2011 AFHTO conference presentation PRESENTER (S): Lucy Bonanno, Executive Director; Nadya Zukowski, Health Promotion Specialist FHT/ORG: Summerville FHT ABSTRACT: The Summerville Arthritis Program is a novel, collaborative approach to community Osteoarthritis care. Our interdisciplinary team partnered with The Arthritis Society and Pfizer to map out the delivery of a comprehensive yet flexible program. The program guides the patient through in-house services including a group education session, one-on-one counseling, a joint injection clinic and the ‘Maximize Your Health’ Stanford Chronic Disease Self-Management Program. It also identifies a pathway for Rheumatoid Arthritis care. The program was piloted winter 2011 and is now being offered Summerville-wide starting fall 2011, thus optimizing patient-centered care. Click here to view presentation.
Tag: Past Conference Materials
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Advancing the RN role in Chronic Disease Management
2011 AFHTO conference presentation TITLE: Advancing the RN role in Chronic Disease Management and Prevention in Primary Care PRESENTER (S): Sylvia Scott, Clinical Manager FHT/ORG: Guelph FHT ABSTRACT: Health care systems continue to be challenged to respond effectively to the increasing impact of chronic diseases on population health and health care resources. Using the Ontario Chronic Disease Management and Prevention Model, Guelph Family Health Team (GFHT) responded by integrating advanced registered nurse roles in primary care practice team settings with a goal to improve care for individuals with and or at high risk for chronic conditions. This presentation will discuss a unique interdisciplinary and collaborative model led by RN as the case manager within programs or embedded in the practice team. Their role is provide a holistic approach to the patient/caregiver in order to prevent or manage chronic health conditions by engaging the patient to identify and prioritize their own physical and emotional well-being. The RN also works with the patient/caregiver by monitoring progress and barriers to achieving wellness goals and clinical outcomes. The overall goal is to build patient/caregiver and interdisciplinary team capacity. This is achieved through the RN’s role by triaging in order to facilitate patient focused care, timely provider and community collaboration, patient education, and systems navigation across the entire health care spectrum. Outcomes measures include improved access to primary care, reduced number of emergency room visits and or hospital admissions, improved self-management and improved overall quality of life. Click here to view presentation.
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The use of Genetics and Personalized Medicine in Health Promotion and Chronic Disease Management
2011 AFHTO conference presentation PRESENTER (S): Sean Blaine, BSc MD CCFP, Lead Physician; Jill Davies, MSc., CCGC, Genetic Counsellor, Program Director, Medcan Clinic FHT/ORG: STAR FHT ABSTRACT: Genomic information is growing at an exponential rate and can be used as a tool in clinical decision making. It is now technically and economically feasible to consider the application and utilization of genomic sequence data in clinical care. Identifying individuals at increased risk for rare hereditary diseases as well as common diseases can lead to improved clinical outcomes through health promotion and early detection. This requires a proactive multidisciplinary approach combining new technologies with family history information, clinical data and patient education around risk reduction and disease prevention. New technologies can also identify specific genetic variants in enzymes of drug metabolism which have an impact on the selection and dosing of medication. In this way, pharmacogenomic (PGx) testing allows physicians to optimize drug selection and dosing based on a patient’s unique genetic makeup. The application of PGx in clinical practice is expected to improve health outcomes by decreasing medical costs and increasing patient compliance with medication regimens. Click here to view presentation.
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Preparing for Electronic Labs
2011 AFHTO conference presentation PRESENTER (S): Katharine De Caire, RN (EC), MN; Katalin Ivanyi, MD, CCFP, FCFP FHT/ORG: McMaster FHT, Stonechurch Site ABSTRACT: Laboratory information systems are an important component of an electronic health record. The ability to electronically access laboratory test information assists health care providers to make faster, better patient care decisions, enables timely access to information, provides better coordination of care and improves workflow Shared care is the basis of a Family Health Team. In a shared care environment a team’s Physicians and Nurses are both accountable for managing patient lab results and these accountabilities need to be clearly defined, communicated, and documented. In 2011 Stonechurch Family Health Centre began to prepare for the implementation of electronic labs. Our team recognized that managing test results effectively is vital to quality patient care and a failure to follow up on test results can lead to patient harm. In this presentation we will highlight our team’s paper-based process for results management, discuss our journey to prepare for electronic labs and present our final plan. Click here to view presentation.
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New Innovations and Best Practices in a FHT
2011 AFHTO conference presentation PRESENTER (S):
Karen Y. Brooks, RN, BScN, CRE, CDM Nurse Educator; Dr. Margaret Tromp, MD, CCFP, FCFP
FHT/ORG: Prince Edward FHT
ABSTRACT: “Left undiagnosed or untreated, chronic disease may also exact serious health and economic consequences from patients, families, and communities” (Every, 2007, p. 70). A FHT Family Physician and CDM Nurse Educator, have implemented aspects of The Edmonton Southside Primary Care Network Chronic Disease Model. This has brought the care of chronic disease back into the family physician’s office, where FHT team members contribute, but work to improve care and coordination of service is achieved within. We have customized this approach within our family practice. Highlighted is the MOHLTC’s seven themes of priorities for FHT’s, correlated with practice management of several chronic diseases. Utilization of upstream approaches to patient preventatives and screening is addressed. A patient may see the CDM Nurse Educator, the Family Physician, or both, and spend time discussing disease management. “This team approach frees the physicians to see more patients, to concentrate on those who need them and to take satisfaction from knowing they are doing a good job” (Spooner, 2007, as cited in Every, 2007). You won’t want to miss ‘The Pork’n Beans’ of CDM. Click here to view presentation.
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iPrep: Illness Prevention and Rehabilitation Program
2011 AFHTO conference presentation PRESENTER (S): Dr. Lori Teeple FHT/ORG: Bluewater Area FHT ABSTRACT: To assist participants to transform their lifestyle into one of healthy eating and exercise so as to achieve and maintain a healthier body weight and waist circumference to prevent or remit disease such as diabetes, hypertension, cardiovascular and cerebrovascular events. Target Group: Patients with BMI > 25 and Waist Circumference WC>102 cm (men) and WC> 88 cm (women). Program Objectives: 1. To help six women achieve a weight loss of 10% of their body mass in 12 months through a combination of education, mentoring and coaching utilizing advanced internet technology and weekly/bi-weekly visits. 2. The program will be evaluated on an annual basis by determining the number of females who have completed the 12 month program and reduced their weight and waist circumference, creating a healthier body and rehabilitating disease such as diabetes, hypertension and lipid disorders. The program will give the females encouragement to continue with their ongoing lifestyle changes. Each participant will be asked to complete and evaluation upon the completion of program. Evaluation: The iPrep program was started January 2011 and after six (6) months all participants have seen positive results and are encouraged about their lifestyle changes. The program is looking to expand the number of participants and include men. Click here to view presentation.
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Successfully Integrating Spirometry Into Primary Care
This slide presentation from the AFHTO 2010 conference is for FHT health care providers and administrators interested in integrating spirometry into their clinical practice. The session will review New Vision’s successes in integrating spirometry and discuss strategies for other FHTs to implement spirometry including resources available in Ontario. This workshop includes powerpoint presentation and group discussion. PRESENTERS: Angie Shaw, Amy Massie FHT: New Vision Family Health Team Click here to view.
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Primary Care Memory Clinics: Improving the Care of Cognitively Impaired Patients within a Family Health Team
This slide presentation from the AFHTO 2010 conference reviews the Centre for Family Medicine (CFFM) Family Health Team’s Memory Clinic, established in 2006 to address the challenges in caring for patients with cognitive difficulties. The CFFM Memory Clinic functions to enhance the care that family physicians can provide for patients at a primary care level. It ultimately aims to assist and empower the patient’s family physician in developing a greater degree of comfort and skill in managing patients with cognitive problems while maintaining a central role in patient care. The CFFM Memory Clinic ensures a balance of diagnostic accuracy and effective interventions with efficient, sustainable utilization of resources in a FHT. A comprehensive, independent evaluation of all patients assessed in the CFFM Memory Clinic over 3 years has demonstrated high level of satisfaction from referring physicians, patients, caregivers, clinic team members, and geriatricians supporting the clinic. In collaboration with the Ontario College of Family Physicians, the CFFM FHT has developed an accredited, comprehensive 5-day training program for family physician-leads and inter-professional health care team members to develop the practical knowledge and skills required for optimal management of patients with cognitive impairment. As of June 2010, 11 FHT Memory Clinics have been established throughout Ontario as a result of this training program. PRESENTER: Linda Lee FHT: The Centre for Family Medicine Click here to view.
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My Voice: Advance Care Planning
This slide presentation from the AFHTO 2010 conference reviews Advance Care Planning (ACP) from the Prince Edward Family Health Team’s perspective. ACP means ensuring that patients and families have the necessary information to make choices about their future care. Our FHT sought guidance from Fraser Health Authority (FHA) in British Columbia, which has a nationally recognized program stressing the importance of having ‘the conversation’, engaging the community and providing resources. The presentation shows how the FHA model was applied in a rural primary health care environment. Examples of ACP in clinics, patients homes, the ER, and community will be described. There are numerous challenges and pitfalls from the patient, family and provider perspectives. PRESENTERS: Joscelyn Matthewman, Mary Stever FHT: Prince Edward Family Health Team Click here to view.
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Mapping the Adult Learner
This slide presentation from the AFHTO 2010 conference outlines a unique approach to motivating and educating the adult learner. The approach focuses on increasing confidence, skills and knowledge by using tools and techniques that satisfy varying adult learning styles. PRESENTERS: Laura Briden, Alicia Atkinson, Sarah Micks FHT: Guelph Family Health Team Click here to view.