Tag: Concurrent Sessions

Theme 5. Advancing manageable meaningful measurement

Presentation Materials (members only)

Leveraging convergence of healthcare delivery, business dynamics and technology advancements to advance collection and utilization of meaningful COPD patient data Beyond an electronic paper file – Optimizing your EMR for population-based measurement Data Tracking: Creating Your Own Path How do you make the most of your EMR? Six teams pitch their methods for optimizing custom queries to gather precise, meaningful data. Join moderator/”dragon” Darren Larson of OntarioMD as he presides over this lively, fast-paced session.

(I) Quality Based Improvements in Care (QBIC): How EMR Data can Transform Care

Presenters

• Centre for Family Medicine FHT:
  • Dr. Mohamed Alarakhia, Director, eHealth Centre of Excellence, Family Physician, eHealth Centre of Excellence
  • Ted Alexander, MA, Research Associate, eHealth Centre of Excellence
  • Masood Darr, Technical Specialist, eHealth Centre of Excellence
  • Kathryn Flanigan, Nurse Practioner

Presentation Materials (members only):

• To view the presentation slides, click here.
• Materials will be posted following the 2015 Conference.

Learning Objectives

1. Attendees will learn how to use EMR templates with simple clinical decision support tools to facilitate care of patients
2. Attendees will increase awareness of enhanced use of EMR to identify patients with chronic conditions
3. With the use of structured data in EMR, attendees will be introduced to a model that can help predict at-risk patients in need of additional support.

Summary

Quality Based Improvement in Care (QBIC) is based on the understanding that optimizing primary care’s use of electronic medical records (EMRs) is essential to supporting improvements in our health care system and achieving positive health outcomes at the patient, practice and population levels. With support from an eHealth coach and Information Technology expert, 91 primary care clinicians in 6 primary care organizations were able to enhance quality improvement, chronic disease management best practices and information management. Furthermore, after clinicians were encouraged to document chronic diseases in a structured way, reminders were created in 2 pilot Family Health Teams. After six months, data was evaluated linking workflow to patient outcomes using these reminders. Furthermore, a model was created using structured EMR data to identify at-risk patients who require further support. This advanced use of the EMR will be critical as primary care organizations use system-level strategies to achieve higher quality care while reducing costs (e.g. Health Links patients).

(II) Data Tracking: Creating Your Own Path

Presenters

• Burlington FHT:
  • Melonie Mawhiney, Clinic Manager
  • Caitlin Grzeslo, Program Co-ordinator

Presentation Materials (members only)

• Materials will be posted following the 2015 Conference.

Learning Objectives

The key learnings are how to approach data tracking to work around EMR limitations. With some ‘out of the box’ thinking, you can customize data measurements based on unique programs and services, IHP roles etc. This improves program management as well as eliminating manual tracking for Ministry reports. It provides efficient and effective reporting of statistics and performance measures for the AOP, QIP and quarterly reports. Chronic Disease Management also benefits from queries and other reports developed through QIDSS support by identifying specific health issues in patient charts. Data integrity is also improved through comparative analysis.

Summary

“You can’t manage what you can’t measure” That was our mantra in developing our data tracking system. We will describe how we used ‘fake’ billing codes and unused data fields to measure patient encounters by type and by program. Through innovative thinking, we found ways to extract data from our EMR (Oscar) that did not have the specific functionality we wanted, allowing us to measure what we wanted, not just what was available. With support from our QIDSS, we developed specific queries for programs based upon the performance indicators in our QIP. We can measure time spent by IHP on various tasks and programs with the next step being a ‘Return on Investment’ analysis with the return being measured by patient outcomes. We are able to better manage our Chronic Disease preventions and target patients that would benefit from one of our programs. Our QIP has significantly improved through allowing us to set realistic targets that can be justified by statistics. We can now measure the QIP performance indicators efficiently, effectively and most importantly, accurately.   Given the Ministry’s emphasis on providing “solid evidence of the value of FHTS/NPLCs and team-based care” our FHT can demonstrate this is a quantifiable versus qualitative manner. 

(III) Beyond an Electronic Paper File – Optimizing Your EMR for Population-Based Measurement

Presenters

• Partnering for Quality, South West CCAC
  • Rachel LaBonte, Program Lead
  • Gina Palmese, eHealth Coach

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

Participants will:

• gain a shared understanding of challenges that exist in optimizing the use of EMRs in primary care settings;
• gain an understanding that improving the use of basic/intermediate functionality is often a prerequisite for using intermediate/advanced features (e.g. queries and reports depend on good data integrity, structured and searchable data) and;
• learn a few tips/tricks to help them optimize the current use of their EMR and next steps to population-based care (multiple EMRs will be discussed).

Summary

With 80% of health care encounters occurring in primary care settings the vast majority of patient data is collected and managed at the primary care level and the transformative change to be undertaken will be reliant on information management supports and tools. Not all users are using their EMR to its fullest potential. Through the results of the Primary Care EMR Needs Assessment, primary care physicians, nurse practitioners and physician assistants have demonstrated that they are comfortable using EMRs for episodic care, however challenged to shift EMR use for practice level management. Through the optimization of EMR use for practice level management, primary care practices will be positioned to achieve positive health outcomes at both individual and population levels, leveraging the full benefits of EMR adoption. This further provides a significant opportunity to optimize the use of EMRs for chronic disease prevention and management and delivery of quality patient care. This presentation will not only outline high level results of the EMR needs assessment but will also highlight the rest of the journey towards population-based care. NOTE: This presentation will cover multiple EMR systems. 

(IV) Leveraging Convergence of Healthcare Delivery, Business Dynamics and Technology Advancements to Advance Collection and Utilization of Meaningful COPD Patient Data

Presenters

• Couchiching FHT:
  • Stephanie Kersta, MSc, Health Promoter
  • Greg Armstrong, MD, Lead Physician
  • Stephen Graper, President, Healthcare Together Ltd
  • Doug Kavanagh, Founder, Cognisant MD

Authors and Contributors

• Liz McCormick, IT Manager, Couchiching FHT

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

• Become aware of an optimal healthcare delivery method and process to:
  • Integrate a multi-disciplinary, cross functional team into a QI initiative that will optimize COPD population management (prevention and treatment)
  • Use patient generated health data to identify patient needs and resource requirements
• Understand key insights into developing strategic business partnerships with complimentary core competencies and resources to enable FHT’s to achieve CDM (chronic disease management) goals
• Increased awareness of technology advancements to enable rule based processes to optimize efficient and timely collection of patient self-reported clinical insights with direct Telus PSS EMR integration.

Summary

Couchiching FHT (CFHT) insights demonstrated a need to enhance screening of its COPD population to achieve prevention and management goals. It sought an innovative way to engage patients, efficiently collect key COPD clinical insights that could be leveraged in the EMR. CFHT also recognized the need for an internally aligned team, to leverage strategic partnerships and to adopt new technology to ensure success. Through the use of a cloud-based clinical platform, the CFHT is now enabled to use rule-based technology to collect smoking status information, promote smoking cessation programs, inquire about the patient’s desire to quit smoking, complete the Canadian Lung Health Test screening tool and the MRC dyspnea scale. Additionally, email consent and address collection occurs. All of this data is self-reported by the patient, can occur in just a few minutes and is immediately integrated directly into the patient’s EMR. This standardized data entry can be used to identify patient’s needs, direct internal resources (ie. program referral, spirometry required, bill for smoking cessation…) and communicate cross functionally through customized clinical notes. This presentation will:

• Describe current vs desired status of the CFHT COPD population registry and management
• Present an overview of the current COPD data collection processes and gaps compared to processes utilizing new technology
• Identify the value of developing strategic partnerships with private industry that can leverage technology advancements, therapeutic insights, project management and critical resources.
• Highlight the benefit of a multi-disciplinary, cross-functional team with physicians and staff aligned on the QI initiative.

 

(V) Leading Edge Custom Queries and their Applications Across Ontario

Presenters

• Hope Latam, QIDSS, East Wellington FHT
• Windsor FHT:
  • Brice Wong, QIDSS
  • Sara Dalo, QIDSS

Authors and Contributors

• Michelle Karker, ED, East Wellington FHT

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

Participants will gain an understanding of the different types of data in the EMR, and learn how structured data leads to higher data quality. They will be able to take home knowledge of different data extraction tools, in particular the Telus PS custom queries for extracting data from the custom forms. Participants will also learn the various ways FHTs are using the extracted data to guide program development, track staff utilization, and improve patient care. Finally they will gain knowledge about the AFTHO QIDSS program and how it facilitates the development and sharing of data management concepts and tools to FHTs across the province.

Summary

The presentation will introduce the various types of data in EMRs; free text, stamps, encounter assistants and custom forms. It will have a focus on custom forms and how they are ideal for entering structured data into the EMR. We will then discuss the challenges we faced getting data out of the custom forms. This lead to the development and deployment of the custom queries across Ontario with the funding, guidance, and support from AFTHO. The presentation will then review how East Wellington FHT has used the queries to pull valuable data for a wide range of applications. Other QIDSS will then discuss how they have implemented the queries at their FHTs, and what they are using them for. We’ll conclude with the impact this new data has had on the FHTs, and what others can do to use and apply this same methodology.  

(VI) Optimizing EMRs to Accurately Identify COPD and other Chronic Disease Patients

Presenters

• Sara Dalo, QIDSS, Amherstburg | Central Lambton | Chatham-Kent | Harrow Health Centre | Leamington & Area | Rapids | Thamesview | Tilbury District | Windsor FHTs
• Brice Wong, QIDSS, Amherstburg | Central Lambton | Chatham-Kent | Harrow Health Centre | Leamington & Area | Rapids | Thamesview | Tilbury District | Windsor FHT
• Thiv Paramsothy, QIDSS, East GTA FHT | Scarborough Academic FHT | West Durham FHT | Carefirst FHT

 

Authors and Contributors

• Greg Mitchell, Knowledge Translation and Exchange Specialist, QIDS Program, AFHTO
• Chad Moore, QIDSS, North Simcoe FHT
• Allison Palmer, QIDSS, Brockton & Area FHT
• Sandra Taylor Owen, QIDSS, Central Hastings FHT
• Hope Latam, QIDSS, East Wellington FHT                                              

 

Presentation Materials (members only):

• Materials will be posted following the 2015 Conference.

Learning Objectives

This initiative will allow EMR users to reliably generate a list of patients with COPD. Patients already coded/documented as having COPD can be filtered out, so those patients unclearly identified can be reviewed by the primary provider and properly documented in the EMR. EMR- specific instructions and other resources are available for FHTs as they undergo the process of making data quality improvements in their EMRs. Although this presentation is specific to COPD, the development of additional comprehensive queries, for top chronic conditions (ie. diabetes, hypertension, dementia…), are currently underway and will be available in the near future.

Summary

Approximately 12% of Ontarians have COPD and is a leading cause of hospitalization and death in Canada. Primary Care is continuously looking for ways to identify patients living with COPD and linking them with appropriate services that will help them manage their health to reduce ED visits and hospitalizations, and improve overall quality of life. The presentation would include a live demonstration and clearly outline processes around data clean-up initiatives that will optimize the EMR. There will also be next steps around which stakeholders in the community setting can provide services or support for patients identified with having COPD, such as OLA. The Algorithm Project Team is currently in the process of working on the next search for Diabetes and there will be more to come. The data generated could also assist with improving the accuracy and ease of Ministry reporting. This initiative has been broadcasted on several weekly QIDSS calls and professional development sessions, but the AFHTO conference would be an ideal opportunity to share it with members abroad since many can benefit from this search. A significant number of FHTs across Ontario have reported they do not have a reliable COPD registry, which is a drawback since registries allow for identification and tracking for patients with specific conditions, facilitate delivery of health care and track their progress. This solution can allow FHTs to manage their patients effectively and help overcome fragmented care and improve coordination services.

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

Presentation Materials (members only)

Project ECHO – Managing Complex Chronic Conditions without Sweating Bullets

Learning Objectives

Understand the basic ECHO principles:

• Leveraging telemedicine to move knowledge, not people and create a community of practice for continuing professional development
• Multiplying specialist expertise by connecting an expert team (HUB) with multiple primary care providers (SPOKES)
• Using case-based learning
• Sharing best practices to improve quality of care for complex patients.

Identify how ECHO addresses specialist shortages in rural and urban settings, raises primary care providers’ skills to their maximum scopes, and enhances interprofessional team performance. Review the MOHLTC-funded ECHO Ontario Chronic Pain/Opioid Stewardship demonstration project and other ECHO’s under development (Mental Health/Addictions, Hepatitis C, Rheumatology).

Summary

In 2003, Dr. Sanjeev Arora, a New Mexico hepatologist, developed ECHO (Extension for Community Healthcare Outcomes) to reach > 30,000 hepatitis C patients requiring treatment. By holding weekly video-conferencing rounds, distant primary care providers (SPOKES) managed their own hepatitis C patients with the support of an interprofessional expert team (the HUB). Cure rates were identical in both groups (NEJM 2011 364:23). There are now >20 complex chronic disease ECHO projects throughout the US and other countries. In April 2014, the MOHLTC announced funding for the first Canadian ECHO replication: ECHO Ontario chronic pain/opioid stewardship. ECHO sessions start with brief didactics on chronic pain management. Next, a de-identified case is presented by a community SPOKE following a standard template. Their “virtual” colleagues ask questions and provide advice first, with HUB experts acting as “guides on the side.” SPOKES’ knowledge and comfort levels rise and HUB experts also learn from the SPOKES. Hands-on “boot-camps” teach specific skills (the chronic pain sensory exam, myofascial pain, challenging conversations, and managing mental health problems or aberrant opiate behaviours). Curriculum themes include pain fundamentals, opioids and addictions, management (mind, movement, self-management, and medical) and special topics (e.g. medical marijuana). This presentation will educate attendees on the basic principles of ECHO, demonstrate how the model works, and discuss promising ECHO programs under development in Ontario for other complex chronic conditions such as Mental Health/Addictions, Hepatitis C, and Rheumatology.

Presenters

• Ruth Dubin, PhD, MD, CCFP, FCFP; Project ECHO Co-Chair, Asst Professor (adj), Dept of Family Medicine, Queens University; ECHO Ontario
• Leslie Carlin, PhD, Medical Anthropologist, University of Toronto
• Allison Crawford MD, FRCP, Medical Director Northern Psychiatric Outreach Program; Telepsychiatry Centre for Addiction and Mental Health; CAMH
• Other co-presenters TBD

Authors and Contributors

• ECHO Ontario
• Andrea Furlan, MD, PhD, University of Toronto
• Paul Taenzer PhD, Psychologist
• Jane Zhao MSc, Research Coordinator
• Eva Serhal, MBA, Manager, Telepsychiatry, Centre for Addiction and Mental Health

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

Presentation Materials (members only)

Integrated LTC: An Innovative Initiative to Reduce Potentially Avoidable Hospitalizations for Seniors

Learning Objectives

The objectives are to share lessons learnt from the pilot project including:

1. Establishing shared milestones/goals with stakeholders in acquiring real-time data to inform rapid-cycle changes and perform program evaluation.
2. Diversifying activities decreases risk of over-relying on a particular strategy – Program resilience is a key requirement for success. Accordingly, we have developed parallel activities (i.e. Nurse Practitioner support, telemedicine case conference rounds, knowledge translation materials, and quality improvement), in order to support our pilot LTC homes.
3. Impact of pilot:
   • Potential for healthcare sustainability – Estimated cost savings approx $70K (In the first 10 clinical days, the NP was able to change LOC for 6 of 13 residents, eliminating future ER transfers for the subsequent 6 months).
   • Resident outcomes – improved pain and symptom management, in-house palliation (avoiding stressful transfers at the end of life, respect for wishes and best interests
   • Support for families – goals of care enables proactive care plan development.

Summary

Seniors suffer from increased morbidity and mortality when transferred to hospital versus receiving care in their place of residence. In long-term care (LTC) 25-55% of transfers to the Emergency Room (ER) are potentially avoidable and a 15% reduction in Ontario could save over $76 million per year. US & UK QI initiatives have shown 17-25% reduction in ER transfers. The Integrated Long Term Care (ILTC) program, recently featured in the Ontario Medical Review (April 2015), is composed of 3 pillars – capacity building, access to specialist consults, and acute care provision. Juxtaposed to the supporting evidence for the program, there have been some challenges in the first year of implementation. These include identification of a target population, nurse practitioner recruitment and retention, competing demands for staff on the floor, need for palliative care training for front line staff and family’s insistence of ER transfer. Each of these challenges has an associated mitigation strategy which will be discussed during the presentation, as will next steps for the program.

Presenters

• Candy Lipton, Vice President, Operations, Sienna Seniors
• Irene Ying, MD, Palliative Care Consultant, Sunnybrook Health Sciences Centre; Assistant Professor, University of Toronto DFCM

Authors and Contributors

• Joe Pedulla, CHE, RRT, ACP MHSc, BASc, BSc
• Candace Tse, MHSc
• Jason Xin Nie

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (members only)

Collaborative Practice – Messy, Time-Consuming and Worth It.

Learning Objectives

To describe our Family Health Team experience developing and implementing a new interprofessional team process for complex medical patients identified through Health Links and older adults within the TAPESTRY study. We will show the participants how new eyes on a patient can develop new solutions and strategies and expand the ability to provide a preventive health care plan.

Summary

McMaster Family Health Team is an Academic Family Health Team located in Hamilton, Ontario with two sites serving over 31 000 patients. Our broad-based interprofessional team collaborates to maximize primary health care delivery and educational opportunities. We currently provide placements for 81 family practice residents and interprofessional learners. TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a twelve-month randomized control trial that fosters optimal aging for older adults living at home using an interprofessional primary health care team delivery approach centering on meeting a person’s health goals with the support of trained community volunteers, system navigation, community engagement, and use of technology. We are the lead organization for one of three Hamilton Health Links. Health Links targets individuals who use the health care system the most, particularly the use of the emergency department and frequent hospital admissions. The intent of the program is to change the way this population receives health care, driven by the development and implementation of coordinated care plans, and utilizing the insights learned to advocate for system-level change.   By targeting specific at-risk populations for more intensive care planning, we uncover significant health and social issues. When these issues are addressed by the interprofessional team before they become crises, we can shift our focus to health promotion and prevention. The energy created when like-minded professionals work collaboratively is amazing and motivating. Through this process, we have developed greater insight into the scope and skills of our team members to enhance the quality of care of our patients.

Presenters

• McMaster FHT:
  • Kiska Colwill, Clinical Pharmacist, Assistant Clinical Professor
  • Martha Bauer, Occupational Therapist
  • Michael Spoljar, Nurse Practicioner, Assistant Clinical Professor
  • Dan Edwards, RSSW, System Navigator
  • Laura Cleghorn, Research Coordinator TAPESTRY, School of Nursing and DFM

Authors and Contributors

• McMaster FHT/McMaster University Department of Family Medicine:
  • Betty Delmore, Nurse Practictioner, Assistant Clinical Professor
  • Dale Guenther, MD, co-director, Professor
  • Doug Oliver, MD, Associate Professor
  • Glenda Pauw, Registered Dietitian, Assistant Clinical Professor
  • Jessica Peter, MSW, Research Coordinator, TAPESTRY & MedREACH

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

Presentation Materials (members only)

Presentation Slides: Moving Gestational Diabetes Care into the Community.

Learning Objectives

Participants will learn about the successful and seamless transitioning of the Gestational Diabetes program from a hospital based model of care to primary care. During our presentation, we will highlight the transition process from start to finish and will elaborate on key aspects that made it a success. We will review our training strategies for new staff, referral process and evaluation of our program. We will conclude our presentation with opportunities and aspirations to continue to enhance our program to continue to serve women with Gestational Diabetes in our region.

Summary

Careful planning with all stakeholders was necessary for the successful transition of the GDM program from GGH to DCG. We plan to outline our processes that promoted a coordinated health care experience for women in Guelph with GDM. Perhaps the most crucial element to be elaborated during our presentation is ongoing communication with stakeholders including face–to- face meetings, shadowing of care, training of staff and sharing of knowledge. Appropriate training of DCG staff was supported by GGH, DCG and ongoing devotion to professional development. DCG’s close working relationship with the Endocrinologists in Guelph also promoted collaborative patient care and inter-professional development. In addition, we are also fortunate to have Registered Kinesiologists and Mental Health Counsellors on our DCG team to help support women with GDM, which is unique to community programs. Presentation highlights will include program flow process, resource allocation, educational strategy and expansion. The results of our one-year transitional evaluation outcomes will be shared and of course would not be complete without a review of lessons learned and next steps.

Presenters

• Diabetes Care Guelph, Guelph FHT:
  • Sarah Duff, BScN RN CDE, Clinical Coordinator
  • Lee Kapuscinski, MSc RD CDE
  • Julie Goodwin, BScN RN CDE

Authors and Contributors

• Jess Voll, Health Promoter, Guelph FHT

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

Presentation Materials (members only)

Presentation Slides: Reaching out to Adolescents in the Community.

Learning Objectives

At the end of this workshop, participants will have the tools to build their own Adolescent Outreach program. Specific learning goals for this workshop include:

1. How to engage local high schools and build relationships with them
2. Create a program that is aligned with the school’s curriculum
3. Create a dynamic interprofessional team to deliver your program
4. Link with local Adolescent Psychiatry / Mental Health professionals
5. Incorporate learners and teaching in this model
6. Evaluate your program
7. Helpful resources, links and services.

Summary

The Adolescent Outreach Program was created in 1988 to allow adolescents in our community an opportunity to ask questions and have their health concerns addressed by physicians in a confidential and non-judgmental setting. The program was also aimed to increase Family Medicine residents’ exposure to the health issues and concerns facing adolescents, a group that traditionally does not visit their Family Physician regularly. In 2011, with the establishment of Sunnybrook Academic Family Health Team, interprofessional teams consisting of a physician, residents, dietitian and social worker as appropriate started visiting local high schools to provide education on topics such as mental health, sexual health, body image etc. Each session is approximately one hour in duration, with approximately 20 – 25 students in attendance. Students have the opportunity to submit written questions anonymously and ask questions directly on pre-identified topics. Teams led by residents use various interactive methods such as games/quiz/small group activities to engage adolescents. With information technology available at finger tips of adolescents, it’s necessary to have a secure platform to provide correct health education early. Therefore, primary care involvement in Adolescent health needs to be increased across the province. Our program is one such example of platform to educate and promote health for adolescents. This session will outline the process of creating a formal interprofessional Adolescent Outreach program in a Family Health Team, whether it be in an Academic setting or not. We will share our best practices as well as lessons learned since the establishment of the program.

Presenters

• Sunnybrook Academic FHT and University of Toronto DFCM:
  • Dr. Purti Papneja, MD, CCFP / Staff Physician, Co-Program Director
  • Dr. Anne Wideman, MD, CCFP / Staff Physician, Co-Program Director

Authors and Contributors

• Ingrid Wirsig, BA

 

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

Presentation Materials (members only)

HERSTORY Peer Directed Group Exercise Programs Improving Clinical Outcomes Group medical visits, including peer-led and peer-facilitated exercise groups, and care-based focus groups, are emerging as an efficient and effective way to care for patients with complex needs. Four teams describe how they have implemented group visits and share their results.

(I) HERSTORY: An Innovative Group Model for Mental Health Care Using Peer Facilitation and Patient Co-design

Learning Objectives

WHAT MAKES A PATIENT COMPLEX? The Bridgepoint FHT would like to present an approach for dealing with a complex and underserved population- those with a past history of sexual childhood trauma. In this interactive presentation you will learn about the impact of this model, be provided with the tools to spread this model to your FHT and hear directly from the voice of patients and peer facilitator.

Summary

The Bridgepoint FHT in partnership with our patients have developed a cutting edge women’s trauma program entitled “HERSTORY”. The current community wait times for referral to trauma therapy are measured in YEARS. In order to respond better to our patient needs we developed an inter professional group model of care using focus groups, peer leadership and ongoing patient and provider feedback. This presentation will illustrate our process, review our outcomes both qualitative and quantitative, provide insights into the challenges and victories of this unique group and allow the audience to hear directly from our patient representative and peer facilitator.

Presenters

• Bridgepoint FHT
  • Lora Judge, MSW,RSW
  • Lora Cruise, Medical Director

Authors and Contributors

• Christine Gordon

(II) Shared Medical Appointments: The Why, the How, the Impact

Presentation Materials (members only)

• Materials will be posted following the 2015 Conference.

Learning Objectives

• Summarize SMAs – what they are, evidence for their use.
• Describe our process to initiating and adapting SMAs in busy practices -listen to/hear experiences of SMA participants (practitioners and patients).

Summary

Shared Medical Appointments are an exciting and innovative way to provide care to patients with chronic diseases. Our interdisciplinary teams introduced Shared Medical Appointments (SMAs) to patients living with diabetes in 2012. An SMA is a 90 min appointment held simultaneously with 5-10 patients and 2 providers in an interactive visit. All parameters of diabetic care are monitored as with any individual diabetic visit, patient questions are addressed by both peers and providers and true collaboration is encouraged between patient and health care professionals. Participants (providers and patients) experiences will be highlighted in this presentation. 

Presenters

• Hamilton FHT:
  • Anneli Kaethler, MSc, RD, CDE
  • Cornelia Mielke, BSc, MD, CCFP

Authors and Contributors

• Hamilton FHT:
  • Catherine Bednarowski, Clinical Pharmacist, CDE, Hamilton FHT
  • Sheilah Lamb, MD
  • Barbara Teal, MD
  • Robert Kerr, MD

(III) Peer-Directed Group Exercise Programs Improving Clinical Outcomes

Learning Objectives

Attendees will learn about how building group exercise programs with peer co-leaders and patient directed educational discussions not only cn affect A1c, BMI, BP and MaxMETs in a population with metabolic syndrome or diabetes, but also improves patient attitude towards being physically active. The program leaves participants confident and prepared to maintain activity levels after completion. This model increases patient independence and thrives off of group cohesion and the support of peer co-leaders. In addition, attendees will learn how to implement similar programs with varying resources in their own community.

Summary

Supervised group exercise programs have been proven effective in improving outcomes in patients with diabetes. At the Guelph FHT we have implemented group exercises classes that incorporate peer co-leadership and patient directed educational discussions. The program runs on a rotating basis twice per week for 12 weeks. Participants complete cardio, strength, balance, and flexibility activities during each session. Upon completion, patients have the option of undergoing training to become peer co-leaders. The program’s goal is to improve outcomes (a1c, BP, BMI, WC, lipids, MaxMET) for people with diabetes and metabolic syndrome and increase physical activity levels and leave patients confident with their ability to maintain after program completion. Results are collected and analyzed in an ongoing basis. As of April 2015, average days completing cardio exercises increased from 1.8 to 4.5 and resistance training from <1 to 3.5 days. Perception of exercise improved during the program and 90% of graduates believed they had attained the necessary confidence, skills, and strategies to maintain their activity levels. Average a1c decreased 0.3%. Estimated MaxMETs increased approximately 20%. Both WC and BMI showed decreasing trends. Using a highly peer directed group exercise program can increase physical activity levels and improve outcomes. Similar programs could be created using partnerships with community gym facilities or with minimal equipment. This model also places the focus on the patient and empowers them make positive and hopefully lifelong changes in their perception of and motivation to be physically active. 

Presenters

• Krista Crozier, R.Kin, CDE Diabetes Care Guelph, Guelph FHT

(IV) Group Medical Visits (GMV) for Primary Care Diabetes: The McMaster Family Health Team Experience

Learning Objectives

1. To gain knowledge about how to organize and implement a group medical visit
2. To learn the value of using group medical visits effectively within primary care
3. To hear positive patient accounts about their experience with group medical visits

Summary

The increasing prevalence of diabetes poses a threat to the sustainability of Canada’s health care system. Group medical visits (GMVs) are emerging as an efficient strategy to deliver care to multiple patients and have been shown to improve glycemic control, patient satisfaction and patient self-efficacy in disease management. The purpose of this study was to examine a number of process and quality of care outcomes measures to compare GMVs to traditional care and a diabetes clinic model that existed within the McMaster Family Health Team. This was a cohort study comparing GMVs to traditional care and a diabetes clinic model over the period 2008-2012. During each visit, patients saw a family physician and registered practical nurse with foot care certification and one of the following diabetes educators: nurse practitioner, dietitian or pharmacist. Group visit content included physical exam, medication review, group diabetes education review, question and answer time and goal setting. The numbers in each group were small so data was analyzed descriptively. The benefits and challenges of GMVs as compared to conventional care will be highlighted during this presentation and suggestions on how GMVs can be used effectively for diabetes care within primary care will be provided.

Presenters

• McMaster FHT:
  • Inge Schabort, MB ChB CCFP FCFP
  • Michele MacDonald Werstuck, RD MSc CDE

Authors and Contributors

• Kalpana Nair, PhD, McMaster University
• Christie Tasch, BA, McMaster University

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

Presentation Materials (members only)

Aging at Home Indicator Management

Learning Objectives

Our Aging at Home program’s focus is to provide interdisciplinary home care to seniors and reduce unnecessary emergency department visits. We will share our experience with team building, physician engagement as well as collaboration with CCAC and Joseph Brant Hospital. Our team were participants in the IDEAS program. We will discuss how the resources made available assisted in developing tangible goals and performance indicators and how this carried over into our QIP. The goal for our presentation is to have the attendees benefit from our learnings in:

• Program Development
• Team Building
• Internal and External Collaboration
• Embedding QI into a program.

Summary

The LHIN’s Aging at Home Strategy identified that a wider range of homecare and community support services will be needed. They project that the population of seniors will double in the next 16 years. Approximately 40% of the population of Burlington is over the age of 50. For our aging population, the Burlington Family Health Team has developed a program through clinical innovations to keep seniors at home and out of hospital. The Aging at Home program aims to reduce preventable emergency department visits and helps to promote optimal health for our patients in the community. This is achieved through assessment and intervention by the FHT Occupational Therapist and Nurse Practitioner for patients who have difficulty accessing services, and who are at high risk for repeat emergency department visits and hospitalizations. Several aspects of the program will be highlighted, including monthly rounds with physicians and members of the interprofessional team as well as ongoing monitoring of emergency department data for quality improvement purposes. A key feature of the program is the ongoing collaboration and integration with our local CCAC and Joseph Brant Hospital. The Burlington FHT will also continue to build on our close relationship with Burlington Health Links. Future goals include utilization of emergency department data to screen for high risk patients who may benefit from the program.

Presenters

• Burlington FHT:
  • Shawna Cronin, Occupational Therapist
  • Theresa Hubley, Nurse Practitioner
  • Caitlin Grzeslo, Program Coordinator

Authors and Contributors

• Joanne Pearson, Executive Director, Burlington Family Health Team
• Courtney Field, MD, Burlington Family Health Team

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Presentation Slides: Culture Eats Accountability for Breakfast

Learning Objectives

This workshop will invite participants to rethink the importance of team culture by:

1. Understanding ‘whole-mind’ thinking
2. Leading inter-professional collaboration
3. Shifting the leadership culture of their teams.

Summary

Team-based primary care in Ontario is driven by a ‘left-brain’ approach to healthcare. Accountability, fiscal restraint, governance, policy, structure, patient statistics- these are the things that drive Ministry-funded primary care organizations. But for the people leading these teams, the need to embrace ‘right-brain’ thinking brings a healthy balance to the experience. Purpose, collaboration, trust, creativity, relationships and patient stories- these are the things that inspire a high performance team culture. Participants will be invited to reflect on their own team’s ethos and identify new ways of balancing the demands of accountability with the desire for a thriving team environment. They will hear how taking a ‘whole-brain’ approach to leadership can create a healthier high performance team culture. And they will be invited to consider how they might shift the leadership culture of their team by unleashing the leadership potential of all team members.

Presenters

• Dave Courtemanche, Principal and Founder, Leading Minds Inc

Theme 5. Advancing manageable meaningful measurement

Presentation Materials (members only)

Presentation Slides: Measlesgate

Learning Objectives

Review the clinical signs and symptoms associated with Measles and the appropriate tests to confirm the diagnosis. Outline the infection control steps to prevent measles exposure as well as other airborne infections to patients and staff present in the office setting. Emphasize the importance of collaboration with local public health for contact tracing after an office measles exposure. Discuss the recommendations by the Markham FHT Occupational Health & Safety Committee to collect immunity data on staff and providers with respect to vaccine preventable diseases (e.g. MMR, varicella, Hep B) and institute baseline TB skin testing.

Summary

Measles is a viral infection that classically presents with fever, rash and the 3 “Cs” – cough, coryza and conjunctivitis. While most people with measles are sick for a few days and recover completely, it can lead to complications and even death. In Canada, due to high immunization rates, measles is rare. However, several factors have contributed to recent outbreaks including patients who only received one immunization against measles, those who refuse to be immunized due to a discredited claim that there is a link to developing autism, and unintended exposures in countries endemic to measles. Given the virus spreads through respiratory droplets, multiple exposures can occur when an infected patient presents to a primary care practitioner’s office. Providers need to be comfortable responding to such a scenario and this session will provide a practical approach on how to manage a measles exposure based on our FHT’s experience from earlier this year. Consistent with the theme of “Advancing manageable meaningful measurement”, we will highlight the importance of leveraging one’s EMR system to access patient health records for contact tracing. Topics including collaboration with public health, and the importance of transparent messaging to patients and staff will be reviewed. Providers will also be imparted with valuable lessons learned such as the importance of infection control practices to prevent spread, and knowing the immunization status of office staff/providers to ensure protection in the event of a measles outbreak. A review of the diagnostic tests for measles will also be provided.

Presenters

• Markham FHT
  • Dr. Allan Grill, MD, CCFP, MPH, Lead Physician
  • Lisa Ruddy, RN, Clinical Program Manager

Authors and Contributors

• Anthony Pallaria, Clinical/IT Manager, Markham Family Health Team