Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 2 & 3
• 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

Participants will identify and learn about the implementation of a tablet based program, how the FHT spread the initiative to identification of other chronic diseases, and learnings after one year of implementing an initiative that took off drastically.

Summary/Abstract

The results have been truly transformative; in just over four months, over 40 percent of patients (~3000) were screened for smoking and their status was updated in the EMR. Of those, 432 current smokers were identified, and the Canadian Lung Health Test (CLHT) was administered to 1300 patients, resulting in over 500 patients identified at risk for COPD. This compared to just 45 CLHTs completed in the previous year. The FHT also experienced a 33 percent increase in smoking cessation program referrals in the four months after launching the program. As an added benefit, patients updated an average of three demographic details in their patient record and email consent was collected from over 30 percent of the total patient population. On average, the screening process took just 4.5 minutes. Instead of spending this time unproductively in the waiting room, the patient was able to actively contribute to their patient visit and patient record. We are currently completing year one evaluation and are very pleased with the results and are looking forward to sharing the results with the AFHTO attendees.

Presenters

• Stephanie Kersta, Project Manager, Couchiching Family Health Team
• TBD, CFHT
• TBD, CFHT

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 9
• 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

Attendees will develop an understanding of the barriers faced by some older adults with serious mental illness and other chronic conditions. They will learn about the approach developed by John Gibson House (JGH) and Village FHT to improve health outcomes for this very difficult to serve and vulnerable population. Application of technology such as OTN and secure email will be discussed.

Summary/Abstract

This holistic and comprehensive approach has resulted in medication adjustments/decreases, new diagnoses and follow up treatments. Homebound patients, who  refused to see a family physician for years now receive in-house services. Daily OTN monitoring enables staff to intervene earlier.   The number of:

1. ED visits has decreased from 10 visits to 6 visits
2. Hospitalizations decreased from 29 visits to 14 visits, just over 50%.

Secure email communication between JGH and VFHT supported rapid response to Flu Outbreak (2014/2015). The coordinated care enabled patients to receive prompt treatment, daily updates were easily facilitated and preventative measures (Tamiflu) were accessible to all patients.

Presenters

• Breanne John, John Gibson House, LOFT
• Diana Noel, Executive Director, Village FHT
• David Verrilli, Lead Physician, Village FHT

Authors & Contributors

• Laura Pye

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• 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

Learning Objectives

1. Understand the role and benefits of the Markham FHT’s “Collaborative Care Group (CCG)”
2. Hear practical examples of how the CCG is integrated
3. Recognize the benefits to the Lead Physician (LP) and Executive Director (ED) in sharing FHT clinical oversight through the CCG
4. Learn how to implement a similar group at your FHT

Summary/Abstract

Approximately 15 program reviews are conducted annually, as well as 9 clinical role reviews on a biennial basis. Sharing the clinical leadership responsibility of the FHT among CCG members ensures the burden of this does not fall to the Lead Physician alone. The LP looks to group members to provide insight and guidance for all FHT clinical processes, while remaining accountable to the organization on deliverables.  The multi-disciplinary membership also ensures that the FHO/IHP group has representation in decision-making, and a venue for 2-way communication.

Presenters

• Lisa Ruddy, RN, Clinical Program Manager, Markham FHT
• Allan Grill, MD, CCFP, MPH, FCFP, CCPE, Lead Physician, Markham FHT, Markham FHT
• David Marriott, Executive Director, Markham FHT

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 7 & 8
• 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

Learning Objectives

At the end of this session, attendees will be able to:

• Drill down into the Quality roll-up indicator to make sense of it at the team level
• Connect the “generalist” approach of primary care to the comprehensive approach to measuring quality with the composite Quality roll-up indicator
• Continue advocating for comprehensive (vs body-part-focused) measurement of quality in LHIN-sub-region reporting in preparation for launch of Patients First

Summary/Abstract

The strength of primary care is  that it specializes in being generalized.  It focuses on the person, and is works from the strength of the relationship with that person to improve and sustain their health as a person.  Primary care providers don’t manage diabetes.  They manage patients with diabetes (and whatever else they came with).  Measurement of quality in primary care needs to be “generalist” as well, and have a comprehensive view, not a body-part-specific focus.  AFHTO’s response to this need is the Quality roll-up indicator.  The down side of a comprehensive measure like this is that it is hard for front line providers to make sense of and take action on.  This presentation outlines how teams can drill down into the composite measure to guide local responses to the their overall quality score as reflected in the composite Quality roll-up indicator.  This presentation also outlines how local teams can use the Quality roll-up indicators to demonstrate the contribution of teams to the quality of primary care in LHINs (and eventually LHIN sub-regions).  It models a way to discuss planning, measurement and reporting in the context of Patients First that leverages this “generalist” mindset to minimize the risk of defaulting to the easier but less meaningful path of body-part-focused measures of quality.

Presenters

• Ross Kirkconnell, Executive Director, Guelph FHT
• Monique Hancock, Executive Director, STAR FHT
• Carol Mulder, QIDS Provincial Lead, AFHTO

Authors & Contributors

• Ross Kirkconnell, Executive Director, Guelph FHT
• Monique Hancock, Executive Director, STAR FHT
• Alan Maclean, Lead Physician, Superior FHT
• Carol Mulder, QIDS Provincial Lead, AFHTO

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Harbour B
• 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

Learning Objectives

1. Be able to describe the components of an effective daily micro-meeting (huddle) in a clinical team
2. Understand the impact of such a strategy on one FHT practice
3. Identify strategies for effective implementation, buy-in, and sustained engagement of daily team huddles

Summary/Abstract

A qualitative descriptive design was used to analyze participant perspectives around the influences of the team huddle on the quality of collaboration. Results confirm that daily team huddle improved awareness and knowledge sharing on the team and created an environment of teaching and learning. Huddle led to quality improvements on the team in both improved patient care communication and improved clinic processes. Results indicate improvement in areas including a positive work environment, integration and understanding of roles, team member engagement, communication, collaboration and accountability. Final results will be presented.

Presenters

• Katharine De Caire, MN, RN (EC), Clinical Director, McMaster Family Health Team

Authors & Contributors

• Ainsley Moore MD, CCFP, MSc
• Allyn Walsh MD, CCFP, FCFP
• Jennifer Everson BScN, MD, CCFP, FCFP

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Harbour A
• 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

Learning Objectives

This session will provide attendees the valuable lessons learned throughout the course of implementing a rapid assessment model of care for patients referred to Social Work services. Participants will also learn the outcomes of implementing a model similar to the rapid assessment not only for mental health services, but all services provided for patients and learn how to reduce long wait-times.

Summary/Abstract

The Rapid Assessment Model was implemented due to the increasing wait time for initial assessments for patients newly referred to the Social Worker. Wait-times have decreased from upwards of 4 weeks to an average of 12 business days for an initial appointment through the rapid assessment model. Not only has the rapid assessment model decreased wait times, it is also helping with a reduction in case load for the professional, with only 60% of patients continuing with counselling after the rapid assessment model. 40% of patients are referred to programs, community services, or EAP, or providing with resources and their cases closed.

Presenters

• Cheryl Hines, BSW RSW, Social Worker, Thames Valley Family Health Team
• Natalie Clark, BHSc, Program Administrator, Thames Valley Family Health Team

Authors & Contributors

• Cheryl Hines, BSW RSW Social Worker, Thames Valley Family Health Team
• Natalie Clark, BSW RSW Social Worker, Thames Valley Family Health Team

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 4
• 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.), Representatives of stakeholder/partner organizations

Learning Objectives

Participants will gain knowledge on the importance of population-based planning and an understanding of how to ensure that equity is incorporated into this planning. This will be discussed in the context of an equity-based population planning project that was just undertaken in the SW LHIN. Methods, results and actionable outcomes/strategies will be reviewed.

Summary/Abstract

Characteristics of vulnerable populations will be discussed  and clinical factors (physical and mental health) will be described. Geographical access based on various factors will be reviewed. Important gaps were mainly found in the rural areas of the SW LHIN. These gaps/risk factors included lower access to primary care providers, less access to team-based care and increased risk of primary care physicians retiring. People living in the lowest income quintile in the SW LHIN were often in the areas with the lowest accessibility to primary care providers.

Presenters

• Jennifer Rayner, Research and Evaluation Lead, Association of Ontario Health Centres
• Andy Kroeker, Executive Director, West Elgin CHC

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• 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, Representatives of stakeholder/partner organizations

Learning Objectives

Learn about the philosophy of care behind the Couchiching Community Health Link, the variables leading to successful system navigation, and the examples of how generative relationships came together to support a patient through a significant challenge affecting their life.

Summary/Abstract

This presentation will provide an overview of the philosophy of care employed by the Couchiching Community Health Link, identify the variables leading to the success of clinical system navigation, and, through using the patient’s journey, describe how formative relationships allowed for a significant improvement in their life. This presentation will allow participants to follow a patient through their healthcare journey and hear how clinical system navigation supported them, as well as hear patient feedback and recommendations for the future of health care and Health Links.

Presenters

• Sandy Dupuis, Clinical System Navigator, Couchiching Family Health Team
• Stephanie Kersta, Project Manager, Couchiching Family Health Team
• Patient Video Appearance

Authors & Contributors

• Sandy Dupuis, Clinical System Navigator, Couchiching Community Health Link
• Stephanie Kersta, Project Manager, Couchiching Community Health Link

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• Room: Harbour B
• 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.), Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Participants will learn from the Brighton Quinte West FHT experience of advancing a community governance model built on collaborative leadership to achieve their organizational transformation.   The presentation will outline the process to create a standard approach for accountability and link strategic direction within a policy framework.  The process focused on consistent application of relevant priorities based on the identified organizational deficits and opportunities for corporate standardization.  The approach to link system performance targets and organizational measurement will be beneficial to other organizations in defining a high performing team and incorporating unique community perspectives.

Summary/Abstract

The MOHLTC Governance Attestation catalyzed a strategic planning process that aligns performance measurement with fiduciary accountability

1. The board identified areas of development that aligned with the Provincial transformation and the LHIN Integrated Health Service Plan
2. A quarterly scorecard based on quality and financial indicators is reported and reviewed to assess performance and facilitate course corrections consistent with the operating and quality plans
3. The Corporate Bylaws revisions promoted compliance with the recent amendments to legislative requirement and established an annual schedule of corporate policies revision
4. The evidence based approach promoted a culture of accountability including integration, standardization and collaboration

Presenters

• Wendy Parker, Executive Director, Brighton Quinte West Family Health Team
• Richard Wiginton, MD, CCFP, Board Chair / Lead Physician, Brighton Quinte West Family Health Team

Authors & Contributors

• Wendy Parker, RN, BSC, MHA, Executive Director, Brighton Quinte West Family Health Team
• Richard Wiginton, MD, CCFP, Board Chair and Physician Lead, Brighton Quinte West Family Health Team
• Bonnie Ainsworth, Program Coordinator, Brighton Quinte West Family Health Team