Category: Uncategorized

Theme 1. Population-based primary health care: planning and integration for the community

Presentation Materials (members only)

Presentation Slides: Reaching out to Adolescents in the Community.

Learning Objectives

At the end of this workshop, participants will have the tools to build their own Adolescent Outreach program. Specific learning goals for this workshop include:

1. How to engage local high schools and build relationships with them
2. Create a program that is aligned with the school’s curriculum
3. Create a dynamic interprofessional team to deliver your program
4. Link with local Adolescent Psychiatry / Mental Health professionals
5. Incorporate learners and teaching in this model
6. Evaluate your program
7. Helpful resources, links and services.

Summary

The Adolescent Outreach Program was created in 1988 to allow adolescents in our community an opportunity to ask questions and have their health concerns addressed by physicians in a confidential and non-judgmental setting. The program was also aimed to increase Family Medicine residents’ exposure to the health issues and concerns facing adolescents, a group that traditionally does not visit their Family Physician regularly. In 2011, with the establishment of Sunnybrook Academic Family Health Team, interprofessional teams consisting of a physician, residents, dietitian and social worker as appropriate started visiting local high schools to provide education on topics such as mental health, sexual health, body image etc. Each session is approximately one hour in duration, with approximately 20 – 25 students in attendance. Students have the opportunity to submit written questions anonymously and ask questions directly on pre-identified topics. Teams led by residents use various interactive methods such as games/quiz/small group activities to engage adolescents. With information technology available at finger tips of adolescents, it’s necessary to have a secure platform to provide correct health education early. Therefore, primary care involvement in Adolescent health needs to be increased across the province. Our program is one such example of platform to educate and promote health for adolescents. This session will outline the process of creating a formal interprofessional Adolescent Outreach program in a Family Health Team, whether it be in an Academic setting or not. We will share our best practices as well as lessons learned since the establishment of the program.

Presenters

• Sunnybrook Academic FHT and University of Toronto DFCM:
  • Dr. Purti Papneja, MD, CCFP / Staff Physician, Co-Program Director
  • Dr. Anne Wideman, MD, CCFP / Staff Physician, Co-Program Director

Authors and Contributors

• Ingrid Wirsig, BA

 

Theme 3. Transforming patients’ and caregivers’ experience and health

Presentation Materials (members only)

HERSTORY Peer Directed Group Exercise Programs Improving Clinical Outcomes Group medical visits, including peer-led and peer-facilitated exercise groups, and care-based focus groups, are emerging as an efficient and effective way to care for patients with complex needs. Four teams describe how they have implemented group visits and share their results.

(I) HERSTORY: An Innovative Group Model for Mental Health Care Using Peer Facilitation and Patient Co-design

Learning Objectives

WHAT MAKES A PATIENT COMPLEX? The Bridgepoint FHT would like to present an approach for dealing with a complex and underserved population- those with a past history of sexual childhood trauma. In this interactive presentation you will learn about the impact of this model, be provided with the tools to spread this model to your FHT and hear directly from the voice of patients and peer facilitator.

Summary

The Bridgepoint FHT in partnership with our patients have developed a cutting edge women’s trauma program entitled “HERSTORY”. The current community wait times for referral to trauma therapy are measured in YEARS. In order to respond better to our patient needs we developed an inter professional group model of care using focus groups, peer leadership and ongoing patient and provider feedback. This presentation will illustrate our process, review our outcomes both qualitative and quantitative, provide insights into the challenges and victories of this unique group and allow the audience to hear directly from our patient representative and peer facilitator.

Presenters

• Bridgepoint FHT
  • Lora Judge, MSW,RSW
  • Lora Cruise, Medical Director

Authors and Contributors

• Christine Gordon

(II) Shared Medical Appointments: The Why, the How, the Impact

Presentation Materials (members only)

• Materials will be posted following the 2015 Conference.

Learning Objectives

• Summarize SMAs – what they are, evidence for their use.
• Describe our process to initiating and adapting SMAs in busy practices -listen to/hear experiences of SMA participants (practitioners and patients).

Summary

Shared Medical Appointments are an exciting and innovative way to provide care to patients with chronic diseases. Our interdisciplinary teams introduced Shared Medical Appointments (SMAs) to patients living with diabetes in 2012. An SMA is a 90 min appointment held simultaneously with 5-10 patients and 2 providers in an interactive visit. All parameters of diabetic care are monitored as with any individual diabetic visit, patient questions are addressed by both peers and providers and true collaboration is encouraged between patient and health care professionals. Participants (providers and patients) experiences will be highlighted in this presentation. 

Presenters

• Hamilton FHT:
  • Anneli Kaethler, MSc, RD, CDE
  • Cornelia Mielke, BSc, MD, CCFP

Authors and Contributors

• Hamilton FHT:
  • Catherine Bednarowski, Clinical Pharmacist, CDE, Hamilton FHT
  • Sheilah Lamb, MD
  • Barbara Teal, MD
  • Robert Kerr, MD

(III) Peer-Directed Group Exercise Programs Improving Clinical Outcomes

Learning Objectives

Attendees will learn about how building group exercise programs with peer co-leaders and patient directed educational discussions not only cn affect A1c, BMI, BP and MaxMETs in a population with metabolic syndrome or diabetes, but also improves patient attitude towards being physically active. The program leaves participants confident and prepared to maintain activity levels after completion. This model increases patient independence and thrives off of group cohesion and the support of peer co-leaders. In addition, attendees will learn how to implement similar programs with varying resources in their own community.

Summary

Supervised group exercise programs have been proven effective in improving outcomes in patients with diabetes. At the Guelph FHT we have implemented group exercises classes that incorporate peer co-leadership and patient directed educational discussions. The program runs on a rotating basis twice per week for 12 weeks. Participants complete cardio, strength, balance, and flexibility activities during each session. Upon completion, patients have the option of undergoing training to become peer co-leaders. The program’s goal is to improve outcomes (a1c, BP, BMI, WC, lipids, MaxMET) for people with diabetes and metabolic syndrome and increase physical activity levels and leave patients confident with their ability to maintain after program completion. Results are collected and analyzed in an ongoing basis. As of April 2015, average days completing cardio exercises increased from 1.8 to 4.5 and resistance training from <1 to 3.5 days. Perception of exercise improved during the program and 90% of graduates believed they had attained the necessary confidence, skills, and strategies to maintain their activity levels. Average a1c decreased 0.3%. Estimated MaxMETs increased approximately 20%. Both WC and BMI showed decreasing trends. Using a highly peer directed group exercise program can increase physical activity levels and improve outcomes. Similar programs could be created using partnerships with community gym facilities or with minimal equipment. This model also places the focus on the patient and empowers them make positive and hopefully lifelong changes in their perception of and motivation to be physically active. 

Presenters

• Krista Crozier, R.Kin, CDE Diabetes Care Guelph, Guelph FHT

(IV) Group Medical Visits (GMV) for Primary Care Diabetes: The McMaster Family Health Team Experience

Learning Objectives

1. To gain knowledge about how to organize and implement a group medical visit
2. To learn the value of using group medical visits effectively within primary care
3. To hear positive patient accounts about their experience with group medical visits

Summary

The increasing prevalence of diabetes poses a threat to the sustainability of Canada’s health care system. Group medical visits (GMVs) are emerging as an efficient strategy to deliver care to multiple patients and have been shown to improve glycemic control, patient satisfaction and patient self-efficacy in disease management. The purpose of this study was to examine a number of process and quality of care outcomes measures to compare GMVs to traditional care and a diabetes clinic model that existed within the McMaster Family Health Team. This was a cohort study comparing GMVs to traditional care and a diabetes clinic model over the period 2008-2012. During each visit, patients saw a family physician and registered practical nurse with foot care certification and one of the following diabetes educators: nurse practitioner, dietitian or pharmacist. Group visit content included physical exam, medication review, group diabetes education review, question and answer time and goal setting. The numbers in each group were small so data was analyzed descriptively. The benefits and challenges of GMVs as compared to conventional care will be highlighted during this presentation and suggestions on how GMVs can be used effectively for diabetes care within primary care will be provided.

Presenters

• McMaster FHT:
  • Inge Schabort, MB ChB CCFP FCFP
  • Michele MacDonald Werstuck, RD MSc CDE

Authors and Contributors

• Kalpana Nair, PhD, McMaster University
• Christie Tasch, BA, McMaster University

Theme 7. Clinical innovations keeping people at home and out of the hospital

Presentation Materials (members only)

Aging at Home Indicator Management

Learning Objectives

Our Aging at Home program’s focus is to provide interdisciplinary home care to seniors and reduce unnecessary emergency department visits. We will share our experience with team building, physician engagement as well as collaboration with CCAC and Joseph Brant Hospital. Our team were participants in the IDEAS program. We will discuss how the resources made available assisted in developing tangible goals and performance indicators and how this carried over into our QIP. The goal for our presentation is to have the attendees benefit from our learnings in:

• Program Development
• Team Building
• Internal and External Collaboration
• Embedding QI into a program.

Summary

The LHIN’s Aging at Home Strategy identified that a wider range of homecare and community support services will be needed. They project that the population of seniors will double in the next 16 years. Approximately 40% of the population of Burlington is over the age of 50. For our aging population, the Burlington Family Health Team has developed a program through clinical innovations to keep seniors at home and out of hospital. The Aging at Home program aims to reduce preventable emergency department visits and helps to promote optimal health for our patients in the community. This is achieved through assessment and intervention by the FHT Occupational Therapist and Nurse Practitioner for patients who have difficulty accessing services, and who are at high risk for repeat emergency department visits and hospitalizations. Several aspects of the program will be highlighted, including monthly rounds with physicians and members of the interprofessional team as well as ongoing monitoring of emergency department data for quality improvement purposes. A key feature of the program is the ongoing collaboration and integration with our local CCAC and Joseph Brant Hospital. The Burlington FHT will also continue to build on our close relationship with Burlington Health Links. Future goals include utilization of emergency department data to screen for high risk patients who may benefit from the program.

Presenters

• Burlington FHT:
  • Shawna Cronin, Occupational Therapist
  • Theresa Hubley, Nurse Practitioner
  • Caitlin Grzeslo, Program Coordinator

Authors and Contributors

• Joanne Pearson, Executive Director, Burlington Family Health Team
• Courtney Field, MD, Burlington Family Health Team

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Presentation Slides: Culture Eats Accountability for Breakfast

Learning Objectives

This workshop will invite participants to rethink the importance of team culture by:

1. Understanding ‘whole-mind’ thinking
2. Leading inter-professional collaboration
3. Shifting the leadership culture of their teams.

Summary

Team-based primary care in Ontario is driven by a ‘left-brain’ approach to healthcare. Accountability, fiscal restraint, governance, policy, structure, patient statistics- these are the things that drive Ministry-funded primary care organizations. But for the people leading these teams, the need to embrace ‘right-brain’ thinking brings a healthy balance to the experience. Purpose, collaboration, trust, creativity, relationships and patient stories- these are the things that inspire a high performance team culture. Participants will be invited to reflect on their own team’s ethos and identify new ways of balancing the demands of accountability with the desire for a thriving team environment. They will hear how taking a ‘whole-brain’ approach to leadership can create a healthier high performance team culture. And they will be invited to consider how they might shift the leadership culture of their team by unleashing the leadership potential of all team members.

Presenters

• Dave Courtemanche, Principal and Founder, Leading Minds Inc

Theme 5. Advancing manageable meaningful measurement

Presentation Materials (members only)

Presentation Slides: Measlesgate

Learning Objectives

Review the clinical signs and symptoms associated with Measles and the appropriate tests to confirm the diagnosis. Outline the infection control steps to prevent measles exposure as well as other airborne infections to patients and staff present in the office setting. Emphasize the importance of collaboration with local public health for contact tracing after an office measles exposure. Discuss the recommendations by the Markham FHT Occupational Health & Safety Committee to collect immunity data on staff and providers with respect to vaccine preventable diseases (e.g. MMR, varicella, Hep B) and institute baseline TB skin testing.

Summary

Measles is a viral infection that classically presents with fever, rash and the 3 “Cs” – cough, coryza and conjunctivitis. While most people with measles are sick for a few days and recover completely, it can lead to complications and even death. In Canada, due to high immunization rates, measles is rare. However, several factors have contributed to recent outbreaks including patients who only received one immunization against measles, those who refuse to be immunized due to a discredited claim that there is a link to developing autism, and unintended exposures in countries endemic to measles. Given the virus spreads through respiratory droplets, multiple exposures can occur when an infected patient presents to a primary care practitioner’s office. Providers need to be comfortable responding to such a scenario and this session will provide a practical approach on how to manage a measles exposure based on our FHT’s experience from earlier this year. Consistent with the theme of “Advancing manageable meaningful measurement”, we will highlight the importance of leveraging one’s EMR system to access patient health records for contact tracing. Topics including collaboration with public health, and the importance of transparent messaging to patients and staff will be reviewed. Providers will also be imparted with valuable lessons learned such as the importance of infection control practices to prevent spread, and knowing the immunization status of office staff/providers to ensure protection in the event of a measles outbreak. A review of the diagnostic tests for measles will also be provided.

Presenters

• Markham FHT
  • Dr. Allan Grill, MD, CCFP, MPH, Lead Physician
  • Lisa Ruddy, RN, Clinical Program Manager

Authors and Contributors

• Anthony Pallaria, Clinical/IT Manager, Markham Family Health Team

Theme 3. Transforming patients’ and caregivers’ experience and health

Presentation Materials (members only)

Extending the EMR with Patient Tablets Using an automated patient reminder service and survey to collect information on patients’ experiences Add some SaaS to your patient experience surveys Collecting meaningful data on patient experience can be a time-consuming and challenging, but it can have invaluable results. Four different approaches that have proven successful are explored in this session.

(I) Extending the EMR with Patient Tablets: Using Interactive, Point-of-Care Patient Surveys in the Waiting Room to Generate Clinical Content and Save Time

Learning Objectives

Learn how mobile devices and a cloud-based platform can unlock and extend your EMR, enhance patient communication, and save time. In this session, you will hear how primary care clinics are using mobile tablets and a large library of clinical content with their existing EMRs to allow patients to securely update contact information, provide a detailed patient history, or complete forms like the Nipissing Well-Baby Screen. Data entered by the patient can be automatically used to calculate scores, recommend treatment based on clinical guidelines, add a clinical note to the EMR, and even generate customized patient educational materials and handouts.

Summary

In this presentation, you will see firsthand how one physician is using tablets to transform his practice. Learn how online patient questionnaires – completed on tablets in the waiting room, or from home before the appointment – are reducing appointment time requirements by as much 65%, while allowing more time spent face-to-face with the patient. By automating administrative tasks like email consent and demographic updates, you will also hear how clinics are becoming more efficient and reducing the burden on front-desk staff. Finally, you will see how replacing the scanning of paper forms with digital data entry, patient records can become more structured, more accurate, and minable. Learn how Ocean’s EMR-agnostic, integrated support for mobile tools and the largest library of openly available clinical questionnaires is transforming primary care across the province. With over 300,000 patient record EMR updates completed by patients in waiting rooms and exam rooms in just under two years, this technology is making it possible to access and share crucial healthcare resources in a whole new way.

Presenters

• Dr. Douglas Kavanagh, MD, North York FHT; Founder, CognisantMD
• Dr. Robert Davis, MD, Happy Valley FHT

(II) Transforming Primary Health Care Delivery through Innovative Patient Experience Tool

Learning Objectives

1. Importance of obtaining Patient Feedback on primary health care services delivery
2. Value of Real Time innovative Patient Feedback tools in aiding analysis and relevance
3. Removing Communication Barriers between patients and health care team
4. The value of patient feedback tools on measuring quality improvement of patient experience.
5. Summary (II):

This innovative tool of collecting patient feedback has resulted in removing barriers for patients to provide feedback to their health care team about their experience due to the ease of use and accessibility. Furthermore, we are now using the provincial QIP patient questions in our survey for the past 1 month. This will allow our tool to be leveraged across primary care teams to compare patient experience in different settings and ensuring our alignment with provincial strategy. 

Presenters

• Wise Elephant FHT:
  • Sanjeev Goel, Lead Physician
  • Virgiliu Bogdan Pinzaru, Health Informatics Analyst, QIDSS
  • Lopita Banerjee, Physician

Authors and Contributors

• Jaipaul Massey Singh

(III) Using an Automated Patient Reminder Service and Survey to Collect Information on Patients’ Experiences

Learning Objectives

This session will inform participants about how to use an automated patient reminder service to survey patients on their experiences seeking and receiving care at their FHT. Participants will learn about the cost and minimal burden of this approach as well as the patients it can reach and which survey questions can be used.

Summary

In order to improve the care we deliver, FHTS need to understand patients’ experiences in seeking and receiving their health care. FHTs are also required to survey their patients annually to contribute to their quality improvement plans. At the same time, many FHTS are seeking ways to improve their care through automated reminder systems such as appointment reminders. This session will present an overview of a new approach to surveying FHT patients using automated surveys similar to patient reminder calls, emails, or texts. It will present the results and experiences from FHTs which have used this technology. The strengths and weakness of this technology including the patients it reaches and whom it may not, the burden on practices, and the cost will be shared with participants. 

Presenters

• Anthony Mar, President, Cliniconex Inc.
• Sharon Johnston, Family Physician, Clinician Investigator, University of Ottawa Department of Family Medicine, Bruyère FHT

Authors and Contributors

• Bill Hogg, University of Ottawa Department of Family Medicine, Bruyère Continuing Care

(IV) Add some SaaS to your Patient Experience Surveys

Learning Objectives

Participants will learn novel strategies for coordinating and collecting patient experience surveys that reduce FHT staff and patient burden.

Summary

While the collection of patient experience data is mandated by HQO, there is little guidance around how to collect this data with existing resources. Strategies are needed to support survey distribution that minimize burden on both FHT staff and patients. To address this challenge, the Women’s College Hospital Academic FHT has developed an automated system to collect patient experience data. We designed 3 short surveys, each focussed on a different domain of patient experience. Each survey includes:

• the questions mandated by HQO,
• questions related to chosen domain, and
• demographics questions.

Patients receive an email with survey link during their birth month, so that each patient only receives one survey annually. Our process, which involves use of SaaS (software as a service) solutions, allows us to:

• Minimize data entry and analysis burden by automating distribution, data entry, and analysis
• Minimize patient burden, while still collecting feedback on a wider variety of issues (3 short surveys)
• Monitor improvements over time (the 3 surveys are rotated throughout the year, allowing for quarterly analysis on all domains)
• Semi-automate qualitative analysis of patient comments
• Adopt best practices in electronic survey distribution, including via mobile devices
• Minimize privacy and confidentiality issues related to the US Patriot Act
• Be compliant with Canada’s anti-spam legislation (CASL) which came into effect July 1, 2014.

While subscription costs for SaaS solutions are not inexpensive, economies of scale may be achieved if a system is adopted and shared across FHTs.

Presenters

• Women’s College Academic FHT:
  • Nicole Bourgeois, Dietitian and Health Promoter
  • Holly Finn, Program Coordinator
  • Susie Kim, Family Physician and FHT QI Lead
• Craig Thompson, Director of Digital Communications, Women’s College Hospital

Authors and Contributors

• Ranjana Shardha, Quality Improvement Decision Support Specialist

Theme 4. Building the rural health care team: making the most of available resources

Presentation Materials (members only)

Presentation Slides: From Soup to Tomatoes

Learning Objectives

1. Learn how to access this free program via OTN and the “how- to’s” for implementing.
2. Learn the rationale and benefits in offering an arm-chair based exercise program to the citizens of a community.
3. Participate in a demonstration of the three programs “From Soup to Tomatoes” offers.
4. Be inspired to offer “From Soup to Tomatoes” exercise programs in your own community.

Summary

The session begins with a 15-minute PowerPoint presentation outlining “From Soup to Tomatoes”; from inception, growth, current programs, future plans and brief reports of studies and statistics. Presented information will include the following: In 2006 From Soup to Tomatoes was conceived by Susan Clarke who believed that in order to help patients become active, a new approach was needed. A free program that addressed accessibility, nutrition, financial constraints, and transportation was the answer. Inspiration was found from quoting Dr. Ian Blumer, who once told an audience “studies have proven that using two cans of soup to exercise just ten minutes a day is beneficial”. So Susan started a patient out with two cans of soup with instructions to slowly increase reps and weight. The patient quipped that one day, she may just advance to cans of tomatoes. From this conversation came an armchair-based exercise program named From Soup to Tomatoes, consisting of three non-consecutive days of armchair-based resistance exercises that would meet the CDA guidelines. The three classes offered (basic, gentle, and yoga) are viewed “live” via the Ontario Telemedicine Network (OTN) at many locations. All webcasts are archived and available free of charge to anyone with internet access. Many hundreds view via the web. Participants report enhanced physical, mental and social well-being. After the PowerPoint presentation, Renee Desjardins will lead the audience to participate in a 15-to-20-minute demonstration of the basic, gentle and yoga programs. 10 minutes of Q and A will follow.

Presenters

• Espanola and Area FHT:
  • Susan Clarke, RN, Certified Diabetes Educator, Telemedicine Coordinator
  • Renee Desjardin, BA, RN, PTS (Personal Training Specialist), OAS(Older Adult specialist)

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (members only)

Presentation Slides: Charting a Blueprint for Improved Interprofessional Primary Care Team Effectiveness

Learning Objectives

The University of Toronto (U of T) Department of Family and Community Medicine (DFMC) Quality Improvement (QI) Program has launched an 18-month “teaming” project. Teaming refers to the collective actions or processes associated with an interprofessional primary care team performing optimally. This session will introduce the results of the environmental scan and how they have framed a blueprint that will guide interprofessional primary care teams to function effectively, and with ultimate outcomes leading to improved health of populations, improved patient and provider experiences, and improved value.

Summary

A significant provincial investment has been made in Ontario in family health teams and inter-professional models of care. Significant work has also been done in Ontario on improving team governance and leadership. There has been a large transformation from solo practitioners to teams yet there has been very little structured team function guidance and support. The opportunity exists for change and improvement; teaming will promote the best possible function from interprofessional primary care teams, leading to better patient care and improved outcomes. The development of a conceptual framework has been derived from the environmental scan, guided a research design and blueprint to be tested at the Trillium Health Partners affiliated Credit Valley FHT, Family Medicine Teaching Unit. Change ideas, tools, instruments and qualitative and quantitative measurement related to team performance and patient outcomes have been defined to support team effectiveness improvement. The teaming project will enable individuals and teams to embark on a journey of thinking and working differently in order for them to drive change and improvement.

Presenters

• University of Toronto DFCM:
  • Dr. Philip Ellison, MD MBA CCFP FCFP
  • Patricia O’Brien, RN BA CNeph(C)

Authors and Contributors

• Monica Aggarwal, PhD, Innovative Health Care Management Soluntions Inc.
• MaryKay Whittaker, BScN, DFCM

Theme 1. Population-based primary health care: planning and integration for the community

(I) Going Upstream: Building the Infrastructure to Address Social Determinants at the St. Michael’s Hospital Academic Family Health Team

Learning Objectives

At the end of the presentation, participants will have: 1. Gained knowledge of initiatives being implemented to intervene on the social determinants of health at St. Michael’s Hospital Academic Family Health Team, including work on income security, access to legal services, access to decent work and child literacy. 2. Gained skills in developing an administrative structure and partnerships required to administer these new programs, including the creation of a Social Determinants of Health Committee. 3. Gained knowledge of the role of evaluation in helping build and sustain new programs that address social determinants.

Summary

Social determinants of health (SDOH) are “the conditions in which people are born, grow, live, work and age.” The concept of the SDOH is not new, and indeed, can be found in the observations of Hippocrates. However, modern healthcare organizations have typically not considered addressing SDOH as part of their core business, with few exceptions (e.g. community health centres). The landmark 2008 Final Report of the Commission on Social Determinants of Health triggered renewed interest in this area, followed closely by calls by the British Medical Association, the Canadian Medical Association and the College of Family Physicians of Canada for greater action by health professionals on SDOH. Family Health Teams are well-placed to address SDOH as they aim to provide quality primary care to Ontarians. Over the past two years, we have identified a number of new and innovative approaches to address SDOH in a practical manner. These include:

• the routine collection of detailed socio-demographic data on all patients in order to assess health equity;

• the implementation of an innovative Income Security Health Promotion service;

• the implementation of a medical-legal partnership;

• the implementation of a Reach Out And Read early childhood literacy program; and

• the development of a combined advocacy and service program to address employment conditions and access to decent work.

Our experiences implementing and evaluating novel interventions will be described and used as a springboard for supporting participants to effect changes to the SDOH in their own communities. 

Presenters

• St. Michael’s Hospital Academic FHT
  • Andrew D. Pinto, MD CCFP FRCPC MSc, Staff Physician & Scientist
  • Gary Bloch, MD CCFP, Staff Physician & Chair, Social Determinants of Health Committee

(II) Community Engagement Can Support Population-Based Primary Health Care: Lessons learned at St. Michael’s Hospital Academic Family Health Team

Learning Objectives

At the end of the presentation, participants will have:

1. Gained knowledge of what community engagement is and how it relates to patient engagement.
2. Gained knowledge of the role of community engagement in Family Health Teams, particularly in supporting population-based primary health care.
3. Gained skills around applying for funding to support community engagement specialists and reporting on performance measures, based on lessons learned within the St. Michael’s Hospital Academic Family Health Team.

Summary

Community engagement is defined as the process of working collaboratively with groups of people – connected by geographic proximity, interest, identities or similar situations – to address issues affecting their health and wellbeing. St. Michael’s Hospital Academic Family Health Team was recently successful in obtaining funding for a full-time Community Engagement Specialist as part of opening a clinic site in a new community. The need to ensure that services was responsive to community needs was evident, alongside the growing focus within the Family Health Team on addressing social determinants of health and improving access to care for the most vulnerable populations. The key actions of community engagement are

1. intelligence gathering,
2. relationship building, and
3. conceptualizing innovative services.

The focus to date has been on relationship-building with residents, health care providers, other community members and organizations through formal and informal activities. The Community Engagement Specialist acts as a liaison: mobilizing information, connections and resources between the Family Health Team and various groups to support action that improves primary health initiatives through intersectoral collaborations and partnerships. This role provides value to primary health providers and to communities through better informed decision-making, an increased sense of involvement and responsibility, an increased range of ideas and options for improvements in primary care, better access and outcomes, and increased credibility, transparency and accountability. It is an approach that aims to engage beyond our patient population, reaching unattached patients, community members and residents in communities to reduce health inequities.

Presenters

• St. Michael’s Hospital Academic FHT:
  • Cian Knights, MBACED HonBA, Community Engagement Specialist
  • Andrew D. Pinto, MD CCFP FRCPC MSc, Staff Physician & Scientist

Theme 7. Clinical innovations keeping people at home and out of the hospital

Learning Objectives

Participants will learn about the value, effectiveness and availability of Telehomecare, which connects patients to their healthcare teams in real time for monitoring and coaching. Data will highlight how Telehomecare is helping to shift resources from hospital-based acute and ER care to a more proactive, community-based model. Participants will gain an understanding of how Telehomecare helps patients remain independent and optimize their health using self-management skills, bridging the gap between appointments, increasing access to care and making better use of healthcare resources. Participants will also learn how to refer patients or start their own Telehomecare program in their FHT.

Summary

The evolution of Telehomecare will be the focus of the panel presentation, led by Ontario Telemedicine Network (OTN) CEO Dr. Ed Brown. Telehomecare brings together specially trained clinicians and simple technology to coach patients with chronic obstructive pulmonary disorder (COPD) and/or congestive heart failure (CHF) to monitor vital signs and manage their health at home. Offered in eight LHINs in Ontario through hospitals and Community Care Access Centres, Telehomecare has been delivered to more than 5,000 patients to date. It enhances patient confidence and self-management skills significantly, avoiding unnecessary ER visits and reducing inpatient hospitalizations. Telehomecare is now expanding to target patients with COPD and/or CHF with diabetes as a comorbidity, as well as patients with chronic complex needs. To enhance accessibility, the program is now being offered in a format that can be tailored to smaller, individual sites, to accommodate particular needs and resources. The panel will feature a Telehomecare physician “champion”, a representative involved in the diabetes pilot and a representative from a Family Health Team involved in a pilot for patients withchronic complex needs. They will highlight how expansion of Telehomecare across Ontario can offer the community supports to manage chronic disease and prevent exacerbations, promoting improved access to care for enrolled patients and reduced healthcare resource utilization.

Presenters

• Dr. Ed Brown, CEO, Ontario Telemedicine Network
• Co-presenters TBD

Authors and Contributors

• Ontario Telemedicine Network:
  • Shelley Morris, Engagement & Implementation Lead
  • Kimindra Tiwana, Engagement & Implementation Lead