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.

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.

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).