Author: sitesuper

7. Clinical innovations keeping people at home and out of the hospital

Presentation Materials (members only)

Presentation Slides: MedREACH              

Learning Objectives

At the end of the session, participants will be able to:

1. Describe the health care needs and barriers of medically complex patients (MCP) being addressed by the MedREACH project
2. Describe the different components of the MedREACH project and how they work together to support the medically complex patient
3. Describe the preliminary results of the MedREACH project.

Summary

The MedREACH pilot project (Medical Rapid Education and Assessment for Complete Health) is a demonstration pilot funded jointly by the Ministry of Health and Long-Term Care and the Ontario Medical Association. The goal of MedREACH is to improve the overall health of the medically complex patient (MCP) by seeking to re-forge the therapeutic relationship between the MCP and their family physician and interprofessional team. MedREACH consists of three distinct yet coordinated health care delivery models:

• Primary MedREACH involving clinical nursing outreach to MCPs;
• Specialist MedREACH involving integrated health care delivery by specialists and allied health professionals at McMaster University Medical Centre; and
• Mobile MedREACH involving facilitated interaction between specialists and primary care providers enabling direct and timely consultation for patients with barriers to health care access in their family practice setting or home environment.

The MedREACH project aims to address current gaps in the following areas:

• Medical service provision for MCPs in the primary care and tertiary care setting in order to ensure more timely and coordinated care
• Existing silos of operation in primary and specialty care by building bridges for communication and partnership between primary care and specialty care.

This session will familiarize participants to the MedREACH project framework, how each component of the project was operationalized, and the program evaluation strategy with preliminary results.

Presenters

• Henry Siu, Physician, MedREACH Evaluation Lead, McMaster FHT; McMaster University, Department of Family Medicine
• Laurel Cooke, BES, BScN, RN, Nursing Program Manager, Hamilton FHT

Authors and Contributors

• Hamilton FHT:
  • Laurie Panagio
  • Janelle Kolenich, RN
  • Nicole Steward, MedREACH Project Manager, RN

Theme 3. Transforming patients’ and caregivers’ experience and health

Presentation Materials (members only)

The Vitality Interprofessional Team Approach to Food, Mood and Fitness

Learning Objectives

Participants will:

• Become familiar with a interactive lifestyle program for overweight or obese (BMI 26-40) patients facilitated by an interprofessional team including a RD, OT and SW with a focus on health and well being vs. weight alone
• Gain an appreciation of a patient-centered approach to program content and delivery
• Identify key outcome measures of success for a lifestyle program in primary care
• Access tools and resources to offer a similar program in your family health team setting.

Summary

With 25% of Canadian adults classified as overweight or obese and recent systematic reviews emphasizing the importance of offering structured behavioural interventions in primary care aimed at weight loss and adding small amounts of exercise to reduce risk of chronic disease, the Vitality Healthy Lifestyle program nicely aligns with current best evidence while meeting the needs of our patients. The 11 week lifestyle program offered at the McMaster Family Health Team uses a non-diet approach to educate and empower patients on healthy lifestyle choices to improve health outcomes and promote a small weight loss in a healthy, realistic way. Facilitated by a Registered Dietitian, Social Worker and an Occupational Therapist, participants have the opportunity to learn what influences their food, mood and activity patterns and practice cognitive behavioural strategies to manage emotional eating, eat more mindfully, reframe negative self talk, become more active, try different physical activities, develop action plans and achieve health goals. Patients choose topics of interest and activities they would like to engage in. Linkages with local community resources are explored to assist with managing future relapses. Patients are highly satisfied with this interactive, patient-centered approach that affords opportunities to access specialized advice from the right provider at the right time along with opportunities to learn from each other and become empowered to make positive life-style changes.

Presenters

• McMaster FHT:
  • Michele MacDonald Werstuck, RD MSc CDE Registered Dietitian and Diabetes Educator
  • Colleen O’Neill, OT Reg (ONT) Occupational Therapist
  • Miriam Wolfson, SW Mental Health Counselor

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (members only)

Presentation Slides: Telemedicine Impact Plus  

 (I) Telemedicine IMPACT PLUS (TIP): Bringing Inter-Disciplinary Team Resources to the Community

Learning Objectives

1. Demonstrate how Telemedicine complex care clinic can provide high-quality comprehensive care for medically complex patients and support community primary care
2. Model how to leverage FHT inter-professional skills to promote working to full scope of practice
3. Outline the efficiencies needed to offer this service via protected video-conferencing
4. Describe the opportunities and risks in extending FHT resources to community primary care
5. Demonstrate the value of this approach in coordinated care planning.

Summary

Telemedicine IMPACT PLUS is an innovative, proactive interdisciplinary model of care for serving complex patients and supporting their solo primary care providers (PCPs). TIP has been implemented across the Toronto Central LHIN offering clinics since 2013. Through TIP, both the complex patient and family physician are connected to an interdisciplinary care team over a one-hour consultation via secure videoconferencing technology. The teams leverage inter-disciplinary support from FHTs to focus on critical issues identified by patient, family and PCP. A dedicated TIP nurse facilitator, as care coordinator, provides pre- and post-clinic follow-up supports to all stakeholders. The model recognizes the “perfect storm” created by an aging demographic within a health care system founded on treating acute illness. Currently, disconnected serial consultations based on single disease entities do not reduce the burden of chronic illness for these patients nor provide coordinated care planning for their PCPs. TIP built upon the success of IMPACT PLUS, a Bridges evaluated inter-professional care model. By marrying the power of a skilled inter-professional team, including general internist and psychiatrist, to telemedicine technology, TIP provides one stop coordinated real-time care planning in the PCP office or at home. Evidence from the literature found that intensive inter-professional care succeeds in reducing health care costs with at least equivalent outcomes for complex populations. Preliminary results demonstrate high patient, provider and caregiver satisfaction with this model of care. Already the model has shown itself to be scalable with plans to spread TIP to 2 other teams within the Toronto Central LHIN. 

Presenters

• Taddle Creek FHT:
  • Pauline Pariser, Co-lead; Lead, Mid-West Toronto Health LInk
  • Sherry Kennedy, Executive Director
  • one of Shazmah Hussein, Victoria Charkow or Karen Finch, Registered Nurse
  • Jessica Lam, Pharmacist
• one of Jocelyn Charles, Chief of Family Medicine, Sunnybrook FHT, or Tia Pham, Physician Lead, South East Toronto FHT

(II) Blitzing Integrated Care for the Super Complex Patients

Learning Objectives

1. Recognizing the need for an inter-professional and primary care led team to address patients’ medical and social complexities.
2. The importance of starting a coordinated care plan with the patient physically present at the case conference with the inter-professional team.
3. The importance of having primary care, community agencies (CCAC and CSS), and specialists such as Psychiatrists working collaboratively towards patient’s care coordination and follow-up, and for the patient to have an individualized care team.
4. The impact of using Hospitalization Admission Risk Monitoring System (HARMS-8) to identify complex patients in primary care, and who are then recipients of an electronic coordinated care plan. 5. Share results of patient/caregiver experiences via patient/caregiver stories.

Summary

East Toronto Health Link has developed an innovative approach to address the needs of 1-5% complex patients who have significant social and medical concerns. ETHeL is trying to demonstrate that high risk hospitalization (using HARMS-8) justifies increased use of resources such as Complex Care Plan Management (intensive care management with dedicated follow-up and requiring an inter-professional team approach maximizing scopes of practice, and integration of multiple sectors) . CCT is composed of a small core team of hospital based programs currently operating within ETHeL (Virtual Ward, Geriatric Emergency Medicine (GEM) Nurse, Telemedicine Impact Plus (TIP)-RN, Primary Care Physicians, specialists, as well as a CCAC care coordinator), AND a community-based team consisting of multiple sectors including community support services, mental health, addictions, housing, and Toronto Paramedics. Primary target population for CCT intervention is the frail elderly with complex medical/social needs residing in ETHeL’s catchment area; however, any individual identified by CCT members as complex and in need of coordinated care planning, is supported, though a case conference might not be the desired or effective mechanism in all cases. Some of the key primary characteristics that qualify an individual as ‘complex’ and who would require care coordination via CCT’s case conference are as follows:

• At least one (preventable) hospital inpatient admission and/or multiple (preventable) emergency department visits in the last 12 months (mandatory requirement) and at least two of the following:
• 55 years and older (65 years old and over is ideal except when individuals have conditions that deem them to be frail and elderly)
• Unattached to primary care or ‘poorly’ attached to primary care
• Physical immobility including staying upright, maintaining balance and walking resulting in falls, immobility or delirium
• Multiple/chronic co-morbidities including dementia
• Mental health and addiction complexities leading to barriers to access care
• Polypharmacy
• High caregiver burden and stress

Presenters

• Thuy-Nga (Tia) Pham, MD, Physician Lead, South East Toronto FHT and Toronto East General Hospital; Assistant Professor, University of Toronto DFCM
• Richard Doan, MD, FRCPC, Psychiatrist, South East Toronto FHT and East Toronto Health Link

Theme 1. Population-based primary health care: planning and integration for the community

Presentation Materials (members only)

An Improved Tool for Meaningful Program Planning

Summary

Both FHT/NPLC Executive Directors and staff in MOHLTC’s Primary Health Care Branch have identified the need to improve the ministry’s template for reporting on program plans (known as “Schedule A” in the FHT contract and “Schedule E” in the NPLC contract). A joint working group from the MOHLTC Primary Health Care Branch and AFHTO will be working over the summer to improve this Schedule as a useful tool for program planning and reporting. This workshop will include tips from the working group on how to do effective program planning and evaluation, ministry needs for reporting, and how to use the reporting tool effectively.

Presenters

• Bryn Hamilton, Provincial Lead, Governance and Leadership Program, AFHTO
• Representative from Primary Health Care Branch, MOHLTC
• Representative from AFHTO members on the joint MOHLTC-AFHTO working group Summary

Theme 1. Population-based primary health care: planning and integration for the community

Presentation Materials (members only)

Strategic Approaches to Population Health Planning

Learning Objectives

This presentation will demonstrate a strategic, population-health approach to program planning and QI initiatives. Participants will gain an increased knowledge of how to develop an evidenced- based, patient-informed, comprehensive health promotion plan. They will understand and take home practical tools that help to systematically identify needs, inform decision-making, and support program planning and evaluation processes. This presentation will discuss the benefits of embracing patient feedback, creating community partnerships, and developing meaningful evaluation tools. Participants will be able to identify aspects of building collaboration, and gaining buy-in and support from key stakeholders. Also, it will highlight the importance of utilizing this approach when creating the health promotion plan and for FHT wide organizational improvements.

Summary

FHTs face many competing priorities and interests for program planning. How can they respond to the needs of FHT patients and the broader community, while considering an evidence-based approach to planning in an efficient and effective manner? This presentation will highlight systematic approaches to the annual health promotion plan and QI initiatives within a small and medium sized FHT. There will be two approaches and tools presented to assess community needs and identify top priorities for action. Windsor FHT will review the steps they take throughout the annual program planning process including: reviewing evaluations from the previous year, analyzing targets met and unmet, gaining and incorporating patient feedback regarding program and service wants and needs, fostering existing partnerships and creating new ones, examining and comparing chronic condition priorities and statistics across the country, province, locally, and within individual FHT’s, and developing evaluation tools. Summerville’s Chronic Disease Management Committee (CDMC) developed a systematic tool that considered the top 10 chronic conditions within the FHT against various criteria: 1) prevalence of condition, 2) health care providers’ perspective, 3) patient feedback, 4) complexity of care for patients and providers, 5) probable impact of a program on health outcomes, 6) existing resources and care gaps, at Summerville and in the community, and, 7) feedback from the MOHLTC which helped inform the population health measures within Summerville FHT’s QIP. At Family Health Teams we work in interdisciplinary teams; Health Promotion planning and activities should be no different. It is crucial to engage the team, community members, organizations and businesses, in order to make health promotion activities successful and sustainable. Drawing on internal resources, statistics, and utilizing external partners is key in developing a plan that meets the needs of your FHT and local community.

Presenters

• Chantelle Cecile, RN, MN, BScN, Manager of Quality, Experience and Patient Safety, Windsor FHT
• Nadya Zukowski, Health Promotion Specialist, Summerville FHT

Authors and Contributors

• Christine Wellington, Registered Dietician, Windsor Family Health Team

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Navigating by the stars? Try GPS. How two FHT Leaders used Brain Research to Increase Team Collaboration and Physician Engagement

Summary

• An essential challenge of leaders within Family Health Teams is to create the conditions for high functioning individuals to reorganize into higher functioning, complex and adaptive teams. To do that successfully requires navigating the invisible barriers to engaging others. In this workshop we will demonstrate how understanding the social wiring of the brain can lead to powerful strategies to motivate and engage others. We will present examples of how targeting these social drivers of behaviour led to increased physician engagement and improved team performance in 2 Family Health teams. You will leave with practical and simple tools that you can use to lead your team to a more collaborative and effective level of functioning.

Presenters

• Penny Paucha, Principal, Instincts at Work
• Mary Atkinson, Executive Director, North Perth FHT
• Barb Major McEwan, Executive Director, North Huron FHT
• F Elyse Savaria, MD, Lead Physician, Owen Sound FHT

Learning Objectives

• Identify leadership and governance challenges that derail the effectiveness of FHT’s Identify hidden, structural barriers that prevent effective collaboration Highlight key leadership skills Learn about the social drivers of team behaviour. Learn new strategies to reduce conflict and increase engagement. Develop an action plan to more effectively engage others.

Theme 5. Advancing manageable meaningful measurement

Presentation Materials (members only)

Leveraging convergence of healthcare delivery, business dynamics and technology advancements to advance collection and utilization of meaningful COPD patient data Beyond an electronic paper file – Optimizing your EMR for population-based measurement Data Tracking: Creating Your Own Path How do you make the most of your EMR? Six teams pitch their methods for optimizing custom queries to gather precise, meaningful data. Join moderator/”dragon” Darren Larson of OntarioMD as he presides over this lively, fast-paced session.

(I) Quality Based Improvements in Care (QBIC): How EMR Data can Transform Care

Presenters

• Centre for Family Medicine FHT:
  • Dr. Mohamed Alarakhia, Director, eHealth Centre of Excellence, Family Physician, eHealth Centre of Excellence
  • Ted Alexander, MA, Research Associate, eHealth Centre of Excellence
  • Masood Darr, Technical Specialist, eHealth Centre of Excellence
  • Kathryn Flanigan, Nurse Practioner

Presentation Materials (members only):

• To view the presentation slides, click here.
• Materials will be posted following the 2015 Conference.

Learning Objectives

1. Attendees will learn how to use EMR templates with simple clinical decision support tools to facilitate care of patients
2. Attendees will increase awareness of enhanced use of EMR to identify patients with chronic conditions
3. With the use of structured data in EMR, attendees will be introduced to a model that can help predict at-risk patients in need of additional support.

Summary

Quality Based Improvement in Care (QBIC) is based on the understanding that optimizing primary care’s use of electronic medical records (EMRs) is essential to supporting improvements in our health care system and achieving positive health outcomes at the patient, practice and population levels. With support from an eHealth coach and Information Technology expert, 91 primary care clinicians in 6 primary care organizations were able to enhance quality improvement, chronic disease management best practices and information management. Furthermore, after clinicians were encouraged to document chronic diseases in a structured way, reminders were created in 2 pilot Family Health Teams. After six months, data was evaluated linking workflow to patient outcomes using these reminders. Furthermore, a model was created using structured EMR data to identify at-risk patients who require further support. This advanced use of the EMR will be critical as primary care organizations use system-level strategies to achieve higher quality care while reducing costs (e.g. Health Links patients).

(II) Data Tracking: Creating Your Own Path

Presenters

• Burlington FHT:
  • Melonie Mawhiney, Clinic Manager
  • Caitlin Grzeslo, Program Co-ordinator

Presentation Materials (members only)

• Materials will be posted following the 2015 Conference.

Learning Objectives

The key learnings are how to approach data tracking to work around EMR limitations. With some ‘out of the box’ thinking, you can customize data measurements based on unique programs and services, IHP roles etc. This improves program management as well as eliminating manual tracking for Ministry reports. It provides efficient and effective reporting of statistics and performance measures for the AOP, QIP and quarterly reports. Chronic Disease Management also benefits from queries and other reports developed through QIDSS support by identifying specific health issues in patient charts. Data integrity is also improved through comparative analysis.

Summary

“You can’t manage what you can’t measure” That was our mantra in developing our data tracking system. We will describe how we used ‘fake’ billing codes and unused data fields to measure patient encounters by type and by program. Through innovative thinking, we found ways to extract data from our EMR (Oscar) that did not have the specific functionality we wanted, allowing us to measure what we wanted, not just what was available. With support from our QIDSS, we developed specific queries for programs based upon the performance indicators in our QIP. We can measure time spent by IHP on various tasks and programs with the next step being a ‘Return on Investment’ analysis with the return being measured by patient outcomes. We are able to better manage our Chronic Disease preventions and target patients that would benefit from one of our programs. Our QIP has significantly improved through allowing us to set realistic targets that can be justified by statistics. We can now measure the QIP performance indicators efficiently, effectively and most importantly, accurately.   Given the Ministry’s emphasis on providing “solid evidence of the value of FHTS/NPLCs and team-based care” our FHT can demonstrate this is a quantifiable versus qualitative manner. 

(III) Beyond an Electronic Paper File – Optimizing Your EMR for Population-Based Measurement

Presenters

• Partnering for Quality, South West CCAC
  • Rachel LaBonte, Program Lead
  • Gina Palmese, eHealth Coach

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

Participants will:

• gain a shared understanding of challenges that exist in optimizing the use of EMRs in primary care settings;
• gain an understanding that improving the use of basic/intermediate functionality is often a prerequisite for using intermediate/advanced features (e.g. queries and reports depend on good data integrity, structured and searchable data) and;
• learn a few tips/tricks to help them optimize the current use of their EMR and next steps to population-based care (multiple EMRs will be discussed).

Summary

With 80% of health care encounters occurring in primary care settings the vast majority of patient data is collected and managed at the primary care level and the transformative change to be undertaken will be reliant on information management supports and tools. Not all users are using their EMR to its fullest potential. Through the results of the Primary Care EMR Needs Assessment, primary care physicians, nurse practitioners and physician assistants have demonstrated that they are comfortable using EMRs for episodic care, however challenged to shift EMR use for practice level management. Through the optimization of EMR use for practice level management, primary care practices will be positioned to achieve positive health outcomes at both individual and population levels, leveraging the full benefits of EMR adoption. This further provides a significant opportunity to optimize the use of EMRs for chronic disease prevention and management and delivery of quality patient care. This presentation will not only outline high level results of the EMR needs assessment but will also highlight the rest of the journey towards population-based care. NOTE: This presentation will cover multiple EMR systems. 

(IV) Leveraging Convergence of Healthcare Delivery, Business Dynamics and Technology Advancements to Advance Collection and Utilization of Meaningful COPD Patient Data

Presenters

• Couchiching FHT:
  • Stephanie Kersta, MSc, Health Promoter
  • Greg Armstrong, MD, Lead Physician
  • Stephen Graper, President, Healthcare Together Ltd
  • Doug Kavanagh, Founder, Cognisant MD

Authors and Contributors

• Liz McCormick, IT Manager, Couchiching FHT

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

• Become aware of an optimal healthcare delivery method and process to:
  • Integrate a multi-disciplinary, cross functional team into a QI initiative that will optimize COPD population management (prevention and treatment)
  • Use patient generated health data to identify patient needs and resource requirements
• Understand key insights into developing strategic business partnerships with complimentary core competencies and resources to enable FHT’s to achieve CDM (chronic disease management) goals
• Increased awareness of technology advancements to enable rule based processes to optimize efficient and timely collection of patient self-reported clinical insights with direct Telus PSS EMR integration.

Summary

Couchiching FHT (CFHT) insights demonstrated a need to enhance screening of its COPD population to achieve prevention and management goals. It sought an innovative way to engage patients, efficiently collect key COPD clinical insights that could be leveraged in the EMR. CFHT also recognized the need for an internally aligned team, to leverage strategic partnerships and to adopt new technology to ensure success. Through the use of a cloud-based clinical platform, the CFHT is now enabled to use rule-based technology to collect smoking status information, promote smoking cessation programs, inquire about the patient’s desire to quit smoking, complete the Canadian Lung Health Test screening tool and the MRC dyspnea scale. Additionally, email consent and address collection occurs. All of this data is self-reported by the patient, can occur in just a few minutes and is immediately integrated directly into the patient’s EMR. This standardized data entry can be used to identify patient’s needs, direct internal resources (ie. program referral, spirometry required, bill for smoking cessation…) and communicate cross functionally through customized clinical notes. This presentation will:

• Describe current vs desired status of the CFHT COPD population registry and management
• Present an overview of the current COPD data collection processes and gaps compared to processes utilizing new technology
• Identify the value of developing strategic partnerships with private industry that can leverage technology advancements, therapeutic insights, project management and critical resources.
• Highlight the benefit of a multi-disciplinary, cross-functional team with physicians and staff aligned on the QI initiative.

 

(V) Leading Edge Custom Queries and their Applications Across Ontario

Presenters

• Hope Latam, QIDSS, East Wellington FHT
• Windsor FHT:
  • Brice Wong, QIDSS
  • Sara Dalo, QIDSS

Authors and Contributors

• Michelle Karker, ED, East Wellington FHT

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

Participants will gain an understanding of the different types of data in the EMR, and learn how structured data leads to higher data quality. They will be able to take home knowledge of different data extraction tools, in particular the Telus PS custom queries for extracting data from the custom forms. Participants will also learn the various ways FHTs are using the extracted data to guide program development, track staff utilization, and improve patient care. Finally they will gain knowledge about the AFTHO QIDSS program and how it facilitates the development and sharing of data management concepts and tools to FHTs across the province.

Summary

The presentation will introduce the various types of data in EMRs; free text, stamps, encounter assistants and custom forms. It will have a focus on custom forms and how they are ideal for entering structured data into the EMR. We will then discuss the challenges we faced getting data out of the custom forms. This lead to the development and deployment of the custom queries across Ontario with the funding, guidance, and support from AFTHO. The presentation will then review how East Wellington FHT has used the queries to pull valuable data for a wide range of applications. Other QIDSS will then discuss how they have implemented the queries at their FHTs, and what they are using them for. We’ll conclude with the impact this new data has had on the FHTs, and what others can do to use and apply this same methodology.  

(VI) Optimizing EMRs to Accurately Identify COPD and other Chronic Disease Patients

Presenters

• Sara Dalo, QIDSS, Amherstburg | Central Lambton | Chatham-Kent | Harrow Health Centre | Leamington & Area | Rapids | Thamesview | Tilbury District | Windsor FHTs
• Brice Wong, QIDSS, Amherstburg | Central Lambton | Chatham-Kent | Harrow Health Centre | Leamington & Area | Rapids | Thamesview | Tilbury District | Windsor FHT
• Thiv Paramsothy, QIDSS, East GTA FHT | Scarborough Academic FHT | West Durham FHT | Carefirst FHT

 

Authors and Contributors

• Greg Mitchell, Knowledge Translation and Exchange Specialist, QIDS Program, AFHTO
• Chad Moore, QIDSS, North Simcoe FHT
• Allison Palmer, QIDSS, Brockton & Area FHT
• Sandra Taylor Owen, QIDSS, Central Hastings FHT
• Hope Latam, QIDSS, East Wellington FHT                                              

 

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

This initiative will allow EMR users to reliably generate a list of patients with COPD. Patients already coded/documented as having COPD can be filtered out, so those patients unclearly identified can be reviewed by the primary provider and properly documented in the EMR. EMR- specific instructions and other resources are available for FHTs as they undergo the process of making data quality improvements in their EMRs. Although this presentation is specific to COPD, the development of additional comprehensive queries, for top chronic conditions (ie. diabetes, hypertension, dementia…), are currently underway and will be available in the near future.

Summary

Approximately 12% of Ontarians have COPD and is a leading cause of hospitalization and death in Canada. Primary Care is continuously looking for ways to identify patients living with COPD and linking them with appropriate services that will help them manage their health to reduce ED visits and hospitalizations, and improve overall quality of life. The presentation would include a live demonstration and clearly outline processes around data clean-up initiatives that will optimize the EMR. There will also be next steps around which stakeholders in the community setting can provide services or support for patients identified with having COPD, such as OLA. The Algorithm Project Team is currently in the process of working on the next search for Diabetes and there will be more to come. The data generated could also assist with improving the accuracy and ease of Ministry reporting. This initiative has been broadcasted on several weekly QIDSS calls and professional development sessions, but the AFHTO conference would be an ideal opportunity to share it with members abroad since many can benefit from this search. A significant number of FHTs across Ontario have reported they do not have a reliable COPD registry, which is a drawback since registries allow for identification and tracking for patients with specific conditions, facilitate delivery of health care and track their progress. This solution can allow FHTs to manage their patients effectively and help overcome fragmented care and improve coordination services.