2011 AFHTO conference presentation PRESENTER (S): Dr. Ainsley Moore, MSc, MD CCFP; Joy White, RN-EC, MSN; Kalpana Nair, MSc, PhD; Maria Chacon, MD FHT/ORG: McMaster FHT & Department of Family Medicine, McMaster University ABSTRACT: Background: Multidisciplinary, integrated primary care-based programs involving multiple practitioners are recommended for frail seniors with complex concurrent conditions. This study sought to understand the perceptions and experiences of family physicians and nurses whose patients had been seen through a multidisciplinary, integrated primary care-based program for seniors, the Seniors Collaborative Care Program (SCCP). Methods: This study used a qualitative descriptive approach and took place at Stonechurch Family Health Centre (SFHC) in Hamilton, Ontario. Purposive sampling was used and each participant took part in a semi-structured, individual interview. Analysis involved a content analysis approach. Results & Conclusions: Five family physicians and 4 nurses working at SFHC took part. Main themes centred on need for clear communication and role clarity. Access to the SCCP Program was also a predominant theme, suggesting that availability of specialized geriatric services in primary care is an important step towards increasing knowledge and skills of primary care clinicians. Click here to view presentation.
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Point of Care INR
2011 AFHTO conference presentation
PRESENTER (S): Katharine De Caire RN (EC), MN; Jennifer Scott, RPN; Mary Park, RPN; Joan Morris, RPN; Brian Hemens, RPh BScPhm; Shelly House RPh BScPhm
FHT/ORG: McMaster FHT, Stonechurch Family Health Centre
ABSTRACT: Monitoring the international normalized ratio (INR) is a key component of using Warfarin therapy effectively and safely. Traditionally, measuring an INR has involved routine visits to laboratories for venipuncture. Point-of-care testing is an effective alternative. By putting patient, practitioners and test results in the same place at the same time, they facilitate timely and proper patient evaluation and education and leads to improved patient satisfaction. Multiple studies have shown that a systematic approach to anticoagulation management, focused at the point-of-care, may increase the time patients are in range and reduce the risk of adverse events. In this presentation, we will highlight our RPN lead INR clinic and our experience with the development and ongoing logistics associated with a FHT-based point-of-care INR testing program. Our evaluation focuses on time in therapeutic range, patient satisfaction, and costs
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Patient Centred Access
2011 AFHTO conference presentation
PRESENTER (S): Margaret Tromp MD, CCFP, FCFP, FRRMS; Karen Brooks, RN, BScN, CRE
FHT/ORG: Prince Edward FHT
ABSTRACT: Patients who have primary care providers often perceive that they are unable to get timely appointments. Open Access is proposed as a response to this, but does not meet the needs of patients with chronic disease or those requesting health maintenance visits (well baby, prenatal, periodic health review). We are piloting Patient Centred Access, as described by Leonard et al (Ann Int Med 2003). We offer same day appointments to those with acute problems. We encourage those with chronic health issues to book follow up appointments in advance and they are seen jointly by the chronic disease nurse educator and the physician. The nurse educator also does lifestyle and preventive counselling for all patients. We also offer telephone appointments for those who do not need to be seen in person, usually to follow up tests or treatments. We are introducing web based medication refills and conveyance of normal test results.
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New Innovations and Best Practices in a FHT
2011 AFHTO conference presentation PRESENTER (S):
Karen Y. Brooks, RN, BScN, CRE, CDM Nurse Educator; Dr. Margaret Tromp, MD, CCFP, FCFP
FHT/ORG: Prince Edward FHT
ABSTRACT: “Left undiagnosed or untreated, chronic disease may also exact serious health and economic consequences from patients, families, and communities” (Every, 2007, p. 70). A FHT Family Physician and CDM Nurse Educator, have implemented aspects of The Edmonton Southside Primary Care Network Chronic Disease Model. This has brought the care of chronic disease back into the family physician’s office, where FHT team members contribute, but work to improve care and coordination of service is achieved within. We have customized this approach within our family practice. Highlighted is the MOHLTC’s seven themes of priorities for FHT’s, correlated with practice management of several chronic diseases. Utilization of upstream approaches to patient preventatives and screening is addressed. A patient may see the CDM Nurse Educator, the Family Physician, or both, and spend time discussing disease management. “This team approach frees the physicians to see more patients, to concentrate on those who need them and to take satisfaction from knowing they are doing a good job” (Spooner, 2007, as cited in Every, 2007). You won’t want to miss ‘The Pork’n Beans’ of CDM. Click here to view presentation.
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It Takes a Team
2011 AFHTO conference presentation
PRESENTER (S): Dr. Pauline Pariser, Physician Lead; Dr. Nadiya Sunderji, Consulting Psychiatrist
FHT/ORG: Taddle Creek Family Health Team
ABSTRACT: The Complex Medical Care Clinic is a partnership between the Taddle Creek Family Health Team and the Centre for Innovation in Complex Care at UHN. The clinic proactively addresses patients with complex co-morbid disease in order to improve their quality of care. Our consulting internist and psychiatrist, as well as professionals representing six disciplines, meet with the patient to develop a coherent treatment plan. The intended outcomes include reduction in emergency room visits and hospital admissions, reduction of the burden of care for the primary care provider and modeling synergistic problem solving for all health care providers. We will present a 20minute film of a clinic in action. Discussion will focus on the benefits of this service for the patient and family as well as for members of the team and the challenges in setting up this initiative for a family health team.
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Innovative Community Partnership Reduces ER Visits
2011 AFHTO conference presentation
PRESENTER (S): Katherine Campbell, BSc., MHS
FHT/ORG: Dryden Area FHT
ABSTRACT: An innovative program was developed to address senior community service needs providing the opportunity to reduce ER visits while focusing on supporting seniors in their home setting of choice. The Dryden Area FHT in partnership with Patricia Region Senior Services (PRSS) has developed a position that has evolved to assist in service integration through a Community Service Guide (CSG). The CSG attends hospital morning interdisciplinary meetings to discuss patient care within the site and visits with in-patients that may benefit from the FHT and PRSS programs. The CSG attends the ED and collects the referrals for the day which are then distributed for physician/NP follow-up. The CSG receives all referrals for the FHT and navigates the patient through the system. The seniors are then linked into the PRSS community programs for services as identified. In addition, the FHT has developed senior outreach clinics addressing caregiver burnout, education, medication reconciliation, treatment and chronic disease management/prevention.
Click here to view presentation.
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Emergency Department Visits
2011 AFHTO conference presentation
PRESENTER (S): Kirk Miller, Business Services Manager
FHT/ORG: Guelph FHT
ABSTRACT: Emergency departments see rostered patients for non-urgent care every day. Using acute care resources to process non-urgent visits is costly and impedes access for patients requiring urgent care. The WWLHIN has targeted a 10% reduction in CTAS 4 and 5 for hospitals in the region. The Guelph Family Health Team (GFHT) began a study of Guelph General Hospital (GGH) ED visits using a Learning community PDSA approach in March 2011. This presentation summarizes the methods for data collection, the process to present data to physicians, the collaborative work between GFHT and GGH and the strategies to achieve ED visit reductions.
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iPrep: Illness Prevention and Rehabilitation Program
2011 AFHTO conference presentation PRESENTER (S): Dr. Lori Teeple FHT/ORG: Bluewater Area FHT ABSTRACT: To assist participants to transform their lifestyle into one of healthy eating and exercise so as to achieve and maintain a healthier body weight and waist circumference to prevent or remit disease such as diabetes, hypertension, cardiovascular and cerebrovascular events. Target Group: Patients with BMI > 25 and Waist Circumference WC>102 cm (men) and WC> 88 cm (women). Program Objectives: 1. To help six women achieve a weight loss of 10% of their body mass in 12 months through a combination of education, mentoring and coaching utilizing advanced internet technology and weekly/bi-weekly visits. 2. The program will be evaluated on an annual basis by determining the number of females who have completed the 12 month program and reduced their weight and waist circumference, creating a healthier body and rehabilitating disease such as diabetes, hypertension and lipid disorders. The program will give the females encouragement to continue with their ongoing lifestyle changes. Each participant will be asked to complete and evaluation upon the completion of program. Evaluation: The iPrep program was started January 2011 and after six (6) months all participants have seen positive results and are encouraged about their lifestyle changes. The program is looking to expand the number of participants and include men. Click here to view presentation.
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Central Intake Triage
2011 AFHTO conference presentation PRESENTER (S): Dr. Kathleen Brooks, M.D., FRCP (C); Mary Jane McDowell, MSW FHT/ORG: Prince Edward FHT ABSTRACT: Within the services offered by the Prince Edward Family Team nowhere is critical decision making more important than at the point of entry to our mental health system. At a time when demand for mental health services exceeds available resources, the importance of effective triage at the front door takes on increased importance. Mental health agencies can sometimes be reluctant to divert scarce clinical staff, especially the more experienced, in order to perform the role of coordination, intake and triage. The PEFHT views mental health intake as a critical decision point in serving our patients with mental health issues and as such our first hire to the program was a social worker who assumed the title of mental health program coordinator. Experienced and effective coordination and triage provides for a cohesive, accessible and equitable use of a limited resource. Click here to view presentation.
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Pan-Canadian PHC Indicators
2011 AFHTO conference presentation PRESENTER (S): Brenda Tipper, M.H.Sc; Jennifer D’Silva, M.Sc. FHT/ORG: Canadian Institute for Health Information ABSTRACT: In 2006, the Canadian Institute for Health Information (CIHI) released 105 consensus and evidence-based pan-Canadian primary health care indicators (PHC) with which to measure and compare PHC at multiple levels across jurisdictions in Canada. This year CIHI is embarking on an initiative to identify and update two priority sets of indicators. One set will be oriented to policy-makers for use in assessing the performance of the primary health care system and another to providers of PHC for use in monitoring quality within their organizations and practices. While the project is currently ongoing, the list of identified priority indicators for PHC providers will be presented along with an overview of the changes made to update the indicators and lessons learned along the way. Potential data sources and intended use of the indicators will also be discussed. Click here to view presentation. (Hold cursor over top left corner of each slide to see additional background on the slide.) Click here to view the 15 indicators for which data can be drawn from EMRs that meet OMD spec 4.0.