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  • Toward the next ministry contract: Principles and guidance for moving forward

    FHTs and NPLCs have matured over the 5 – 9 years that each organization has been in existence. Contracts between MOHLTC and FHTs expire on March 31, 2016, with this comes the opportunity to develop a much more mature and meaningful approach to governing these organizations, from the Ministry and through to the board of each FHT and NPLC, to deliver high-quality primary care and improve the health of people in the communities served.

    As the representative voice for FHTs and NPLCs, AFHTO’s board, committees and staff embarked on a process with the membership to identify the key principles to guide this journey toward more mature relationships, including contracts that support high-quality comprehensive interprofessional primary care.  To date the process has included:

    1. Initial issues identification and concept development through the Governance + Leadership (GLAC) and ED (EDAC) Advisory Committees
    2. Survey e-mailed to the board chair, lead MD/NP and executive director of each AFHTO member organization (115 responses received between Sept. 10-29, 2014)
    3. Leadership session held immediately before the AFHTO conference (about 180 attended on Oct.15, 2014)
    4. Resulting from steps 2 + 3, this report-back to the membership on principles + priorities to guide AFHTO’s work

    Guided by the principles and priorities that have emerged from the AFHTO membership, this journey will continue with on-going:

    • Oversight by AFHTO board
    • Advice from GLAC, EDAC and soon-to-be-established Lead MD/NP Council
    • Updates and further consultations with the full AFHTO membership as the process unfolds

    1         Principles to guide our way forward

    1.1      Principles for governance of primary care organizations

    Given the strong level of support indicated through the survey of leaders of AFHTO member organizations AFHTO adopts the following governance principles: FHTs and NPLCs are not-for-profit corporations in a health system mandated to provide appropriate, equitable, sustainable care.  Their boards:

    • Are accountable to the patients, funders and members of their organization.
    • Ensure their organizations are appropriately managed and advocate for appropriate resources so that patients can access high-quality comprehensive care that is sustainably delivered and strives to meet patient and public expectations.
    • Ensure the culture of their organization supports development of high-functioning interprofessional teams.
    • Provide leadership to harmonize and optimize policies and practices for effective and efficient teamwork within the organization and with other entities contributing to the health and health care of the organization’s patients and community.
    • Provide leadership and collaborate with other organizations to spread best practice and encourage growth in capacity so that all Ontarians can have access to high quality interprofessional comprehensive primary care.
    • Ensure that patients and community members are engaged in the development of programs and services.

    These principles describe the more mature relationship the leaders of AFHTO’s member organizations want to have with their funders, members, staff and other stakeholders. They will guide AFHTO’s work in advocacy and in developing learning opportunities and support for members to succeed in their roles as governors and leaders.

    1.2      Principles for accountability and reporting to funders

    The strength of the survey results also lead AFHTO to adopt the following principles for accountability and reporting to funders. These principles will guide AFHTO’s advocacy with government, on behalf of members, on development of the next set of contract templates:

    • Financial and clinical reporting should minimize duplication in data collection and reporting.
    • Accountability should be defined in terms of collectively agreed upon measures that reflect value delivered.
    • Reporting requirements should place more emphasis on the work of the team to achieve outcomes and less on individual member activities and patient encounters.

    1.3      Principles for determining accountability measures

    While AFHTO members are strongly in favour of accountability and reporting based on meaningful measures, they are also cautious about how these measures will be determined. Leaders who attended the Oct. 15 leadership session provided the following guidance on principles for determining accountability measures that should be followed by AFHTO, the Ministry and any other stakeholders involved in the process:

    • MOHLTC must engage in a collaborative process to define outcome measures to be used for reporting.
      • Input from providers/engagement of AFHTO membership is essential.
    • MOHTLC must provide adequate support so that FHTs/NPLCs have the capacity (i.e. the people and technology needed) to collect and report their data.
    • Measures must be meaningful, measurable, consistent and comparable.
      • More specifically, measures must be evidence-based, clinically important, include process and outcome, be easy-to-track on an on-going basis, clearly defined and standardized for meaningful comparisons, and aligned with other Ministry priorities and reporting requirements.
      • Measures must also incorporate patient experience, and involve patients in what the measures will be.
    • The approach to accountability measurement must be sufficiently flexible to account for variation in patient complexity and their social determinants of health, in regional and rural-urban settings, and in size and maturity of teams.

    2         Additional guidance received from members

    2.1      Help needed to move toward accountability for outcomes

    If FHTs and NPLCs are to be held accountable for meaningful outcomes, what is the evidence as to what must be in place to achieve this? Participants in the Oct.15 leadership session were presented findings from a not-yet-published study by the Ontario College of Family Physicians to identify characteristics and predictors for high performance in FHTs. The factors found to be associated with quality outcomes included:

    • Strong leadership is associated with better governance and integration of FHT and Family Health Organizations (FHO).
    • Team leadership promotes higher team functioning.
    • Understanding and respecting practitioner scope of practice is essential to optimal team functioning.
    • Co-location and effective office design impacts team functioning.
    • Differential pay among co-workers as a result of dual funding creates problems in teams.

    The September 2014 AFHTO leadership survey had also found that 80% of respondents agreed that “greater harmony between the physician-funded groups and the FHT-funded groups is essential to the FHTs moving forward to ensure optimal interprofessional comprehensive primary care.” Through small group discussion followed by voting on top ideas, FHT and NPLC leaders in AFHTO’s leadership session then identified their priority needs “to help strengthen team collaboration and move toward team accountability for agreed upon outcome measures.” These priorities emerged:

    • The critical need for alignment:
      • Between FHTs/NPLCs and their associated physician groups
      • Among objectives of key players, including the Ministry, Ontario Medical Association and Ontario Primary Care Council
      • Among all team members, invested in a common purpose
      • Between performance and funding to encourage people to work towards clearly defined and transparent measures
    • Joint accountability of physician group and FHT/NPLC to increase provider participation and engagement, and mechanisms by which such engagement is supported financially and otherwise
    • Addressing system conflicts that FHTs/NPLCs are being held accountable to but have no authority over (e.g. hospital efficiency, ER visits etc.)

    AFHTO is guided by the fact that some FHTs have already undertaken measures to harmonize working conditions and expectations between their physician-funded and FHT-funded groups, i.e.:

    • Close to half of leadership survey respondents have:
      • Adopted one common set of HR policies
      • One ED with reporting authority over all physician-funded and FHT-funded staff
    • Close to half of leadership survey respondents have:
      • A common compensation scheme for FHT-funded and physician-funded employees
      • One common employer arrangement
      • A service contract between the physician group and FHT
    • Over one-third have no formal arrangements in place at all.

    2.2      Basis for funding allocation

    When it comes to the factors that should be reflected in allocation of funds, the leadership survey revealed:

    • Solid agreement that case mix (patient complexity) is a critical factor (91% agree or somewhat agree, 3% disagree)
    • Support for other factors as well:
      • achievement of performance targets (80% agree, 5% disagree)
      • geography/dispersion of services (77% agree, 5% disagree)
      • degree to which organization plays a system role (78% agree, 11% disagree)
      • number of patients enrolled (77% agree, 15% disagree)

    Comments overwhelmingly pointed to the need for sufficient funding to recruit and retain staff and for greater budget flexibility. Additional comments concerned the timing for budget approvals and other needs for added funds.

    2.3      Hopes and concerns regarding accountability for outcomes

    The final question asked of the 180 participants in AFHTO’s leadership session was – “If we move in this direction, what are you most hopeful about, and concerned about, the next set of contract templates?” About 100 responses indicated members are hopeful that the move toward strengthened team collaboration and team accountability for outcomes would lead to:

    • Improvement in outcomes (including both patient experience and provider engagement/satisfaction) and evidence of value delivered
    • Improvement in funding and greater flexibility in using funds
    • Greater efficiency in measurement and reporting (less duplication, less waste of time)

    Another 100 responses clustered around concerns about:

    • The choice of measures
    • Capacity to measure
    • Funding ( potential expectation to “do more with less”, consequences of failing to meet targets)
    • The Ministry and other stakeholders (e.g. lack of transparency, lack of common vision, power imbalance)
    • The need to be able to reflect differences among teams and the communities they serve

    3         Next steps

    Thank you to all of the leaders in AFHTO’s member organizations who have made their views known through the September survey and/or the October 15 Leadership Session.  Guided by the principles and priorities that have emerged from the AFHTO membership, this journey will continue with on-going:

    • Oversight by AFHTO board
    • Advice from Governance + Leadership Advisory Committee, Executive Director Advisory Council and soon-to-be-established Lead MD/NP Council
    • Updates and further consultations with the full AFHTO membership as the process unfolds.

    AFHTO members are welcome to send further comments and ask questions at any time:

    • Regarding work toward new contract templates, to Executive Director Angie.Heydon@afhto.ca
    • Regarding the governance and leadership of FHTs and NPLCs, to the Provincial Lead for the Governance and Leadership Program, Bryn.Hamilton@afhto.ca
    • Regarding AFHTO’s work to advance measurement capacity, to the Provincial Lead for the Quality Improvement Decision Support Program, Carol.Mulder@afhto.ca
    • General questions/comments, to info@afhto.ca.

  • AFHTO 2014 Conference: Theme 2 – Engaging the patient in their care

    Theme Description: Patients and caregivers are increasingly looking to be engaged and consulted in their own care. Primary care is finding innovative ways to support patient decision-making about their care and support for self-care. Presentations in this stream will include topics such as education programs for patients and their families; patient involvement in care planning; tools and coaching for patients to manage their own care; and using patient feedback to achieve a seamless patient experience. AB2 – Engaging Patients through Portals: Tools and Tales 1.       My Cancer IQ®: a new tool for engaging your patients in cancer prevention and screening This presentation will outline the evidence base, objectives, target audience and capacities of My CancerIQ® and describe how it can be leveraged by family health teams to promote patient-centred collaboration (e.g., between dietitians, nurse practitioners, physicians and health promoters) and to educate their patients, engage them in dialogues on cancer screening and prevention, and empower those with behavioural risk factors to undertake positive change. 2.       Patient Portal: Perks and Pitfalls Learn about one Family Health Team’s experience with the portal including the common physician/staff misconceptions that were initially present vs the real world experiences of physicians/staff after deployment. Through our mistakes over the first 1-2 years, learn the best way to deploy this technology and how it helps to engage patients in their care. 3.        Engaging patients in their care through a secure internet portal This presentation will demonstrate how Village Family Health Team uses a secure website and mobile app called Wellx to exchange electronic messages with patients. Using Wellx, the team saves time by sharing test results, specialist appointment details and other information with patients, without worrying about the privacy and security concerns associated with email. 4.       Toward the new paradigm of Patient Centred Care (presentation to follow) The Wise Elephant Family Health Team along with 4 other FHTs have implemented the miDASH patient portal for their patients, a new paradigm in the way FHTs can engage patients in their own care.  This presentation will discuss these tools (including how patients can ebook appointments, evisit, erefill, and eview their charts) and how they have impacted patient engagement in our teams. C2-a Using the NHS’s Experience Based Design (ebd) methodology to capture and understand your patient’s experiences and co-design solutions together. The Partnering for Quality Team will be delivering a session on Experience Based Design (ebd), a methodology developed by the NHS in the United Kingdom. During the presentation attendees will learn the theory of the methodology and understand the specific tools that can be applied in their practices to achieve successes similar to those that will be described in the presentation. C2-b Timmins Health Link: Practical Applications of Patient Engagement The main presentation will describe Patient Discovery Interview (interview tool with modifications made by presenter to be appropriate in a primary care setting, Patient Goal Coaching (Timmins Health Link team’s use of motivational interviewing techniques and client readiness assessment to effectively engage patient in care plan co-design), presentation of case studies, review of project evidence and results, strategies for continued patient engagement through primary care and sustainability of health system transformation D2-b Engaging Rural Adults Living with Chronic Conditions in Exercise (presentations to follow) In rural areas, healthcare organizations struggle to support their clients with chronic disease to get enough physical activity due to lack of local support. Engaging clients in their care is a key component of all education programs that are developed to respond to the needs of that community. This presentation will illustrate three approaches to address gaps in physical activity in rural communities. 1.     Client feedback on a prediabetes lifestyle education program for rural adults 2.     HealtheSteps: Engaging Rural Canadian Men in Chronic Disease Prevention and Management Programs 3.     Chronic Disease Rehabilitation with Rural Style E2 Patient Engagement: Progressing from Pamphlets to Partnerships (presentation to follow) The Change Foundation, an Ontario based Health Policy think tank, along with 2 of its engaged patients/family members, will highlight key evidence, strategies, and examples of successful improvement resulting from partnerships between health system providers and those that they serve. F2-a Optimizing End-of-Life Planning for Medically Complex Patients (presentation to follow) In evaluating the North York Central Health Link (NYCHL) “high user” data, they identified a lack of clarity around the timing of transition from active treatment into palliative care for patients with end-stage respiratory conditions. Studies show that most people want to die at home, but over 70% die in hospital (Canadian Hospice Palliative Care Association, 2012). This pilot project optimizes end-of-life planning through standardized provider training and patient-focused, end-of-life care discussions earlier in the course of illness than otherwise would typically occur. The clearly defined, simple and sustainable clinical pathway can be easily spread among primary care providers. F2-b Telehomecare: Engaging patients with chronic disease in their care using remote monitoring technology and clinical expertise in the home The current Telehomecare Program provides COPD and Heart Failure patients with improved quality of life by motivating patients and teaching them the skills to self- manage their condition with confidence. As a result, patient confidence and self-management skills increase significantly; thereby avoiding unnecessary ER visits and inpatient hospitalizations are reduced.

  • AFHTO 2014 Conference: Theme 3 – Responding to community needs

    Theme Description: Primary care organizations serve communities with diverse populations facing unique needs and barriers. Identifying needs and planning programs to improve population health and achieve greater equity requires engagement and collaboration with patients and other community partners. Presentations in this stream will include population-based approaches to program planning; methods for identifying community needs, potential partners, and funding for patient and population needs. A3 Cardiac Rehab in rural Primary Care: it takes a community. Prince Edward County is a rural (island) community, populated primarily by seniors and with a high prevalence of cardiovascular disease. A Cardiac Rehab program in Kingston required a 200 km round trip by car twice weekly, no public transportation is available and very few patients were attending following their cardiac event. The rural community spirit kicked in and within a year, a fully equipped exercise area was made available through local fund raising events. A comprehensive medically supervised program of exercise and education, followed by supporting community activities and planned events, is now available to our patients requiring cardiac rehabilitation. B3 Knowledge to Action: “Health Checks”, A Clinical Innovation in Comprehensive Primary Care of Adults with Developmental Disabilities (presentation to follow) The presentation will be introduced by researchers with a brief description of the “knowledge” that comes from a unique database linking the Ontario Ministries of Health and Long-Term Care and Community and Social Services and identifying a cohort of over 65,000 adults with developmental disabilities. This has yielded information about use of primary care services, hospitalizations, rates of annual preventive health exams, cancer screening, and medication use. C3 Development of a Teen Group at a FHT (presentation to follow) This presentation will explore the development of the Teen Group at the Stonechurch Family Health Centre, part of the McMaster Family Health Team. The experience of this site may help inform other FHTs about possible use of group methodology when working with teens. Some teens to date have indicated a preference for group therapy over individual therapy. Group therapy appears to provide an effective cost-effective treatment modality that is well received by the teens, and has produced promising results. D3 “It makes you feel more like a person than a patient”: Findings from patients receiving integrated home-based primary care (IHBPC) services in Toronto, Ontario A successful health care system will be one in which there is seamless integration and collaboration across care sectors. Innovative approaches are also needed to contend with the complex and inter-related health and social problems faced by the frail older adult population. One approach that is gaining momentum is the home-based primary care (HBPC) model. We add the word ‘integrated’ to describe our HBPC model (renamed IHBPC), recognizing the importance of fully integrating medical, cognitive and social care services at the point of care. This model reflects these key design features: the provision of ongoing, comprehensive medical and social care to frail older adults, interprofessional team service delivery and after hours availability for urgent issues. E3 Addressing income security within a primary health care setting: Lessons learned (presentation to follow) A large body of literature links income security with health, yet interventions to improve income security rarely exist in our health care system. First, we will present a conceptual model of how income security health promotion works within primary health care. Second, we will discuss lessons learned from engaging in income security health promotion at the St. Michael’s Hospital Academic Family Health Team over the past six months. Third, we will discuss our plans for a pragmatic randomized controlled trial, the IGNITE (addressInG iNcome securITy in primary carE) Study. F3 Primary Care Outreach and Connection in Rural Communities The Rural Wellington Community Team (RWCT) was born out of the statement “we don’t know what we don’t know”. This presentation will review the barriers and gaps that patients experience and the resulting effects on their health that are often unidentified.    

  • AFHTO 2014 Conference: Theme 4 – Team collaboration in patient-centred care

    Theme Description: Interprofessional comprehensive primary care is focused on a collaborative practice that improves on the patient’s experience each time they interact with the organization – from making an appointment through their care episodes and follow-up reminders. Presentations in this stream will focus on interprofessional team collaboration and factors affecting how the team coordinates their work to meet patient needs (ie. team development activities, conflict resolution, and flexibility in scope of work for team members). A4 Our Best Foot Forward: Setting the Standard for Evidenced Based Multi-Disciplinary Approach for Foot Care Management Participants will learn from the Guelph FHT’s experience in delivering a standardized foot care program which is comprised of two primary components: a multidisciplinary team approach to clinical foot care interventions and individual and group foot care education. B4 The Most Valuable Player (MVP) Clinic – Our Collaborative Journey to Improving Patient Outcomes The MVP Clinic was created to support phase one of the Barrie Community HealthLink’s business plan. As the lead organization for our HealthLink, the BCFHT recognized the need to change the way healthcare is delivered in our community and therefore committed resources to this project.  Using an interprofessional approach to care, our goal was to open a clinic for patients with multiple complex conditions, limited access to a primary care physician, and who are ‘high cost’ users of the healthcare system. C4 Implementation of a Homebound Senior’s Program: The Sunnybrook Academic Family Health Team’s Story The Sunnybrook Academic Family Health Team’s Homebound Seniors Program is an innovative, integrated, interprofessional project that provides team based care to homebound seniors (those who require a home visit due to a physical, social and/or psychological barrier which prevents them from accessing the clinic.) This session will describe the development and implementation of this program as well as some preliminary outcome data. C4-Items to bring on a Home Visit_handout C4-Initial & Follow-up Visit Stamps_handout D4 Renewal of interdisciplinary team processes to enhance linkages to the community and home based health care The provision of care for older adults can be challenging due to complex life and health realities for this population. TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a community based primary health care program that aims to foster optimal aging for older adults living at home using an interprofessional primary health care team delivery approach that centres on meeting a person’s health goals with the support of trained community volunteers, system navigation, community engagement, and use of technology. This presentation will share learnings from the initial development and implementation of TAPESTRY within a 2-site Family Health Team (FHT). E4 The Village Family Health Team’s Stepped Care Depression Management Update (presentation to follow) Village FHT presented the concept of a Stepped Depression Management Program at AFHTO 2012. At AFHTO 2014, they will present the outcome of two years of work.  Stepped Depression Management is a treatment to target program. The PHQ-9 is used to detect major depression and systematically monitor patient’s status. It provides a clear, evidence-based stepped-care approach for the provider to know how to best change or intensify treatment if needed.  A consulting psychiatrist reviews the patient case load with the social worker and family physician and offers assistance for patients with depression that is severe or not improving. Our presentation will consist of a review of literature demonstrating effectiveness of this approach in other settings as well as a review of public policy supporting shift of mental health management to primary care. F4 Expanding Capacity for Dementia Care: Primary Care-Based Memory Clinics Across the Province (presentation to follow) A primary care-based memory clinic model has been developed to address existing challenges of providing dementia care within family practice. To support this model, a training program was developed as a capacity-building initiative to support primary care providers to maintain the majority of dementia care within primary care practice. This presentation will describe the memory clinic care model, training program, implementation across the province, and potential applicability to other complex geriatric conditions.

  • AFHTO 2014 Conference: Theme 6 – Using data to improve transitions of care and care coordination

    Theme Description: Primary care providers collect and share patient information to help patients move safely and efficiently through the health care system. Presentations in this stream will share experiences to increase our collective capacity for:

    • collecting more consistent data AND using the data we already have more safely and effectively (even if it isn’t consistent);
    • making personal health records available to patients;
    • knowing when and what personal patient information could and should be shared between providers; and
    • getting the most out of existing technology, even while working to make it better.

    A6-a Utilizing EMRs to Support Cancer Screening Primary care providers (PCPs) play a crucial role in the journey of a cancer patient, both in ensuring that patients get screened for cancer and navigating them through the healthcare system should they require care. The focus of this presentation will be on providing PCPs with information on tools and resources to support cancer screening through the use of current functionality in their EMRs. A6-b Transitioning between EMR Systems The NYFHT Information Management/Information Technology (IM/IT) Committee formed an EMR Task Force to review the FHT’s goals in moving toward a ‘one EMR and one server’ system. The EMR Task Force began by creating a comprehensive needs/readiness survey to understand current and future EMR requirements, which included readiness to change. Based on findings of the comprehensive needs assessment, the EMR taskforce developed recommendations to support physicians in their vendor procurement process. This process is still ongoing at this time. B6 Using Run Charts to Evaluate Quality Improvement Using run charts to analyze data over time simplifies the analysis of improvements made to processes or systems. They allow teams to easily identify if the quality improvement initiatives are obtaining the desired results. Once improvement has been achieved, run charts allow teams to monitor if the improvement is being sustained.    This presentation will provide attendees with an example of how a Family Health Team has modified the reporting format of their indicators by replacing a colour-coded data table with run charts. C6 Mining for data gold: how to recycle imperfect EMR data into useful information EMR data are problematic. Quality can be poor and free text/unstandardized data are often difficult to query. However, many FHTs have already been able to derive significant value from currently existing data. This can involve activities such as querying data in EMRs (“front end data”), supplementing EMR data with external information (for example, the provincial Screening Activity Report or SAR) or participating in projects such as CPCSSN where cleaned/standardized data are returned to FHTs or clusters of FHTs (“back end data” for FHT data warehousing). As an example, we are using data on breast cancer received from the provincial SAR to update and standardize both personal and family history of breast cancer. This will allow us to more accurately categorize patients and refer them for high risk breast cancer screening in the future. D6 Optimizing Quality of EMR Data to Improve Care: Leading the Human Side of Change The difficult task of persuading individuals and groups to change their behaviour has been addressed by many existing change management strategies in the literature. It has been estimated that 70% of change initiatives fail mainly because change plans do not consider human behaviours. The aim of this presentation is to describe change management strategies widely used in healthcare industry that will improve EMR data quality in your healthcare facility. D6-b Primary care performance measurement — why bother? Primary care providers are facing an ever- increasing number of options and obligations related to performance reporting.  This session outlines a measurement approach that can help focus attention on what really matters to primary care providers: the relationship with our patients and our ability to deliver the care that they value.   It will show how D2D and the Starfield model consider disease-specific outcomes (e.g. “What’s your A1C?”) in the context of the relationship between the patient and provider, as distinct from other measurement models. E6 Using Hospital Data: Doing Analyses and Building Warehouses 1.     Using Hospital Emergency Department Data for Quality Improvement in Family Health Teams The Quality Improvement Decision Support Specialist (QIDSS) for Upper Canada FHT, Athens District FHT, Community & Primary Health Care – Community FHT, and Prescott FHT receives hospital data on a monthly basis from Brockville General Hospital (BGH) and Perth & Smiths Falls District Hospital (PSFDH). During the presentation, the QIDSS will outline how data is received from hospitals, the difference analyses that can be performed on the above data, and how this is used to promote quality improvement in FHTs. 2.     Analyzing health data across care systems: The NYFHT – NYGH Joint Data Warehouse Patients access care in multiple settings, including hospital and primary care; this is especially common for complex patients. Despite this, data about care are usually contained in electronic silos. Joining and combining health data across systems in order to more fully analyze care is challenging. We generated the first database containing joint data, which will enable quality improvement and research activities to be undertaken. F6 Advancing and Leveraging the Investment Value of EMRs – Project ALIVE Good quality EMR data can be a major enabler to supporting transitions of care and improving patient care coordination. Within primary care the level of maturity relative to information management and support tends not to be well developed. With a focus on adoption and innovation, this presentation will share a hands on practical guide of enhancing the quality of data in EMRs.

  • AFHTO 2014 Conference: Poster Displays

    Theme 1 – Accountability and governance for patient-centred care 1         Accountability Management System: Manage Accountabilities, Plan Programs, Organize Indicators and Measure Success- Our Performance Storybook and Song sheet! 2         Leading the Way: Safety Climate as an Indicator of Organizational Culture and Improved Patient Care Theme 2 – Engaging the patient in their care 3      Development of a New Patient Experience Questionnaire for Lifestyle Services in Team-based Primary Care 4      The Markham FHT “Wellness Poster”: A Key Educational Reference Tool For Your Clinic 5      Impact of Curriculum Design on Patient-centred Care: Integrating Adult Learning Theory and Constructivism into Diabetes Group Education and its Effects on Patient Satisfaction, Confidence and Learning Outcomes 6      Engaging the Patient in Direct Observation for Hand Hygiene in a Primary Care Setting 7      Using a Well Baby Video for the Rourke recommended “Education and Advice” Counseling during Well Baby Visits for Infants Two Months or Younger 8      Improving Documentation of Our Patients’ Decision Makers 9      The iGeneration Goes to Grade 9: Resources to Promote Adolescent Mental Health and Well-Being 10   Improving Self-referral Rates to the Safe Medication Use for Seniors Program: A Pilot Project 11   Who is in the Driver’s Seat? – Creating Sustainable Habit Change Through Interdisciplinary Education and Client Self-Management: A “How-To” in New Program Development 12   The Use of Technology in TAPESTRY to Facilitate Data Collection and Communication between Patients, Volunteers and Interprofessional Teams 13   Living Healthy with Chronic Disease 14   Patient Survey for Patients with Low Literacy 15   The iPad Project: an Innovative Way to Engage Patients and Caregivers in Healthcare and Literacy 16   Measuring the Patient Experience – a Novel Approach to Getting Valid, Meaningful, Comparable Results Monthly with Relative Ease 17   Growing a Baby Friendly Ontario with Family Health Teams Theme 3 – Responding to community needs 18   The Role of Cognitive Impairment in Causing and Perpetuating Homelessness 19   Speaking Your Language: Improving Language Inquiry and Recording with a Multi-Ethnic Population at Toronto Western Hospital 20   Driving Cessation: Traveling a New Road 21   Improving Care to High Risk Populations through Outreach 22   After Rural Residency: Where do Doctors Choose to Practice? An Evaluation of the Goals of the Rural Ontario Medical Program 23   Healthy Pregnancy Strategy: What to Expect when Rural Wellington Women are Expecting 24   McQuesten Community Nurse Networker Pilot- an Innovative Collaboration in a High Priority Hamilton Neighbourhood 25   Responding to Community Needs: INR Point of Care Testing in Rural Ontario Theme 4 – Team collaboration in patient-centred care 26   It Takes a (Small) Village: How a Physician and RPN can Ensure Best Care for Patients with HIV 27   Exploring the Role of the Pharmacist during the Referral Process between Primary and Specialty care 28   Planned Diabetes Days: Enhancing Patient Care Through Use of the EMR 29   Team-Based Approach to Smoking Cessation 30   Group Well Baby Visits: Satisfaction Among Patients, Residents and Providers in a Community Family Health Team 31   Impact of Attachment Disorder in Fetal Alcohol Spectrum Disorder: A Signs/Team Approach 32   Using Rounds Centred on Patient Narratives: Building Capacity within a Family Health Team to Improve the Delivery of Care to Vulnerable Seniors 33   Hospital Discharge Med Wrecks: Processes for Pharmacist-Driven Tune-Ups 34   Seamless Access to Care: Owen Sound Family Health Team and Keystone Child, Youth and Family Services 35   The Primary Care Lung Health Quality Improvement (QI) Guide: Partnerships and Teamwork to Create a QI Guide for Primary Care Lung Health Programs 36   Improving Eye Care for Patients with Diabetes: Collaborating Across Specialties 37   Enhanced Patient Care for Diabetics in Family Health Teams 38   COPD Readmission Avoidance Project 39   Patient Initiated Referral 40   A Multi-Institutional Approach to Improving Maternal and Fetal Health 41   Pathways to Practice™ at Two Rivers Family Health Team 42   Management of Osteoporosis Through an Evidence-Based Pilot Program 43   A New Model to a Group Program: a Physician-Specialist to Help Motivate Patients 44   IMPACT RD: An Innovative Tool to Engage Your Team in Medical Nutrition Therapy 45   From Disney to Depression: How a Storyboard is being used to Design a Patient-Centred Care Pathway Theme 5 – Integrating the community around the patient 46     Impacting Cancer Screening By Employing Different Strategies within Primary Care Settings 47     Beyond Our Front Door: Promoting Community Partnerships to Improve Patient Care 48     Primary Care Providers’ Perspectives on Using the Champlain BASE eConsult service – a Qualitative Study 49     A Partnership Approach to the Well Child Checkup Theme 6 – Using data to improve transitions of care and care coordination 50      Collecting and Sharing Colorectal Cancer Screening Data with Primary Care Providers 51      UTOPIAN CPCSSN Project: Past, Present and Future 52      Using Visual Analytics to Support Quality Improvement in Primary Care 53      The Step Approach: Standard Treatment and Collaborative Care Lead to Better Hypertension Outcomes 54      Opioid Prescribing Patterns in a Family Health Team: The Good, the Bad and the Ugly 55      Patient Encounter Tracking Form – Moving into the Electronic Century! 56      Utilization of Custom Spreadsheets to Support Chronic Disease Management within the London Family Health Team 57      Creating Registry for Patients with Hypertension: Embarking on a Quality Improvement (QI) Methodology to Improve Care for Patients with Hypertension 58      Documentation Tools to Assist in the Transition and Transfer of Spina Bifida Patients from a Pediatric Multidisciplinary Clinic to the Adult Healthcare System 59      Integrating Hospital Report Manager into a Family Health Team 60      The EMR ‘Adoption Chasm’ – Looking at EMR Current Use and How to Bridge the ‘Chasm’ between Basic and Intermediate/Advanced Use 61      Reduction of Social Work Referral Wait Times Through Effective Triaging and Utilization of Resources Theme 7 – Clinical innovations in comprehensive primary care 62     FluFOBT Program: A Proven Approach to Increase Colorectal Cancer Screening 63     Chronic Pain Management – A Collaborative Primary Care Model to Support Patients Living With Non-Cancer Chronic Pain 64     The Transition from Hospital-Based Care for Stable HIV-Positive (HIV+) Patients in Ottawa 65     The Effect of a Structured versus Non-structured Homebound Seniors Program on Resident Attitudes towards House Calls 66     The Successful Implementation and Integration of eConsultation into a Family Health Team to Improve Access to Specialist Care 67     Senior’s Health Day – Providing an Integrated, Seamless Care to Seniors 68     Cognitive Assessment Clinics: A Model of Shared Care – Nurse Practitioner, Family Physician & Geriatrician 69     Senior Wellness Program: An Innovative Collaborative approach to Provide Comprehensive Patient-centred Care to Promote Healthy and Independent Living at Home 70     Physician Led Support Group for Low Carb Lifestyle: Carbs and Fats De-Mystified 71     Individualized versus Standard Treatment for Smoking Cessation: Findings from STOP with Family Health Teams 72     Creating Greater Collaboration by Utilizing Motivational Interviewing as a Common Language within an Inter-Professional Practice Team 73     Getting dermatology consults in less than 5 days by leveraging OTN and technology 74     One Small Step at a Time:  A Team Approach to Integrating a COPD Program in the FHT

  • AFHTO 2014 Conference: Theme 1 – Accountability and governance for patient-centred care

    Theme Description: How does the board know that their organization is patient-centred? Presentations in this stream will include examples and stories of boards who have successfully incorporated the patient voice into strategic planning; created structures such as patient and family advisory committees; and processes for including patient stories in quality improvement planning. A1 – Implementing a Patient Advisory Council in an Academic FHT The presentation will take the participants through our internal process from conceptualizing a PAC to implementation and next steps for the evolution of the Council. WE will include concrete examples of how other teams can practically incorporate the PAC into their own environments and we hope to give opportunity for participants hear from one of our PAC members. B1 – How do we as governors ensure we hear and respond to the patient voice? Each panelist will present a brief synopsis of the techniques his/her organization employs to hear and respond to the patient voice and will then outline their successes, challenges, outcomes and recommendations. D1 – Creating cultures of quality improvement and patient safety The Queen’s FHT started their QI and safety journey in 2008 and a key part of this effort has been to examine and address issues of culture. This presentation will focus on defining the aspects of culture that impact QI and safety, how to recognize them in your team, and what steps you can take to improve the culture in your team. E1 – Rural Wellington Shared Governance Across Health Care Partners Presenters will provide a history of the journey the partner agencies have experienced to date, provide details of the steps used to create the vision and mission, challenges and lessons learned, and plans for future endeavors. The focus of the presentation will be on the change management approach that we have found to be successful.

  • AFHTO Annual Meeting takes place Wednesday October 15, 2014 at 9:00AM

    All who work within an AFHTO member organization or serve on its board are welcome to attend the AFHTO Annual Meeting. It takes place just before the official opening of the AFHTO 2014 Conference, on:

    Wednesday October 15, 2014 at 9:00AM Harbour Ballroom A+B, Westin Harbour Castle One Harbour Square, Toronto, Ontario.

    At this Annual Meeting, the AFHTO board will present its Annual Report to the Members.

    • Click here for a PDF copy of the Annual Report.
    • A print copy of the Annual Report will be mailed to each member organization, and conference attendees will receive a copy in their registration kits.
    • Further updates will be provided at the meeting, with particular focus on AFHTO’s work on recruitment and retention and on promoting the value of comprehensive interprofessional primary care.

    The meeting also includes a report on AFHTO’s financial outlook, in addition to the annual Audited Financial Statements, as well as the board’s Nominations Report and acclamation of five new board of directors. These reports are attached. There will be plenty of opportunity for AFHTO members to ask questions and present opinions. Each AFHTO member organization is entitled to designate one voting representative for the meeting.  Voting delegates will be required to register before the meeting to receive their voting card. The Notice of Meeting, agenda and reports for AFHTO’s Annual Meeting have been sent to the e-mail addresses AFHTO has on file for the Board Chair, Executive Director and Lead MD/NP of these eligible organizations. AFHTO members may request this package from Sombo.Saviye@afhto.ca. Each member organization is asked to contact her in advance to indicate who will be the organization’s voting representative so that a voting package can be prepared in advance for that person.

  • Data to Decisions 1.0 report launches TODAY! Join the Webinar Today (Oct 1, 4 – 5 pm) or tomorrow (Oct 2, 12-1 pm)

    The on-line tool — Data to Decisions 1.0: Advancing Primary Care (D2D 1.0) – has been posted on the AFHTO’s members-only website. D2D 1.0 is a summary of primary care data that are currently available, comparable and mean the most to AFHTO members in their efforts to advance quality of care for their patients.  The report displays data submitted anonymously by 50 teams.  It can be used by ALL members – whether or not your team has contributed data. The report is accompanied by a suite of supporting materials to help teams use the data to advance their work to improve quality for their patients. Join the webinar this afternoon or tomorrow (Oct 1, 4-5 pm or Oct 2, 12-1 pm) for more information and education on using D2D 1.0 in your team.   Click on links below to register for one of the two sessions:

    • Wed., Oct 1, 2014,4:00 – 5:00 PM EDT
    • Thurs., Oct 2, 2014, 12:00 noon – 1:00 PM EDT

    Click here to view the slides from the webinar. Additional education opportunities include:

  • What the mandate for Minister of Health and Long-Term Care means for AFHTO members

    This afternoon the Premier publicly released the mandate letters sent to each of her Ministers.  These letters outline the specific priorities that each member of cabinet and their ministry will focus on. The mandate letter addressed to the Minister of Health and Long-Term Care begins by pointing out government’s overall priorities, i.e. growing the economy, creating jobs, fiscal prudence. The Health Minister is specifically mandated to “lead the shift toward a sustainable, accountable system that provides co-ordinated quality care to people, when and where they need it.” The priorities named in the Health Minister’s letter include: “Bringing forward a plan to ensure that every Ontarian who wants one has a primary care provider.” The Liberal election platform articulated that one of the steps needed to make this a reality is to “Improve the recruitment and retention of community-based primary care teams.”  AFHTO continues to press this commitment, working in an environment where the Treasury Board President’s mandate letter says, “You will help ensure that any modest wage increases negotiated are absorbed by employers within Ontario’s existing fiscal plan through efficiency and productivity gains, or other trade-offs, so that service levels continue to meet the public’s needs.”

    The Health Minister’s mandate letter provides the possibility for the role of primary care to be strengthened. Statements include:

    • You will foster collaboration across the system and make the necessary trade-offs to shift spending to where Ontario will get the best value for our health care dollars — which must be shared between our health system partners.
    • Ensuring that patients receive timely access to the most appropriate care in the most appropriate place — and that the needs of Ontario’s patients are at the centre of the system.
    • Championing the delivery of quality co-ordinated care to patients by making the best use of the skills and capacity of all our health care providers, hospitals, community clinics and organizations, long-term care homes and others. You will take the lead in ensuring that changes are informed by evidence — and that Ontario’s precious health care dollars improve quality of care and health outcomes for patients and families.
    • Continuing to ensure that our system has the health human resources it requires to deliver quality and efficient care. This includes exploring appropriate expanded scope of practice for providers and more models for collaborative care.

    While primary care is not specifically named in these statements, AFHTO believes the strength of evidence that investment in a strong primary care system leads to better health and lower costs, combined with the evidence we anticipate will emerge as we progress with our “Data to Decisions: Advancing Primary Care” initiative, give us ample opportunity to build the strength of our sector. “Accountability and transparency” is a strong theme throughout the letter. One of the many references states:

    • You will now work with them (health care administrators, institutions and providers), as outlined below, to continue to drive accountability, transparency and quality throughout the system, while limiting expenditure growth.
    •  One of the outlined specifics is “Exploring options to further strengthen the framework for ensuring that the community sector and LHIN-funded health service providers are accountable for delivering quality patient care, including expanding the Excellent Care for All Act.”

    AFHTO is well-positioned to address these issues with and on behalf of members.  We have already begun to work with the leaders of our member FHTs and NPLCs to develop a common statement of principles and priorities for governance and accountability. This will guide our continuing work to advocate for our members and be a resource to support you. We look forward to receiving responses to our leadership survey from board chairs, lead MDs/NPs and executive directors, and building from the results at our Toward the Next Ministry Contract session immediately before the AFHTO conference.