Success Story: Working together to care for those with Chronic Complex Diseases

When someone has a complex chronic disease, such as diabetes, cancer or chronic respiratory disease, it can be challenging to manage their health. This is doubly challenging when they lack a regular family physician and/or when multiple chronic conditions occur concurrently. When these patients need immediate medical advice, they often come to the emergency room, get referred to the internal medicine clinic, which may result in a wait time of several weeks to several months. Internal Medicine physicians David Shanks, Brian McArdle, and Alison Walzak felt there could be a better way to care for these patients with chronic multi-morbidities.

After receiving funding from the South Island Medical Staff Association, their first step was to organize a day-long retreat with their internal medicine colleagues and a trained facilitator from Hone Consulting, to learn about other current care models for complex patients and brainstorm what care in Victoria could look like.

There were both expected and unexpected outcomes from this meeting. The group confirmed the need for a multi-faceted clinic focusing on complex disease care, and clarified what kind of service they would like to provide. To this end, they are putting together a proposal for a pilot project to Island Health. Their discussion of their workload also yielded the unanticipated benefit of highlighting the need to address the wait times associated with the Urgent Medical Assessment Clinic (UMAC) clinic. As Dr. Walzak stated, “We all knew there was a problem but we didn’t have the time to fix it in the course of our regular working hours”. With the assistance of a temporary loan of a booking clerk from Island Health, they subsequently revamped their scheduling and saw a drastic drop in wait times especially for urgent referrals.

Speaking about the process, Dr. Walzak explained, “The funding spearheaded the process we needed to undertake – it gave us the ability to have some focused meetings and bring everybody together. People are protective of their time, whether weekend time or evening time. To have a little bit of incentive for people to come out, people were really excited”.

 

 

 

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