AFHTO’s 2017 Annual Conference Leadership Session on care coordination generated enthusiasm and was relevant, timely and successful. The majority of AFHTO members are ready to ‘embed’ care coordinators and have made written commitments to advance discussions and plans that support local implementation of the Minister’s mandate letter. Most importantly, AFHTO members – governors, administrators, lead physicians and nurse practitioners – are actively seeking to enhance the relationship, engagement and communications within, and across LHINs, on care coordination and other topics impacting the patient experience in primary care. Earlier this week the LHINs were provided with a guidance document entitled Connecting Care Coordination in Primary Care Settings: Guidance for Ontario’s Local Health Integration Network – this document is intended to guide LHINs in developing plans to enable stronger connections between care coordinators and primary care. LHINs are being charged with quite a few deliverables before the end of the fiscal year, including completing a readiness assessment with primary care looking at improving relationships and connections with care coordinators, with the intention of embedding these providers where possible. The interprofessional team-based models of FHTs, NPLCs, CHCs and AHACs have also been identified as the target groups for early implementation. With the guidance document now out, the LHINs need to be engaging with our teams in order to meet their mandate letter deliverable, so they’re interested in hearing from you. To support your ongoing conversations with the LHINs, and to articulate how FHTs and NPLCs are more than ready to be at the forefront of primary care/care coordination integration, please find attached the summary report from the October 25th Leadership Session – The Way Forward: Care Coordination Being Led by Primary Care. This summary report will also be shared with policy makers at the Ministry, as well as all LHIN CEOs and their senior management team. We encourage our FHT and NPLC leadership to use this report and request a meeting with your LHINs to keep the conversation going and to speak to the commitments that were developed during the session. If you have any questions or need assistance in moving forward with this really important initiative, please contact us at info@afhto.ca. Please also let us know about your ongoing conversations so we can keep a pulse on what is happening in the province.
Tag: Members Only
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Managing Medication as a Team
On November 17th, 2017, 75 interprofessional health-care providers from across Ontario came together to share their knowledge and experiences in order to spread innovative practices in team-based medication management across the province. The workshop was organized around four core themes:
- Managing polypharmacy and deprescribing
- Medication management to support transitions in care
- Medication management for chronic disease
- Managing health to reduce the need for medication
Read on and follow the links to learn more about programs that are currently in place and ready for spread. One (or more) of them may be a perfect fit for your team!
Managing Polypharmacy and Deprescribing Medication Management to Support Transitions in Care Medication Management for Chronic Disease Managing Health to Reduce the Need for Medication Opening Remarks
Michael Pe, Pharmacist | Caroline FHT Preventable drug-related incidents bring patients to emergency departments and create a burden on the health system. In this word, “preventable,” lies an incredible opportunity for primary care. Pharmacists are one piece of the puzzle, but it is through interprofessional approaches to medication management that we can have the most impact on population health.
An Interdisciplinary Approach to Deprescribe Sedative-Hypnotics in Elderly Patients.
Dr. Maria Muraca, MD, Medical Director | North York FHT Heather Rambharack, Social Worker | North York FHT Eric Lui, Pharmacist | North York FHT The North York Family Health Team took an interprofessional approach to deprescribe sedative-hypnotics in elderly patients with chronic insomnia. Evidence shows that the harms of taking sedative-hypnotics considerably outweigh the benefits. This FHT has taken the approach to wean patients off sedative-hypnotics by introducing a non-pharmacological therapy known as Cognitive Behavioural Therapy – Insomnia (CBT-I), where a combination of behavioural and cognitive techniques is used to rebuild the body’s natural sleep system. The patient is weaned off their sedative-hypnotics, with consultations and assessments with both the pharmacist and family physician, before starting CBT-I, which is a 13-week program, outlined below:
- Orientation with social workers, pharmacists and dieticians
- 2 weeks to maintain sleep logs
- 5 weeks of group sessions with social workers
- 1 individual session with social workers
For this team to conduct this interdisciplinary approach, they had Dr. Colleen Carney from Ryerson come to their FHT to run a workshop about CBT-I. Other resources necessary for this program are EMR data mining to identify patients, experts in CBT-I, a space to conduct the group sessions and communication between social workers, pharmacists and family physicians.
- See their slide deck here. [PDF]
- Contact Eric Lui for more information.
Managing to Reduce Need for Medication: Lower Back Pain Program
Robin Brown, Pharmacist | Mount Forest FHT and Minto-Mapleton FHT Jenna Crane, Registered Kinesiologist |Rural Wellington Low Back Pain Pilot Karin McEachern, Registered Occupational Therapist | Rural Wellington Low Back Pain Pilot Dr. Sean Lisk, Chiropractor | Rural Wellington Low Back Pain Pilot A pharmacist, kinesiologist, occupational therapist, and chiropractor from rural Wellington described an interprofessional, interorganizational low back pain program which focuses on increasing access to physical therapies. It started as a ministry-funded pilot program in seven primary care models across Ontario. The key players are kinesiologists, physiotherapists, occupational therapists, a pharmacist and chiropractors from three Family Health Teams: East Wellington FHT, Minto-Mapleton FHT, and Mount Forest FHT.
- A pharmacist provides consultations on the appropriate use of medications for the treatment of low back pain to patients.
- A kinesiologist works with patients to develop home exercise routines to help manage their pain through individualized programs involving targeted exercises to improve core strength and increase flexibility as well as helping patients to increase overall activity levels and their level of fitness.
- An occupational therapist helps participants better self-manage their pain using an interdisciplinary, functional restorative approach.
- A chiropractor provides assessment, treatment, and consultation.
- See their slide deck here. [PDF]
- Watch a video here. [MP4]
- Contact Robin Brown for more information.
Medication Management to Support Transitions in Care
Medication Management follows Medication Reconciliation in Rural Family Health Team
Glenys Vanstone, Pharmacist | Atikokan Family Health Team A pharmacist from Atikokan FHT described how their team works together with other partners, including hospitals, community pharmacists, and medical clinics to ensure that primary-care providers have the most accurate list possible of all medications the patient is taking. This information often changes as a result of hospitalization, provision of care by an outside prescriber, or patient purchases of over-the-counter medications, or it may have already been outdated. After the FHT receives and scans a discharge report into the EMR, the pharmacist receives a message and follows up with the patient to do a preliminary medication review and update the EMR. If the patient wishes to do so, they also schedule a one-on-one meeting to take place over the phone or via OTN. The pharmacist then consults with the physician to develop recommendations for the patient, from which she creates a user-friendly medication schedule in the EMR. The physician prints this schedule and gives it to the patient when they come in for a follow-up visit. The FHT pharmacist in this setting works remotely, providing collaborative care over the phone or telemedicine portal. This allows her to consult with far more patients than she could see in person. By working with the physician to develop recommendations before the patient’s follow-up visit, she is able to streamline those visits and help to ensure that a medication review takes place if needed. Of the 81 Atikokan FHT patients discharged from hospital this year, medication reconciliations have been conducted for 77. This makes patients safer and improves their health literacy.
- See their slide deck here. [PDF]
- Contact Glenys Vanstone for more information.
IDEAS Project for Medication Reconciliation
Karen Peters, Pharmacist | Northumberland FHT Christine McCleary, Registered Dietitian | Northumberland FHT The Northumberland FHT identified a need to get better at following up with their patients after discharge from hospital, and they were able to do so with the help of an IDEAS grant and QI training from HQO. They used the grant to obtain access to MediTech (the hospital’s records management system), which allows them to generate daily discharge reports. FHT staff reach out to patients two days after discharge to schedule an appointment with the FHT pharmacist, which takes place either in the office, in the patient’s home, or by phone, and it includes a medication review as well as an opportunity for the patient to ask questions or share any concerns. The pharmacist updates the EMR and links the patient to other services as appropriate. The team implemented this program using a QI approach – start small, grow slowly, improve as you grow. The team’s three sites were brought into the program one at a time, each time starting with a single physician who then championed it to his or her peers. Early results are positive. The average time between hospital discharge and follow-up with a Family Health Team clinician has been reduced from 30 days to 6. In responding to patient experience surveys, patients describe it as helpful and a good use of their time. An average of 10.8 medication discrepancies have been identified between what a patient is taking and what is listed in the EMR. An additional benefit has been the availability to connect patients to the FHT dietitian in the first few days after hospital discharge. Many patients are at risk of malnutrition during transitions in care, and they may have new dietary restrictions, difficulty swallowing, digestive problems, or anxiety about eating. When a patient shares this with their pharmacist, she immediately refers them to the team dietitian, who follows up with a phone call the same or next day.
- See their slide deck here. [PDF]
- Contact Karen Peters for more information.
Medication Management for Chronic Disease: Diabetes Medical Visit
Shared Medical Appointments
Catherine Bednarowski, Pharmacist | Hamilton FHT The Hamilton Family Health Team implemented shared medical appointments (SMAs) as a way to improve patient access for diabetes care. Shared medical appointments are 90-minute appointments held simultaneously with 8-10 patients with chronic diseases or similar medical conditions in an interactive visit. There is a range of evidence supporting the use of SMAs including improved clinical outcomes, increased patient satisfaction and provider benefits. The SMAs take 3-6 months to implement and the roles of the providers are outlined prior to the SMA. Recruitment strategies include personal invitations as well as advertisements within the clinic. In order to implement SMAs a team will need the following: certified diabetes educator, physician champion, planning committee, physical space for the group, and medical supplies.
- See their slide deck here. [PDF]
- Contact Catherine Bednarowski for more information.
Patient Work Sheet and Drug Therapy Recommendations
Mary Nelson, Pharmacist| Burlington FHT A pharmacist at Caroline FHT has developed patient work sheets and drug therapy recommendations to help to increase the impact of pharmacist involvement in the diabetes clinic while reducing pharmacist time. The worksheets and drug therapy recommendations improve pharmacist access by reducing one-on-one appointments, so they can be involved in other patient care initiatives. The pharmacist’s role is to update medication lists in patient files, prepare patient flow sheets, provide lab requisitions and review patient results prior to the diabetes clinic. The physician or resident then review the worksheet and recommendations with the patient during the clinic. One-on-one appointments with the pharmacists are reserved for specific cases such as insulin starts, patients with adherence issues, new diagnoses and extremely elevated A1c/FBS. Next steps include improving the efficiency of completing the worksheets by receiving assistance from administration and nursing and improve the diabetes roster to better identify potential patients.
- Blood Glucose Monitoring Worksheet [download Excel file]
- Patient Diabetes Flow Sheet [PDF]
- Patient Work Sheet [PDF]
- SAD MANS tool for patients [PDF]
- Contact Mary Nelson for more information.
Wisdom from the Field: AFHTO member stories about their medication management initiatives
In addition to the above presentations, we heard short stories from two other teams who are currently using interprofessional programs to help manage and reduce reliance on medication.
Guelph Family Health Team Chronic Pain Program
Matthew Mendes | Registered Kinesiologist Chung-Ying Chou | Mental Health Counsellor Shawna Druif | Occupational Therapist The Guelph FHT Chronic Pain Program is an integrated program focusing on mindfulness-based self-management strategies to help patients improve quality of life when living with chronic pain. The program has three components: A series of five workshops led by a mental health counsellor; one-on-one consultations with an occupational therapist and kinesiologist to develop pain-management plans for patients; and an ongoing peer support group. The program helps patients to move from a pain-centred life to a function-centred life by identifying and acknowledging the pain cycle. Participating patients report being better able to understand and self-manage their pain.
- See their slide deck here. [PDF]
Sinai Health System HeLp Program
Jessica Munro | Nurse Practitioner The HeLP program (Healthy Living with Pain) demonstrates how an interdisciplinary non-cancer chronic pain management team can support best practices in opioid prescribing and patient care. The program was designed to mitigate certain challenges and risks that arise when medical residents provide opioid prescriptions. The program supports residents through education and mentorship and EMR tools. A nurse practitioner leads the program and conducts periodic “check ins” with patients as well as back-up visits when a resident is unavailable. When a patient calls, staff know to contact the NP for guidance. The program so far shows that more patients are being counselled and supported to taper their opioid use and fewer opioids are being prescribed. Residents report being significantly more comfortable in managing chronic non-cancer pain.
DO try this at home!
At the end of the day, we asked participants, What is ONE thing we can do to be more INTERprofessional in our approaches to medication management? Here are some of the answers we got:
- Really learn what other allied health do and teach them your expertise.
- Would love to see time to collaborate, even within a team, incorporated into day-to-day work.
- Don’t be afraid to start with a small idea. Find one person who supports you and go from there.
- Find and use more interdisciplinary & shared EMR tools.
- Have joint appointments with other providers.
- Share homemade potato chips!
Thank you to our supporting partner
Managing Medication as a Team was supported by a contribution from our partner, FeelingBetterNow® by Mensante.
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EMR tools and queries for phone encounters (to help you track 7-day follow-up)
Tracking Phone Encounters: An Essential Step in Tracking Follow-Up After Hospitalization
In D2D 5.0, Follow-Up after Hospitalization was introduced as a core indicator. The D2D definition differs from the Ministry of Health and Long-Term Care definition, which is based on billing data, includes only in-office visits with physicians, and does not take into account that timely discharge information may not be available. Based on input from AFHTO members, the D2D definition of this indicator is “% of those hospital discharges (any condition) where timely (within 48 hours) notification was received, for which follow-up was done (by any mode, any clinician) within 7 days of discharge.” While different teams may have different approaches to tracking this indicator, an important first step for many teams is to track phone encounters. Below we have listed a number of tips, tricks and tools, including EMR queries, that can be used for this.
Please note:
- Reason for phone call: we are NOT looking for calls about lab results, appointment reminders, invitations to programs, appointment bookings etc.
- Access to hospital data: we recognize that access to hospital discharge data may be a challenge and continuing efforts to improve this.
- We are not looking for unique patients – a patient may have had a number of hospitalizations and discharges requiring follow-up care, depending on their condition and care plan.
- Please refer to the EMR specific instructions below to generate data for phone encounters. A number of different options are presented. Once you have decided which tools to use, consider sharing your choices, challenges and successes with your EMR Communities of Practice or with the QIDS team so we can all get better at doing this!
- This definition is comprehensive and may be unattainable at first. The tools and queries below will help your teams get started at documenting and extracting phone encounter data in a consistent way. The queries will be refined as workflows become established, EMR functionality improves, and more meaningful data becomes available.
EMR Tips and Tools for Extracting Phone Encounter Data
Telus PS
Using an appointment scheduler to track phone encounters:
- This guide shows you how to set up a “phone call” appointment type.
- Here’s the search to find phone call appointments for a desired time period and for select physicians.
- Can your IHPs use this method as well?
Using an encounter assistant to track phone encounters:
- This guide describes how an encounter assistant can be used to track IHP stats including phone encounters.
- Here’s the search to find phone encounter text in the encounter note created by an encounter assistant.
- Note: you will need to create your own encounter assistant specific to your team.
Using custom forms and custom queries to track phone encounters:
- A video about the tools and processes suggested in this option is accessible through Trello then Dropbox – please review the video and/or read this guide before proceeding.
- Here is the custom form for doctors and here is the custom form for patients/IHPs.
- If you don’t have the custom queries installed (over 70 teams do have them!) please contact us to arrange a time to get them installed. More details about the custom queries can be found on Trello
Accuro
Using encounter type (headers) to track phone encounters:
- This guide illustrates how to use encounter headers to identify patients with a phone encounter.
- Here’s a guide for the query to extract phone encounter data using encounter type (headers).
Using appointment type to track phone encounters:
- Here’s a guide for the query to extract phone encounter data using appointment type.
Using shadow billing codes to track phone encounters
- Here’s a guide for the query to extract phone encounter data using shadow billing.
Nightingale
Using encounter type to track phone encounters:
- Here’s a guide that explains how to use data miner to extract data for the number of encounters labelled with “phone” within the past 12 months for all members of Team (Physicians, NPs, IHPs, office nurse and/or admin). Consider sharing your experiences running this query with us.
OSCAR
Using “fake billing codes” to track phone encounters:
- Here’s how one team uses fake billing codes and report by template to successfully track IHP phone encounters (and other activities!).
Using eForms to track phone encounters:
- Consider using this eForm to track patient encounters with IHPs, including phone encounters
- Query to extract phone encounter data – UNDER CONSTRUCTION
- Is there an eForm for physicians? Would you like to create one? Please connect with the OSCAR CoP.
Using appointment type to track phone encounters:
P&P
Using shadow billing to track phone encounters:
- A guide on how to use and query shadow billing is under construction.
Please review the options in this guide that the P&P CoP is investigating for tracking phone encounters – there is lots more work to be done, queries to be written! Contact us if you’d like to help. This guide describes how to use day sheet reports to track post-hospital visits. Can we modify it to capture post-hospital phone encounters? Contact us if you think this might work!
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Program Planning & Evaluation Tools
AFHTO and the Ministry of Health have prepared the following tools to assist members with program development:
- Program Planning & Evaluation Framework [PDF]
- Programs & Services Tip Sheet and Flow Diagram (Appendix A from the 2016-17 AOP Submission Form)[PDF]
- Schedule A Template (2016-2017) [downloads an Excel spreadsheet]
Hyperlinks in the text will take you to relevant sample tools, suggested references and related information. Some of the documents refer to HQO’s Primary Care Performance Measurement Framework, found here [external link; opens in a new tab].
Picking the right indicators for your program
NEW and IMPROVED: The Program Performance Measures Catalogue [downloads an Excel workbook] has been refreshed and improved for 2018-2019. This spreadsheet is a list of the program measures (indicators) that your peers included as Performance Measures in Schedule A of their 2015, 2016, and 2017 Annual Operating Plans. It will help you to identify measures to consider using to evaluate your programs and to complete Step 4: Conducting a Program Evaluation of the AOP.
UPDATED: Quick Reference Guide to the Catalogue. To make the catalogue more user-friendly, we’ve created a one-page guide to walk you through the process of using it.
NEW: Choosing Better Indicators: How teams are using the PPMC [PDF]. This handout provides an overview of the PPMC and a look at the different ways your peers are using it. UPDATED: Video Walk-through of the Catalogue (below).
It’s important to remember that the catalogue is a tool, not a recipe, and there’s no “right” way to use it. Some teams use it at the brainstorming stage, to help them come up with a list of potential indicators to choose from. Others use it to narrow down their list or to refine the indicators they’re already using. Different indicators will be relevant to different teams depending on the size and structure of the team and the needs of the local population.
If you’re not sure where to start, consider reading about how other teams are using the catalogue and whether any of these approaches would work for you. The catalogue is a work in progress. The first edition was published in the spring of 2016. Based on feedback from members who used it, we made a number of improvements. The second edition, which is linked above, was published in the spring of 2017. A third, even better, edition is coming soon.
If you have feedback you would like to share about the catalogue – what works, what could be improved – or if you would like to be involved in the work of making it better, please don’t hesitate to contact us.
Program planning webinar & workshop
On March 6, 2017, AFHTO held a program planning webinar, in partnership with Public Health Ontario and the Ministry of Health and Long-Term Care. Topics covered include principles of program planning and evaluation, program planning for population-based care, and a review of the AOP submission process and timeline. We also reviewed the presented a brief demonstration of the new Catalogue. The recording and a link to the program planning slides can be found below. .
On October 24, 2017, as part of the annual AFHTO Conference, AFHTO held a 3-hour program planning workshop, Beyond Schedule A: Evidence-Based Program Planning for Community Needs. It was hosted by Allison Meserve of Ontario Public Health along with Lori Richey (Peterborough FHT) and Susan Hache (MOHLTC).
- Slide deck: Beyond Schedule A: Evidence-Based Program Planning for Community Needs [PDF] (Alison Meserve, Ontario Public Health)
- Handout: Beyond Schedule A: Evidence-Based Program Planning for Community Needs [PDF] (Alison Meserve, Ontario Public Health)
- Slide deck: Schedule A: One Size Does not Fit All [PDF] (Susan Hache, MOHLTC)
Supplemental materials
The following materials were produced to support the Program Planning & Evaluation Framework. Links to these materials are found within the document itself; they are provided here for convenient access.
- Sample Run Chart and Histograms – Cardiometabolic Program [PDF]
- Programs & Services Decisions Flow Chart [PDF]
- Step 1: Needs Assessment – Template [opens an editable Word document]
- Step 2: Setting Program Direction – Template [opens an editable Word document]
- Step 2 Example: COPD [PDF]
- Step 2 Example: Diabetes [PDF]
- Step 2 Example: Eating Disorder [PDF]
- Step 2 Example: Immunizations [PDF]
- Step 3: Determining Program Elements – Template [opens an editable Word document]
- Step 3 Example: COPD [PDF]
- Step 3 Example: Diabetes [PDF]
- Step 3 Example: Eating Disorder [PDF]
- Step 3 Example: Immunizations [PDF]
- Step 4: Program Evaluation – Template [opens an editable Word document]
Program Planning and Quality Improvement: Introducing the SAPD* Cycle
In June 2017, over 50 Quality Improvement Professionals – including QIDS Specialists, interprofessional health care providers, and partners from Health Quality Ontario and OntarioMD — gathered for a day of networking and learning. The theme for this Knowledge Translation Exchange (KTE) day was Program Planning and the SAPD* cycle. You may already be familiar with the Plan-Do-Study-Act (PDSA) cycle. SAPD is the same cycle – it just starts at “Study” or measurement, instead of at “Plan,” to build on the momentum in measurement that AFHTO members have achieved.
You can find the workshop synopsis, materials, and other links here.
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October 2017 Compensation Update and Market Refresh Webinars
Due to the sensitive nature of the discussion, we ask that you treat all of the contents of this page, including the links to the videos, as confidential information.
Compensation Update Webinar – October 16, 2017
Market Refresh for Primary Care Salary Structures Webinar – October 31, 2017
For slide decks and and answers to questions posed during the Oct. 31 webinar, please email us at info@afhto.ca.
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2017 Poster Gallery
Thank you to all of our poster presenters who came to the AFHTO 2017 conference. Posters were submitted by interprofessional health teams across the province. Like the concurrent session presentations, they represent the full breadth of professions within collaborative primary care and showcase evidence-based, impactful innovations that will be useful to other teams.
2017 Posters Displays
Poster # Theme Title 1 1. Effective leadership and governance for system transformation A Centralized Approach to Standardize Electronic Medical Record Tools and Templates in a Multi-Site Family Health Team: Formation of a Data Standardization Committee 2 1. Effective leadership and governance for system transformation Workplace Violence Prevention in Primary Care: Reflections from the 2017-2018 Quality Improvement Plans 3 2. Planning programs for equitable access to care Acceptability of Telephone-Based Mental Health Support for Patients in Primary Care 4 2. Planning programs for equitable access to care Creating a Health Equity Curriculum 5 2. Planning programs for equitable access to care Collaboration with Community Partners for Equitable Access for Low Back Care and Services 6 2. Planning programs for equitable access to care Feasibility of Group CBT-Insomnia 7 2. Planning programs for equitable access to care From Prenatal to Postpartum and Beyond: How to Maximize your Capacity to Comprehensive Care for Mothers and Babies 8 2. Planning programs for equitable access to care Mind Over Mood: A CBT Approach to Anxiety and Depression 9 2. Planning programs for equitable access to care A Transition in Primary Healthcare : An Interdisciplinary Model of Providing Transgender Care 10 3. Employing and empowering the patient and caregiver perspective Feedback on a Self-Management Booklet from Individuals Who Have Been Prescribed Osteoporosis Medication 11 3. Employing and empowering the patient and caregiver perspective Partnering with Patients to Improve After-Hours Primary Care 12 3. Employing and empowering the patient and caregiver perspective Healthy Lifestyle Journeys: Highlighting Patient Success Stories Using Experience Based Design 13 3. Employing and empowering the patient and caregiver perspective Barriers and Facilitators in Primary Care Follow-Up Upon Hospital Discharge: Patients and Caregivers Perspectives 14 3. Employing and empowering the patient and caregiver perspective Advance Care Planning: Before Its Too Late 15 3. Employing and empowering the patient and caregiver perspective Walk Your Way To Better Health : Enhancing the Patient Experience One Step at a Time 16 4. Strengthening partnerships Strengthening Partnerships: What Our Running Group Taught Us 17 4. Strengthening partnerships Coordinating Complex Paediatric Nutrition in the Medical Home Model 18 4. Strengthening partnerships Challenges in Collaborative Mental Health Care Research: Understanding Primary Care Providers Participation in the PARTNERs Study 19 4. Strengthening partnerships Days of Taste: A FHT-Community Partnership for Promoting Nutrition Education in a Local School 20 4. Strengthening partnerships Be Well Community Collective: Healthy Kids for a Healthier Tomorrow 21 4. Strengthening partnerships A Pilot Program to Determine the Feasibility of Organizing a Walking/Healthy Lifestyle Program for Seniors in a Rural Community 22 4. Strengthening partnerships Partnerships to Promote Diet and Exercise: The CHANGE Program 23 4. Strengthening partnerships Maximizing Collaboration in an Interprofessional Outreach Team: Contributions of Implementation Science, Relational Coordination, and Interprofessional Competencies 24 4. Strengthening partnerships Together in Movement and Exercise – TIME: Community Exercise for People with Balance and Mobility Challenges 25 4. Strengthening partnerships Home Based Primary Care Program; Quality Improvement in Palliative Care 26 4. Strengthening partnerships Switching to FIT: Strengthening Partnerships and Relationships to Improve a Population Based Screening Program in Ontario 27 4. Strengthening partnerships “Getting it Right” A Model for a Center of Excellence in the Delivery of Hospice, Palliative Care in the Development of a 10-Bed Hospice in Stratford, Ontario 28 4. Strengthening partnerships Partnering in the Community to Help Eliminate Opioid Overdoses 29 4. Strengthening partnerships Taking HealtheStepsâ„¢ to Reducing Chronic Disease Risk through Partnerships with Family Health Teams 30 4. Strengthening partnerships Effective Diet and Exercise Programs in Primary Care? Lessons from The CHANGE Study 31 4. Strengthening partnerships Partnering with the Baby-Friendly Initiative Strategy for Ontario: A Getting Started Story 32 5. Optimizing use of resources Pharmacist-Led Medication Reconciliation to Improve Transition of Care from Hospital to Home 33 5. Optimizing use of resources A Web Based Conference Series on COPD for Healthcare Providers in Ontario 34 5. Optimizing use of resources Improving the Quality of Care for Depression and Anxiety in Ontario Family Health Teams: Incentives and Disincentives Influencing Access within the Interprofessional Context 35 5. Optimizing use of resources Integration of Social Workers in Primary Health Care: Findings from a Provincial Survey with Social Workers in Family Health Teams in Ontario 36 5. Optimizing use of resources Sharing is Caring: Our Model for Dividing FHT Patients Among Diabetes Services in Barrie 37 6. Using data to demonstrate value and improve quality of care Improving Telephone Traffic Control: The Transition from a Decentralized Phone Management System to a Centralized Phone Centre 38 6. Using data to demonstrate value and improve quality of care Using Screening Activity Report (SAR) Data to Increase Cancer Screening Rates 39 6. Using data to demonstrate value and improve quality of care Taking Stock: Cleaning One of Ontario’s Largest Primary Care Databases 40 6. Using data to demonstrate value and improve quality of care Improving Patient Outcome One FHT Pharmacist at a Time 41 6. Using data to demonstrate value and improve quality of care Measuring Collaboration: Performance Indicators for Interprofessional Primary Care Teams 42 6. Using data to demonstrate value and improve quality of care An EMR Advance Care Planning (ACP) Tool for Talking with Patients About End of Life 43 6. Using data to demonstrate value and improve quality of care Reconnecting Health Link Patients from Hospital to Primary Care 44 6. Using data to demonstrate value and improve quality of care Translating Knowledge into Action: Integrating Best Practices for CHF and COPD Management into EMR Decision Support Tools for Primary Care Providers 45 6. Using data to demonstrate value and improve quality of care Pregnancy Risks and Womens Future Cardiovascular Health: A Missed Opportunity 46 6. Using data to demonstrate value and improve quality of care Moving Beyond Performance: Supporting Primary Care Improvement Efforts through Vascular Health Quality Improvement Toolkits 47 6. Using data to demonstrate value and improve quality of care Channeling Positive Deviance: A New Approach for Improving Timely Access for Patients in Primary Care 48 6. Using data to demonstrate value and improve quality of care One-Stop Shop Charting Approach to Interdisciplinary Diabetes Management Using Standardized Template Embedded with Advanced Features 49 6. Using data to demonstrate value and improve quality of care Power in Numbers: Unlocking the Potential of the Diagnostic Data in Your EMR 50 6. Using data to demonstrate value and improve quality of care Examining Growth Monitoring Practices in Primary Care 51 6. Using data to demonstrate value and improve quality of care Improving Population Health by Aligning EMR Optimization with Clinical Workflow Design 52 7. Clinical innovations for specific populations Determining Prevalence of Malnutrition in North York Family Health Team Geriatric Population at High Risk 53 7. Clinical innovations for specific populations Introduction of a Multidisciplinary Program to Deprescribe Sedative Hypnotics (SH) in Patients >65 Years of Age in a Large Multi-Site Family Health Team (FHT). 54 7. Clinical innovations for specific populations How Equine Facilitated Wellness Enhances Mental Health Social Work Programs 55 7. Clinical innovations for specific populations Preventing Chronic Disease in a Vulnerable Population Through Implementation of a Community Kitchen 56 7. Clinical innovations for specific populations Breathe Easy: An Interdisciplinary Approach to COPD Care in Vulnerable Populations 57 7. Clinical innovations for specific populations Enhancing Preventative Care Visit through a Shared-Care Model 58 7. Clinical innovations for specific populations An Innovative Smoking Cessation Program for Cancer Survivors Within the Primary Care Setting 59 7. Clinical innovations for specific populations Caring for Vulnerable Patients Leaving Hospital : Transition to Home 60 7. Clinical innovations for specific populations Beyond Resettlement: Nurse Practitioner Practice Model: Addressing Social Determinants of Health for Karen Refugees 61 7. Clinical innovations for specific populations Family Physician- Based Care of Patients with Serious Mental Illness: Using a Case-Managed Approach 62 7. Clinical innovations for specific populations Income Rx: A Look into Income Security Work in a Primary Care Setting 63 7. Clinical innovations for specific populations OPTIMUM: Optimizing Outcomes of Treatment-Resistant Depression in Older Adults 64 7. Clinical innovations for specific populations ROAR: Outcomes of a Two Year Journey for Literacy 65 7. Clinical innovations for specific populations Treating Opioid Use Disorder in Primary Care 66 7. Clinical innovations for specific populations Frailty Five Checklist: Use of a “cheeky checklist” to teach care of frail elderly in the home 67 7. Clinical innovations for specific populations Treponema Be Gone: An Interprofessional Approach to Increasing Serologic Testing After Syphilis Treatment 68 7. Clinical innovations for specific populations Cervical Cancer Screening in Trans and Gender Non Binary Persons : Perspectives on Barriers to Screening and Strategies for Improvement 69 7. Clinical innovations for specific populations HERstory: Lessons Learned from a Womens Trauma Therapy Group 70 7. Clinical innovations for specific populations Optimizing Smoking Cessation Efforts Within the St. Michaels Hospital Academic Family Health Team 71 7. Clinical innovations for specific populations Making the Coordinated Care Plan (CCP) Work: Chronic Disease Management that Matters 72 7. Clinical innovations for specific populations Collaboration to Address the Opioid Crisis -
2017 Concurrent Sessions Slides & Materials
Thank you to all of our concurrent session presenters who came to the AFHTO 2017 conference. Please see below for the uploaded concurrent session slides. Our concurrent session presentations are organized into six 45-minute timeslots (3 per day) and seven themes. We have arranged the sessions by timeslot and theme in the table below.
Concurrent Session Selection
Concurrent session presentations were chosen by working groups consisting of AFHTO members across Ontario, representing the full breadth of professions within collaborative primary care. Submissions were chosen for reflecting the conference theme, usefulness/applicability to interprofessional primary care teams, innovativeness, evidence of impact, and clear learning objectives.
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Clinical Health Services Policies
Please share your resources to help build our library.
Chronic Pain Management & Opioid Prescribing Practices
- Marathon FHT Chronic Pain Program Binder [PDF]
- The Use of Urine Drug Screening for Safer Opioid Prescribing in Chronic Non-Cancer Patients in Rural Northern Ontario (poster – Marathon FHT) [PDF]
Well-Women Screening
Telephone Follow-Up
Medical Directives
Return to the Library of Organizational Policies and Procedures.
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MOL Healthcare Sector Plan – Primary Care Webinar Oct. 4
Be prepared! The MOL has initiated their random site inspections of FHTs and CHCs to determine compliance with the OHSA and associated regulations. AFHTO has partnered with Public Services Health & Safety Association (PSHSA) to help our members get ready – our online Health & Safety Resources Webpage is now live! We have added sample policies and a Health and Safety Resource Manual, in addition to other resources…be sure to check it out! Missed the August health & safety webinar? By popular demand, we’re offering a second session on October 4th from 1-2 pm. Register now. Password- AFHTO2 -
Exceptional Access Program (EAP) Update – New Online Service
This Message is Being Sent out on Behalf of the Ministry of Health and Long-Term Care’s Ontario Public Drug Programs Division The Exceptional Access Program at the Ministry of Health and Long-Term Care is developing a new online service for prescribers which will allow them to research, create, and manage exceptional access program requests for their patients. The Exceptional Access Program (EAP) facilitates patient access to drugs not funded on the Ontario Drug Benefit (ODB) Formulary, or where no listed alternative is available. The new online service (to be called The Special Authorization Digital Information Exchange [SADIE]) will deliver two core advancements in the EAP service: 1) an online digital service for prescribers to manage EAP requests; and 2) automation of the many currently manual back office processes. The online service will create a digital channel for prescribers to access the EAP program, research drug criteria and availability, create, submit, and manage requests, receive notifications and alerts from the ministry for tasks such as responding to requests for additional information, submitting renewals, etc. The introduction of automation to many manual processes, including to the adjudication process itself, will provide real-time, automated responses for many drug requests ensuring that patients receive timely decisions on funding for drugs. As part of the implementation of this new service, the ministry has been reaching out to various prescriber groups and drug manufacturers to make them aware of SADIE and to engage them with respect to what this service needs to be able to do in order to meet the needs of the various stakeholder groups. In addition, this session will provide a sneak peek into how SADIE will look and its functionality. When: Friday, September 29th, 2017 from 1:00 to 2:30 ONLINE (with audio if your computer has mic/speakers) https://ali.health.gov.on.ca/AFHTO DIAL-IN for AUDIO: 416-212-8012/1-866-633-0848 / Conf Id 5749341#