Team-based health care is not only beneficial for patients but could improve Ontario’s health-care system on a whole. In this episode, we hear from Dr. Allan Grill and Dr. Catherine Yu who share their experiences and hopes for the future of accessible team-based care in the province.
Team-based health care is not only beneficial for patients but could improve Ontario’s health-care system on a whole. In this episode, we hear from Dr. Allan Grill and Dr. Catherine Yu who share their experiences and hopes for the future of accessible team-based care in the province.
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Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association.
On this podcast, doctors discuss the benefits of team-based health care on patients, wait times, and the system as a whole. Dr. Allan Grill is chief of family medicine at Markham Stouffville Hospital and lead physician of the Markham Family Health Team. Dr. Catherine Yu is a family physician and is the medical director of the Health Access Thorncliffe Park Community Health Centre, which is part of the East Toronto Health Team.
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Dr. Allan Grill: Team-based care is important primarily because I think it takes the focus on the patient. The typical family medicine practice where you might have one or two docs, maybe you have a nurse — here you have a team of people that's all focused on one goal and that goal is to improve patient care. And because you have a team in front of you, you actually have more resources to serve that patient than you would in another model.
It's a much more integrated, patient-focused model when you're dealing with a team in-house that knows each other and has a common goal and can communicate easily as opposed to the classic siloed situation where you have one provider, they might need to refer out to somebody else they don't know that well.
You can't just walk down the hall and find out, "how's the patient doing?". You'd have to somehow phone or maybe email, depending on how you can communicate with that other person, and that's just one of many examples where you not only increase efficiency in your office, you increase efficiency for the patient. And you create a model where everybody's focused on the same client who already has working relationships, and then they're going to just strengthen that overall relationship with the patient.
So, if I'm super busy and I don't feel like we give the patient what they need, it's very easy for me to refer. But it's going to take months to get into a psychiatrist, potentially. And so every patient I can prevent referring — because I'm doing it within my scope of practice, I have the time and I have the staff in-house — not only is that going to decrease the clogging up of our healthcare system for specialists, but it's actually going to allow the more complex patients that really need to see that specialist get access quicker. It opens up things for the specialist. I think it saves money because now you're not having unnecessary referrals where OHIP is getting charged.
Secondly, the whole point of having a specialist in your office isn't just to see patients – that’s part of it – it's also to have an educational resource. So, physicians like myself who want to learn more about managing complex cases, we're referring to our colleague, but then we're learning from them, we're getting experience, maybe we realize the next time we can do it on our own.
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Dr. Grill: If you have somebody that has anxiety or depression and they need just a multidisciplinary approach to that problem — so they need counseling, they might need stress management, they might need family dynamic management, they might need medication — it's much easier doing it in a team-based approach, because you have different people that can intervene.
So, we're all sort of using our scope of practice together to manage that patient. And by doing it that way, it opens up opportunities so other patients aren't waiting to get in to see us, and it's avoiding a potential referral. I'm actually helping the system by creating a team of professionals to have a more broad scope of care, to not have to refer everything out. That's what we call comprehensive, team-based, primary care.
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Dr. Grill: Right now, if you look at family health teams and community health centres, that care, which is team-based, only represents 25 percent of Ontario's population. So, if you ask me if we're doing well, I'd say that 25 percent is doing well. I'd say there's 75 percent of the province that still don't have access to team-based care.
It's increasing with Ontario health teams, but remember, we're only in year two. They're quite immature, it's going to take a while to rev them up. Some of these concepts are very foreign to other health care professionals that haven't worked in this type of model.
One of the things that the Association of Family Health Teams of Ontario has been very good about is giving advice to the OMA and to the Ontario health teams in terms of governance principles. So, what does a board look like? What does accountability look like? What's it like to set deliverables? Because these aren't easy concepts. Before I was in a family health team, I went to work, I saw my patient, I hoped I made them better. There weren't these other principles behind it. So, I think we need more team-based care.
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Dr. Grill: I remember there was this one guy who presented with fever and a cough. He had a COVID test, it was positive, my nurse practitioner called them up — sounded pretty good on the phone, he wasn't huffing and puffing, but as she was going through the questions, he basically hit a bunch of the red flags. And she said to him, “I think you need to come to hospital.” And he's like, “I'm not coming to hospital, I feel fine. Coughing a little, I got this fever, I'll be fine.” She's like, “I really think you need to come to hospital.” She spent about 10 minutes with him on the phone, convinced him to come to the hospital — the next day he was intubated in the ICU. Now, can you imagine what would have happened to this guy if, A, he didn't listen to us, and B, there was no COVID at Home program.
So, this is an example of where you have a group of health care professionals bringing the care to the patient – because this was a virtual program – and making decisions that actually have an impact on saving lives. And for the ones that didn't have to go to hospital, by the way, think about how that helps the system.
I can't stress enough this idea that, because we're one team and we get to know each other and we have access to the same electronic medical record. It's like a family. So, when I'm struggling with a patient, I'm not embarrassed — I'll walk down the hall to one of my colleagues, whether they're a doctor, a nurse practitioner, a pharmacist, and I'll say, "I need some help, can I run something by you?" In real time. There's no guessing game.
We all have a common goal, working together. And the more you work together, the more you build relationships, the more efficient you become, the more confident you are to start new programs, to be innovative. Having it all under one roof makes a massive, massive difference for the patient.
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Dr. Yu: I actually primarily trained in family practice in the hospital-based setting. I was an emergency doctor for the first decade of my work. My team, often, was the immediate health care providers that was available to me within a hospital context. And then I had decided that, over the past 10 years, to make a real difference in a lot of the acute care that I was doing, it was probably more impactful to be right in the community before the worst things happen that bring people to the emergency department.
We have set up those systems in the hospital where we know our roles and we know where to come in when a team member needs assistance. And those systems are so crucial for us to be a high-functioning team. We needed to do something similar in the community. We needed to actually form teams that look after patients where our team members are actually from different agencies and different organizations that are traditionally managed separately in a siloed way.
So, in the community you got your family doctor, you've got home and community care, you've got some other community agencies that provide caseworkers for social determinants of health — all of these are organizationally siloed, where you do referrals to each of the organizations. And, hopefully, some way, we kind of figure out what we're all looking for. It's very inefficient.
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Dr. Yu: With COVID, it became virtual. We had the opportunity to actually build virtual teams. We started the virtual teams because we knew that we were going to have a lot of seniors isolated at home and we needed to get to them.
COVID has really made us see how much opportunity we had to really deliver care in a localized, integrated way. We're used to our health care system as being very fragmented, so we hope and rely on Toronto Public Health, we rely on Ontario Health now, and the Ministry of Health to give us guidance on, "what next?". But, during COVID, these broad strokes-type of strategies to address the pandemic can really only go so far. You really need very localized neighborhood approaches to the pandemic itself where there’s specific strengths and perhaps vulnerabilities in specific neighborhoods.
Unfortunately, I think it's taken COVID to actually make us look at ourselves as a health system, to figure this out. Actually, I'm concerned that we're going to forget the lessons of COVID. I think I'm already seeing that quickly. We're going back to our strategies from previous of egocentric organizational goals, rather than inter-organizational team-based goals.
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Dr. Yu: How does it make the patients’ lives better? Imagine not having to tell your story over and over again to separate providers from separate organizations, and having to only say it once. Having somebody that you trust talk about another team member as somebody that they also trust. So, there's sort of that transferable trust that really, for the most part, our healthcare system has not really been able to facilitate.
When I refer patients to a psychiatrist, for example, with a lifelong type of relationship that I've had for some of the patients — so youth, for example — the idea that they're going to get sent to somebody in some ivory tower and get assessed for their mental health, a sensitive aspect of their whole being, is very scary. But when I say to them, “It's actually a colleague of mine who works with me who I know well and trust,” it just makes things so much easier for the patients they go, "Okay, if you say so, I trust you, I've known you for years," because they know their family doctor and because the family doctor has relationships with them and with other care providers.
If the teams weren't built at all, or were built as hospital-based teams, there goes your relationship, as well. You're living in the community and there's a team in the hospital that's looking after you — could be very high skills, very specialized, very good — but you don't have that longer-term relationship. With primary care in a team-based approach, you would have different providers with different specialties pulled in as part of the team along the ways, but you have a core home. You've got the Patient-Centered Medical Home which includes your primary care provider looking after you.
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Dr. Yu: One of the most difficult transitions that's more relevant to home-based care is dementia. Think of a patient with dementia and think of a patient who I've known for a while and now is going through that life stage of losing their memory. For my patients with dementia, home-based team care is absolutely, absolutely what's most important in terms of integration. Can you imagine having dementia and having to try and tell your story each time to somebody who just came in? A referral was made by your family doctor to home care, and home care sends in a PSW, and the PSW has never met your family doctor, has never spoken to your family doctor, and all they have is a little scribble on a piece of paper that you need some home care supports. And you open the door as the patient and you go, "Who are you, and who sent you here?"
So, with the OHT [Ontario Health Team] model and the integrated teams, I actually know who the care coordinator is. We have regular meetings and discussions about that individual, and we do have regular check-ins. And the rich information that I get from the homecare provider, the information that I can give to the homecare provider, just makes the care that's given at home that much better.
By far, most families, most individuals I find, prefer very much to stay at home for as long as they can. As one ages, as that starts to become an issue, it's really hard to adapt to a new space such as a long-term care facility. It is so much better for most to be at their environments that they've been used to all the while and that they're comfortable in. It's a better quality of life, and I'm really proud of the teams that we built.
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Dr. Yu: When the Ontario Health Teams idea came, I really saw it as an opportunity to co-design locally what works best for my patients. We need to ensure that there's distributed leadership, that it's co-designed, and that primary care and community investments are there, and that we're a learning health system, that we iterate. We can, in a low-rules environment, try a few things, see what works and if it doesn't work, we do some adjustments. And so that has empowered us to iterate different models.
Of course, we need standards. Otherwise, how else do we know that we're succeeding? I do think that those standards need to be less than just counting beans, that it needs to be around the quality of life of people.
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Dr. Yu: Oh my goodness, I think of this past year and how many of my seniors have been isolated because of COVID, not been able to go out. I think of how many physical complaints that they might have felt comfortable, especially my newer patients — I do still take homebound seniors into my practice – how I see their evolution from, "Doctor, can you talk to me about my insomnia? And can you fix my leg problem? And can you fix my back problem," and switch it over to, "You know what? I’ve really been enjoying the phone calls from your wellness program, and I've actually learned how to work an iPad."
It comes down to the simple things. “On a day-to-day basis, I am now comfortable being at home and feel some sense of quality of life rather than before where I was thinking very much about my insomnia, feeling alone, my back pain.” I truly believe that if we invest in primary care, in the right kinds of primary care, and build Patient-Centered Medical Home models across our geographies, that we can get there.
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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.
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