GP16

A Day in the life of a general practice, 2016

The future is already here — it’s just not very evenly distributed. William Gibson

0300h – Melissa, mother of Sophie, aged 3

Sophie has woken up with a fever and cough. I access the Careline Nurse via a video call through the After Hours Care website. The Nurse accesses Sophie’s history while I speak to her. We agree that I will give Sophie some Nurofen now and, if she does not improve quickly or I have any new concerns, I should video back and I will be transferred to the doctor on call for our nominated practice. She recommends I use my practice’s online appointment system to book Sophie a visit in the morning. It is reassuring to know that I can get an appointment for any member of my family on the day I need it.

0830h – Paul, GP Partner

Start with a coffee.

I open the clinical software and review my overnight notifications from the eConnect service, part of the National Health Record.
I read that my patient Malcolm Jones, 80, had chest pain last night and called the ambulance. He was taken to the Base Hospital. Malcolm had nominated our practice as his ‘medical home’, and I had recently updated his medical history in the National Health Record. Therefore Malcolm’s old ECGs, risk factors, past history and medication history were available to the ambulance and hospital teams when they needed them last night.

We are resourced to maintain this shared record through the AMHP (Australian Medical Home Program). We switched to AMHP in 2014. (Some practices chose to stay with the old PIP). Our practice aspires to provide comprehensive, patient centred care and the new program provides us with the resources we need to function as a fully-realised Medical Home. As such, we choose to be accountable for our patients care, even when they are not standing in front of us.

A summary of the Accident and Emergency team’s findings for Malcolm are available to me. Under the new ‘GP Inreach’ program in AMHP, Malcolm will be a dual admission – (physically) under the cardiologist of the day, the expert in the condition, and (virtually) under me, the expert in that patient. Our respective roles are quite clear. I can log in to the hospital system and access the current inpatient management plan, medication list, results and observations. I can also contribute to Malcolm’s inpatient record based on my knowledge about his other conditions, self management skills, confidence and home resources. I schedule a slot in my call time later on this morning to have a video chat with Malcolm. He’ll receive my call on his bedside monitor, which doubles as an education and entertainment unit, and he can also use it to communicate with his wife and family at home. By remaining involved I can ensure that his transition back to the community is as safe as possible. Patients and their families find it reassuring to know that their usual providers of care know what is happening to them while they are in hospital. There have been many problems identifed with transition of care. These are resolved when the community care team remains part of the patients care team while they are in hospital (there is no ‘transition’ of care – it remains shared). AMHP and the ‘GP Inreach’ program funds my contribution to the admission. The savings that result from waste reduction, decreased length of stay, and decreased readmission rates are large. 

Malcolm has been managed by our practice under the Integrated Care Program of AMHP, which replaced the EPC program. He has a number of medical conditions, and benefits from care coordination. He has an ‘Integrated Care Team’ that includes Donna  (our practice care manager), Caroline (our dietician), Leanne (our diabetic educator), Andrew (clinical pharmacist), Ben (physiotherapist), and myself. For the period of his admission, his team will now also include the hospital cardiology team. The hospital is able to identify all members of Malcolm’s care team, and the whole team will have received notification about his hospital admission. I task Donna to contact Malcolm’s wife and see if she needs anything at home while Malcolm is in hospital. Knowing Donna, she probably already has this on her to-do list.
There is also a notification from the After Hours line that they had spoken with Sophie’s mum about a fever and cough. I see that she has an appointment at 9.00 this morning with our practice registrar. I was on call for the practice last night. I guess the fever must have settled as it wasn’t escalated to me and I didn’t have to go and see her. You win some, you lose some. At least there is now a reasonable on-call rate for after hours coverage, supported by  ‘Healthy North Coast’ (our Medicare Local). The ability to have a video consultation at night is very helpful – sometimes there is nothing like ‘eyeballing’ the patient. There is appropriate remuneration for these virtual consultations and also on those occasions when you do get up to see the patient. The enhanced MBS that resulted from a major review in 2014 now aligns financial incentives with community benefits. Consequently general practice has become a favoured speciality.

0850h – Helen, Practice Manager

‘Access’ is shaping up well today.

Broadly speaking, we manage our patients in one of three ‘care streams’.

It is our practice philosophy that if any of our patients feel that they need an appointment on any particular day, we will see them. This is the ‘Acute Care Stream’. We know that every Tuesday there will be about 54 people who will need an ‘acute’ appointment, and we have reserved 54 appointment slots for that purpose. They will be seen in the Acute Treatment Area by the On-Call team for the day.

The ‘Routine Care Stream’ is for patients requesting a non-urgent consultation, who will generally value seeing their usual GP. We actively manage our appointment system, measuring our demand and matching it to our supply of clinicians. We are proud that the ‘Third Available Routine Appointment’ in our practice is now 3 days. We measure this as part of our participation in GPIP2, and this figure is submitted monthly to our Medicare Local through the ‘improvement portal’. We know that many practices have a shorter wait, but we have improved significantly. 12 months ago there was a 7 day wait for a routine appointment. We also regularly measure the satisfaction of our patients, clinicians and staff with the appointment system. By submitting and tracking these measures we can be sure that the changes we make are leading to improvement.

The third care stream is the ‘Integrated Care Program’, which is for patients with chronic or long term conditions. We are proactive in chronic disease management. Patients in the Integrated Care Program are booked with their usual GP and their Care Manager on a regular basis under an annual Care Calendar.

My role as practice manager leads to better outcomes for our patients. I develop the systems and gather the resources that are needed by the clinic to provide accessible, safe, sustainable and high-quality care.

0900h – Liz, Practice Nurse

Today I’m working in the Acute Care stream of the practice. I’ll be working with Joy (another practice nurse), Dr Jimmy (a partner) and Dr Anthea (one of our registrars). We’ll also have the students Kirby (medical), and Janine (nursing) as part of our team. In addition to acquiring new clinical skills, they will learn how to operate as a team in a medical home model. We feel it is important to ‘give back’.
The Infrastructure Grant that we received in 2013 enabled us to greatly expand our acute treatment area, and now it is ideally suited to the team approach we use in the practice. We have four resuscitation beds, four treatment chairs, and four consulting rooms. This is a great improvement on the space we previously had available as ‘the nurses room’. Here we will see all those patients who have made appointments with conditions that they feel needed to be seen today, as well as people who need dressings, immunisations, or have been asked to come back for quick reviews.

I take our first patient, Sophie, into one of the consulting rooms. Sounds like a rough night for her mum, Melissa. I check Sophie’s observations and write in her record. 

The resources we receive under AMHP facilitate this team based approach to care. Our nurses work at the top of their skill set, and we leverage the doctors time so that they can spend more of the consultation focused on the care needs of the patient and less time doing ‘wasteful’ things. While Anthea is seeing Sophie, I take the next patient, Bob, into another consulting room. He has already entered his reason for coming in today by using the tablet computer in the patient’s lounge (previously known as the waiting room). He was also able to use the tablet to check that the clinical summary we have about him is accurate and that the medication list we have for him is current. His observations are automatically entered into the clinical record by the scales, thermometer and sphygmomanometer. He has had some blood in his urine, so we collect an MSU and do a UA ready for the consultation.

I return to Sophie and Melissa after Anthea has seen them. Anthea has asked Melissa to ring her in two days time to report on Sophie, and I check that Melissa is confident that she has the information she needs, and knows what to do if Sophie gets worse. The clinical software indicates that Sophie’s immunisations are due, so I remind Melissa to bring her back next week to see me. 

0915h Anthea, GP registrar.

Bob, 65, is the second patient of the day. He has had painless haematuria for the last two days, and his UA is certainly positive for blood. Liz has it bottled, ready for sending off, and I click the ePath referral.

When I enter ‘haematuria’ as the presenting complaint in the clinical record, the ‘Health Pathway’ for haematuria automatically opens. This web based pathway was developed by a local team of clinicians, including GPs and urologists, and provides a recommended set of ‘next steps’ for Bob. Previously there had been a significant delay in obtaining a urology appointment, but during the process of developing the pathway, haematuria was identified as a priority referral. There is a contact number in the Pathway for Bob to get an expediated appointment. The ‘Health Pathway’ advises me on the correct work-up before that consultation, and how to access the recommended investigations. When he sees the urologist he will not need to be sent away for more preliminary tests, and then have to make a second appointment to discuss the results. Reducing this ‘rework’ has improved access to specialist care. Unnecessary investigations are also avoided. I am new to town, and I am glad that the Bob’s access to care is not dependent on me being able to pull favours with the urologist’s receptionist. Liz makes sure our practice team books the necessary appointments for Bob, and ensures that he is confident he can complete his ‘chores’.

AMHP provides the resources that are needed by the practice to fund this level of decision support capability, and also funds the resources, tools and teams I need to make my job easier.

1000h Donna, Nurse Care Manager

I work in the Chronic Care stream of the practice. Patients in this stream have long term conditions, and have nominated our practice as their ‘Medical Home’. They are being managed under the new AMHP Integrated Care Program, which provides us with a block of funding for managing their care proactively and systematically. This enables me to be employed as the Care Manager, as well as funding other essential resources.

Shirley, 75, is our next patient. We last saw her here three months ago, and I call her by phone at least every six weeks to check how she is managing. I have previously visited her at home. Wal, her husband, has recently gone into a residential facility. She is very sad that this has come to pass.

I work with our patients on goal-setting, lifestyle modification, and improving self management skills and confidence. Shirley and I identify each member of her ‘Integrated Care Team’, which includes myself, her GP Dr Michael, our clinical pharmacist, the community nurse, an orthopaedic surgeon, the local physiotherapist, a diabetic educator, and a cardiologist. We make sure that there is ‘informational consistency’ between all members of the team, including shared goals and targets. We use the 10CC framework for chronic condition consultations to make sure we cover all bases at each visit.

We run through her recent results, and compare those to the targets we have set. We talk about her confidence in managing her health and explore ways to improve her confidence. We make sure that she has the appointments she needs and transport to them. We also keep track of her preventative health activities. 

It is relief to me that under the new streamlined AMHP Integrated Care Program I am no longer responsible for keeping track of which EPC Item Number we are due to claim. I am a valued partner in Shirley’s care, and I find it satisfying to be working in this role with each patient, their family and their usual GP.

Shirley will now see Dr Michael, and then our diabetic educator. I make a reminder to myself to ring her in four weeks, and I book her next review appointment in three months time.

1030h Michael, GP Partner

Today I’m working in the Chronic Care stream. Donna has already seen Shirley, my next patient. The work done by Donna and the team free me up to work with Shirley at a more ‘strategic’ level.

I have had recent consultations with Shirley by telephone and also by video conference. The GPIP2 block funding means that consultations can be done by the right person using the right tools. I know that Shirley has been very concerned about Wal going into aged care. We have the opportunity today to have a good talk about this.

I have access to communication from other members of Shirley’s care team. We review the outcomes of these visits and ensure that their recommendations are followed.

We review her overall health and her concerns, and make sure that she has everything she needs to manage her care before we see her again in three months. She is confident that she knows what to do if she has an exacerbation of her symptoms. 

Success in Chronic Disease Management is very much concerned with the management of multi-morbidty. 50% of our patients aged over 65 have three or more chronic conditions, and 30% have five or more.

Chronic Disease Management is not about producing a piece of paper which can be waved as ‘the Care Plan’.
 
It is about practicing in a very proactive and systematic way, providing regular scheduled patient contacts as well as having timely mechanisms for dealing with acute problems. It is about ensuring that each patient has an ‘integrated care team’.

It also requires a focus on ‘the real work’, which is the work carried out by the patient and their family in their own home. Shirley says that we have a partnership in which she has to do all the work!

Our Integrated Care stream has delivered tremendous improvements in our patients’ self management skills. It has measurably improved their health outcomes and has also improved the satisfaction of our clinicians. By measuring key outcomes, we are sure that our care is improving.

The AMHP funding means that these improvements are sustainable.

1130h Shirley, Patient

At the practice today I have seen Donna and Dr Michael, and also Leanne, the diabetic educator. I am very happy to receive all this care on the one occasion. When I do see health professionals in different locations, such as Ben, my physiotherapist, I am glad that they are up to date with what is happening to me. I always found it surprising that I was often the one responsible for communication between my providers. “What did the cardiologist say? What dose are you on now?” I am more confident in managing at home by myself, and my care feels ‘joined up’. It is good to be able to ring the clinic and speak to Donna when I am worried. I know that she lets Dr Michael know what is happening, and I can talk to him, video chat or come in to see him if I need to.

I am also glad that Wal will still be cared for by his usual GP and the team, even though he has gone into the nursing home.
My daughter lives a long way away. However, she is able to access Wal’s and my history, medications and results through the National eHealth record. She finds this reassuring, and I find it helpful. It is hard to remember everything I’m meant to.

1330h Jimmy, GP Partner

Today I have one hour of ‘protected time’ to meet with Helen, our practice manager, and review our practice systems and patient outcomes. This is part of the Quality Improvement stream in AMHP.

Each month, we collate clinical indicators from all our patients with specific conditions to determine whether our care is effective. We know that 54% of our 322 diabetic patients have a HbA1C less than 7%. This figure was 44% 12 months ago. We know that 89% of our patients with Coronary Artery Disease are on an anti-platelet agent. 

We also collect other measures related to preventative care, appointment times and patient satisfaction. For example, we know that 69% of eligible women have had a PAP smear – this figure was 75% two years ago. It seems we have a problem. We will work on a practice approach to improving this figure.

We submit a large number of clinical indicators each month to our Medicare Local, Healthy North Coast, via an improvement portal. We receive feedback as to how we are tracking over time against our previous results. We can also compare our outcomes with other practices in our region, and indeed nationally. 

Although we collect many clinical indicators, the ones we particularly track at any point in time are of three kinds. Some, such as PAP smear rates, have been chosen as a national priority for this year. Others, such as childhood immunisation rates, have been chosen as a regional priority by Healthy North Coast. And others, such as appointment delays, have been chosen by our own practice as a local priority. The AMHP QI Program is therefore somewhat flexible on the outcomes that we report against.

AMHP provides us with the funding that we need to have our staff participate in this Quality Improvement Program. We need ‘protected time’ to measure and evaluate our systems for providing care. We also have regular whole of practice meetings where we review our progress on these indicators, and explore better ways of delivering care. Healthy North Coast runs a local and regional ‘Kaizen’ program where we share our ideas and improvement experiences with our neighbouring colleagues.

AMHP is not a ‘pay for performance’ program, but rather a ‘pay for improvement’ program. It gives us the resources we need to participate in a quality improvement program of this kind.

1400h Paul, GP Partner

This afternoon I am rostered for rounds at the local Aged Care Facility. With the support of Healthy North Coast, our clinic medical records are now integrated with the nursing home records.

I am accompanied on my round by the RN at the facility. I think we work well together as a team. When I see Wal, I can access and update his clinical information on my iPad 7. Medication management has been ‘sorted’, so that there is one electronic medication chart for each resident. This same chart acts as a PBS prescription, and is used by the staff on their dispensing rounds. Having one ‘point of truth’ has immeasurably improved patient safety, and we have been able to get off the merry-go-round of paper work. Of course, Wal’s clinical information is available on the National Health Record, where there is also a copy of his Advanced Care Directive.

AMHP has provided us with funding to provide telehealth consultations via an RN at the facility, and also adequately remunerates telephone calls and eConnect messages between the facility and the practice. These measures, and the solving of the paper work issues, have made it much more rewarding professionally and financially for GPs to provide comprehensive care in Aged Care Facilities.

1530h Ben, Physiotherapist

I’m a physiotherapist working in private practice. One of my clients today, Shirley, has severe degenerative osteoarthritis of the lumbar spine, and I see her on a regular basis as part of her Integrated Care Team. The AMHP program has significantly increased the number of occasions on which patients can receive care from allied health providers. I share many other clients with the Clinic, not all of whom have long term conditions. Some present to me as first point of contact. For example, Melissa has recently come to see me with an acute knee injury sustained while on a family skiing holiday. With the technical support of Healthy North Coast, the clinical record we use can now share all the investigations, assessments and treatments provided by each member of a care team. I can therefore access the information I need to provide top quality care. I also keep Shirley and Melissa’s medical home and their wider care team informed about my findings and their progress. We have consistency of clinical information, roles and goals.

I was concerned that the ‘Medical Home’ model would restrict access to the services I provide. However working as a member of each persons Integrated Care Team as part of the ‘Medical Neighbourhood’ has improved outcomes for my clients, has increased my professional satisfaction by reducing clinical isolation, and has made a positive impact on my practice’s bottom line.

1600h Andrew, Clinical Pharmacist

Clinical pharmacy is a relatively new role in a Medical Home. However, it is already hard to imagine how the team would get by without it.
Today I have prepared for the inhouse evidence based education session that we hold each fortnight. Part of this involves an audit of our medication use. We actively monitor adverse outcomes and ‘near misses’ and we participate in a national post-marketing medication evaluation program, I have completed three home medication reviews, researched a number of queries from our doctors and had ‘corridor consultations’ about a number of patients. I am first point of contact with our local retail pharmacist. Today I have reviewed the records of all the patients who have requested repeat prescriptions, which they do through our practice web portal. If they fall into the category delegated to me by the patient’s usual doctor, I have sent a repeat eScript to the national repository. As the GPs become more familiar with my role, I find that the quantum of delegated medications increases.

1700h Robyn, patient

I am chair of the clinic’s Patient Advisory Group, which is having its bi-monthly meeting this afternoon. Ten patients of the clinic, acting as ‘critical friends’, meet with Dr Jimmy, Helen and Liz to address issues of concern to the practice. We can also raise our own issues. In the past, we have discussed the adoption of the National Health Record, and also the physical redesign of the surgery that was possible after the Infrastructure Grant was awarded.

Today, we will review the results of the annual patient survey. This addresses patient satisfaction with care, clinic administration, waiting times and other issues. We assist the practice in identifying those factors which require improvement, and what might be done.
It is good to see that the practice recognises that health outcomes are better when those who receive the care are involved in the design of that care. 

The practice has a stated mission of providing the best possible care it can for its community. The patient advisory group and the practice have defined three aims

1. to improve the health of our patients, 
2. to improve the satisfaction of our patients with the care they receive and the satisfaction of our staff and clinicians in providing it,
3. to do this sustainably by improving the practice bottom line.

The changes made as part of AMHP (General Practice Improvement Program) have made it substantially easier to achieve these goals.

References

A day in the life of a GP, circa 2005 (Tony Lembke, 2002)

http://practiceimprovement.com.au/2002/04/a-day-in-the-life-of-a-gp-circa-2005/

A Day in the Life of the CEO of a Medicare Local : 2013 (Tony Lembke, 2011)

http://practiceimprovement.com.au/2011/04/a-day-in-the-life-of-the-ceo-of-a-medicare-local-2013/

(In 1975, I remember that we had to write an essay on what life would be like in the Year 2000. It remains a great disappointment that my predicted flying cars and robot dogs did not come about. In 2002 and 2011 I wrote the articles above. Doing another predictive essay this year can therefore be seen as a triumph of hope over experience’)

What is a Medical Home? (Australian Center for the Medical Home)

http://medicalhome.org.au/what-is-a-medical-home/

A Quality General Practice of the Future (RACGP Position Statement, Di O’Halloran)

http://www.racgp.org.au/download/Documents/Policies/Health%20systems/quality-general-practice-of-the-future-2012.pdf