A Decade of Change For Seniors in Long-Term Care Facilities in Nova Scotia

Barry Clarke and his team have engineered a major change in the way that family physicians provide primary care to seniors in nursing homes in the Halifax area.

After identifying that the scattershot approach to patient care in nursing homes – with multiple physicians caring for patients on a single floor of one facility – led to poor patient outcomes, Dr. Clarke and colleagues developed an initiative called Care by Design. Under this plan, one physician is assigned to each floor in each nursing home in the Halifax area; each doctor makes weekly visits to the facility and participates in the call schedule, making it easier for patients to develop relationships with their physicians and facilitating better communication with nursing home staff.

Physician access is only one aspect of the plan. Care by Design also set standards of care, introduced regular care reviews and created the Extended Care Paramedic Program, a specialized EHS team that provides extended care to nursing home residents.

The results are encouraging: instances of polypharmacy and unnecessary emergency room visits and concomitant complications are down, and the predictable schedule makes it a more sustainable option for practising physicians.

But the changes didn’t happen overnight.

A long time coming

In fact, it’s been more than a decade since Dr. Clarke embarked on his mission to change the way family physicians provide care to seniors.

“I had grown frustrated by the differences in the levels of care that I saw at different facilities,” he says. “It struck a nerve – I wanted to be able to treat everyone the same, and to treat them well, to give them dignity at the end of their lives.” Dignity that wasn’t there when elderly patients were spending hours on a gurney in the emergency room, awaiting treatment for a relatively minor, but acute issue.

“I thought there had to be a better way,” he says. “But the government answer was: ‘We have a model. It works.’”

In 2005 Dr. Clarke and his colleagues received funding to study that model. Using funding from Capital Health’s Primary Health Care Transition Fund, They launched “Primary Care of the Elderly,” to study key issues surrounding the delivery of physician services in long-term care facilities.

The six-month study “allowed us to examine the evidence in great detail,” says Dr. Clarke; it showed that “the model didn’t work.” The evidence helped Dr. Clarke and his team identify areas for improvement. Care by Design grew out of those findings.

“It was about creating an effective care process that is patient- and family-centric, that costs less and is more effective,” says Dr. Clarke.

Still, years passed before Care by Design came into its own. That gave Dr. Clarke and his colleagues time to run a pilot project, further refining their approach. To Dr. Clarke, it was all part of the process.

“You need to prepare for opportunities. You never know when they’ll come, but if you’re prepared, you’ll be able to act at the right time.”

Opportunity knocks

Finally, the moment arrived. In 2009, with Halifax’s emergency rooms routinely overloaded, it became obvious that something needed to change. One solution was to find a way to keep patient transfers from long-term care facilities – often cases where nursing home staff had been unable to reach a resident’s family physician for consultation about a relatively minor injury, and so called 911 – to a minimum.

The years of preparation paid off. At the request of the Department of Health and Wellness, Dr. Clarke and his colleagues, including physicians, administrators and medical directors, leapt into action. By mid-May, they had gathered to assign doctors to nursing homes; by September, the new assignments were in place. But the change wasn’t just about which doctors cared for which patients.

“We changed the cultural language to foster dialogue and effective communication between nursing home staff, management and physicians,” says Dr. Clarke. “That way, when we do send a patient to the emergency room, the ER staff know the patient is there for a reason, that we’ve already done all we could. We aren’t wasting their time or resources.”

Guiding vision

Dr. Clarke says a number of factors contributed to his ability to effect change from within the health-care system, including active observation, a culture of collaboration and prioritizing action over complaining – with an underlying attitude of interest and positivity.

“At some point I thought, well, I have to go to work every day anyway, why not make it fun, make it interesting, get involved, make a difference?” he says.

That attitude translated into the habit of active observation: looking keenly at what was happening in the different parts of his practice, identifying patterns and seeking opportunities for improvement. Formalizing those observations with the “Primary Care of the Elderly” study opened up new opportunities, allowing Dr. Clarke and his team to seek input from their colleagues. Working with researcher Dr. Emily Gard Marshall, an assistant professor in Dalhousie Medical School’s Department of Family Medicine, added another level of scrutiny and credibility to the work, says Dr. Clarke.

“It’s not enough to have a good idea and do good work,” he says. “You need to put it out there for other people to see, for your peers to look at with a critical eye.”

Gathering a team of colleagues who helped him move his vision forward was another key to his success, he says.

“Great ideas aren’t enough – working with good people is absolutely critical.”

In addition to working with Dr. Marshall on the research aspect, Dr. Clarke acknowledged the help of numerous medical colleagues, as well as Karen Pyra, his former project manager, and program co-ordinator Kelly McDonald.

“It’s important to have a sense of where you’re going,” says Dr. Clarke, and to remember why you’re working for change. “Try to keep it true to the patient, to providing quality care. Complaining isn’t enough. I’m not here to judge the past or anticipate the future. I’m here to improve the present.”

Learn more about Dr. Barry Clarke and his work connecting seniors with family doctors!

This story originally appeared in the October 2015 issue of doctorsNS magazine.