsky Dr. Alfred Dei-Baning Dr. Kathleen Mitchell Dr. Roxanne Goldade Dr. Peter Nieman Dr. Thiru Govender Dr. Danielle Nelson Dr. Janice Heard Dr. Darrell Palmer Dr. H.R. Hegde Dr. Ted Prince Dr. Della Ho Dr. Heidi Schroter Dr. Lori Kardal

Dr. Elizabeth Shyleko Dr. Cheri Stanzeleit Dr. Pam Stone Dr. Tracy Taylor Dr. Ross Truscott Dr. Stephen Wainer Dr. Lori Walker Dr. Byron Wong Dr. Monique Wright Dr. John Wu Dr. Douglas Yeung

Paediatricians of Southern Alberta Dr.Kristin Morrison (Brooks) Dr. Minalti Devi (Medicine Hat) Dr. Charlotte Foulston (Medicine Hat) Dr. Alnoor Gangii (Medicine Hat) Dr. Hendrik Hak (Medicine Hat) Dr. Gerry Vaz (Medicine Hat) Dr. Maya Harital (Lethbridge) Dr. John Holland (Lethbridge)

Dr. Ilona Levin (Lethbridge) Dr. Dale Robertson (Canmore) Dr. Margiret Du Plooy (Red Deer) Dr. Mark Mahood(Red Deer) Dr. Carey Molberg (Red Deer) Dr. Josias Michael Grobler (Red Deer) Dr. Desmond Shulman (Red Deer)

Alberta Health Services- Calgary Health Region Dr. Francois Belanger- Deputy Department Head, Clinical and Strategic Affairs Paediatrics, Alberta Children’s Hospital (ACH) Paula Tyler- Vice President, Child & Women's Health, and Specialized Clinical Services Portfolio Calgary Health Region Toni Macdonald- Director of Child Health, ACH Janice Popp- Director of Southern Alberta Child and Youth Health Network (SACYHN) Sybil Young – Manager Outreach Services (SACYHN) Janet Chafe- Director of Child and Adolescent Mental Health Dr. Chris Wilkes- Medical Director of Child and Adolescent Mental Health Dr. Jean Mah- Division of Neurology, ACH Dr. Joyce Harder- Division of Cardiology, ACH Dr. Iwona Wrobel, Division of Gastroenterology, ACH Dr. April Elliott, Division of Adolescent Medicine, ACH Dr. Michelle Bailey, Hospital Paediatrics, ACH Dr. Lynden Crowshoe, Aboriginal Health, Elbow River Healing Lodge Dr. Mark Sosnowski, Mosaic Primary Care Network Dr. Margaret Churcer, Mosaic Primary Care Network Dr. Jaime McMullen, Mosaic Primary Care Unit Dr. Rollie Nicol, Physician Space Plan Catherine Keenan, Physician Space Plan Micheline Nimmock- Director Community Health Services and Partnerships

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Dr. Nick Meyers, Medical Director, Primary Care Networks Lori Anderson, Executive Director, Primary Health Networks Dave Shorten, Acting Executive Director, Rural Health Bretta Maloff, Director Healthy Living, Wellness and Citizen Engagement Irene Anderson, Patient Care Manager, Peter Lougheed Centre Terry Holden, Patient Care Assistant Manager, Peter Lougheed Centre Jim Strome, Executive Director, Corporate Real Estate Xina Chrapko, Manager Palliative Care, ACH Conny Betuzzi, Patient Care Manager, Paediatric Neurosciences, ACH Johana Kwakernaak, Director of Community Rehabilitation Services Joanne DeForest, Patient Care Manager, ACH Nancy Thornton, Clinical Nurse Specialist, Paediatric Neurosciences, ACH Sheena Mainland, Clinical Nurse Specialist, Complex Care, ACH Andrea Perry, Patient Care Manager, Child Development Centre, ACH Lynda Anderson, Assistant Patient Care Manager, Child Development Centre, ACH Sharon Mkisi, Manager, Paediatric Home Care Heather Hunter, Paediatric Home Care Shirley Leew, Paediatric Clinical Rehabilitation Research Associate, DSRT, ACH Catherine Dunseith, Adolescent Transition Program Coordinator, ACH Maureen NcNaul, Program Planning Manager, Child Health, ACH Calgary Organizations Dr. Brent Scott, Vice-Dean, Faculty of Medicine, University of Calgary Christina Tortorelli, Executive Manager, Calgary and Area Child and Family Services of Alberta Lorie Friesen, Director of the United Way, Calgary Jeff Schulze, Director , Lifemark Health Harvey Schott, Senior Vice President, Corporate Development, CBI Health Karen McDermott, Change Management Advisor, Physician Office Support Program, Alberta Stephanie Chrichton, Consultant, Practice Management Program, Alberta Medical Association Mary McCabe, Calgary and Area AIM Coordinator Sharon Erfle, Project Manager, Medical Access and Innovations Andrew Leung, POSP Capital Health Region, Edmonton Dr. Mel Lewis, Paediatrician, Stollery Children’s HospitalCapital Health Region, Edmonton, Alberta Dr. Lionel Dibden, Acting Chief Of Paediatrics, Stollery Children’s Hospital, Edmonton Alberta Laurene Black, Director, Northern Alberta Child and Youth Health Network (NACYHN) Marion Relf, Director Primary Care networks, Capital Health Region, AHS Canada Marie-Adele Davis, Executive Director, Canadian Paediatric Society Dr. Paul Thiesson, BC Children’s Hospital, Vancouver, British Columbia Lynn Rastelli, Consulting Paediatrics Clinic, Children’s Hospital of Eastern Ontario (CHEO) Dr. Andrew Lynk, Halifax Nova Scotia Emily Desembrana, General Paediatrics Clinic, Sick Kids Hospital, Toronto.

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Overview of National/International Concepts & Models Canada: In 2006 a conference sponsored by the major Canadian paediatric organizations11 and Health Canada addressed Child Health in the 21st Century: The Role of the Paediatrician in an Inter-Professional Environment. Identified the following areas for action: Primary Care The College of Family Physicians of Canada reported that anywhere from 41%-to 80% of family physicians in Canada provide primary child and adolescent health care. Paediatricians are caring for more children with complex care needs and provide primary care especially in large urban centres. The College identified the need to: - prioritize access to primary and specialized paediatric services, -respond to health care disparities in rural areas and vulnerable populations, - promote primary and specialized shared care models, - refocus family medicine education to deal with more complex chronic conditions, - recruit and retain family physicians who want to work with children and youth, - develop shared information systems and create stronger links with public health. Care of diverse and vulnerable populations: Children and youth with serious health risks are frequently associated families of low socioeconomic status, single-parent families, and parents at risk for mental illness, families of cultural/racial minorities and foster families. Therefore, paediatricians should work in partnership with all primary and community care providers (e.g. educators, nurse practitioners, family physicians, public health providers and children/youth and their families) to help build capacity in communities to meet the needs of diverse and/or vulnerable populations. Practice in Rural and Remote Areas Challenges in rural and remote regions include a shortage of family physicians, paediatricians and other sub-specialists. Compared to urban areas, rural residents tend to have lower socioeconomic status, fewer high school completions, higher rates of mortality, morbidity, injuries and suicides and greater public health issues. Accessing health care and ongoing management of care for children and youth especially for those with developmental, behavioral and mental health conditions can be very difficult. Paediatricians in rural and remote areas need to serve as regional consultants for children and youth and increase partnership with pubic health system; work actively with social and child protection services to support at-risk children and youth; participate in new models (e.g. interdisciplinary shared care models) that focus on child development, learning and mental health care; and strengthen models of chronic disease management. Mental Health Care: Family physicians and paediatricians are frequently the first point of contact for children and youth with mental illness. Paediatricians need to be trained to

11

Canadian Association of Paediatric Health Centres, the Canadian Paediatric Society, Health Canada, the Paediatric Chairs of Canada, the Public Health Agency of Canada and the Society of Obstetricians and Gynecologists of Canada

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provide formative and ongoing mental health care, and be willing to engage children and youth in maintaining their mental health. There needs to be a basic standard knowledge of how the system works, a common language and policies, knowledge to get the child to the right service line, and mutual respect and understanding of each other’s roles. There needs to be broader inter-professional and cross-sectoral collaboration between mental health, physical health, education, youth justice, child welfare, developmental services and the criminal justice system. Collaborative Paediatric Care Teams In keeping with the increasing trend for community based paediatric care teams, interdisciplinary paediatric care teams should be established based on the principles of : i) team and individual competency ii) continuity of services iii)care as close to home as possible iv)communication and collaboration v)community driven; vi) Canadian models. Effective community based paediatric care models will vary and evolve depending on the level of care that is needed by the community served and the life stage of the child and family. Depending on the needs of the child, family and larger community, the model of care could include paediatricians, other physicians, pharmacists, dietitians, nurse practitioners, paediatric residents, social workers, mental health professionals, educators, interpreters, and health promotion workers. Every team member has to add value and must have a clear role. Relationships between paediatric care team members (secondary consultation and care) with primary care groups in the community and tertiary/quaternary care/paediatric specialty care (hospital) need to be described including the role of the provider within each level and the communication strategies between the levels and providers. The centre of the team is the family and child. Children need care delivered by a team at each level who are responsible for the development of individual care plans. There will need to be more emphasis on the family’s quality of life and health in addition to the child with the chronic health condition. Teams will need to be supported by technology (electronic records and two-way communication technology with families) and remuneration models that appropriately compensate team members for collaborative care roles. In the case of physicians this might entail a blended model of fee-for-service and capitation. A true team approach rather than a physician led model will ensure success. Evaluation will be key to determine whether they actually achieve anticipated outcomes. Families of Children with Multiple Chronic and Complex Health Needs Parents emphasized the importance of a coordinated multi-disciplinary team where all services are connected and coordinated. Case management was a common concern. Paediatricians should provide medical expertise, support, ready access to all information and help with navigation. Families want paediatricians to help them see and prepare for the future, for the long series of transitions as the child moves through childhood and adolescence to adulthood. They want the paediatrician to provide perspective, guidance, wisdom and advice in the context of a family-centred model, be responsive to the family’s issues and at serve as the case manager for multiple complex needs. The role of case manager is fluid and may be assumed by other members of the paediatric care team depending on the nature of the situation. There needs to be effective engagement of children and families in their care.

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Health Promotion With respect to health promotion12 community paediatricians are in a unique position to identify and respond to local community priorities, build on community strengths, partner with other organizations, and build capacity by developing community and academic champions and through knowledge translation. Innovative Paediatrician and Family Physician Training Models Recognizing that paediatricians care for a population with diverse needs and the importance of taking a cultural approach to care, medical education curriculum needs to emphasize the social, cultural and humanistic aspects of paediatric care in addition to the biological aspects. Paediatric training education should also: - develop skills on advocating for vulnerable infants, children and youth (e.g. aboriginal health, mental health, early literacy, injury prevention). - develop core competencies on a team approach to care and how to collaboratively and effectively work within multi-disciplinary teams. The Royal College of Physicians and Surgeons of Canada recommended that paediatrician residency programs promote: - greater distribution of residency programs across urban and rural centres; - greater use of information technology and high and low technology simulations for individual and inter-professional proficiency assessment; - curriculum content shaped by inter-professional sharing of responsibilities and by the dynamics of the communities being served; - preceptor models that include non-physicians as preceptors and; - the assessment of broader roles including medical expert, communicator, collaborator, manager, health advocate, scholar, professional. For example the collaborator role includes functioning in a team environment across and within disciplines and potentially sectors, relationships with patients and families and conflict identification and resolution. The College of Family Physicians of Canada called for family medicine training programs in paediatrics that addressed: - training in a range of community settings, - third year paediatric training that includes mental health and disabilities, - training as part of community care model staffing (e.g. where universities make this part of the education experience), - promote opportunities for collaborative paediatric education (paediatrics, family medicine, nursing, social work, psychiatry); and - model and develop skills on inter-disciplinary team care in academic teaching centres. Provincial/Regional Child Health Initiatives: British Columbia is embarking on transforming the delivery of children’s services across the province through the implementation of a cross-ministry framework for action13. This model is influenced

12

As defined in the Ottawa Charter for Health Promotion that was adopted by the World Health Organization (WHO) in 1986 in Ottawa, Canada. 13 Ministry of Health, Ministry of Education and Ministry of Children and Family Development. Children and Youth with Special Needs, Cross-Ministry Framework for Action, April 2008

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by the work done by the Center for Healthier Children, Families and Communities at the University of California, Los Angeles which is described later.14 The Ministries of Health, Education and Children and Family Development are reorganizing service delivery along four tiers across the system. The framework for action will initially focus on children and youth with special needs and may potentially evolve to include all children and youth over time (Personal Communications –Dr. M. O’Donnell). Services will be designed to meet the vision: Optimal development, health, well-being and achievement for children and youth with special needs. • Tier 1 consists of local/universal ‘broad-reaching’ service providers who play key roles in special needs identification, screening, referrals and supporting families. Providers include public health nurses, family doctors, social workers, and teachers. •

Tier 2 encompasses specialized community services providers working as a team for a population base of under 250,000. Providers having a breadth of knowledge and skills in paediatric care will diagnose, perform functional assessment and provide treatment and management interventions to meet functional goals in the local community and develop and foster longitudinal relationships with the child and family. This is the home team for children and youth with special needs and their families. Providers include paediatricians, child development workers, and mental health therapists and will be based in the community.



Tier 3 encompasses regional specialized services, e.g. specialized assessment teams located in regional hospitals.



Tier 4 are provincial ‘sub-specialized’ or one-of-a-kind services that are not replicated in each regional authority (e.g. provincial programs).

The province is currently mapping all services and providers for children and youth with special needs and their families across sectors and tiers in order to identify gaps and strategies for future action. In the Capital Health Region in Edmonton, general paediatricians currently provide primary and consultative paediatric care in community offices as well as through a network of ambulatory clinics in Edmonton hospitals and freestanding health centres. • The EPCOR Paediatric Ambulatory Clinic at the Stollery Children’s Hospital is a teaching clinic that provides primary, secondary and consultative paediatric medical care to infants, children and youth aged 0-16 years). The clinic also serves as a base for hospital referred patients who require multiple specialty consultations during a work-up. There are six paediatricians who work in this clinic as part of a multi-disciplinary team that also includes: medical students, paediatric residents, paediatric nurses, a registered dietitian, a social worker and licensed practical nurses. Physician referrals are required for paediatrician consultation services. The team also provides information and other supports to parents. 14

Haflon N, DuPlessis H and Inkelas M. Transforming the US Child Health System. Health Affairs; 26(2), 2007:315-30.

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The Child Health Ambulatory Care Clinics at the Royal Alexandra Hospital offer a range of paediatric services including General Paediatrics, an International and Special Needs Adoption Clinic, Asthma Education, Nutrition, Breastfeeding Clinic, and Paediatric Urology Clinic. There is also a neuro-developmental clinic that provides consultative medical services to children with learning difficulties, developmental and/or behavioral needs. Services are provided by a multi-disciplinary team including six general paediatricians.



The Child Health Clinic at the Misericordia Community Hospital includes a paediatric environmental health specialty unit and enuresis and encopresis clinic, asthma education, breastfeeding clinic, child neuro-developmental clinic for assessment and treatment of neuro-developmental and behavioral disorders The clinic employs a multi-disciplinary team including four general paediatricians. There are site based general paediatricians as well as some community based paediatricians who participate in some of these programs. The program has close linkages with other child service programs including the Regional Paediatric Developmental and Mental Health Program and acute care hospitals including the Stollery and Glenrose Rehabilitation Hospital to ensure smooth transitioning across community-based and acute care services.



The Grey Nuns Community Hospital provides ambulatory breast-feeding, asthma education and paediatric developmental and mental health services through its Child Health Clinic. Some community paediatricians participate in these clinics. Community paediatricians are responsible for newborn care at Grey Nuns as well as at the Misericordia, Royal Alexandra and Sturgeon Community Hospitals.



The North Edmonton Children’s Clinic is a community based ambulatory centre that focuses on medical education in general paediatrics, aboriginal child health (through on-site and outreach services) and providing general paediatric services in an underserved area of the city. Four site-based paediatricians work in collaboration with other Child Health Clinics and programs including the Regional Paediatric Developmental and Mental Health Program.



The Northeast Community Health Centre is a community based primary care model that provides a range of paediatric, adolescent and adult health services through multidisciplinary teams. Paediatric clinic staff include a full-time site based paediatrician who is a specialist in adolescent medicine and a full time paediatric nurse practitioner. Paediatric services include Child and Adolescent Health, Child Health Immunization Clinic, Children’s Asthma Clinic, Early Childhood Oral Health Services and Drop in for New Mothers/families and infants.



Elsewhere in Edmonton paediatric primary care programming is planned for the new Eastwood Community Health Centre and public health centres in some of the smaller centres including Fort Saskatchewan, Redwater, Westview, Leduc, St. Albert and Devon.

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In Ontario there are general paediatric consultation clinics at Children’s Hospital of Eastern Ontario, Toronto Sick Kids and McMaster Children’s Hospital. The Paediatric Consultation Clinic at Toronto Sick Kids Hospital provides consultations for patients from Ontario with complex paediatric problems. Referrals are accepted from paediatricians who require a second opinion or assessments/management by an interdisciplinary team. The PCC team consists of several hospitalist paediatricians and advanced practice nurses who are also supported by a dietitian, social worker and psychologist. The team also teaches paediatric residents and fellows. The PCC also has linkages to a Neurofibromatosis Clinic, Infant and Toddler Growth and Feeding Program (for children under 3 years who fail to thrive)and a Complex Care Clinic which provides a link with the Paediatric Inpatient Unit for patients with complex medical problems who require hospital follow-up. The PCC sees approximately 3000 clinic visits per annum. Children in need of developmental or behavioral assessment are referred to Bloorview McMillan. The hospital implemented a new Ambulatory Referral Management (ARM) System which is an automated web-based system designed to route internal and external referrals for review, triage and booking. It also provides automated fax-back responses to referring professionals to let them know the status of their referrals. The Consulting Paediatrics Clinic at the Children’s Hospital of Eastern Ontario (CHEO) accepts referrals from family doctors and community paediatricians in need of a second opinion for the following issues: Feeding problems Anemia Abdominal Pain Asthma Query developmental delay

Failure to Thrive GERD Fatigue Speech Delay Undiagnosed Medical Problems

The clinic does not accept referrals with ADD/ADHD, learning difficulties, behavioral problems or primary care. The Clinic is run by paediatric hospitalists and two nurses with clerical and secretarial support. Clinic staff also teach fourth year paediatric residents. Program staff identified the need for a multi-disciplinary team that could assess and follow children with complex multi-system needs. Staffing should include a School Liaison to coordinate with school resources on behalf of the patient/family. There are also examples of Paediatric Walk-in Clinics in Canada (the Just for Kids Clinic at St. Joseph’s Health Centre in Toronto, the Kid’z Klinic at Trillium Health Centre in Mississauga and Kensington Medical Clinic in North Burnaby, BC. Staffing typically consist of general paediatricians and paediatric nurses and in some cases, family physicians. The United Kingdom: The National Health Services (NHS) identified the following needs and challenges regarding their paediatric health system: ¾ evolving from a focus on acute care to managing long term conditions in a model that focuses on delivering care closer to home ¾ improving coordination and continuity of services from the patient perspective ¾ a greater emphasis on preventing the preventable

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¾ ¾ ¾ ¾ ¾

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addressing fragmented service delivery reducing unnecessary variations in health and health service outcomes improving the identification of children/families at risk and their access to support poor access to support and therapy services improving transition to adult services

The NHS is calling for a change in healthcare delivery that provides care closer to home and whenever possible outside hospital, based on the principle ‘localize where possible, centralize where necessary”. Unlike the United States where outpatient activity in the community has grown from 10% to 50%, only 10% of outpatient appointments in England are delivered in a community setting (Department of Health, 2007). The government is recommending that health organizations and the Royal Colleges define clinically safe pathways that provide the right care in the right setting, with the right equipment performed by the appropriate skilled person (Department of Health 2006). The Vision of the Royal College of Paediatrics and Child Health includes the delivery of quality healthcare of an agreed standard to babies, children and youth as close to home as possible.

-

To that end the Royal College of Paediatrics and Child Health with its partners the Royal College of Physicians and the Royal College of General Practitioners are pursuing strategies and processes that: redesign service delivery, organize general and specialist children’s health services around clinical pathways of care, implement paediatric standards and protocols at the local level, and promote better access to paediatric care in remote and rural areas through telemedicine. Recent recommendations and position papers15 are calling for integrated and collaborative models of care to improve services for children, particularly those with chronic or long-standing conditions. There is increasing support for multi-professional teams that work in a managed network across the interfaces generalist (primary) and consultant (secondary) and that manage patients on a care pathway designed by local clinicians. The Teams Without Walls model proposes community networks of generalists (primary care physicians and nurses) and specialists (physician consultants and specialist nurses) to collaborate and cooperate on planning and providing health services that are sensitive to the local population. These networks would be sensitive to the broader needs of the local population and maintain a more holistic and preventative approach but would have the skills and supports required to manage outpatient care and minor complications in the community. It is envisioned that these community networks would:

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Royal College of Paediatrics and Child Health. Modeling the Future: A consultation paper on the future of children’s health services (September 2007) and Modeling the Future II (August, 2008). Royal College of Physicians, Royal College of General Practitioners, Royal College of Paediatrics and Child Health Team without walls- the value of medical innovation and leadership. (2008)

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ultimately improve health through heath promotion focus enable earlier diagnosis and problem identification provide more comprehensive and accessible services allow easier navigation of the system ensure quality and safety through the development and implementation of shared management protocols and clinical care pathways enhance opportunities and the quality of community health teaching and research Examples of integrated care models cited included: Care of the elderly Respiratory Service (involves patient-centred guidelines on early treatment and patient education, close collaboration across primary care physicians and specialists, and an outreach team). Gastroenterology (involves patient education in physician office, blood test monitoring and advice by email or text. Resulted in freed outpatient slots, significant savings and allowed rapid advice to patients suffering relapse). Community Cardiology (involves a general physician with special interest in Cardiology, a pharmacist and specialist nurses. Access to echocardiography and support from a consultant resulted in good care and reduced admissions). Rheumatology Service (involves collaboration between community physicians and consultants in a shared care model that includes protocols and referral pathways. Co-located urgent care centre and emergency department (involves protocols and processes involving family physician, paediatricians and emergency staff and triage by a children’s nurse to primary urgent care, emergency care or children’s specialty assessment. Community children’s teams for life-threatening conditions (involves community children’s nursing teams who proactively plan for acute care problems that arise for complex chronic conditions including telephone advice and 24/7 end of life nursing care. Musculoskeletal pain management. Factors critical for success include: clinical leadership and involvement primary and secondary care partnerships more appropriate payment models that recognize both episodic care and long-term conditions (payment models that encourage efficiency without considering effectiveness result in failure) clear governance arrangements agreed measures and standards to improve the quality and quantity of work clear patient focus for a defined group a whole system approach to planning The United States: In 1999 the American Academy of Paediatrics produced a policy statement that defines the paediatrician’s role in community paediatrics and identified recommendations to guide future community paediatrician practice and ensure comprehensive paediatric primary care. Policy recommendations call for community paediatricians to:

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- build partnership with local communities to create and disseminate innovative programs to improve child health; - collaborate more with community agencies concerned with child health and welfare, - become more active in child health advocacy, - identify and implement evidence based practice - participate in community based integrated models such as those supported through the Community Access to Child Health Program and the Healthy Tomorrow’s Partnership for Children; - continuing medical education in areas relevant to community paediatric practice - the development of educational opportunities for medical students and resident in community practice that encompasses both community based clinical care and health promotion. Over the past decade more than half of paediatricians in the United States have reported participation in community-based activities. Examples include coalitions and collaborations with community partners around improving access to health care in local communities, childhood obesity prevention, and school- readiness, promotion of breastfeeding and treatment of maternal depression. In 2006, a federal expert work group on Paediatric Subspecialty Capacity identified promising approaches for strengthening the interface between primary and specialty paediatric care for the American Academy of Paediatrics and the Maternal and Child Health Bureau, Department of Health and Human Services. These approaches address transfer of care referral approaches, consultation approaches (one-time or limited time) and collaborative management approaches (ongoing shared management and co-located services).

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Promising referral practices include: Development of referral guidelines that define a recommended set of clinical thresholds that indicate the need for specialty care. They can include specifications about initial diagnosis and management, ongoing management and criteria for return to primary care. They are typically based on clinical standards of care and quality and utilization guidelines. Examples include: Cerebral Palsy Referral Guidelines and the Diagnosis and Treatment of Otitis Media in Children. Pre-Appointment Management of Referrals (review of prior medical records and other pertinent information prior to a first time specialty appointment in order to determine the most appropriate care. Promising Consultation Approaches included: Child Psychiatry consultation and liaison approaches to assist the paediatrician in addressing a broad range of behavioral health needs obtaining real time psychiatric consultation by paging a child psychiatrist which could result in: an answer to a question; referral for acute psychopharmacologic or diagnostic consultation and short term treatment or referral to mental health system. The team (child psychiatrists, paediatric mental health nurse clinical specialist with prescribing privileges and a program coordinator. The team would also visit paediatric practices annually

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to discuss administrative, patient care and educational issues. (The Massachusetts Child Psychiatry Access Project). Outcomes included: 50% of the referred children could be managed through a telephone consultation with the child psychiatrist within 20 minutes; 16% were scheduled for a 90 minute assessment with the child psychiatrist within 3 weeks that resulted in an diagnosis and treatment plan and were subsequently managed by the paediatrician in consultation with the psychiatrist; a third of the children with more significant needs were referred to mental health services for ongoing care. -

Family Physician Paediatric Consultation Using paediatrician anchors to support a network of family physicians that are the primary source of care for children with special care needs. Promising Collaborative Management Approaches include: Integrated Mental Health Primary Care Program which provides paediatric care and behavioral health services at community-based general paediatric clinics. Psychiatrists and psychologists see patients at the clinic as identified by the paediatrician. Psychiatric evaluation and short term treatment are available at the clinic and information is shared through an electronic medical record. The Center for Healthier Children, Families and Communities in UCLA (Halfon et al, 2007) presents a vision and framework to transform the US child health system to optimize child health development. The vision and framework are predicated on the definition of child health recommended in the 2004 Institute of Medicine report on Children’s Health, the Nation’s Wealth: Children’s health should be defined as the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities to allow them to interact successfully with their biological, physical and social environments. Halfon identifies a shift in the focus of health care over time from fighting infections (Health System 1) to the management of chronic diseases (Health System 2) to focusing on achieving optimal health status in the general population (Health System 3). While there has been progress in the treatment of traditional medical conditions there are increasing rates of chronic conditions (e.g. asthma, diabetes (10-14% of the paediatric population), particularly mental health (15-22%), developmental and behavioral conditions (10-17%) and childhood obesity (18-26% includes overweight and obese children and youth) as well as increasing health disparities in the general population. The authors identify that the current system is fraught with problems including: o disconnected children’s programs/services across health/mental health, school and children’s community services; o emphasis on disease diagnosis and treatment rather than an addition and emphasis on prevention, promotion and developmental optimization; o emphasis on episode of care rather than functional capacity across the life sources which recognizes critical and sensitive periods of developmental

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vulnerability; the delivery and organization of services is focused on a vertical hierarchy of primary, secondary and tertiary care rather than on a distributive care model with care pathways that integrate within (vertical) and across (horizontal) specific sectors, and over time (longitudinal). funding focuses on episodes of care for medical conditions and does not recognize chronic care needs or the infrastructure to support population based prevention and promotion. performance is based on condition specific quality improvement ; but should also include system improvement

Their proposed framework calls for vertical, horizontal and longitudinal integration to effectively enable the health system to optimize children’s health. This means expansion of the medical care sector to include the delivery of prevention and health promotion programs; the formation of productive partnerships across medical, public health, education and social service sectors including more innovative delivery platforms such as comprehensive school readiness centers that serve as hubs for integrated service delivery; and optimizing health trajectories that are organized around developmentally sensitive services, anticipatory guidance, and sustainable delivery pathways capable of optimizing transitions (e.g. from pre-school to school) and providing continuity of relationships and services across a child’s life. They describe one option of a local Child Health Development system where a paediatric health service hub would be co-located or virtually linked to a network of child service centres such as schools, child care centres, pre-natal care sites, teen development programs to form integrated networks to provide continuums of coordinated care. These paediatric health networks would also integrate public and population health services. Examples of national integrated frameworks include the “Every Child Matters: Change for Children program” program in the United Kingdom, the U.S.’s Early Childhood Comprehensive Systems initiative that supports the integration of early childhood medical, mental health, parent education, preschool and childcare and family support services, Washington’s Thrive by Five Program and California’s First 5 program. US health care organizations16 are turning to innovation management models to effectively reinvent health care. Health care systems including Kaiser Permanente, Intermountain Healthcare in Utah, the Mayo Clinic, the Geisinger Health System in Pennsylvania and the Veterans Health Administration are devising new health care models that emphasize: - continuums of care that follows the patient within an integrated health system based on patient needs rather than on patient crises; - more individualized care; - health and wellness promotion; - the use of nurse practitioners and other health professionals to administer treatments for routine ailments to enable doctors to practice ‘intuitive medicine” to help diagnose and treat patients presenting with more complex and complicated symptoms;

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Janet Rae-Dupree. Disruptive Innovation Applied to Health Care. New York Times, February 1, 2009. YBU P.3

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a greater shift to decentralization of service delivery, e.g. to more in low cost facilities in the community for more routine treatment and consultation and restricting high cost hospital and specialty care for more complicated cases. the proliferation and adoption of information/communication technology (videoconferencing systems) to deliver care in non-traditional settings (e.g. patient homes) and extend the reach of health manpower integration instead of duplication (medication prescriptions, diagnostic testing) adopting new fee structures

As a result proponents such as Kaiser Permanente have realized a 22% cost efficiency (Hewitt Associates, 2007) since implementing an integrated system. Polyclinics: Polyclinics describe a variety of different approaches to unite different types of care in the community. They range from large community based health centres where a broad range of primary and secondary care services are co-located under the same roof to the hub-and-spoke model where a network of existing practices share access to a set of new services in one facility. Polyclinics have been implemented in a number of European countries including England, France, Sweden, Germany, Denmark, Finland and the Netherlands, in Russia, the United States (e.g. Kaiser Permanente and United Healthcare’s Evercare), Australia and New Zealand. (Ettelt et al, 2006) The introduction of polyclinics has largely been in response to the need for a comprehensive range of services for the identification and management of complex and chronic diseases and more effective follow-up following hospitalization. Features may include: -

an expanded nursing role to include prescriptions of selected drugs, ordering of medical tests, maternal and child care, simple respiratory infection treatment, injections, health promotion programmes, family planning consultations, school health care, immunizations, reproductive health checks and health counseling.

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In England many practices employ nurse practitioners (who work independently and are regulated by an explicit protocol. They attend to minor health problems and lead the care of patients with complex chronic conditions in walk-in centres. They can prescribe any licensed medicine for any medical condition with the exception of controlled drugs. The role of community pharmacists is under review for the possible introduction of pharmacist prescribing.

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multi-disciplinary teams (nurses, physiotherapists, dietician, social workers and other health professionals) to support primary and secondary care in prevention, assessment, treatment, self management education, case management, and home care functions prevention screening and early detection measures

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very few (England and Sweden) have implemented integrated population based models that involve call and recall, integrated diagnostic systems and quality assurance

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some include diagnostic services (laboratory and radiology)

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the use of national electronic patient medical records, patient smart cards a more systematic approach to support patients with long term conditions including self-management , disease management and case management

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use of protocols of care (France) and (Netherlands)

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Out-of-hours service arrangements and 24 hour walk-in-centres, nurse led triage systems

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Specialist units (examples include paediatrics, internal medicine, gynaecology, surgery, orthopediacs, ophthalmology, ENT, psychiatry, diabetes, rehabilitation units) can be managed by a hospital or may be joined with a local primary care facility or network.(Sweden, England, Denmark)

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use of e-consultation (e.g. Finland) in which a general practitioner forwards a query with clinical data to a specialist and receives advice and/or recommendations for action within one or two days.

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financial incentives to community physicians to improve quality of care and encourage coordination of care for patients with chronic conditions such as the Practice Incentives Program, the Enhanced Primary Care scheme and Service Incentives Payments in Australia.

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In Germany polyclinic physicians are salaried or contracted as self-employed practitioners. The Polyclinics are administered by professional managers. Physicians are attracted to the reduced financial risk associated with establishing an independent private practice while at the same time maintaining freedom of clinical practice.

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Cuba’s approach to maternal and early childhood development involves polyclinics. Cuba currently operates 498 polyclinics which each serve an average of 22,000 rostered patients (1 physician per 159 people and 1 nurse per 79.5 people) The average polyclinic here offers 22 services including rehabilitation, radiography, ultrasound, endoscopy, family planning, family medicine, paediatrics, internal medicine, immunization, obstetrics, gynecology, dentistry, emergency services and cardiology. They provide mental health, maternal and child care and care for the elderly. They effectively integrate prevention with other levels of care. Infant mortality rates rival Canada’s at lower costs (Keon, 2009) Imison et al (2008) provide a comprehensive review of Polyclinic approaches in their paper Under One Roof: Will Polyclinics Deliver Integrated Care? They report on various opportunities and risks relating to quality of care, access and cost associated with Polyclinics. They conclude: (1) While co-location of multiple services presents opportunities for delivering more integrated care, particularly for people with complex or chronic diseases, a major limiting factor has been the lack of an overall governance structure with clear lines of accountability and no single leader or management board.

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(2) The evidence from published research shows that community -based services can not always be expected to be less costly than hospital-based equivalents, despite the theory that cost-savings should be realized given the lower overheads of community-based services. (3) Polyclinics can provide more integrated, patient focused care with considerable planning, effort and resources. (4) The primary focus for integrated care should be on developing new pathways, technologies and ways of working (virtual polyclinics) rather than on new buildings. Co-location alone is not sufficient to generate co-working between different teams and professionals. Change management and strong clinical and managerial leadership will be required. Other considerations for the implementation of Polyclinics include: Approaches to assure quality of out-of-hospital care and support professional development are required as well as a strong framework for inspection and accreditation. Polyclinics should ideally be located in natural transport hubs. Otherwise integrate services within existing facilities or sites. Polyclinics will not likely result in cost savings and will likely require transitional funding for development. Scheduling of services will be a major challenge to ensure effective use of space and staff time. There are significant workforce implications to attract, sustain and retain health professionals from all potential disciplines. Polyclinic development should respond to local needs rather than some national target. Any polyclinic development should be subject to rigorous evaluation to fill current gaps in the evidence base.

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