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Ross  E.G.  Upshur BA( Hons Ross  E.G.  Upshur BA( Hons

Ross E.G. Upshur BA( Hons - PowerPoint Presentation

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Ross E.G. Upshur BA( Hons - PPT Presentation

MAMDMScCCFPFRCPC Head Division of Clinical Public Health Dalla Lana School of Public Health Scientific Director Bridgepoint Collaboratory for Research and Innovation Assistant ID: 934722

health care treatment complex care health complex treatment social problem solving model aging patients patient primary healthcare providers collaborative

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Presentation Transcript

Slide1

Ross E.G. Upshur BA(Hons.)MA,MD,MSc,CCFP,FRCPCHead, Division of Clinical Public Health, Dalla Lana School of Public HealthScientific Director, Bridgepoint Collaboratory for Research and InnovationAssistant Director, Lunenfeld Tanenbaum Research Institute, Sinai Health SystemProfessor, Department of Family and Community Medicine and DLSPHUniversity of Toronto

Some thoughts on multi-morbidity and complex patient populations

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BabylonNext in ingenuity to the marriage custom is their treatment of disease. They have no doctors, but bring their invalids out into the street, where anyone who comes along offers the sufferer advice on his complaint, either from personal experience or observation of a similar complaint in others…Nobody is allowed to pass a sick person in silence; but everyone must ask him what is the matter.

Slide5

The Challenge

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Chronic Health ConditionsDenton and Spencer 2010Canadian Journal on Aging

Slide7

Schaink et al.

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Patient Complexity

Mental

Health,

Addiction,

Cognition

Social Determinants of Health

Multiple Concurrent Complex Conditions

± Aging

CCAC

Primary Care

LTC

Specialty Care

Mental Health

Social Services

Acute Care

Complex Continuing Care

/Rehab

Emergency Department

System Complexity

Slide9

Alignment of Treatment GoalsProvidersCaregivers

Patients

Treatment Goals Aligned

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Interprofessional Model of Practice for Aging and Complex Treatments IMPACT PLUS: a comprehensive model ofAssessmentCare PlanningMentorship and training

Interprofessional problem solving model

Includes PCPs, CCAC worker, pharmacist, RNs, NPs, social workers, physiotherapist, OT, dieticians, trainees

PLUS

Psychiatrist & General Internist

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Healthcare Providers Collaborative Problem Solving and Decision MakingPatient and Healthcare Provider Collaborative Problem Solving and Decision Making

IMPACT

PLUS

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Patients :feel cared for and heard, given time to actually surface what is importantCo-develop care plans that focus on what is achievable given very diverse and complicated treatment burdensFamily caregivers: feel supported able to give voice to their stressfeel empowered to continue to deal with difficult and complex situations

Lessons learned

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Health Care Providers: experience true inter-professional learning, Are able to crowd-source solutions to complex problemsReduce stress/burnout through group support and validation that creates a “way forward” with complex patientsincrease their willingness to care for a challenging patient population

Find patients are

easier to manage in subsequent primary care

visits

Lessons learned

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ChallengesInnovative projects often not persuasive on their ownScale and cost considerationsMeasures are not necessarily well calibrated to the phenomenon Systems need to be rethought and reconfigured