Theme 1 – Leadership and governance for quality 1 The Role of an Interprofessional, Cross-Sectoral Planning and Priorities Committee in the Successful Function and Evolution of an FHT Theme 2 – Using data to improve care 2 Using EMR as a partner: Can an EMR system make you smarter about Diabetes care? 3 Lifting the Load: Utilizing University Students in Primary Care for Programming and Quality Improvement 4 How Quality Improvement and Decision Support Specialists (QIDSS) can help transform care 5 Laying the Foundation for Primary Care Performance Measurement in Ontario 6 The ABCs of M&M in a Family Health Team 7 Using EMR Data for Self Reflection and Facilitate Change to Enhance Patient Care (poster to follow) 8 Improving the Quality and Efficiency of Post-hospital Admission Visits to the Primary Care Provider 9 Healthy Weight Surveillance Pilot Study Theme 4 – Integration: building the team beyond the FHT 10 Standardization Committee: The Answer to Effective Utilization of Registered Nurses to Full Scope of Practice (poster to follow) 11 Evaluation of the Integration of the Physiotherapy Practitioner into the Toronto Western Hospital Family Health Team 12 Managing Systems Transitions – Integrated Hospital Transition Management Initiative – Poster Presentation 13 INR Clinics: the next step 14 The Nutrition Resource Centre as a Means for Collaboration between Family Health Teams and Public Health 15 Expanding Our QI team to Improve Patient Outcomes and Enhance Provider Engagement and Collaboration: Public Private Collaboration (PPC) (poster to follow) 16 Supporting Caregivers Through Problem Solving Therapy 17 Driving Transformation By Seeing The System Through The Eyes of Patients and Their Families Theme 5 – Advances in health promotion and chronic disease management 18 AFib Innovation Program (poster to follow) 19 Reducing CVD risk factors through Fostering Self-Management Skills using an Interprofessional Team in a Shared Medical Visit Setting 20 Smoking Cessation Program at St. Michael’s Academic Family Health Team (poster to follow) 21 Readiness – A Key Concept in Mental Health Intake Assessments 22 Colon Cancer Screening: A Family Health Team Approach to Improve Patient Awareness and Access (poster to follow) 23 EPIC: Expanding Paramedicine in the Community 24 Exploring Hand Hygiene in Primary Care (poster to follow) 25 Evaluation of a nursing led chronic disease management program 26 Group Visit Implementation and Program Evaluation: Interprofessional Well-Baby Group Visits (poster to follow) 27 Effect of’Beyond the Fork’ program on chronic disease self-management: a pilot RCT 28 Partnering with Patients in the Development of a Trauma Program (poster to follow) 29 Using a Novel Instructional Video on the Fecal Occult Blood Test to improve Rates of Colon Cancer Ccreening in Low Risk Patients: a pilot study at the Toronto Western Hospital Family Health Team 30 Meeting Parental Needs for Infant Feeding Education with Well Baby Group Visits (WBGV) (poster to follow) 31 The 4 Ps of Effective Health Promotion in Family Health Teams: Enhancing Patient Engagement in Community-based Programming. 32 Provider Education Program: Evidence-Based Asthma Knowledge Transfer into Primary Care Practice 33 Improved Cancer Screening Rates with Introduction of an EMR 34 Right Care, Right Time, Right Place: A Lung Health Collaborative in Primary Care (poster to follow) 35 Some Injuries You Can’t Kiss and Make Better: Fall Prevention in Young Children 36 Diabetes Group Visits – A Collaborative & Supportive Approach to Patient Care 37 Progress Beyond The Scale: Using Data Collection to Provide Patient and System Level Feedback in Healthy Weight Management Program 38 Health Coaching for patients with diabetes: impact on interdisciplinary teams 39 The Ontario Renal Network: Reducing the Impact of Chronic Kidney Disease through Early Detection – A Primary Care Innovation (poster to follow) 40 Bridging the Gap: Increasing cancer screening rates through quality improvement 41 Upstream Solutions for Downstream Congestion 42 See the Difference an HgbA1C Onsite Makes (poster to follow) Theme 6 – Improving care for seniors 43 Guelph Family Health Team Cooking Classes: A “Healthy Bite” closer to prevent and manage chronic disease 44 Evaluating a Health and Social Care Innovation; Findings from the Integrated Home-Based Primary Care (IHBPC) Study 45 Safe Medications And Reviews Taskforce (SMART Seniors Project) – An Interprofessional Collaboration at the St Michael’s Academic Family Health Team 46 Health Equity and Geriatric Care in a Rural Practice 47 Prescribing and Deprescribing in Frail Elderly: Use of an interdisciplinary team to enhance safe medication use in frail and homebound older adults. 48 Medication Reviews for Improving Care in Elderly Family Health Team Patients on Multiple Medications (poster to follow) Theme 7 – Innovation in interprofessional collaborative team implementation 49 The Primary Care Asthma Program (PCAP): A Standardized Program Model for Evidence-based Primary Care Asthma Management in Ontario 50 An Interdisciplinary Approach to Increasing Awareness of RD’s Medical Nutrition Therapy Services 51 Making Patient Safety a Priority: Moving from a culture of blame to learning via narrative 52 Improving Patient Access to Care: Removing Barriers to Receiving Assessment and Education by Health Disciplines of the St. Michael’s Hospital Academic Family Health Team 53 The Patient Engagement Project: Lessons Learned 54 The Value of an Optometry-integrated Primary Care Model to Lowering Risk of Blindness and Augment Chronic Disease Management 55 Investigating the role of a NP and a PA in a Family Health Team 56 Strengthening the Circle of Mental Health Care: Social Work and Psychologists in Collaboration: A Panel of Physician/Social Worker and Psychologist 57 The “Missing Link”: The Integration of Registered Kinesiologists in Primary Care 58 Integrating Palliative Care into an Academic Family Health Team 59 Longitudinal Study of Mental Health Services at Summerville Family Health Team 60 “In the Wee Small Hours of the Morning”: An Insomnia Reversal Program for Primary Care 61 Primary Health Care: Chiropractic Collaboration (poster to follow) 62 A Collaborative Approach in Integrating Evidence Based Practice in Smoking Cessation- A Paradigm Shift (poster to follow) 63 Evaluation & Lessons Learned from the Interprofessional Memory Clinic: Loyalist Family Health Team – impact on the patients, care partners, health care providers and community partnerships (poster to follow) 70 PAASSPORT: Primary Care Advanced Access Study: Spreading the Practice and Optimizing interprofessional Resources and Treatment Theme 8 – Meaningful use of EMRs 64 Advanced Access – Same Day Next Day Physician Access 65 The McMaster Pain Assistant: The why, what and how of a new EMR tool that teaches. 66 Updating and Standardizing Nutrition Handouts on the EMR 67 Supporting the implementation of the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain in primary care 68 Preventing Clinically Significant Drug/Disease Interactions in Primary Care
Tag: Team Collaboration
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AFHTO 2013 Conference – Innovation in Interprofessional Collaborative Team Implementation
Theme Description: The whole is greater than the sum of its parts – this is the goal of interprofessional teams. Interprofessional collaboration is the process of communication and decision making that enables the separate and shared knowledge and skills of care providers – and the patient – to create synergy in patient care. It involves the concepts of mutual respect, maximum use of collective resources, and awareness of individual accountabilities, and competence and capabilities within respective scopes of practice. Presentations in this stream will focus on innovative methods to develop evolving, dynamic teams focused on the value of collaboration and inclusiveness. A7-A – Unhealthy FHOs Equals an Underperforming FHT: Common Problems in FHO’s and How they can be Corrected to Improve FHT Performance A major factor in the success of every Family Health Team is how well the Family Health Organization (FHO) is performing. Cirrus Consulting Group has learned the common problems that exist between FHOs and FHTs and best practices to improve both, the relationship between the two parties and overall FHT performance. A7-B – A focus of health care reform: managing physical disabilities/complex patients in primary care The Centre for Family Medicine in Kitchener has operated an inter-professional clinic for the past 3 years that has broken down the barriers to improve access and quality of care to persons with disabilities. This presentation will review the set up and organization of the clinic and strengths and challenges encountered. A7-C – Collaborating With Physicians Into Mental Health Treatment This presentation will be aimed at demonstrating examples whereby family physicians and their Interdisciplinary Health professionals have collaborated mental health practice. The overview provides ideas on how to motivate physicians to participate in individual or group sessions including viewpoints by a psychometrist/mental health program lead and two physicians to ensure a collaborative approach. B7 – The Obesity Story: Using the Obesity Services Planning Framework to Improve Team Practice This session aims to familiarize participants with the key features and possible uses of a flexible population-based planning framework for managing obesity in team-based primary care. C7 – Nurturing Collaboration in a Large, Geographically Dispersed FHT Strategies look to respect and respond to local differences, while also capitalizing on the advantages of a larger organization to develop FHT-wide policies and programs. This presentation will share some of those strategies and note the successes and challenges. D7 – The System Navigator – the new role in the McMaster Family Health Team At McMaster FHT, the Case Manager/System Navigator was developed in recognition of the many issues, medical and non-medical, a patient faces that affect their health and well-being. This presentation will introduce this new position in the health care team, explore strategies for describing and applying for this role within the inter-professional family health team setting and discuss case scenarios /patient experiences. E7 – A Unique Interprofessional Approach to Delivering Ongoing Care to Patients with Celiac Disease in a Primary Care Setting : A Dietitian, Physician and Chaplain Collaboration A unique team including a dietitian, family physician and chaplain began to look closer at how to better identify and accommodate a vulnerable population with celiac disease, often lost to care in family practice, with the intention to enhance knowledge translation and earlier intervention by clinicians. F7 – Developing Resilience in our FHT’s through Innovative Program in Mindfulness Training Mindfulness based programs have been shown to enhance provider resilience, team functioning and quality of care. This workshop with begin with a definition of mindfulness and review some of the burgeoning evidence of the effectiveness of mindfulness programs for health care providers and teams.
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Update on employment of Physician Assistants
AFHTO members may be interested in the time-limited funding to be made available by MOHLTC in the “Physician Assistant Career Start” program and other news related to the employment of PAs. Click here to read the memo from Suzanne McGurn, ADM, Health Human Resources Strategy Division, Ministry of Health and Long-Term Care.
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In case you missed AFHTO’s June 5 e-mail, please click here for the full report of our recent meeting with the FHT Unit. Topics covered:
- QIDSS implementation: how the allocations have been made and what to expect in their implementation
- Physiotherapy in FHTs: timing and process to apply for positions
- Health Links: staffing implications for FHTs that are coordinating and/or taking on care for more patients
- Changes in Ministry reporting: ensuring FHTs have adequate training and lead time
- Flexibility and accountability in FHT budgets: finding the way toward greater budget flexibility while enabling the Ministry to ensure good value and appropriate oversight for public funds
- A number of specific budget pressures: recognizing that 2013-14 budget packages are already in the approval process, these were noted with the view to improving the situation for the 2014-15 budget cycle
- Transfer of rostered patients within a group: FHTs are seeking clarification of Ministry policy and application
- As well as quick updates on other issues.
These topics zeroed in on the priority issues identified and developed by AFHTO’s ED Advisory Council and Board of Directors, with input from the AOHC CFHT ED Executive group.
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Sample Memorandum of Understanding for Clinical Data Use
Click here to access the following sample Memorandum of Understanding for Clinical Data Use.
This document outlines the need for effective coordination and collaboration between the FHT and the FHO in the collection, use, disclosure and retention of patient personal information and personal health information for the purposes of approved research, quality improvement, program planning, educating trainees and reporting to the Ministry of Health & Long Term Care.
This document has been created by the North York Family Health Team, and posted for information and use by other FHTs. Written by Dr. Kimberly Wintemute, Lead Physician, North York FHT; reviewed by the North York FHT IT/IM Committee and by two separate privacy officers at North York General Hospital and at CPCSSN.
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Post-Drummond Report and Budget: Moving Forward with Implementation of Health Care Reforms
Monday, June 11, 2012
This conference explored recommendations made in both the Drummond Report and the Action Plan that proposed a new local integrated health model. This model sets out primary care as the focal point, with access to health services shifted away from emergency rooms towards community care and alternative forms of care.
AFHTO’s Executive Director, Angie Heydon participated in a panel discussion, Moving Forward with Integrating Primary Care.
Panelists:
- Melissa Farrell, Director, Primary Health Care, Ministry of Health and Long-Term Care
- Jan Kasperski, President and CEO, Ontario College of Family Physicians
- Angie Heydon, Executive Director, Association of Family Health Teams of Ontario
- Paul Huras, CEO, South East LHIN
- Matthew Anderson, President and CEO, William Osler Health System- Brampton
- Sandra Coleman, CEO, South West CCAC; Board Member, Ontario Hospital Association
Please find Angie’s presentation for the conference here.
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Realizing Patient Goals
2011 AFHTO conference presentation PRESENTER (S): Andrea Petroff, BA Honours. Psych, M.I.R. (Masters of Industrial Relations), Executive Director; Claudia Mariano, NP-PHC, MSc Primary Health FHT/ORG: West Durham FHT ABSTRACT: Our commitment to our patients, our community, and to ourselves, to provide the best possible care for chronically ill patients, meant that we needed to take a cold, hard look at how we currently manage versus how we need to be managing this vulnerable patient population. Focusing first on patients with diabetes; we took a strategic approach to establishing FHT procedures and policies that can be easily applied in managing other chronic illness. These are the tactics we employed:
- Developed outcome and monitoring goals for all Type Two diabetic patients >18yrs
- EMR review of baseline patient statistics measured against goals set
- In-depth analysis of current resources, practice design, interprofessional collaboration and office efficiencies to identify gaps that jeopardized our goals
- Prioritized actions to address areas of concern and assigned personnel to lead change for improvement
Click here to view presentation.
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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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Chronic Respiratory Disease Management in the Community
2011 AFHTO conference presentation PRESENTER (S): Maria Savelle, RN, Certified Respiratory Educator, Nurse Educator FHT/ORG: Stratford FHT ABSTRACT: The Stratford Family Health Team Respiratory Clinic began as a pilot project in June 2009 after it was identified there was a need to assess and provide education regarding patient self-management of chronic respiratory conditions (COPD and Asthma). After a successful trial period, the SFHT Respiratory Clinic opened to all patients rostered with the 13 physicians of the Stratford Family Health Team. A specially trained registered nurse (COPDTrec, AsthmaTREC, SpiroTREC, TEACH trained) accepts referrals from physicians and Allied staff. Office spirometry is performed, and three champion physicians interpret the results to diagnose COPD and/or asthma. Pharmological management is decided between the Nurse Educator and the responsible physician. Follow up education regarding self-management of their respiratory condition is then provided either one-on-one, or in a group education session by the Nurse Educator. Follow up visits are arranged to ensure compliance with respiratory medications, assessing control/management of symptoms, and further patient teaching is provided to aid the patient in optimum self-management (Action Plans, Diary of symptoms, identifying need for reassessment in times of increased symptoms, etc.) If the patient is smoking, smoking cessation counseling is offered by the Nurse Educator as part of the follow up visit regime. The SFHT was a part of the QIIP COPD Learning Community, and was able to identify a number of patients appropriate for spirometry testing by way of screening with the Canadian Lung Health Test – a number of patients were newly diagnosed with lung conditions earlier, due to this screening process, and a number accepted smoking cessation counselling as a result of their screening and spirometry testing procedures. The Stratford Family Health Team Respiratory Clinic continues with the Nurse Educator assessing patients Monday to Friday, 8-4, where a constant flow of referrals for new patients continues in the busy clinic. The goal of the clinic is to identify respiratory conditions, ensure proper treatment according to current guidelines, teach patient self-management of respiratory conditions, in the hopes of reducing physician office and ER visits related to respiratory symptoms. Click here to view presentation.
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Practitioner Experience of an Interprofessional Integrated Primary Care-Based Programs For Seniors
2011 AFHTO conference presentation PRESENTER (S): Dr. Ainsley Moore, MSc, MD CCFP; Joy White, RN-EC, MSN; Kalpana Nair, MSc, PhD; Maria Chacon, MD FHT/ORG: McMaster FHT & Department of Family Medicine, McMaster University ABSTRACT: Background: Multidisciplinary, integrated primary care-based programs involving multiple practitioners are recommended for frail seniors with complex concurrent conditions. This study sought to understand the perceptions and experiences of family physicians and nurses whose patients had been seen through a multidisciplinary, integrated primary care-based program for seniors, the Seniors Collaborative Care Program (SCCP). Methods: This study used a qualitative descriptive approach and took place at Stonechurch Family Health Centre (SFHC) in Hamilton, Ontario. Purposive sampling was used and each participant took part in a semi-structured, individual interview. Analysis involved a content analysis approach. Results & Conclusions: Five family physicians and 4 nurses working at SFHC took part. Main themes centred on need for clear communication and role clarity. Access to the SCCP Program was also a predominant theme, suggesting that availability of specialized geriatric services in primary care is an important step towards increasing knowledge and skills of primary care clinicians. Click here to view presentation.
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Chiropractic Collaboration in Centre for Family Medicine FHT
The Ontario Chiropractic Association has extended the offer to provide further information on how a tailored model of chiropractic collaboration could fit into your FHT. Click here to see a case study of successful collaboration in Kitchener’s Centre for Family Medicine FHT. o Contact Andrea Endicott at 416-860-7188 or by e-mail at aendicott@chiropractic.on.ca .