What is the purpose?
The purpose of the Reducing the Impact of Financial Strain (RIFS) Change Package is to assist primary care clinics in optimizing processes for paneled patients who are experiencing financial strain.
What is the aim statement?
By a specific date, the clinic team will have improved screening rates by a specific percentage.
What is the outcome measure?
The number of patients with a documented financial strain assessment out of the total number of paneled patients.
What constitutes the balancing measure?
The time to the third next available (TNA) appointment.
What do I need to do before proceeding?
These are the foundational change packages that should be reviewed:
Panel Processes Change Package Summary Relational Continuity Change Package Summary Care Planning Change Package SummaryHigh Impact Changes
-
Improve the patient experience
Potentially Better Practice
Establish a multidisciplinary improvement team and consider including a patient with lived experience.
Process Measures
Team meetings are scheduled regularly.Tools
Sequence to Achieve Change Including a Patient Partner on an Improvement Team
Potentially Better Practice
Incorporate a patient-centred care approach.
Process Measures
The number of patients screened for financial strain in the last 18 monthsTools
Care Plan Template with Prompt
Potentially Better Practice
Create a culture that allows for open conversations with patients about financial strain.
Process Measures
Conduct a patient survey or interview.
Survey your team to allow opportunities for improvement.Tools
Poster - RIFS Scripting Samples - RIFS -
Identify paneled patients
Potentially Better Practice
Define the segment of paneled patients who would most benefit from an assessment of financial strain.
Process Measures
Definition of the patient population eligible for screening.
Tools
HQCA Primary Health Care Panel Report
Potentially Better Practice
Generate lists of patients who have been identified as needing an assessment for financial strain and review the list with the team.
Process Measures
The number of patients on the EMR list.
Tools
EMR Guides - RIFS -
Standardize documentation
Potentially Better Practice
Define the social determinants of health the team will use for care provision and standardize documentation in the EMR.
Process Measures
The number of patients with social determinants of health documented in the EMR.
Tools
EMR Guides - RIFS -
Optimize care management
Potentially Better Practice
Use a process to assess patients for financial strain.
Process Measures
The number of panel patients assessed for financial strain.
The number of completed PDSA
Tools
Poverty Screening Questions Rapid Cycle Improvements with Plan, Do, Study, Act (PDSA)
Potentially Better Practice
Use a process for responding to patients with financial strain
Process Measures
The number of patients with documented financial strain.
Tools
Scripting Samples - RIFS PCN Resource Handouts - RIFS
Potentially Better Practice
Use a process for ongoing review of patient-centred goals and care coordination.
Process Measures
The number of patients with financial strain who have care follow-up due for re-assessment.
Tools
Care Plan Template with Prompt -
Coordinate care in the medical home
Potentially Better Practice
Establish clear roles and responsibilities for supporting patients with financial strain amongst the medical home team.
Process Measures
Discuss the results of the Team Assessment together.
Roles and Responsibilities - RIFS Introductions with Intention Introductions with Intention - RIFS Team Huddles Guide Team Assessment - RIFS Sample Process Maps - RIFS -
Coordinate care in the health neighbourhood
Potentially Better Practice
Establish processes that facilitate effective transitions of care.
Process Measures
The number of patients with visits within seven days post-hospital discharge.
Tools
Process Mapping H2H2H Change Package Summary Collaborative Care Agreement
Learn@AMA Training
Learn more about RIFs from AMA's free online training through Learn@AMA. Sign up your whole community-based clinic team today!
Enrol todayAdditional Resources
RIFS Comprehensive Change Package Sequence to Achieve Change Evidence and Rationale - RIFS
Developed by
