Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/17/2016
• Concurrent Session A & B
• Time: 2:30pm – 4:15pm
• Room: Harbour A
• Style: Workshop (session is structure for interaction and/or hands-on learning opportunities)
• 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

Learning Objectives

1. Obtain Information on the use of administrative data for quality improvement purposes
2. Gain hands-on experience on how to use the information in the group-level Primary Care Practice Report for FHT Executive Directors to drive quality improvement in their practice
3. Connect with peers to share local approaches for how data can be used to fuel quality improvement in team-based primary care

Summary/Abstract

The PCP Reports provide cross-sectional and longitudinal aggregate data on cancer screening, diabetes management, patterns of service use, practice demographics and case mix. Based on results from a recent survey of FHT executive directors, 87% have found the report useful to drive quality improvement in their practice. Currently, 133 FHTs have already signed up to receive the report and 88% would recommend the reports to their peers. By reflecting on their current performance, individual physicians or primary care teams can identify and select an improvement target and leverage change ideas to move their practice toward the desired target.

Presenters

• Wissam Haj-Ali, Senior Methodologis, Health Quality Ontario
• Maria Krahn, Quality Improvement Specialist, HQO
• Chloe Sherr, Research Analyst, HQO
• Dave Zago, Quality Improvement Team Lead, HQO

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Pier 7 & 8
• 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

1. Understand the opportunities and challenges with using a self-administered health equity survey to collect information on the socio-demographic characteristics of patients, linked to the EMR
2. Learn how data from a health equity survey can be applied to understand inequities, using the example of cancer screening
3. Identify options and strategies for collecting data related to health equity in your FHT

Summary/Abstract

It can be challenging to uncover and address health inequities at a practice-level with the current data available to us. This interactive workshop will provide practical guidance to teams interested in using data to identify potentially vulnerable populations and reduce inequities in care. Over the last three years, more than 11,000 patients at SMHAFHT have completed a health equity survey that includes questions on gender, sexual orientation, housing, income, disability, ethnicity, and language. The survey was developed collaboratively by multiple stakeholders in the Toronto Central LHIN and is now mandated at hospitals and other health organizations across the LHIN. We will discuss some of the early challenges faced with implementing this survey. We will share results of our research assessing the quality of the health equity data we have collected. We will also share results from interviews and focus groups with patients, administrative staff, FHT leadership, and clinicians about their views of the survey and how to best use the data. We will also discuss the application of this data to our patients who are under-screened for cancer. Participants will be asked to help interpret our results. By working with the data directly, participants will get a sense of the challenges and opportunities in using a health equity survey to develop and target   clinical interventions. We will share how we are using the health equity data to inform work related to cancer-screening at SMHAFHT. We will end with a discussion of the different types of data that could be collected to understand and address health equity, strategies to collect the data, and potential uses.

Presenters

• Tara Kiran, Family Physician, Michael’s Hospital Academic Family Health Team
• Sam Davie, QIDSS, Michael’s Hospital Academic Family Health Team
• Aisha Lofters, Family Physician, Michael’s Hospital Academic Family Health Team

Authors & Contributors

• Andree Schuler
• Rosane Nisenbaum
• Tatiana Dowbor
• Kim Devotta
• Andrew Pinto

Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Pier 5
• 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, Administrative staff,

Learning Objectives

1. How to improve timely post-hospital discharge follow-up by identifying and overcoming barriers
2. How to integrate allied health professionals during transitions of care with a focus on medication reconciliation
3. How to integrate different FHT programs together to aid patients during transitions of care

Summary/Abstract

Patients seen within 7 days increased from 12.5% to 66%  Elicited reasons why patients are not seen in clinic after hospital discharge EMR Rx list inaccuracy is 98% following discharge  Avg # of Rx discrepancies per chart is 5.5.

Presenters

• Yali Gao, Clinical Pharmacist, Health for All FHT

Authors & Contributors

Yali Gao, Clinical Pharmacist, Health for All FHT

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Harbour B
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. Describe the attributes of high-functioning primary care teams in Canada from the perspective of system, organizational, interpersonal and individual factors
2. Identify the barriers of developing high-functioning primary care teams
3. Discuss potential interventions and related assessment tools to improve team function

Summary/Abstract

Identified attributes of high-functioning primary care teams.

Presenters

• Phil Ellison, MD, MBA, CCFP, FCFP Vice Chair Quality – Department of Family & Community Medicine, U of T, Department of Family & Community Medicine, U of T
• Patricia O’Brien, RN, Department of Family & Community Medicine, U of T
• Mary-Kay Whittaker, BSc, Department of Family & Community Medicine

Authors & Contributors

• Monica Aggarwal, PhD QI Lead Policy & Research, Department of Family & Community Medicine, U of T

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff

Learning Objectives

1. The process of self-reflection: how to evaluate your mental health patient population and program needs and use this information to streamline your provision of care
2. Practical techniques to address patient needs more quickly
3. Does everyone need individual therapy? What are the other options and how can you tell who should get what
4. How we drastically reduced our wait times and how this is helping our patients improve their mental health
5. How to implement and evaluate an effective screening/triage process, intake calls, single session treatment, on-going individual counselling and therapy groups

Summary/Abstract

Wait times reduced from 12 months to 2 months for individual therapy and from 12 months to 2 weeks for initial service provision (Single Session Tx and short-term follow-up). Urgent patients can now be contacted and often seen face-to-face within a few days.    Wait list reduced from 140 patients to 20 patients. Number of patients seen in 1 year increased from 300 to 350 and continue to grow. Pre/post outcome measures by patients showing a reduction in MH symptoms.

Presenters

• Matthew Ottaviani, MSW, RSW, LCSW, Connexion Family Health Team

Authors & Contributors

• Carmen Sadoway, MSW, RSW, Connexion FHT
• Dylan Myllymaki, MSW, RSW, Connexion FHT

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Harbour C
• 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. The evidence on the prevention of diabetes and metabolic syndrome from both the Diabetes Prevention Program and the Primary Care Diabetes Prevention Program
2. What the Group Lifestyle Balance program is and how successful it has been
3. Ideas for working collaboratively and successfully with health care providers within and outside of your FHT
4. Tips and strategies for working with community partners to run a successful lifestyle program
5. How you can implement this program into your community setting; including details about training, tools, and resources available to support using this program

Summary/Abstract

Outcome measures were based on the DPP goals of 7% weight loss and 150 minutes of moderate physical activity.

• 36% reached the goal of 7% weight loss, 51% reached a 5% weight loss by the end of the core phase
• Physical activity goals were reached and maintained throughout the core phase
• 76% completed the core phase and 45% completed total 22 session
• 24% dropout rate during the core, 31.1% dropout rate during the maintenance

These numbers mirror US statistics for the GLB program and would suggest we are reducing risk of DM and metabolic syndrome across the province.

Presenters

• Sarah Pink, RD, CDE, GLB Lifestyle Coach and Master Trainer, Mount Forest Family Health Team
• Diane Horrigan, RN, CDE, GLB Lifestyle Coach and Master Trainer, Mount Forest Family Health Team
• Paul Osadzuk, PT, GLB Lifestyle Coach and Master Trainer, Owen Sound Family Health Team
• Given Cortes, TRS, RMT, GLB Lifestyle Coach and Master Trainer, Assiginack (Manitowaning) Family Health Team

Authors & Contributors

• Dianne Bigby, Assistant Senior Policy Advisor, MOHLTC

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. How to get started—identify your geographical area of interest for impact and what partners exist within that area who have an interested in Community Development. Open a discussion with your local public health unit and partners.
2. Coming together—steps to help get to know one another, what you do, what you’d like to do, understanding mandates and creating a service inventory to identify work that has commonality. Establish responsibilities, terms of reference (if needed), initiatives and defining objectives.
3. Sustainability—how to keep the collaboration alive and growing.

Summary/Abstract

Observations include:  There is a high degree of interest in fostering partnerships, supporting collective impact, reducing overlap with respect to the work of partners. Partnering on common programs such as healthy eating and physical activity allows for shared messaging, shared promotion, increased reached, and the ability to track impact across the region and individually. In addition, this strategy reduces confusion for the public and allows for a single evidence based message. Public Health resourcing (infrastructure and staffing) can be optimized to support the identification of population based priorities, to assist in the development of evidence based programs and support the delivery of common priority programs and services at the primary care level and to access funding to sustain collaborative efforts. Although it is too early to measure the collective impact of the individual initiatives identified the value of working collectively will at minimum achieve improved public health stewardship and create an environment for shared learning and support.

Presenters

• Nicole Dupuis, Director, Health Promotion Division, Windsor Essex County Health Unit
• Mark Ferrari, Executive Director, Windsor Family Health Team

Authors & Contributors

• Margo Reilly, Executive Director, Harrow FHT
• Pauline Gemmell, Executive Director, Essex NPLC
• Lisa Ekblad, Lead NP, VON NPLC Lakeshore
• Jennie Boyd, Manager, City Centre CHC
• Hardeep Sadra, Director, Windsor Essex CHC