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  • Data to Decisions eBulletin #32: Using EMRs to reflect team’s contribution to care

    Progress with a better measure of 7-day follow-up: As an important first step in measuring what your team REALLY does for follow-up after hospitalization, we are working with our EMR communities of practice to develop queries and processes to track phone encounters in your EMR. Learn more at the links above, and/or talk to your QIDSS. Exploring equity: QIDSS are exploring AFHTO members’ baseline capacity to collect socio-demographic data in EMRs, in order to help track health equity for your patients. Moving beyond measuring to improving diabetes care: AFHTO, in collaboration with Toronto LHINs, is presenting a free learning event for QIDSS, IHPs, and patients with diabetes. Space is limited and will be available on a first come, first served basis. Registration opens on Monday, May 2, 2016. D2D data dictionary update: We’re starting to collect input on what changes will be made this year. Members will be asked to vote on potential changes in May 2016, prior to the release of the updated Data Dictionary in June. Visit our site for more information and progress updates. Increase consistency of Schedule A reporting with the help of the Program Planning & Evaluation Framework, Indicator Catalogue, and other resources from AFHTO, designed to help you choose better indicators for your AOP submission.

    Help spread the word about D2D – invite others to sign up for the e-Bulletin online.  Getting too many emails? Scroll to the bottom of the original email for the unsubscribe link.

  • Exploring Health Equity

    Health equity is achieved when people are able to reach their full health potential and receive high-quality care that is fair and appropriate to them and their needs, no matter where they live, what they have or who they are. AFHTO is committed to helping members work towards this goal and to identify gaps and opportunities to improve health care for all of their patients. We have begun work towards establishing a baseline on social demographic data collection and the capacity of EMRs to record and track this information, starting with a conversation in our weekly QIDSS calls and EMR CoP meetings focused on two main questions:

    • What social demographic data is currently being captured in the EMR?
    • What social demographic data can be easily recorded in the EMR today?

    The Tri-Hospital + TPH Health Equity Data Collection Research Project have begun work on answering the question of what Socio-Demographic factors to measure. Their findings, presented in the report We Ask Because We Care, were reviewed and shared with the QIDSS and EMR CoPs, and we have started our conversation with the data elements presented there. This work will lead to recommendations for adding social demographic data to the EMR Data Quality Indicator for D2D 4.0.

  • Data to Decisions Data Dictionary: Updates for D2D 4.0 Coming Soon!

    Watch this space for the updated Data Dictionary for D2D 4.0!

    AFHTO has begun the consultation process with members on what changes will occur to the Data Dictionary for D2D 4.0. Changes will be proposed based on this consultation process, and members will be asked to vote on them in May 2016, prior to the release of the updated Data Dictionary in June. To ensure that the indicators in D2D reflect what is manageable and meaningful to for member teams to collect, it is essential that our members’ voices are heard throughout process.

    • Wherever possible, the definitions and data sources for these indicators are based on the Primary Care Performance Measurement Framework (PCPMF).
    • There will be no change for the majority of the indicators — particularly, the ICES indicators, which are based on billing data.

    A draft of Data Dictionary for D2D 4.0 will be shared with QIDS Specialists for review shortly, and the final version will be published in late June. The next release of the team level HQO Primary Care Practice Report (PCPR) will be at the end of May 2016; it will contain refreshed data, current to March 2015. We suggest teams begin the review of their PCPR data at that time, in order to prepare for D2D 4.0, launching in Fall 2016. If you have any questions regarding D2D or the Data Dictionary contact your local QIDS Specialist or the QIDS Program staff via carol.mulder@afhto.ca. For link to and information on the Data Dictionary for D2D 3.0, released in November 2015, read on below.

     

    Data Dictionary (version 4) for D2D 3.0

    The data dictionary version 4 describes indicators for D2D 3.0 and includes some changes from the initial set of indicators reported in D2D 1.0 and D2D 2.0. The definitions and data sources for these indicators are based on the Primary Care Performance Measurement Framework (PCPMF) wherever possible. Please ensure that you are working with Version 4 of the data dictionary. Please clear your cache before opening the PDF. For help in data extraction and submission, please see the D2D 3.0 Planning and Preparation page or contact your local QIDS Specialist or the Provincial QIDS Program staff via carol.mulder@afhto.ca.

  • D2D 4.0 Data Dictionary – Coming Soon!

    Watch this space for the updated Data Dictionary for D2D 4.0.

    AFHTO has begun the consultation process with members on what changes will occur to the Data Dictionary for D2D 3.0. Changes will be proposed based on this consultation process, and members will be asked to vote on them in May 2016, prior to the release of the updated Data Dictionary in June. To ensure that the indicators in D2D reflect what is manageable and meaningful to for member teams to collect, it is essential that members voices are heard throughout process.

    • Wherever possible, the definitions and data sources for these indicators are based on the Primary Care Performance Measurement Framework (PCPMF).
    • There will be no change for the majority of the indicators — particularly, the ICES indicators, which are based on billing data.

    The next release of the team level HQO Primary Care Practice Report (PCPR) will be at the end of May 2016; it will contain refreshed data, current to March 2015. We suggest teams begin the review of their PCPR data at that time, in order to prepare for D2D 4.0, launching in Fall 2016. If you have any questions regarding D2D or the Data Dictionary contact your local QIDS Specialist or the QIDS Program staff via carol.mulder@afhto.ca.  

  • Diabetes prevention program back in Owen Sound

    Owen Sound Sun Times article published on Apr. 6, 2016. Article in full pasted below. Denis Langlois, Owen Sound Sun Times Dr. Bruce Stanners says a diabetes prevention program in Owen Sound has helped to improve many lives since its start five years ago. “The outcomes have been excellent,” the local family physician, who serves as medical adviser for the program, said in an interview Wednesday. “We’ve seen a subjective side and objective. Subjectively, I’ve never heard people be so happy with how they feel in a program. I’ve had patients say I’ve never felt better in my life.” Objectively, participants have dropped an average of 20 pounds each during the program, lost three inches around their waist and reduced their blood sugar levels, he said. “That’s proving to us that we’re preventing diabetes. The original program that was done in the United States showed that this type of program can reduce diabetes by 39 per cent. We’ve had less than five per cent of our participants become diabetic,” he said. The primary care diabetes prevention program began as a two-year demonstration project in Owen Sound in 2011 after the Owen Sound Family Health Team received special funding from the Ministry of Health and Long Term Care. Funding was renewed in 2013, which kept the program going until March 2015. About 720 people registered for the program during those first four years. However, no new money was announced in 2015, so the program was shelved. Then, two months ago, the province identified the Owen Sound Family Health Team as a “centre of excellence in diabetes prevention.” It, along with five other family health teams in Ontario, were chosen to receive additional funding to offer diabetes prevention programs for people at risk of developing the chronic condition. The local family health team was also asked to train other FHTs in the region to set up their own programs. Paul Osadzuk, a local physical therapist who serves as a lifestyle coach for the program, attended a course at the University of Pittsburgh – where the program originated 20 years ago – to become a master trainer. The Owen Sound Family Health Team is planning to start offering the program again in early May. It is looking for participants. People with pre-diabetes – which is when a person’s blood sugar levels are higher than normal, but not yet high enough for a Type 2 diabetes diagnosis – or a metabolic syndrome can be referred by their family doctor or nurse practitioner. People with diabetes who have tried other programs without success can also request a referral. Participants are put into groups of 15 to 20 people and attend about 22 one-hour sessions with a lifestyle coach over nine to 12 months. They receive advice on healthy eating and how to boost physical activity as well as support to reach their goals, which are to lose and maintain a loss of seven per cent of body weight over a year and participate in 30 minutes of exercise daily. Research has shown that about half of Type 2 diabetes may be prevented by early lifestyle intervention. More than 11 million Canadians are living with diabetes or pre-diabetes, according to the Canadian Diabetes Association. The most common type, known as Type 2, occurs when the pancreas does not produce enough insulin or when the body does not effectively use the insulin available. Diabetes can lead to a number of complications as well as the onset of other illnesses. Heart disease is the leading cause of death in diabetics. Diabetes is also the leading cause in Canada of blindness and of kidney failure. Click here to access the article on Owen Sound Sun Times website.

  • Member News: clinical and patient education resources, updates, tools, and more

    Below are relevant updates and items for AFHTO members:

    Clinical & Patient Resources
    • Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Tool released today by the Knowledge Translation in Primary Care Initiative
    • Mental Health Programs: Spring guide released by Canadian Mental Health Association (CMHA) Middlesex, including free workshops for the region.
    • Psychiatry in Primary Care Toolkit: updated FAQ for mobile app from the Portico Network and the Centre for Addiction and Mental Health (CAMH) available.
    • New ‘Health Check’ toolkit for people with developmental disabilities: Developed by Health Care Access Research and Developmental Disabilities Program (H-CARDD) and available online.

    Leadership Resources 

    Provide Input and Earn Recognition  

    • Submit an abstract for the AFHTO 2016 Conference: Draw from your experience and views to set a course for primary care. Deadline is May 5th.

    Events and Learning Opportunities
    • May 6, 2016, Beyond the Break – Osteoporosis & Long-Term Care Guidelines- Clinical Application: Presented via telemedicine by Osteoporosis Canada and Women’s College Hospital.

  • Geriatric clinic part of possible regional electronic health records hub

    Trent Hills Independent article published on Apr. 5, 2016. 

    Article in full pasted below. Sue Dickens, Trent Hills Independent

    Campbellford – Campbellford Memorial Hospital could become a regional electronic health records (EHR) hub. That is the vision of President and CEO Brad Hilker, who updated hospital board officials at their last meeting on the progress being made in this area.

    Providing a context for this plan, he talked about the Geriatric Assessment and Intervention Network (GAIN) clinic located across the street, where the Trent Hills Family Health Team is situated in the Campbellford Memorial Health Centre at 119 Isabella St. The clinic opened June 2015.

    The GAIN clinics are established in each of the four largest hospitals in the Central East Local Health Integration Network (CE-LHIN), the closest being at the Peterborough Regional Health Centre. The clinics also include eight community-based teams such as the one in Trent Hills.

    The GAIN teams serve seniors, typically aged 75 plus, living at home or in retirement residences, who are frail and require comprehensive assessment.

    “Our GAIN team has worked very closely with our IT vendor to build customized screens that facilitate the documentation of the comprehensive geriatric assessment,” Hilker told the board.

    “The consulting geriatricians have praised the completeness and accuracy of the documentation and assessment record, and our team finds the system easy to use,” he added. The system has been designed to easily track indicators for monthly reporting.

    “Based on our success, the Seniors Care Network is exploring the use of our system as a regional documentation system for the other GAIN teams,” Hilker explained.

    This puts the system front and centre, in terms of it becoming the regional EHR hub for the GAIN program “to assist the Seniors Care Network to a common software solution utilizing our existing relationship with our vendor.”

    Hilker noted, “Further details will come, as we explore this opportunity.”

    The Seniors Care Network is “a group of dedicated health professionals, who share expertise and hard work, to provide the best healthcare experience for frail older adults in the CE-LHIN.”

    It covers an area of 17,000 square kilometres of mostly rural geography.

    The Network’s statistics indicate that 15 per cent of the CE-LHIN’s 1.6 million residents are seniors, “who may require additional support to remain living at home.”

    The LHIN’s population of frail older adults is estimated to grow by 27 per cent in the next decade and double in the next 20 years.

    All of this is happening while the province’s eHealth blueprint is being used as a framework for EHR planning and delivery.

    Click here to access the article on Trent Hills Independent website.

  • ‘Health Check’ toolkit for people with developmental disabilities

    A new toolkit, developed by Health Care Access Research and Developmental Disabilities Program (H-CARDD), will help family health teams provide better care for adults with intellectual and developmental disabilities (IDD), who have more health issues than other adults, but are less likely to receive preventative care. The toolkit, now available online, was developed as part of a larger research study led by CAMH and Dr. Ian Casson, associate professor in the Department of Family Medicine at Queen’s University, which analyzed how St. Michael’s and Queen’s FHTs implemented Health Checks for adults with IDD. Results were published in Intellectual and Developmental Disabilities. “Health Checks are like annual physicals, but they take into account the special needs of adults who have intellectual and developmental disabilities,” said Dr. Casson who is also a family physician with Queen’s Family Health Team. “They help such people get better access to health care, equivalent to people without disabilities, and they help family doctors recognize this population in their practices and serve them more effectively.” The toolkit includes a four step process to implement health checks, along with resources to help clinicians screen for IDD, clinical tools to assist with the exam itself, resources for patients and families, and examples of how the tools can be embedded into Electronic Medical Records for easier access. “Family physicians have the ability to provide excellent, guideline-directed care to adults with developmental disabilities but have been hampered by ways to identify this population in their practice,” said Dr. Laurie Green physician with St. Michael’s Family Health Team in Toronto. “Using this tool kit is a big step towards improving the physical health and well-being of adults with developmental disabilities. Relevant Links:

  • New ‘Health Check’ toolkit can improve primary healthcare for people with developmental disabilities |Montreal Gazette

    Montreal Gazette article published on Apr. 1, 2016. Article in full pasted below. CNW News Release, Montreal Gazette Adults with intellectual and developmental disabilities (IDD) have more health issues than other adults, but they are less likely to receive preventative care. A new toolkit, developed by Health Care Access Research and Developmental Disabilities Program (H-CARDD), will help family health teams provide better, more proactive care for this vulnerable and underserved population. “Right now too many people with developmental disabilities are not getting the routine care they need and this can lead to crisis and emergency room visits,” said Dr. Yona Lunsky, clinician-scientist at the Centre for Addiction and Mental Health (CAMH) and director of the H-CARDD program. “If you can improve the quality of care upstream at the primary care level, then you can address health issues early and prevent more serious health issues from emerging.” Despite current Canadian guidelines that recommend adults with IDD receive an annual comprehensive assessment, including a physical exam, the majority of adults with IDD in Ontario are not receiving Health Checks. “Guidelines are not necessarily a product ready to be used in practice,” said Dr. Lunsky. “We needed something to help bridge that gap and make it easier for busy family health teams to implement these guidelines into everyday practice and improve care.” The toolkit, launched today and available online, was developed as part of a larger research study led by CAMH and Dr. Ian Casson, associate professor in the Department of Family Medicine at Queen’s University, which analyzed how two Ontario family health teams implemented Health Checks for adults with IDD. The two clinical teams were St. Michael’s Family Health Team based in Toronto with 70 staff physicians, and Queen’s Family Health Team in Kingston with 25 staff physicians. Detailed study results were published today in Intellectual and Developmental Disabilities. “Health Checks are like annual physicals, but they take into account the special needs of adults who have intellectual and developmental disabilities,” said Dr. Casson who is also a family physician with Queen’s Family Health Team. “They help such people get better access to health care, equivalent to people without disabilities, and they help family doctors recognize this population in their practices and serve them more effectively.” The toolkit includes a four step process to implement health checks, along with resources to help clinicians screen for IDD, clinical tools to assist with the exam itself, resources for patients and families, and examples of how the tools can be embedded into Electronic Medical Records for easier access. “Family physicians have the ability to provide excellent, guideline-directed care to adults with developmental disabilities but have been hampered by ways to identify this population in their practice,” said Dr. Laurie Green physician with St. Michael’s Family Health Team in Toronto. “Using this tool kit is a big step towards improving the physical health and well-being of adults with developmental disabilities. The H-CARDD program, led by Dr. Lunsky at CAMH, has been studying the health and health care of over 66,000 adults with developmental disabilities in Ontario since 2010. In addition to describing health disparities faced by these adults, H-CARDD works closely with provincial stakeholders to translate research findings into changes in practice. The Health Check toolkit is the latest resource developed by the team to improve the health and healthcare of Ontarians with IDD. “These are evidence informed, clinically relevant tools that can help change practice and improve lives,” said Dr. Lunsky. “We hope to see the Health Check toolkit go province-wide.” The Centre for Addiction and Mental Health (CAMH) is Canada’s largest mental health and addiction teaching hospital and a world leading research centre in this field. CAMH combines clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental illness and addiction. CAMH is fully affiliated with the University of Toronto, and is a Pan American Health Organization/World Health Organization Collaborating Centre. For more information, please visit camh.ca or follow @CAMHnews on Twitter. Click here to access the article on Montreal Gazette website.

  • Support for AOP submission, Privacy and More!

    Published March 31, 2016. Updated Aug. 27, 2019.

    • Annual Operating Plan Submissions
    • New Tools for Privacy
    • Looking for more?

    Annual Operating Plan Submissions

    The deadline to submit FHT/NPLC operating plans to MOHLTC is 5:00 pm Sep. 25, 2019. AFHTO has prepared a number of resources to assist you in meeting this deadline:

    • Program Planning & Evaluation Framework [link]
    • Programs & Services Tip Sheet and Flow Diagram [link]
    • Program Performance Measures Catalogue (formerly the Indicator Catalogue) (link)
    • Schedule A Template for FHTs [download]

    These tools were presented jointly by AFHTO and MOHLTC during the February 24 and March 1 webinars. Video recording is available along with a number of supplemental program planning tools on our Program Planning and Evaluation Tools web page.

     

    New Tools for Privacy

    You asked, we listened! In response to your requests, the following new privacy tools have been developed:

    •  13 Privacy Tips for FHTs [link]
    • FHT Privacy Impact Assessment Template [download]
    • PHIPA Terms & Conditions for Vendor Contracts Template [download]

    AFHTO’s Privacy Resources web page contains a number of additional tools and resources developed in partnership with DDO Health Law to assist you in understanding and meeting the new privacy criteria from the Office of the Information and Privacy Commissioner of Ontario (IPC/O), including the following:

    • Answers to the top 5 privacy questions asked by FHTs and FHT staff [link]
    • Template FHT/FHO PHIPA Agency Agreement [download]
    • Recorded privacy webinars presented by AFHTO and DDO Health Law for Executive Directors and for Board Chairs.

     

    Looking for more?

    In addition to the above, AFHTO has a repository of governance-related tools and supports for Executive Directors, Board Members, and others. These include an ED Resource Toolkit, an ED Peer Mentorship program, a repository of organizational policies and procedures, the Fundamentals of Governance Guidebook, Governance Education Webinars and numerous tools to help you address Legislative and Contractual Issues.

    We hope that you will find these tools helpful as you wind up 2015/16 and prepare for 2016/17. If you have any questions or require assistance in using these tools and completing your annual reporting, please do not hesitate to contact Bryn Hamilton (Provincial Lead, Governance & Leadership).