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Community Based Group Family Practice in a Fee For Service (FFS) Model

John Hadley OD. MD. CCFP.

St. Paul Family Medical Practice Structure

5 family physicians (3 female, 2 male, age 30-40 yrs.)

8 staff including 2 1/2 RN’s

Services Provided by SPFMC

Office based care, Hospital based care, Obstetrical care, Palliative Care (Hospital and home), Nursing home care, Mental Health Counseling. Cambridge Cancer Clinic.

For our patients we provide Hospital Rounds 365 days per year

Services Provided by SPFMC (cont’d)

Members of group provide administrative services at the hospital, including chief of department of family medicine, Medical Director of the Brant Community Cancer Clinic, membership on quality assurance committee, perinatal morbidity/mortality committee, obstetrical quality assurance committee, library committee, BGH palliative care committee.

Services Provided by SPFMC (cont’d)

Part of a larger call group (17 members to cover after hours, weekends)

3 members of group have provided care in the Brant County Health Unit sexual health clinic

VON medical director

Patient Demographics

Mixed urban/ruralRepresentative of community

re: socioeconomic, age and sexPalliativeObstetricsNursing home

Interactions with Public Health Department

Immunization programmesInfectious diseases (T.B., HIV, STDs)Healthy Babies, Healthy Children

ProgrammeLactation supportSexual Health Clinic

Provision of Clinical Preventive Maneuvers

Preventive Care is an important part of Family Medicine

Many important determinants of health are largely beyond the scope of clinical intervention (socioeconomic factors, lifestyle decisions, pollution etc.)

Preventive Care Challenges

Competing priorities (underserviced areas)

“System” BarriersCommunity partners’ pressures

(Public Health, CCAC cutbacks.Inappropriate use of physician time.

Practice in an Underserviced Area

There are up to 10,000 people without a family physician in Brant (pop. 126,000)

BGH admits 2-10 patients daily who have no Family Physician (F.P.)

HRCC is asking us to assume care of Brant cancer patients who have no F.P.

We are daily asked to take on new patients by colleagues, patients, friends.

Ethical Dilemma

“Optimal care for a limited number of patients” vs. “Providing some care for a larger number of patients”.

Who is your commitment to: Your present patient population or the

community at large? Are you getting the biggest “bang for your

buck”?

Ethical Dilemma

Hence in underserviced areas, preventive care can take a back seat to more acute medical needs

“System” Road Blocks to Preventive Care

FFS system does not support the infrastructure to allow FFS physicians to optimize preventive care services. (E.g. Hire the most appropriate/cost effective staff to provide these services, install and maintain databases which will allow for outcome measures and recall systems etc.)

“System” Road Blocks to Preventive Care (cont’d)

The Ontario Fee Schedule does not reflect support for preventive services.

Community Partners’ Pressures

Community services are facing shrinking resources.

This often results in difficulties such as communication problems due to limited hours, voice mail, manpower limitations.

Programs are cut back.

Inefficient Use of MD Time

Suboptimal public education regarding management of minor illnesses (e.g. colds, flu)

Inordinate time spent negotiating the healthcare system (e.g.. arranging specialist consultation, accessing test results)

Optimizing Interaction with Public Health to Improve Preventive Health Care

Present Strengths

The human connection (MOH attending department of family practice meetings)

Periodic letters outlining health unit programmes/changes etc.

The Future

WE ALL WANT TO IMPROVE THE HEALTH OF PATIENTS

It is often difficult to judge the effectiveness of preventive interventions

We need good quality data, and need to be able to measure in some concrete way an intervention’s effectiveness.

Information Technology

This calls for I.T., electronic medical records and databases.

Collection of good quality data at local and regional levels

Allows for easy production of recall lists

Health Unit’s Role

Utilizing and supporting data capture in family practices, the Public Health Unit/Health Council could use their epidemiological expertise to provide more analysis/outcome measures at a local level in a timely manner.

This provides the Family Physician needed feedback and validates the utility of the intervention.

Community Based Group Family Practice in a Fee For Service (FFS) Model

John Hadley OD. MD. CCFP.