Unattached Patient Assessment (UPA), Screening, Triage and Referral Initiative Demonstration Project - updated February 12, 2010

Background

In Spring 2008 Sam Berman, a constitutional lawyer, approached the Central East LHIN’s Primary Care Working Group (PCWG) and challenged them to provide leadership in the design and development of a Central East LHIN strategy to improve access to general health assessments and referral for people who do not have a regular primary care provider.  Mr. Berman, with the help of Samantha Dalby Nurse Practitioner (NP), developed the Unattached Patient Assessment model.  Dr Kim Ferguson and Antoinette Larizza joined the team to help with further refinement of the model.

The development process entailed the design of clinical care pathways, a determination of initial communities to be served, review by Dr. Josh Tepper, ADM MOHLTC and receipt of input from the College of Physicians and Surgeons of Ontario (CPSO), the Canadian Medical Protective Association (CMPA) and Canadian Nurses Protective Society (CNPS).

On June 16, 2009 the Central East LHIN Board of Directors approved funding for a 9 month UPA demonstration project.

Purpose

To provide unattached residents with access to a full general assessment, screening and referral to community, specialists and as available/agreed to primary care practices. To support earlier detection of asymptomatic disease and risk factors, earlier management, reduced acuity and ED visits.

Burden

The Ministry of Health and Long-Term Care (MOHLTC) estimates there are 86,000 unattached patients in the Central East LHIN. This is similar to the provincial average of 7% but represents the highest number of individuals for any LHIN in the province. Although reliable estimates of sub-LHIN or community level estimates of unattached patients are not readily available, Emergency Department visits by unattached individuals; volumes of less urgent and non-urgent (CTAS 4 & 5) ED visits and dialogue with existing primary care providers do provide some reasonable insight into potential communities with high need.

Education

Patients will be given education and written information on their health status with guidance for follow-up and referral as required.

Model

Inter-disciplinary team utilizing late career physicians, walk-in clinic physicians, NPs, and Registered Nurses.

• Rural: Mobile team travelling to under-serviced areas of the Central East LHIN
• Urban: Fixed sites in partnership with existing provider groups
• Communities identified for phase 1 include City of Kawartha Lakes and Scarborough
  

Patient Enrollment with Primary Care Providers

The availability of information from an UPA general health assessment will reduce ‘unknowns’ for both patients and providers. Screened patients will remain on the provincial Health Care Connect primary care waiting list until a suitable provider is found. The UPA team will provide a limited level of follow-up. UPA is not intended to provide comprehensive primary care; rather, emphasis is on assessment, screening, required follow-up and referral/triage.

Alignment to newly established Health Care Connect 

UPA will provide assessments, screening, referral and system navigation to residents on the Health Care Connect (HCC) list who are awaiting a primary care match.

Physicians and Nurses - Would You Like to Get Involved or Obtain More Information?

Contact: Dr. Kim Ferguson through Samuel Berman, Lead Consultant at 1-416-859-6896 or bermansmb@aim.com