Spotlight on Collaboration
Canada's beacon of interdisciplinary collaboration is shining brightly from Southern Alberta where there are no tall buildings, trees or mountains to block the long view. Taber is a town known for its big sky, excellent sweet corn and now for great primary health care. Ask anyone who knows the scene and the Taber Project comes up.
You can tell from the spark in his voice that Dr. Rob Wedel, one of the Project's founders, is a committed advocate for interdisciplinary collaboration and he confirms that collaboration in Taber is working very nicely for both the patients and providers. "It's easy to measure success here in Taber," he says. "If your patients leave for Lethbridge you know you're doing something wrong. Well that's not happening by a long shot."
A general practitioner of 28 years, recent past president of The College of Family Physicians of Canada and a local Director of Palliative Care, Dr. Wedel speaks with great satisfaction about the vision he and his partners have put into action at the Taber Clinic. They, the small local hospital and a scattering of other professionals are primary health care in Taber. The clinic's eight physicians saw that they could either continue to go it alone or call in reinforcements from where they were immediately available — the other health care professions. In the interests of their patients, they found a way to collaborate with their fellow professionals, to team up and make things happen.
Dollars from the Canadian Health Services Research Foundation, the Alberta Heritage Foundation for Medical Research, Chinook Health Region, and Alberta Health and Wellness helped get things moving on a four-year project that ran from1998 through to 2003. "We focused the funding on three objectives to create: a local decision-making and management structure; an alternative payment scheme that enabled better service by the appropriate provider; and a new technological infrastructure to flow patient information. The funds gave us the resources for the computer switch, a project manager, and a nurse-practitioner to start the collaborative ball rolling."
Taber is a farming community with a catchment-area population of 16,000, with 8000 living town. Health care is provided by the clinic, the hospital, public health services from the Chinook Health Region and the usual roster of health care professionals. The Taber project aimed to integrate these services to focus on the patient and overcome what Wedel calls "systemic drift, the tendency for systems to provide services according to their built-in structural and administrative limitations rather than flexing to meet changing needs".
"I can remember the first meeting of primary care providers very well. Eyes were glazing over with all the talk of integrated care, alternative payment schemes, the usual top down stuff. Then for some reason we started talking about Mrs. Smith who is a patient we all knew very well but, it turns out, we had never talked over together. The discussion intensified immediately, and the project began to flow from there. We just mapped out how we could make real cases like hers work better and all of a sudden everyone was talking turkey, in the picture, with their contribution ready to be integrated."
In essence, the Taber Project turned the clinic into a one-stop health care experience for patients where what they needed was assessed, prioritized and addressed by the right provider. The key moves were to bring the Diabetes educators, the Asthma team, the public health nurses and a nurse-practitioner under one roof, to expand the presence of the clinic at the hospital and to link them all on a reliable, centralized patient information network. "Now in addition to formal exchanges we do a lot of very efficient hallway consultations that mean quick turnarounds for the patient. And our clinic records are now accessible at the emergency department which means we have the information we need after hours," says Dr. Wedel. "Doing a better job this way doesn't just make the patient feel better and the providers feel good about their work, which is really important of course — ultimately it penetrates the system and means less crisis visits and fewer unnecessary visits to ER."
Dr. Wedel remembers a vivid example of parents presenting their asthma-stricken child to Emergency holding a dog-eared pamphlet from their asthma educator, explaining that they had followed the checklist like they usually do, but this time it had gone beyond their capability. "The child really needed to be there. They knew what was happening and we were able to provide treatment fast, knowledgably and with minimum stress all round. What a difference!"
"Reports from our partner professionals indicate how well they have been accepted and integrated. Patients might say, 'You know my doctor doesn't really like you.' (and that hurts - the person and the relationship). Now it's 'My Doctor thinks it is very important for me to be here.' We're not just collaborating; we're now a team and we like it."
The expansion of the clinic team also provided more options for service. Female patients could now opt for an appointment with a female nurse-practitioner, instead of a male physician, if that was their preference. Due to the Taber Project, physiotherapists, dieticians, pharmacists and home care nurses are all in the loop. As a result, things like well-baby visits have been reduced from an average of 13 with lots of duplication, to five to seven, with the same quality of service and outcomes. "It was a funny thing but once we got it going, the turf issues didn't rise from the physicians but from other quarters that shall go unnamed."
It wasn't all sweetness and light. "I admit we made some mistakes, "says Dr. Wedel. "Let me just say you've got to keep health system middle management in the picture or things will unravel fast. We were in recovery mode very quickly for a while after a false start. We didn't get discouraged, however. I guess we were quick learners and began to adopt appropriate survival behaviour —like good communication."
Taber's community characteristics offer some advantages too. It's small, everybody knows each other, all of Taber's physicians were involved and the Chinook Health Region was ready to innovate. "But necessity also played a decisive role. This wasn't about philosophy, although we are all patient-focused; it was about practically meeting demand and avoiding burnout, " notes Dr. Wedel. "It was about doing the job and finding greater job satisfaction. It was about finding help and making it work."
And the Taber Project is leaving a lasting legacy in Alberta. "Our project coordinator, Eileen Patterson, has been hired by the regional health authority to spread our approach around the region and we have found a way to keep our nurse-practitioner on board because she's a critical component of our success. The information technology and the new modus operandi are in place and running well."
"Now when I hear a doctor say 'I make referrals so I'm collaborating' I say well there's a lot more to it than that. Mainly, it's not a one-way thing. You've got to recognize that others can do something better than you and actively involve them, which means being open to and accepting feedback. For instance, nurses educate better, no doubt about it. And you've got to include the patient in the loop so the communication is three-way at the very least. It's a fact, it works, so open the door to teamwork."
"It's going to happen," says Dr. Wedel. "The shortages dropped morale, but we've gone through the low and know that we can't carry on the same way. We need all hands on deck if we are going to help our patients and if anyone is going to continue doing this wonderful but difficult work. But you've got to have enough energy to say I'm going to do it differently because it's going to take up your time and emotion before you get the returns. Funding helps."
"I think the critical mass for this kind of positive change has been reached by the health professions in Canada. Projects like the Enhancing Interdisciplinary Collaboration in Primary Health Care (EICP) Initiative are extremely important to start the chain reaction needed to accelerate the change; along with funding, accessible electronic health records and some regulatory adjustment. The main thing is human resources though: you can't have a team without the people."