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The Right Care, in the Right Place, at the Right Time, by the Right Health Team

What is One:carepath?

One:carepath is an Integrated Supportive Care Pathway that takes a proactive and co-managed approach in care planning with patients who have advanced-stage (non-curative) lung, heart, liver and kidney disease and/or cancers. This provincial initiative aims to provide symptom and crisis management, help patients maintain quality of life and functional status, avoid aggressive treatments, where appropriate, and align care with patient preferences and values.

Primary care physicians do an excellent job of providing needed care for patients, however, in some cases physicians do not always have the right supports and tools at their fingertips to optimize the approach to chronic complex care. Patients with advanced stage chronic diseases or other conditions, often characterized by high rates of hospitalization or aggressive use of treatments with limited benefit, present significant challenges. Additionally, physicians lack the support to effectively communicate and coordinate the care that these patients have expressed they want outside the walls of the clinic. This results in a poor quality of life for patients, frustration, and rework for providers with increased costs to the health system. Thinking proactively, and having an effective, efficient, patient centered and evidence-based approach are critical to success.

To attain quality patient outcomes and optimize system performance there needs to be an integrated approach to care. Integrated care is a multi-level, demand-driven and person-centered strategy designed to address complex and costly health needs by better coordinating services across the care continuum. The use of clinical pathways has been shown to be effective in integrating care, increasing uptake of evidence-based practice, and optimizing patient outcomes.

This project is lead by Dr. Sara Davison and Dr. Brad Bahler and will work with primary care and community providers to adapt, scale, and extend the Conservative Kidney Management Pathway to other areas of chronic illness.

For more information about how to get involved please contact Kirby Scott, Senior Project Manager at kirby.scott@ahs.ca.

One:carepath is co-funded by the Canadian Institute of Health Research, Alberta Health Services and Alberta Innovates through the SPOR iCT Rewarding Success Operating Grant.

How Will This Be Accomplished?

One:carepath aligns with ongoing Primary Care Network (PCN) priorities helping to further advance the Patient's Medical Home through 1) process re-design, 2) gathering practice level measures over time, 3) building on existing panel and health screening work, and 4) designing a shared-care plan. It also strongly aligns with Phase 1 of Patients Collaborating with Teams (PaCT). One:carepath will help Albertans live well, on their terms, until they die, by providing the best care possible within the Patient’s Medical Home, avoiding unnecessary Emergency Department visits and Acute Care admissions.

  • This initiative offers training for practice facilitators that combines a novel approach to implementation, and an opportunity for practice facilitators to add to their current skillset and help build capacity. More importantly, this unique training can be applied to other priority work advancing the Patient Medical Home.
  • One:carepath will provide funding and resources to Primary Care Networks and participating practices to co-design and test solutions that are tailored at a local level. Support will be provided to identify the most advanced-stage patients within a participating physicians’ panel.

Why is Integrated Supportive Care Important?

Participation in this initiative is worth considering as a healthcare provider to:

  • Strengthen continuity of care and move forward with complex care planning that is proactive.
  • Manage complexity over time rather than in one single encounter. Providing a workable solution to the potential changes to the complex modifier code; so physicians can see patients and bill appropriately with additional support using a Chronic Disease Management (CDM) team along with Practice Facilitators and other change agents.
  • Co-design a systematic process for identifying and proactively managing the most complex patients within your panel.
  • Work together with your patients, specialists, and other healthcare providers to define problems, set priorities, establish goals, create treatment plans and solve problems.
  • Help patients understand symptoms related to their condition and what they can do at home to deal with symptoms.
  • Observe the evidence and measure and evaluate your progress against non-participating physicians in your zone.
  • Access secured funds to build capacity at the PCN and practice level to further advance the Patient’s Medical Home.

The Benefits of One:carepath

This Program Will Benefit Albertans By:

What Does the Program Offer Primary Care Organizations?

What Does the Program Offer Physicians & Team Members?

  • Enhancing community-based care across Alberta, supporting frail patients with advanced stage chronic diseases who are unlikely to benefit from aggressive treatments.
  • It will help provide patients with the right care, in the right place, at the right time, by the right health team through innovative, sustainable changes to health service delivery, irrespective of their location in the province.
  • It will support patients who choose a conservative approach to manage their chronic condition.
  • It will facilitate integrated approaches to home and community-based care, including rural/remote communities across Alberta.
  • It will reduce resource use/cost across the health system and improve patient outcomes.
  • Leveraging local successes, evidence-based practices, & provincial priority initiatives as the foundation.
  • Building capacity within the PCNs to advance chronic disease management processes in primary care & customizing training for Practice Facilitation applicable to this and other projects.
  • Building a value-based model of care with performance metrics to trigger further investment & recapture savings.
  • Providing direct support (~50% of total funding) to PCNs to help them support their physicians & teams to accelerate Patient’s Medical Home implementation & enhance continuity of care.
  • Opportunity to participate in a high-quality evidence-based initiative demonstrating the value of PCNs to the health system.
  • Co-designing tools and processes with end-users to readily integrate into clinic practices & workflows.
  • Specific outcome measures adapted to a clinics strengths/weaknesses and unique patient populations.
  • Further develop relationships between primary care, specialists and specialty programs for enhanced integration of care.
  • Administrative & project management support for participating sites.
  • Practical, evidence-based approach to support clinics with implementation of elements of the Patient’s Medical Home.

Participant Expectations

Primary Care Organizations Will:

  • Identify clinical leaders (physician) & Practice Facilitators within each PCN to help initiate physician engagement.
  • Identify practices willing to participate & support each to work with assigned Practice Facilitators to advance the Supportive Care Initiative within their practices.
  • Establish an agreement with those practices to mutually participate in both the co-design & implementation of the initiative so they can be readily integrated into current clinic practices.
  • Support measurement & evaluation including facilitating measures from individual practices.
  • Participate in one World Café or co-design activity & skill building sessions.

Primary Care Providers & Team Members Will:

  • Identify a local improvement team who will work with the Practice Facilitator to test changes to implement practical tools.
  • Provide advice on the co-development & implementation of the initiative & tools designed specifically for primary care practices .
  • Advise on processes to support primary care coordinate with AHS programs/services & medical specialties.
  • Coordinate & align where possible the Integrated Supportive Care Initiative with the current patient medical home resources developed to advance the complex care planning process into primary care practices (PaCT).
  • Share lessons learned in implementing to scale in primary care.
  • Screen EMR for patients with advanced stage chronic diseases & complete supportive care plans with patients over a 2.5 - 3 year period (approx. 10-15 care plans a year).

Additional Resources

Frequently Asked Questions

Covers topics such as value proposition, priority alignment and supports for PCNs, clinics and patients

PCN Readiness Questions

To help better understand how to support participating PCNs

Vision: To help people enjoy life while living with advanced chronic kidney disease by becoming a world leader in kidney supportive care research and clinical innovation.

Kidney Supportive Care Research Group (KSCRG)  l  Mailing Address: 8-105 Clinical Sciences Building, University of Alberta, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3  l  Email: kscrg@ualberta.ca  l  Phone: (780) 492-0926 l  Fax: (780) 407-8117

This project is lead by Dr. Sara Davison and Dr. Brad Bahler and will work with primary care and community providers to adapt, scale, and extend the Conservative Kidney Management Pathway to other areas of chronic illness.

For more information about how to get involved please contact Kirby Scott, Senior Project Manager at kirby.scott@ahs.ca.

One:carepath is co-funded by the Canadian Institute of Health Research, Alberta Health Services and Alberta Innovates through the SPOR iCT Rewarding Success Operating Grant.

One:carepath is co-funded by the Canadian Institute of Health Research, Alberta Health Services and Alberta Innovates through the SPOR iCT Rewarding Success Operating Grant.