Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 2 & 3
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Clinical providers

Learning Objectives

1. Learn how a single physician leader can successfully act as a change agent and help drive others to embrace new technology and processes
2. Hear how the adoption of an EMR-integrated patient engagement tool helped foster better patient-physician encounters, increased patient care consistency, and cut charting time in half
3. See how an automated patient questionnaire platform is driving system-level changes including universal smoking screening and email consent, resulting in clinic efficiencies and better patient care
4. Learn the key steps you can take in your own clinic to overcome behaviours and barriers to change

Summary/Abstract

Feedback from patients indicates that they feel more actively involved in their care, having the ability to express concerns on their own terms and – for some questions – in their own words. For providers, there is a significant decrease in time spent on documentation while actually having more documented in the chart. Early figures around usage indicate that there have been significant increases to population screening for smoking and the facilitation of smoking cessation.

Presenters

• Joan Chan, MD CCFP, Guelph Family Health Team
• Kathleen Vanleeuwen, BAHSc, Guelph Family Health Team

Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 9
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

1. Learn about ER and Hospital usage data specifically for patients with IDD from a province-wide study completed in 2015. Characteristics of this population contributing to high use and complexity will be reviewed
2. Learn about coordination tools designed specifically for patients with IDD:
   1. a guide to CCP completion
   2. an adapted CCP template
   3. a Health Passport to ensure safety in emergencies
   4. a standardized set of IDD specific preventative care recommendations
3. Review a logic model designed to evaluate a health links approach to care coordination and intersectoral/interministerial collaboration for supporting complex, vulnerable populations

Summary/Abstract

Health Links is an Ontario initiative that brings together local healthcare providers to redesign an enhanced coordinated model that is patient-centered for the purpose of improving outcomes for the most complex patients in our region. We will discuss a unique approach which brings MOHLTC health system coordination capacity together with the MCSS developmental service sector’s IDD expertise and ability to identify those most complex and in need.  The presentation will review recently developed tools that support targeted care coordination (Health Link) to this particular population. Such tools include a CCT template  to cover communication and behavioural issues, a Health Information Passport to ensure safety and communication in emergency situations as well as a standardized set of IDD specific preventative care recommendations for primary care teams. It is anticipated that these approaches may be generalized to targeted care coordination of other vulnerable  populations in need of tailored approaches.

Presenters

• Linda Robb Blenderman, RN, BScN, Msc, Kingston Health Link Project Coordinator
• Marg Alden, Lead Agency Representative, Kingston Health Link
• Liz Grier, MD, CCFP, Queen’s Department of Family Medicine
• Ian Casson, MD, CCFP, Queen’s Department of Family Medicine
• Laura Cassidy, Quality Improvement Decision Support Specialist, Kingston Health Link

Authors & Contributors

• Margaret Gemmill, MD, CCFP Queen’s Department of Family Medicine
• Mary Martin, Research Assistant, Queen’s Department of Family Medicine
• Dr Yona Lunsky, Director of H-CARDD and Clinician Scientist at the Centre for Addiction and Mental Health
• Janet Durbin, Project Evaluation Lead, Independent Scientist – Provincial Support Services Program at the Centre for Addiction and Mental Health
• Richelle Uens, Health Care Facilitator, Networks of Specialized Care (MCSS)

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 7 & 8
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

1. Appreciate how a multidisciplinary team can most effectively support families, primary care providers, and educators to assess and support children struggling at school
2. Analyze our School Success Program’s experience to identify the factors contributing to the development and evolution of effective collaboration within our core team, the broader Family Health Team, and across sectors in our community
3. Reflect on the challenges in evaluating this type of work and implications for strengthening team collaboration

Summary/Abstract

After the first academic year, the SSP surveyed family doctors, local schools, and referred families. Recognizing the challenge in identifying meaningful outcome measures at a client level in the short term, this evaluation focussed on process, satisfaction, and perspective on impact. A common theme was the importance of clear communication and shared understanding. Satisfaction with quality, range, and timeliness of service was high amongst schools and physicians. Eighty-two percent of educators and 97% of physicians agreed SSP involvement was a valuable addition to their work; all but one respondent felt it made a positive difference for most referred children/youth.

Presenters

• John Stokreef, School Success Program Family Doctor Lead, Couchiching Family Health Team
• Susan Surry, School Success Program Pediatrician, Couchiching Family Health Team
• Michelle McLaughlin, School Success Program Registered Nurse, Couchiching Family Health Team
• Cassandra Eriksson, School Success Program Social Worker, Couchiching Family Health Team
• TBA, Educator

Authors & Contributors

• John Stokreef, Family Doctor Lead, Couchiching Family Health Team, j.stokreef@cfht.ca
• Susan Surry, Pediatrician, CFHT School Success Program, s.surry@cfht.ca
• Michelle McLaughlin, RN, CFHT School Success Program, m.mclaughlin@cfht.ca
• Cassandra Eriksson, Social Worker, CFHT School Success Program, c.eriksson@cfht.ca
• Education representative TBA

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Metropolitan Ballroom West
• Style: Panel Discussion (in addition to providing information, panelists interact with one another to explore/debate a topic)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

This practical presentation will provide attendees with concrete ways to enhance the roles of FHT RNs collaborating in-office with family physicians. Specific procedures and treatments will be cited and steps presented to increase scope of practice and open important conversations with FHT physicians to the end of enhancing FHT RN in-office practice for maximum health outcomes for patients.    A copy of the City of Kawartha Lakes “Family Registered Nurse Scope of Practice” guidelines will be provided to attendees.

Summary/Abstract

Survey results will be shared as part of this presentation. The survey data will compare the time FHT RNs spent on more episodic care to time spent on the same – and new – care in our FHT RNs’ enhanced scope of practice. For example, time/number of routine injections conducted weekly pre-change compared to time/number of injections and new well-baby visits conducted since the enhanced RN practice initiative began.  Graph and chart visuals will be included to illustrate rate and strength of change.

Presenters

• Kylie Pankhurst, Family Health Registered Nurse, City of Kawartha Lakes Family Health Team
• Leslie Broadworth, Family Health Registered Nurse, City of Kawartha Lakes Family Health Team
• Steve Oldridge, President, City of Kawartha Lakes Family Health Team
• Name TBA (participation confirmed), RN Coordinator, Hamilton Family Health Team
• Marina Hodsom, Executive Director, Kawartha North Family Health Team

Authors & Contributors

• Mike Perry, Executive Director, City of Kawartha Lakes Family Health Team
• Linda Ready NP, Clinical Practice Coordinator, City of Kawartha Lakes Family Health Team

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/17/2016
• Concurrent Session B & C
• Time: 3:30pm – 5:15pm
• Room: Pier 5
• Style: Workshop (session is structure for interaction and/or hands-on learning opportunities)
• Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

• What is Collective Impact:
  • Definition of Collective Impact
  • History of the Term ‘Collective Impact’
  • 3 Preconditions
  • 5 Conditions
  • 3 Mindset Shifts
  • Importance of Community Engagement –
• Collective Impact in Action in a subLHIN Region: Rural Hastings Health Link (RHHL)
  • Description of RHHL
  • RHHL as Collective Impact and Community Engagement in Action
  • Quadruple Aim Impacts of RHHL

They will then engage in small group discussions on the implications of the learnings in their multi-stakeholder work. They will share highlights through a plenary report back.

Summary/Abstract

Confirmed that 100% of Rural Hastings Health Link (RHHL) clients identified social barriers preventing optimal health outcomes. Patient feedback through surveys and fora concluded that their experience with the health system improved by 86%. Provider satisfaction represented 87%. The RHHL demonstrated an 89% reduction in emergency department visits, 87% reduction in hospital admissions and 91% reduction in lengths of stay, which represents a net program benefit of $3,031,267.00 and a return on investment of 230%.

Presenters

• Leah Stephenson, Director of Policy and Stakeholder Relations, Association of Ontario Health Centres
• Lyn Linton, Executive Director and Health Link Backbone Support, Gateway Community Health Centre and Rural Hastings Health Link

Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/17/2016
• Concurrent Session B
• Time: 3:30pm – 4:15pm
• Room: Pier 4
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Clinical providers

Learning Objectives

1. Identify key components of proactive or planned COPD management utilizing various members of the inter-professional team
2. Learn how to design and implement a COPD management program within your office setting
3. Understand how the EMR can be a tool for the identification, management and evaluation of COPD patient care
4. Demonstrate an approach to care coordination and transition into primary care post COPD related ER visits or hospitalization

Summary/Abstract

The “INSPIRE” program is currently being implemented and therefore data collection is underway. We anticipate the following clinical outcomes:

• Improved MRC Dyspnea Scale and CAT (COPD assessment test) scores
• High patient satisfaction with care
• Increased rates of patients who are up to date with their vaccinations – influenza, pneumococcal
• 100% of patients receive a personalized COPD action plan and referral to smoking cessation resources
• Reduction in the number of yearly COPD exacerbations, ER visits or hospitalizations
• 90% of patients will be seen by team within 2 weeks of ER or hospital discharge related to COPD

Presenters

• Colleen Youngs, Primary Care Nurse Practitioner, RN EC, Bridgepoint Family Health Team
• Victoria Siu, Pharmacist, Bridgepoint Family Health Team

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/17/2016
• Concurrent Session B
• Time: 3:30pm – 4:15pm
• Room: Metropolitan Ballroom West
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Research/Policy (e.g. Presentation of research findings, analysis of policy issues and options)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers

Learning Objectives

1. Increase knowledge of indicators of palliative care in primary care
2. Increase ability to identify patients needing end of life care
3. Broaden understanding of facilitators and barriers to providing a primary palliative care approach
4. Become familiar with strategies and care approaches currently used by primary care providers/teams in the provision of end of life care.

Summary/Abstract

We will present findings from our qualitative research, which uncover the strategies that primary care providers and teams use to deliver end of life care, as part of comprehensive primary care.    Our research questions include:  What current processes used by family practices to provide care to patients with progressive life limiting illness?  A) How are these patients identified?  B) What strategies are used to care for their individual and family caregiver needs?  C) What are the current barriers and facilitators to implementing care for patients with life limiting illness?  The results have been organized to facilitate reflection on how Family Health Teams could develop their own approaches to recognizing needs and providing a palliative approach.

Presenters

• Joy White, Primary Care Nurse Practitioner, MScN, McMaster Family Health Team
• Nicolle Hansen, PHC –NP, McMaster Family Health Team
• Amanda MacLennan, RN, MScN, McMaster Family Health Team

Authors & Contributors

• Nicolle Hansen, PHC-NP
• Amanda MacLennan, MScN
• Alex Rewegan
• Sharef Danho
• Donna Blaney

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/17/2016
• Concurrent Session B
• Time: 3:30pm – 4:15pm
• Room: Pier 2 & 3
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Clinical providers

Learning Objectives

1. Gain an understanding of the importance of early intervention for those patients diagnosed with an eating disorder
2. Learn how the FHT framework supports collaboration and comprehensive patient care when designing and implementing an ED Bridge Program
3. See practical examples of one patient’s journey, and the outcomes achieved by the program

Summary/Abstract

The ED Bridge Program has met the needs of its patients through thoughtful, innovative and focused health assessments and systematic follow up by health care providers with a specialized skill set. Early intervention following an eating disorders diagnosis has enabled closer monitoring of the patients’ physical and mental health, and ensured that no one “falls through the cracks” as they wait for formal treatment.  The program team, as well as referring physicians, have expressed a high level of satisfaction with the collaborative efforts demonstrated through this program. The presentation will include physician and patient/family testimonials.

Presenters

• Kelly Van Camp, NP, Markham FHT
• Rhonda Pompilio, SW, Markham FHT
• Andrea Firmin, RN, Markham FHT

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/17/2016
• Concurrent Session A & B
• Time: 2:30pm – 4:15pm
• Room: Marine
• Style: Workshop (session is structure for interaction and/or hands-on learning opportunities)
• Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Participants will learn the principles of distributed leadership, understand how the principles can be implemented through case examples and stories, explore how to implement the principles in their work setting to drive more seamless, patient centred care across organizations.

Summary/Abstract

Come learn how leaders in Huron Perth developed themselves as leaders and then engaged others across the region to produce the following stellar results:  a 12 fold increase in # of CCP’s; drop in ED visits; increase in collaborative relationships across organizations; increase in the number of providers involved in CCP’s; increase in types of organizations initiating CCP’s; successfully engaging previously resistant physicians and other hcp’s in initiating CCP’s; improved patient and provider experiences; changes in language that indicate a shift to more collaborative, patient centred care.

Presenters

• Penny Paucha, A., Leadership Coach, Principal, Instincts at Work
• Mary Atkinson, RN, B.Sc., MBA, CHE, Executive Director, North Perth Family Health Team
• Shannon Natuik, Family Physician, Maitland Valley FHT
• Janet Obre, Primary Health Care Nurse Practitioner Mental Health, Addictions, Complex Frail Elderly, Huron Perth Healthcare Alliance