Theme 2. Optimizing access to interprofessional teams

Presentation Details

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

Learning Objectives

This session will provide attendees the valuable lessons learned throughout the course of implementing a rapid assessment model of care for patients referred to Social Work services. Participants will also learn the outcomes of implementing a model similar to the rapid assessment not only for mental health services, but all services provided for patients and learn how to reduce long wait-times.

Summary/Abstract

The Rapid Assessment Model was implemented due to the increasing wait time for initial assessments for patients newly referred to the Social Worker. Wait-times have decreased from upwards of 4 weeks to an average of 12 business days for an initial appointment through the rapid assessment model. Not only has the rapid assessment model decreased wait times, it is also helping with a reduction in case load for the professional, with only 60% of patients continuing with counselling after the rapid assessment model. 40% of patients are referred to programs, community services, or EAP, or providing with resources and their cases closed.

Presenters

• Cheryl Hines, BSW RSW, Social Worker, Thames Valley Family Health Team
• Natalie Clark, BHSc, Program Administrator, Thames Valley Family Health Team

Authors & Contributors

• Cheryl Hines, BSW RSW Social Worker, Thames Valley Family Health Team
• Natalie Clark, BSW RSW Social Worker, Thames Valley Family Health Team

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/18/2016
• Concurrent Session F
• Time: 11:45am – 12:30pm
• Room: Pier 4
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Research/Policy (e.g. Presentation of research findings, analysis of policy issues and options)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Representatives of stakeholder/partner organizations

Learning Objectives

Participants will gain knowledge on the importance of population-based planning and an understanding of how to ensure that equity is incorporated into this planning. This will be discussed in the context of an equity-based population planning project that was just undertaken in the SW LHIN. Methods, results and actionable outcomes/strategies will be reviewed.

Summary/Abstract

Characteristics of vulnerable populations will be discussed  and clinical factors (physical and mental health) will be described. Geographical access based on various factors will be reviewed. Important gaps were mainly found in the rural areas of the SW LHIN. These gaps/risk factors included lower access to primary care providers, less access to team-based care and increased risk of primary care physicians retiring. People living in the lowest income quintile in the SW LHIN were often in the areas with the lowest accessibility to primary care providers.

Presenters

• Jennifer Rayner, Research and Evaluation Lead, Association of Ontario Health Centres
• Andy Kroeker, Executive Director, West Elgin CHC

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Learn about the philosophy of care behind the Couchiching Community Health Link, the variables leading to successful system navigation, and the examples of how generative relationships came together to support a patient through a significant challenge affecting their life.

Summary/Abstract

This presentation will provide an overview of the philosophy of care employed by the Couchiching Community Health Link, identify the variables leading to the success of clinical system navigation, and, through using the patient’s journey, describe how formative relationships allowed for a significant improvement in their life. This presentation will allow participants to follow a patient through their healthcare journey and hear how clinical system navigation supported them, as well as hear patient feedback and recommendations for the future of health care and Health Links.

Presenters

• Sandy Dupuis, Clinical System Navigator, Couchiching Family Health Team
• Stephanie Kersta, Project Manager, Couchiching Family Health Team
• Patient Video Appearance

Authors & Contributors

• Sandy Dupuis, Clinical System Navigator, Couchiching Community Health Link
• Stephanie Kersta, Project Manager, Couchiching Community Health Link

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• Room: Harbour B
• 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.), Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Participants will learn from the Brighton Quinte West FHT experience of advancing a community governance model built on collaborative leadership to achieve their organizational transformation.   The presentation will outline the process to create a standard approach for accountability and link strategic direction within a policy framework.  The process focused on consistent application of relevant priorities based on the identified organizational deficits and opportunities for corporate standardization.  The approach to link system performance targets and organizational measurement will be beneficial to other organizations in defining a high performing team and incorporating unique community perspectives.

Summary/Abstract

The MOHLTC Governance Attestation catalyzed a strategic planning process that aligns performance measurement with fiduciary accountability

1. The board identified areas of development that aligned with the Provincial transformation and the LHIN Integrated Health Service Plan
2. A quarterly scorecard based on quality and financial indicators is reported and reviewed to assess performance and facilitate course corrections consistent with the operating and quality plans
3. The Corporate Bylaws revisions promoted compliance with the recent amendments to legislative requirement and established an annual schedule of corporate policies revision
4. The evidence based approach promoted a culture of accountability including integration, standardization and collaboration

Presenters

• Wendy Parker, Executive Director, Brighton Quinte West Family Health Team
• Richard Wiginton, MD, CCFP, Board Chair / Lead Physician, Brighton Quinte West Family Health Team

Authors & Contributors

• Wendy Parker, RN, BSC, MHA, Executive Director, Brighton Quinte West Family Health Team
• Richard Wiginton, MD, CCFP, Board Chair and Physician Lead, Brighton Quinte West Family Health Team
• Bonnie Ainsworth, Program Coordinator, Brighton Quinte West Family Health Team

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• Room: Pier 4
• 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

Learning Objectives

1. Discuss the benefits and drawbacks of using patient-reported outcome measures that assess multiple areas of health and function within interprofessional primary care teams
2. Describe the challenges and strategies for successful implementation of patient-reported outcome measures

Summary/Abstract

Using the case example of falls programming, we explored using the Modified Falls Efficacy Scale and Late Life Function and Disability Instrument – Disability Scale to measure patient outcomes. Findings suggest that scale administration time varies by setting, scales require patients’ insight into their abilities, and follow-up assessment can be a challenge. We will discuss lessons learned regarding the usefulness and process of collecting patient-reported outcomes and preliminary findings on the effectiveness of falls programming in interprofessional primary care. This research provides information to support collection of outcomes data in interprofessional primary care teams to inform service improvement and determine effectiveness.

Presenters

• Carri Hand, PhD, OT Reg. (ON), Assistant Professor, University of Western Ontario
• Catherine Donnelly, Queen’s University
• Maria Borczyk, Aurora-Newmarket FHT
• Martha Bauer, McMaster FHT
• Nicole Bobbette, Queen’s FHT – Belleville site

Authors & Contributors

• Nanette Bowen-Smith
• Cecilia Doesborgh
• Dana Driesman-Klover
• Gillian Fish
• Colleen O’Neill

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Creating a virtual medical home represents an opportunity to improve integration and access to care for patients at risk of or living with diabetes when their primary provider is not part of an interdisciplinary FHT.  In this workshop, participants will:

1. Review the concept of the medical home and the demonstrated benefits of this model
2. Discuss the process and practical steps to implementing this approach
3. Assess the feasibility of offering services in this way
4. Determine capacity and explore how to integrate health professionals from their team into community practices

Summary/Abstract

This program is still in the early stages, having begun in December 2015. We have already seen improvement in attendance and therefore anticipate that there will be accompanying improvements in outcomes.     In the session, we will review preliminary results related to:

1. Access
2. Integration
3. Information sharing
4. Patient satisfaction
5. Provider satisfaction

While focused on DEP services, this session will offer participants the opportunity to participate in a discussion of how to best leverage resources to improve access while considering the demands of providing excellent care to rostered patients.

Presenters

• Lisa Weinberg, RD, Mount Sinai Academic Family Health Team
• Deborah Adams, MA, MHSc, CHE Administrative Director, Mount Sinai Academic Family Health Team

Authors & Contributors

• Lisa Satira, RD Mount Sinai Family Health Team  lsatira@mtsinai.on.ca

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/18/2016
• Concurrent Session E
• Time: 10:45am – 11:30am
• Room: Metropolitan Ballroom West
• 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

1. Attendees will understand how they can implement best practices in quality improvement initiatives
2. Attendees will learn about gaps during transitions of care that highlight needs for further system integration
3. Attendees will understand how members of the multidisciplinary team can be efficiently involved in the post-hospitalization phase to reduce complications at this stage

Summary/Abstract

Data collected from the CVFHT EMR shows an 84% reduction in patient readmissions and a 16% improvement in post-hospitalization follow-up rates using various members of the multidisciplinary team from Jan 2015 to March 2016. The HDP only considers follow-up rates with physicians; in contrast, the CVFHT considered a valid follow-up as one where a contact is made with an MD, NP or RN. This method optimizes the role of various team members, facilitates a sustainable process and supports patient access to primary care. Re-hospitalizations were prevented and home visits were made same day as needed, consistent with patient-centered care.

Presenters

• Gordon Canning, Nurse Practitioner, Credit Valley Family Health Team
• Heather Hadden, Pharmacist, Credit Valley Family Health Team
• Inge Bonnette, Registered Nurse, Credit Valley Family Health Team
• Claudia Mazariegos, Registered Dietitian, Credit Valley Family Health Team
• James Pencharz, MD, Credit Valley Family Health Team

Authors & Contributors

• Hilal Syed, Quality Improvement Decision Support Specialist at the Credit Valley Family Health Team
• James Pencharz, Family Physician, Credit Valley Family Health Team

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Pier 7 & 8
• 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. Extending community partnerships within primary care organizations through a Health Links’ approach
2. The role of Community Service Workers (CSW) embedded in primary care organizations
3. Data on the effectiveness of the initiative
4. Challenges and mitigation strategies with scaling up and spread in an urban primary care setting

Summary/Abstract

Qualitative and quantitative data will be presented to demonstrate the value and need for this role.  Anecdotal feedback from physicians and other health professionals has been positive. On the average there have been 430 referrals annually addressing a variety of  unmet social needs related to education, unemployment, food insecurity, housing, social isolation, social safety net, Aboriginal status and disability.  Income insecurity is the number one unmet need for patients. Examples: CSWs assisted  patients in accessing emergency funds so heat and water would not be shut off and assisted frail seniors in navigating government services and  forms.

Presenters

• Linda Robb Blenderman, RN, BScN, MSc, Kingston Health Link Project Coordinator, Kingston Health Link
• Laura Cassidy, Comm, Quality Improvement Decision Specialist, Kingston Health Link
• Francine Janiuk, RN, BScN, MPA, Nursing Manager, Queen’s Family Health Team

Authors & Contributors

• Maria Sherwood B.A., B.S.T. Community Services Worker, Kingston Health Link
• Sheena Lyons, Community Services Worker, Kingston Health Link
• Michael Curtis, B.Sc., Community Services Worker, Kingston Health Link

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Harbour C
• Style: Panel Discussion (in addition to providing information, panelists interact with one another to explore/debate a topic)
• 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.)

Learning Objectives

1. The benefits of the mixed governance model
2. How our model is structured to deal with conflict of interest
3. Enabling structures we have put in place
4. How patients are involved
5. Issues where we remain challenged

Summary/Abstract

1. High board member satisfaction with 100% of board members agree/strongly agree: “The Board participation is a positive experience for me” and “Generally the Board has a good working relationship with the Executive Director and Lead Physician”
2. Ability to consistently move through the agenda
3. Success to discuss and resolve sensitive issues such as negotiating a FHT FHO Agreement
4. High FHO satisfaction with all FHO members regularly attending weekly team meetings and particpating on team projects
5. High team satisfaction with 0% turnover of IHPs since 2013
6. High patient satisfaction with 92% of patients agree/strongly agree that they would refer a friend or family member to Village FHT and 93% score for HQO Patient Engagement scores

Presenters

• Mr Dev Chopra, Board Member, Village FHT
• Dr David Verrilli, Lead Physician and Board Vice Chair, Village FHT
• Ms Diana Noel, Executive Director, Village FHT