Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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

1. Learn how to improve patient safety as well as improve their health care journey while transitioning from hospital to home and home to hospital
2. Examine ways to prevent hospital re-admissions for both chronic and acutely ill patients
3. Examine the care needs that can be addressed within a patients’ home post-hospital discharge

Summary/Abstract

By October of 2016 we hope to have used our tracking codes and nearly full year of running the Transitions program to determine the following outcomes:

• The number of patients followed up by Transitions who still required readmission to hospital within 30 days of discharge
• Which medical diagnoses required the most follow-up and referrals, and to which disciplines
• How many home visits were done
• How many Primary Care Provider (PCP) visits were booked through Transitions and how many of these were within 7 days of hospital discharge ; if > than 7 days then why?
• The number of times a patient or family member called in to their Transitions program point person with questions or concerns
• How many hospital visits were completed through the Transitions program
• Qualitative data about the patient/family experience using surveys
• We hope to see that readmission rates within 30 days decrease over time. In keeping with our Schedule A and QIP targets, we hope to see > 80 home visits completed and 100 PCP appointments booked with >50% of PCP visits done within 7 days of hospital discharge.  Finally, we hope to see >400 pts at the bedside to initiate the transition from hospital to home.

Presenters

• Danielle Duns, Lead RN, Transitions Program, Markham FHT
• Lisa Ruddy, RN, Clinical Program Manager, Markham FHT
• Rebecca Robinson, Administrative Assistant, Markham FHT

Theme 4. Measuring performance to foster improvement in comprehensive care

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

Learn about OntarioMD’s EMR Progress Assessment (EPA) tool and the support available to users of certified electronic medical records (EMRs) to improve EMR use. The EPA helps you identify opportunities and quick wins by measuring your current use and determining if you are using the EMR’s functionality to the fullest degree. You will also learn how the EPA leads to practical advice for closing any gaps you would like to address through the EMR Practice Enhancement Program. The session will also include an update on the EMR Physician Dashboard and its high-value provincial indicators.

Summary/Abstract

OntarioMD’s EPA is the only comprehensive online tool in Ontario that can assess EMR use and is the starting point for the EMR Practice Enhancement Program. It is based on a nationally-recognized EMR Maturity Model and tailored to Ontario clinicians. The EPA is easy to use and accessible from anywhere with an Internet connection. Over 4,000 clinicians have used it to date. Regular use of the EPA has enabled these clinicians to measure how much they have improved and enhanced care through better use of their EMRs. The EPA also lets clinicians know where they stand compared to their peers.

Presenters

• Darren Larsen, Chief Medical Information Officer, OntarioMD
• Gina Palmese
• Peter Hamer

Authors & Contributors

• Darren Larsen, MD, Chief Medical Information Officer, OntarioMD
• Knut Rodne, Director, Insight, Engagement & Transformation, OntarioMD
• Jack Cooper, Senior Consultant, EMR Reporting, OntarioMD

Theme 3. Strengthening collaboration within the interprofessional team

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Harbour A
• 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, Administrative staff

Learning Objectives

The role of primary care within a population based approach is essential to improving the health and wellbeing of older adults.

1. Learn about best practices for falls risk screen, assessment and intervention among older adults. How best practices were adapted and integrated into an algorithm for the EMR and a tablet based patient completed falls risk screen
2. How patient centered screening has led to optimizing access and fostering collaboration within the interprofessional team
3. The impact of strong collaborative work with six family health teams and the Stay on Your Feet initiative in the NELHIN

Summary/Abstract

The falls prevention risk screen algorithm that was integrated into the EMR is able to identify older adult patients for high risk screen (% YTD). Patient completed screen on the tablet has helped to establish falls prevention screening into the teams current work flow. The falls prevention screen and assessment process has helped to optimize access to the interprofessional team. The falls prevention assessment is ensuring that patients are being seen by the right care provider within the team. The strong collaboration with the 6 family health teams and the SOYF partner has helped to spread change in falls prevention screening and assessment throughout the Northeastern Ontario.

Presenters

• Shirley Watchorn, Executive Director, Great Northern FHT
• Ellen Ibey, Executive Director, Temagami FHT
• Meghan Peters, Quality Improvement Decision Support Specialist, City of Lakes FHT

Authors & Contributors

• Wendy Carew
• Lorna Desmarasis

Theme 2. Optimizing access to interprofessional teams

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

1. To learn strategies to successfully expand FHT services beyond the roster while adhering to shared care model
2. To learn about potential challenges and how to plan for them when expanding FHT services
3. To learn about the benefits of expanding services to the community based on a case study in real time

Summary/Abstract

As primary care teams are being encouraged to expand their focus beyond rostered patients to the community, for the past 5 years, the East GTA Family Health Team has been strategically reaching out and partnering with the broader community towards equitable care. As a result of our efforts, 60 % of our referrals come from outside sources.  Our presentation will discuss the challenges and benefits of expanding services while balancing the needs of rostered patients and FHT resources.  Based on our experience, we will provide first hand insight into simple yet effective strategies for expanding programs and access to our interdisciplinary team that can be practically applied to other Family Health Teams.

Presenters

• Chantal Simms, MSW/RSW, East GTA FHT
• Anusha Sivalogarajah, RN, East GTA FHT

Authors & Contributors

• Patricia Lazarakis, OT East GTA FHT
• Sudin Ray, ED East GTA FHT

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• Room: Pier 4
• 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.), Representatives of stakeholder/partner organizations

Learning Objectives

1. Understand how the St. Michael’s Hospital Academic Family Health Team applied citizen engagement methods to engage patients and families in improving FHT services
2. Learn how to recruit and retain a representative sample of patients and families to partner with on future patient engagement efforts and quality improvement initiatives
3. Identify aspects of SMHAFHT’s approach to patient and family engagement that can be applied to your FHT

Summary/Abstract

Over the last year, we partnered with Mass LBP to apply their innovative methods of citizen engagement to our Family Health Team. Our goal was to have patients and families help us improve the typical medical visit. Mass LBP has worked with all levels of governments, non-profit organizations, and health care organizations to bring citizens together to shape public policies on topics ranging from urban growth to mental health services.  They conduct civic lotteries typically mailing tens of thousands of Canadian residents each year and inviting them to participate in a series of weekend meetings about a specific policy issue. Workshop attendees will learn how we invited 10,000 of our patients to attend a one-day patient engagement session and the methods we used to ultimately select 36 of 350 patient and family volunteers who were representative of our practice population. We will describe the structure of the day, including the tools we used elicit recommendations from patients and families. We will share these recommendations and how we partnered with patient volunteers to engage FHT staff in the work ahead. We will discuss our evaluation of the engagement day including ethnographic observations and qualitative interviews conducted with patients and staff involved with the engagement. Finally, we will detail how we have continued to engage the 350 patients and family members who volunteered for the initial engagement event and how we are drawing on their expertise for other initiatives in our FHT.

Presenters

• Tara Kiran, Family Physician, FHT Board Chair, Quality Program Director, St. Michael’s Hospital Academic Family Health Team
• Sam Davie, Quality Improvement & Decision Support Specialist, Michael’s Hospital Academic Family Health Team

Authors & Contributors

• Katie Dainty, PhD. Scientist, Li Ka Shing Knowledge Institute
• Peter MacLeod, Principal and Founder, MASS LBP
• Chris Ellis, Director of Business Development, MASS LBP

Theme 1. Planning programs and fostering partnerships for healthier communities

Presentation Details

• Date: 10/18/2016
• Concurrent Session D
• Time: 9:30am – 10:15am
• 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: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers

Learning Objectives

1. Understand some of the barriers preventing refugees from easily navigating our healthcare system
2. Understand some of the challenges facing health care providers in providing care for a newcomer population and ideas for facilitating the care relationship
3. Learn some techniques for optimizing the medical visit and beginning the promotion of health

Summary/Abstract

The Syrian refugee population coming to Canada faces many challenges, including being able to properly navigate our healthcare system because of system understanding, language barriers and transportation challenges.  Many of the refugee families have had little health care for an extended period, and often have some very complex health challenges, with feelings of vulnerability, fear and isolation. With the help of our community partners, the Bruyere Academic FHT has developed a clinic which provides the Initial Medical Assessment (IMA) for some of the Syrian families relocated to Ottawa. By providing all necessary components of the IMA on site (venipuncture technician for blood work, nursing staff for immunization, IMA templates for physician and residents, clerical staff and Arabic speaking interpreters) we provide a one stop shop for these patients. At the initial assessment clinic, we spend an average 5 hours with the families, which are often large. During this time, we provide a nourishing dinner; some information about life in Ottawa and the healthcare system , and volunteers move around with the families to help with navigation and understanding of processes.   There is visible relaxation, comfort, understanding and satisfaction. In this presentation, we will discuss some of the factors that create barriers for refugees, techniques used to optimize the visit and start the process of health literacy, and the ongoing challenges and rewards of taking on these vulnerable new arrivals as rostered patients.

Presenters

• Karine Gauthier, Training Officer, Bruyère Academic Family Health Team
• Kelly Kelly, Venipuncture technician, Bruyère Academic Family Health Team
• Julie Lalonde, Registered Nurse, Bruyère Academic Family Health Team
• Meagan MacCullough, Clerk, Bruyère Academic Family Health Team

Authors & Contributors

Samira Belaid, Volunteer, Bruyère Academic Family Health Team

Theme 7. Clinical innovations to address equity

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 4
• 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

• Understand the health equity themes reported in the 2016/17 QIPs submitted by team-based interprofessional primary care organizations in Ontario
• Learn from a family health team on how they have integrated equity into their QIPs and QI activities
• Understand Health Quality Ontario’s work on this evolving quality improvement theme

Summary/Abstract

QIPs provide multi-sector data on activities related to equitable health care in Ontario. In this presentation, we will share what primary care organizations are working on related to equity as reported their QIP.  Qualitative analysis of equity indicators, activities and change ideas planned for implementation in 2016/17 will be highlighted.  Strategies related to clinical equity of population health indicators will be described.

Presenters

• Danyal Martin, Manager, Quality Improvement Plans & Quality Improvement Strategies, Health Quality Ontario
• Margaret Millward, Specialist, Quality Improvement Plans & Quality Improvement Strategies, Health Quality Ontario
• Jo Connelly, Clinical Lead Manager, Inner City Health Family Team

Authors & Contributors

• Lee Fairclough Vice President, Quality Improvement
• Sudha Kutty Director, Quality Improvement Plans & Quality Improvement Strategies
• Danyal Martin Manager, Quality Improvement Plans & Quality Improvement Strategies
• Margaret Millward, RN MN Specialist, Quality Improvement Plans & Quality Improvement Strategies
• Jorge Ginieniewicz PhD  QIP Qualitative Analyst, Quality Improvement Plans & Quality Improvement Strategies

Theme 6. Leadership and governance in a changing environment

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• 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. Learn how a single physician leader can successfully act as a change agent and help drive others to embrace new technology and processes
2. Hear how the adoption of an EMR-integrated patient engagement tool helped foster better patient-physician encounters, increased patient care consistency, and cut charting time in half
3. See how an automated patient questionnaire platform is driving system-level changes including universal smoking screening and email consent, resulting in clinic efficiencies and better patient care
4. Learn the key steps you can take in your own clinic to overcome behaviours and barriers to change

Summary/Abstract

Feedback from patients indicates that they feel more actively involved in their care, having the ability to express concerns on their own terms and – for some questions – in their own words. For providers, there is a significant decrease in time spent on documentation while actually having more documented in the chart. Early figures around usage indicate that there have been significant increases to population screening for smoking and the facilitation of smoking cessation.

Presenters

• Joan Chan, MD CCFP, Guelph Family Health Team
• Kathleen Vanleeuwen, BAHSc, Guelph Family Health Team

Theme 5. Coordinating care to create better transitions

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 9
• 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. Learn about ER and Hospital usage data specifically for patients with IDD from a province-wide study completed in 2015. Characteristics of this population contributing to high use and complexity will be reviewed
2. Learn about coordination tools designed specifically for patients with IDD:
   1. a guide to CCP completion
   2. an adapted CCP template
   3. a Health Passport to ensure safety in emergencies
   4. a standardized set of IDD specific preventative care recommendations
3. Review a logic model designed to evaluate a health links approach to care coordination and intersectoral/interministerial collaboration for supporting complex, vulnerable populations

Summary/Abstract

Health Links is an Ontario initiative that brings together local healthcare providers to redesign an enhanced coordinated model that is patient-centered for the purpose of improving outcomes for the most complex patients in our region. We will discuss a unique approach which brings MOHLTC health system coordination capacity together with the MCSS developmental service sector’s IDD expertise and ability to identify those most complex and in need.  The presentation will review recently developed tools that support targeted care coordination (Health Link) to this particular population. Such tools include a CCT template  to cover communication and behavioural issues, a Health Information Passport to ensure safety and communication in emergency situations as well as a standardized set of IDD specific preventative care recommendations for primary care teams. It is anticipated that these approaches may be generalized to targeted care coordination of other vulnerable  populations in need of tailored approaches.

Presenters

• Linda Robb Blenderman, RN, BScN, Msc, Kingston Health Link Project Coordinator
• Marg Alden, Lead Agency Representative, Kingston Health Link
• Liz Grier, MD, CCFP, Queen’s Department of Family Medicine
• Ian Casson, MD, CCFP, Queen’s Department of Family Medicine
• Laura Cassidy, Quality Improvement Decision Support Specialist, Kingston Health Link

Authors & Contributors

• Margaret Gemmill, MD, CCFP Queen’s Department of Family Medicine
• Mary Martin, Research Assistant, Queen’s Department of Family Medicine
• Dr Yona Lunsky, Director of H-CARDD and Clinician Scientist at the Centre for Addiction and Mental Health
• Janet Durbin, Project Evaluation Lead, Independent Scientist – Provincial Support Services Program at the Centre for Addiction and Mental Health
• Richelle Uens, Health Care Facilitator, Networks of Specialized Care (MCSS)