AFHTO 2014 Conference: Theme 4 – Team collaboration in patient-centred care

Theme Description: Interprofessional comprehensive primary care is focused on a collaborative practice that improves on the patient’s experience each time they interact with the organization – from making an appointment through their care episodes and follow-up reminders. Presentations in this stream will focus on interprofessional team collaboration and factors affecting how the team coordinates their work to meet patient needs (ie. team development activities, conflict resolution, and flexibility in scope of work for team members). A4 Our Best Foot Forward: Setting the Standard for Evidenced Based Multi-Disciplinary Approach for Foot Care Management Participants will learn from the Guelph FHT’s experience in delivering a standardized foot care program which is comprised of two primary components: a multidisciplinary team approach to clinical foot care interventions and individual and group foot care education. B4 The Most Valuable Player (MVP) Clinic – Our Collaborative Journey to Improving Patient Outcomes The MVP Clinic was created to support phase one of the Barrie Community HealthLink’s business plan. As the lead organization for our HealthLink, the BCFHT recognized the need to change the way healthcare is delivered in our community and therefore committed resources to this project.  Using an interprofessional approach to care, our goal was to open a clinic for patients with multiple complex conditions, limited access to a primary care physician, and who are ‘high cost’ users of the healthcare system. C4 Implementation of a Homebound Senior’s Program: The Sunnybrook Academic Family Health Team’s Story The Sunnybrook Academic Family Health Team’s Homebound Seniors Program is an innovative, integrated, interprofessional project that provides team based care to homebound seniors (those who require a home visit due to a physical, social and/or psychological barrier which prevents them from accessing the clinic.) This session will describe the development and implementation of this program as well as some preliminary outcome data. C4-Items to bring on a Home Visit_handout C4-Initial & Follow-up Visit Stamps_handout D4 Renewal of interdisciplinary team processes to enhance linkages to the community and home based health care The provision of care for older adults can be challenging due to complex life and health realities for this population. TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a community based primary health care program that aims to foster optimal aging for older adults living at home using an interprofessional primary health care team delivery approach that centres on meeting a person’s health goals with the support of trained community volunteers, system navigation, community engagement, and use of technology. This presentation will share learnings from the initial development and implementation of TAPESTRY within a 2-site Family Health Team (FHT). E4 The Village Family Health Team’s Stepped Care Depression Management Update (presentation to follow) Village FHT presented the concept of a Stepped Depression Management Program at AFHTO 2012. At AFHTO 2014, they will present the outcome of two years of work.  Stepped Depression Management is a treatment to target program. The PHQ-9 is used to detect major depression and systematically monitor patient’s status. It provides a clear, evidence-based stepped-care approach for the provider to know how to best change or intensify treatment if needed.  A consulting psychiatrist reviews the patient case load with the social worker and family physician and offers assistance for patients with depression that is severe or not improving. Our presentation will consist of a review of literature demonstrating effectiveness of this approach in other settings as well as a review of public policy supporting shift of mental health management to primary care. F4 Expanding Capacity for Dementia Care: Primary Care-Based Memory Clinics Across the Province (presentation to follow) A primary care-based memory clinic model has been developed to address existing challenges of providing dementia care within family practice. To support this model, a training program was developed as a capacity-building initiative to support primary care providers to maintain the majority of dementia care within primary care practice. This presentation will describe the memory clinic care model, training program, implementation across the province, and potential applicability to other complex geriatric conditions.