Ultimate Blogging Championship

Tag: Team Collaboration

  • Coordinated Care Plan Template Revised

    Health Quality Ontario has launched a newly revised coordinated care plan (CCP) template. Using Quality Improvement methodology, they worked with system partners to review the current CCP template, aligning the updated content with innovative practices. The goal of this refresh is to increase patient engagement by focusing on patient values, wishes, and concerns and by outlining the patient’s journey rather than episodic events. This new CCP includes physical, mental, and social components and will help integrate care plans among patients, providers, and caregivers. To achieve this goal, the new CCP template includes the following key updates:

    • The new template is shorter and modular. Optional sections (medication lists, assessments, recent hospital visits) are now placed in the appendix.
    • The “More About Me” section includes questions on the social determinants of health.
    • Language now aligns with the Health Care Consent Act, the Substitute Decision Act, and the Personal Health Information Protection Act.
    • A new section on palliative care has been added.

    A comprehensive user guide is included with the revised template. In addition, further discussion is underway on how best to support teams in integrating this version into their current processes including the use of electronic solution to enable coordinated care. More information on this will follow in the future. Relevant Links:

  • Case Study: Embedding Care Coordinators in your team

    AFHTO, in partnership with the Osborne Group, has prepared a case study for AFHTO members which looks at how five Family Health Teams (Mount Forest FHT, Sunnybrook Academic FHT, City of Lakes FHT, Guelph FHT,* and South East Toronto FHT) have effectively embedded the Care Coordinator role within primary care. Their advice to other primary care teams, and the lessons they have learned in the process, include the following:

    • Having a care coordinator as part of the team has a significant impact on quality and effectiveness of care.
    • Pay attention to the principles of change management as new models of service delivery are rolled out. Change may be difficult, and it may take some time to build relationships and trust.
    • With increased system coordination and collaboration there is a learning curve; it may take time but effective relationships are important to success.
    • Learn from other FHTs and primary care teams about their approaches so that you can build on their experience to build a collaborative model that fits the profile of your team and leverages your strengths.
    • Define the role broadly giving the Care Coordinator access to a broad array of providers and services.
    • Have a home base for the Care Coordinator at your site, or dedicated on-site time when inter-professional providers can see and talk to them. This improves efficiency and builds a sense of collaboration and teamwork.
    • Enable access to your EMR for the Care Coordinator.
    • A quality improvement perspective will contribute to a broad understanding of the role.

    *Please note: The case study on Guelph FHT, which was completed in 2016, no longer reflects the current state of care coordination in the Waterloo Wellington LHIN region. The LHIN has opted for a different approach and is not embedding care coordination in primary care. AFHTO asserts the role of primary care providers to lead care coordination. Primary care providers work to ensure access to interprofessional care for patients and identify a single point of contact to help patients and families navigate and access programs and services. The Ministry’s Patients First proposal speaks to deploying care coordinators in primary care. A number of teams have already done this and their experience can help other primary care teams as well.

    Learning from your peers: additional case studies

    AFHO has developed a series of case studies for our members to share the experience of colleagues on topics identified as being important to you:

     

  • Social Workers and Social Service Workers Professional Development Fund

    Ontario has launched a special two-year pilot project to provide financial assistance (up to $300 per year) for professional development activities completed by social workers and social service workers. Seminars, online courses, conferences and more are eligible for reimbursement. Training that supports the province’s priorities to care for vulnerable populations and their complex needs will be given priority. To learn more please visit the Ontario Association of Social Workers site.

  • NP referral to specialists / updated Grow Your Own NP Initiative

    Today government has announced that, effective May 1, 2015, NPs are now able to refer directly to specialists. Government first mentioned its intent to make this policy change in the 2015 Provincial Budget, released on April 23. The announcement and OHIP bulletin below provide details. This welcome announcement was followed by another – the ministry has launched the updated Grow Your Own Nurse Practitioner Initiative. For information on:

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

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

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

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

  • AFHTO 2014 Conference: Theme 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.

  • Invitation to primary care team members to join province-wide communities of practice

    We invite all staff in AFHTO member organizations to participate in a community of practice for their profession. AFHTO members are made up of diverse teams of professionals working together to provide excellent patient care. Communities of practice provide invaluable help in fostering a culture of interprofessional collaboration which enhances patient-centred care. AFHTO has been supporting the development of communities of practice for the different professions working within FHTs and NPLCs.

    Benefits of participation in a community of practice:

    • Online community of people working in similar roles within primary care teams:
      • Optimize teamwork within and across disciplines by sharing best practices and experiences.
      • Explore opportunities to enhance interprofessional collaboration within FHTs, NPLCs and other team-based settings.
      • Free half-day networking session on October 15, 2014 in Toronto (before the start of the AFHTO conference):
        • Meet and mingle with peers to identify common practices and optimize teamwork.
        • Click here to register for the conference or contact the community of practice contact below to sign up for the session.

    How to sign up for a community of practice:

    To join a network, staff should send an e-mail to one of the contacts listed below. They will follow up with more information about their network and instructions to join.

    Community of Practice Lead / Contact Organization
    Administration Michelle Smith Guelph FHT
    Chiropractor Craig Bauman Centre for Family Medicine FHT
    Health Promoter Sandy Turner Minto-Mapleton FHT
    Mental Health and Social Workers Catherine McPherson-Doe Hamilton FHT
    Nurse (RN/RPN) Tara Laskowski Hamilton FHT
    Nurse Practitioner Claudia Mariano West Durham FHT
    Occupational Therapists TBD contact Marg Alfieri for information
    Pharmacist Lisa Dolovich McMaster FHT
    Physician Assistant Melissa Holm Hamilton FHT
    Psychologist Veronica Asgary-Eden Family First FHT
    Registered Dietitian Jacquie Reeds Andrea Firmin Hamilton FHT Markham FHT

    Our community of practice leads emerged from within the FHT/NPLC community to create forums to exchange knowledge and share best practices with peers in similar roles from across the province. Thank you to all of our volunteer community of practice leads and to their EDs for supporting their leadership role in the community of practice.

  • Invitation to participate in upcoming primary care programs

    AFHTO members have been invited to participate in and provide feedback for the following programs (scroll down for more information):

    • Nominate a team or individual for the Public Health and Primary Health Care Together Awards (deadline April 7)
    • Provide feedback by completing the RNAO and RPNAO Primary Care Toolkit Survey
    • Provide information on Diabetes and Obesity Prevention Programs (deadline March 21)

    2014 Nominations Open: Public Health and Primary Health Care Together Awards

    The joint Public Health and Primary Health Care awards will be presented during the Prevent More To Treat Less: Public Health and Primary Health Care Together Conference on June 4 and 5, 2014. Primary care organizations are invited to submit nominations in any of the three award categories:

    1. Champion for Public Health and Primary Health Care: awards an individual for significant leadership in advancing the relationship between Primary Health Care and Public Health at system, managerial and/or frontline levels.
    2. Innovation in Public Health and Primary Health Care Award: awards a policy, program or initiative for excellence in advancing collaborative practice between Public Health and Primary Health Care.
    3. Media Award: awards a journalist, body of work, or media outlet which has highlighted the importance of addressing the determinants of health to improve population health and advance health equity.

    Deadline for nominations is Monday, April 7, see below for nomination forms and submission guidelines:

    Invitation to participate in RNAO and RPNAO Primary Care Toolkit Survey

    The Registered Nurses’ Association of Ontario (RNAO) and the Registered Practical Nurses Association of Ontario (RPNAO), with funding from the Ministry of Health and Long-Term Care, are collaborating on a project to develop a toolkit on maximizing primary care registered nurses’ (RN) and registered practical nurses’ (RPN) full scope of practice utilization in primary care. If you are a clinical director, executive director, manager, physician, primary care nurse, team leader, or other health care professional in a primary care organization, such as a Community Health Center, Family Health Team, Nurse Practitioner-Led Clinic, Aboriginal Health Access Centre, patient enrollment model (FHN, FHO, etc.) or a solo practice clinic, you are invited to take part in this short survey. Click here to fill out the survey. This survey should only take approximately 5 to 7 minutes of your time and your answers will be completely anonymous. Your answers cannot be saved so please be prepared to complete this survey in one session.

    Seeking Information on Diabetes and Obesity Prevention Programs

    The Physical Activity Resource Centre (PARC) supports community leaders working in public health, community health centres, recreation and sport organizations, non-government organizations, and schools to enhance opportunities for healthy active living in Ontario. PARC has been asked by the Health Promotion Division, Ministry of Health and Long Term Care to identify existing best practice interventions related to the prevention of type 2 diabetes and is working with consultants on the execution of this scan. Organizations and community agencies that offer health promotion programs to adults, children and youth and specific populations focused on the prevention of diabetes and/or obesity are asked to provide information on their program. Please complete one survey for each program offered by your organization. Each survey should take no more than 10-15 minutes to complete. If you are not sure whether or not your programs are appropriate, please complete the survey. Your responses would be appreciated by March 21, 2014.

  • Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients, organizational, and system outcomes

    The Registered Nurses Association of Ontario (RNAO) has published a best practice guideline, Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients, organizational, and system outcomes. This guideline is intended to foster healthy work environments. The focus in developing this guideline was identifying attributes of interprofessional care that will optimize quality outcomes for patients/clients, providers, teams, the organization and the system. This guideline identifies best practices to enable, enhance and sustain teamwork and interprofessional collaboration, and to enhance positive outcomes for patients/clients, systems and organizations. It is based on the best available evidence; where evidence was limited, the recommendations were based on the consensus of expert opinion. Click here for the guideline and additional resources for implementation.