Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. To learn strategies to successfully expand FHT services beyond the roster while adhering to shared care model
2. To learn about potential challenges and how to plan for them when expanding FHT services
3. To learn about the benefits of expanding services to the community based on a case study in real time

Summary/Abstract

As primary care teams are being encouraged to expand their focus beyond rostered patients to the community, for the past 5 years, the East GTA Family Health Team has been strategically reaching out and partnering with the broader community towards equitable care. As a result of our efforts, 60 % of our referrals come from outside sources.  Our presentation will discuss the challenges and benefits of expanding services while balancing the needs of rostered patients and FHT resources.  Based on our experience, we will provide first hand insight into simple yet effective strategies for expanding programs and access to our interdisciplinary team that can be practically applied to other Family Health Teams.

Presenters

• Chantal Simms, MSW/RSW, East GTA FHT
• Anusha Sivalogarajah, RN, East GTA FHT

Authors & Contributors

• Patricia Lazarakis, OT East GTA FHT
• Sudin Ray, ED East GTA FHT

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Pier 4
• 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.), Representatives of stakeholder/partner organizations

Learning Objectives

1. Understand how the St. Michael’s Hospital Academic Family Health Team applied citizen engagement methods to engage patients and families in improving FHT services
2. Learn how to recruit and retain a representative sample of patients and families to partner with on future patient engagement efforts and quality improvement initiatives
3. Identify aspects of SMHAFHT’s approach to patient and family engagement that can be applied to your FHT

Summary/Abstract

Over the last year, we partnered with Mass LBP to apply their innovative methods of citizen engagement to our Family Health Team. Our goal was to have patients and families help us improve the typical medical visit. Mass LBP has worked with all levels of governments, non-profit organizations, and health care organizations to bring citizens together to shape public policies on topics ranging from urban growth to mental health services.  They conduct civic lotteries typically mailing tens of thousands of Canadian residents each year and inviting them to participate in a series of weekend meetings about a specific policy issue. Workshop attendees will learn how we invited 10,000 of our patients to attend a one-day patient engagement session and the methods we used to ultimately select 36 of 350 patient and family volunteers who were representative of our practice population. We will describe the structure of the day, including the tools we used elicit recommendations from patients and families. We will share these recommendations and how we partnered with patient volunteers to engage FHT staff in the work ahead. We will discuss our evaluation of the engagement day including ethnographic observations and qualitative interviews conducted with patients and staff involved with the engagement. Finally, we will detail how we have continued to engage the 350 patients and family members who volunteered for the initial engagement event and how we are drawing on their expertise for other initiatives in our FHT.

Presenters

• Tara Kiran, Family Physician, FHT Board Chair, Quality Program Director, St. Michael’s Hospital Academic Family Health Team
• Sam Davie, Quality Improvement & Decision Support Specialist, Michael’s Hospital Academic Family Health Team

Authors & Contributors

• Katie Dainty, PhD. Scientist, Li Ka Shing Knowledge Institute
• Peter MacLeod, Principal and Founder, MASS LBP
• Chris Ellis, Director of Business Development, MASS LBP

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers

Learning Objectives

1. Understand some of the barriers preventing refugees from easily navigating our healthcare system
2. Understand some of the challenges facing health care providers in providing care for a newcomer population and ideas for facilitating the care relationship
3. Learn some techniques for optimizing the medical visit and beginning the promotion of health

Summary/Abstract

The Syrian refugee population coming to Canada faces many challenges, including being able to properly navigate our healthcare system because of system understanding, language barriers and transportation challenges.  Many of the refugee families have had little health care for an extended period, and often have some very complex health challenges, with feelings of vulnerability, fear and isolation. With the help of our community partners, the Bruyere Academic FHT has developed a clinic which provides the Initial Medical Assessment (IMA) for some of the Syrian families relocated to Ottawa. By providing all necessary components of the IMA on site (venipuncture technician for blood work, nursing staff for immunization, IMA templates for physician and residents, clerical staff and Arabic speaking interpreters) we provide a one stop shop for these patients. At the initial assessment clinic, we spend an average 5 hours with the families, which are often large. During this time, we provide a nourishing dinner; some information about life in Ottawa and the healthcare system , and volunteers move around with the families to help with navigation and understanding of processes.   There is visible relaxation, comfort, understanding and satisfaction. In this presentation, we will discuss some of the factors that create barriers for refugees, techniques used to optimize the visit and start the process of health literacy, and the ongoing challenges and rewards of taking on these vulnerable new arrivals as rostered patients.

Presenters

• Karine Gauthier, Training Officer, Bruyère Academic Family Health Team
• Kelly Kelly, Venipuncture technician, Bruyère Academic Family Health Team
• Julie Lalonde, Registered Nurse, Bruyère Academic Family Health Team
• Meagan MacCullough, Clerk, Bruyère Academic Family Health Team

Authors & Contributors

Samira Belaid, Volunteer, Bruyère Academic Family Health Team

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 4
• 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

• Understand the health equity themes reported in the 2016/17 QIPs submitted by team-based interprofessional primary care organizations in Ontario
• Learn from a family health team on how they have integrated equity into their QIPs and QI activities
• Understand Health Quality Ontario’s work on this evolving quality improvement theme

Summary/Abstract

QIPs provide multi-sector data on activities related to equitable health care in Ontario. In this presentation, we will share what primary care organizations are working on related to equity as reported their QIP.  Qualitative analysis of equity indicators, activities and change ideas planned for implementation in 2016/17 will be highlighted.  Strategies related to clinical equity of population health indicators will be described.

Presenters

• Danyal Martin, Manager, Quality Improvement Plans & Quality Improvement Strategies, Health Quality Ontario
• Margaret Millward, Specialist, Quality Improvement Plans & Quality Improvement Strategies, Health Quality Ontario
• Jo Connelly, Clinical Lead Manager, Inner City Health Family Team

Authors & Contributors

• Lee Fairclough Vice President, Quality Improvement
• Sudha Kutty Director, Quality Improvement Plans & Quality Improvement Strategies
• Danyal Martin Manager, Quality Improvement Plans & Quality Improvement Strategies
• Margaret Millward, RN MN Specialist, Quality Improvement Plans & Quality Improvement Strategies
• Jorge Ginieniewicz PhD  QIP Qualitative Analyst, Quality Improvement Plans & Quality Improvement Strategies

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