2011 AFHTO conference presentation PRESENTER (S): Lucy Bonanno, Executive Director; Nadya Zukowski, Health Promotion Specialist FHT/ORG: Summerville FHT ABSTRACT: The Summerville Arthritis Program is a novel, collaborative approach to community Osteoarthritis care. Our interdisciplinary team partnered with The Arthritis Society and Pfizer to map out the delivery of a comprehensive yet flexible program. The program guides the patient through in-house services including a group education session, one-on-one counseling, a joint injection clinic and the ‘Maximize Your Health’ Stanford Chronic Disease Self-Management Program. It also identifies a pathway for Rheumatoid Arthritis care. The program was piloted winter 2011 and is now being offered Summerville-wide starting fall 2011, thus optimizing patient-centered care. Click here to view presentation.
Year: 2011
-
Advancing the RN role in Chronic Disease Management
2011 AFHTO conference presentation TITLE: Advancing the RN role in Chronic Disease Management and Prevention in Primary Care PRESENTER (S): Sylvia Scott, Clinical Manager FHT/ORG: Guelph FHT ABSTRACT: Health care systems continue to be challenged to respond effectively to the increasing impact of chronic diseases on population health and health care resources. Using the Ontario Chronic Disease Management and Prevention Model, Guelph Family Health Team (GFHT) responded by integrating advanced registered nurse roles in primary care practice team settings with a goal to improve care for individuals with and or at high risk for chronic conditions. This presentation will discuss a unique interdisciplinary and collaborative model led by RN as the case manager within programs or embedded in the practice team. Their role is provide a holistic approach to the patient/caregiver in order to prevent or manage chronic health conditions by engaging the patient to identify and prioritize their own physical and emotional well-being. The RN also works with the patient/caregiver by monitoring progress and barriers to achieving wellness goals and clinical outcomes. The overall goal is to build patient/caregiver and interdisciplinary team capacity. This is achieved through the RN’s role by triaging in order to facilitate patient focused care, timely provider and community collaboration, patient education, and systems navigation across the entire health care spectrum. Outcomes measures include improved access to primary care, reduced number of emergency room visits and or hospital admissions, improved self-management and improved overall quality of life. Click here to view presentation.
-
Chronic Respiratory Disease Management in the Community
2011 AFHTO conference presentation PRESENTER (S): Maria Savelle, RN, Certified Respiratory Educator, Nurse Educator FHT/ORG: Stratford FHT ABSTRACT: The Stratford Family Health Team Respiratory Clinic began as a pilot project in June 2009 after it was identified there was a need to assess and provide education regarding patient self-management of chronic respiratory conditions (COPD and Asthma). After a successful trial period, the SFHT Respiratory Clinic opened to all patients rostered with the 13 physicians of the Stratford Family Health Team. A specially trained registered nurse (COPDTrec, AsthmaTREC, SpiroTREC, TEACH trained) accepts referrals from physicians and Allied staff. Office spirometry is performed, and three champion physicians interpret the results to diagnose COPD and/or asthma. Pharmological management is decided between the Nurse Educator and the responsible physician. Follow up education regarding self-management of their respiratory condition is then provided either one-on-one, or in a group education session by the Nurse Educator. Follow up visits are arranged to ensure compliance with respiratory medications, assessing control/management of symptoms, and further patient teaching is provided to aid the patient in optimum self-management (Action Plans, Diary of symptoms, identifying need for reassessment in times of increased symptoms, etc.) If the patient is smoking, smoking cessation counseling is offered by the Nurse Educator as part of the follow up visit regime. The SFHT was a part of the QIIP COPD Learning Community, and was able to identify a number of patients appropriate for spirometry testing by way of screening with the Canadian Lung Health Test – a number of patients were newly diagnosed with lung conditions earlier, due to this screening process, and a number accepted smoking cessation counselling as a result of their screening and spirometry testing procedures. The Stratford Family Health Team Respiratory Clinic continues with the Nurse Educator assessing patients Monday to Friday, 8-4, where a constant flow of referrals for new patients continues in the busy clinic. The goal of the clinic is to identify respiratory conditions, ensure proper treatment according to current guidelines, teach patient self-management of respiratory conditions, in the hopes of reducing physician office and ER visits related to respiratory symptoms. Click here to view presentation.
-
The use of Genetics and Personalized Medicine in Health Promotion and Chronic Disease Management
2011 AFHTO conference presentation PRESENTER (S): Sean Blaine, BSc MD CCFP, Lead Physician; Jill Davies, MSc., CCGC, Genetic Counsellor, Program Director, Medcan Clinic FHT/ORG: STAR FHT ABSTRACT: Genomic information is growing at an exponential rate and can be used as a tool in clinical decision making. It is now technically and economically feasible to consider the application and utilization of genomic sequence data in clinical care. Identifying individuals at increased risk for rare hereditary diseases as well as common diseases can lead to improved clinical outcomes through health promotion and early detection. This requires a proactive multidisciplinary approach combining new technologies with family history information, clinical data and patient education around risk reduction and disease prevention. New technologies can also identify specific genetic variants in enzymes of drug metabolism which have an impact on the selection and dosing of medication. In this way, pharmacogenomic (PGx) testing allows physicians to optimize drug selection and dosing based on a patient’s unique genetic makeup. The application of PGx in clinical practice is expected to improve health outcomes by decreasing medical costs and increasing patient compliance with medication regimens. Click here to view presentation.
-
Preparing for Electronic Labs
2011 AFHTO conference presentation PRESENTER (S): Katharine De Caire, RN (EC), MN; Katalin Ivanyi, MD, CCFP, FCFP FHT/ORG: McMaster FHT, Stonechurch Site ABSTRACT: Laboratory information systems are an important component of an electronic health record. The ability to electronically access laboratory test information assists health care providers to make faster, better patient care decisions, enables timely access to information, provides better coordination of care and improves workflow Shared care is the basis of a Family Health Team. In a shared care environment a team’s Physicians and Nurses are both accountable for managing patient lab results and these accountabilities need to be clearly defined, communicated, and documented. In 2011 Stonechurch Family Health Centre began to prepare for the implementation of electronic labs. Our team recognized that managing test results effectively is vital to quality patient care and a failure to follow up on test results can lead to patient harm. In this presentation we will highlight our team’s paper-based process for results management, discuss our journey to prepare for electronic labs and present our final plan. Click here to view presentation.
-
Practitioner Experience of an Interprofessional Integrated Primary Care-Based Programs For Seniors
2011 AFHTO conference presentation PRESENTER (S): Dr. Ainsley Moore, MSc, MD CCFP; Joy White, RN-EC, MSN; Kalpana Nair, MSc, PhD; Maria Chacon, MD FHT/ORG: McMaster FHT & Department of Family Medicine, McMaster University ABSTRACT: Background: Multidisciplinary, integrated primary care-based programs involving multiple practitioners are recommended for frail seniors with complex concurrent conditions. This study sought to understand the perceptions and experiences of family physicians and nurses whose patients had been seen through a multidisciplinary, integrated primary care-based program for seniors, the Seniors Collaborative Care Program (SCCP). Methods: This study used a qualitative descriptive approach and took place at Stonechurch Family Health Centre (SFHC) in Hamilton, Ontario. Purposive sampling was used and each participant took part in a semi-structured, individual interview. Analysis involved a content analysis approach. Results & Conclusions: Five family physicians and 4 nurses working at SFHC took part. Main themes centred on need for clear communication and role clarity. Access to the SCCP Program was also a predominant theme, suggesting that availability of specialized geriatric services in primary care is an important step towards increasing knowledge and skills of primary care clinicians. Click here to view presentation.
-
Point of Care INR
2011 AFHTO conference presentation
PRESENTER (S): Katharine De Caire RN (EC), MN; Jennifer Scott, RPN; Mary Park, RPN; Joan Morris, RPN; Brian Hemens, RPh BScPhm; Shelly House RPh BScPhm
FHT/ORG: McMaster FHT, Stonechurch Family Health Centre
ABSTRACT: Monitoring the international normalized ratio (INR) is a key component of using Warfarin therapy effectively and safely. Traditionally, measuring an INR has involved routine visits to laboratories for venipuncture. Point-of-care testing is an effective alternative. By putting patient, practitioners and test results in the same place at the same time, they facilitate timely and proper patient evaluation and education and leads to improved patient satisfaction. Multiple studies have shown that a systematic approach to anticoagulation management, focused at the point-of-care, may increase the time patients are in range and reduce the risk of adverse events. In this presentation, we will highlight our RPN lead INR clinic and our experience with the development and ongoing logistics associated with a FHT-based point-of-care INR testing program. Our evaluation focuses on time in therapeutic range, patient satisfaction, and costs
Click here to view presentation.
-
Patient Centred Access
2011 AFHTO conference presentation
PRESENTER (S): Margaret Tromp MD, CCFP, FCFP, FRRMS; Karen Brooks, RN, BScN, CRE
FHT/ORG: Prince Edward FHT
ABSTRACT: Patients who have primary care providers often perceive that they are unable to get timely appointments. Open Access is proposed as a response to this, but does not meet the needs of patients with chronic disease or those requesting health maintenance visits (well baby, prenatal, periodic health review). We are piloting Patient Centred Access, as described by Leonard et al (Ann Int Med 2003). We offer same day appointments to those with acute problems. We encourage those with chronic health issues to book follow up appointments in advance and they are seen jointly by the chronic disease nurse educator and the physician. The nurse educator also does lifestyle and preventive counselling for all patients. We also offer telephone appointments for those who do not need to be seen in person, usually to follow up tests or treatments. We are introducing web based medication refills and conveyance of normal test results.
Click here to view presentation.
-
New Innovations and Best Practices in a FHT
2011 AFHTO conference presentation PRESENTER (S):
Karen Y. Brooks, RN, BScN, CRE, CDM Nurse Educator; Dr. Margaret Tromp, MD, CCFP, FCFP
FHT/ORG: Prince Edward FHT
ABSTRACT: “Left undiagnosed or untreated, chronic disease may also exact serious health and economic consequences from patients, families, and communities” (Every, 2007, p. 70). A FHT Family Physician and CDM Nurse Educator, have implemented aspects of The Edmonton Southside Primary Care Network Chronic Disease Model. This has brought the care of chronic disease back into the family physician’s office, where FHT team members contribute, but work to improve care and coordination of service is achieved within. We have customized this approach within our family practice. Highlighted is the MOHLTC’s seven themes of priorities for FHT’s, correlated with practice management of several chronic diseases. Utilization of upstream approaches to patient preventatives and screening is addressed. A patient may see the CDM Nurse Educator, the Family Physician, or both, and spend time discussing disease management. “This team approach frees the physicians to see more patients, to concentrate on those who need them and to take satisfaction from knowing they are doing a good job” (Spooner, 2007, as cited in Every, 2007). You won’t want to miss ‘The Pork’n Beans’ of CDM. Click here to view presentation.
-
It Takes a Team
2011 AFHTO conference presentation
PRESENTER (S): Dr. Pauline Pariser, Physician Lead; Dr. Nadiya Sunderji, Consulting Psychiatrist
FHT/ORG: Taddle Creek Family Health Team
ABSTRACT: The Complex Medical Care Clinic is a partnership between the Taddle Creek Family Health Team and the Centre for Innovation in Complex Care at UHN. The clinic proactively addresses patients with complex co-morbid disease in order to improve their quality of care. Our consulting internist and psychiatrist, as well as professionals representing six disciplines, meet with the patient to develop a coherent treatment plan. The intended outcomes include reduction in emergency room visits and hospital admissions, reduction of the burden of care for the primary care provider and modeling synergistic problem solving for all health care providers. We will present a 20minute film of a clinic in action. Discussion will focus on the benefits of this service for the patient and family as well as for members of the team and the challenges in setting up this initiative for a family health team.
Click here to view presentation.