Theme Description: Primary care organizations serve communities with diverse populations facing unique needs and barriers. Identifying needs and planning programs to improve population health and achieve greater equity requires engagement and collaboration with patients and other community partners. Presentations in this stream will include population-based approaches to program planning; methods for identifying community needs, potential partners, and funding for patient and population needs. A3 Cardiac Rehab in rural Primary Care: it takes a community. Prince Edward County is a rural (island) community, populated primarily by seniors and with a high prevalence of cardiovascular disease. A Cardiac Rehab program in Kingston required a 200 km round trip by car twice weekly, no public transportation is available and very few patients were attending following their cardiac event. The rural community spirit kicked in and within a year, a fully equipped exercise area was made available through local fund raising events. A comprehensive medically supervised program of exercise and education, followed by supporting community activities and planned events, is now available to our patients requiring cardiac rehabilitation. B3 Knowledge to Action: “Health Checks”, A Clinical Innovation in Comprehensive Primary Care of Adults with Developmental Disabilities (presentation to follow) The presentation will be introduced by researchers with a brief description of the “knowledge” that comes from a unique database linking the Ontario Ministries of Health and Long-Term Care and Community and Social Services and identifying a cohort of over 65,000 adults with developmental disabilities. This has yielded information about use of primary care services, hospitalizations, rates of annual preventive health exams, cancer screening, and medication use. C3 Development of a Teen Group at a FHT (presentation to follow) This presentation will explore the development of the Teen Group at the Stonechurch Family Health Centre, part of the McMaster Family Health Team. The experience of this site may help inform other FHTs about possible use of group methodology when working with teens. Some teens to date have indicated a preference for group therapy over individual therapy. Group therapy appears to provide an effective cost-effective treatment modality that is well received by the teens, and has produced promising results. D3 “It makes you feel more like a person than a patient”: Findings from patients receiving integrated home-based primary care (IHBPC) services in Toronto, Ontario A successful health care system will be one in which there is seamless integration and collaboration across care sectors. Innovative approaches are also needed to contend with the complex and inter-related health and social problems faced by the frail older adult population. One approach that is gaining momentum is the home-based primary care (HBPC) model. We add the word ‘integrated’ to describe our HBPC model (renamed IHBPC), recognizing the importance of fully integrating medical, cognitive and social care services at the point of care. This model reflects these key design features: the provision of ongoing, comprehensive medical and social care to frail older adults, interprofessional team service delivery and after hours availability for urgent issues. E3 Addressing income security within a primary health care setting: Lessons learned (presentation to follow) A large body of literature links income security with health, yet interventions to improve income security rarely exist in our health care system. First, we will present a conceptual model of how income security health promotion works within primary health care. Second, we will discuss lessons learned from engaging in income security health promotion at the St. Michael’s Hospital Academic Family Health Team over the past six months. Third, we will discuss our plans for a pragmatic randomized controlled trial, the IGNITE (addressInG iNcome securITy in primary carE) Study. F3 Primary Care Outreach and Connection in Rural Communities The Rural Wellington Community Team (RWCT) was born out of the statement “we don’t know what we don’t know”. This presentation will review the barriers and gaps that patients experience and the resulting effects on their health that are often unidentified.
Category: Uncategorized
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AFHTO 2014 Conference: Theme 4 – Team collaboration in patient-centred care
Theme Description: Interprofessional comprehensive primary care is focused on a collaborative practice that improves on the patient’s experience each time they interact with the organization – from making an appointment through their care episodes and follow-up reminders. Presentations in this stream will focus on interprofessional team collaboration and factors affecting how the team coordinates their work to meet patient needs (ie. team development activities, conflict resolution, and flexibility in scope of work for team members). A4 Our Best Foot Forward: Setting the Standard for Evidenced Based Multi-Disciplinary Approach for Foot Care Management Participants will learn from the Guelph FHT’s experience in delivering a standardized foot care program which is comprised of two primary components: a multidisciplinary team approach to clinical foot care interventions and individual and group foot care education. B4 The Most Valuable Player (MVP) Clinic – Our Collaborative Journey to Improving Patient Outcomes The MVP Clinic was created to support phase one of the Barrie Community HealthLink’s business plan. As the lead organization for our HealthLink, the BCFHT recognized the need to change the way healthcare is delivered in our community and therefore committed resources to this project. Using an interprofessional approach to care, our goal was to open a clinic for patients with multiple complex conditions, limited access to a primary care physician, and who are ‘high cost’ users of the healthcare system. C4 Implementation of a Homebound Senior’s Program: The Sunnybrook Academic Family Health Team’s Story The Sunnybrook Academic Family Health Team’s Homebound Seniors Program is an innovative, integrated, interprofessional project that provides team based care to homebound seniors (those who require a home visit due to a physical, social and/or psychological barrier which prevents them from accessing the clinic.) This session will describe the development and implementation of this program as well as some preliminary outcome data. C4-Items to bring on a Home Visit_handout C4-Initial & Follow-up Visit Stamps_handout D4 Renewal of interdisciplinary team processes to enhance linkages to the community and home based health care The provision of care for older adults can be challenging due to complex life and health realities for this population. TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a community based primary health care program that aims to foster optimal aging for older adults living at home using an interprofessional primary health care team delivery approach that centres on meeting a person’s health goals with the support of trained community volunteers, system navigation, community engagement, and use of technology. This presentation will share learnings from the initial development and implementation of TAPESTRY within a 2-site Family Health Team (FHT). E4 The Village Family Health Team’s Stepped Care Depression Management Update (presentation to follow) Village FHT presented the concept of a Stepped Depression Management Program at AFHTO 2012. At AFHTO 2014, they will present the outcome of two years of work. Stepped Depression Management is a treatment to target program. The PHQ-9 is used to detect major depression and systematically monitor patient’s status. It provides a clear, evidence-based stepped-care approach for the provider to know how to best change or intensify treatment if needed. A consulting psychiatrist reviews the patient case load with the social worker and family physician and offers assistance for patients with depression that is severe or not improving. Our presentation will consist of a review of literature demonstrating effectiveness of this approach in other settings as well as a review of public policy supporting shift of mental health management to primary care. F4 Expanding Capacity for Dementia Care: Primary Care-Based Memory Clinics Across the Province (presentation to follow) A primary care-based memory clinic model has been developed to address existing challenges of providing dementia care within family practice. To support this model, a training program was developed as a capacity-building initiative to support primary care providers to maintain the majority of dementia care within primary care practice. This presentation will describe the memory clinic care model, training program, implementation across the province, and potential applicability to other complex geriatric conditions.
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AFHTO 2014 Conference: Theme 5 – Integrating the community around the patient
Theme Description: Organizations in the community increasingly work in partnership to meet the needs of the patient and their community. Health Links and other initiatives have provided opportunities to improve coordination and transitions in care. Presentations in this stream will demonstrate how the patient’s journey and experience in the system has improved through successful coordination and/or integration of services across organizations.
A5 Collaborative Team focus for Developmental Delayed and Complex Young Man
Our FHT worked seamlessly with other organizations within the community, from the patient’s group home, to his parents, CCAC, local hospital and Developmental services agency to provide the care that this patient required. This was a new patient to our FHT, and because of his extremely high risk, this new team did not have time to do the usual forming, storming and norming. We had to function at a high level as this patient was experiencing oropharyngeal dysphagia, aspiration and malnutrition which were potentially life threatening. Our team would like to share our successes, lessons learned and what motivated us. The patient and his mother will be joining us in discussing how effective collaboration was life saving.
B5 Hospital at Home: Innovations in Rural Primary Care
The aim of the Hospital @ Home is to divert appropriate patients requiring inpatient care to a program that wraps the necessary care around the patient in their own home – the right care at the right time in the right place. The presentation will feature discussion from multiple partner/provider perspectives on their experience of the program and learnings in addition to an incorporation of patient experience in the form of narrative or video.
C5-a Collaborative Care Model: What does it take to create integration?
The making of this health link has the elements of a process that has included the historical stages of team formation and through that process has created change in a positive format for patients and their families. We will show the approach used, the process for creating culture change, the ideas tested, evaluated and re-tested and the outcomes in relation to the patient.
C5-b A Person Centered Health and Wellness Ecosystem (presentation to follow)
With the emphasis shifting to patient- oriented care and collaborative care models with patients as partners, the electronic personal health record (PHR) has generated considerable interest and investment in recent years. The purpose of this panel will be to explore a clinics’ experience with a large eHealth system consisting of an EMR, PHR and a social CDSS, including benefits to patients and providers, implementation tips, and challenges.
DE5 Coordinated Care Planning in the Guelph and East Toronto Health Links
Complex patients and their primary care providers often struggle with chronic disease guidelines and a health care system that has been designed for single disease entities and that does not take into account challenges with mental health, poverty, cognitive impairment, and substance usage. In our presentation we will review how Health Links can identify complex patients in their region using a combination of different approaches.
2. Integrating the community around the patient
Many community health and social service providers are serving the vulnerable population that health link addresses. Audience members will hear how Guelph has engaged both typical and atypical organizations and processes to support health link members as they would like versus, as the systems have been designed to operate.
F5 Improving The Road To Recovery
As a direct result from LHIN funding, service programs such as Addiction Services have allowed for more collaboration with health professionals to come together to meet the needs of the patient. Since our collaboration in February 2013, Addiction Services and primary care have improved communication, and success with patients with addictions. This presentation will demonstrate how simple changes and integration of two models of care can come together and effectively improve the harm reduction and sobriety of patients. A complex case that was successful with the integration of our community services around her harm reduction and sobriety will be presented.
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AFHTO 2014 Conference: Theme 6 – Using data to improve transitions of care and care coordination
Theme Description: Primary care providers collect and share patient information to help patients move safely and efficiently through the health care system. Presentations in this stream will share experiences to increase our collective capacity for:
- collecting more consistent data AND using the data we already have more safely and effectively (even if it isn’t consistent);
- making personal health records available to patients;
- knowing when and what personal patient information could and should be shared between providers; and
- getting the most out of existing technology, even while working to make it better.
A6-a Utilizing EMRs to Support Cancer Screening Primary care providers (PCPs) play a crucial role in the journey of a cancer patient, both in ensuring that patients get screened for cancer and navigating them through the healthcare system should they require care. The focus of this presentation will be on providing PCPs with information on tools and resources to support cancer screening through the use of current functionality in their EMRs. A6-b Transitioning between EMR Systems The NYFHT Information Management/Information Technology (IM/IT) Committee formed an EMR Task Force to review the FHT’s goals in moving toward a ‘one EMR and one server’ system. The EMR Task Force began by creating a comprehensive needs/readiness survey to understand current and future EMR requirements, which included readiness to change. Based on findings of the comprehensive needs assessment, the EMR taskforce developed recommendations to support physicians in their vendor procurement process. This process is still ongoing at this time. B6 Using Run Charts to Evaluate Quality Improvement Using run charts to analyze data over time simplifies the analysis of improvements made to processes or systems. They allow teams to easily identify if the quality improvement initiatives are obtaining the desired results. Once improvement has been achieved, run charts allow teams to monitor if the improvement is being sustained. This presentation will provide attendees with an example of how a Family Health Team has modified the reporting format of their indicators by replacing a colour-coded data table with run charts. C6 Mining for data gold: how to recycle imperfect EMR data into useful information EMR data are problematic. Quality can be poor and free text/unstandardized data are often difficult to query. However, many FHTs have already been able to derive significant value from currently existing data. This can involve activities such as querying data in EMRs (“front end data”), supplementing EMR data with external information (for example, the provincial Screening Activity Report or SAR) or participating in projects such as CPCSSN where cleaned/standardized data are returned to FHTs or clusters of FHTs (“back end data” for FHT data warehousing). As an example, we are using data on breast cancer received from the provincial SAR to update and standardize both personal and family history of breast cancer. This will allow us to more accurately categorize patients and refer them for high risk breast cancer screening in the future. D6 Optimizing Quality of EMR Data to Improve Care: Leading the Human Side of Change The difficult task of persuading individuals and groups to change their behaviour has been addressed by many existing change management strategies in the literature. It has been estimated that 70% of change initiatives fail mainly because change plans do not consider human behaviours. The aim of this presentation is to describe change management strategies widely used in healthcare industry that will improve EMR data quality in your healthcare facility. D6-b Primary care performance measurement — why bother? Primary care providers are facing an ever- increasing number of options and obligations related to performance reporting. This session outlines a measurement approach that can help focus attention on what really matters to primary care providers: the relationship with our patients and our ability to deliver the care that they value. It will show how D2D and the Starfield model consider disease-specific outcomes (e.g. “What’s your A1C?”) in the context of the relationship between the patient and provider, as distinct from other measurement models. E6 Using Hospital Data: Doing Analyses and Building Warehouses 1. Using Hospital Emergency Department Data for Quality Improvement in Family Health Teams The Quality Improvement Decision Support Specialist (QIDSS) for Upper Canada FHT, Athens District FHT, Community & Primary Health Care – Community FHT, and Prescott FHT receives hospital data on a monthly basis from Brockville General Hospital (BGH) and Perth & Smiths Falls District Hospital (PSFDH). During the presentation, the QIDSS will outline how data is received from hospitals, the difference analyses that can be performed on the above data, and how this is used to promote quality improvement in FHTs. 2. Analyzing health data across care systems: The NYFHT – NYGH Joint Data Warehouse Patients access care in multiple settings, including hospital and primary care; this is especially common for complex patients. Despite this, data about care are usually contained in electronic silos. Joining and combining health data across systems in order to more fully analyze care is challenging. We generated the first database containing joint data, which will enable quality improvement and research activities to be undertaken. F6 Advancing and Leveraging the Investment Value of EMRs – Project ALIVE Good quality EMR data can be a major enabler to supporting transitions of care and improving patient care coordination. Within primary care the level of maturity relative to information management and support tends not to be well developed. With a focus on adoption and innovation, this presentation will share a hands on practical guide of enhancing the quality of data in EMRs.
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AFHTO 2014 Conference: Theme 7 – Clinical innovations in comprehensive primary care
Theme Description: Interprofessional comprehensive primary care is the foundation of a sustainable responsive health care system in Ontario. Primary care teams work with patients to develop clinical services that respond to the expectations and needs of their patient population. This theme is focused on the comprehensive aspect of primary care. Presentations in this stream will showcase programs and services that integrate the interprofessional team and focus on a continuum of care for patients on everything from health promotion, illness prevention through chronic disease management to palliative care.
The Markham FHT Medication Reconciliation Program serves to prevent medication related issues post hospital discharge and the potential for readmission through a standardized documentation process whereby patients and physicians will be able to know with 100% certainty what medications the patient is currently taking. The goal of the program is to obtain the “best possible medication list” when patients are discharged from the hospital and facilitate seamless transition from the tertiary care setting back to primary care.
How can healthcare practitioners effectively address chronic disease prevention with their clients? This dynamic workshop is designed to help practitioners improve their skills in screening, assessing and intervening with even the most complex or “resistant” clients. The “6Pack” approach (smoking, alcohol, diet, physical activity, stress tolerance and sleep) will be introduced as a novel method of addressing chronic disease prevention in an integrated way.
B7-b Respiratory Care: From Case Finding to Rehab and Comprehensive Partnerships
3. Case Finding and Managing Chronic Obstructive Pulmonary Disease
4. Exercising the Option to help those with COPD- a Family Health Team approach to Pulmonary Rehab
5. Comprehensive Regional Respiratory Care Program
The aim of the London Family Health Team (LFHT) was to improve outcomes for patients with COPD, while ensuring our care is patient-centered. To achieve this, the LFHT developed a program centered on evidence-based guidelines for case-finding and management of individuals with COPD.
The Stratford Family Health Team Respiratory Clinic, is a nurse-led program, providing four basic work streams: spirometry testing (to confirm diagnosis of a lung condition and assist in management), patient education regarding self-management of a lung condition (COPD, Asthma), Smoking Cessation counselling, and Pulmonary Rehab – to provide a monitored, community supported exercise and education program in an area where access to pulmonary rehab is very limited. The specific benefits in this area will be the focus of the presentation.
The third presentation will showcase the creation of a successful collaboration with 6 FHTs (Windsor, Amherstburg, Harrow, Leamington, Tilbury, Chatham- Hent) and Asthma Research Group (ARGI) within Erie St. Clair LHIN with community based physician leaders, utilization of the CIHR knowledge-translation (KT) framework to contribute to multi-level health system innovation, facilitate guideline implementation, and improve health outcomes, with modest program expenditures in community primary care practices.
C7 Treating Insomnia in a Family Health Team
Chronic insomnia does not disappear on its own. Left untreated, it continues for years, contributing to poor quality of life, increasing the risk of major depression, compromising glucose metabolism and increasing the risk of type 2 diabetes. The Family Health Team is the ideal place to treat insomnia shortly after it is reported to the family physician. There are very effective treatments; the first-line recommended one in medical guidelines in North America and the UK is Cognitive Behavioural Therapy for Insomnia, or CBT-I.
D7 Advances in Mental Health Care: Telepsychiatry Collaborative Care Model/Anxiety Group
6. Ten Years of Anxiety Group at a FHT-What Have We Learned
People are more likely to consult their family physician about mental health than any other provider”. Mental health commission of Canada advised that one of their priority recommendations is to therefore “expand the role of primary health care in meeting the mental health needs”. With a needs assessments proving a lack of mental health consultants we qualified for increased sessional funds. It was evident that an innovative approach would be needed to address this gap in care. Our presentation will establish how telemedicine effectively and efficiently enhances the comprehensive care for patients with mental health concerns.
E7-a Patients supporting patients: self- management in Chronic Pain
The evidence suggests that patients experience poor quality of life and deterioration in their condition during this waiting period. The Chronic Pain self- management program, a six week group workshop facilitated by 2 leaders 1 or both of whom are volunteers living with chronic pain themselves, provides participants with support, self-management and coping skills to help manage their pain. The positive reaction to the program across Ontario suggests that it can make a valuable contribution to the management of chronic pain.
E7-b Identifying and Managing Challenging Complex Chronic Conditions: A FHT/Health Link Initiative to Address Frailty, Complex Geriatric Conditions, and High Health System Resource Use. (presentation to follow)
The “C5-75” (Case-finding for Complex Chronic Conditions in seniors 75+) program has been developed by the Centre for Family Medicine (CFFM) FHT to address frailty in primary care by systematically screening for frailty amongst all persons 75 years of age and older and addressing potential underlying causes using pro-active, evidence-based interventions. Similarly, the “Community Ward” project has been developed to address the unmet needs of community- based patients who are high users of health system resources.
F7-a Advanced Care Planning: practical implementation tools and reflections from two Family Health Teams (presentation to follow)
1. Advance Care Planning: A Quality Improvement Plan Toolkit for Primary Care Teams
This presentation will showcase the Advance Care Planning (ACP) quality improvement (QI) toolkit developed by Cancer Care Ontario to support Primary Care Teams who wish to include ACP as part of their QIP.
The East Toronto Health Link has developed an interdisciplinary facilitator model of the ACP process. The session would provide an overview of the interdisciplinary model, approaches to common barriers to ACP in primary care and an approach to incorporating ACP into routine care of patients within a family health team.
F7-b Finding a BETTER Way to Chronic Disease Prevention and Screening: The BETTER 2 Program
The BETTER Program aims to transform practice and brings together primary care providers, policy/decision makers and researchers to work towards improving CDPS in primary care. Using the BETTER toolkit, the PP determines which CDPS maneuvers the patient is eligible to receive and through shared decision-making and motivational interviewing, develops a unique, individualized “Prevention Prescription” with the patient.
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AFHTO 2014 Conference: Poster Displays
Theme 1 – Accountability and governance for patient-centred care 1 Accountability Management System: Manage Accountabilities, Plan Programs, Organize Indicators and Measure Success- Our Performance Storybook and Song sheet! 2 Leading the Way: Safety Climate as an Indicator of Organizational Culture and Improved Patient Care Theme 2 – Engaging the patient in their care 3 Development of a New Patient Experience Questionnaire for Lifestyle Services in Team-based Primary Care 4 The Markham FHT “Wellness Poster”: A Key Educational Reference Tool For Your Clinic 5 Impact of Curriculum Design on Patient-centred Care: Integrating Adult Learning Theory and Constructivism into Diabetes Group Education and its Effects on Patient Satisfaction, Confidence and Learning Outcomes 6 Engaging the Patient in Direct Observation for Hand Hygiene in a Primary Care Setting 7 Using a Well Baby Video for the Rourke recommended “Education and Advice” Counseling during Well Baby Visits for Infants Two Months or Younger 8 Improving Documentation of Our Patients’ Decision Makers 9 The iGeneration Goes to Grade 9: Resources to Promote Adolescent Mental Health and Well-Being 10 Improving Self-referral Rates to the Safe Medication Use for Seniors Program: A Pilot Project 11 Who is in the Driver’s Seat? – Creating Sustainable Habit Change Through Interdisciplinary Education and Client Self-Management: A “How-To” in New Program Development 12 The Use of Technology in TAPESTRY to Facilitate Data Collection and Communication between Patients, Volunteers and Interprofessional Teams 13 Living Healthy with Chronic Disease 14 Patient Survey for Patients with Low Literacy 15 The iPad Project: an Innovative Way to Engage Patients and Caregivers in Healthcare and Literacy 16 Measuring the Patient Experience – a Novel Approach to Getting Valid, Meaningful, Comparable Results Monthly with Relative Ease 17 Growing a Baby Friendly Ontario with Family Health Teams Theme 3 – Responding to community needs 18 The Role of Cognitive Impairment in Causing and Perpetuating Homelessness 19 Speaking Your Language: Improving Language Inquiry and Recording with a Multi-Ethnic Population at Toronto Western Hospital 20 Driving Cessation: Traveling a New Road 21 Improving Care to High Risk Populations through Outreach 22 After Rural Residency: Where do Doctors Choose to Practice? An Evaluation of the Goals of the Rural Ontario Medical Program 23 Healthy Pregnancy Strategy: What to Expect when Rural Wellington Women are Expecting 24 McQuesten Community Nurse Networker Pilot- an Innovative Collaboration in a High Priority Hamilton Neighbourhood 25 Responding to Community Needs: INR Point of Care Testing in Rural Ontario Theme 4 – Team collaboration in patient-centred care 26 It Takes a (Small) Village: How a Physician and RPN can Ensure Best Care for Patients with HIV 27 Exploring the Role of the Pharmacist during the Referral Process between Primary and Specialty care 28 Planned Diabetes Days: Enhancing Patient Care Through Use of the EMR 29 Team-Based Approach to Smoking Cessation 30 Group Well Baby Visits: Satisfaction Among Patients, Residents and Providers in a Community Family Health Team 31 Impact of Attachment Disorder in Fetal Alcohol Spectrum Disorder: A Signs/Team Approach 32 Using Rounds Centred on Patient Narratives: Building Capacity within a Family Health Team to Improve the Delivery of Care to Vulnerable Seniors 33 Hospital Discharge Med Wrecks: Processes for Pharmacist-Driven Tune-Ups 34 Seamless Access to Care: Owen Sound Family Health Team and Keystone Child, Youth and Family Services 35 The Primary Care Lung Health Quality Improvement (QI) Guide: Partnerships and Teamwork to Create a QI Guide for Primary Care Lung Health Programs 36 Improving Eye Care for Patients with Diabetes: Collaborating Across Specialties 37 Enhanced Patient Care for Diabetics in Family Health Teams 38 COPD Readmission Avoidance Project 39 Patient Initiated Referral 40 A Multi-Institutional Approach to Improving Maternal and Fetal Health 41 Pathways to Practice™ at Two Rivers Family Health Team 42 Management of Osteoporosis Through an Evidence-Based Pilot Program 43 A New Model to a Group Program: a Physician-Specialist to Help Motivate Patients 44 IMPACT RD: An Innovative Tool to Engage Your Team in Medical Nutrition Therapy 45 From Disney to Depression: How a Storyboard is being used to Design a Patient-Centred Care Pathway Theme 5 – Integrating the community around the patient 46 Impacting Cancer Screening By Employing Different Strategies within Primary Care Settings 47 Beyond Our Front Door: Promoting Community Partnerships to Improve Patient Care 48 Primary Care Providers’ Perspectives on Using the Champlain BASE eConsult service – a Qualitative Study 49 A Partnership Approach to the Well Child Checkup Theme 6 – Using data to improve transitions of care and care coordination 50 Collecting and Sharing Colorectal Cancer Screening Data with Primary Care Providers 51 UTOPIAN CPCSSN Project: Past, Present and Future 52 Using Visual Analytics to Support Quality Improvement in Primary Care 53 The Step Approach: Standard Treatment and Collaborative Care Lead to Better Hypertension Outcomes 54 Opioid Prescribing Patterns in a Family Health Team: The Good, the Bad and the Ugly 55 Patient Encounter Tracking Form – Moving into the Electronic Century! 56 Utilization of Custom Spreadsheets to Support Chronic Disease Management within the London Family Health Team 57 Creating Registry for Patients with Hypertension: Embarking on a Quality Improvement (QI) Methodology to Improve Care for Patients with Hypertension 58 Documentation Tools to Assist in the Transition and Transfer of Spina Bifida Patients from a Pediatric Multidisciplinary Clinic to the Adult Healthcare System 59 Integrating Hospital Report Manager into a Family Health Team 60 The EMR ‘Adoption Chasm’ – Looking at EMR Current Use and How to Bridge the ‘Chasm’ between Basic and Intermediate/Advanced Use 61 Reduction of Social Work Referral Wait Times Through Effective Triaging and Utilization of Resources Theme 7 – Clinical innovations in comprehensive primary care 62 FluFOBT Program: A Proven Approach to Increase Colorectal Cancer Screening 63 Chronic Pain Management – A Collaborative Primary Care Model to Support Patients Living With Non-Cancer Chronic Pain 64 The Transition from Hospital-Based Care for Stable HIV-Positive (HIV+) Patients in Ottawa 65 The Effect of a Structured versus Non-structured Homebound Seniors Program on Resident Attitudes towards House Calls 66 The Successful Implementation and Integration of eConsultation into a Family Health Team to Improve Access to Specialist Care 67 Senior’s Health Day – Providing an Integrated, Seamless Care to Seniors 68 Cognitive Assessment Clinics: A Model of Shared Care – Nurse Practitioner, Family Physician & Geriatrician 69 Senior Wellness Program: An Innovative Collaborative approach to Provide Comprehensive Patient-centred Care to Promote Healthy and Independent Living at Home 70 Physician Led Support Group for Low Carb Lifestyle: Carbs and Fats De-Mystified 71 Individualized versus Standard Treatment for Smoking Cessation: Findings from STOP with Family Health Teams 72 Creating Greater Collaboration by Utilizing Motivational Interviewing as a Common Language within an Inter-Professional Practice Team 73 Getting dermatology consults in less than 5 days by leveraging OTN and technology 74 One Small Step at a Time: A Team Approach to Integrating a COPD Program in the FHT
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AFHTO calls for quick action on government’s Primary Care Guarantee
800 Primary Care Providers meet in Toronto to share best practices and push for enhanced primary care.
Toronto, ON (October 16, 2014): The Association of Family Health Teams of Ontario (AFHTO) called for the Wynne government to take quick action to implement one of its election commitments: a guarantee that every Ontarian has access to primary care. “The evidence is in. When patients have access to high quality, team-based primary care they stay healthier longer, get sick less, and we save the health system money by staying out of hospital,” said Angie Heydon, Executive Director of AFHTO. “Evidence from around the world, and more recently in Ontario, demonstrates that the introduction of primary care teams are providing patients with better care, at the best value.” The Association’s members provide primary care in over 200 communities, serving over 3.5 million patients throughout Ontario. AFHTO announced support for the government’s election commitment to guarantee timely access to primary care in Ontario. They also rolled out several key solutions they believe will help ensure the government meets the commitment:
- Introduce immediate measures to help primary care teams recruit and retain health care professionals like dietitians and nurse practitioners that are leaving primary care
- Expand access to interprofessional primary care teams in the province
- Enhance the capacity of primary care teams to measure and track patient outcomes
The Association’s annual conference is taking place October 15 and 16 in Toronto. During the conference AFHTO also announced their third annual Bright Lights Awards, which recognize individuals for their leadership and work to improve the value of services delivered by primary care teams in Ontario. Winners were selected from over 60 submissions in a nomination process that took place in August of this year. A full list of winners can be found below. Profiles of the winners and their work are detailed here. About AFHTO: The Association of Family Health Teams of Ontario is a not for profit organization representing Ontario’s interprofessional primary care teams. AFHTO works to support the implementation and growth of primary care teams by promoting best practices, sharing lessons learned, and advocating on their behalf. Evidence and experience shows that team-based comprehensive primary care is delivering better health and better value to patients.
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AFHTO 2014 Conference: Theme 1 – Accountability and governance for patient-centred care
Theme Description: How does the board know that their organization is patient-centred? Presentations in this stream will include examples and stories of boards who have successfully incorporated the patient voice into strategic planning; created structures such as patient and family advisory committees; and processes for including patient stories in quality improvement planning. A1 – Implementing a Patient Advisory Council in an Academic FHT The presentation will take the participants through our internal process from conceptualizing a PAC to implementation and next steps for the evolution of the Council. WE will include concrete examples of how other teams can practically incorporate the PAC into their own environments and we hope to give opportunity for participants hear from one of our PAC members. B1 – How do we as governors ensure we hear and respond to the patient voice? Each panelist will present a brief synopsis of the techniques his/her organization employs to hear and respond to the patient voice and will then outline their successes, challenges, outcomes and recommendations. D1 – Creating cultures of quality improvement and patient safety The Queen’s FHT started their QI and safety journey in 2008 and a key part of this effort has been to examine and address issues of culture. This presentation will focus on defining the aspects of culture that impact QI and safety, how to recognize them in your team, and what steps you can take to improve the culture in your team. E1 – Rural Wellington Shared Governance Across Health Care Partners Presenters will provide a history of the journey the partner agencies have experienced to date, provide details of the steps used to create the vision and mission, challenges and lessons learned, and plans for future endeavors. The focus of the presentation will be on the change management approach that we have found to be successful.
