Environmental Scan - Government of Nova Scotia

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Physician Resource PlanningAn Environmental ScanFigure 31 Collaborative Care - Cost comparison between Nova Scotia Current State and U.K. ModelPositive financial benefits are achieved if the U.K. Primary Care Trust experience of a GP to GP Practice Nursepatient ratio of 1.9:1.0 is applied compared to 2.8:1.0 (1,124 to 400) in the preceding costing analysis based onlimited experience in Canada. Applying a ratio of 1.9:1.0 implies a collaborative care practice of 1,728 patientsper GP/NP, well above the provider financial payments breakeven point. A saving of $28.4m (next figure) ispotentially achievable using the U.K. model of collaborative care.Collaborative care is integral to the Nova Scotia long-term health system strategy. The above analysisunderscores the need for evidence-based quantitative and qualitative research and analysis on collaborativecare teams to ensure value for money in both the qualitative and quantitative sense is achieved.The same Ontario Panel noted that about 197 midwives were licensed to practice in Ontario and approximately40 more enter practice each year. At the time, the typical caseload for each midwife was 40 deliveries per year(less than one per week) and a significant proportion of those deliveries (25% to 30%) involve shared care withan obstetrician/gynecologist. Anecdotal reports indicate many of the obstetrician/gynecologist interventionswere required for administrative rather than clinical reasons.8.5 Primary Health Care RenewalHealth Canada, through the primary health care transition fund, has invested in the belief that the RomanowCommission 29 statement of “…high-quality, effective primary health care services have profound implicationsfor the entire health care system.” The final report states, "there is almost universal agreement that primaryhealth care offers tremendous potential benefits to Canadians and to the health care system ... no otherinitiative holds as much potential for improving health and sustaining our health care system." A target was setand agreed by first Ministers to a Health Care Accord that identified to a target of 50% of Canadians having24/7 access to an appropriate primary health care provider by 2011.The College of Family Physicians of Canada (CFPC) strategic plan emphasizes that access to comprehensivecontinuing care in a family practice setting is the cornerstone of high-quality health care for the people ofCanada.The Canadian Medical Association (CMA) in its policy for principles to guide health care transformation inCanada states unequivocally, “A strong primary care foundation and collaboration and communication withinand between health professional disciplines along the continuum are essential to achieving patient-centredcare.”The American Academy of Family Physicians conducts a regular assessment of PRP. Among its chief concerns isthe increasing generalist-specialist imbalance in the United States, undermining the nation’s ability to achieve29 Romanow, R., Building Values The Future Of Health Care In Canada, Nov/2002.62 | Page Social Sector Metrics Inc. & Health Intelligence Inc. | 12/31/2011
Physician Resource PlanningAn Environmental Scanuniversal health care access and limits its ability to meet needs of underserved rural and urban populations 3062% of the US physician workforce is specialists.The Council on Graduate Medical Education and the Association of American Medical Colleges have called for50 percent of U.S. medical graduates to enter generalist careers. In Nova Scotia (section 13) 42% of Full-TimeEquivalent (FTE) physicians are general practitioners and 50.5% as generalists (general practice, generalsurgery, general internal medicine, and general paediatrics). CIHI 2008-09 data reports 58% of the nationalphysician workforce FTEs are general practice with a range from 51% in Nova Scotia to 63% in Saskatchewan.Initiatives focused on strengthening primary care have and continue to be developed and implemented acrossCanada.8.6 Hospital Inpatient CareHospital inpatients, particularly in tertiary settings, are increasingly acute as measured by prevalence ofcomorbid conditions, multi-system dysfunction, and patient age. Subspecialization has contributed to thefragmentation of inpatient care. Hospitalist programs are 95% staffed by family physicians 31 . A school ofthought is inpatient care will be enhanced if a GIM specialist is involved early in the admission process to ahospitalist unit (Raju M., DFM, Kassen B., St. Paul’s Vancouver). Raju and the Canadian Society of InternalMedicine propose a model of one GIM from a formal community-based rotation per 36 inpatients. Theproposed model sees the GIM specialist in a consultative role to family physicians and as a direct bridgebetween family physicians and subspecialists 32 .One of the first major studies (76,000 admissions across multiple facilities between 2002-2005 and acrossseven target diagnoses) of hospitalist cost and quality was published in 2007. The USA-based study found littleor no difference in cost or quality of care between patients cared for by family physicians, GIM, orhospitalists 33 . They did find a small reduction (0.4) in length of stay without adverse effect on death rate orreadmission for those managed by hospitalists. In the USA 75% of hospitalists are general internists, 11%general paediatricians, and only 3% family physicians 34 . Hospitalists work a median of 1,833 inpatients on wardshift hours (206 shifts, 8.9 hours per shift) plus 1,139 call hours (82 days on call, 12.8 hours per day on call).The findings of the major study suggest caution in launching into any one particular model. Currently in NovaScotia 39.8% of all hospital admissions list a family practitioner as the most responsible doctor service. 33.5% ofadmissions within DHA 9 are also family practitioner.30 American Academy of Family Physicians, Family Physician Workforce Reform: Recommendations of the AmericanAcademy of Family Physicians (AAFP Reprint No. 305b), 200931 Ennis, E.M., Latest Developments in the Hospitalist Model: A New Paradigm for Inpatient Care. Canadian Hospital SurveyResults. Insight Conference. Toronto. June 16, 2004.32 Raju, M., The Care of Acute Medical In-Patients – Whose Job Is It? Hospitalist Program in Canada, Care-Fully: Defining aPlan for General Internal Medicine in Canada, Canadian Society of Internal Medicine, October, 200533 Lindenauer, P.K., Auerbach, A.D., et.al., Outcomes of Care by Hospitalists, General Internists, and Family Physicians, NEngl J Med 2007; 357:2589-2600, December 20, 200734 The SHM 2005-2006 Survey: The Authoritative Source on the State of the Hospitalist Movement.63 | Page Social Sector Metrics Inc. & Health Intelligence Inc. | 12/31/2011
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3 KEY OBSERVATIONS3.1 IntroductionP
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Environmental Scan - Government of Nova Scotia

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