Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• Room: Pier 4
• 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

Learning Objectives

1. Discuss the benefits and drawbacks of using patient-reported outcome measures that assess multiple areas of health and function within interprofessional primary care teams
2. Describe the challenges and strategies for successful implementation of patient-reported outcome measures

Summary/Abstract

Using the case example of falls programming, we explored using the Modified Falls Efficacy Scale and Late Life Function and Disability Instrument – Disability Scale to measure patient outcomes. Findings suggest that scale administration time varies by setting, scales require patients’ insight into their abilities, and follow-up assessment can be a challenge. We will discuss lessons learned regarding the usefulness and process of collecting patient-reported outcomes and preliminary findings on the effectiveness of falls programming in interprofessional primary care. This research provides information to support collection of outcomes data in interprofessional primary care teams to inform service improvement and determine effectiveness.

Presenters

• Carri Hand, PhD, OT Reg. (ON), Assistant Professor, University of Western Ontario
• Catherine Donnelly, Queen’s University
• Maria Borczyk, Aurora-Newmarket FHT
• Martha Bauer, McMaster FHT
• Nicole Bobbette, Queen’s FHT – Belleville site

Authors & Contributors

• Nanette Bowen-Smith
• Cecilia Doesborgh
• Dana Driesman-Klover
• Gillian Fish
• Colleen O’Neill

Theme 2. Optimizing access to interprofessional teams

Presentation Details

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

Learning Objectives

Creating a virtual medical home represents an opportunity to improve integration and access to care for patients at risk of or living with diabetes when their primary provider is not part of an interdisciplinary FHT.  In this workshop, participants will:

1. Review the concept of the medical home and the demonstrated benefits of this model
2. Discuss the process and practical steps to implementing this approach
3. Assess the feasibility of offering services in this way
4. Determine capacity and explore how to integrate health professionals from their team into community practices

Summary/Abstract

This program is still in the early stages, having begun in December 2015. We have already seen improvement in attendance and therefore anticipate that there will be accompanying improvements in outcomes.     In the session, we will review preliminary results related to:

1. Access
2. Integration
3. Information sharing
4. Patient satisfaction
5. Provider satisfaction

While focused on DEP services, this session will offer participants the opportunity to participate in a discussion of how to best leverage resources to improve access while considering the demands of providing excellent care to rostered patients.

Presenters

• Lisa Weinberg, RD, Mount Sinai Academic Family Health Team
• Deborah Adams, MA, MHSc, CHE Administrative Director, Mount Sinai Academic Family Health Team

Authors & Contributors

• Lisa Satira, RD Mount Sinai Family Health Team  lsatira@mtsinai.on.ca

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

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

Learning Objectives

1. Attendees will understand how they can implement best practices in quality improvement initiatives
2. Attendees will learn about gaps during transitions of care that highlight needs for further system integration
3. Attendees will understand how members of the multidisciplinary team can be efficiently involved in the post-hospitalization phase to reduce complications at this stage

Summary/Abstract

Data collected from the CVFHT EMR shows an 84% reduction in patient readmissions and a 16% improvement in post-hospitalization follow-up rates using various members of the multidisciplinary team from Jan 2015 to March 2016. The HDP only considers follow-up rates with physicians; in contrast, the CVFHT considered a valid follow-up as one where a contact is made with an MD, NP or RN. This method optimizes the role of various team members, facilitates a sustainable process and supports patient access to primary care. Re-hospitalizations were prevented and home visits were made same day as needed, consistent with patient-centered care.

Presenters

• Gordon Canning, Nurse Practitioner, Credit Valley Family Health Team
• Heather Hadden, Pharmacist, Credit Valley Family Health Team
• Inge Bonnette, Registered Nurse, Credit Valley Family Health Team
• Claudia Mazariegos, Registered Dietitian, Credit Valley Family Health Team
• James Pencharz, MD, Credit Valley Family Health Team

Authors & Contributors

• Hilal Syed, Quality Improvement Decision Support Specialist at the Credit Valley Family Health Team
• James Pencharz, Family Physician, Credit Valley Family Health Team

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Pier 7 & 8
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. Extending community partnerships within primary care organizations through a Health Links’ approach
2. The role of Community Service Workers (CSW) embedded in primary care organizations
3. Data on the effectiveness of the initiative
4. Challenges and mitigation strategies with scaling up and spread in an urban primary care setting

Summary/Abstract

Qualitative and quantitative data will be presented to demonstrate the value and need for this role.  Anecdotal feedback from physicians and other health professionals has been positive. On the average there have been 430 referrals annually addressing a variety of  unmet social needs related to education, unemployment, food insecurity, housing, social isolation, social safety net, Aboriginal status and disability.  Income insecurity is the number one unmet need for patients. Examples: CSWs assisted  patients in accessing emergency funds so heat and water would not be shut off and assisted frail seniors in navigating government services and  forms.

Presenters

• Linda Robb Blenderman, RN, BScN, MSc, Kingston Health Link Project Coordinator, Kingston Health Link
• Laura Cassidy, Comm, Quality Improvement Decision Specialist, Kingston Health Link
• Francine Janiuk, RN, BScN, MPA, Nursing Manager, Queen’s Family Health Team

Authors & Contributors

• Maria Sherwood B.A., B.S.T. Community Services Worker, Kingston Health Link
• Sheena Lyons, Community Services Worker, Kingston Health Link
• Michael Curtis, B.Sc., Community Services Worker, Kingston Health Link

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Harbour C
• Style: Panel Discussion (in addition to providing information, panelists interact with one another to explore/debate a topic)
• 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.)

Learning Objectives

1. The benefits of the mixed governance model
2. How our model is structured to deal with conflict of interest
3. Enabling structures we have put in place
4. How patients are involved
5. Issues where we remain challenged

Summary/Abstract

1. High board member satisfaction with 100% of board members agree/strongly agree: “The Board participation is a positive experience for me” and “Generally the Board has a good working relationship with the Executive Director and Lead Physician”
2. Ability to consistently move through the agenda
3. Success to discuss and resolve sensitive issues such as negotiating a FHT FHO Agreement
4. High FHO satisfaction with all FHO members regularly attending weekly team meetings and particpating on team projects
5. High team satisfaction with 0% turnover of IHPs since 2013
6. High patient satisfaction with 92% of patients agree/strongly agree that they would refer a friend or family member to Village FHT and 93% score for HQO Patient Engagement scores

Presenters

• Mr Dev Chopra, Board Member, Village FHT
• Dr David Verrilli, Lead Physician and Board Vice Chair, Village FHT
• Ms Diana Noel, Executive Director, Village FHT

Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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

1. Learn how to improve patient safety as well as improve their health care journey while transitioning from hospital to home and home to hospital
2. Examine ways to prevent hospital re-admissions for both chronic and acutely ill patients
3. Examine the care needs that can be addressed within a patients’ home post-hospital discharge

Summary/Abstract

By October of 2016 we hope to have used our tracking codes and nearly full year of running the Transitions program to determine the following outcomes:

• The number of patients followed up by Transitions who still required readmission to hospital within 30 days of discharge
• Which medical diagnoses required the most follow-up and referrals, and to which disciplines
• How many home visits were done
• How many Primary Care Provider (PCP) visits were booked through Transitions and how many of these were within 7 days of hospital discharge ; if > than 7 days then why?
• The number of times a patient or family member called in to their Transitions program point person with questions or concerns
• How many hospital visits were completed through the Transitions program
• Qualitative data about the patient/family experience using surveys
• We hope to see that readmission rates within 30 days decrease over time. In keeping with our Schedule A and QIP targets, we hope to see > 80 home visits completed and 100 PCP appointments booked with >50% of PCP visits done within 7 days of hospital discharge.  Finally, we hope to see >400 pts at the bedside to initiate the transition from hospital to home.

Presenters

• Danielle Duns, Lead RN, Transitions Program, Markham FHT
• Lisa Ruddy, RN, Clinical Program Manager, Markham FHT
• Rebecca Robinson, Administrative Assistant, Markham FHT

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Learn about OntarioMD’s EMR Progress Assessment (EPA) tool and the support available to users of certified electronic medical records (EMRs) to improve EMR use. The EPA helps you identify opportunities and quick wins by measuring your current use and determining if you are using the EMR’s functionality to the fullest degree. You will also learn how the EPA leads to practical advice for closing any gaps you would like to address through the EMR Practice Enhancement Program. The session will also include an update on the EMR Physician Dashboard and its high-value provincial indicators.

Summary/Abstract

OntarioMD’s EPA is the only comprehensive online tool in Ontario that can assess EMR use and is the starting point for the EMR Practice Enhancement Program. It is based on a nationally-recognized EMR Maturity Model and tailored to Ontario clinicians. The EPA is easy to use and accessible from anywhere with an Internet connection. Over 4,000 clinicians have used it to date. Regular use of the EPA has enabled these clinicians to measure how much they have improved and enhanced care through better use of their EMRs. The EPA also lets clinicians know where they stand compared to their peers.

Presenters

• Darren Larsen, Chief Medical Information Officer, OntarioMD
• Gina Palmese
• Peter Hamer

Authors & Contributors

• Darren Larsen, MD, Chief Medical Information Officer, OntarioMD
• Knut Rodne, Director, Insight, Engagement & Transformation, OntarioMD
• Jack Cooper, Senior Consultant, EMR Reporting, OntarioMD

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Harbour A
• 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

Learning Objectives

The role of primary care within a population based approach is essential to improving the health and wellbeing of older adults.

1. Learn about best practices for falls risk screen, assessment and intervention among older adults. How best practices were adapted and integrated into an algorithm for the EMR and a tablet based patient completed falls risk screen
2. How patient centered screening has led to optimizing access and fostering collaboration within the interprofessional team
3. The impact of strong collaborative work with six family health teams and the Stay on Your Feet initiative in the NELHIN

Summary/Abstract

The falls prevention risk screen algorithm that was integrated into the EMR is able to identify older adult patients for high risk screen (% YTD). Patient completed screen on the tablet has helped to establish falls prevention screening into the teams current work flow. The falls prevention screen and assessment process has helped to optimize access to the interprofessional team. The falls prevention assessment is ensuring that patients are being seen by the right care provider within the team. The strong collaboration with the 6 family health teams and the SOYF partner has helped to spread change in falls prevention screening and assessment throughout the Northeastern Ontario.

Presenters

• Shirley Watchorn, Executive Director, Great Northern FHT
• Ellen Ibey, Executive Director, Temagami FHT
• Meghan Peters, Quality Improvement Decision Support Specialist, City of Lakes FHT

Authors & Contributors

• Wendy Carew
• Lorna Desmarasis