Opinion

There is no debate – Patient Medical Homes are the way to go

“When Alexander saw the breadth of his domain, he wept, for there were no more worlds to conquer.”

I too weep.

Last year, I proposed an article to managing editor Jack Romanelli at Healthy Debate about Patient Medical Homes (PMHs). After reviewing the article, he tossed it back at me with great disdain and said, “This is Healthy Debate! Where’s the debate? Go find someone who will debate this! And get me more pictures of that menace Spider-Man!” (Ed. note: may be slight exaggeration on the Spider-Man part.)

So, I left Jack’s office in search of someone who would debate me on this issue. Like Cain in Kung-Fu, I wandered the land (I sent a few emails) in search of someone who would take the “No” side on this issue. Like Bruce Wayne, I honed my skills in a Chinese prison fighting hardened criminals (I talked to my friends about it) to train my body and mind for the coming battle. Like Maximus, I fought gladiators for the pleasure of Rome and stared down the Emperor with a steely gaze (my friends got tired of talking to me about it).

For those who don’t know, the community palliative medicine program at the Hospice of Windsor is one of those aforementioned PMHs: “In 2011, the CFPC (College of Family Physicians of Canada) presented the Patient’s Medical Home “as a vision for the future of family practice in Canada. The goal of this initiative is for every family practice in every community across Canada to be able to offer comprehensive, coordinated, and continuing care to their populations through a family physician working with health care teams.”

Further details are available at https://patientsmedicalhome.ca/

Given that palliative care is literally patient-centered medicine in action, it makes sense that a palliative medicine program should adhere to pillars of a Patient Medical Home.

Why do Patient Medical Homes matter?  Well, according to their website, their practices result in:

  • Higher patient satisfaction;
  • Improved access to appointments;
  • Higher provider satisfaction;
  • Reduced use of emergency departments and after-hours clinics;
  • Better management of chronic diseases.

In Ontario, the best example of a PMH is the Family Health Team (FHT).  Since 2005, 200 FHTs have been serving more than 3.5 million enrolled Ontarians across the province. Other interprofessional team-based models in Ontario include nurse practitioner-led clinics, community health centres, and Aboriginal health access centres.

To be a Patient Medical Home, one must meet 10 criteria:

10 Pillars of a Patient Medical Home:

  1.         Patient-centred care
  2.         Personal family physician
  3.         Team-based care
  4.         Timely access
  5.         Comprehensive care
  6.         Continuity of care
  7.         Electronic medical records
  8.         Education, training, research
  9.         Quality improvement and evaluation
  10.       Internal and external supporters

So, let’s break down our program and see how it compares:

  1.         Patient Centered Care – we had the initials “PC” before PC was PC so yeah, we provide patient (and family) centered care.
  2.         Each of our patients has an MRMP (most responsible medical professional). Each of our physicians either has a Certificate of Added Competency (CAC) or Royal College certified in Palliative Medicine.
  3.         Our interdisciplinary team includes physicians, RNs, RPNs, social work, volunteers, spiritual care and administrative support. We work closely with community nurses and nurse practitioners employed by Home & Community Care Support Services.
  4.         As a CPOC (Community Palliative On-Call) group, we offer 24/7/365 on-call support to all of our patients. We see new referrals within 3-5 days and can do same day/next appointments when necessary. We provide home visits, telephone and virtual visits through teleconferencing.
  5.         We provide comprehensive care at end of life. Prior to this, we provide care in parallel to patients who are still receiving care from their specialists and family physicians.
  6.         Our model provides continuity of care by providing 24/7 access to care, an integrated EMR, a dedicated locum for vacation coverage and interdisciplinary team meetings to review patients routinely. We also collaborate with our palliative colleagues in our local acute care hospitals, outpatient clinics and palliative care units.
  7.         We are on Cerner Millennium (a Java and Cloud-based automated EMR). As such, we are fully integrated with our local hospitals and cancer centre. As of June 1, our eReferrals will be through Ocean. Our team uses secure messaging to coordinate patient care.
  8.         The Hospice of Windsor is a hub for education in Erie St. Clair. Our nurse educators provide real-time support to community nurses as they care for patients in their homes. We are a training site for family medicine residents and PGY3s.
  9.         Our Centre of Excellence provides a focus on Quality Improvement through dashboards and we are evaluated through the Caregiver Voice survey and other metrics.
  10.       Our program is a product of our community and thus it behooves us to remain responsive to our community. We exist because our community needed this service and has shown unflagging support through its vision to help create this model and fund it through generous donation. We have a board and an executive director.  We regularly engage in strategic planning.

Why does this matter?

I can confidently say that our program meets the standard as a Patient Medical Home and operates as such.

First, we aim to provide high-quality care for all things palliative to the 400,000+ patients in Windsor-Essex. The PMH is the gold standard for a medical practice.

Second, we aim to be leaders in the field of palliative care and lead by example. I have often said that Windsor is small enough to get stuff (not the word I normally use) done but big enough to matter. We serve a large patient population and our model is easily transferable to other communities and scalable across the province.

Third, we have a healthy rivalry with neighbours in Sarnia and Chatham. While the Windsor Spitfires routinely spank the Sarnia Sting in the Ontario Hockey League, we also like to one-up them in a friendly game of “who can provide palliative care better.” Windsor and Sarnia boast Royal College and Focused Practice specialist level palliative care in all care settings including community, hospital, outpatient clinic, LTC and hospice. We both have residential hospices and a hospital-based palliative care unit to meet the demand for palliative placement in our region.  But like Bruno, we don’t talk about Chatham …

So, like Conan the Barbarian, I come back to Windsor after years in the wild and set up my throne (Muskoka chair) and lament the fact that no one has risen to the debate challenge (everyone kind of agreed with me that PMHs are the way to go).

As such, I think I can confidently say that our program meets the standard as a Patient Medical Home and operates as such. And the Ontario College of Family Physicians agrees. In 2018, we were the only focused practice in their history to win their prestigious Family Practice of the Year.

Oh, and the assessment tool at the www.patientmedicalhome.ca agrees with us too.

Finally, all good palliative care involves prognostication.  So in 2022, I foresee that The Medical Post is going to show some love to our PMP when it announces its Innovative Practice and Interprofessional Team Awards this fall because if we can pull off a Patient Medical Home in a focused practice, what is stopping every family and specialist practice from doing the same thing?

Thus ends the debate.

 

 

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Authors

Darren Cargill

Contributor

Dr. Darren Cargill is a fellow of the College of Family Physicians of Canada, the Royal College of Physicians of Canada, and American Association of Hospice Palliative Medicine. He is the past medical director for the Hospice of Windsor and Essex County and lead physician for its community-based Palliative Medicine Program. He is one of only two certified hospice medical directors in Canada and has his designation as a certified Canadian physician executive.  He received HPCO’s Larry Librach award in 2017 for excellence in leadership and advancing palliative care through mentorship.

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