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  • A better way to track follow-up after hospitalization

    Primary care providers know the importance of following up with their patients after hospitalization. They also know the importance of tracking how well they are doing with that. Read on for a description of a better measure of how the entire team provides follow-up after hospitalization.

    Definition of the new indicator for follow-up after hospitalization:

    The new indicator is defined as % of those discharges (any condition) where timely (within 48 hours) notification was received, for which follow-up was done (by any mode, any clinician) within 7 days of discharge. Note that this is a different definition from the Ministry of Health and Long-Term Care (MOHLTC) indicator available on the Health Data Branch (HDB) portal. Based on the input from AFHTO members, this new definition includes follow up by ANY member of the team by ANY method (e.g., phone or in-person visit).

    Why is a new definition needed?

    The definition above is a better reflection of how follow-up actually happens in primary care teams.  In-person visits with physicians are not required for many patients after they are discharged from hospital, especially if it was their own physician who just discharged them. However, many patients DO receive follow-up by a pharmacist to make sure all of their medications are in order or by a social worker to make sure they are adjusting to being home. Teams do this because it is what their patients want and need. It is also more efficient, freeing up physician appointment time. Unfortunately, as teams get increasingly good at this patient-centered, efficient approach to follow-up, their performance on the current MOHLTC indicator (which is based only on physician billing data) will paradoxically look worse. This is why a new definition is needed.

    We already track follow-up in a way that works for our team. Why should we change?

    Just as follow-up is important to primary care providers, it is important to MOHLTC as a measure of the quality of transitions in the healthcare system. Transitions are such an important focus that MOHLTC will continue to use whatever measures are available. The current measure has the advantage of being readily available for all primary care providers (i.e., not just AFHTO members). This is a non-negotiable characteristic for any system-level measure. MOHLTC does, however, recognize that the current measure may paradoxically indicate that transitions are getting worse as primary care providers become increasingly efficient at team-based care, with less physicians and more Interprofessional Health Providers (IHPs) providing follow-up care. Data to Decisions (D2D) 2.0 illustrated that AFHTO members have developed many creative solutions for tracking follow-up in a meaningful way. These solutions undoubtedly are useful in ensuring good quality transitions within the team. However, it is not possible to make a strong argument for system change on the basis of a collection of different strategies in use at small numbers of teams. When AFHTO members can propose a consistent, unified approach, it is easier for system-level decision-makers to respond to our needs. AFHTO members can help themselves and the system by adopting the following consistent approach to measuring follow-up. This would help in the efforts to reframe, expand or even retire the current measure in favour of one that better reflects what does, could and should happen in team-based primary care.

    Why track follow-up if teams don’t get hospitalization data?

    Tracking follow-up after hospitalization requires 2 bits of data: date of discharge from hospital, and date of follow-up by primary care provider. It is necessary for primary care providers to become proficient at tracking patient encounters with all members of the team in all modes (e.g., phone, in person), no matter what the state of hospital data-sharing is. In fact, better data about how much your team interacts with your patients in all ways is important data beyond follow up after hospitalization. For example, it is a good way to demonstrate the amount of care your team provides. It can also support arguments to reconsider the historic requirement that physicians can only bill in-person visits.  Both of these also require consistent approaches to measurement.

    What is the evidence that follow-up even really makes a difference?

    Recent analysis is showing that follow-up by a primary care physician within 7 days of discharge from hospital is associated with 68 fewer readmissions per 1000 patients. Follow links for more details:

    Who came up with the new definition? Were members and clinicians involved?

    Learnings from D2D 2.0 Exploratory indicator: 7-Day Follow up, along with feedback received from Clinical consultations for Strategic D2D indicators, were used to create a proposed indicator definition. This definition was subsequently recommended by the Indicator Working Group (IWG) to be included in the membership wide vote on D2D 4.0. The indicator definition was endorsed by a membership-wide vote, in which more than 240 members from at least 75 teams participated.

    Why just phone encounters?

    Actually, it is important to track all encounters with patients. However, most EMRs are good at tracking in-person encounters, at least through the scheduling system. The gap remains in tracking discussions with patients that are not scheduled, in-person visits. Hence, our focus on improving our collective ability to consistently track phone encounters. Eventually, email encounters may also be considered; for now, the focus is on phone encounters as an easier place to start.

    But what about the hospitalization data?

    AFHTO continues to work with external partners including OntarioMD, local hospitals as well as the Ontario Hospital Association, eHealth Ontario, and LHINs to improve the flow of data from hospitals to primary care. In the meantime, teams are continuing their local efforts to get as much information as quickly as possible from their local hospitals. Teams can make progress in tracking all patient encounters with any provider (including phone) in a consistent way. This is important not only because the information is useful in itself but also to demonstrate to our external partners our commitment to a better solution and thus help expedite changes in their systems.

  • OTN Professional Learning Series – Perinatal Mental Health

  • Minister’s mandate letter/ Compensation funding letters out “in weeks, not months”

    This morning, government released Premier Wynne’s mandate letters to her Ministers, and the Health Minister spoke at the annual NPAO conference. Key points for members below. Government’s top 10 overall priorities included one health item:

    • “Building a health care system everyone can rely on by improving the availability of same-day, after-hours and weekend care, and continuing to grow the number of frontline workers providing the care people want in home and community settings.”

    The Health Minister’s mandate letter re-stated this. In addition, his list includes:

    • Ensuring that patients who want a primary care provider have one.
    • Implementing the expanded scope of practice of registered nurses to allow them to prescribe some medications directly to patients.
    • Ensuring, as you work to improve access to services, that a focus on equity of access is reflected in solutions.

    The letter also lists “key results” that have been achieved, including:

    • Provided support and stability to the health care workforce, including funding to improve primary care recruitment and retention of nurses and other interdisciplinary team members.

    While this was promised in the Ontario Budget last February, it has not yet been “provided”.  Interprofessional primary care organizations are awaiting their funding letters, which the Minister must sign in order for the dollars to actually flow. On this last point, the Minister told the NPAO audience, “You’ve been waiting a long time.” Speaking about the funding letters, he said three things:

    • “We’re very close.”
    • “When the dollars do flow, it will be retroactive to April 1.”
    • “It will be in weeks, not months.”

    The senior leaders of all three associations, AFHTO, AOHC and NPAO, have been pressing the Minister and his office to give urgency to this. Needless to say, the Minister and NDP Health Critic France Gelinas, who was in the audience, heard this again this morning. The three associations subsequently issued a news release.

  • Diabetes Care

    Primary care teams are doing better than most in diabetes management. And what’s more, we’re getting better faster than most. This might not be that surprising to AFHTO members, almost all of whom have well-developed diabetes programs. What might be a bit of a shock is how far we have yet to go. While about 60% of patients with diabetes might meet at least one aspect of the guidelines for care, only about 10% meet the targets for a more comprehensive group of the key metrics: appropriate frequency of testing and levels of  blood sugar and blood pressure, and appropriate prescription of statin for cardiovascular protection (pers. comm., K. Tu, 2015). It seems improbable that AFHTO members can’t do better than 10%, especially since some teams already are. AFHTO has already had success in working together to MEASURE primary care. We can take this one step further and work together IMPROVE care. To that end, the QIDS Steering Committee, in conversation with the board of AFHTO, have identified diabetes care as a priority to advance IMPROVEMENT of primary care across AFHTO. You can be part of this in the following ways:

    • Get up close with your peers.
    • Get up close with your data.
    • Get close to help.

    Get up close with your peers:

    Connect with peers about diabetes program planning, setting objectives and measuring progress, including selection of consistent indicators as outlined in the Schedule A indicator catalogue (available at the same link as the program planning information, above).

    Get up close with your data:

    Increasing robustness of D2D diabetes indicator in D2D 4.0

    Prior to D2D 4.0, the composite indicator used three measures for diabetes – this is inadequate. Additional indicators were added to integrate process and outcome measures and thus increase the robustness of the composite indicator. The intended result is an increasingly more meaningful tool to assess, measure, and compare quality of diabetes care. AFHTO members considered a number of indicators, based on their importance in clinical management of diabetes, scientific soundness, and feasibility. The following indicators were shortlisted. They are based on the latest guidelines from the Canadian Diabetes Association, Health Quality Ontario’s (HQO) Primary Care Performance Measurement Framework (PCPMF) and consultations with QIDS Specialists, clinicians and members of the AFHTO diabetes community of practice.

    • Percent of people with diabetes and LDL-C ≥ 2.0 mmol/L who are on statins.
    • Percent of people with diabetes who received a retinal eye exam in the past two years.
    • Percent of people with diabetes who received at least one peripheral neuropathy screening in the past year.
    • Percent of people <80 years old with diabetes whose HbA1C ≤7.0% in the past year.
    • Percent of people with diabetes with HbA1C levels at their individualized target (i.e.,≤7.0% or 7.1-8.5%).
    • Percent of people with diabetes who are confident in their ability to manage their condition.

    The one indicator chosen to be added to the composite diabetes care indicator was percentage of patients with diabetes aged 40 years and older who have been prescribed a statin therapy. It is derived from the first indicators short-listed but modified for alignment with the most recent Canadian Diabetes Association guidelines.

    Get close to help:

    1. Bump up your QI skills with instructional videos from the University of Toronto Family Medicine department.
    2. Tap into external resources to support clinical process changes such as those from HQO or others (check with your QIDS Specialist).

    This list of resources is a start. We will be adding to it – keep checking back and adding your stories. Together, AFHTO members are changing the game of measurement in primary care. The time is right to build on this collective momentum to move beyond MEASURING to actually IMPROVING care.

  • AFHTO’s next CEO assumes office November 30

    On behalf of the AFHTO board of directors, I’m pleased to announce that Ms. Kavita Mehta has accepted the offer to become AFHTO’s next CEO, effective November 30, 2016.

    As a past president of AFHTO, current Executive Director of the South East Toronto Family Health Team, and Executive Sponsor for the East Toronto Health Link, Kavita has been a passionate advocate for high-quality comprehensive interprofessional primary care. She has deep, first-hand knowledge of the issues and opportunities facing interprofessional primary care. She’s a leader in bringing patients into the planning, design and governance processes of her FHT, and fosters that perspective as board member of the Change Foundation. Her previous roles as a primary care program consultant in the Ministry of Health and Long-Term Care and as a public health nurse bring perspectives that are highly valuable to AFHTO’s role as the advocate, champion, network and resource for interprofessional primary care.

    Kavita’s appointment comes after an extensive search launched last June when AFHTO’s first CEO, Angie Heydon, announced her intention to retire by the end of the year. The high calibre of candidates that came forward – from inside and outside our sector – is a testament to AFHTO’s role and reputation as a leader in our health system. We thank all of the candidates who came forward, and thank Angie for her leadership in building AFHTO to this point over the past six years.

    AFHTO members and others interested in interprofessional primary care will have the opportunity to welcome Kavita to her upcoming role and bid Angie a fond farewell at the 2016 AFHTO Conference, October 17-18.  We hope to see you there.

    Sean Blaine MD

    Family Physician, Stratford, Ontario

    Clinical Lead, STAR Family Health Team

    President, Association of Family Health Teams of Ontario (AFHTO)

  • Data to Decisions eBulletin #43: D2D 4.0 Interactive Report launches September 29

    Sign up for the launch of D2D 4.0 on September 29th: See how your team compared with nearly 120 of your peers who contributed data. Check out the new features, including summaries by LHIN and the ability to PRINT the report. Using data to improve: Whether or not you contributed data to D2D, you have a story to tell about what is (and isn’t) working when it comes to using data to drive QI. If you’re an ED, please complete this survey to share your story and help us all get even better at gathering and using data to improve care. Improving outcomes for CHF patients: Now that you’re able to identify your CHF patients (with standardized, TESTED EMR queries), learn more about how to improve outcomes for them. Register for this FREE webinar from the Cardiac Care Network of Ontario.   Changes are coming to the post-discharge follow-up indicator in next year’s QIP! It will include follow-up from any clinician, whether in-person or via telephone (much like the D2D 4.0 measure). AFHTO members’ input made this possible! To learn about these and other changes, don’t forget to sign up for the webinar on Oct 5. Want to share your knowledge of measurement and improvement beyond AFHTO? HQO is seeking volunteers for three Quality Standards Advisory Committees. These committees help develop evidence-based indicators, designed to drive improvement in health care. Learn more and apply here. D2D at the AFHTO conference: Stay tuned for details about a session geared toward D2D – how it’s capturing the generalist nature of primary care and the importance of relationships, using your data to move to improvement, and the implications for Patients First. Also, if your team participated in D2D, look for a little something special in your registration bags! D2D 4.0 Timeline: 2016-09-15-d2d-timeline

    Help spread the word about D2D – invite others to sign up for the eBulletin online. 

  • Government’s Throne Speech confirms commitment to Patients First Act and Primary Care Guarantee

    Today’s Speech from the Throne outlines the Ontario government’s priorities leading up to the next election in two years. Included is confirmation of their commitment to:

    This health care document credits the increase in the number of doctors and nurses and the introduction of family health teams among government’s actions resulting in “patient experiences and outcomes have steadily improved”.

    Looking forward, this document states, “… the proposed Patients First Act will better coordinate and integrate access to primary care and home and community care for all Ontarians, helping the government deliver on its commitment to connect a family doctor or nurse practitioner to everyone who wants one.”

    The document also commits to:

    • Ensuring fair compensation and investing in front-line health care professionals: The province is committed to growing the number of frontline healthcare professionals who provide high-quality patient care in Ontario. To do so, it has taken a firm stance that any new health care dollars must go to services in the community that provide care to the most people, and not only to higher salaries for administrators or certain specialists who are already receiving fair compensation for their services. The province will continue to work with Ontario’s doctors to reach an agreement that honours this shared commitment to enhance primary care and put patients first. Ontario’s doctors will continue to be among the most highly paid in Canada. Personal support workers are receiving the raises the government committed to, and that they deserve, for their role in caring for millions of people’s loved ones. To help ensure every available resource is going towards patient care, the province will reduce bureaucratic inefficiencies by merging Community Care Access Centres with Local Health Integration Networks.

    While Minister Hoskins commited $85 million over three years to improve compensation in interprofessional primary care, this is but a first step on the road to achieving the compensation structure recommended by AFHTO and its partners (AOHC and NPAO) in “Toward a Primary Care Recruitment and Retention Strategy for Ontario.”

    Funding letters for each FHT, NPLC, AHAC (and through the LHINs for CHCs) await ministerial sign-off; fortunately, this funding is retroactive to April 1, 2016. AFHTO and our partners, AOHC and NPAO, continue to follow up to get these letters out to teams as soon as possible. In the next few months, we will also gear up advocacy to get government commitment for funding to completely fulfill these compensation recommendations.

    Angie Heydon, Chief Executive Officer

  • AFHTO ED Mentorship Program

    AFHTO’s Executive Director Mentorship Program connects experienced EDs with new EDs who feel they would benefit from the support of a mentor. 

    Executive directors and admin leads play a key role as leaders, facilitators, and links within their teams and across their communities, with their peers, staff, physicians, boards, patients, and other system leaders. Mentoring is about supporting people to develop into their role, and this mentorship program is in place to help leaders in primary care teams excel.

     

    ED Mentorship Program Overview

    New executive directors tell AFHTO when they would benefit from this program and if there are specific areas in which they need guidance or support. This helps with mentor-mentee matching. We also make every effort to match EDs whose teams work in similar environments, taking into consideration geography, size, governance structure, academic or Francophone status, and other characteristics that reflect the diversity of teams.

    EDs then decide frequency of meetings and communication. While there is no timeline on a mentorship program, EDs tend to work together for six months to a year. While formal mentorship rarely goes longer, the EDs tend to stay in touch from the relationships they build.

     

    Benefits of the ED Mentorship Program

    Benefits to Mentors Benefits to Mentees
    • Being part of a solution to build capacity for leadership in primary care
    • Pleasure of giving back and passing on skills, knowledge and wisdom
    • Satisfaction of enhancing a mentee’s understanding of the primary care team workplace
    • Heightened profile within their workplace
    • Coaching practice and leadership skills
    • Heightened self-awareness
    • Access to wisdom and expertise in a confidential safe relationship
    • Opportunities for self-assessment
    • Greater understanding of current business practices
    • Introduction to business networks and related supports

    What we have heard is a testament to the strong leaders in our membership. Mentees agree that their mentors are knowledgeable and able to provide needed support and guidance. Mentors tell us that their mentees are happy to receive input and guidance; willing to self-evaluate; and open to applying a mentor’s insights to their own situation. 

    Here is a sample of what the participants have said:

    • “My mentor is awesome, very helpful! She provides amazing support.”
    • “My mentor is very knowledgeable and easy to work with. She always makes time to answer questions and provide guidance when required.”
    • “I would suggest having a mentor work with all new EDs when they come onboard.”
    • “I can learn as much from my mentee as she can from me. Seems to be working for both of us.”

     

     

    Resources for ED mentors and mentees

    The materials are available to assist our ED mentors and mentees in defining and developing the mentoring relationship.

    The program launched in February 2016 with an orientation webinar for ED mentors, presented in partnership with the Centre for Effective Practice (CEP).

     

    More Information

    Interested in becoming a mentor or a mentee? Please contact info@afhto.ca

  • Member news: Members in the media, funding opportunities, and more

    Below are relevant updates and items for AFHTO members:

    Members in the Media

    Funding Opportunities

    Professional Development & Networking

    • Free networking & learning opportunity in interprofessional collaboration at AFHTO 2016 Conference, only for AFHTO-member IHPs.

    Clinical Resources for Providers & Patients

    Send your Input to Help Develop Policy and Resources
    • Infant Growth Monitoring Study: Researchers from the University of Toronto and the Hospital for Sick Children are studying how infant growth is monitored in primary care. To participate, email sarah.carsley@sickkids.ca.
    • Survey: Assessing perceptions of food introduction and risk of allergic disease; 5-minute survey available in English or French.

    AFHTO News

    Upcoming Events

  • FHT study: Team approach improves quality of life for COPD patients

    UPDATE – 05 October, 2016: Another story about this award-winning research project was published in the Amherstburg River Town Times.

    Windsor Star article published on September 7, 2016. Article in full pasted below. Brian Cross, Windsor Star *Note: The study cited in this article was conducted across a partnership of 6 FHTs in the Erie St. Clair LHIN region: Amherstburg, Windsor, Harrow Health Centre,  Leamington & Area, Tilbury District, and Chatham-Kent, although the article mentions only Amherstburg. AFHTO extends congratulations to all of the participating teams. An innovative team approach to caring for local lung disease patients improved their quality of life so tremendously it’s receiving international recognition. “Huge, impressive, substantial,” are words London academic respirologist Dr. Chris Licskai uses to describe the results of the local study he was involved with, along with physicians and respiratory therapists from family health teams in Windsor-Essex and Chatham-Kent. The study proves that proactively caring for these chronic obstructive pulmonary disease (COPD) patients before they become acutely unwell and teaching them to manage their own illness reverses their downward spiral. Licskai said patients who suffered on a daily basis from wheezing, coughing and shortness of breath so severe they couldn’t do such simple activities as walk from room to room, climb stairs or get dressed, improved to the point they experienced symptoms only a couple of times a week. “The tremendous finding here was that the patients’ quality of life substantially improved,” Amherstburg family doctor Dr. Tim O’Callahan said this week from London, England, where he, Licskai and lead educator Madonna Ferrone presented their research to the European Respiratory Society meeting, the largest respiratory conference in the world. The society was so impressed that the group’s paper was chosen the best primary care research paper and will be published in the Primary Care Respiratory Care Medicine Journal. O’Callahan said health professionals at family health teams wanted to try a new approach to caring for COPD patients — who make up about 12 per cent of their practice. An estimated 850,000 Ontarians have COPD, which includes such chronic, incurable illnesses as emphysema. COPD is most often caused by smoking. “It’s a very common problem in our patients in primary care and it has a major impact on their quality of life,” said O’Callahan, who works at the Amherstburg Family Health Team. The group took a total of their 181 worst-off COPD patients and divided them into two groups: one group received the kind of care they’d always received from their family doctor, and the other received “collaborative self management.” This involved sit-down sessions with respiratory therapists to get detailed assessments, to learn about their disease and to devise an action plan so the patient knew what to do when symptoms worsened. The action plan often included getting prescriptions filled ahead of time for antibiotics and the steroid pregnizone. In the event of a flareup of symptoms, they treated themselves immediately, avoiding the wait to get in to see their doctor, which can sometimes delay treatment by several days or a week. Doctors were regularly brought in to the meetings to consult on changes. Patients learned to recognize when their symptoms were getting out of control and what to do. “We worked on making the patient the expert in their own disease,” said Ferrone, who said she was “completely amazed by the results.” Every three months, patients in both groups were given a COPD assessment test that measures quality of life. The CAT score runs from zero (no impairment) to 40 (completely impaired). The patients in the collaborative self-management group had an average score of 22 when they started and dropped down to 15 in the course of a year. The control group receiving regular care started with a score of 19 and worsened to 22. “Improvement of over three is considered significant and patients in our study increased by seven,” O’Callahan said. Collaborative self management also reduced urgent visits to the doctor by 67 per cent. Trips to the hospital emergency also dropped by 67 per cent. That means that the extra cost of providing COPD patients with collaborative self management is more than offset by the money saved, said O’Callahan. “We can reduce costs and improve quality of life, so it’s all good, all the way around.” The local group was initially turned down for funding from the Ministry of Health and relied on money from pharmaceutical companies. But the early results proved so promising that the ministry changed its mind and provided funding, O’Callahan said. Now, the researchers believe the evidence justifies expanding the program to many more people suffering from COPD, beyond the family health teams. “I’m hoping that our study will contribute to practise change in Canada and perhaps beyond Canada, in a way that will have a longstanding impact on patients with COPD,” said Licskai. For info on the participating teams, visit:

    Click here to access the article on the Winsdor Star website.