Tag: Concurrent Sessions

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (Members only)

Presentation Slides: Sustaining Change

Learning Objectives

In an effort to be patient-centred, the Guelph FHT since inception adopted the decentralized model/approach in allocating IHPs across all 22 practices where every practice gets its share from FHT funded IHPs depending on # of physicians, population served and roster size. In other words each practice is a “patient medical home. Attendees will gain understanding of how this model works, how to allocate, manage resources, promote ownership and accountability, tailor services according to population needs and embrace collaborative team approach to population health. It is important to note that there is no perfect structure fits all organisations but it crucial to understand your stakeholders and plan your approach to organisational structure accordingly.

Summary

We broadly agree on the core objectives that health care systems should pursue. The list is strikingly straightforward: universal access for all people, effective care for better health outcomes, efficient use of resources, high-quality services and responsiveness to patient concerns. It is a formula that resonates across the spectrum but the diversity of health system configurations that has developed in response to broadly common objectives leads quite naturally to questions about the advantages and disadvantages inherent in different arrangements, and which approach is “better” or even “best” given a particular context and priorities. The logic of a decentralized model is based on an intrinsically powerful idea. It is, simply stated, that smaller organizations, properly structured and steered, are inherently more agile and accountable than are larger organizations. With ownership, delegation and autonomization often implemented, decentralized GFHT structure provides efficiency in terms of reducing the risk of bottlenecks and improving access at practice level, thus increasing the overall throughput capacity of Guelph primary care system Objectives of decentralization

• To improve clinical efficiency through developing skills and knowledge of practice based IHPs to manage more diversified patient portfolio.
• To increase allocative efficiency through better matching of FHT services to practice preferences for improved patient care.
• To empower individual practices through taking the lead in planning and initiating services that meets patients needs.
• To increase team accountability through collaborative and holistic approach to patient health.
• To increase quality of health services through integration of services and improved IM systems and access for vulnerable groups.
• To increase equity through allocating resources to better meet the needs of particular groups.

Presenters

• Guelph FHT:
  • Sam Marzouk, Director, Operations and Finance
  • Sylvia Scott, Director, Clinical and Professional Services

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

Learning Objectives

Participants will leave with a broader sense of what we mean by Health Equity. Full spectrum training in and operationalisation of Health Equity must include all parts of the BODY of Health Equity. Participants will learn the elements of each – Information – Attitude – Capacity-building – and how they intersect and complement one another, why one without the others is inadequate and its potential for profound system-wide impact.

Summary

The presentation will cover the elements of full-spectrum Health Equity, focussing on its present and potential impact on individuals, communities, on systems – and what kind of courage is needed to do so. It will be provide information and it will be interactive and fun!

• The HEAD of health equity is all about increasing our knowledge, open to and acquiring new information on best practices and applying it to the practice site environment. It’s about definitions, effective community engagement that never ends, rethinking Population Health Needs Assessments to take into account the social determinants of health, using its key concepts as the lens through which one does planning, asks questions, designs space, ensures accessibility (in every sense of that word); finding and recruiting the right staff and volunteers and ensuring their regular training in these concepts and applications as well as putting in place measures and mechanisms for open, transparent, safe communication, resolution of conflicts and team-building.
• The FEET of Health Equity institutionalises your commitment to health equity, providing monitoring and ongoing learning opportunities for improvement.
• The HEART moves beyond knowledge transfer to a focus on people and the encounters that make up our work-days: with our clients, our funders, our colleagues and ourselves – how we are with one another, our behaviours and the impacts of often unacknowledged social location and unrecognised privilege, cultural conditioning (on the part of both provider and client/ patient), unsurfaced attitudes, interests and motivations.

The HEART asks, “What are the internal and organisational dynamics, structures, policies/procedures, unwritten protocols, personal values, rank and privilege that have an impact, positive or otherwise, on effective people-centred care?” Training in the HEART of Health Equity also provides insight with respect to the architecture of space and the constructs and properties of power and stigma. Getting at the HEART drives passion for and interest in greater knowledge, skills and commitment to one’s part in the organisation’s goals and planning. Getting to the HEART is the indispensable ingredient. The IMPACT of this kind of full-spectrum operationalisation is huge, measurable both in traditional methods, checking off boxes, monitoring change, evaluating experience – and in the more subjective measurements that have to do with self- and other-awareness, one’s capacity to broach difficult conversations, to identify internal barriers to effective ‘encountering’ of all sorts, to communicate more effectively. To paraphrase Steven Lewis, ‘if we meant what we say about health equity, the very system itself would be turned inside out and upside down.’ It would move us to ask different questions:

• How would we communicate differently?
• How would we define performance and productivity differently?
• How would we train our providers differently?
• How would we use health information differently?
• How would we value time and
• What would we reward differently?
• How would we allocate resources differently?

Presenters

• Lee McKenna, Executive Director, Partera International

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

Presentation Materials (Members only)

Presentation Slides: Community Paramedicine Models for Primary Care

(I) Community Paramedicine – Review of a Dedicated Model in Primary Care (FHT)

Learning Objectives

At the end of this presentation, attendees should be abIe to identify the types of patients who would benefit from visits from a Community Paramedic in (CP) their own home or community setting, understand the role that CP’s can play in community health systems including Family Health Teams, understand how the unique paramedic skill set can augment and support existing community health supports without duplicating service, and decrease reactive system utilization (9-1-1, ED visits) by taking a proactive approach to providing care for specific, at risk, patient populations.

Summary

Medavie EMS Ontario, Chatham-Kent (MEMSO-CK) is the contracted service provider for the provision of land ambulance services for the single tier municipality of Chatham-Kent. MEMSO-CK was an active stakeholder in the development of the Chatham-Kent Health Link (HL) as where directors with the Thamesview Family Health Team and Chatham-Kent Family Health who together have aproximately 60,000 rostered patients in the municipality. In a collaboration with the HL partners, MEMSO-CK was successful in receiving one time funding from the Ministry of Health and Long Term Care to develop and examine CP programs. Medavie EMS has extensive history and experience with CP programs in Atlantic Canada and the north eastern US and sought to bring some of that experience to our Ontario operations. This novel program was developed in consultation and collaboration with the the FHT’s in the region in addition to the CCAC, CHC, CKHA and medical oversight physicians from the South West Ontario Regional Base Hospital Program. Three specific referral sources feed patients into the program: HL high users as determined by a care cooridinator at CKHA, waitlisted cardiac rehab patients, and CCAC rapid response RN patients. The 2 CP’s selected for the program attended an 8 week custom CP program developed by Fanshawe College. Working in a non response vehicle, 5 days per week, the CP’s provide supportive care, health coaching using the NHS wellness index, advanced assessment and diagnostics (eg. 12 lead ECG, POC testing), fall education, end of life care planning, and consultative/advocacy link for the patient population being served. 

Presenters

• Medavie EMS Ontario:
  • Steve Pancino, General Manager
  • Ken Langlois, Community Paramedic
• Dr. David LaPierre, Family Physician, CK-CHC

Authors and Contributors

• Lisa Richardson, Health Link Care Manager, CKHA
• Carol Kolga, Senior Research Associate, Western University
• Nancy Snobelen, Director, Chatham-Kent Health Alliance
• Denise Waddick, Executive Director, Thamsview FHT

(II) Community Paramedicine in a Rural FHT

Learning Objectives

At the end of this presentation, attendees should be abIe to identify the types of patients who would benefit from visits from a Community Paramedic in their own home, understand how to integrate Community Paramedic into a Family Health Team, understand the benefit to physicians of having a Community Paramedic visit patients on behalf of the Family Health Team, understand the importance of identifying all medications that patients may be taking including prescription medications, over the counter medications and herbal supplements, understand the limits of technology in rural communities and how to integrate community care and advocate on behalf of patients.

Summary

West Carleton Family Health Team (WCFHT) is one of the few medical service providers in Rural Northwest Ottawa, and is located in the Village of Carp, within the amalgamated City of Ottawa. The largest portion of this practice population resides in this area, a sparsely populated region that traditional home services find difficult to service. In 2014 the Ministry of Health and Long Term Care distributed $6 million dollars in Ontario to expand paramedicine programs. WCFHT was chosen to pilot a paramedicine program where extensively trained and experienced Community Paramedics (CP) are integrated into the FHT to provide patient services in their own home. This novel program was developed in consultation and collaboration with the two regional providers of Paramedical Services in Rural Northwest Ottawa. Patients accepted into this program were chosen by physicians in the FHT . The patient population includes patients with chronic diseases, co-morbidities, palliative care, mental health concerns, recently discharged from hospitals or any patient identified as at risk. The program focuses on reducing the stress on limited health services, while at the same time, improving patient’s quality of life and assisting patients to live independently in their own home. CPs provide services that are normally provided within the FHT to patients, such as but not limited to; blood pressure checks, blood glucose testing, suture removal, immunizations and a thorough identification of medications. Most importantly the CP acts on behalf of the patient as an advocate in coordinating care from community partners.

Presenters

• Bev Atkinson, Quality Information Decision Support Specialist, West Carleton FHT

Authors and Contributors

• West Carleton FHT:
  • Mark Fraser, MD
  • Barb Jones, Program Administrator
• Tracey Suprunchuck, Community Paramedic, City of Ottawa

Theme 6. Leadership and governance for accountable care

Presentation Materials (members only)

Presentation Slides: Creating and Implementing the Markham Family Health Team Lead Physician Performance Review

Supporting Materials (members only)

• Markham FHT Lead Physician Review cover letter
• Markham FHT Lead MD 360 Review
• Markham FHT Individual Development Plan
• Markham FHT Accountability Framework – Performance Appraisal
• Markham FHT 360 Degree Feedback Policy
• Markham FHT Board Assessment Template for Survey

Learning Objectives

1. To outline the steps required in creating a performance review with a focus on the FHT Lead Physician role.
2. To explore the function of the Governance Committee and the FHT Board of Directors with respect to implementing the LP performance review.
3. To discuss the importance of a transparent process when designing a performance review and its influence on accountability.

Summary

The MOHLTC, a key “shareholder” of FHT Boards of Directors, expects accountability to be linked to performance. In order for FHTs to succeed in this regard, strong leadership is required. Therefore, evaluating the performance of individuals holding leadership positions within FHTs is crucial. Furthermore, from a professional standpoint, advice from peers and colleagues creates the opportunity for leadership growth and in turn organizational maturity. Constructive feedback also holds a leader accountable by determining if s/he meets their stated deliverables. In this regard, the Markham FHT recently designed a performance review process for their Lead Physician. This presentation will outline the various steps taken by the Governance Committee including updating the LP job description, developing an evaluation survey, selecting FHT members of various roles to partake in the survey, choosing an on-line method to gather and analyze feedback, and communicating the results to the FHT Board and members of the organization. Perspectives from the Chair of the Markham FHT Governance Committee, Executive Director and Lead Physician will be shared. It will also provide a step-by-step practical outline of how to initiate a process to measure the performance of the Lead Physician, and other staff, for FHTs who have not yet participated in this exercise. Furthermore, this presentation falls within the AFHTO theme of “Leadership and governance for accountable care” by focusing on tools to support leaders in good governance and supporting the development of leadership within the team.

Presenters

• Markham FHT:
  • Dr. Allan Grill, MD, CCFP, MPH, Lead Physician
  • Dr. Parm Singh, MD, CCFP, Family Physician & Chair, Governance Committee
  • David Marriott, B.A., Executive Director

Authors and Contributors

• Lisa Ruddy, RN, Clinical Program Manager, Markham FHT

 

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

Presentation Materials (Members only)

Presentation Slides: Building the rural health care team

Learning Objectives

Participants will learn:

• How a Northern FHT maximizes service delivery to expand available technology and minimize travel through OTN for shared care where there are no obstetrical services. A woman not traveling an hour for prenatal follow- up has made a difference in the lives of families experiencing a normal life event.
• How the FHT fostered collaborative relationships with the local hospital sharing IHP’s in order to maximize outpatient services.
• How collaborative partnerships maximized delivery of collective resources before Health Links inception. As a member of Timiskaming Health Link, our FHT led establishing and developing ICCPs (Integrated coordinated care plans).

Summary

The Kirkland Lake Family Health Team is located in Northeastern Ontario, serving a population of approximately 10,000 with demographics skewed towards the elderly and complex patients. The doctor shortage was severe, and reliance on locum physicians was high. Nurse Practitioners and IHPs have been the most stable part of our delivery team, at times being the main service providers in our community. Managing patients with complex care, multiple specialists, home care, and high demand for services caused frustration and fragmentation in care delivery for patients and providers. The integration of individual coordinated care plans (Health Links) has alleviated stress and demand on workload and enabled clients to better self-manage. Part of facilitating this has been involving the whole team as part of the process so that the delivery can be shared. We make extensive use of OTN. That has saved money and thousands of kilometers in travel, and hs avoided significant lost time at work for patients. We are currently participating in a research project to examine how to better prepare NP students for the challenges of managing patients with multiple comorbidities. The abstract for this paper has been accepted for presentation at the Canadian Association of Advanced Practice Nurses annual conference in Winnipeg in October, 2015. We provide placement for NP, RN and medical students. We hope to be setting the stage for professionals to return to practice in a facility which is proud to offer a truly integrated team approach. We are proud to discuss the innovations we have made to enhance service delivery as well as provider satisfaction and team integration at the AFHTO conference.

Presenters

• Kirkland District FHT:
  • Christina Woollings, NP-PHC, Clinical Lead
  • Julie Moody, RPN, Telemedicine Coordinator
  • Mandy Weeden, Executive Director
• Sandra Dal Pai, NP-PHC; Adjunct Professor, Laurentian University

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

Presentation Materials (Members only)

Tips and Tools to capture the patient’s experience in primary care. What are they thinking? Approaches, ideas, and tools to measure patient experience in your practice.

(I) Tips and Tools to Capture the Patient’s Experience in Primary Care using the NHS’s Experience-Based Design (EBD) Methodology

Summary

Patient experience – what’s it all about? Differentiating between and understanding our patient’s experiences of care from their level of satisfaction are essential in the delivery of high quality patient care. Experience Based Design (ebd) is a methodology developed by the NHS in the United Kingdom. It is comprised of four phases: Capture, Understand, Improve, and Measure, all designed to assess and improve patients’ experiences. During the presentation attendees will learn the theory of the methodology and understand the specific tools that can be applied in their practices to achieve successes similar to those that will be described in the presentation. The objective of this presentation is to build capacity in primary care and community organizations to lead and implement patient experience improvement work in their teams. 

Presenters

• Partnering for Quality Program, South West CCAC:
• Rachel LaBonte, Program Lead
• Jennifer Jackson, Quality Improvement Coach

Learning Objectives

Attendees will :

• Receive an introduction to the tools and techniques developed in the NHS to capture and understand patient’s experiences.
• Experience some of the tools in action
• Leave with the foundational knowledge of the ebd approach in hopes they consider application back at their own team/site.

(II) What are they thinking? Approaches, Ideas and Tools to Measure Patient Experience in Your Practice

Learning Objectives

Session attendees will learn about primary care patient experience measurement activities at the health system level (provincial, regional) as well as the practice-level. Participants will acquire knowledge about the tools and resources available to them to support practice-level patient experience measurement and gain insight into practical ideas for how to design, implement, interpret, and then translate patient experience data into meaningful quality improvement in their practice environment.

Summary

Including the voice of the patient in our efforts to improve primary care quality has become a key objective of policy makers, primary care organizations, and patients themselves. However, it has not always been clear how best to measure and then use data on the patient experience. This session will present the new primary care patient experience survey developed and tested through a collaborative project that included HQO, AFHTO, OMA, OCFP, and the AOHC. Presenters from across the primary care health system will highlight the provincial and regional resources available to assist organizations with patient experience measurement and approaches for translating patient feedback into practice improvement. The collaborative approach of the Champlain LHIN’s FHT patient experience measurement partnership project, which developed and supported a common patient survey across 19 FHTS, reported results back to the FHTS for benchmarking performance, identifying priorities for improvement, and enabling sharing of experiences and strategies across FHTS, will be presented. Practical ways to design, implement, and then act upon patient experience data in a primary care practice will be presented. The alignment of patient experience measurement to broader performance measurement strategies such as quality improvement plans, data to decisions, the provincial primary care performance measurement framework, and the primary care practice reports will be discussed.

Presenters

• Sharon Johnston, Family Physician, Clinician Investigator, University of Ottawa, Department of Family Medicine, Bruyère FHT
• Gail Dobell, PhD, Director, Performance Measurement, Health Quality Ontario
• Susan Taylor, Director, Quality Improvement, Health Quality Ontario
• Elizabeth Muggah, MD, MPH, Family Physician, Director of Quality Improvement, University of Ottawa, Department of Family Medicine, Bruyère FHT
• Ellie Kingsbury, MLT, QIDSS, Équipe de santé familiale académique de Monfort

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (Members only)

Presentation Slides: “Welcome to your new reality – you have diabetes this week!”

Learning Objectives

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

1. Describe an innovative educational process to understand the patient experience of living with a chronic condition.
2. Reflect on their own clinical practice related to working with patients with diabetes.
3. Explore the possibility of implementing this program in their own clinical setting.

Summary

The Diabetes Education Team at the Sunnybrook Academic Family Health Team believed that exposing professionals to the tasks involved in the day-to-day management of the diabetes would increase their understanding of the complexity and time associated with self-management. This session will describe a program developed and offered to the interprofessional team including family medicine residents, faculty physicians, nurses, pharmacists, social worker, OT, and support staff to provide them with the opportunity to live with diabetes for a week. Learning objectives were developed and the nurse educator and dietitian provided the participants with a health history and scenario entitled “Welcome to Your New Reality”. Through the course of the week, they progressed through ~ 8 years of living with diabetes. Self—glucose monitoring, insulin “dry” injections, paging the participant informing them they were experieincing low blood sugar and medication changes were all part of the program. The team met every morning to debrief expereinces, consider how they would counsel patients in a similar situation and to provide new scenarios and challenges. By going through the program team members learned about the patient experience of living with diabetes (i.e. how to fit diabetes into one’s life) and about each other’s roles and perspectives around caring for patients with chronic conditions. The program is now offered ~ every 2 months.

Presenters

• Sunnybrook Academic FHT:
  • Leigh Caplan, RN, BSc, MA, CDE, Diabetes Nurse Educator
  • Judith Manson, RN, BScN, NCMP, Executive Director

Authors and Contributors

• Nancy Teskey, RN, BScN, CDE, Diabetes Nurse Educator
• Jill Zweig, RD, BAA, CDE, Dietitian

Theme 5. Advancing manageable meaningful measurement

Presentation Materials (Members only)

Optimizing EMR Use: Merging Data, Managing Patients and More Cancer Screening

Learning Objectives

1. Learn how to access Cancer Care Ontario’s Screening Activity Report (CCO SAR) for all family health team (FHT) physicians and merge it with EMR data.
2. Describe how to use postal code to understand variation in cancer screening rates by neighbourhood income quintile and the impact of interventions on equity.
3. Learn how use of physician billing codes, and the creation of IHP tracking codes have helped to account for the work produced by Markham FHT, as well as enabled the creation and evaluation of clinical programs.

Summary

1. How to Optimize EMR Use for Maximum Data Usability: EMR search capability and data extraction has moved beyond the “keyword search” and into the next level of meaningful management. With the introduction of Quality Improvement Plans, Ministry of Health and Long-Term Care reporting requirements, and now the Association of Family Health Team’s Data to Decisions, Markham FHT has had no difficulty extracting the data necessary for submission, due in large part to the careful planning and attention to how EMR data is entered and interpreted. 2. Managing Patient Rostering: Patient rostering data is an important area that could be optimized within EMR systems. Patient rostering is central to a high-performing primary health care system. Rostering can enable the practice to better define its panel size, manage access to care, track health indicators and outcomes. In 2014, North York FHT reviewed and updated 3,864 (4%) patient records, and mailed out 1,758 roster invitation letters to patients. Similarly, Queen Square FHT reviewed and updated nearly 4,000 (11%) patient charts, and invited 2,000 (50%) patients by telephone to roster. We will discuss roster management and cleanup processes in Queen Square and North York FHTs. 3. Merging data sources to understand and improve cancer screening rates and related inequities Last year, Cancer Care Ontario made it easy for physicians to download an integrated summary of their patients eligible and overdue for cervical, breast, and colorectal cancer. We will describe how we accessed this data for the majority of our FHT physicians and merged it with our own EMR data. We noted a large variation in cancer screening rates between our physicians as well as significant disparities in screening related to patient income. Our FHT used the merged cancer screening data to deliver a multifaceted, evidence-based quality improvement intervention that included patient recall letters signed by their physician, physician audit and feedback, and enhanced point-of-care reminders. The intervention improved overall screening rates and improved rates for most physicians. We noted a narrowing of income-related inequities for colorectal cancer but not cervical or breast. The results of our intervention have spurred further work on how to improve disparities in cancer screening in our FHT

 Presenters

• Markham FHT
  • Lisa Ruddy, RN, Clinical Program Manager
  • Tony Pallaria, IT Manager
• St. Michael’s Hospital Academic FHT
  • Tara Kiran, MD
  • Sam Davie, QIDSS
• Marjan Moenedin, QIDSS, North York FHT
• Abel Gebreyesus, QIDSS, Queen Square FHT

Authors and Contributors

• Markham FHT:
  • Stephen McLaren, MD
  • Tom Filosa, MD
  • Allan Grill, MD, Lead Physician
  • Deepti Pasricha, MD

Theme 2. Optimizing capacity of interprofessional teams

Presentation Materials (Members only)

Optimizing Capacity of the Mental Health team. Triaging the patient: who is the right provider? Responding to the Needs of Patients with Anxiety-Developing a Comprehensive Group Program at a FHT

(I) Integrated Care for Better Outcomes: Supporting Primary Care Patients with Mental Health and Addictions Issues

Learning Objectives

At the end of this session, the learner will understand:

• Factors that influence the implementation of evidence-based integrated care in addressing mental health and addictions issues in the primary care settings.
• The role of a Mental Health Care Technician in supporting and enhancing the interprofessional collaboration between primary care and mental health providers.
• The experiences of primary care providers, at participating Family Health Teams working within the context of the integrated care model
• Challenges and strategies for successful implementation.

Summary

Depression, anxiety, and at-risk drinking are among the most common health problems for patients receiving general medical care. The majority of patients are seen exclusively in primary care, and never see a mental health or addictions provider. Undetected, untreated or under-treated these conditions create a significant public health burden. This interactive presentation will overview a three-year research project partnering with Ontario Family Health Teams (FHTs) evaluating an innovative integrated care model of telephone-based, computed aided care management to support the mental health care of primary care patients. The project will compare enhanced usual care (EUC) and a telephone-based intervention — including psychoeducation, regular monitoring, and support from a Mental Health Technician (MHT) and team supervision from a psychiatrist. Demands in primary care make it difficult for physicians to obtain needed information, follow-up as frequently as needed, and use best practices effectively. The proposed model addresses these gaps by facilitating collaboration with PCP and new MHT role, to provide screening and symptom monitoring, follow-up calls, access to on-line psychotherapies, while enhancing patient self-management and supporting adherence to treatment and medication management. Clinical updates and specific recommendations are sent to PCP to facilitate initiation of evidence-based pharmacotherapy or psychotherapy, and referrals to specialty mental health services when indicated. Within the context of primary care and an integrated care model, partnering FHTs will speak to their experiences identifying and referring patients, utility of recommendations, and communication and collaborating with MHT role. The presentation will discuss challenges and strategies for successful implementation. 

(II) Optimizing Capacity of the Mental Health Team. Triaging the Patient: Who is the right provider?

Learning Objectives

Primary care is often the first place a patient with mental health concerns present. These presentations are varied in complexity and urgency and require expert care. How does one decide the best way to support this patient? Understanding the skills mix of the Mental Health Team is essential. At McMaster FHT, a Mental Health Summit was organized and all staff who was interested in mental health services was invited to attend. This meeting revisited the priority and focus of the FHT; the skill set required to meet that focus and the direction of new programming, including a commitment to the interprofessional triage team comprised of the system navigators, occupational therapists, administrative support, leadership, psychology and psychiatry. Outcomes were predicted (and achieved) with regard to wait times, provider and service delivery times.

Summary

This presentation will describe the interprofessional team, the challenges and successes of the triage process and the successful outcome achievement of reduced wait times. The interprofessional mental health team is committed to supporting the various needs of the patient with mental health concerns. Role definition and clear understanding of that role are important in the triaging of referrals appropriately. Identifying the most appropriate provider/professional supports patient centered care by aligning that patient with the profession best suited to meet their needs. This has reduced wait times and resulted in timely and effective care planning that includes the patient. The one hour weekly triage meeting reviews all new referrals, closes files as appropriate, and manages patients who have missed appointments. Complex cases are reviewed as a team and recommendations for ongoing care (patient and provider) are shared. Community Resources are an essential part of the extended interprofessional team. Seeking out appropriate community resources and employment supports is an important strategy within the FHT. The importance of process measures and timely reporting of those measures has worked to keep the team focused on excellence in patient care and effective triaging to the most appropriate team member. Ongoing training was recommended and supported by the Mental Health and the Leadership teams and to that end, DBT training opportunities have been levered. Next (ongoing) steps include further reducing the wait times to within 2 weeks, gathering patient feedback and strengthening the relationships with community partners (i.e. Teen services).

Presenters:

McMaster FHT

• Kathy De Caire, Clinical Director, Stonechurch FHC; McMaster FHT
• Jill Berridge, Clinical Manager, McMaster Family Practice; McMaster FHT

(III) Responding to the Needs of Patients with Anxiety – Developing a Comprehensive Group Program at a FHT

Learning Objectives

In the last 12 years the McMaster Family Health Team has developed a three part group treatment program to address the ever increasing numbers of clients being referred for treatment of anxiety. This presentation will focus on the development of the core anxiety treatment group, a teen group and the aftercare group. It will follow the challenges and sucesses of our groups and help participants develop some practical ideas about how to develop interprofessional group leadership, how to publicize groups, how to structure group sessions and tips about when to move from offering the core anxiety group to offering more specialized programming.

Summary

Patients presenting with anxiety use a signficant amount of many primary care givers time. Skills for managing anxiety can be taught and practiced in a group setting. Learning the skills for managing anxiety in a group can be a normalizing experience and can provide a sense of peer support. Treatment groups provide the opportunity to utilize the skills of numerous health care providers including the pharmacist, dietitian, occupational therapist, psychologist, physicians and social workers. In this presentation, we will begin with a discussion of the structure of our group programs, group resources, treatment modalities, publicity, interprofessional networking, and common mistakes. We will then examine the outcomes of the client satisfaction sureys. Finally, we will provide time for participants to ask questions about their specific clinical experiences. We now have several hundred people referred to our anxiety groups each year. Groups are offered 5-6 times a year so the wait is much shorter for group programming than the wait for individual counselling. We are able, through an interdisciplinary collaborative appraoch, to provide quality care to many more patients than could be served in 1-1 sessions. Client feedback indicates that many clients prefer group sessions to individual counselling particularly in some age groups. Teens, a challenging population to network with, have routinely indicated that they prefer group to individual treatment. The aftercare group provides ongoing clinical support to patients who might otherwise be taking individual appointment spaces. Group programming is an effective response to a significant mental health need and may be part of the solution to the significant numbers of patients seeking mental health care through Family Health Teams.

Presenters:

• McMaster FHT
  • K. Lynn Dykeman, Social Worker
  • Colleen O’Neill, Occupational Therapist

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

Presentation Materials (Members only)

Presentation Slides: Reducing the Revolving-Door Syndrome: Hospital and Primary Care Working Together to Reduce 30 day Re-admission Rates for COPD and CHF Patients

Learning Objectives

Attendees will:

• Understand the benefits from hospital and primary care perspectives of working together to address hospital readmissions versus working in silos
• Explain how care transitions impacts avoidable and unavoidable readmissions for populations at risk
• Understand why COPD /CHF populations were targeted
• Discuss how hospital utilization data informed the initiation of improvement activity
• Describe tests of change undertaken by each organization and in collaboration
• Discuss expected outcomes, system gaps and current mitigation strategies.

Summary

To respond to a growing readmission rates and hospital length of stay for COPD and CHF populations, Guelph General Hospital (GGH) implemented clinical pathways to ensure best practice. A key intervention in the clinical pathway was to establish a follow up appointment with primary care, for the patient prior to discharge. This intervention was implemented via a fax to provider’s office.   Collaboration between GGH and GFHT was initiated to explore the uptake and rates of scheduled appointments received before patients were discharged. This initiative resulted in the following changes:

1. Primary care involvement in hospital discharge planning (including where needed, phone calls from the charge nurse to discuss patient discharge needs)
2. Primary care calling patients at risk of readmission within 48 hours post hospital discharge
3. Shared lists of practice based primary care contacts to facilitate scheduled telephone appointments prior to discharge
4. Electronic notification of primary provider of hospital patient admission and or discharge to facilitate patient centred and effective transition planning
5. Regular collaborative meetings to explore what is working well and what needs to be improved

Our test efforts have occurred within three pilot practices within the Guelph Family Health Team. Regular practice team meetings with the QI facilitator to review team improvement progress. Lessons learned will be integrated shared and tested for implementation across all practices.

Presenters

• Guelph FHT
  • Tricia Wilkerson, Director, Quality and Evaluation
  • Sylvia Scott, Director, Clinical and Professional Services
• Jackie Beaton, Inpatient Flow Coordinator, Guelph General Hospital

Authors and Contributors

• Laurie Williamson, R.N., BScN, Clinical Educator Ambulatory Care/Clinical Pathway Coordinator, Guelph General Hospital