Tara Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team and the Fidani Chair of Improvement and Innovation at the University of Toronto.
I have never been so grateful to be part of a team.
Every day, I feel overwhelmed by the mountain of information coming to me via the newspaper, radio, social media, and worst of all, my own email inbox. Sifting through what is important and deciding how to change practice often seems like an impossible task. But thankfully it’s one I don’t need to do alone.
In my clinical practice, I have the luxury of being a follower.
In the last month, our primary care team has rallied to change the way we deliver care several times over. Like others, our focus has been on providing accessible, equitable patient care while keeping patients and staff safe. These changes have only been possible because of the leadership of many.
Like most outpatient practices, we pivoted quickly to minimize in-person appointments. Clinicians and clerical staff worked together to call hundreds of patients to change their booked appointments – cancelling them or changing to a phone visit. We made the difficult decision to defer non-urgent visits including cancer screening and stable chronic disease follow-up.
We designated specific clinic times for in-person assessment of patients at high-risk of COVID-19 complications to minimize their contact with symptomatic patients.
At first, clinicians conducted most phone visits from clinic. These phone visits were interspersed with the occasional in-person visit. But to conserve PPE and avoid infecting each other, we soon agreed physicians should limit the number of days they saw patients in-person and work remotely the rest of the time. Physicians in clinic would rotate and provide in-person coverage for patients of physicians who were not in clinic.
Members of our team organized a mass sign-up for OTNhub, Ontario’s free video visit platform, for all of our 80 physicians to use for patient care. One of our staff did the paperwork, all we had to do was sign. Members of our team developed guidance on using video visits, gave (virtual) grand rounds on integrating virtual visits into practice, and developed tip sheets to troubleshoot common challenges when working remotely.
Clerical staff, nurses, physicians, and managers worked together to develop and implement screening and assessment algorithms. Time and again, I have relied on the clear guidance from our team when deciding who should be told to stay home, who should go to a COVID-19 assessment centre, and who should be seen in the emergency department.
Most inspiring has been our team’s immense efforts to support those left most vulnerable to COVID-19 complications – complications from the disease itself or from the social and economic consequences of the shut down.
A group is proactively reaching out by phone to patients who are at risk of complications, including those who are immunocompromised, those with mental health and addictions and those who are homebound. At-risk patients were identified through a search of our electronic records and by individual clinicians. Our team has pulled together a shared drive with folders of resources to help support patients facing challenges with employment, housing, income, and food security. We have developed in-house guidance about what to do when someone who is homeless presents with COVID-19 symptoms. Team members have also circulated information to support advanced care planning and end-of-life care at home. And, shortly after the government announced liquor stores would be closed on two of three days of the Easter long weekend, one of our physicians sent around guidelines for managing alcohol withdrawal in the community.
Our in-person volumes have decreased dramatically. To further conserve PPE and reduce staff exposure, we have recently made the difficult decision to physically amalgamate our sites and allow patients to be seen in person at only two of our six clinics. But members of our team are rightly worried about how in-person service closures will affect patients who are used to arriving without an appointment. So, as one strategy, they have organized donations to fund cell phones that we can hopefully start distributing to patients in need.
Our team will no doubt continue to evolve the care we deliver in the coming weeks and months.
But we are among the lucky.
We are among the minority of family practices in Canada where physicians work alongside other health professionals. Unlike most doctors, our physicians are paid by capitation so are not suffering the same degree of reduced income faced by fee-for-service colleagues. We operate as part of a hospital so we have better access to PPE than our community colleagues. We are also a large multi-site organization with established governance and distributed leadership which gives us more opportunity to learn from each other and efficiently provide care to our population.
Many family doctors have been wanting to move to a team-based, capitated model but options have been closed in Ontario for years. Perhaps others have been held back by potential downsides including more compromise and less autonomy. But, to me, the benefits of being part of a team have never been more clear.
Perhaps it should be titled owed to our primary care team