Category: Uncategorized

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Presentation Slides: Solutions for Managing Patient Privacy across Clinics and Community Partners

(I) A Stewardship Privacy Model for a FHT and its Clinics

Learning Objectives

As the province’s third largest FHT, the Guelph FHT has 76 doctors and is operationally broken down into 17 clinics. While privacy is always a challenge, privacy in the Guelph FHT’s environment is especially challenging and requires a purposeful privacy governance structure to ensure consistency across clinics, to support FHT staff and to meet legal obligations. Participants will learn about the Guelph FHT’s approach to privacy governance, how the model was implemented and how other FHTs may take a similar approach.

Summary

FHTs are continually asked to provide leadership in data. This leadership often involves searching, accessing and summarizing data about clinics. Often, however, the relationship between a FHT and its clinics from a privacy perspective is ambiguous, and questions of custodianship, responsibility and training are unclear. As FHTs are strategically moving to play a even stronger role in data, the question of privacy and privacy governance needs to be formally resolved. As the province’s third largest FHT, privacy in the Guelph FHT’s environment is especially challenging and requires a purposeful privacy governance structure to ensure consistency across clinics, to support FHT staff and to meet legal obligations. The Guelph FHT’s privacy model is based on the concept of privacy stewardship, and sharing privacy roles and responsibilities between the Guelph FHT and its clinics. The goal of this model is to allow the Guelph FHT to participate in regional data programs, while simultaneously giving individual clinics appropriate control and responsibility for their privacy responsibilities. The Guelph FHT’s approach is broken down into two parts: the first part of this governance model is based on a common set of privacy principles that are adopted by all clinics. This “Harmonized Privacy Policy” establishes universal privacy policies for all clinics and clearly outlines the role of the FHT and the role of the clinic regarding privacy responsibilities and obligations. The second part of the governance model is a Stewardship Agreement, which formalizes the relationship between the FHT and its clinics from a data and privacy perspective. The presentation will conclude with a review of lessons learned through the process of negotiating this privacy model, and an update on its current status. 

Presenters

• Kirk Miller, Director of Performance and Accountability, Guelph FHT
• Justin St-Maurice, Privacy Consultant, St-Maurice Consulting Services

(II) Quality-Based Reporting and PHIPA Compliance

Learning Objectives

Increase overall awareness of privacy, security and confidentiality of data. Review current PHIPA regulations and the relevance to Family Health Teams in quality-based reporting. Provide an overview of the current challenges faced by Family Health Teams in meeting PHIPA requirements Share useful and practical ideas that may be adopted by other FHTs in terms of contract negotiations with internal and external partners, implementation of processes, policies and procedures, and internal quality monitoring through audits.

Summary

Quality-Based Reporting and PHIPA Compliance. No one would argue that information from data is key to improving efficiencies within the healthcare system, influencing public policy development and administration and supporting research to advance patient care. At the same time, information security and privacy in the healthcare sector is an issue of growing importance, where breaches can incur serious consequences for both the individual and the organization involved. The adoption of electronic patient medical records and the increasing need for providers and funders to access and utilize patient data all point towards the need for a better understanding and adoption of policies and protocols regarding information security. The main threats to patient privacy and information security are those that arise from inappropriate access of patient data either internally or by exploiting disclosed data, including big data, beyond its intended use. Compliance with provincial regulations governing privacy and security of health information is mandatory (PHIPA, 2004) and yet, many Family Health Teams and other healthcare organizations are failing to comply and struggling to understand the risks they face by not meeting these requirements. This presentation will highlight some of the challenges faced by the North York Family Health Team in meeting PHIPA requirements as we continually strive to implement best practices in addressing quality-based reporting both internally and with our external partners. The importance of a data flow chart; end-user agreements; staff training and education; privacy, security, data breach and confidentiality policies and procedures; audits; and other necessary checks and balances will be discussed.

Presenters

• Susan Griffis, Executive Director
• Jennifer Leung, Clinical Manager, North York FHT
• Marjan Moeinedin, Quality Information Decision Support Specialist

Authors and Contributors

• Joyce Lo, Project Manager, North York FHT
• Andrew Levstein, Information Technology Support, North York FHT

Theme 5. Advancing manageable meaningful measurement

Presentation Materials (members only)

Presentation Slides: Measuring what really matters to patients

(I) Indicator Management: Weighted Indicator Selection Matrix (QSFHT Experience)

Summary

The presentation showcases the Weighted Indicator Selection Matrix a complementary tool to the Accountability Management System (AMS) (“QIDSS Innovation Fund”). Since indicators are key part systemic system performance, they need a uniform and robust approach for selection and measurability. The AMS, manages and organizes indicators by linking them through goals, objectives and activities. But, how should we select the best indicators to highlight an organization’s performance? We need to have an objective system; and that is why we developed the “Weighted Indicator Selection Matrix”. The presentation will deal with the process of how a FHT team can develop their own customized Matrix and translated it into a practical decision-making process to enhance data gathering and collection tools.

Presenters

• Queen Square FHT:
  • Abel Gebreyesus, BA, MHI, QIDSS
  • Heba Sadek, Executive Director
• Lindsey Thompson, RN, BScN, MPH – Health Services Planner/RN

Learning Objectives

The objective is:

1. Why indicators matter to primary care performance
2. Mastering prioritization of indicators efficiently
3. Exercising objectivity in indicator selection evidenced through Six Sigma Tool.

(II) Measuring What Really Matters to Patients

Learning Objectives

The partnership between AFHTO and Patients Canada on the Patient/Doctor survey to find out what matters to patients in their relationship with their doctor and clinic, led to two important areas of learning:

• About why patient/caregiver collaboration in developing the survey led to better uptake and results
• About the value and process of the partnership itself

You will learn why partnering with informed patients can help target and improve a survey and increase the response rate. You will also learn what makes an effective partnership and how to develop the partner relationship.

Summary

The presentation will look at the development and results of the Patient/Doctor survey and why and how the successful partnering of AFHTO and Patients Canada impacted the quality of the survey and increased the response rate. The goal of the survey was to determine what is important to patients and how important each question was in how patients evaluated their relationship with their primary care provider. The results of the survey will inform clinicians which are the most important questions to include in their own surveys to determine the quality of the care they deliver. The Key Performance Targets (KPTs) developed by Patients Canada from patient experiences helped identify questions important to patients. Initially, the survey design was complex, with levels of questions framed in research speak. The challenge was how to make the survey goal, its structure and language understandable to patients. It took several rounds of work with AFHTO researchers and informed patients from Patients Canada to rework and streamline the survey. After all, if patients cannot understand the need for the survey, its questions and how to answer, what value can come of it? So what did we learn? The nature of the patient partnership determines the depth of value patients can bring to the project. Measuring what is important to patients from their perspective and acting on the results can lead to better experience of primary care for patients in Ontario.

Presenters

• Patients Canada
  • Alies Maybee, Patient Advisor, Patients Canada
  • Brian Clark, Patient Advisor, Patients Canada
• Puja Ahluwalia, Project Coordinator, Quality Improvement Decision Support, QIDS, AFHTO

Authors and Contributors

• Carol Mulder, Provincial Lead, Quality Improvement and Decision Support, AFHTO
• Jenny Cockram, consultant to AFHTO, J. Cockram & Associates

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

Presentation Materials (members only)

Presentation Slides: Rural Health Hubs Framework for Ontario

Summary

Rural communities face unique challenges in delivering high-quality care due to lack of critical mass and economies of scale. Some communities have worked hard to overcome these challenges through innovative local solutions and are well-positioned to continue to improve access to care as part of health system transformation. Rural health hubs and improved health and social service integration are important to all local providers, including physicians in rural and remote practice. Therefore, the OHA and the OMA agreed to establish a Multi-Sector Rural Health Hub Advisory Committee with broad stakeholder representation to develop a framework for implementation of rural health hubs in Ontario. By the end of the presentation we want to hear from the audience what aspects of the Rural Health Hub model could work in your community? Is there anything like this already? What are the issues, barriers and/or opportunities where you are?

Presenters

• Randy Belair, Executive Director, Sunset Country FHT
• Dr. Adam Steacie, Physician, Upper Canada FHT

Learning Objectives

By the end of the presentation, participants will:

1. Review the rural health hub framework and the context for its creation
2. Identify existing health hubs and pilot projects – what makes them work? What are the elements of community partnership that are relevant for primary care across Ontario
3. Discuss issues and opportunities for implementation in primary care

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

Presentation Materials (Members only)

Presentation Slides: Measuring the Patient Experience

Learning Objectives

Observe the benefit of centralizing the development, implementation, collating, and reporting of a standardized patient experience survey that would require limited resources from FHTs. Compare response rates, responses, and respondent demographics from different survey methods including waiting room, web-based, and emailed surveys. Reflect on how patient experience surveys can be used to differentiate patients’ experience within different clinics and/or for different physicians/clinicians. Reflect on challenges with feeding back survey data to staff to drive improvements in quality of care. Reflect on the best method of delivering a patient experience survey in your FHT context.

Summary

First, FHTs from the Champlain LHIN will describe the implementation of their second annual Patient Experience Survey, the goal of which was to understand the key elements of patient’s experience in the Champlain LHIN according to key performance indicators. While each FHT is distinct and cares for a unique population, the results of the survey should help FHTs establish their own priorities for improvement. The FHTs are provided with a report, which aims to provide information for the Quality Improvement Plan, initiate action within the FHTs, enable FHTs to learn from each other, and perform benchmarking within a FHT year over year; it is not intended to compare FHTs. We will describe the creation of the survey, the various methods of delivery, and the questions asked. Second, the St. Michael’s Hospital Academic Family Health Team will describe their experience with two different survey delivery methods – emailing a link to an online survey and approaching patients in the waiting room to complete a survey using tablet computers. They will share how response rates, respondent characteristics, and responses differed between the two survey methods. This interactive workshop will engage participants in a discussion around how to administer surveys using few resources, how survey responses can be used to improve quality of care, and what survey delivery methods can sustainably produce generalizable, meaningful results in your setting.

Presenters

• Ellie Kingsbury, QIDSS, Champlain FHTs
• St. Michael’s Hospital Academic FHT:
  • Tara Kiran, Family Physician, QI Program Director
  • Sam Davie, QIDSS
  • Morgan Slater, PhD, Senior Research Associate
  • Lisa Miller, EMR Administrator

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (Members only)

Well Baby Group Baby Friendly Initiative (BFI)

(I) Well-Baby/Well-Child Care Groups: The Bridgepoint FHT Report Five Years Later

Learning Objectives

The Bridgepoint FHT has been providing well baby care in a group model since 2010. Well baby groups optimize the scope of nursing practice, primary provider time and create a community of support for new parents. In this workshop we will explain how to get groups started, discuss pitfalls and successes and how to automate your processes to keep this model sustainable.

Summary

Well-baby groups were started at the Bridgepoint FHT due to the overwhelming demand for well child appointments. Since 2010 we have utilized and revised our model for well baby group visits. This model of care optimizes the nursing scope of practice, improves primary provider efficiency while meeting the needs of the growing young community our FHT serves. In this workshop we will provide the practical perspective from nurses, administration and primary providers of what works and what does not in the well baby and child care model. We will provide tools to get your team started, discuss how to optimize your team roles to keep this model sustainable and how to spread this model within and across teams. 

Presenters

• Bridgepoint FHT
  • Lora Cruise, Medical Director
  • Alice McDermott, Administrative Assistant
• Meghan Rule, RN, NP Candidate Ryerson, Bridgepoint FHT

Authors and Contributors

• Colleen Youngs, RN, NP candidate Bridgepoint FHT

(II) Baby Friendly Initiative (BFI): Leveraging the EMR to Capture Breastfeeding Statistics

Learning Objectives

Using the Newborn Support and Breastfeeding Program as a case example, presenters will demonstrate how breastfeeding data collection has evolved from paper-based surveys distributed at group classes, to retrospective data collection through the Healthy Beginnings Program, to custom forms integrated into encounter assistants using the EMR. Presenters will describe the team-based approach taken to ensure consistent and reliable data collection for Baby Friendly Initiative (BFI) reporting. Participants will learn about the challenges in accurately capturing breastfeeding statistics and tips and tricks to promote organization wide data collection.

Summary

In pursuing Baby Friendly Initiative (BFI) accreditation, Two Rivers Family Health Team is required to monitor breastfeeding rates, duration and exclusivity. Since 2010 when the breastfeeding program was first developed we have struggled to find an accurate method to capture breastfeeding statistics. Although breastfeeding status is collected at each well-baby visit, extracting data from the Rourke is a challenge due to inconsistencies in documentation. We initially started with paper-based surveys distributed at breastfeeding classes, but found a bias as we were only reaching those patients who attended the sessions. Data collection then evolved to a retrospective approach extracted from the 3-year old Healthy Beginnings appointment. Finally, through taking a team-based approach, breastfeeding rates are now recorded at each well-baby visit using a breastfeeding status custom form. Medical office assistants input a breastfeeding status form at patient each encounter- 2 months, 4 months, 6 months, 9 months, 12 months, 15 months and 18 months. Through taking a consistent and team-based approach, BFI data collection has progressed to a more accurate, reliable and meaningful process.

Presenters

• Kim Lichty, RN, International Board Certified Lactation Consultant, Two Rivers FHT

Authors and Contributors

• Jessie Rumble, RN, MScN, Health Promoter, Two Rivers FHT

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (Members only)

Presentation Slides: Sustaining Change

Learning Objectives

In an effort to be patient-centred, the Guelph FHT since inception adopted the decentralized model/approach in allocating IHPs across all 22 practices where every practice gets its share from FHT funded IHPs depending on # of physicians, population served and roster size. In other words each practice is a “patient medical home. Attendees will gain understanding of how this model works, how to allocate, manage resources, promote ownership and accountability, tailor services according to population needs and embrace collaborative team approach to population health. It is important to note that there is no perfect structure fits all organisations but it crucial to understand your stakeholders and plan your approach to organisational structure accordingly.

Summary

We broadly agree on the core objectives that health care systems should pursue. The list is strikingly straightforward: universal access for all people, effective care for better health outcomes, efficient use of resources, high-quality services and responsiveness to patient concerns. It is a formula that resonates across the spectrum but the diversity of health system configurations that has developed in response to broadly common objectives leads quite naturally to questions about the advantages and disadvantages inherent in different arrangements, and which approach is “better” or even “best” given a particular context and priorities. The logic of a decentralized model is based on an intrinsically powerful idea. It is, simply stated, that smaller organizations, properly structured and steered, are inherently more agile and accountable than are larger organizations. With ownership, delegation and autonomization often implemented, decentralized GFHT structure provides efficiency in terms of reducing the risk of bottlenecks and improving access at practice level, thus increasing the overall throughput capacity of Guelph primary care system Objectives of decentralization

• To improve clinical efficiency through developing skills and knowledge of practice based IHPs to manage more diversified patient portfolio.
• To increase allocative efficiency through better matching of FHT services to practice preferences for improved patient care.
• To empower individual practices through taking the lead in planning and initiating services that meets patients needs.
• To increase team accountability through collaborative and holistic approach to patient health.
• To increase quality of health services through integration of services and improved IM systems and access for vulnerable groups.
• To increase equity through allocating resources to better meet the needs of particular groups.

Presenters

• Guelph FHT:
  • Sam Marzouk, Director, Operations and Finance
  • Sylvia Scott, Director, Clinical and Professional Services

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

Learning Objectives

Participants will leave with a broader sense of what we mean by Health Equity. Full spectrum training in and operationalisation of Health Equity must include all parts of the BODY of Health Equity. Participants will learn the elements of each – Information – Attitude – Capacity-building – and how they intersect and complement one another, why one without the others is inadequate and its potential for profound system-wide impact.

Summary

The presentation will cover the elements of full-spectrum Health Equity, focussing on its present and potential impact on individuals, communities, on systems – and what kind of courage is needed to do so. It will be provide information and it will be interactive and fun!

• The HEAD of health equity is all about increasing our knowledge, open to and acquiring new information on best practices and applying it to the practice site environment. It’s about definitions, effective community engagement that never ends, rethinking Population Health Needs Assessments to take into account the social determinants of health, using its key concepts as the lens through which one does planning, asks questions, designs space, ensures accessibility (in every sense of that word); finding and recruiting the right staff and volunteers and ensuring their regular training in these concepts and applications as well as putting in place measures and mechanisms for open, transparent, safe communication, resolution of conflicts and team-building.
• The FEET of Health Equity institutionalises your commitment to health equity, providing monitoring and ongoing learning opportunities for improvement.
• The HEART moves beyond knowledge transfer to a focus on people and the encounters that make up our work-days: with our clients, our funders, our colleagues and ourselves – how we are with one another, our behaviours and the impacts of often unacknowledged social location and unrecognised privilege, cultural conditioning (on the part of both provider and client/ patient), unsurfaced attitudes, interests and motivations.

The HEART asks, “What are the internal and organisational dynamics, structures, policies/procedures, unwritten protocols, personal values, rank and privilege that have an impact, positive or otherwise, on effective people-centred care?” Training in the HEART of Health Equity also provides insight with respect to the architecture of space and the constructs and properties of power and stigma. Getting at the HEART drives passion for and interest in greater knowledge, skills and commitment to one’s part in the organisation’s goals and planning. Getting to the HEART is the indispensable ingredient. The IMPACT of this kind of full-spectrum operationalisation is huge, measurable both in traditional methods, checking off boxes, monitoring change, evaluating experience – and in the more subjective measurements that have to do with self- and other-awareness, one’s capacity to broach difficult conversations, to identify internal barriers to effective ‘encountering’ of all sorts, to communicate more effectively. To paraphrase Steven Lewis, ‘if we meant what we say about health equity, the very system itself would be turned inside out and upside down.’ It would move us to ask different questions:

• How would we communicate differently?
• How would we define performance and productivity differently?
• How would we train our providers differently?
• How would we use health information differently?
• How would we value time and
• What would we reward differently?
• How would we allocate resources differently?

Presenters

• Lee McKenna, Executive Director, Partera International

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

Presentation Materials (Members only)

Presentation Slides: Community Paramedicine Models for Primary Care

(I) Community Paramedicine – Review of a Dedicated Model in Primary Care (FHT)

Learning Objectives

At the end of this presentation, attendees should be abIe to identify the types of patients who would benefit from visits from a Community Paramedic in (CP) their own home or community setting, understand the role that CP’s can play in community health systems including Family Health Teams, understand how the unique paramedic skill set can augment and support existing community health supports without duplicating service, and decrease reactive system utilization (9-1-1, ED visits) by taking a proactive approach to providing care for specific, at risk, patient populations.

Summary

Medavie EMS Ontario, Chatham-Kent (MEMSO-CK) is the contracted service provider for the provision of land ambulance services for the single tier municipality of Chatham-Kent. MEMSO-CK was an active stakeholder in the development of the Chatham-Kent Health Link (HL) as where directors with the Thamesview Family Health Team and Chatham-Kent Family Health who together have aproximately 60,000 rostered patients in the municipality. In a collaboration with the HL partners, MEMSO-CK was successful in receiving one time funding from the Ministry of Health and Long Term Care to develop and examine CP programs. Medavie EMS has extensive history and experience with CP programs in Atlantic Canada and the north eastern US and sought to bring some of that experience to our Ontario operations. This novel program was developed in consultation and collaboration with the the FHT’s in the region in addition to the CCAC, CHC, CKHA and medical oversight physicians from the South West Ontario Regional Base Hospital Program. Three specific referral sources feed patients into the program: HL high users as determined by a care cooridinator at CKHA, waitlisted cardiac rehab patients, and CCAC rapid response RN patients. The 2 CP’s selected for the program attended an 8 week custom CP program developed by Fanshawe College. Working in a non response vehicle, 5 days per week, the CP’s provide supportive care, health coaching using the NHS wellness index, advanced assessment and diagnostics (eg. 12 lead ECG, POC testing), fall education, end of life care planning, and consultative/advocacy link for the patient population being served. 

Presenters

• Medavie EMS Ontario:
  • Steve Pancino, General Manager
  • Ken Langlois, Community Paramedic
• Dr. David LaPierre, Family Physician, CK-CHC

Authors and Contributors

• Lisa Richardson, Health Link Care Manager, CKHA
• Carol Kolga, Senior Research Associate, Western University
• Nancy Snobelen, Director, Chatham-Kent Health Alliance
• Denise Waddick, Executive Director, Thamsview FHT

(II) Community Paramedicine in a Rural FHT

Learning Objectives

At the end of this presentation, attendees should be abIe to identify the types of patients who would benefit from visits from a Community Paramedic in their own home, understand how to integrate Community Paramedic into a Family Health Team, understand the benefit to physicians of having a Community Paramedic visit patients on behalf of the Family Health Team, understand the importance of identifying all medications that patients may be taking including prescription medications, over the counter medications and herbal supplements, understand the limits of technology in rural communities and how to integrate community care and advocate on behalf of patients.

Summary

West Carleton Family Health Team (WCFHT) is one of the few medical service providers in Rural Northwest Ottawa, and is located in the Village of Carp, within the amalgamated City of Ottawa. The largest portion of this practice population resides in this area, a sparsely populated region that traditional home services find difficult to service. In 2014 the Ministry of Health and Long Term Care distributed $6 million dollars in Ontario to expand paramedicine programs. WCFHT was chosen to pilot a paramedicine program where extensively trained and experienced Community Paramedics (CP) are integrated into the FHT to provide patient services in their own home. This novel program was developed in consultation and collaboration with the two regional providers of Paramedical Services in Rural Northwest Ottawa. Patients accepted into this program were chosen by physicians in the FHT . The patient population includes patients with chronic diseases, co-morbidities, palliative care, mental health concerns, recently discharged from hospitals or any patient identified as at risk. The program focuses on reducing the stress on limited health services, while at the same time, improving patient’s quality of life and assisting patients to live independently in their own home. CPs provide services that are normally provided within the FHT to patients, such as but not limited to; blood pressure checks, blood glucose testing, suture removal, immunizations and a thorough identification of medications. Most importantly the CP acts on behalf of the patient as an advocate in coordinating care from community partners.

Presenters

• Bev Atkinson, Quality Information Decision Support Specialist, West Carleton FHT

Authors and Contributors

• West Carleton FHT:
  • Mark Fraser, MD
  • Barb Jones, Program Administrator
• Tracey Suprunchuck, Community Paramedic, City of Ottawa

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Presentation Slides: Creating and Implementing the Markham Family Health Team Lead Physician Performance Review

Supporting Materials (members only)

• Markham FHT Lead Physician Review cover letter
• Markham FHT Lead MD 360 Review
• Markham FHT Individual Development Plan
• Markham FHT Accountability Framework – Performance Appraisal
• Markham FHT 360 Degree Feedback Policy
• Markham FHT Board Assessment Template for Survey

Learning Objectives

1. To outline the steps required in creating a performance review with a focus on the FHT Lead Physician role.
2. To explore the function of the Governance Committee and the FHT Board of Directors with respect to implementing the LP performance review.
3. To discuss the importance of a transparent process when designing a performance review and its influence on accountability.

Summary

The MOHLTC, a key “shareholder” of FHT Boards of Directors, expects accountability to be linked to performance. In order for FHTs to succeed in this regard, strong leadership is required. Therefore, evaluating the performance of individuals holding leadership positions within FHTs is crucial. Furthermore, from a professional standpoint, advice from peers and colleagues creates the opportunity for leadership growth and in turn organizational maturity. Constructive feedback also holds a leader accountable by determining if s/he meets their stated deliverables. In this regard, the Markham FHT recently designed a performance review process for their Lead Physician. This presentation will outline the various steps taken by the Governance Committee including updating the LP job description, developing an evaluation survey, selecting FHT members of various roles to partake in the survey, choosing an on-line method to gather and analyze feedback, and communicating the results to the FHT Board and members of the organization. Perspectives from the Chair of the Markham FHT Governance Committee, Executive Director and Lead Physician will be shared. It will also provide a step-by-step practical outline of how to initiate a process to measure the performance of the Lead Physician, and other staff, for FHTs who have not yet participated in this exercise. Furthermore, this presentation falls within the AFHTO theme of “Leadership and governance for accountable care” by focusing on tools to support leaders in good governance and supporting the development of leadership within the team.

Presenters

• Markham FHT:
  • Dr. Allan Grill, MD, CCFP, MPH, Lead Physician
  • Dr. Parm Singh, MD, CCFP, Family Physician & Chair, Governance Committee
  • David Marriott, B.A., Executive Director

Authors and Contributors

• Lisa Ruddy, RN, Clinical Program Manager, Markham FHT

 

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

Presentation Materials (Members only)

Presentation Slides: Building the rural health care team

Learning Objectives

Participants will learn:

• How a Northern FHT maximizes service delivery to expand available technology and minimize travel through OTN for shared care where there are no obstetrical services. A woman not traveling an hour for prenatal follow- up has made a difference in the lives of families experiencing a normal life event.
• How the FHT fostered collaborative relationships with the local hospital sharing IHP’s in order to maximize outpatient services.
• How collaborative partnerships maximized delivery of collective resources before Health Links inception. As a member of Timiskaming Health Link, our FHT led establishing and developing ICCPs (Integrated coordinated care plans).

Summary

The Kirkland Lake Family Health Team is located in Northeastern Ontario, serving a population of approximately 10,000 with demographics skewed towards the elderly and complex patients. The doctor shortage was severe, and reliance on locum physicians was high. Nurse Practitioners and IHPs have been the most stable part of our delivery team, at times being the main service providers in our community. Managing patients with complex care, multiple specialists, home care, and high demand for services caused frustration and fragmentation in care delivery for patients and providers. The integration of individual coordinated care plans (Health Links) has alleviated stress and demand on workload and enabled clients to better self-manage. Part of facilitating this has been involving the whole team as part of the process so that the delivery can be shared. We make extensive use of OTN. That has saved money and thousands of kilometers in travel, and hs avoided significant lost time at work for patients. We are currently participating in a research project to examine how to better prepare NP students for the challenges of managing patients with multiple comorbidities. The abstract for this paper has been accepted for presentation at the Canadian Association of Advanced Practice Nurses annual conference in Winnipeg in October, 2015. We provide placement for NP, RN and medical students. We hope to be setting the stage for professionals to return to practice in a facility which is proud to offer a truly integrated team approach. We are proud to discuss the innovations we have made to enhance service delivery as well as provider satisfaction and team integration at the AFHTO conference.

Presenters

• Kirkland District FHT:
  • Christina Woollings, NP-PHC, Clinical Lead
  • Julie Moody, RPN, Telemedicine Coordinator
  • Mandy Weeden, Executive Director
• Sandra Dal Pai, NP-PHC; Adjunct Professor, Laurentian University