Comox Valley Long-Term Care Initiative – Letter of Agreement

DATE:                     

Dear LTC Physician,

Thank you for your interest in participating in the Comox Valley Long-Term Care Initiative (LTCI). I am pleased to confirm your participation.

Summary – Comox Valley LTC After Hours Call Group

(Full Call Group Overview is included as Appendix A)

• A single call group for all participating LTC Family Physicians and Nurse Practitioners (FPs/NPs) in the Comox Valley
• Two (2) On-Call shifts per week:
  • Weekdays, 6pm – 8am, Monday – Thursday;
  • Weekends, 6pm Friday – 8am Monday (+ stats).
  • Subsequent shifts can be combined for a full-week shift (per preference).
• Compensation for on-call availability is approx. $21/hr for FPs (exact rates below in Areas of Agreement)
• Minimum one shift/year per FP or NP. Additional shifts per preference. Remaining shifts allocated among the group. Inclusive
• Schedule developed by the Division: Priority scheduling for members with complex or combined call scheduling needs, including those who also provide after-hours inpatient or maternity care; others are scheduled based on their requested ‘unavailable’ dates (as best as possible). Trading with colleagues is available.
• Optional back-up coverage shifts: Optional to sign-up as a 2nd-on-call for some shifts, with compensation of approx. $7/hr for FPs (exact rates below in Areas of Agreement)

Purpose

This Letter of Agreement (the “Agreement”; LOA) outlines the responsibilities and resources shared between the parties participating in the Long-term Care Initiative (LTCI) program: the Physician and the Comox Valley Division of Family Practice LTCI program (“LTCI” or “the Division”).

Participation in the LTCI is voluntary. By opting-in to the LTCI program, the Physician agrees to support and work towards achieving best practice expectations (BPE) for all residents for whom they are MRP, at all facilities at which their residents are located.

Background

The FPSC Long-Term Care Initiative provides annually-renewable funding support, administered through divisions, to design and implement local solutions that deliver dedicated MRP services for patients in Long-term care (LTC) facilities. For the purposes of this Initiative, a dedicated Family Physician Most Responsible Physician (FP MRP) is defined as one who delivers patient care according to the following five best practice expectations (BPEs) and promotes three system level outcomes:

Best Practice Expectations	System Level Outcomes
24/7 availability and on-site attendance, when required Proactive visits to residents Meaningful medication reviews Completed documentation Attendance at case conferences	Reduced unnecessary or inappropriate hospital transfers Improved patient-provider experience Reduced cost/patient as a result of a higher quality of care

The LTCI program will be implemented with the principles of continuous quality improvement, using PDSA (Plan-Do-Study-Act) cycles to: assess the current state with regards to meeting the best practice expectations, develop and test new approaches to improving best practice expectations, and integrate learning into the LTCI program.

Areas of Agreement

1. The Physician agrees to the following:
   1. Work toward meeting the best practice expectations for all their patients who reside in Comox Valley LTC homes. i.e. Physicians may not opt-in to the LTCI program for only some of their LTC patients. While the LTCI program does not require physicians to maintain patient panels in all local LTC homes, call shifts with the LTC Call Group cover all LTC homes.
   2. Participate in the “Comox Valley LTC After-Hours Call Group”, within the terms and standards listed in the Call Group Overview (Appendix A), or, if the physician declines to participate in the Call Group, they will otherwise provide 24/7 availability for their LTC patients, with on-site attendance when required.
   3. Where there are challenges in meeting one or more BPEs, work with facility staff and the LTCI program team to develop and trial approaches to consistently meet all BPEs.
   4. Participate in evaluation of the LTCI program, including sharing data on attachment numbers and frequency of care delivery activities, and provide input on the direction of the program.
2. The Comox Valley Long-Term Care Initiative (LTCI) program agrees to the following:
   1. Provide On-Call Availability Payments (OCAP):
      1. OCAP are available at the following rates:
         1. On-Call FP:
            • Weekday (M–Th) day rate = $296.60/day (6pm – 8am)
            • Weekend/Stat (F–Sun, holiday) day rate = $508.46/day (per 24 hr)
         2. Back-up (2nd-on-call) FP:
            • Weekday (M–Th) day rate = $100.91/day (6pm – 8am)
            • Weekend/Stat (F–Sun, holiday) day rate = $172.99/day (per 24 hr)
      2. Quarterly payments: Following end-of-quarter (financial quarters end on June 30, September 30, December 30, and March 31), the Division will submit an invoice for payment for all LTC OCAP for that quarter, based on the schedule available at the end-of-quarter. If physicians change or swap any of their on-call shifts, they are responsible for advising the Division of the changes, before the affected dates, as per the call group scheduling process.
      3. A single physician may provide coverage simultaneously for more than one FPSC-approved call group (such as an inpatient care or maternity care group and a LTC group) but can only receive on-call payment on a daily basis for participating in one group.
      4. All patient care services provided by physicians during their on-call time will be compensated by their payment model (e.g. LFP Payment Model, fee-for-service, Alternate Payment arrangements).
   2. Provide LTCI Program Resources:
      • Quality Improvement & Program Administration: Support facility teams, physicians, and NPs to develop, trial, and assess approaches to meeting the best practice expectations, as budget and capacity allow.

Terms of Agreement

1. Term: The Term of this Agreement shall commence on July 2, 2024, or the first of the month in which the fully executed Agreement is received by the Division, whichever is later, and conclude upon termination of this Agreement by any party pursuant to the provisions of Section 2 hereof.
   1. The LoA will be reviewed annually, with updates if needed based on the terms of the LTCI funding Memorandum of Understanding.
   2. The LoA may also be periodically reviewed and updated based on results from LTCI evaluation and monitoring activities, stakeholder engagement, and local quality improvement activities.
   3. Physicians may be requested to review and renew their LoA annually, or periodically as needed, including confirming their contact, on-call and practice preferences.
2. Termination: In the spirit of continuity of care for LTC residents, all parties are encouraged to meet to explore an agreeable resolution before dissolving this agreement. Any party may terminate this Agreement without cause upon providing to the other party hereto written notice of at least 30 days.
3. Payment Process: Payments will be made through automated funds transfer. Physicians will be requested to submit a direct deposit form if they are not already set up for automated funds transfer.
4. T4A: The Division must provide a T4A to physicians who are not incorporated and have received remuneration throughout the year. To issue a T4A the Division requires the physician’s Social Insurance Number. It is the responsibility of the Physician to ensure the Division has their Social Insurance Number on file.

List of Appendices

Please review all relevant information.

• Appendix A – LTC Call Group Overview
• Appendix B – LTC Contact & Attachment Preferences (only if new to LTC)

---

The undersigned agree to participate in the Comox Valley Long-Term Care Initiative as outlined in this Letter of Agreement.

Relevant Practice Details

1. Do you participate in any additional Comox Valley after-hours on-call programs?

2. Do you have a community longitudinal clinic practice (i.e. are you eligible for the CLFP payment)?

Physicians answering ‘No’ may be eligible for a LTCI payment directly through FPSC.

Billing Information

Fill this section in only if you are new to the LTCI, or if your billing info has changed.

Are you GST-registered (applicable for sessional payments only)?

Will you bill LTCI payments (On Call Availability Payments & any sessional payments for QI work) as:

Submit completed and signed LoA via:
Fax: 1-866-386-2224  |  Email: LTCI@comoxvalleydivision.ca

---

Appendix A

Comox Valley LTC After Hours Call Group Overview

Overview

• The LTC Call Group provides after-hours coverage for all participating LTC Family Physicians and Nurse Practitioners (FPs/NPs) in the Comox Valley; covering up to 586 LTC & respite residents.
• All FPs/NPs with LTC patients are invited and encouraged to participate. LTC physicians maintain autonomy in determining how they meet care delivery standards in their practices; call group participation is optional.
• LTC FPs must join the Long-Term Care Initiative (LTCI) to participate in the call group. LTC NPs must agree to the Call Group Terms & Standards to participate in the call group.

Scope of Coverage

The call group scope of coverage is determined by the resident status within the LTC home and MRP status, per:

Resident Status	MRP is part of the LTC call group	MRP is not part of the LTC call group	Resident not attached to a physician/NP
LTC Resident	Yes	Not covered	Not covered
Respite Resident	Yes	Yes	Not covered
Hospice Resident	Not covered	Not covered	Not covered

Scope of Availability

• The LTC Call Group takes urgent after-hours calls from LTC homes during:
  • Weekday evenings & overnights: 6pm – 8am, Monday – Thursday nights
  • Weekends: 6pm Friday – 8am Monday
  • Stat holidays: additional 24-hour day (8am – 8am)
• When providing on-call after hours, FPs/NPs must:
  • Respond to urgent calls by telephone within 30 minutes;
  • Provide or arrange urgent in-person on-site services as clinically indicated.
• LTC homes are encouraged to continue using SBAR fax (or another mutually agreed-upon method) to a resident’s FP/NP to communicate non-urgent issues.

On-Call Shifts

• There are 2 on-call shifts per week, which can be combined to a full-week shift, based on provider preference:
  • Weekday shift: Weekday evenings & overnights, as defined above. Weekday shift will be shorter when the week includes a stat holiday on a Monday.
  • Weekend shift: Over a weekend, as defined above. When a stat holiday falls on a Monday, it is added to the weekend shift.
• Participating FPs are compensated for on-call availability as outlined in their Long-Term Care Initiative Letter of Agreement (LoA). This is approximately $21/hr; $1,186.40 for a regular weekdays shift (no stat); $1,313.52 for a regular weekend shift (no stat); $2,500 for a full week (if no stat).

Commitment & Scheduling

• Call group members are expected to take a minimum of 1 shift (weekdays, weekend, or a full week) per year. Members may request additional shifts if they prefer.
• Remaining shifts will be allocated among group members.
• The call group schedule will be developed by the Division based on the Scheduling Process section below. If group members prefer different shifts or have a change in their availability once the schedule has been posted, they are welcome to, and responsible for, arranging swaps or changes with colleagues.

Back-up Plan

• There is an optional back-up (2nd-on-call) shift for some on-call shifts, if requested by the on-call FP/NP.
• If the on-call FP/NP cannot be reached within 30 minutes, calls will be dispatched to the back-up FP/NP, if a back-up shift is in place. The back-up schedule is not mandatory, and is based on sign-up, not assigned shifts.
• The same person cannot fill the ‘on-call’ shift and the ‘backup’ shift for the same date.
• FPs filling a back-up shift are compensated as per their LoA, at approximately $7/hr: $403.64 for a regular weekdays shift; $446.89 for a regular weekend shift.
• If the back-up shift has not been filled, or the 2nd-on-call FP/NP cannot be reached after 30 minutes, the call will then be dispatched to the patient’s own FP/NP.

Call Group Scheduling Process

• Call Group schedules will be made up bi-annually (January – June, July – December).
• A schedule request message will typically be emailed out 6–8 weeks before the schedule start date. Please submit your requested dates and preference for number of shifts and request for having a back-up shift available or not, by the due date indicated.
• Those members with complex or combined call scheduling needs, including those who provide after-hours on-call services for multiple FPSC-funded call groups (such as LTC and inpatient care groups) will be offered priority scheduling based on their preferred availability, to support coordinating their complex scheduling needs.
• We will do our best to schedule according to requested dates and shift preferences, but it may not always be possible to meet all preferences if many physicians/NPs submit the same preferences.
• The Division will aim to have the schedule complete one month before the start of the 6-month term.
• Once the schedule is sent out, FPs and NPs are responsible for arranging with colleagues any swaps or changes (for example, due to scheduling preferences or changes in availability). If swapping a shift:
  • ALWAYS notify the Division, as soon as possible: LTCI@comoxvalleydivision.ca or text: 250-207-2097
  • Notify the answering service if changing a shift within the next 7 days: info@pttas.ca  |  Phone: 1-888-686-3036  |  Fax: 1-604-524-2721

Personal Circumstances

If you wish to be part of the Call Group but have a personal circumstance that limits your after-hours availability to respond to calls, please reach out to us. This group aims to provide comprehensive coverage across the community and to be inclusive and accommodating of all LTC FPs/NPs in the Comox Valley.

---

Appendix B

LTC Contact & Attachment Preferences

Use of Contact Information

Your contact information below will be used by the Comox Valley Division of Family Practice for program-related purposes like communicating call schedules, program updates, etc. Member contact info will also be shared with other members of the LTC After-Hours Call Group (if covered by the group), with Personal Touch Telephone Answering Service and all local LTC homes to facilitate your attachment, care delivery, on-call and related services for LTC residents in the Comox Valley. Your consent for the sharing of this contact information as outlined is affirmed in your signing of this Letter of Agreement. If you have any concerns, please let us know.

Contact Details

Cell #:
Fax #:
Office / Clinic Name:
Office Phone #:
Email Address:
Other 1 (specify):
Other 2 (specify):
Any notes?

Contact Preferences

For urgent calls from LTC Homes please indicate your preferred contact arrangements for each timeframe below.

	Mon 8a–6p	Tues 8a–6p	Wed 8a–6p	Thurs 8a–6p	Fri 8a–6p	Evenings on-call (M–F, 6p–8a)	Weekends on-call (Fri 6p – Mon 8a, + stats)
Office phone
Cell phone
Other (specify)

For non-urgent issues: LTC homes are encouraged to continue using SBAR fax (or another mutually agreed-upon method) to a resident’s FP/NP.

Are there any notes or special arrangements that should be listed with your contact arrangements with LTC Homes and PTTAS?

LTC Attachment Preferences

Clustering:   I will cluster at one or more LTC homes:   Yes   No

Clustering involves maintaining a certain panel size where the LTC home can generally expect you to accept the next unattached resident when your panel drops below the set number. The panel is likely a mix of your existing community patients who are admitted to this LTC home, and others.

Please indicate max panel size (#) for the LTC homes where you will cluster your care:

Providence Living at The Views	CV Seniors Village	Ocean Front Village	Glacier View Lodge	Cumberland Lodge	Cummings Home

Community Patients

For each LTC home, please indicate whether you prefer to follow your community patients into care, or prefer to transfer patient care of your community patients to a colleague if someone becomes available to accept their care at that LTC home.

	Providence Living at The Views	CV Seniors Village	Ocean Front Village	Glacier View Lodge	Cumberland Lodge	Cummings Home
Prefer to FOLLOW my community patients
Prefer to TRANSFER care of my community patients

Current # LTC Patients (if applicable)

Providence Living at The Views	CV Seniors Village	Ocean Front Village	Glacier View Lodge	Cumberland Lodge	Cummings Home

Notes: Any other notes about your attachment preferences?