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ABSTRACT

The Fraser Health Multiple Sclerosis Clinic in Burnaby, British Columbia, Canada, implements a “5 C” approach to the collaborative care of multiple sclerosis patients. This model includes evaluation and management of medical, psychological, social, and rehabilitative services related to multiple sclerosis in-clinic or virtually. The model has yielded high patient satisfaction and improved patient outcomes due to the integration of specialists and accessibility to cognitive and mobility assessments. The model has led to increased communication and collaboration among the care team and decreased administrative burden and overhead cost.

INTRODUCTION

Providing comprehensive, coordinated care is a common goal for health care institutions and systems across the world. This can be difficult to fund and implement in practice, especially within the confines of a given health care system that may be riddled with fragmentation. There are several patient populations, such as multiple sclerosis patients that require care from subset of multidisciplinary providers and would benefit from a comprehensive, coordinated approach where they have access to the various facets of their care in a coordinated, “one stop shop” type of clinic.

The AAN’s Care Delivery Subcommittee, under the guidance of the Medical Economics and Practice committee continues to seek out and better understand different care delivery models, their core functions and features, and the professional and personal advantages and disadvantages of these models for neurologists and neurology APPs. The subcommittee expanded its perspective to explore the innovative care model that one of its members, Galina Vorobeychik, MD, FRCPC, FAANi, uses in her clinic in British Columbia, Canada. While the United States and Canada have different health care systems, the tenants of the care model may be widely applicable or aspirational for practices of all kinds.

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The Care ModeL

The Fraser Health Multiple Sclerosis Clinic in Burnaby, British Columbia, Canada, implements a “5 C” approach to comprehensive, coordinated, community-based, close-to-home care of multiple sclerosis patients. To date, there are more than 4,000 patients receiving care at the clinic, in a territory with a population of approximately two million residents. The 5C model includes evaluation and management of medical, psychological, social, and rehabilitative services related to multiple sclerosis in-clinic or virtually. The multidisciplinary care team is led by a neurologist and includes various other clinicians to provide comprehensive care. Staffing and scope is detailed in the table below.

How It Works

The 5C model is funded by a public-private partnership between Fraser Health, the British Columbian provincial government, and the Canadian Health Agency. Physicians are paid via fee-for-service from the provincial government, clinical staff hired by the clinic is paid by Fraser Health, while research staff is hired and paid privately from research generated income from industry clinical trials and non-industry funding. Fraser Health and Burnaby Hospital provides in-kind support for the facility and technology
support. This means physicians are paid fee-for-service via the provincial government and the public funding covers facilities, nursing, and support staff costs. Physicians directly supervise the publicly funded allied health care providers. Patients are able to receive comprehensive, coordinated, multidisciplinary care in one setting, which is affordable only through the unique public-private funding model. The staffing and funding model has led to strong recruitment and retention of physicians (ranging from 6-8 on staff), nurses and other allied health professionals in the MS clinic and Burnaby Hospital. For example, a new patient to the clinic would receive an initial multiple sclerosis diagnosis and disease-modifying therapy and management from a neurologist. The patient would also receive all necessary physical and psychiatric interventions depending on their unique symptom management needs. This could include care from any combination of neuro-ophthalmology, radiology, psychiatry, physical medicine and rehabilitation, urology, gastroenterology, and physical and occupational therapy, as there is a prioritized patient pathway for the Multiple Sclerosis Clinic patients with these specialists.

Patients receive care from physical medicine and rehabilitation physicians directly in the clinic and may see the other specialists in the clinic or the specialty office. Social work and primary care practitioners provide key coordination and education to patients and caregivers throughout the spectrum of care. Local health units offer at-home safety assessments at home, personal care physiotherapy, or at-home occupational therapy and mental health units with access to physiatrists, psychiatric nurses and counseling also may get involved in patient care if referral sent from the MS Clinic. These services are funded publicly. The MS Clinic coordinates patient care and involve only services needed to meet unique needs of each patient.

The delivery care in the model supports an improved patient and provider experience, lower costs, and better outcomes. Access to comprehensive care “close to home” for multiple sclerosis patients in the clinic has resulted in high patient satisfaction. While most patients travel to the clinic to receive care, they may also receive care virtually, for those that do not reside locally, COVID or other constraints. In this model, patients have frequent follow up appointments with nurses, which increases access to care while maintaining lower costs compared to follow up with physicians. Prior to COVID, physicians at Fraser’s Multiple Sclerosis Clinic rarely used virtual care, as there was no fee-for-service reimbursement for virtual care in place. At time of writing, physicians are providing 90% of care to multiple sclerosis patients virtually, and nurses are providing 100% of care virtually. In the future, the clinic hopes to deliver 60% of physician care and 90% of nursing care virtually.

The Provider Experience

Providers working in the Fraser Health Multiple Sclerosis Clinic report high rates of career satisfaction and increased earnings compared to more traditional, siloed care models. While this case study focuses on the neurologist’s experience, the collaborative, multidisciplinary nature of the model is the driving force of satisfaction for physicians and others’ satisfaction. It offers neurologists the opportunity to discuss complicated cases on regular rounds and despite working with complex patients, physicians may earn more under this model. Historically, it is not financially beneficial to have frequent physician follow ups and under this funding and delivery model, patients receive frequent nurse follow ups, resulting in cost savings. Also, due to the separate staff funding sources, physicians bear no overhead costs compared to more traditional models, which can be 15-25% of income.