MAMDMScCCFPFRCPC Head Division of Clinical Public Health Dalla Lana School of Public Health Scientific Director Bridgepoint Collaboratory for Research and Innovation Assistant ID: 934722
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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
Slide2Slide3Slide4BabylonNext 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.
Slide5The Challenge
Slide6Chronic Health ConditionsDenton and Spencer 2010Canadian Journal on Aging
Slide7Schaink et al.
Slide8Patient 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
Slide9Alignment of Treatment GoalsProvidersCaregivers
Patients
Treatment Goals Aligned
Slide10Slide11Interprofessional 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
Slide12Healthcare Providers Collaborative Problem Solving and Decision MakingPatient and Healthcare Provider Collaborative Problem Solving and Decision Making
IMPACT
PLUS
Slide13Patients :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
Slide14Health 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
Slide15ChallengesInnovative 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