Theme 2. Healthy relationships, healthy teams Presentation Details

• Date: Wednesday, October 24, 2018
• Concurrent Session A&B
• Time: 2:30 – 4:15pm
• Room:
• 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, Administrative staff, Representatives of stakeholder/partner organizations

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

1. Define a model of care and the role of core team members (which includes the patient and family/caregiver) in the Palliative Care Health Services Delivery Framework.
2. Describe the process for developing the Health Services Delivery Framework in Ontario and the roles or functions of the care team.
3. Identify how the provincial Health Services Delivery Framework can be aligned with their local models of care for patients residing in community settings (e.g. their usual place of residence, which includes retirement homes, long term care homes, streets or shelters).

Summary/Abstract There is variation in the availability and delivery of palliative care services within and across Local Health Integration Networks, and less than 60% of Ontarians are known to be receiving these services in their last year of life. The Ontario Palliative Care Network’s Health Services Delivery Framework aims to leverage a team-based approach in meeting the palliative care needs for patients, their families, and caregivers. This framework aims to describe and recommend a model of care for adult patients residing in community settings (e.g. their usual place of residence, which includes retirement homes, long term care homes, streets or shelters). Recommendations are based upon evidence and input from the OPCN, its interdisciplinary Working Group of health care providers, Patient and Family/Caregiver Advisors and multiple stakeholder groups. The framework describes the services related to the assessment, coordination, planning, and delivery of palliative care within the eight domains of issues associated with illness and bereavement. It identifies the services, supports, and care that are needed to support patients, families and caregivers within a palliative care team, as well as recommendations for implementation considerations. An integrated palliative approach to care, earlier identification at the primary care level, and primary care capacity building are recognized as enablers for the Health Service Delivery Framework. This session provides an opportunity to provide an overview of the development process and emerging recommendations. The primary objective will be to gain feedback on the draft Health Services Delivery Framework from the interdisciplinary perspectives of the session participants. Presenters

• Robert (Bob) Sauls, MD, CCFP(PC), FCFP, Ontario Palliative Care Network

Authors & Contributors

• Robert (Bob) Sauls, MD, CCFP(PC), FCFP
• Hasmik Beglaryan, MPP, Group Manager, CCO Models of Care
• Lindsey Thompson, RN, BScN, MPH, Lead, CCO Models of Care
• Deanna Bryant, BAh, MPA, Group Manager (A), OPCN Secretariat
• Yuna Chen, MPH, Specialist, OPCN Secretariat

Theme 1. Mental health and addictions Presentation Details

• Date: Wednesday, October 24, 2018
• Concurrent Session B
• Time: 3:30-4:15pm
• Room: Harbour A
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

• Review updated evidence on the risk and safety concerns associated with the use of benzodiazepines/Z-drugs in older adults
• De-prescribing in primary care
• Setting goals, creating a workplan, and tracking outcomes
• How to implement a benzodiazepine/Z-drug de-prescribing initiative in your clinical practice

Summary/Abstract TC FHT’s Quality Improvement Committee (QIC) and St. Michael’s Hospital’s Mental Health & Addiction Service Research Team, collaborated to develop the De-prescribing (tapering & stopping) of benzodiazepines & Z-Drugs QI initiative.  The purpose of the initiative is to reduce the unnecessary use of benzodiazepines and/or Z-drugs among older adults (age 65 and above).  Studies have shown increased risk of adverse effects (i.e. falls, pneumonia, interference with cognition) when taking these medications.  This QI and medication safety initiative is about informing patients of the risks and offering support if they wish to taper or stop taking these drugs, and informing providers of these risks and how to support patients. An interprofessional team comprised of MDs, NPs, Pharmacists, Social Workers and Nurses was created to implement this QI initiative. A detailed workplan outlining the step-by-step process was developed by an appointed QIC working group. This workplan emphasized optimization of existing clinical programs and resources, including CBT-insomnia workshops, drop-in sessions with the Social Work team, and medication tapering support with MDs and/or Pharmacists. Some of the highlights that made this initiative successful included educating clinicians about the latest evidence on the safety concerns associated with these medications and informing patients about the potential risks of taking these medications. Patient empowerment and self-advocacy for medication tapering was also emphasized by utilizing an evidence-based patient-directed tapering tool. Presenters

• Jessica Lam, Registered Pharmacist, Taddle Creek Family Health Team
• Ranjana Shardha, Director of QI, Taddle Creek Family Health Team

Authors & Contributors

• Sherry Kennedy, Executive Director Taddle Creek FHT

Theme 6. The future of the regional approach to healthcare Presentation Details

• Date: Wednesday, October 24, 2018
• Concurrent Session A
• Time: 2:30 – 3:15pm
• Room: Pier 4 & 5
• 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

Learning Objectives The presentation will review a joint Quality Improvement Plan initiative between two rural Family Health Teams, and their local hospital organization.  It will demonstrate how the project has strengthened the partnership between the organizations, and how it has and continues to change the way they now work together operationally to improve the care they provide.  It will show how organizations can work together as a LHIN sub region to improve outcomes. Summary/Abstract The North Perth Family Health Team, North Huron Family Health Team and Listowel Wingham Hospital Alliance  embarked on a joint quality improvement initiative beginning in 2016/17.  The project was targeted at reducing the readmission rates for COPD patients discharged from the hospital.  The project’s improvement outcomes were two-fold.  First the organizations were able to complete all of their change ideas and strengthen their Lung Health program.  Change ideas included staff education (hospital and primary care), booking of follow-up appointments at time of discharge, and implementation of order sets and care pathways in the hospital setting.  As a second outcome, the project strengthened partnerships between staff at various levels within the organizations and has set a foundation for continuous joint quality improvement.    The presentation will review how these organizations operationally work together as a LHIN sub region and will review the enablers to this (which includes but isn’t limited to): Joint I.T. infrastructure and data sharing agreement, governance partnerships, FHT Quality Committee accountabilities , Decision Support partnership, and alignment of FHT programs.  It will review these enablers, using the joint COPD project as an example. Presenters

• Lindsay McGee, Quality Manager / QIDSS, NHFHT / NPFHT
• James Brown, Clinical Pharmacist: BSc Phm RPh CDE CRE, NHFHT
• Joanne Fox, Clinical Pharmacist: Pharm D, BScPhm, Clinical Pharmacist
• Christine Reyes, RN, Coordinator of Professional Practice LWHA

Authors & Contributors

• Heidi Dupuis, Decision Support, LWHA
• Ainsley Morrison, Patient Experience Coordinator, LWHA
• Christine Reyes, Professional Practice Coordinator, LWHA

Theme 5. Why hasn’t this expanded: scalable pilot programs Presentation Details

• Date: Wednesday, October 24, 2018
• Concurrent Session A
• Time: 2:30 – 3:15pm
• Room: Pier 7 & 8
• 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: Clinical providers

Learning Objectives The objective of this presentation/poster is to demonstrate the benefits and the need for hands on nutrition education (HONE) in primary care.  Participants will learn about the community partnership between the TVFHT – St. Thomas location and Elgin St. Thomas Public Health.    Nutrition counseling in an office setting does not always translate into successful healthy eating changes.  Many patients lack the knowledge and skills necessary when working with fruit and vegetables.  YTC bridges the gap between knowledge and successful application of knowledge. Summary/Abstract You’re the Chef (YTC) is a cooking program designed to develop skills and confidence in the kitchen. The program aims to help participants increase consumption of a variety of vegetables and fruit easily into their daily lives.  The program originated from Niagara Public Health with a focus on children and youth and Elgin St. Thomas Public Health (ESTPH) adapted the program to meet the needs of their adult population.  A partnership between ESTPH and TVFHT – St. Thomas locations was formed to assist in meeting the needs of the Elgin county population. Each 3-4 week session provides a short demonstration on how to cut, select or use a particular vegetable or fruit and ensures that all recipes are kept to low cost food items. Participants also learn basic kitchen safety and safe food handling practices. Once the cooking is completed, participants sit down with the dietitian facilitators to discuss the nutritional benefits and any recipe substitutions that can be done. Presenters

• Sonia Colautti, RD CDE, Thames Valley Family Health Team
• Natalie Clark, Quality Specialist, Thames Valley Family Health Team
• Elena Usdenski, RD MScFN

Authors & Contributors

• See above

Theme 3. Expanding your reach Presentation Details

• Date: Wednesday, October 24, 2018
• Concurrent Session A
• Time: 2:30 – 3:15pm
• Room: Harbour A
• 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, Representatives of stakeholder/partner organizations

Learning Objectives

• What is TIP and how did it get started
• How to use an interprofessional team to proactively address complex medical needs
• How to maximize specialist sessionals and IHPs to help community family physicians

Summary/Abstract The Sunnybrook Academic Family Health Team first published our innovative interprofessional model of practice for aging and complex treatments (IMPACT) in 2013.  The bulk of chronic disease care is provided in primary care but the amount of time needed to address complex patient needs prohibits us from meeting their needs during regular clinic visits.  IMPACT is a team based model which involves a pre-visit assessment, a 1-2 hour visit with the patient, family, our interprofessional team and a geriatrician.  We have had tremendous success with improving the care for complex seniors.      The program has evolved over the years and another model has been created to help non-FHT physicians access this type of care.  Telemedicine Impact Plus (TIP) has spread across the Toronto Central LHIN with a number of teams now providing this care.   As a Wave 5 FHT with limited resources, we have had to be creative about the use of our team members to be able to provide both IMPACT and TIP clinics regularly.  We now piggyback one of each type of visits using the same team to make scheduling easier, minimize travel and maximize use of our sessional funding.    There are now 12 teams doing TIP and the model is being used for all age groups. Presenters

• Tracy Hussey-Whalen, Executive Director, Sunnybrook Academic Family Health Team
• Annie Huong, RD, Sunnybrook Academic Family Health Team
• Tia Pham, MD, South East Toronto Family Health Team
• Kay McGarvey, RN CCHN, Telemedicine IMPACT Plus Facilitator- Lead

Authors & Contributors

Theme 1. Mental health and addictions Presentation Details

• Date: Wednesday, October 24, 2018
• Concurrent Session A
• Time: 2:30 – 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: Clinical providers

Learning Objectives

1. Participants will understand how a strong collaborative program design – utilizing both Wraparound and Peer Support – enhances family capacity – within healthcare and mental health systems – with cost-efficiency
2. Presenters will analyze this successful model of care and discuss its implementation
3. Presenters will discuss possibilities for further growth and replication across provincial family health teams

Summary/Abstract In 2014, the Caroline Families First Wraparound Program (CFF) was introduced in Halton, Ontario.  Wraparound programs are evidence-based approaches that have been shown to have a positive impact in complex mental health care.  However, the Caroline Families First program is unique in its funding, location, and inclusion of a paid peer support role – which address many of the recommendations within the Mental Health Strategy for Canada.  This program is jointly funded by the Ministries of Health and Long-term Care and Child and Youth Services and co-led by a children’s mental health organization and a family health team.  The program is designed to improve the coordination between primary and community-based mental health care for children and youth with suspected or diagnosed mental health problems and illnesses that require multidisciplinary intervention.  The CFF programs family-centered approach involves care coordinators and paid Family Support Providers (peer supports with lived experience of raising children/youth with mental health challenges).  The program focuses on building the capacity of the families to support their children/youth and access and navigate the appropriate services that would better suit their need for intervention rather than relying on primary health care providers to provide services that are outside of their scope.  One of the hopes of the program is to allow for practitioners to practice at the top of their license by connecting families to a variety of supports that meet their needs.  • Presenters will share how they accessed funding to build the program.  • How to successfully replicate across the province   • Share their success stories  • Describe the roles and responsibilities of each team member Presenters

• Michelle Domonchuk-Whalen, Program Manager, ROCK-Reach Out Center for Kids
• Alexis Wenzowski, Program Team Lead, ROCK-Reach Out Center for Kids
• Lori Chalklin, Program Physician Lead, Caroline Family Health Team
• Kathleen Whittaker, Executive Director, Caroline Family Health Team

Authors & Contributors See above

Theme 1. Effective leadership and governance for system transformation

Presentation Details

• Date: Wednesday, October 25, 2017
• Concurrent Session B
• Time: 3:30pm-4:15pm
• Room:
• Style:
• Focus:
• Target Audience:

Learning Objectives Summary/Abstract Almost a year since it has been passed, register for this session to hear an update on the implementation of the Patients First Act and its implications for primary care. Learn more about the integration of CCAC into the LHINs, strengthening the relationship of care coordinators in primary care, the enhanced role of LHINs and investments being made to support the expansion of more team-based care in the province. Presenters

• Phil Graham – Director, Primary Health Care Branch
• Alison Blair – Director, LHIN Renewal Branch

Theme 4. Strengthening partnerships

Presentation Details

• Date: Thursday, October 26, 2017
• Concurrent Session E
• Time: 10:45am-11:30am
• Room:
• 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. To demonstrate how applying the pillars trust can build a strong partnership among those who typically do not work together:  primary care, public health and the LHIN.
2. To examine strategies to link the clinical work of primary care with the community based efforts of public health units to improve population outcomes

Summary/Abstract Primary care and public health share the goal of improving the health of all people, however they often operate independely of one another.   This initiative intentional brings togehter the unique role of the primary care team and the community based approach of local public health units and demonstrates one way to enhance  primary and secondary prevention efforts.  Preventing falls among older adults is a multifaceted problem requiring strong interdisciplinary partnerships at the local and regional levels.   A strong working partnership between primary care and public health benefits the patient by ensuring a more seamless system of screening, assessment and community intervention.  This model has promise for supporting work on other common health concerns. Presenters

• Wendy Carew, Regional Coordinator Falls Prevention, NE LHIN
• Shirley Watchorn, ED, Great Northern Family Health Team
• Kerry Schubert-Mackey, Director, Timiskaming Health Unit

Theme 6. Using data to demonstrate value and improve quality of care

Presentation Details

• Date: Thursday, October 26, 2017
• Concurrent Session F
• Time: 11:45am-12:30pm
• Room:
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. Learn how a large family health team adapted a program developed in a specialized clinical setting to meet the needs of primary care patients and providers
2. Understand how EMR-integrated patient tablets are used to complete clinical assessment scales, automatically calculate scores, and update the patient chart
3. Learn tips and tricks used to standardize program data entry and allow for quick, easy, single-search data extracts
4. Hear creative ways to reduce barriers and increase patient comfort when using technology for data collection

Summary/Abstract The DAVINCI program is an integrated care pathway developed by CAMH to concurrently treat patients with a diagnosis of depression and alcohol use disorder. In this session, you will hear how the Hamilton FHT adapted the program to optimize delivery for a large primary care organization through a series of clinical and technical innovations. This includes introducing a shared care group format model and using the Ocean Tablet platform to improve patient experience and easily collect and manage large amounts of data – with real-time feedback to clinicians. You’ll get a detailed look at how the FHT developed and implemented an integrated care pathway for the 16-week program that can be easily repeated. You’ll also learn how the team at Hamilton FHT leveraged the Ocean Platform to administer bi-weekly assessment scales before the group session, automatically completing a series of complex algorithms that were not possible in the EMR. This data collection approach meant that the patient’s chart was updated in the EMR in real-time, thereby allowing the psychiatrist to review each patient’s results before seeing them. The presentation will cover the clinical, technical, and patient perspectives of the program innovations, and include a live demo of the data collection approach so that attendees can see it in action.

Presenters

• Jesse Lamothe, QIDSS, Hamilton FHT
• Brad Laforme, MSW, RSW, Substance Use Program Coordinator, Hamilton FHT
• Nadeem Akhtar, MBBS (Lond),MA (Cantab),MRCPsych(UK), Psychiatrist, Hamilton FHT

Authors & Contributors

• Sari Ackerman, Research Assistant, HFHT, sari.ackerman@hamiltonfht.ca

Theme 5. Optimizing use of resources

Presentation Details

• Date: Thursday, October 26, 2017
• Concurrent Session F
• Time: 11:45am-12:30pm
• Room:
• 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, Representatives of stakeholder/partner organizations

Learning Objectives

1. Learn what it takes to develop a successful Discharge Patient Program
2. Learn which specialized nursing skills were identified by our program as necessary to implement a holistic telephone-based Discharge Patient Program
3. Learn how primary care, in a small rural setting, supports patient’s safe discharge back home and prevents potential re-admission to acute care
4. Learn about the positive effects of optimizing resources for both the nurse and patient

Summary/Abstract The Algonquin FHT developed a Discharge Patient Program to meet the needs of our patients, recently discharged from acute care, to support their seamless transition back into primary care.  We identified gaps during this transitional period, which negatively impact the patient’s ability to stay safely at home. These identified gaps could lead to repeat ER visits and readmission to acute care. The Discharge Patient Program RN has real-time access to the local hospital’s daily discharge summaries and in-patient charts.  HRM is installed in our EMR which allows for timely access to our patient’s discharge summaries.  Utilizing these available resources, our RN is able to build a complete patient history and thoroughly prepare for a telephone-based holistic patient assessment. The RN identifies and pro-actively resolves any high-risks that might lead to a hospital re-admission including:  1.  Best possible medication history,  2.  Symptom review and management,  3.  Assessment of safety at home  4.  Assessment of need for referral to community agencies or FHT supports,  5.  Booking follow-up appointments with the PCP including urgent and home visits as needed.  The RN provides timely consultation with our physicians, pharmacies, CCACs, community supports and FHT programs to support the patient’s safe return home.  Huntsville is a rural community with limited resources to support our patient’s successful transition home post-acute care discharge.  Our Discharge Patient Program, through early assessment and identification of high risks to re-admit, prompt medical interventions, promoting patient self-management and preventing medication errors, shows remarkable results that support our patient’s safe return home and prevent hospital re-admissions. Presenters

• Jane Derbyshire, RN CRE, Primary Care Team Lead, Algonquin FHT
• Heather Aben, RN, Discharge Patient Program, Algonquin FHT