Theme 4. Strengthening partnerships

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: Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

• The purpose of the presentation is to share the model of bringing an Opioid Use Disorder  Clinic into a community pharmacy setting, with a counselling agency to provide addiction support avenues for members of the community who are experiencing an opiate dependency.
• At the end of this session, the learner will gain knowledge on:
  1. The framework that best supports integration of  the FHT pharmacist  with a physician specialist in the area of opiate addictions, and a counselling center specializing in providing supports for individuals experiencing  an opioid dependency.
  2. The key partnerships to implement a successful Opioid Use Disorder Clinic to the community to ensure sustainability.

Summary/Abstract Responding to the MOHLTC vision for an integrated, primary health care system for Ontario, through the Price/Baker Report (May, 2015), which provides opportunities for innovative care delivery, increased integration with other primary health care providers and the broader system to collectively promote the health of community populations, there was a recognized need to better support people in Huron-Perth county experiencing an opioid dependency. To address this concern, the STAR FHT pharmacist providing his expertise as well as his pharmacy space, in collaboration with a family physician specializing in Methadone/Suboxone substitution therapies, a Nurse Practitioner from a local hospital providing primary care for unattached patients, and a community Addictions Counselling Center have teamed up to provide an Opioid Use Disorder Clinic. The motivation behind the development of this clinic reflects on some interesting statistics.  Although Perth and Huron Counties ranks on a provincial level as having some of the lowest rates of opioid users (n=3,453 Perth), (n=3,363 Huron) only 2% (Perth), and 2.5% (Huron) respectively, of this population receives opioid maintenance therapy, which underscores the concerns about possible opioid dependency in this population and therefore the need for the provision of an available comprehensive addiction support clinic. The clinic is structured where STAR FHT patients as well as individuals from the community, who are experiencing an opioid addiction, and wish to seek treatment, have an opportunity to receive a comprehensive approach to help manage their drug dependency. The clinic involves the collaboration of a family physician skilled in providing a Medication-Assisted Treatment Program for Substance Dependence, STAR FHT Pharmacist who offers his expertise in area of dosing, titration, interaction, prevention of adverse events etc., as well as providing the pharmacy space two afternoons a week for the clinic, a hospital Nurse Practitioner for the provision of primary healthcare services for people who come to the clinic and are not attached to a family physician, and an available drug counselor from Choices for Change, who can provide support through education, counseling, service referral, relapse prevention strategies, harm reduction etc. This comprehensive collaborative approach to care of individuals experiencing an opioid addiction supports an environment that is non-judgmental, emphasizing a holistic approach to each person in all the services they offer. The following is a list of services available at the clinic:

• Help with understanding opiate dependence, methadone/suboxone and adjusting to the program; suggestions regarding management of withdrawal, treatment options, and taper readiness Help with health issues (Hep C, HIV/AIDS) and access to health care
• Referrals and links to local mental health agencies, OW/ODSP, residential treatment, employment/education agencies, and help with basic life issues
• Support for mental health issues such as depression, anxiety, trauma; referral to psychiatrist
• Access to STAR FHT Smoking Cessation program (STOP) for STAR FHT patients, or Smoking Cessation support for patients with no Family Physician, through Choices for Change
• Counseling including reducing harm, relapse prevention, stress management
• Access to Nurse Practitioners for primary healthcare, and a Dietitian
• Access to harm reduction supplies (safer crack smoking kits, safe injection kits, condoms, and lubricant). Safe disposal of used supplies.
• Naloxone Kits

This comprehensive model of care, although in its early stages, of less than a year,  presents as a sustainable approach to supporting and treating individuals in the community who have an opioid dependency.  It provides as a viable option for patients of family health teams who are experiencing drug addiction to seek anonymous treatment, education, counseling, and referral to services to support their journey to remain addiction free. Presenters

• George Jansen,  STAR FHT Pharmacist, STAR FHT, Owner of  Remedy’sRx Pharmacy (Westend Pharmacy Stratford)
• Stacey Shantz,  Addiction Counsellor,  BA OCGC, Choices For Change Alcohol, Drug and Gambling Counselling Centre

Authors & Contributors

Theme 2. Planning programs for equitable access to 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: 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 Participants will learn about the program and collaborative between the Hospital for Sick Children and CFHT.  Participants will hear about challenges and successes and the evidence supporting the continued implementation of this program. Summary/Abstract In the Fall of 2016, the Couchiching Family Health Team (CFHT) began work on an exciting new partnership with Hospital for Sick Children (HSC) through the Collaborative Integrated Care Initiative. The CFHT was selected to be the pilot site for development of an innovative program for youth between ages 8-17 who are experiencing unexplained medical symptoms and co-occurring mental health issues. Working with an HSC psychiatrist, the child’s family doctor and/or community paediatrician, the clinic provides a 16 week protocol to treat children and youth with comorbid medically unexplained symptoms and mental health issues.  Psychiatric consultations occur through the Ontario Telehealth Network and involve the child, family, a CFHT Social Worker, as well as the child’s medical/psychiatric team. The goal of the project is to provide comprehensive, seamless, coordinated service to complex children and families, while simultaneously building the capacity of paediatricians and family doctors to effectively manage these cases in the future  MUS in youth is a clinical classification describing a pattern of behaviour in which young people and their parents repeatedly seek medical help for disabling physical symptoms.  Despite extensive medical evaluation, there is no identifiable organic pathology to explain the severity of symptoms or functional impairment. The families generally attribute the condition entirely to physical disease. In addition to the term MUS, there are several other descriptive terms applied to this population. These include psychosomatic symptoms, somatoform disorders, functional disorders and now Somatic Symptom Disorders (DSM V). Common MUS presentations include abdominal pain, headaches, chest pain, gait disturbances, pseudo seizures or other somatic symptoms associated with decreased ability to function. This CFHT- HSC project is a quality improvement initiative supported by the Medical Psychiatry Alliance (MPA), an innovative partnership between the Centre for Addiction & Mental Health, the Hospital for Sick Children (HSC), Trillium Health Partners and the University of Toronto; the goal of which is to create new innovative models of care.  The integrated collaborative initiative is a team-based care service where outcome is tracked and treatment modified accordingly. The team consists of a care manager Ms. Norangie Carballo-Garcia MA, MSW, the primary care physician who remains the most responsible physician (MRP) and a HSC psychiatrist Dr. Rose Geist. The team will use OTN for team and patient based consultation and care planning. Dr Geist will be available to discuss patient care issues with the Mapmaking the collaboration from MRPs key in successful intervention for these patients and families. Our goal is to support primary care in the management of these patients using this collaborative service delivery model (described below) for 16 weeks, after which time the patient will be referred back to their MRP with ongoing support to the primary care physician by the care manager and the psychiatrist. Presenters

• CFHT

Theme 1. Effective leadership and governance for system transformation

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.)

Learning Objectives In this session, participants will learn about the journey embarked on by the Garden City and Niagara on the Lake Family Health Teams as they underwent a voluntary merger to form the Niagara North Family Health Team. Lessons learned, planning and implementation of this merger will be discussed. Summary/Abstract On April 1, 2017 the NOTL and Garden City Family Health Teams joined to form the Niagara North Family Health Team. This merger involved a change in name, dissolving a family health team, changes in governance structures, resource allocation, human resources management as well as many process changes. In this session, we will present on not only the process that brought us to the decision to merge, but also on the development of the implementation and communication plan for the project. We will share the legal, financial and communication challenges that we encountered in order to prepare other family health teams considering this type of merger. In addition, human resources issues will be presented with their associated resolution. We will present on the past and current organizational structures and well as the changes in governance. The Patient’s First legislation challenges us to think about how we can integrate and enhance our services to patients. The overall goals of our merger were to facilitate change, increase access to programs and services and to provide a platform for enhanced integration into our communities. Presenter

• Mary Keith, Executive Director, Niagara North Family Health Team

Authors & Contributors

• Dr. Jorin Lukings, Vice-Chair Niagara North Family Health Team
• Dr. Brian Kerley, Board Chair, Niagara North Family Health Team
• Dr. Lou Ricciardi – Merger Committee, NOTL Family Health Team
• Dr. Tim Bastedo, Merger Committee NOTL Family Health Team

Theme 7. Clinical innovations for specific populations

Presentation Details

• Date: Thursday, October 26, 2017
• Concurrent Session E & F
• Time: 10:45am-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

Learning Objectives Each year more than 650,000 Ontario Drug Benefit (ODB) eligible Ontarians receive a prescription for opioids. This represents 20% of all ODB eligible residents. More than 34,000 are on long term opioid therapy. Today, prescription opioids are more likely to be found on the street than heroin and have become the drug of choice for teens. More than 3,000 opioid related emergency department visits and 640+ opioid related deaths occur each year. Primary care needs to focus on this issue! Through the use of innovative new EMR tools, we will demonstrate how primary care clinicians can optimize their approach to the safe prescribing of opioids and have a significant impact on the clinical outcomes of these patients. Summary/Abstract Meeting the recommended prescribing requirements and having the time and expertise required to provide optimal, individualized opioid treatment for patients with chronic non-cancer pain is a real challenge for primary care physicians. In response to this, and built upon the updated 2017 Canadian Guidelines, through a collaborative effort supported by the Guelph FHT, the East Wellington FHT, the eHealth Centre of Excellence, and TELUS Health, a new set of EMR tools have been developed to enable clinicians to safely and effectively prescribe opioid medications to their patients with chronic non-cancer pain. These tools are presented in the form of a toolbar which appears in the patient’s chart within the EMR should they require opioid therapy. A highlight of the toolbar is that it displays the calculated morphine equivalents (MEQ’s) that the patient is on, and it turns color to attract attention when the levels are above certain ranges. The toolbar also includes a number of simple buttons which represent each of the guideline requirements (ex. pain condition diagnosis, risk screening, goal setting, informed consent, appropriateness of opioid(s) selected and dose, opioid effectiveness, and drug testing). The buttons also turn colour if any of the requirements are either missing or out of date, providing clinicians with an ‘at a glance’ view of the status of the patient’s opioid management. Clicking the buttons brings up standardized, evidence based tools used to manage their care. There are also buttons that provide links to other related tools, references, handouts and patient report cards. We look forward to sharing our experiences and results and to showing you how you can use these tools in your practices. Presenters

• Kevin Samson, Family Doctor, IT Lead, East Wellington Family Team
• John Swekla, Senior Health Business Consultant, TELUS

Authors & Contributors

• Guelph Family Health Team
• East Wellington Family Health Team
• eHealth Centre of Excellence
• TELUS Health

Theme 3. Employing and empowering the patient and caregiver perspective

Presentation Details

• Date: Thursday, October 26, 2017
• Concurrent Session E & F
• Time: 10:45am-12:30pm
• Room:
• Style: Workshop (session is structure for interaction and/or hands-on learning opportunities)
• 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. Improve knowledge of the patient experience of discharge from hospital and the connection to adherence to primary care follow up.
2. Provide an overview of patient and family involvement in the design of patient oriented discharge summaries (PODS), including the input of vulnerable populations.
3. Provide hands-on experience using innovative design thinking methodology and patient-experience mapping to re-think discharge and the link to follow up.

Summary/Abstract The period following discharge from a hospital is a vulnerable time for patients. Discharge summaries are an increasingly common tool to aid communication between the hospital-based health care providers and the patient’s primary care team.  While some discharge summaries also contain instructions intended for patients to follow when they get home, these are not usually patient-centered. Our team co-developed a patient-oriented discharge summary (PODS) template and guidelines with many patients and families and this initiative is now being rolled out across Ontario. Results from early pilot studies have shown an improvement in understanding and adherence to primary care follow up appointments. Our team is encouraged by those results and feels that there is potential in further integration between PODS and primary care via FHTs. PODS is currently being rolled out at 25 hospitals across all 14 Local Health Integration Networks in Ontario, so this session will be relevant to staff at many FHTs throughout the province. This session will start by sharing insights regarding the patient experience at discharge and patient and family input on PODS. A case study will then be shared, followed by preliminary results and an exploratory discussion of proposed integration between hospitals and primary care using PODS. Lastly, this interactive session will allow attendees to implement this information by guiding groups through patient-experience mapping of the discharge through to follow up process.  We encourage attendees to bring sample discharge summaries from their own patients to aid in the discussion and re-design of patient-centered discharges. Presenters

• Shoshana Hahn-Goldberg, PhD, Post-Doctoral Fellow, OpenLab, University Health Network
• Tai Huynh, MBA, MDes, Creative Director, OpenLab, University Health Network
• Dr. Karen Okrainec, MD, Clinician Scientist, University Health Network

Authors & Contributors

• Dr. Howard Abrams
• Rasha Kubba

Theme 5. Optimizing use of resources

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: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

• Learn tips on how to implement group diabetes visits from a FHT that has been doing them for over 5 years.
• Questions addressed include:
  1. Are group visits right for your FHT?
  2. What do patients think of them?
  3. What are the privacy concerns?
  4. How many staff members are needed?
  5. What is the ideal size for a group?
  6. What should the frequency be?
  7. What should you never discuss in a group visit?
  8. What are the billing codes?
  9. Are they financially sustainable?
  10. What is it the data on their effectiveness?

Summary/Abstract In medical literature, group visits have been described as a highly effective method of delivering healthcare to patients, especially those with chronic diseases such as coronary artery disease, congestive heart failure and diabetes. They are a more efficient way for health practitioners to see patients. Patient satisfaction is high for patients in group visits. Participants have the opportunity to learn from each other. Behavioural changes that otherwise might not occur have been observed in group visits. We started group diabetes visits over 5 years ago and they have enabled our practice to provide high quality care to over 225 of our diabetic patients. Measured outcomes have been equal to and better than our one on one visits. In addition, patients have been more satisfied in a group setting. Patients have learned from each other and we have had success stories with smoking cessation, insulin starts and lifestyle modification where the family doctor was not successful, often for many years. Finally, these visits have been revenue neutral to revenue positive when compared to one on one visits (even with the loss of Q040A bonus codes which are only available with individual visits). Presenters

• Anil Maheshwari, MD, Family Physician, Grandview Medical Centre FHT
• Christine Paquin, RN, RN/CDE, Grandview Medical Centre FHT

Authors & Contributors

Theme 2. Planning programs for equitable access to care

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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives Attendees will see how reaching out to a high needs elementary school has shown that through community partnership and collaboration, it is possible to bring health promotion and education to youth that may not have access otherwise. Students are equipped with the confidence and skills to prepare healthy foods, and shown how to make smarter food choices. They are given education and hands on training to incorporate an exercise component into their daily routine. This initiative makes it possible to connect with and empower the health of our future generation, making a positive impact on the youth and their families, as they are at a significantly higher risk of facing the many challenges that are attributed to social determinants of health. Summary/Abstract Thamesview Family Health Team has partnered with the Chatham Kent Community Health Centre and the Maple City Run Group to provide a Youth Program to Victor Lauriston Public School, geared towards supporting students with high needs/social determinants of health challenges. A dietitian provides on site services aimed at students in grades 5/6 with cooking classes and nutritional education. Students are randomly selected to participate. Two classes run every week. The fitness certified FHT Registered Nurse and CHC Child and Youth Worker, as well as the Maple City Run Group provide on site services to students in grades 7/8 with learn-to-run groups.  Two run groups run every week. Students selected, participate in the 8 week program. Pre and Post Surveys are completed and evaluated for program improvement.    Fitness surveys will evaluate current level of fitness – post survey will measure increase of activity.  Nutrition surveys will evaluate current knowledge of nutrition to knowledge once education has been introduced. Presenters

• Kerri Wood, Registered Nurse / Fitness Instructor, Thamesview Family Health Team
• Coraine Wray, Registered Dietician, Thamesview Family Health Team

Authors & Contributors

• Kerri Wood, Registered Nurse, Thamesview Family Health Team
• Coraine Wray, Dietician, Thamesview Family Health Team
• Brooke Smith, Child and Youth Worker, Chatham Kent Community  Health Centre
• Scott Bacik, Vice Principal, Victor Lauriston Public School
• Doug Robbins, Maple City Mile Run Group

Theme 1. Effective leadership and governance for system transformation

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.), Representatives of stakeholder/partner organizations

Learning Objectives The Patients First Act empowers local governing bodies to play a key role in leading system transformation. This session will foster a clearer understanding of this important role.  “Systems Thinking” is a way of thinking about, and a language for describing and understanding, the forces and interrelationships that shape the behavior of human systems.  This session will explore this idea in the Ontario context. Summary/Abstract North Simcoe Muskoka LHIN has been working closely with the governing bodies of its health service providers as well as the boards of other human service providers to develop a clearer understanding of the role governors play in moving from siloed service delivery to integrated service delivery systems.  This session will report on the key learnings of the NSM journey.    The presentation will include a description of systems thinking and how it is being applied in NSM.  This particular experience in NSM will be used as an illustration of how systems thinking can be applicable in differing ways in other LHINs. Presenter

• Robert Morton, Past Chair, North Simcoe Muskoka Local Health Integration Network

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

Presentation Details

• Date: Thursday, October 26, 2017
• Concurrent Session D
• Time: 9:30am-10:15am
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. Understand the priority joint initiative of Family Health Team Dietitian (FHT RD) Network and Ontario Primary Health Care Action Group (PHCAG-ON) in collaboration with the Quality Improvement Decision Support Specialists (QIDSS) community
2. Learn about the standardized malnutrition screening and assessment process in primary care settings
3. Determine the level of readiness on adopting a collaborative interprofessional team approach to identify and manage malnutrition
4. Inform the development process of EMR tools to capture outcome data and assess quality of care
5. Identify your team’s niche in supporting provincial quality improvement projects

Summary/Abstract

• Background: Despite the fact that 34% Canadians over 65 years are at nutritional risk and 47% of seniors are malnourished on hospital admission, malnutrition is often overlooked. The Dietitians of Canada Ontario Primary Healthcare Action Group (PHCAG) has made malnutrition screening for seniors in primary care settings a priority initiative and has been advocating for standardized malnutrition screening and assessment, a collaborative interprofessional team approach to manage malnutrition and electronic medical record (EMR) customized charting templates to collect outcome data to assess quality of care and support upcoming provincial quality improvement projects.
• Methods: Gaps were identified in practice with respect to malnutrition screening and assessment (eg. low referral rate, variability in assessment approach and lack of standardized data collection). EMR customized charting templates (i.e. encounter assistants) are designed to guide clinical workflow in identifying patient populations, using appropriate screening instruments and processes, and standardizing data collection to facilitate on-going monitoring/evaluation of service quality and effectiveness.
• Results: Malnutrition encounter assistants were created to include 3 validated instruments (eg. CNST, MNA-SF and SCREEN II-AB) appropriate for screening vulnerable seniors (eg. recently discharged from hospital and with cognitive issues).   Positive screenings are referred to dietitians for further assessment including subjective global assessment to determine level of malnutrition and appropriate intervention. Nutrition diagnosis, weight status, Mediterranean diet score, hand-grip strength, biochemical tests and internal/external referrals are recorded in the encounter assistants. These encounter assistants have recevied exceptional feedback by the QIDSS community after the dissemination at a weekly teleconference in Winter 2017.
• Implication: New encounter assistants for malnutrition have embedded validated screening/assessment instruments into EMR and simplified the process of data collection. More than 150 dietitians and other providers have been trained at PHCAG RD Research Day, AFHTO conference/webinars and via AFHTO IHP community of practice to screen seniors at nutritional risk in a standardized manner with a systematic approach to outcome measurement.  Recommended outcome indicators have been shared with Quality Improvement and Decision Support Specialist (QIDSS) network to facilitate adoption and spread in provincial quality improvement projects.

Presenters

• Denis Tsang, Registered Dietitian/Lead of AFHTO Diabetes Community of Practice, Carefirst Family Health Team/AFHTO
• Amy Waugh, Registered Dietitian, Upper Grand Family Health Team
• Michele MacDonald Werstuck, Registered Dietitian, Hamilton Family Health Team

Authors & Contributors

• Marg Alfieri, RD, President (Association of Family Health Team of Ontario), Associate Professor (McMaster University), Registered Dietitian (Centre for Family Medicine FHT)
• Jennifer McGregor, RD, Registered Dietitian (Niagara North Family Health Team)
• Ashley Hurley, RD, Registered Dietitian (City of Lakes Family Health Team)
• Lee Kapuscinski, RD, Registered Dietitian (Guelph Family Health Team)