CRAJ Fall 2015

Fall 2015 (Volume 25, Number 3)

Academic Alternative Relationship Plan at the University of Calgary

By Liam Martin, MB, MRCPI, FRCPC

The Academic Alternative Relationship Plan (AARP) in the Department of Medicine at the University of Calgary began in 2004. The leaders in the department recognized a need to change the way we practiced medicine, and the AARP was developed to address these needs. Amongst all the subspecialties, rheumatology was identified as having increasing numbers of patients with complex medical profiles who would benefit from a team-based approach to the management of their illnesses. It was felt that an innovative approach was needed through which such care would be delivered. The department also recognized that we needed to recruit more consultants to address the changing demographic of our members and the community we served. Our neighbours to the North had an alternative funding plan; we felt that such a plan would enable us to make the necessary changes to our practices. An organizing committee consisting of the division heads of all the subspecialties in the department was struck, and further refined into four sub-committees which addressed manpower, assessment and evaluation, innovation, and compensation. There were numerous meetings with government and local health authorities as well as with the members of the department over the next 18 months, culminating with the final plan launched in April 2004.

All department members, both clinical and academic, were invited to participate in the AARP. Those who joined are paid a monthly stipend dependent on their subspecialty and their years of service. The stipends are generated through funds from the provincial health plan Physician Services budget, a conditional grant from the provincial Department of Higher Education and, where applicable, the members’ university salary. Clinical members whose offices are not on a hospital site are given a yearly stipend to help offset their office costs. Non-university members are also given a yearly stipend equivalent to the cost of the benefits package that the university members receive.

The plan is overseen by the AARP management committee, which includes a member from each subspecialty within the Department of Medicine and a chair who is voted in by the committee. The department head sits on the committee as an ex-officio non-voting member. We also have a business manager and a budget manager who are employees of the AARP. Each member has an Independent Service Agreement (ISA) that addresses their responsibilities at the clinical, research, administration, and teaching levels. Each member decides on the proportion of their time that they will devote to each area; they are evaluated each year by their division head using their respective ISA as the framework for the assessment of their activities. All clinical activities are monitored through shadow billing. This process is mandatory as it allows the plan to demonstrate to government that members are actually working. It is a relatively tedious process, unfortunately, especially for members who have never worked in a fee-for-service environment.

The AARP has been very successful to date across all subspecialties. We in rheumatology have been able to develop a number of initiatives to improve patient care, including our Central Triage program, and clinics focusing on early inflammatory arthritis (EIA), young adults with rheumatic diseases (YARD), spondyloarthropathy, and biologics. We have been able to hire a number of rheumatologists to address the shortage of specialists in the community and in academic areas. We have also hired extra staff to help deliver the above programs and clinics. These new staff members include a nurse practitioner, four clinic nurses who work in our general clinics, and two nurses who work in the biologic clinic. We have also hired a part-time pharmacist, social worker, and a physiotherapist.

The Central Triage program has allowed us to prioritize patient appointments and initially reduced wait-times by 30%. Although our wait-times have increased since the initiation of Central Triage, we are still able to address urgent referrals in a more efficient manner than before. We have developed educational programs for newly diagnosed rheumatoid arthritis (RA) which are delivered bi-weekly in an interactive class environment at the clinic by our pharmacist and physiotherapist. These classes have helped patients and their significant others gain a better understanding of the disease and its treatment.

The development of the EIA clinic has allowed us to evaluate our care of patients with early disease and given our trainees an opportunity to undertake quality improvement and other clinical studies in these patients, which has subsequently led to a number of publications. The biologic clinic has allowed us to monitor patients very closely. The nurses who manage the clinics are a tremendous resource for patients taking biologic treatments. The EIA clinic has also provided us with significant research opportunities; the data that we collect have been instrumental in allowing us to publish outcomes results, in collaboration with our University of Alberta colleagues, on biologic therapies in patients with severe RA.

Education has always been an important part of our activities at the University of Calgary and the AARP has increased the opportunities for clinical members to contribute to the education of undergraduate and postgraduate physicians. In the past, clinical members were not compensated for their important contribution to teaching; however, through the AARP this issue has been addressed, making it much easier to include our clinical members in our education activities.

In summary, the AARP has provided us in the Division of Rheumatology, and in the Department of Medicine in general, with significant opportunities to improve the way we manage patients with complex medical conditions. It has also allowed us to recruit rheumatologists and allied health providers to address the needs of our community.