Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/17/2016
• Concurrent Session B
• Time: 3:30pm – 4:15pm
• 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: Clinical providers

Learning Objectives

1. Identify key components of proactive or planned COPD management utilizing various members of the inter-professional team
2. Learn how to design and implement a COPD management program within your office setting
3. Understand how the EMR can be a tool for the identification, management and evaluation of COPD patient care
4. Demonstrate an approach to care coordination and transition into primary care post COPD related ER visits or hospitalization

Summary/Abstract

The “INSPIRE” program is currently being implemented and therefore data collection is underway. We anticipate the following clinical outcomes:

• Improved MRC Dyspnea Scale and CAT (COPD assessment test) scores
• High patient satisfaction with care
• Increased rates of patients who are up to date with their vaccinations – influenza, pneumococcal
• 100% of patients receive a personalized COPD action plan and referral to smoking cessation resources
• Reduction in the number of yearly COPD exacerbations, ER visits or hospitalizations
• 90% of patients will be seen by team within 2 weeks of ER or hospital discharge related to COPD

Presenters

• Colleen Youngs, Primary Care Nurse Practitioner, RN EC, Bridgepoint Family Health Team
• Victoria Siu, Pharmacist, Bridgepoint Family Health Team

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/17/2016
• Concurrent Session B
• Time: 3:30pm – 4:15pm
• Room: Metropolitan Ballroom West
• 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

Learning Objectives

1. Increase knowledge of indicators of palliative care in primary care
2. Increase ability to identify patients needing end of life care
3. Broaden understanding of facilitators and barriers to providing a primary palliative care approach
4. Become familiar with strategies and care approaches currently used by primary care providers/teams in the provision of end of life care.

Summary/Abstract

We will present findings from our qualitative research, which uncover the strategies that primary care providers and teams use to deliver end of life care, as part of comprehensive primary care.    Our research questions include:  What current processes used by family practices to provide care to patients with progressive life limiting illness?  A) How are these patients identified?  B) What strategies are used to care for their individual and family caregiver needs?  C) What are the current barriers and facilitators to implementing care for patients with life limiting illness?  The results have been organized to facilitate reflection on how Family Health Teams could develop their own approaches to recognizing needs and providing a palliative approach.

Presenters

• Joy White, Primary Care Nurse Practitioner, MScN, McMaster Family Health Team
• Nicolle Hansen, PHC –NP, McMaster Family Health Team
• Amanda MacLennan, RN, MScN, McMaster Family Health Team

Authors & Contributors

• Nicolle Hansen, PHC-NP
• Amanda MacLennan, MScN
• Alex Rewegan
• Sharef Danho
• Donna Blaney

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/17/2016
• Concurrent Session B
• Time: 3:30pm – 4:15pm
• 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. Gain an understanding of the importance of early intervention for those patients diagnosed with an eating disorder
2. Learn how the FHT framework supports collaboration and comprehensive patient care when designing and implementing an ED Bridge Program
3. See practical examples of one patient’s journey, and the outcomes achieved by the program

Summary/Abstract

The ED Bridge Program has met the needs of its patients through thoughtful, innovative and focused health assessments and systematic follow up by health care providers with a specialized skill set. Early intervention following an eating disorders diagnosis has enabled closer monitoring of the patients’ physical and mental health, and ensured that no one “falls through the cracks” as they wait for formal treatment.  The program team, as well as referring physicians, have expressed a high level of satisfaction with the collaborative efforts demonstrated through this program. The presentation will include physician and patient/family testimonials.

Presenters

• Kelly Van Camp, NP, Markham FHT
• Rhonda Pompilio, SW, Markham FHT
• Andrea Firmin, RN, Markham FHT

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/17/2016
• Concurrent Session A & B
• Time: 2:30pm – 4:15pm
• Room: Marine
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Participants will learn the principles of distributed leadership, understand how the principles can be implemented through case examples and stories, explore how to implement the principles in their work setting to drive more seamless, patient centred care across organizations.

Summary/Abstract

Come learn how leaders in Huron Perth developed themselves as leaders and then engaged others across the region to produce the following stellar results:  a 12 fold increase in # of CCP’s; drop in ED visits; increase in collaborative relationships across organizations; increase in the number of providers involved in CCP’s; increase in types of organizations initiating CCP’s; successfully engaging previously resistant physicians and other hcp’s in initiating CCP’s; improved patient and provider experiences; changes in language that indicate a shift to more collaborative, patient centred care.

Presenters

• Penny Paucha, A., Leadership Coach, Principal, Instincts at Work
• Mary Atkinson, RN, B.Sc., MBA, CHE, Executive Director, North Perth Family Health Team
• Shannon Natuik, Family Physician, Maitland Valley FHT
• Janet Obre, Primary Health Care Nurse Practitioner Mental Health, Addictions, Complex Frail Elderly, Huron Perth Healthcare Alliance

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