DiscoverOne Nail at a Time: Insights for Building Your Patient's Medical Home
One Nail at a Time: Insights for Building Your Patient's Medical Home
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One Nail at a Time: Insights for Building Your Patient's Medical Home

Author: Alberta Medical Association

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Welcome to One Nail at a Time: Insights for Building Your Patient's Medical Home. This podcast brings together physicians and others from across Alberta to share their stories and tips related to building Patient's Medical Homes.
19 Episodes
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Join us as we talk to Dr. Ernie Schuster about practical strategies that physicians and clinic teams can take to provide timely access to care and optimize the opportunity for continuity of care.  Highlights include: Specific strategies to balance your supply of appointments with the demand for themThe value of eliminating ‘backlog’ for providing just-in-time careUsing the medical home team to increase efficiency(NOTE: To listen to Part 1, go to Episode 11: Tips for Enhancing Access with Dr. Janet Craig)Resources:HQCA Primary Healthcare Panel Reports
Join us as Dr. Karen Seigel shares the work she and her team have been doing focused on care of patients with COPD.  Some of the many highlights include:How patients with low relational continuity (<50%) are 7 times more likely to be admitted to hospital compared to those who see their own physician at least 80% of the time.How Dr. Seigel and her team used their EMR and HQCA reports to identify COPD patients at risk of exacerbation/hospitalizationHow the team shares the workload and focuses on streamlining clinic processes for COPD careUseful resources developed with the Health Quality Council of Alberta (HQCA)Simple steps teams can take to improve relational continuityResourcesHQCA Quality Exchange: https://hqca.ca/health-care-provider-resources/qe/primary-healthcare/
Join Dr. Heather La Borde and Dr. Brad Bahler as they discuss their mutual sense of grief and loss related to the changes and uncertainty that COVID has brought, as well as how they’re finding hope and taking steps to prevent burnout.AMA Physician and Family Support ProgramWell Doc AlbertaWould you like to learn more?The  Alberta Medical Association and Well Doc Alberta are offering a 1.25 hour session on physician wellness on Tuesday, June 16, from 7 p.m. – 8:15 p.m. entitled Physician Wellness: Feeling Distress, Understanding Loss and Finding Meaning.  During this session, physicians will have the opportunity to consider and better understand their distress during these challenging times. Along with knowledge offered by content expert Fleur Yumol, the webinar co-facilitators will guide you through short pauses for self-reflection and provide opportunities for sharing experiences with physician peers. This webinar is designed for physicians, but interested family members are also welcome to join.Register in advance for this Zoom webinar:https://albertadoctors.zoom.us/webinar/register/WN_qK1BhlH6T6KRNpw55_uqXw
Join us as we hear about the experiences of community physicians who are currently participating in the Community Information Integration-Central Patient Attachment Registry (CII-CPAR) initiative.  Featuring: Dr. Joseph Ojedokun, Dr. Steve Tilley and Dr. Chris Le CII-CPAR Primary Care Tools & ResourcesCII Specialty Tools & ResourcesAlberta NetcareAlberta Patients Survey Press Release
Join Dr. Heidi Fell as she discusses the Community Information Integration-Central Patient Attachment Registry (CII-CPAR) initiative.  CII-CPAR Primary Care Tools & ResourcesCII Specialty Tools & ResourcesAlberta NetcareAlberta Patients Survey Press Release
Dr. Rick Ward joins us again to talk about how his clinic is managing team, patient and physician wellness the during this challenging time.AMA Physician and Family Support ProgramWell Doc AlbertaAHS COVID-19 Information for AHS Staff & Health ProfessionalsSpecialist Link COVID-19 ResourcesAMA Covid-19 Resource Page
A PMH Culture of Joy with Kush BadshahJoy in work is not just about reducing burnout and increasing resilienceHow joy impacts primary care teams and also patientsSimple tips for creating a culture of joy in your clinicBe sure to check out IHI Framework for Improving Joy in Work.
Today’s podcast covers:Dr. Kim’s experience working with PCN CDM RN, Sharon Parmar, and how they worked together with patient Bill Olson to achieve great health outcomesThe importance of introducing team members to patients with intentionCommunication strategies in a busy practiceThe impact and influence of care team relationships on patient engagement – a little fun goes a long way!Resources:Introducing team members with intentionQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Dr. Janet Craig shares with us:Simple strategies for improving efficiency that lead to better access for patientsThe relationship between panel, continuity and accessResources:Panel Size: How Many Patients Can One Doctor Manage?This is just Part 1 of Enhanced Access!  Watch for Part 2, which will address issues like part time providers and locums.Questions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Today’s podcast covers:Supporting patients in self-management through an inclusive team approachUse of a patient portal and ‘virtual’ patient care through secure messagingLeveraging team to optimize patient careThe importance of the team ‘huddle’ – formal or informal, virtual or in personResources:Team Huddles Guide – scroll to ‘Test Box 2: Sample Huddle Checklist’Health Service Code 03.01S: Physician to patient secure electronic communicationQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Today’s podcast covers:The evolution of Dr. Ward’s practice from physician-based to team-based careHow a practice facilitator can support the clinic in developing team processes How sharing the burden of complex patients can impact physician and team moraleHow solo practitioners can practice a type of team-based careThe unexpected benefits of dealing with conflict in a team Resources:Training Opportunities for Practice Facilitators  https://top.albertadoctors.org/events/Pages/Core-Practice-Facilitator-Training-Sept-19-Oct-22-Oct-23.aspxHQCA Panel Report https://www.hqca.ca/health-care-provider-resources/panel-reportsQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Today’s podcast covers:The positive effects of relational continuity of care on patients, providers and healthcare systems, according to research – including the very significant reduction in patient mortality ratesHow continuity ‘weaves’ through and impacts the other Patient’s Medical Home implementation elementsIdeas for getting started, including conversations with patientsBeyond relational continuity – a description of informational and management continuityResources:HQCA Primary Healthcare Panel Report https://www.hqca.ca/health-care-provider-resources/panel-reportsTOP Continuity Clinical Practice Guideline  http://www.topalbertadoctors.org/cpgs/15981166Continuity posters for patients https://pcnpmo.ca/continuity/Pages/default.aspxCommunity Information Integration (CII) and Central Patient Attachment Registry (CPAR) https://top.albertadoctors.org/PMH/panel-continuity/CII-CPAR/Pages/default.aspxQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Today’s Podcast Covers:The value of care planning with patients with complex health conditions and how it can enhance continuity of careUsing the care plan document to share and receive information with other providers (e.g., pharmacist) about the patient and their conditions Engaging the clinic team to help coordinate and manage care planning activitiesHow care planning can lead to increased physician job satisfaction and improved health outcomes for the patientResource:Care Planning – tools & resources: http://www.topalbertadoctors.org/pact/toolsresources/Questions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Today's Podcast Covers:Difference between research and QIEach person in the clinic has a part in improvingWhere do you start with your clinic team?Importance of measuresWhere do I get QI skills?Quick Links:PMH Implementation Element Graphic: http://www.topalbertadoctors.org/file/guide-to-implementation-elements-pmh.pdfIHI (Institute for Healthcare Improvement) website: http://www.ihi.org/University of Calgary Department of Family Medicine Resident Manual: https://www.calgaryfamilymedicine.ca/Research/Resources/QI%20handbook%202018.pdfTOP (Toward Optimized Practice) Quality Improvement Guide: https://www.topalbertadoctors.org/file/quality-improvement-guide.pdfTOP Improvement Facilitator Training: http://www.topalbertadoctors.org/events/improvementfacilitatortraining/Questions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
Sit in as we discuss the opioid response with Dr. Christine Luelo. We discuss the role of primary care in Alberta’s opioid response, practical tips for primary care clinics to do this work effectively (using all of the team members), how to use non-judgmental language talking to patients and the importance of panel – knowing who your patients are.Primary Health Care Opioid Response Initiative:  http://www.topalbertadoctors.org/phc-opioid-response/Alberta College of Family Physicians: https://acfp.ca/tools-resources/tools-resources-opioid-response/Questions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
In this episode Dr. Joseph Ojedokun, Family Physician, and Lacey Barendregt, Registered Nurse, talk about the Patient’s Medical Home implementation element “Patient-centered Interactions”. Changing the conversation their team has with patients has resulted in increased satisfaction in the practice and improved outcomes for patients.  PaCT website:  http://www.topalbertadoctors.org/pact/APCC presentation link:  https://pcnpmo.ca/events-news/pastevents/2018%20APCC/The%20Complex%20patient%20.pdfQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
In this episode Dr. Lee Green, Family Physician and Health Services Researcher at the University of Alberta, discusses the international and local evidence in support of the Patient’s Medical Home model.  PMH Evidence Summary: http://www.topalbertadoctors.org/file/top--evidence-summary--benefits-of-pmh.pdfIF Training Link:  http://www.topalbertadoctors.org/events/improvementfacilitatortraining/Scaling up Primary Care Transformation Report:  https://primarycareresearch.ca/images/scaling_up.pdf#page=1Scaling up Primary Care Transformation Presentation:  https://youtu.be/pJHUjlJ8cR4General PMH Evidence:  http://www.topalbertadoctors.org/tools--resources/patientsmedicalhome/#pmhevidenceQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
In this episode Dr. Brad Bahler, Director of Primary Care Evolution in Alberta, discusses his personal journey toward achieving a Patient’s Medical Home model in his clinic that was driven by dissatisfaction with traditional family practice.General PMH:  http://www.topalbertadoctors.org/change-concepts/introduction/patientsmedicalhomeinalbertaGuide to PMH Implementation Elements:  http://www.topalbertadoctors.org/file/guide-to-implementation-elements-pmh.pdfCFPC A Vision for Canada: Family Practice The Patient’s Medical Home:   https://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdfPMH Evidence Graphic: http://www.topalbertadoctors.org/tools--resources/patientsmedicalhome/#pmhevidenceQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
What is a Patient’s Medical Home?  Where did the concept come from?  This inaugural podcast features two of the podcast’s hosts discussing a vision of the PMH in Alberta.  General PMH:  http://www.topalbertadoctors.org/change-concepts/introduction/patientsmedicalhomeinalbertaGuide to PMH Implementation Elements:  http://www.topalbertadoctors.org/file/guide-to-implementation-elements-pmh.pdfCFPC A Vision for Canada: Family Practice The Patient’s Medical Home:   https://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdfPMH Evidence Graphic: http://www.topalbertadoctors.org/tools--resources/patientsmedicalhome/#pmhevidenceQuestions? Ideas?  Leave us a comment or send an email to michele.hannay@albertadoctors.org
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