Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Harbour B
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Research/Policy (e.g. Presentation of research findings, analysis of policy issues and options)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. Describe the attributes of high-functioning primary care teams in Canada from the perspective of system, organizational, interpersonal and individual factors
2. Identify the barriers of developing high-functioning primary care teams
3. Discuss potential interventions and related assessment tools to improve team function

Summary/Abstract

Identified attributes of high-functioning primary care teams.

Presenters

• Phil Ellison, MD, MBA, CCFP, FCFP Vice Chair Quality – Department of Family & Community Medicine, U of T, Department of Family & Community Medicine, U of T
• Patricia O’Brien, RN, Department of Family & Community Medicine, U of T
• Mary-Kay Whittaker, BSc, Department of Family & Community Medicine

Authors & Contributors

• Monica Aggarwal, PhD QI Lead Policy & Research, Department of Family & Community Medicine, U of T

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Pier 2 & 3
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff

Learning Objectives

1. The process of self-reflection: how to evaluate your mental health patient population and program needs and use this information to streamline your provision of care
2. Practical techniques to address patient needs more quickly
3. Does everyone need individual therapy? What are the other options and how can you tell who should get what
4. How we drastically reduced our wait times and how this is helping our patients improve their mental health
5. How to implement and evaluate an effective screening/triage process, intake calls, single session treatment, on-going individual counselling and therapy groups

Summary/Abstract

Wait times reduced from 12 months to 2 months for individual therapy and from 12 months to 2 weeks for initial service provision (Single Session Tx and short-term follow-up). Urgent patients can now be contacted and often seen face-to-face within a few days.    Wait list reduced from 140 patients to 20 patients. Number of patients seen in 1 year increased from 300 to 350 and continue to grow. Pre/post outcome measures by patients showing a reduction in MH symptoms.

Presenters

• Matthew Ottaviani, MSW, RSW, LCSW, Connexion Family Health Team

Authors & Contributors

• Carmen Sadoway, MSW, RSW, Connexion FHT
• Dylan Myllymaki, MSW, RSW, Connexion FHT

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Harbour C
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

1. The evidence on the prevention of diabetes and metabolic syndrome from both the Diabetes Prevention Program and the Primary Care Diabetes Prevention Program
2. What the Group Lifestyle Balance program is and how successful it has been
3. Ideas for working collaboratively and successfully with health care providers within and outside of your FHT
4. Tips and strategies for working with community partners to run a successful lifestyle program
5. How you can implement this program into your community setting; including details about training, tools, and resources available to support using this program

Summary/Abstract

Outcome measures were based on the DPP goals of 7% weight loss and 150 minutes of moderate physical activity.

• 36% reached the goal of 7% weight loss, 51% reached a 5% weight loss by the end of the core phase
• Physical activity goals were reached and maintained throughout the core phase
• 76% completed the core phase and 45% completed total 22 session
• 24% dropout rate during the core, 31.1% dropout rate during the maintenance

These numbers mirror US statistics for the GLB program and would suggest we are reducing risk of DM and metabolic syndrome across the province.

Presenters

• Sarah Pink, RD, CDE, GLB Lifestyle Coach and Master Trainer, Mount Forest Family Health Team
• Diane Horrigan, RN, CDE, GLB Lifestyle Coach and Master Trainer, Mount Forest Family Health Team
• Paul Osadzuk, PT, GLB Lifestyle Coach and Master Trainer, Owen Sound Family Health Team
• Given Cortes, TRS, RMT, GLB Lifestyle Coach and Master Trainer, Assiginack (Manitowaning) Family Health Team

Authors & Contributors

• Dianne Bigby, Assistant Senior Policy Advisor, MOHLTC

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/17/2016
• Concurrent Session A
• Time: 2:30pm – 3:15pm
• Room: Pier 4
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. How to get started—identify your geographical area of interest for impact and what partners exist within that area who have an interested in Community Development. Open a discussion with your local public health unit and partners.
2. Coming together—steps to help get to know one another, what you do, what you’d like to do, understanding mandates and creating a service inventory to identify work that has commonality. Establish responsibilities, terms of reference (if needed), initiatives and defining objectives.
3. Sustainability—how to keep the collaboration alive and growing.

Summary/Abstract

Observations include:  There is a high degree of interest in fostering partnerships, supporting collective impact, reducing overlap with respect to the work of partners. Partnering on common programs such as healthy eating and physical activity allows for shared messaging, shared promotion, increased reached, and the ability to track impact across the region and individually. In addition, this strategy reduces confusion for the public and allows for a single evidence based message. Public Health resourcing (infrastructure and staffing) can be optimized to support the identification of population based priorities, to assist in the development of evidence based programs and support the delivery of common priority programs and services at the primary care level and to access funding to sustain collaborative efforts. Although it is too early to measure the collective impact of the individual initiatives identified the value of working collectively will at minimum achieve improved public health stewardship and create an environment for shared learning and support.

Presenters

• Nicole Dupuis, Director, Health Promotion Division, Windsor Essex County Health Unit
• Mark Ferrari, Executive Director, Windsor Family Health Team

Authors & Contributors

• Margo Reilly, Executive Director, Harrow FHT
• Pauline Gemmell, Executive Director, Essex NPLC
• Lisa Ekblad, Lead NP, VON NPLC Lakeshore
• Jennie Boyd, Manager, City Centre CHC
• Hardeep Sadra, Director, Windsor Essex CHC

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

Presentation Materials (members only)

Presentation Slides: MedREACH              

Learning Objectives

At the end of the session, participants will be able to:

1. Describe the health care needs and barriers of medically complex patients (MCP) being addressed by the MedREACH project
2. Describe the different components of the MedREACH project and how they work together to support the medically complex patient
3. Describe the preliminary results of the MedREACH project.

Summary

The MedREACH pilot project (Medical Rapid Education and Assessment for Complete Health) is a demonstration pilot funded jointly by the Ministry of Health and Long-Term Care and the Ontario Medical Association. The goal of MedREACH is to improve the overall health of the medically complex patient (MCP) by seeking to re-forge the therapeutic relationship between the MCP and their family physician and interprofessional team. MedREACH consists of three distinct yet coordinated health care delivery models:

• Primary MedREACH involving clinical nursing outreach to MCPs;
• Specialist MedREACH involving integrated health care delivery by specialists and allied health professionals at McMaster University Medical Centre; and
• Mobile MedREACH involving facilitated interaction between specialists and primary care providers enabling direct and timely consultation for patients with barriers to health care access in their family practice setting or home environment.

The MedREACH project aims to address current gaps in the following areas:

• Medical service provision for MCPs in the primary care and tertiary care setting in order to ensure more timely and coordinated care
• Existing silos of operation in primary and specialty care by building bridges for communication and partnership between primary care and specialty care.

This session will familiarize participants to the MedREACH project framework, how each component of the project was operationalized, and the program evaluation strategy with preliminary results.

Presenters

• Henry Siu, Physician, MedREACH Evaluation Lead, McMaster FHT; McMaster University, Department of Family Medicine
• Laurel Cooke, BES, BScN, RN, Nursing Program Manager, Hamilton FHT

Authors and Contributors

• Hamilton FHT:
  • Laurie Panagio
  • Janelle Kolenich, RN
  • Nicole Steward, MedREACH Project Manager, RN

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

Presentation Materials (members only)

The Vitality Interprofessional Team Approach to Food, Mood and Fitness

Learning Objectives

Participants will:

• Become familiar with a interactive lifestyle program for overweight or obese (BMI 26-40) patients facilitated by an interprofessional team including a RD, OT and SW with a focus on health and well being vs. weight alone
• Gain an appreciation of a patient-centered approach to program content and delivery
• Identify key outcome measures of success for a lifestyle program in primary care
• Access tools and resources to offer a similar program in your family health team setting.

Summary

With 25% of Canadian adults classified as overweight or obese and recent systematic reviews emphasizing the importance of offering structured behavioural interventions in primary care aimed at weight loss and adding small amounts of exercise to reduce risk of chronic disease, the Vitality Healthy Lifestyle program nicely aligns with current best evidence while meeting the needs of our patients. The 11 week lifestyle program offered at the McMaster Family Health Team uses a non-diet approach to educate and empower patients on healthy lifestyle choices to improve health outcomes and promote a small weight loss in a healthy, realistic way. Facilitated by a Registered Dietitian, Social Worker and an Occupational Therapist, participants have the opportunity to learn what influences their food, mood and activity patterns and practice cognitive behavioural strategies to manage emotional eating, eat more mindfully, reframe negative self talk, become more active, try different physical activities, develop action plans and achieve health goals. Patients choose topics of interest and activities they would like to engage in. Linkages with local community resources are explored to assist with managing future relapses. Patients are highly satisfied with this interactive, patient-centered approach that affords opportunities to access specialized advice from the right provider at the right time along with opportunities to learn from each other and become empowered to make positive life-style changes.

Presenters

• McMaster FHT:
  • Michele MacDonald Werstuck, RD MSc CDE Registered Dietitian and Diabetes Educator
  • Colleen O’Neill, OT Reg (ONT) Occupational Therapist
  • Miriam Wolfson, SW Mental Health Counselor

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (members only)

Presentation Slides: Telemedicine Impact Plus  

 (I) Telemedicine IMPACT PLUS (TIP): Bringing Inter-Disciplinary Team Resources to the Community

Learning Objectives

1. Demonstrate how Telemedicine complex care clinic can provide high-quality comprehensive care for medically complex patients and support community primary care
2. Model how to leverage FHT inter-professional skills to promote working to full scope of practice
3. Outline the efficiencies needed to offer this service via protected video-conferencing
4. Describe the opportunities and risks in extending FHT resources to community primary care
5. Demonstrate the value of this approach in coordinated care planning.

Summary

Telemedicine IMPACT PLUS is an innovative, proactive interdisciplinary model of care for serving complex patients and supporting their solo primary care providers (PCPs). TIP has been implemented across the Toronto Central LHIN offering clinics since 2013. Through TIP, both the complex patient and family physician are connected to an interdisciplinary care team over a one-hour consultation via secure videoconferencing technology. The teams leverage inter-disciplinary support from FHTs to focus on critical issues identified by patient, family and PCP. A dedicated TIP nurse facilitator, as care coordinator, provides pre- and post-clinic follow-up supports to all stakeholders. The model recognizes the “perfect storm” created by an aging demographic within a health care system founded on treating acute illness. Currently, disconnected serial consultations based on single disease entities do not reduce the burden of chronic illness for these patients nor provide coordinated care planning for their PCPs. TIP built upon the success of IMPACT PLUS, a Bridges evaluated inter-professional care model. By marrying the power of a skilled inter-professional team, including general internist and psychiatrist, to telemedicine technology, TIP provides one stop coordinated real-time care planning in the PCP office or at home. Evidence from the literature found that intensive inter-professional care succeeds in reducing health care costs with at least equivalent outcomes for complex populations. Preliminary results demonstrate high patient, provider and caregiver satisfaction with this model of care. Already the model has shown itself to be scalable with plans to spread TIP to 2 other teams within the Toronto Central LHIN. 

Presenters

• Taddle Creek FHT:
  • Pauline Pariser, Co-lead; Lead, Mid-West Toronto Health LInk
  • Sherry Kennedy, Executive Director
  • one of Shazmah Hussein, Victoria Charkow or Karen Finch, Registered Nurse
  • Jessica Lam, Pharmacist
• one of Jocelyn Charles, Chief of Family Medicine, Sunnybrook FHT, or Tia Pham, Physician Lead, South East Toronto FHT

(II) Blitzing Integrated Care for the Super Complex Patients

Learning Objectives

1. Recognizing the need for an inter-professional and primary care led team to address patients’ medical and social complexities.
2. The importance of starting a coordinated care plan with the patient physically present at the case conference with the inter-professional team.
3. The importance of having primary care, community agencies (CCAC and CSS), and specialists such as Psychiatrists working collaboratively towards patient’s care coordination and follow-up, and for the patient to have an individualized care team.
4. The impact of using Hospitalization Admission Risk Monitoring System (HARMS-8) to identify complex patients in primary care, and who are then recipients of an electronic coordinated care plan. 5. Share results of patient/caregiver experiences via patient/caregiver stories.

Summary

East Toronto Health Link has developed an innovative approach to address the needs of 1-5% complex patients who have significant social and medical concerns. ETHeL is trying to demonstrate that high risk hospitalization (using HARMS-8) justifies increased use of resources such as Complex Care Plan Management (intensive care management with dedicated follow-up and requiring an inter-professional team approach maximizing scopes of practice, and integration of multiple sectors) . CCT is composed of a small core team of hospital based programs currently operating within ETHeL (Virtual Ward, Geriatric Emergency Medicine (GEM) Nurse, Telemedicine Impact Plus (TIP)-RN, Primary Care Physicians, specialists, as well as a CCAC care coordinator), AND a community-based team consisting of multiple sectors including community support services, mental health, addictions, housing, and Toronto Paramedics. Primary target population for CCT intervention is the frail elderly with complex medical/social needs residing in ETHeL’s catchment area; however, any individual identified by CCT members as complex and in need of coordinated care planning, is supported, though a case conference might not be the desired or effective mechanism in all cases. Some of the key primary characteristics that qualify an individual as ‘complex’ and who would require care coordination via CCT’s case conference are as follows:

• At least one (preventable) hospital inpatient admission and/or multiple (preventable) emergency department visits in the last 12 months (mandatory requirement) and at least two of the following:
• 55 years and older (65 years old and over is ideal except when individuals have conditions that deem them to be frail and elderly)
• Unattached to primary care or ‘poorly’ attached to primary care
• Physical immobility including staying upright, maintaining balance and walking resulting in falls, immobility or delirium
• Multiple/chronic co-morbidities including dementia
• Mental health and addiction complexities leading to barriers to access care
• Polypharmacy
• High caregiver burden and stress

Presenters

• Thuy-Nga (Tia) Pham, MD, Physician Lead, South East Toronto FHT and Toronto East General Hospital; Assistant Professor, University of Toronto DFCM
• Richard Doan, MD, FRCPC, Psychiatrist, South East Toronto FHT and East Toronto Health Link

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

Presentation Materials (members only)

An Improved Tool for Meaningful Program Planning

Summary

Both FHT/NPLC Executive Directors and staff in MOHLTC’s Primary Health Care Branch have identified the need to improve the ministry’s template for reporting on program plans (known as “Schedule A” in the FHT contract and “Schedule E” in the NPLC contract). A joint working group from the MOHLTC Primary Health Care Branch and AFHTO will be working over the summer to improve this Schedule as a useful tool for program planning and reporting. This workshop will include tips from the working group on how to do effective program planning and evaluation, ministry needs for reporting, and how to use the reporting tool effectively.

Presenters

• Bryn Hamilton, Provincial Lead, Governance and Leadership Program, AFHTO
• Representative from Primary Health Care Branch, MOHLTC
• Representative from AFHTO members on the joint MOHLTC-AFHTO working group Summary

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

Presentation Materials (members only)

Strategic Approaches to Population Health Planning

Learning Objectives

This presentation will demonstrate a strategic, population-health approach to program planning and QI initiatives. Participants will gain an increased knowledge of how to develop an evidenced- based, patient-informed, comprehensive health promotion plan. They will understand and take home practical tools that help to systematically identify needs, inform decision-making, and support program planning and evaluation processes. This presentation will discuss the benefits of embracing patient feedback, creating community partnerships, and developing meaningful evaluation tools. Participants will be able to identify aspects of building collaboration, and gaining buy-in and support from key stakeholders. Also, it will highlight the importance of utilizing this approach when creating the health promotion plan and for FHT wide organizational improvements.

Summary

FHTs face many competing priorities and interests for program planning. How can they respond to the needs of FHT patients and the broader community, while considering an evidence-based approach to planning in an efficient and effective manner? This presentation will highlight systematic approaches to the annual health promotion plan and QI initiatives within a small and medium sized FHT. There will be two approaches and tools presented to assess community needs and identify top priorities for action. Windsor FHT will review the steps they take throughout the annual program planning process including: reviewing evaluations from the previous year, analyzing targets met and unmet, gaining and incorporating patient feedback regarding program and service wants and needs, fostering existing partnerships and creating new ones, examining and comparing chronic condition priorities and statistics across the country, province, locally, and within individual FHT’s, and developing evaluation tools. Summerville’s Chronic Disease Management Committee (CDMC) developed a systematic tool that considered the top 10 chronic conditions within the FHT against various criteria: 1) prevalence of condition, 2) health care providers’ perspective, 3) patient feedback, 4) complexity of care for patients and providers, 5) probable impact of a program on health outcomes, 6) existing resources and care gaps, at Summerville and in the community, and, 7) feedback from the MOHLTC which helped inform the population health measures within Summerville FHT’s QIP. At Family Health Teams we work in interdisciplinary teams; Health Promotion planning and activities should be no different. It is crucial to engage the team, community members, organizations and businesses, in order to make health promotion activities successful and sustainable. Drawing on internal resources, statistics, and utilizing external partners is key in developing a plan that meets the needs of your FHT and local community.

Presenters

• Chantelle Cecile, RN, MN, BScN, Manager of Quality, Experience and Patient Safety, Windsor FHT
• Nadya Zukowski, Health Promotion Specialist, Summerville FHT

Authors and Contributors

• Christine Wellington, Registered Dietician, Windsor Family Health Team

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Navigating by the stars? Try GPS. How two FHT Leaders used Brain Research to Increase Team Collaboration and Physician Engagement

Summary

• An essential challenge of leaders within Family Health Teams is to create the conditions for high functioning individuals to reorganize into higher functioning, complex and adaptive teams. To do that successfully requires navigating the invisible barriers to engaging others. In this workshop we will demonstrate how understanding the social wiring of the brain can lead to powerful strategies to motivate and engage others. We will present examples of how targeting these social drivers of behaviour led to increased physician engagement and improved team performance in 2 Family Health teams. You will leave with practical and simple tools that you can use to lead your team to a more collaborative and effective level of functioning.

Presenters

• Penny Paucha, Principal, Instincts at Work
• Mary Atkinson, Executive Director, North Perth FHT
• Barb Major McEwan, Executive Director, North Huron FHT
• F Elyse Savaria, MD, Lead Physician, Owen Sound FHT

Learning Objectives

• Identify leadership and governance challenges that derail the effectiveness of FHT’s Identify hidden, structural barriers that prevent effective collaboration Highlight key leadership skills Learn about the social drivers of team behaviour. Learn new strategies to reduce conflict and increase engagement. Develop an action plan to more effectively engage others.