The following presentations were made at the conference under this theme: Caring for patients with severe physical challenges “Speak Freely”: Counselling Drop in Clinic for Teens Developing a Patient-centred Primary Care Model for Vulnerable Older Adults How can Family Health Teams promote the health of people with developmental disabilities?: Practical steps that Teams can implement and extend to other special populations Introduction to Traditional Healing Practitioners/Knowledge and Methods: working with the Aboriginal Patient The Rural Geriatric Glue How the Enhanced 18-month Well-Baby Visit Has Led to Primary Care-Public Health Partnerships
Tag: Care for Specific Populations
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AFHTO 2012 Conference – Leveraging Technology to Improve Quality and Efficiency of Care
The following presentations were made at the conference under this theme: Realizing the Benefits of an EMR using a Maturity Model Framework Have your specialist come to you: Ontario Telemedicine Network Endocrinology Project Can a New EMR Tool Make Caring for People with Pain Easier Chronic Pain in Primary Care: Integrating Clinical Evidence into an EMR
- Integrating Clinical Evidence into an EMR – Project overview
- Opioid Manager
- Opioid Manager – Switching Opioids
An IT platform for seamless patient care through the healthcare system E Bridging the Gaps in Patient Care Benefits of EMR: Using your system to optimize the Management of Chronic Disease Med Tools: A Shared Clinician and Patient Education Resource MI OWL –Medical Interprofessional Open source Web-based Library – An informatics tool for enhanced practice and collaboration The New Frontier: Using home-based technology to coach patients on self-management skills
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Realizing Patient Goals
2011 AFHTO conference presentation PRESENTER (S): Andrea Petroff, BA Honours. Psych, M.I.R. (Masters of Industrial Relations), Executive Director; Claudia Mariano, NP-PHC, MSc Primary Health FHT/ORG: West Durham FHT ABSTRACT: Our commitment to our patients, our community, and to ourselves, to provide the best possible care for chronically ill patients, meant that we needed to take a cold, hard look at how we currently manage versus how we need to be managing this vulnerable patient population. Focusing first on patients with diabetes; we took a strategic approach to establishing FHT procedures and policies that can be easily applied in managing other chronic illness. These are the tactics we employed:
- Developed outcome and monitoring goals for all Type Two diabetic patients >18yrs
- EMR review of baseline patient statistics measured against goals set
- In-depth analysis of current resources, practice design, interprofessional collaboration and office efficiencies to identify gaps that jeopardized our goals
- Prioritized actions to address areas of concern and assigned personnel to lead change for improvement
Click here to view presentation.
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Chronic Respiratory Disease Management in the Community
2011 AFHTO conference presentation PRESENTER (S): Maria Savelle, RN, Certified Respiratory Educator, Nurse Educator FHT/ORG: Stratford FHT ABSTRACT: The Stratford Family Health Team Respiratory Clinic began as a pilot project in June 2009 after it was identified there was a need to assess and provide education regarding patient self-management of chronic respiratory conditions (COPD and Asthma). After a successful trial period, the SFHT Respiratory Clinic opened to all patients rostered with the 13 physicians of the Stratford Family Health Team. A specially trained registered nurse (COPDTrec, AsthmaTREC, SpiroTREC, TEACH trained) accepts referrals from physicians and Allied staff. Office spirometry is performed, and three champion physicians interpret the results to diagnose COPD and/or asthma. Pharmological management is decided between the Nurse Educator and the responsible physician. Follow up education regarding self-management of their respiratory condition is then provided either one-on-one, or in a group education session by the Nurse Educator. Follow up visits are arranged to ensure compliance with respiratory medications, assessing control/management of symptoms, and further patient teaching is provided to aid the patient in optimum self-management (Action Plans, Diary of symptoms, identifying need for reassessment in times of increased symptoms, etc.) If the patient is smoking, smoking cessation counseling is offered by the Nurse Educator as part of the follow up visit regime. The SFHT was a part of the QIIP COPD Learning Community, and was able to identify a number of patients appropriate for spirometry testing by way of screening with the Canadian Lung Health Test – a number of patients were newly diagnosed with lung conditions earlier, due to this screening process, and a number accepted smoking cessation counselling as a result of their screening and spirometry testing procedures. The Stratford Family Health Team Respiratory Clinic continues with the Nurse Educator assessing patients Monday to Friday, 8-4, where a constant flow of referrals for new patients continues in the busy clinic. The goal of the clinic is to identify respiratory conditions, ensure proper treatment according to current guidelines, teach patient self-management of respiratory conditions, in the hopes of reducing physician office and ER visits related to respiratory symptoms. Click here to view presentation.
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Practitioner Experience of an Interprofessional Integrated Primary Care-Based Programs For Seniors
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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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.