For many patients struggling to get an appointment with their primary care provider, the answer is better access.

The University of Manitoba department of family medicine, in partnership with Shared Health, is working to reduce wait times and improve patient access through an innovative new program featuring eight workshops and modules along with a mentored project.

The Access Improvement Model (AIM) program is helping primary care clinics put their own practices under the microscope to find out what’s working – and what isn’t.

“We’ve brought everyone together on this,” said Teri Greenwood, primary care manager for ACCESS Fort Garry, one of two pilot sites engaged in the new program since January. “It’s not just about the doctor and the patient,” said Greenwood. “It’s about everything in between.”

From the front-desk staff and physician assistants to nurse practitioners and the clinic’s physicians, ACCESS Fort Garry has been working with the AIM team to think through how they deliver care, right from when a patient makes an appointment to when they arrive in the examination room.

“It’s really helped us to assess what we’re doing and why we’re doing things,” said Greenwood.

Apple Qin, an improvement specialist with the Max Rady College of Medicine department of family medicine and one of AIM’s facilitators, said clinics often want to jump straight to solutions. “When there are too many people calling the clinic phone, the clinic might just think of adding more people at reception or increasing the number of hotlines,’” said Qin. “But sometimes that’s not the answer.”

A thorough evaluation of the clinic itself can go a long way, she said. Where needed, additional training is included for all staff members. “We teach them about different technologies, process improvement, skill sets, tools and methodologies,” said Qin.

At Access Ft. Garry, they’ve already made changes like adding information screens to the clinic and ensuring all team members have access to updates and clinic news.

They’re currently engaged in a longer-term project to identify what barriers patients might be facing when they book an appointment but don’t come in.

So far, Greenwood says the hardest part of the process is the time commitment.

“There’s a lot of demand for health care and our focus is providing care to patients,” she said. “But this process has made us take the time to stop and assess. It’s really been worth it.”

Ultimately, Qin would like to see a culture of continuous improvement in clinics across the province, supported by the AIM program. “We want to bring as many new clinics on board as possible,” she said. “We’re here to facilitate and help them along the way.”

For more information, contact aim@umanitoba.ca or visit the program’s website.

A key lesson of that journey, she says, is that health is multifaceted, with needs based on physiological, emotional and social factors.

Halas, who was raised in Winnipeg, is an assistant professor in the School of Dental Hygiene at the Dr. Gerald Niznick College of Dentistry, where her academic career started 22 years ago.

Her passion for primary health-care research took hold when, from 2006 to 2016, she was mentored by Dr. Alan Katz [M.Sc./95], working as a research associate in family medicine at the Max Rady College of Medicine. Spurred on by that experience, she completed her PhD in 2016 through UM’s individualized interdisciplinary program.

“I wanted to look not just at health or oral health, but to consider the whole person and the social world immediately outside of the person,” she says. “I thought listening to patients’ experiences and feedback could be pivotal for optimizing the way forward.”

Halas holds adjunct appointments in family medicine and community health sciences. In 2019, she was appointed the inaugural Rady Chair in Interprofessional Collaborative Practice.

Her current research focuses on how different health-care professionals collaborate in providing primary health care. Collaboration, she says, is not the easiest thing to study.

“Collaboration could be a consultation between two health-care providers, or a provider referring a patient to another professional, or people with a range of roles supporting a patient when they leave the hospital.  It’s complex.”

In one of her studies, Halas is looking at individuals experiencing homelessness who are hospitalized at St. Boniface Hospital with heart conditions. When they are discharged, where do they go? How can they settle back into the community in a vulnerable state?

“This is something physicians and social workers have struggled with. So how about something in between? Not a medical unit, but something that helps facilitate the process,” says Halas.

Her team is working with community advisors, including the Salvation Army, to create a hub for accessing peer support and community assistance after being discharged.

Halas is also studying how COVID-19 has changed the way patients access care. She is examining how health-care providers and patients have experienced virtual care, in order to get a sense of how virtual visits might be sustained.

“I was interested in learning about the shifting roles of health professionals during the pandemic. However, that was quite a challenge,” she says.

“Virtual visits are one piece of the health-care system’s capacity. To better examine workforce capacity, we need a data infrastructure with information on the health workforce regarding scope of work, training, and how health teams work together. This has been a long-standing issue in Canada, even predating the pandemic.” 

In all her research, Halas says she wants to focus on the individual patient.

“All the things we do as health-care providers and researchers affect individuals. How does that translate to meaningful and integrated patient care?”

One research team aims to better understand the lingering condition known as “long COVID” and the other to examine, at the cellular level, how a receptor for the disease-causing virus works.

Long COVID

The post-COVID-19 syndrome that some patients experience – a condition called long COVID – is poorly defined, said Dr. Alan Katz, director of the Manitoba Centre for Health Policy (MCHP) and professor of community health sciences and family medicine at the Max Rady College of Medicine in the Rady Faculty of Health Sciences.

Dr. Alan Katz

“This condition is really brand new, and clinicians just don’t know enough about it,” said Katz, the project’s nominated principal investigator. “I’m hoping that we can shine a light on these long-term effects of COVID-19 in a way that can help people deal with this in the future.” 

When a person visits their family doctor with long COVID symptoms – such as fatigue, shortness of breath or cough – it’s not easy for the physician to diagnose the syndrome because there is no test to confirm it, Katz said.

The goal of the study, which received $202,000 from the CIHR for one year, is to help clearly define the risk factors, determine who is more likely to get long COVID and describe the long-term effects of the syndrome. The researchers want to define the kinds of symptoms people are reporting, determine how frequent those symptoms are and provide guidance around diagnosing the condition.

To do this, they will study anonymized health data from the Manitoba Population Research Data Repository held at the MCHP. The researchers will zero in on patients with a COVID-19 diagnosis and follow them, analyzing whether there is an increase in visits to their doctors and tracking their symptoms.

The project’s other principal investigators are Dr. Lisa Lix, professor of community health sciences and Canada Research Chair in methods for electronic health data quality, Dr. Yoav Keynan, associate professor of internal medicine, and Dr. Alex Singer, associate professor of family medicine.

Viral signal transmission inside cells

Dr. Ruey-Chyi Su co-leads a team that will investigate how the binding of the spike proteins of various coronavirus variants to the host-cell receptor known as ACE2 affects viral spread and mortality rates. 

Dr. Ruey-Chyi Su

Little is known about what happens inside cells when the spike protein engages the receptor ACE2, said Su, a research scientist at the Public Health Agency of Canada and adjunct professor of medical microbiology and infectious diseases at the Max Rady College of Medicine.

“This is a much-understudied area,” Su said. “It’s very exciting for us because this grant allows us to study whether the engagement of coronavirus variants with ACE2 triggers different sets of events inside the infected cells, leading to increased viral replication and influencing the severity of the disease.”

The study, which received $430,000 from the CIHR for one year, aims to profile molecular changes caused by the viral spike protein binding to the ACE2 receptor and to identify the changes that are unique to the spike protein of each variant. These changes will be examined in cells from both men and women to determine whether sex has any influence.

The researchers also want to know if the cells of healthy people respond differently to the virus binding to the receptor than the cells of people with chronic diseases, such as diabetes.

“I believe what we find will open up a lot of questions, like, ‘Why do our cells respond differently during a viral infection, and what determines that difference?’” Su said. “The project will increase our knowledge of what to expect during a viral infection and also provide knowledge that might lead to treatments. It’s really a knowledge-building study.”

Su’s co-principal investigator is Dr. James Davie, distinguished professor of biochemistry and medical genetics. The co-applicants are Dr. Brad Doble, associate professor and Bihler Chair in Stem Cell Research in pediatrics, biochemistry and the regenerative medicine program, and Dr. Sandra Gonzalez-Diaz, Su’s post-doctoral fellow.

The summer work was led by College of Nursing assistant professors Dr. Dan Nagel and Jamie Penner, along with Dr. Gayle Halas, Rady Chair in Interprofessional Collaborative Practice.

Nagel noted the centre is based around three foundational “pillars”: community-based health programs; family caregiver initiatives; and interprofessional education and practice. The idea is to create an environment where students work interprofessionally under the supervision of licensed professionals and clinical instructors to develop competencies and learn more about community health.

Nagel, Penner and Halas believe that many of the competencies that nursing students and other pre-licensure health professional students need can be learned in a community setting, such as establishing therapeutic relationships, assessments, chronic disease management, interprofessional practice and understanding research.

Nagel said the centre may become a physical entity within five or so years.

“It’s the same idea where we put students into clinical placements in hospitals, surgical units and long-term care facilities, except that they’re working in the community,” Nagel said.

He said the first program for the centre is being planned in collaboration with Southern Health-Santé Sud health region and will be an assessment, exercise and health education program for clients with mild to moderate respiratory disease.

“There are a lot of people in rural areas who have to come to Winnipeg for services, but if it’s for a duration of several weeks, that can be a huge burden for clients. And we know from chronic disease that we need to have ongoing contact with people in order to help support the,  understand and manage their illness,” he said. “And family caregivers of these clients need support, too.”

Eleven students were involved in the initiative over the summer, working on several different projects related to each of the pillars. Five students will continue on into the fall term.

Taylor Naccarato, a third-year nursing student, was involved in research into how student-led initiatives have been run in other North American jurisdictions. This fall she’ll be continuing to reach out to individuals involved in those projects to see how they work.

“What we want to learn is: Are they free services? Are they part of a curriculum or a partnership? Was it started by students?” she said.

Naccarato said she was drawn to the project because of the family caregiving aspect, something she has experience with in her own family.

“It’s interesting to see that there isn’t a lot of support out there for family caregivers,” she said. “There are a lot of programs that say they’re going to teach the caregivers skills to support the patient, but they never look at the caregiver’s mental health and well-being, which I think is really important to address to prevent caregiver burnout.”

Prabhnoor Osahan, a second-year medical student in the Max Rady College of Medicine, also has a personal interest in family caregiving. She was involved in a project to identify evidence-based resources and interventions that exist for family caregivers in rural communities. Another explored interventions that exist to train health-care providers how to assess and support family caregivers.

“As someone who’s been on both sides of the coin – as a family caregiver and now as a student in a professional health-care field – I can appreciate that there are not a lot of interventions that are currently in place for family caregivers,” she said.

Victoria Ploszay, a third-year respiratory therapy student in the College of Rehabilitation Sciences, led an epidemiology survey of the Southern Health-Santé Sud health region, comparing community health programming to other health regions in Manitoba.

“We came up with a list of potential programming that we think would be beneficial to the region,” she said.

Ploszay noted the inter-disciplinary aspect of the project removes the “hierarchical status” she’s seen on some of the teams she’s worked on.

 “All the students had an appreciation of one another, so it was nice to actually engage in dialogue and suggest opinions or recommendations without worrying about crossing some kind of barrier,” she said.

Third-year nursing student Mark Philip agreed that working on the project reinforced how important teamwork is to patient care.

“It’s not just doctors and nurses, it’s everyone on the health-care team – pharmacists, occupational therapists, respiratory therapists, physiotherapists. I feel like this has really hit home for me. It’s a collective effort,” he said.

At Kildonan Medical Centre, it used to take an average of 11 minutes for each fax sent by a pharmacy to reach the hands of the appropriate physician. Sometimes it took as long as 49 minutes.

Such faxes are usually sent to verify details about a patient’s prescription, or to get the go-ahead to refill a prescription. The clinic received about 18 of them per day.

As of a year ago, a staff member was periodically printing out batches of faxes from the document queue and handing them out to nine doctors. The process was time-consuming. And so many errors occurred – often because pharmacies kept faxing the same prescription until they received a doctor’s response, resulting in duplicates – that 20 per cent of the faxed queries got fouled up in some way.

“Those errors had implications for patient safety and were costing the clinic about $97 a day in staff time,” says Christian Becker, a professional engineer who is managing director of the department of family medicine in the Max Rady College of Medicine, Rady Faculty of Health Sciences.    

Kildonan Medical Centre is a teaching site for UM residents in family medicine. Becker knew there were many processes there that could be “leaner” – more efficient, less wasteful and better for patients.

He reached out to Vern Campbell, engineer-in-residence at the UM Price Faculty of Engineering, who teaches a course in operational excellence. The course gives fourth-year engineering students experience at working in teams to apply quality-improvement methods to real-world problems.    

Through the partnership devised by Becker and Campbell, engineering students can now tackle health-care processes at family medicine teaching sites. As part of the reciprocal arrangement, two members of Becker’s departmental staff took Campbell’s course.

In the spring of 2020, they teamed with engineering students to address the Kildonan Medical Centre fax-processing routine – the partnership’s first project.

After analyzing every detail of the fax-handling process – and calculating the error rate and other statistics mentioned above – the team decided to test the hypothesis that using the clinic’s electronic medical record system would be more effective.

“The staff member responsible for delivering the faxes was asked to try sending them individually – not on paper, but electronically – to one doctor as a test subject,” Becker recalls. “The results were so impressive that within one month, the change was rolled out to all the prescribers.”  

The new method reduced the average fax delivery time by more than 96 per cent, from about 11 minutes to about 24 seconds. With the process streamlined and paper eliminated, the error rate plummeted.

The physician who was the test subject is Dr. Allison Paige, a UM lecturer in family medicine. She is the associate director of quality improvement for the department and quality improvement lead for the medical centre.

“I was astounded when I found out how much time it was taking to manage each prescription fax that arrived at the clinic,” says Paige. “I was even more astounded at how much time could be saved by a small adjustment in our process.

“I was so happy to have this project demonstrate that quality improvement methods can give back time and improve our work lives. I look forward to having more engineering students join us, because the project highlighted other processes that could be streamlined.”

The engineering/family medicine partnership will have ongoing benefits, Becker says. It will expose family medicine residents to the scientific approach to quality improvement, introduce engineering students to health care as a potential career path, and give family medicine staff training opportunities to foster a culture of continuous improvement.

“We’re hoping to have a family medicine resident take the engineering course,” says Becker. “This interprofessional collaboration between two UM faculties has been eye-opening and inspiring for everyone.”