Guest Post: Ali Damji (Canada) – Working Together: What can we learn from Jonkoping?

My last blog post focused on how providers can better work with patients and how Jonkoping is showing some considerable success in this regard. This post will focus on how providers can best work with one another, specifically from what I witnessed in primary care.

I recently had the opportunity to experience Oxnehaga Primary Care Centre, located in a smaller suburb within Jonkoping with a larger representation of low socioeconomic status, new immigrant and refugee populations. Here are some of the highlights.

What’s with the bubble? When you arrive, you take a number and for privacy you enter and speak with the receptionist when your number is called. This protects confidentiality in the waiting room.

Funding: All practices receive a budget from the region based on how many patients they have. There are premiums for both socioeconomic and medical complexity. Using this budget, the providers must work with administrators to manage the budget and ensure that the primary care centre does not run a deficit. This budget also pays all of their salaries. Notably, tests and investigations lead to more expenditures, so these must be ordered judiciously.

Labs are onsite in the primary care unit. This allows blood tests to be taken and interpreted quickly on site (typically within 10-15 minutes). This allows patients to avoid needing to come back for unnecessary repeat visits and get an answer quickly for common tests.

Clear Intake Processes: To come to the primary care unit, almost all patients will call in advance. There are always 2 nurses running phone booths in the office on a rotating shift schedule. If there is a wait to have your call answered, the patient can request a call-back time. Some patients can choose to come in for a drop-in appointment but they often will need to wait or hope there is an opening. Once the patient has been assessed over the phone and needs a visit, the nurse will book them into the schedule for the most appropriate provider (usually a nurse). Same day and next day appointments are common. If it is something that the patient does not need to come in personally for (such as a medication renewal that is more benign), the nurse will flag this in the appropriate person’s calendar and schedule a time for that task to be completed that day.

Possible direct pathways to the right provider for a patient in primary care. Decided by the nurse.

Who sees the patient first? This is up to the nurse on the phone. Typically it is a nurse. There are a wide variety of specialized nurses in areas such as Heart Disease, Asthma, Diabetes, Smoking Cessation, Incontinence, Care of the Elderly, Care of Children and Hypertension. These nurses are able to see patients independently, make basic medication changes (e.g. encourage patients to take medications twice or three times per day on same dosage), interpret labs and tests such as spirometry and ECG, and consult other services. They cannot prescribe a new medication nor order tests. But if the patient needs a drug or test they can either directly ask a physician or “Distrikt Nurse” (similar to Nurse Practitioners in Canada) to see the patient that same day by pulling them in from the hall, or they can place the order in the EMR and send an instant message for the other practitioner to sign during a free moment.

Meet Diagnostick. This device when grasped behaves like a one lead ECG. Patients can receive a device from the centre on loan and can use this when they feel their heart racing. The data can then be transmitted right into the EMR digitally at the next visit. Useful for those patients who are fine in the clinic but have arrhythmia at home! Nurses coordinate and interpret the results from this and consult when necessary.

Informal Consults: Hallway consultations are very common. If a nurse is assessing a patient and wants a physician to lay eyes on the patient, they will quickly see if one is available to come into the patient room, and then continue managing the care of the patient unless it is something significantly complex or acute that requires a formal transfer of care. Similarly if a mistake was made and a patient was inappropriately assigned to a nurse but requires a physician, the team works together informally to make sure the patient is seen the same day by the physician. These informal consultations exist across all the services offered in primary care.

Physiotherapy in Primary Care: In Sweden, physiotherapy is part of universal health care. There is abundant evidence that exercise is one of the best treatment modalities for low back pain and should be a first-line treatment before medications. In Jonkoping, a patient presenting with low back pain or most MSK concerns will be booked into the physiotherapist’s calendar by the nurse through the process mentioned above, and may not ever see a physician. Patients even have the option of calling the physiotherapists directly during certain hours. The physiotherapist will work with the patients to teach them exercises in an on-site gym and see them in the gym regularly. Patients can even purchase a temporary membership if desired. If the patient is unable to control the back pain, then a family physician can become involved as a consultant to assist with medications. This is the case for not just back pain, but many chronic and acute musculoskeletal diseases. Physicians will also become involved in medical complexity arises (e.g. fever with back pain, red flag symptoms etc).

On-site gym at the primary care centre. Also can be used by med students!

Physicians: The physician resources in the primary care centre are reserved for diagnosis and management of complex medical patients. Every 2 years every patient with a chronic illness will be seen by the MD for a complete exam. This type of model makes sure physicians are utilized for the patients that need to be seen by them.

No escaping the white scrubs! They are required uniform in primary care units too. All staff have the same ones but can be distinguished by badges. All for infection control! 

Technology: The shared EMR is crucial in supporting this environment. All notes, tests, and investigations are on the same EMR and this is also true for specialist consultations and care received anywhere in the region. This enables all members of the team to be aware of how patients are doing, without necessarily seeing them in person.

Culture: This is often something we take for granted but “the small stuff” really does matter. There is no hierarchy from what I could see in this system. Nurses, doctors, physiotherapists, administrators, social workers, and kurators all eat lunch and Fika together, are dressed similarly, and address one another by first name. Not knowing someone’s name who looks after your patients is unheard of. There is respect for one another’s scope of practice and no “turf war”. Physicians feel relieved that RNs and physiotherapists see more of the chronic patients so physicians can focus on the more medically complex ones that their training is best suited for. This isn’t just a primary care phenomenon. I’ve noticed this in the hospital too where there are nurses who have been trained by physicians in endoscopy and now complete almost all routine screening colonoscopies, leaving the GI doctors and surgeons to focus on more complex ones and be available on-demand for consultations.

“Care is better in teams” is something that is often said, but actions speak louder. I am excited to walk the talk in my future family practice using what I’ve learned here.

Till next time,

Ali D

Today’s traditional Swedish Fika treat is a chokladboll (chocolate ball). Simply amazing!

2 thoughts on “Guest Post: Ali Damji (Canada) – Working Together: What can we learn from Jonkoping?

  1. Thanks for sharing this Ali. Great to see evidence of teams embedded in culture and org/facility design and behavioural practices (lunch room, uniforms, etc.).

    Liked by 1 person

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