Theme 4. Strengthening partnerships

Presentation Details

• Date: Wednesday, October 25, 2017
• Concurrent Session A
• Time: 2:30pm-3:15pm
• 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

Learning Objectives

• Participants will learn:
  1. Why Guelph determined the need to integrate A/MH services into Primary Care
  2. How to scope the integration strategy
  3. What the “patient medical home” focus offered this integration effort
  4. How Guelph engaged patients, clinicians, leaders and governors
  5. Why medical/clinical leadership was critical to the success
  6. How human-centred design practices (e.g. empathy mapping) facilitated innovation and patient/caregiver engagement

Summary/Abstract

• Partners: Guelph FHT, Guelph CHC, CMHA Waterloo-Wellington, Stonehenge Therapeutic Community, Student Health – University of Guelph    The Act as One Service strategy: despite years of tweaking systems, there is a significant gap between primary care and A/MH providers in Guelph.  In addition, access to psychiatry and other specialized A/MH remains difficult, unclear and has long wait times.  The Sub-Region focus under Patients First presents an opportunity to fully integrate services around the population of Guelph and area.    The Process: With strong clinical leadership, partner organizations committed to comprehensive service integration based on the “Patient Medical Home” model.  A shared psychiatry lead was hired and four “prototype practices” volunteered to iteratively test changes, so that a new comprehensive model can be expanded to the whole community.

Presenters

• Ross Kirkconnell, Executive Director, Guelph Family Health Team
• Fred Wagner, Executive Director, CMHA Waterloo Wellington
• Raechelle Devereaux, Executive Director, Guelph Community Health Centre

Authors & Contributors

• Ross Kirkconnell, Executive Director, Guelph Family Health Team
• Fred Wagner, Executive Director, CMHA Waterloo Wellington
• Raechelle Devereaux, Executive Director, Guelph Community Health Centre
• Heather Kerr, ED, Stonehenge  Therapeutic  Community
• Alison DeMuy, CMHA WWD
• (MDs) Dr. Douglas Friars; Dr. Risa Adams; Dr. Dorothy Bakker; Dr. Joan Chan
• Julie Bruin, Systems Coordinator, Waterloo-Wellington Addictions and Mental Health Network

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

Presentation Details

• Date: Wednesday, October 25, 2017
• Concurrent Session A
• Time: 2:30pm-3:15pm
• 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,

Learning Objectives It’s time to go beyond collecting and reporting data for measurement sake. This has value, but the ultimate goal is to have a direct impact on population health. We’ve all been making progress on issues like data quality, searches, and reporting. Data itself, however, does not necessarily affect outcomes, as evidenced by the lack of membership-wide improvement to date on D2D indicators. It’s time to close the loop! We need to use our resources to develop systems and workflows that directly improve clinical outcomes. We’re going to go through a practical, real life example to show how this can be done. Summary/Abstract At EWFHT, we’ve developed tools to improve cancer screening rates by optimizing data quality, encouraging opportunistic screening, and connecting with patients on a population level.     To improve data quality, we developed a tool to synchronize the monthly CCO Screening Activity Reports with the EMR. We’ve also developed a Preventive Care Toolbar which displays a ‘Prev Care’ button in the middle of the patient’s chart. The button is green if all tests are up to date, yellow if there is a test due within 6 months, and red if a test is overdue.    Clicking the button opens a Preventive Care Summary form which shows the status of each screening test at a glance. It is also colour coded, it allows for individualized screening criteria for each patient, and it provides shortcuts to corresponding forms and requisitions.    The data from the Preventive Care forms is then used by EMR searches to generate lists of patients who are due for screening tests. These lists are linked to personalized letters which are automatically emailed to the patients. Patients can then email back to arrange for the tests to be done.     Screening rates and response rates are monitored on a regular basis to ensure patients actually get the tests done, closing the loop.    We’ve deployed these tools to other FHT’s and we’re measuring increased cancer screening rates.    With the right tools and workflows, data can be used to actually improve clinical outcomes for cancer prevention and many other aspects of health care. Presenters

• Dr. Kevin Samson, Family Physician and IT Lead, East Wellington Family Health Team
• Hope Latam, QIDS Specialist, East Wellington Family Health Team
• Michelle Karker, Executive Director, East Wellington Family Health Team

Authors & Contributors

• Joel Wilson, IT Data Management, East Wellington Family Health Team
• Michelle Karker, Executive Director, East Wellington Family Health Team
• Viviana Keir, Integrated Patient-Centred Quality Coordinator, East Wellington Family Health Team
• Heidi Evans, Conestoga Co-op Student, East Wellington Family Health Team

Theme 3. Employing and empowering the patient and caregiver perspective

Presentation Details

• Date: Wednesday, October 25, 2017
• Concurrent Session A
• Time: 2:30pm-3:15pm
• 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, Representatives of stakeholder/partner organizations

Learning Objectives On completion of this session, the participants should be able to:

1. Understand the complexities of multimorbidity in older adults
2. Understand how to involve patients in the co-design of interventions/tools.
3. Learn how to apply knowledge translation science in the design of complex interventions and tools

Summary/Abstract Background: More than half of older adults have ≥ 2 chronic conditions. Clinical guidelines and tools are created mostly for a single disease, not created for older adults, and do not consider health priorities. Our objective was to develop a patient-centered, web-based knowledge transation (KT) tool called “KeepWell” with the potential to optimize self-management of older adults and to facilitate the clinical decision making of family physicians in the context of multimorbidity. Design and participants: Integrated KT strategy involving: older adults with multimorbidity (age ≥ 65 years), e-health and KT experts and providers; and the Knowledge-to-Action framework to create KeepWell. The tool (including its name, features and design) was co-designed by a working group of 10 older adults with multimorbidity in 7 informal focus groups. The prototype was iteratively created using input from: older adults; evidence-based clinical practice guidelines; family physicians, geriatricians, KT researchers; and literature on KT and behaviour change. Setting: KeepWell is a web-based application that can be used on any computer, tablet, or smartphone in the community and primary care. Significance: KeepWell is innovative as it integrates the care of any combination of 11 chronic conditions affecting older adults, has a clinical decision support component for providers, and responds to the complexities of disease concordance/discordance. KeepWell has great potential for scale and spread. It is a web-based platform, so it will be relatively inexpensive to deliver and no human resources will be required for its functioning in the community. It will need little more than the dissemination mechanisms to be scaled up, so it can be easily spread across Ontario primary care practices and teams. Presenters

• Monika Kastner, Research Chair, Knowledge Translation and Implementation, North York General Hospital

Authors & Contributors

• Leigh Hayden
• Julie Makarski
• Yonda Lai
• Nate Gerber
• Joyce Chan

Theme 2. Planning programs for equitable access to care

Presentation Details

• Date: Wednesday, October 25, 2017
• Concurrent Session A
• Time: 2:30pm-3:15pm
• Room:
• Style: Workshop (session is structure for interaction and/or hands-on learning opportunities)
• 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. To gain knowledge on how collaboration and coordination of services decrease barriers and improve accessibility for the most marginalized and vulnerable populations.
2. To receive evidence of how collaboration and coordination of services maximize positive client outcomes, including stable housing, reduced hospitalizations, ER visits, and incarcerations.
3. To experience a pre-recorded interactive inter-professional client engagement encounter via video.
4. To learn how collaboration improves not only access to programs and services, but also how they impact the social determinants of health.

Summary/Abstract The Health Centre at 410, St. Michael’s Hospital is an inner-city primary care practice in Toronto, ON, comprised of approximately 10,000 patients, many of which who are under-housed and poor, and who live with multiple medical and psychiatric co-morbidities. The Centre is also in part funded by the AIDS Bureau of Ontario with a dedicated inter-professional team that provides care to approximately 1,500 HIV+ patients. The Centre has signed two memorandums of understanding (MoU) along with community partners to participate in the Positive Service Co-ordination for Homeless People Living with HIV/AIDS Program, and the HIV Complex Care Pilot Project. These MoUs aim at increasing cross-sector collaboration and partnerships to address the social determinants of health of our most vulnerable and marginalized HIV+ patients, many of which who also live with mental illness and addictions. The Centre has agreed to an open primary care referral process with our community partners, and our community partners provide intensive and comprehensive case management and housing supports. The presentation will explore with participants how partnerships between a hospital and community agencies support vulnerable and marginalized people living with HIV/AIDS, and help increase access to the social determinants of health. Presenters

• Daniel Bois, RN, HIV Resource Nurse, St. Michael’s Hospital
• Gordon Arbess, MD, HIV Program Director, St. Michael’s Hospital
• Kay Roesslein, Executive Director, LOFT Community Services

Authors & Contributors

• Sue Hranilovic, NP, St. Michael’s Hospital

Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/18/2016
• Concurrent Session E & F
• Time: 10:45am – 12:30pm
• Room: Harbour C
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

• Describe three clinical innovations for transitions and coordination of care for complex patients
• Determine feasibility of adopting and/or adapting one or more of the innovations presented
• Identify success factors in developing and spreading clinical innovations
• Consider potential roles for their own HealthLinks initiative in supporting innovation

Summary/Abstract

This presentation highlights clinical innovations in transitions and coordination of care for complex patients.  It illustrates key elements of three different approaches and outlines the success factors and learnings so others with similar needs can consider implementing in their settings. The three presentations will be followed by a panel discussion to explore the role of HealthLinks structures in these innovations and themes around enablers and barriers to developing and spreading these innovations.  Briefly, the three programs to be presented are as follows:

• Thamesview : 3 Family Health Teams located in the same LHIN who have worked closely with the community hospital and community partners will present on the Health Link High User Process.  Who the cohorts are, how the patients are identified, validated, the stratification (ie: frequent vs. long user over period of time), connection (how to connect with the patient, phone, home and office visits), monitoring (establishing Action Plan and its effectiveness) and how inactivation of the patients occurs.
• Prescott : Health Link is an innovative initiative that provides care to the most complex patients. Personal health goals are identified and the elaboration of a coordinated care plan is shared among the circle of care. The particularity of our Health Link is the home visit by a nurse practitioner, who provide direct care to the patient, on top of coordinating care. All pertinent interventions are shared with the primary care provider.
• Northumberland: The presentation will highlight the innovative and successful model of care that was created through a collaboration between the Northumberland Family Health Team  and Northumberland Hills Hospital  that provides interventions that reduce gaps in care for patients, with COPD/and or CHF  as they transition from the hospital to home. A team based approach to care, lead by an NP,  provides more intensive care in the patient’s homes in order to prevent hospital readmission, ER visits and to ensure positive patient experiences and positive health outcomes for the patient. 

Presenters

• Andrea Atkinson, Health Links Case Manager, Thamesview FHT
• Diana Hegedus, Health Links Case Manager, Tilbury District FHT
• Barb Lather, Business and Program Manager, Thamesview Family Health Team
• Francois P. de Courval, NP, M.SC, Nurse Practitioner, Prescott-Russell Health Link
• Sylvie Lemaire, Programm Manager, Prescott-Russell Health Link
• Laurie Angione, MN-NP Adult – Lead “Home Based Transition Care Team”, Northumberland Family Health Team
• Karen Peters, RPh, Northumberland Family Health Team
• Joanne Jury, Access & Patient Flow Improvement Specialist, Northumberland Hills Hospital

Authors & Contributors

• Laura Johnson, Executive Director, Chatham Kent Family Health Team
• Kelly Griffiths, Executive Director, Tilbury District Family Health Team
• Denise Waddick, Executive Director, Thamesview Family Health Team
• Nancy Snobelen, Director Partnerships & System Integration, Chatham-Kent Health Alliance
• Audrey Larocque –A.A. – Prescott-Russell Health Link

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 2 & 3
• 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

Participants will identify and learn about the implementation of a tablet based program, how the FHT spread the initiative to identification of other chronic diseases, and learnings after one year of implementing an initiative that took off drastically.

Summary/Abstract

The results have been truly transformative; in just over four months, over 40 percent of patients (~3000) were screened for smoking and their status was updated in the EMR. Of those, 432 current smokers were identified, and the Canadian Lung Health Test (CLHT) was administered to 1300 patients, resulting in over 500 patients identified at risk for COPD. This compared to just 45 CLHTs completed in the previous year. The FHT also experienced a 33 percent increase in smoking cessation program referrals in the four months after launching the program. As an added benefit, patients updated an average of three demographic details in their patient record and email consent was collected from over 30 percent of the total patient population. On average, the screening process took just 4.5 minutes. Instead of spending this time unproductively in the waiting room, the patient was able to actively contribute to their patient visit and patient record. We are currently completing year one evaluation and are very pleased with the results and are looking forward to sharing the results with the AFHTO attendees.

Presenters

• Stephanie Kersta, Project Manager, Couchiching Family Health Team
• TBD, CFHT
• TBD, CFHT

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 9
• 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

Attendees will develop an understanding of the barriers faced by some older adults with serious mental illness and other chronic conditions. They will learn about the approach developed by John Gibson House (JGH) and Village FHT to improve health outcomes for this very difficult to serve and vulnerable population. Application of technology such as OTN and secure email will be discussed.

Summary/Abstract

This holistic and comprehensive approach has resulted in medication adjustments/decreases, new diagnoses and follow up treatments. Homebound patients, who  refused to see a family physician for years now receive in-house services. Daily OTN monitoring enables staff to intervene earlier.   The number of:

1. ED visits has decreased from 10 visits to 6 visits
2. Hospitalizations decreased from 29 visits to 14 visits, just over 50%.

Secure email communication between JGH and VFHT supported rapid response to Flu Outbreak (2014/2015). The coordinated care enabled patients to receive prompt treatment, daily updates were easily facilitated and preventative measures (Tamiflu) were accessible to all patients.

Presenters

• Breanne John, John Gibson House, LOFT
• Diana Noel, Executive Director, Village FHT
• David Verrilli, Lead Physician, Village FHT

Authors & Contributors

• Laura Pye

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 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

1. Understand the role and benefits of the Markham FHT’s “Collaborative Care Group (CCG)”
2. Hear practical examples of how the CCG is integrated
3. Recognize the benefits to the Lead Physician (LP) and Executive Director (ED) in sharing FHT clinical oversight through the CCG
4. Learn how to implement a similar group at your FHT

Summary/Abstract

Approximately 15 program reviews are conducted annually, as well as 9 clinical role reviews on a biennial basis. Sharing the clinical leadership responsibility of the FHT among CCG members ensures the burden of this does not fall to the Lead Physician alone. The LP looks to group members to provide insight and guidance for all FHT clinical processes, while remaining accountable to the organization on deliverables.  The multi-disciplinary membership also ensures that the FHO/IHP group has representation in decision-making, and a venue for 2-way communication.

Presenters

• Lisa Ruddy, RN, Clinical Program Manager, Markham FHT
• Allan Grill, MD, CCFP, MPH, FCFP, CCPE, Lead Physician, Markham FHT, Markham FHT
• David Marriott, Executive Director, Markham FHT

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 7 & 8
• Style: Panel Discussion (in addition to providing information, panelists interact with one another to explore/debate a topic)
• 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

At the end of this session, attendees will be able to:

• Drill down into the Quality roll-up indicator to make sense of it at the team level
• Connect the “generalist” approach of primary care to the comprehensive approach to measuring quality with the composite Quality roll-up indicator
• Continue advocating for comprehensive (vs body-part-focused) measurement of quality in LHIN-sub-region reporting in preparation for launch of Patients First

Summary/Abstract

The strength of primary care is  that it specializes in being generalized.  It focuses on the person, and is works from the strength of the relationship with that person to improve and sustain their health as a person.  Primary care providers don’t manage diabetes.  They manage patients with diabetes (and whatever else they came with).  Measurement of quality in primary care needs to be “generalist” as well, and have a comprehensive view, not a body-part-specific focus.  AFHTO’s response to this need is the Quality roll-up indicator.  The down side of a comprehensive measure like this is that it is hard for front line providers to make sense of and take action on.  This presentation outlines how teams can drill down into the composite measure to guide local responses to the their overall quality score as reflected in the composite Quality roll-up indicator.  This presentation also outlines how local teams can use the Quality roll-up indicators to demonstrate the contribution of teams to the quality of primary care in LHINs (and eventually LHIN sub-regions).  It models a way to discuss planning, measurement and reporting in the context of Patients First that leverages this “generalist” mindset to minimize the risk of defaulting to the easier but less meaningful path of body-part-focused measures of quality.

Presenters

• Ross Kirkconnell, Executive Director, Guelph FHT
• Monique Hancock, Executive Director, STAR FHT
• Carol Mulder, QIDS Provincial Lead, AFHTO

Authors & Contributors

• Ross Kirkconnell, Executive Director, Guelph FHT
• Monique Hancock, Executive Director, STAR FHT
• Alan Maclean, Lead Physician, Superior FHT
• Carol Mulder, QIDS Provincial Lead, AFHTO

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Harbour B
• 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

1. Be able to describe the components of an effective daily micro-meeting (huddle) in a clinical team
2. Understand the impact of such a strategy on one FHT practice
3. Identify strategies for effective implementation, buy-in, and sustained engagement of daily team huddles

Summary/Abstract

A qualitative descriptive design was used to analyze participant perspectives around the influences of the team huddle on the quality of collaboration. Results confirm that daily team huddle improved awareness and knowledge sharing on the team and created an environment of teaching and learning. Huddle led to quality improvements on the team in both improved patient care communication and improved clinic processes. Results indicate improvement in areas including a positive work environment, integration and understanding of roles, team member engagement, communication, collaboration and accountability. Final results will be presented.

Presenters

• Katharine De Caire, MN, RN (EC), Clinical Director, McMaster Family Health Team

Authors & Contributors

• Ainsley Moore MD, CCFP, MSc
• Allyn Walsh MD, CCFP, FCFP
• Jennifer Everson BScN, MD, CCFP, FCFP