Tag: Past Conference Materials

2015 Poster Gallery

Thank you to all of our poster presenters who came to the AFHTO 2015 conference.

Poster descriptions listed by theme [PDF]
Theme descriptions [PDF]

2015 Posters Displays

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.

Poster #	Theme	Title
1	1. Population-based primary health care: planning and integration for the community	Collaborative Care programs: a nurse practitioner approach to address the needs of our community
2	1. Population-based primary health care: planning and integration for the community	Community-Based Falls Prevention by an Interprofessional Team
3	1. Population-based primary health care: planning and integration for the community	Development, Implementation and Evaluation of the KidneyWise Clinical Toolkit for Chronic Kidney Disease (CKD) in Primary Care
4	1. Population-based primary health care: planning and integration for the community	Diamonds in the Rough-Utilizing Positive Deviance to Optimize Care for Complex Patients
5	1. Population-based primary health care: planning and integration for the community	East Mississauga Health Link: Patient Driven Care
6	1. Population-based primary health care: planning and integration for the community	Focusing on Adult Immunizations
7	1. Population-based primary health care: planning and integration for the community	Hungry for Knowledge: Leveraging Community Partnerships and Utilizing an Interdisciplinary Family Health Team to Deliver an Interactive Renal Patient Group Education Program
8	1. Population-based primary health care: planning and integration for the community	Mythbusters: Baby-Friendly Edition
9	1. Population-based primary health care: planning and integration for the community	PATH: Promoting Access to Team-based Primary Healthcare
10	1. Population-based primary health care: planning and integration for the community	Prescribing literacy for preschool infants/children: a practical partnership model
11	1. Population-based primary health care: planning and integration for the community	Public Health and FHT Collaboration: Strategic Processes to Further Desired Outcomes
12	1. Population-based primary health care: planning and integration for the community	Rapid Recovery Services – Helping patients meet their rehabilitation needs at home vs. hospital
13	1. Population-based primary health care: planning and integration for the community	Students are Valuable Too: Collaboration with Western: Community Engaged Learning Program
14	1. Population-based primary health care: planning and integration for the community	Transition Navigation for medically complex patients following discharge from hospital: lessons learned
15	1. Population-based primary health care: planning and integration for the community	Working with the Thorncliffe Park community to design and deliver primary obstetrics care
16	2. Optimizing capacity of interprofessional teams	1-800-Imaging Pilot: Building Partnerships between Primary Care and Medical Imaging
17	2. Optimizing capacity of interprofessional teams	A Community of Practice Approach to Building Capacity for Quality Improvement Planning: The DFCM Academic FHT Experience
18	2. Optimizing capacity of interprofessional teams	Building Blocks to Better Bones: Bone Health and Fracture Prevention Initiative
19	2. Optimizing capacity of interprofessional teams	Building Diagnostic Imaging Appropriateness Pathways for Primary Care from Primary Care
20	2. Optimizing capacity of interprofessional teams	Development of an innovative nursing led persistent non-cancer pain program in primary care: lessons learned and initial outcomes
21	2. Optimizing capacity of interprofessional teams	Effects of a Multi- Faceted Mentoring Intervention on Spirometry Knowledge, Quality and Usage in Primary Care
22	2. Optimizing capacity of interprofessional teams	Expanding capacity within Primary Health Care: Development of a Physiotherapy Community of Practice
23	2. Optimizing capacity of interprofessional teams	Health professional perspectives regarding the use of patient-reported outcome measures in an integrated primary care health centre: A pilot project.
24	2. Optimizing capacity of interprofessional teams	Healthy At Every Size (HAES): Collaborating for best practice in weight management.
25	2. Optimizing capacity of interprofessional teams	Lend Me Your Ear: Using Auricular Acupuncture to treat substance use and anxiety/depression.
26	2. Optimizing capacity of interprofessional teams	Healthy Living with Pain (HeLP): an interprofessional chronic pain primary care initiative
27	2. Optimizing capacity of interprofessional teams	SOARing to new heights: Exploring opportunities for NP leadership in family health teams
28	2. Optimizing capacity of interprofessional teams	Turn Key Approach to Quality Improvement for Stroke Prevention: A Practical Team Application
29	2. Optimizing capacity of interprofessional teams	Up the Creek without a paddle: How the Care Navigator at SETFHT helps patients steer through the system
30	3. Transforming patients and caregivers experience and health	Advanced Care Planning in Primary Care – Lessons Learned
31	3. Transforming patients and caregivers experience and health	Breaking Down the Barriers of Care to Support a Deaf, Developmentally Delayed Patient within the London Family Health Team
32	3. Transforming patients and caregivers experience and health	Comparing two assessment approaches in a primary care diabetes setting to obtain descriptive high quality feedback on the patient experience
33	3. Transforming patients and caregivers experience and health	Confused and Lost – Where do I Begin Navigating the Health Care Labyrinth
34	3. Transforming patients and caregivers experience and health	Evaluation of the Ontario Stroke Networkâ€™s Hypertension Management Program: A Model for Stroke Prevention in Primary Care Settings
35	3. Transforming patients and caregivers experience and health	Health Literacy: You were heard but were you understood?
36	3. Transforming patients and caregivers experience and health	Improving Cervical Cancer screening rates: Quality improvement pilot initiative
37	3. Transforming patients and caregivers experience and health	Interprofessional Maternity care in the Mt Sinai Hospital Academic FHT. Keeping family doctors in the game.
38	3. Transforming patients and caregivers experience and health	My Values, My Wishes, My Plan: e-Module for Inter-Professional Teams Toward Effective ACP Conversation with Patients.
39	3. Transforming patients and caregivers experience and health	Rx Meditation is Medicine
40	4. Building the rural health care team: making the most of available resources	Helping Patients Overcome Barriers to Regular Exercise
41	4. Building the rural health care team: making the most of available resources	One-Week Rural Placements for First-Year Medical Students â€“ Building the Rural HealthCare Teams of Tomorrow
42	5. Advancing manageable meaningful measurement	A better Flavour of 7-day follow-up
43	5. Advancing manageable meaningful measurement	A Partnership Approach to Pilot Primary Health Care EMR Content Standard: CIHI and Team-based Primary Health Care Organizations
44	5. Advancing manageable meaningful measurement	An E-Learning Approach to Improving Primary Care Team QI Measurement Knowledge and Skill
45	5. Advancing manageable meaningful measurement	Data for Quality Improvement: Working with our Hospital Partner on QIP Access and Integration Goals
46	5. Advancing manageable meaningful measurement	Health Equity: the key to meaningful evaluation
47	5. Advancing manageable meaningful measurement	Improving Patient Access
48	5. Advancing manageable meaningful measurement	Ontario’s Enhanced 18-month Well-Baby Visit EMR Integration and Repository Project
49	5. Advancing manageable meaningful measurement	Putting data in the hands of primary care providers to support quality improvement
50	5. Advancing manageable meaningful measurement	Quality Improvement in Primary Care through an Integrated Vascular Health Care Approach
51	5. Advancing manageable meaningful measurement	The Cervical Screening Reminder Calls Pilot: An EMR Optimization Initiative to Support Primary Care
52	5. Advancing manageable meaningful measurement	Turning data lemons into data lemonade: Our journey with 7-day Post discharge
53	5. Advancing manageable meaningful measurement	What’s a QIDSS and what can they do for you in particular and primary care in general
54	6. Leadership and governance for accountable care	Explaining governance and accountability to all members of the FHT: Making it happen and getting them involved.
55	6. Leadership and governance for accountable care	Implementing an infection prevention and control program for primary care
56	6. Leadership and governance for accountable care	Improving Patient Access and Clinic Efficiency
57	7. Clinical innovations keeping people at home and out of the hospital	An Interprofessional Approach to Post-Discharge/ER Visit Follow-up: Minding the Gap between Acute and Primary Care
58	7. Clinical innovations keeping people at home and out of the hospital	Cancer …how to live through the diagnosis.
59	7. Clinical innovations keeping people at home and out of the hospital	Destigmatizing mental health shortens wait times.
60	7. Clinical innovations keeping people at home and out of the hospital	Early integration of palliative care in primary care: INTEGRATE Quality Improvement project
61	7. Clinical innovations keeping people at home and out of the hospital	Effective implementation of a geriatric home care program in a Toronto based family health team
62	7. Clinical innovations keeping people at home and out of the hospital	Implementing Health Checks in Primary Care for Adults with Developmental Disabilities in Family Health Teams in Ontario: Engaging Interprofessional Care, Community-based Health Care and Developmental Services
63	7. Clinical innovations keeping people at home and out of the hospital	Improving the care and quality of life of patients with Asthma
64	7. Clinical innovations keeping people at home and out of the hospital	Cancer Survivorship Care: An Important Role for Nurse-Practitioners
65	7. Clinical innovations keeping people at home and out of the hospital	Leveraging the OCEAN Platform and Tablet Technology to Improve Patient Care
66	7. Clinical innovations keeping people at home and out of the hospital	Post Hospital Transition of Care: From Inpatient to Family Practice.
67	7. Clinical innovations keeping people at home and out of the hospital	Too Fit To Fracture: Exercise and Physical Activity Recommendations for Fall and Fracture Prevention

October 30, 2015

2015 IHP Sessions & Networking

Interprofessional Collaboration as the anchor of team based primary care

AFHTO members are made up of diverse teams of professionals working together to provide excellent patient care. This interactive workshop, hosted by AFHTO’s IHP Communities of Practice, guided FHT/NPLC staff and providers through exercises designed to strengthen interprofessional collaboration. This 3 hour workshop was divided into two segments. Members could attend one or both of these.

(I) Knowing How to Play and What to Build in the Sandbox We Call Primary Healthcare — A Vision for Ontario’s Primary Care Teams

Presented by Dr. Ivy Oandasan, Professor, Department of Family and Community Medicine, University of Toronto

Click here to access the slides from the workshop. Workshop for all staff and health care providers in FHTs and NPLCs to develop building a common understanding of what it looks like and what it means to work in an interprofessional team. By the end of this interactive workshop participants will:

Learn from and celebrate successes of our collective advancement of interprofessional collaboration
Identify structures, processes, practices and behaviors required to foster an interprofessional quality focused and patient centred culture of primary care

Commit to being agents of change within our own primary care settings supporting tangible, feasible and measurable interprofessional collaboration possibilities.

(II) Profession-Based Networking Sessions

Presented by the AFHTO Community of Practice Leads

This was an opportunity for all members to meet, mingle and share insights with peers in similar roles from across Ontario. Agendas for each session were developed by their Community of Practice Lead. The AFHTO IHP Communities of Practice are a member-driven initiative, led by dedicated IHP volunteers from teams across the province and supported by AFHTO. They provide resources, advice and opportunities for staff and clinicians in primary care teams. The following groups and communities of practice participated and hosted a networking session:

Administration	Nurse (RN/RPN)	Physician & Quality Improvement Decision Support Specialist (QIDSS)
Chiropodist	Nurse Practitioner	Physiotherapist
Chiropractor	Occupational Therapist	Psychologist
Health Promoter	Pharmacist	Registered Dietitian
Mental Health and Social Worker	Physician Assistant	Respiratory Therapist

To learn more about and join an IHP Community of Practice click here.

Accreditation

Attendance at this program was certified Canadian College of Health Leaders members (CHE / Fellow) for up to 1.5 Category II credits.
This program was accredited by the College of Family Physicians of Canada and the Ontario Chapter for up to 3 Mainpro-M1 credits.

Archive

In 2014, we offered profession-based programming by and for 12 communities of practice.
- See 2014 pre-conference program information here.
In 2013, we offered profession-based programming by and for 9 communities of practice.
- See 2013 pre-conference program information here.

October 28, 2015

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.

October 17, 2014
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.

October 17, 2014
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.

October 17, 2014
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.
October 17, 2014
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

October 17, 2014
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.

October 14, 2014
AFHTO 2013 Conference – EMR Users Meetings
EMR Vendors hosted information and knowledge sharing sessions for AFHTO member users with the aim of working towards responding to evolving measurement and reporting requirements. The EMR User Meetings give FHTs the opportunity to develop their skills, knowledge and share best practices for maximizing their use of the EMR system. AFHTO –TELUS Health: PS Suite working group presentations The spreadsheet posted below presents the details of the responses from TELUS Health to the priority items identified by the working group and outlined in the presentation.
- TELUS Health response to AFHTO working group action items
October 28, 2013
AFHTO 2013 Conference – Meaningful Use of EMRs
Theme Description: “Meaningful use” goes beyond storing patient information in an electronic version of a paper chart. It includes using the data and functionality of the EMR to advance the clinical process of care and improve outcomes. The US Centres for Medicare/Medicaid Services (CMS) has defined “meaningful use” as using EHR/EMR technology to:
- Improve quality, safety, efficiency, and reduce health disparities
- Engage patients and families in their health care
- Improve care coordination
- Improve population and public health
- All the while maintaining privacy and security
Presentations in this stream will focus on what can be done in the FHT environment to develop a greater degree of “meaningful use” to achieve these ends. C8 – Guelph HealthLink: Resurfacing an integrated Electronic Health Record (IEHR) The long promised integrated Electronic Health Record (IEHR)is developing a new energy through the HealthLink initiative. A Guelph FHT IT team explains their approach to providing tools to patients and HealthLink partners that shares useful information supporting coordinating community assessment and ongoing care. D8 – How can I remember what FHT programs are offered? – How the EMR can help! This presentation will describe an effective collaboration for integrated quality improvements across partner agencies through joint LEAN training to develop skills and enrich the understanding of the organizations for future teamwork, integrated process enhancements and change. E8 – Personal Health Records – not so scary after all The purpose of this panel will be to explore several clinics’ experiences with a PHR, including benefits to patients and providers, implementation tips, and potential challenges. Through these clinics’ stories, attendees will gain valuable knowledge regarding the current state and future vision of PHRs and how they can get started in their own teams.
October 24, 2013