Success Story: Supporting Highly Complex Patients in Community

It is well acknowledged that a minority of patients experience a disproportionate amount of morbidity and, as a result, use a disproportionate amount of acute care resources. Dr. Spencer Cleave advanced an ambitious plan to generate a High Complexity Care Team (HCCT) in the South Island to care for these patients in ways that both reduced their suffering as well as reduced acute care expenditure. Yet putting this plan into action required countless hours advocating and networking with key stakeholders including the Victoria and South Island Divisions of Family Practice, the Ministry of Health, local family physicians, Island Health administrators, hospital-based specialists, allied health providers, the General Practice Services Committee (GPSC), and Doctors of BC. Without intense engagement with these groups, even a well-designed and innovative idea may not achieve the traction it deserves.

He sought a grant from the South Island Medical Staff Association to cover the costs associated with these essential activities. Over the year of his project, he met face-to-face and over the phone with a diverse array of stakeholders to better understand their own agendas, and develop a plan for how to integrate these priorities with the HCCT. In his words, “I’ve been able to meet and engage with so many contacts in the health authority and ministry and other docs that I otherwise wouldn’t have been able to”.

One of the key outcomes to derive from these activities was a series of formalized rounds with mental health providers, specialists, community providers, and the Enhanced Discharge Team from Island Health for high-needs patients. Rather than wait for faxes to arrive about specific patients, the team’s weekly meetings allowed for timely communication and better patient care.

Through this funding, Dr. Cleave build the relationships and laid the groundwork for the HCCT to be recognized as part of the Specialized Community Service Program (SCSP) and receive funding from the Ministry of Health through the Primary Care Networks (PCN) program to launch the clinical phase of the program.

As a result of doing the project, Dr. Cleave has become something of an informal resource for other physicians interested in innovation in the South Island. He has mentored colleagues with their own project ideas and helped them to both navigate the complex system of engagement and avoid duplication of services. He describes the value of the funding as allowing him “to build the network I need to make the project successful and to develop tools and contacts I can share with others who wish to do similar things.”

Thanks for all your hard work Dr. Cleave!

 

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