| Computer system |
|
| Increase availability |
“[When they come to the ED], patients are automatically triaged to the ED. Couldn’t we plan a deferred admission? When certain criteria are met, the patient is put on the emergency schedule of his PCP and not sent to an emergency service to address (his/her) complaint” (U-PCP8)
|
| Enhance collaboration |
“I think having meetings with the patient from time to time… so that the patient knows and can say what’s okay and what’s not to everybody, so that we can make changes, but having all heard the same things. Because with separate consultations, patients don’t always say the same things.” (U-PCP6) “For people who come a lot [to the ED], we’ve started protocols to try having coordinated care. But people often visit the ED 20 times before it’s put in place.” (U-PCP3) “I think that the PCP has to be convinced that it is useful [CMT care]. And that (he/she) knows what they [the team] can propose. Because when we don’t know, we think “one more thing to do, more paperwork”. And if we know what the services are, who are the people we are working with, it helps succeeding as a team.” (U-PCP14) “It facilitates communication [having a case manager in the staff of PCPs], that’s for sure. Because if it is always the same person, we can quickly say something about a patient, even if we’re meeting to talk about another patient.” (U-PCP12) |
| Reference person identification |
“With this way of functioning ([in Unisanté], maybe having somebody else, who would be in charge of this part [social part] would help ensure a better follow-up to the patient… because every 6 months, each year or 1.5 year, the PCP will change. So, there’s information loss also.” (U-PCP6) “Somebody who would stay longer than the PCPs. A medical assistant or a social worker could create a bond.” (U-PCP11) |
| PP-PCPs |
| Enhance collaboration |
“We [ED and PCP] put a protocol in place so that every time the patient comes to the ED, he has the same [treatment]. And I think that this protocol is really good. (…) At least the doctor and the nurse caring for this patient at 3 am don’t have to think about what to do. And it is not at 3 am that we should decide if we give him morphine and in what quantities. This should be decided beforehand. (…) It’s a chronical pathology, we shouldn’t decide every night what we should do.” (PP-PCP5) “And coordinate the whole thing [FUEDs’ healthcare team]. With the patient in the middle. The patient must be present [during the meeting]. That (he/she) feels that people work together. They [the patients] don’t like it when one specialist says one thing, another something else. (…) They are lost. (…) We must work together. And there should be somebody to coordinate it all. It can be the PCP or somebody else, it doesn’t matter. But everybody should be fine with the decision.” (PP-PCP4) “I think for the CMT, it is important to see if there is a PCP and if (she/he) is used. Or here… if there’s already a healthcare team… to see what’s already in place… Instead of everybody doing things apart from each other.” (PP-PCP2) |
| Case manager adequacy |
“There should be a volume [of patients] big enough to warrant having somebody [case manager] in the practice. It can be good for big infrastructures, who have many of those patients. But for a practice where the PCP is alone, I think it is completely exaggerated.” (PP-PCP7 [working alone in a practice]) “If we could delegate case management in the practice, it would be extraordinary. Our medical assistants partially do this job. But if we had a person, like for him [the FUED patient] for example, who contacts the IPT ["Integration Pour Tous" - paralegal service], who contacts… I would have gained time.” (PP-PCP2 [working in a group practice]) |
| Best care setting |
|
