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Concurrent Sessions by Theme of 41

CONCURRENT SESSIONS

Listed by Theme

Theme 1 – Population-based primary health care: planning and integration for the community

A1-a Taking Collaboration to the Next Level…Dealing with the Social Determinants of Health

A1-b Nutrition Education at Your Local Coffee Shop

BC1 The BODY of Health Equity: Head, Heart and Feet!

D1 Engaging the Community and Addressing the Social Determinants of Health at St. Michael’s Hospital Academic FHT Going upstream: Building the Infrastructure to Address Social Determinants at the St. Michael's Hospital Academic

Family Health Team Community Engagement Can Support Population-Based Primary Health Care: Lessons Learned at St. Michael’s

Hospital Academic Family Health Team

E1-a Reaching out to Adolescents in the Community – The Sunnybrook Academic Family Health Team’s Story

E1-b Moving Gestational Diabetes Care into the Community

F1-a Strategic Approaches to Population Health Planning

F1-b Presenting An Improved Tool for Meaningful Program Planning and Reporting

Theme 2 – Optimizing capacity of interprofessional teams

A2 Developing Principles for Family Practice: Sharing a Common Approach to Care

AB2 Bettering Mental Health Outcomes through Optimized Team Care Integrated Care for Better Outcomes: Supporting Primary Care Patients with Mental Health and Addictions Issues Optimizing Capacity of the Mental Health team. Triaging the patient: who is the right provider? Responding to the Needs of Patients with Anxiety-Developing a Comprehensive Group Program at a FHT

B2 "Welcome to your new reality - you have diabetes this week!"

C2 Sustaining Change: A FHT Structure that Works

D2 Charting a Blueprint for Improved Interprofessional Primary Care Team Effectiveness – The Teaming Project

E2 Collaborative Practice – Messy, Time Consuming and Worth It!

F2 Integrated Care Planning for Complex Patients Telemedicine IMPACT PLUS (TiP): Bringing inter-disciplinary team resources to the community Blitzing Integrated Care for the Super Complex Patients


Theme 3 – Transforming patients’ and caregivers’ experience and health A3 Patient Councils: Experiences within the GTA

Community Engagement - Mississauga Halton Share CCAC Share Care Council Patients' Perspectives: Getting Patients Involved and Engaged to Participate in PAC (Patient Advisory Council)

B3 Tips for Capturing and Understanding Patient Experience Tips and Tools to Capture the Patient’s Experience in Primary Care using the NHS’s Experience Based Design (EBD)

Methodology What are they thinking? Approaches, Ideas, and Tools to Measure Patient Experience in your Practice

C3-a Well-Baby Visits in Primary Care Well-Baby/Well-Child Care Groups: The Bridgepoint FHT Report 5 years later

Baby Friendly Initiative (BFI): Leveraging the EMR to capture breastfeeding statistics

C3-b Measuring the Patient Experience: How to Select a Delivery Method for Best Results and Minimal Effort

DE3 The Power of the Collective: FHT Experiences with Group Medical Visits HERSTORY: An Innovative Group Model for Mental Health Care Using Peer Facilitation and Patient Co-design

Shared Medical Appointments: the why, the how, the impact

Peer Directed Group Exercise Programs Improving Clinical Outcomes

Group Medical Visits (GMV) for Primary Care Diabetes: The McMaster Family Health Team Experience

F3 The Vitality Interprofessional Team Approach to Food, Mood and Fitness

Theme 4 – Building the rural health care team: making the most of available resources

A4 Community Quilt – The Story of How Our FHT has been Woven into the Fabric of the Community

B4 Innovative Service Provision in a Rural Underserviced Community: The Virtual Visit, Shared Innovations, Patient-Centered Service Delivery

C4 Organizing The Community Around The Patient – Rural And Remote Regions of Ontario

Rural Health Hubs Framework for Ontario

D4 "From Soup to Tomatoes" – An Armchair-Based Exercise Program

EF4 Project ECHO (Extension for Community Healthcare Outcomes) – Managing Complex Chronic Conditions Without Sweating Bullets


Theme 5 – Advancing manageable meaningful measurement AB5 Optimizing EMR and Use of External Data Sources to Measure and Improve Quality of Care

C5 Boiling Multiple Measures Down To A Single Indicator: The Queen Square FHT and Patients Canada Experiences Indicator Management: Weighted Indicator Selection Matrix (QSFHT Experience) Measuring What Really Matters to Patients

D5-a Tools To Enhance And Track Patient Experience Extending the EMR with Patient Tablets: Using Interactive, Point-of-Care Patient Surveys in the Waiting Room to

Generate Clinical Content and Save Time Transforming Primary Health Care Delivery through Innovative Patient Experience Tool Using an Automated Patient Reminder Service and Survey to Collect Information on Patients’ Experiences Add some SaaS to your Patient Experience Surveys

D5-b Measlesgate: A Case Study in Leveraging Your EMR to Protect Your Patients and Staff

EF5 Dragon’s Den: Pitching Real-Life Innovations in EMR Queries Quality Based Improvements in Care (QBIC): How EMR data can Transform Care Data Tracking: Creating Your Own Path Beyond an electronic paper file - Optimizing your EMR for Population-Based Measurement Leveraging Convergence of Healthcare Delivery, Business Dynamics and Technology Advancements to Advance

Collection and Utilization of Meaningful COPD Patient Data Leading Edge Custom Queries and their Applications Across Ontario Optimizing EMRs to Accurately Identify COPD and other Chronic Disease Patients

Theme 6 – Leadership and governance for accountable care

A6 Quality Improvement Leadership Team (QuILT): Hearing Everyone's Voice

B6 Creating and Implementing the Markham Family Health Team Lead Physician Performance Review: An Exercise in Accountability and Transparency

C6 Solutions for Managing Patient Privacy across Clinics and Community Partners A Stewardship Privacy Model for a FHT and its Clinics Quality-Based Reporting and PHIPA Compliance

D6 Culture Eats Accountability for Breakfast

EF6 Navigating by the stars? Try GPS. How Two FHT Leaders Used Brain Research To Increase Team Collaboration And Physician Engagement

Theme 7 – Clinical innovations keeping people at home and out of the hospital

A7 Reducing the revolving door syndrome: hospital and primary care working together to reduce 30 day re-admission rates for COPD and CHF patients

B7 Community Paramedicine Models for Primary Care Community Paramedicine – Review of a Dedicated Model in Primary Care (FHT) Community Paramedicine in a Rural FHT

C7 The Evolution of Telehomecare: Targeting More Chronic Conditions and Offering Customized Approaches

D7 Aging at Home: Interprofessional Care to Keep Seniors at Home and out of Hospital

E7 Integrated LTC: An Innovative Initiative to Reduce Potentially Avoidable Hospitalizations for Seniors Living in East Toronto Long-Term Care Homes

F7 The MedREACH Pilot Project – Integrating Primary and Tertiary Care to Support Medically Complex Patients

Concurrent Sessions by Theme: Theme 1 Page 5 of 41

Theme 1 – Population-based primary health care: planning and integration for the community

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 community partners. This stream will focus on population-based approaches to program planning to respond to community needs, developing partnerships, caring for patients in the broader community and Health Links. Sessions:

A1-a Taking Collaboration to the Next Level…Dealing with the Social Determinants of Health



D1 Engaging the Community and Addressing the Social Determinants of hHalth at St. Michael’s Hospital Academic FHT




F1-b Presenting an Improved Tool for Meaningful Program Planning and Reporting

A1-a Taking Collaboration to the Next Level… Dealing with the Social Determinants of Health

Theme: 1. Population-based primary health care: planning and integration for the community

Length: 45 Minute Presentation

Dr. Alan McLean, MD, CCFP; Physician Lead, Superior FHT

Learning Objectives:

The purpose of this presentation is to share the knowledge we have gained through our Medically Complex Patient Pilot Program and the changes in practices that have resulted in reaching out to more patients and their caregivers.

1. How to identify patients.

2. How to determine which partnerships can best serve the patients.

3. How to provide health care when those most in need don’t show up.

4. How Mental Health, addictions, physical health and crime can be tackled together with success.

Summary:

The Family Health Team interdisciplinary model has increased accessibility and revolutionized primary care. However, complex patients with significant medical and social problems require a different approach to providing care. During our Medically Complex Patient Pilot Program (MCPPP) some of the most complex patients identified by our partners did not come to appointments and were frequently unreachable. These were often folks with no phone, no fixed address or had mental health and addiction problems which made travelling to appointments and or making appointments near impossible for them.

The Innovation Centre is an organization in Sault Ste Marie which uses data to drive innovation. They identified an area of the city where a significant number of residents are marginalized and

economically and socially disadvantaged. It indicates that this area of the Sault has the highest poor academic performance and poor health, the highest crime rates and mental health and addiction issues. The police had already initiated a Neighbourhood Resource Centre (NRC) located in the heart of the identified region where frontline Mental Health workers work side by side with police officers to serve the population in a better way.

We identified a lack of primary care through a community engagement survey funded by NELHIN and with support from Police Services, the Resource Centre was equipped with an examination room and a weekly drop in clinic was started. Through our MCPPP and the NRC, we have forged collaborations with various agencies to identify and address a broad spectrum of concerns, including medical and social issues. Regular case conferencing that may include the patient keeps everyone involved connected. Thus far there have been plenty of anecdotal reports of better chronic disease management and emergency room diversion and these stats will be followed.




Michele MacDonald-Werstuck, Registered Dietitian, DFM McMaster University; McMaster FHT; Stonechurch FHC

Rev. Sue Carr BSc MTS, Executive Director 541 Eatery and Exchange, DFM McMaster University, Stonechurch FHC

Marika Smit, Registered Dietitian (pending July 2015), 541 Eatery and Exchange


Participants will:

Understand the barriers preventing connection with marginalized individuals who lack food security.

Concurrent Sessions by Theme: Theme 1 of 41

Learn how to connect with and equip individuals to use food bank items together with cheap local produce to prepare nutritious meals and snacks.

Learn how to start from the home setting and work with individuals at their own pace.

Learn how useful printed materials are for this population.

Learn how to effectively provide nutrition advice outside a health care setting.

Summary:

541 Eatery and Exchange is a for benefit not for profit business that provides affordable nutritious homemade food in an area of Hamilton where this is not otherwise available. Using volunteers and very few paid staff keeps costs low and encourages community participation. There is a pay it forward system that uses buttons, and the café is full of all kinds of people. It has become a focus for the resilience and strengths in the neighbourhood.

Using a grant from the Learning by Giving Foundation – McMaster University, we will describe hiring a Registered Dietitian to work with participants from our community, beginning with home visits to each participant to ensure the program meets their needs. Using existing resources as much as possible she will develop a simple illustrated text that accompanies each of the six sessions per series.

Food is available but not always accessible or usable for our neighbors. It is easier to rely on fast food rather than deal with the contents of a food bank box. We will unpack a typical box and make meals from it, adding simple fresh ingredients. We will look at what a store cupboard should contain. We will visit the local farmers market together.

This presentation will demonstrate how collaboration with local organizations and businesses enhances access to nutrition advice for hard to reach populations, and offers health care in an unexpected setting.




Lee McKenna, Executive Director, Partera International


Participants will leave with a broader sense of what we mean by Health Equity. Full spectrum training in and operationalisation of Health Equity must include all parts of the BODY of Health Equity. Participants will learn the elements of each – Information – Attitude – Capacity-building – and how they intersect and complement one another, why one without the others is inadequate and its potential for profound system-wide impact.

Summary:

The presentation will cover the elements of full-spectrum Health Equity, focussing on its present and potential impact on individuals, communities, on systems – and what kind of courage is needed to do so. It will be provide information and it will be interactive and fun!

• The HEAD of health equity is all about increasing our knowledge, open to and acquiring new information on best practices and applying it to the practice site environment. It’s about definitions, effective community engagement that never ends, rethinking Population Health Needs Assessments to take into account the social determinants of health, using its key concepts as the lens through which one does planning, asks questions, designs space, ensures accessibility (in every sense of that word); finding and recruiting the right staff and volunteers and ensuring their regular training in these concepts and applications as well as putting in place measures and mechanisms for open, transparent, safe communication, resolution of conflicts and team-building.

• The FEET of Health Equity institutionalises your commitment to health equity, providing monitoring and ongoing learning opportunities for improvement.

• The HEART moves beyond knowledge transfer to a focus on people and the encounters that make up our work-days: with our clients, our funders, our colleagues and ourselves – how we are with one another, our behaviours and the impacts of often unacknowledged social location and unrecognised privilege, cultural conditioning (on the part of both provider and client/ patient), unsurfaced attitudes, interests and motivations.

The HEART asks, What are the internal and organisational dynamics, structures, policies/procedures, unwritten protocols, personal values, rank and privilege that have an impact, positive or otherwise, on effective people-centred care? Training in the HEART of Health Equity also provides insight with respect to the architecture of space and the constructs and properties of power and stigma. Getting at the HEART drives passion for and interest in greater knowledge, skills and commitment to one’s part in the organisation’s goals and planning. Getting to the HEART is the indispensable ingredient.

The IMPACT of this kind of full-spectrum operationalisation is huge, measurable both in traditional methods, checking off boxes, monitoring change, evaluating experience – and in the more subjective measurements that have to do with self- and other-awareness, one’s capacity to broach difficult conversations, to identify internal barriers to effective ‘encountering’ of all sorts, to communicate more effectively.

To paraphrase Steven Lewis, ‘if we meant what we say about health equity, the very system itself would be turned inside out and upside down.’ It would move us to ask different questions:


• How would we communicate differently?

• How would we define performance and productivity differently?

• How would we train our providers differently?

• How would we use health information differently?

• How would we value time and

• What would we reward differently?

• How would we allocate resources differently?

D1 Engaging the community and addressing the social determinants of health at St. Michael’s Hospital Academic FHT



(I) Going Upstream: Building the Infrastructure to Address Social Determinants at the St. Michael's Hospital Academic Family Health Team

St. Michael's Hospital Academic FHT

Andrew D. Pinto, MD CCFP FRCPC MSc, Staff Physician & Scientist

Gary Bloch, MD CCFP, Staff Physician & Chair, Social Determinants of Health Committee


At the end of the presentation, participants will have: 1. Gained knowledge of initiatives being implemented to intervene on the social determinants of health at St. Michael's Hospital Academic Family Health Team, including work on income security, access to legal services, access to decent work and child literacy. 2. Gained skills in developing an administrative structure and partnerships required to administer these new programs, including the creation of a Social Determinants of Health Committee. 3. Gained knowledge of the role of evaluation in helping build and sustain new programs that address social determinants.

Summary:

Social determinants of health (SDOH) are “the conditions in which people are born, grow, live, work and age.” The concept of the SDOH is not new, and indeed, can be found in the observations of Hippocrates. However, modern healthcare organizations have typically not considered addressing SDOH as part of their core business, with few exceptions (e.g. community health centres). The landmark 2008 Final Report of the Commission on Social Determinants of Health triggered renewed interest in this area, followed closely by calls by the British Medical Association, the Canadian Medical Association and the College of Family Physicians of Canada for greater action by health professionals on SDOH.

Family Health Teams are well-placed to address SDOH as they

aim to provide quality primary care to Ontarians. Over the past two years, we have identified a number of new and innovative approaches to address SDOH in a practical manner. These include:

a) the routine collection of detailed socio-demographic data on all patients in order to assess health equity;

b) the implementation of an innovative Income Security Health Promotion service;

c) the implementation of a medical-legal partnership;

d) the implementation of a Reach Out And Read early childhood literacy program; and

e) the development of a combined advocacy and service program to address employment conditions and access to decent work.

Our experiences implementing and evaluating novel interventions will be described and used as a springboard for supporting participants to effect changes to the SDOH in their own communities.

(II) Community Engagement Can Support Population-Based Primary Health Care: Lessons learned at St. Michael’s Hospital Academic Family Health Team

St. Michael’s Hospital Academic FHT:

Cian Knights, MBACED HonBA, Community Engagement Specialist

Andrew D. Pinto, MD CCFP FRCPC MSc, Staff Physician & Scientist

Learning Objectives (II):

At the end of the presentation, participants will have:

1. Gained knowledge of what community engagement is and how it relates to patient engagement.

2. Gained knowledge of the role of community engagement in Family Health Teams, particularly in supporting population-based primary health care.

3. Gained skills around applying for funding to support community engagement specialists and reporting on performance measures, based on lessons learned within the St. Michael’s Hospital Academic Family Health Team.

Summary (II):

Community engagement is defined as the process of working collaboratively with groups of people – connected by geographic proximity, interest, identities or similar situations – to address issues affecting their health and wellbeing. St. Michael’s Hospital Academic Family Health Team was recently successful in obtaining funding for a full-time Community Engagement Specialist as part of opening a clinic site in a new community. The need to ensure that services was responsive to community needs was evident, alongside the growing focus within the Family Health


Team on addressing social determinants of health and improving access to care for the most vulnerable populations.

The key actions of community engagement are

1. intelligence gathering,

2. relationship building, and

3. conceptualizing innovative services.

The focus to date has been on relationship-building with residents, health care providers, other community members and organizations through formal and informal activities. The Community Engagement Specialist acts as a liaison: mobilizing information, connections and resources between the Family Health Team and various groups to support action that improves primary health initiatives through intersectoral collaborations and partnerships. This role provides value to primary health providers and to communities through better informed decision-making, an increased sense of involvement and responsibility, an increased range of ideas and options for improvements in primary care, better access and outcomes, and increased credibility, transparency and accountability. It is an approach that aims to engage beyond our patient population, reaching unattached patients, community members and residents in communities to reduce health inequities.




Sunnybrook Academic FHT and University of Toronto DFCM:

Dr. Purti Papneja, MD, CCFP / Staff Physician, Co-Program Director

Dr. Anne Wideman, MD, CCFP / Staff Physician, Co-Program Director


At the end of this workshop, participants will have the tools to build their own Adolescent Outreach program. Specific learning goals for this workshop include:

1. How to engage local high schools and build relationships with them

2. Create a program that is aligned with the school’s curriculum

3. Create a dynamic interprofessional team to deliver your program

4. Link with local Adolescent Psychiatry / Mental Health professionals

5. Incorporate learners and teaching in this model

6. Evaluate your program

7. Helpful resources, links and services.

Summary:

The Adolescent Outreach Program was created in 1988 to allow adolescents in our community an opportunity to ask questions and have their health concerns addressed by physicians in a confidential and non-judgmental setting. The program was also aimed to increase Family Medicine residents’ exposure to the health issues and concerns facing adolescents, a group that traditionally does not visit their Family Physician regularly.

In 2011, with the establishment of Sunnybrook Academic Family Health Team, interprofessional teams consisting of a physician, residents, dietitian and social worker as appropriate started visiting local high schools to provide education on topics such as mental health, sexual health, body image etc. Each session is approximately one hour in duration, with approximately 20 – 25 students in attendance. Students have the opportunity to submit written questions anonymously and ask questions directly on pre-identified topics. Teams led by residents use various interactive methods such as games/quiz/small group activities to engage adolescents.

With information technology available at finger tips of adolescents, it’s necessary to have a secure platform to provide correct health education early. Therefore, primary care involvement in Adolescent health needs to be increased across the province. Our program is one such example of platform to educate and promote health for adolescents.

This session will outline the process of creating a formal interprofessional Adolescent Outreach program in a Family Health Team, whether it be in an Academic setting or not. We will share our best practices as well as lessons learned since the establishment of the program.




Diabetes Care Guelph, Guelph FHT:

Sarah Duff, BScN RN CDE, Clinical Coordinator

Lee Kapuscinski, MSc RD CDE

Julie Goodwin, BScN RN CDE


Participants will learn about the successful and seamless transitioning of the Gestational Diabetes program from a hospital based model of care to primary care. During our presentation, we will highlight the transition process from start to finish and will elaborate on key aspects that made it a success. We will review our training strategies for new staff, referral process and evaluation of our program. We will conclude our presentation with opportunities and aspirations to continue to enhance our program to continue to serve women with Gestational Diabetes in our region.


Summary:

Careful planning with all stakeholders was necessary for the successful transition of the GDM program from GGH to DCG. We plan to outline our processes that promoted a coordinated health care experience for women in Guelph with GDM. Perhaps the most crucial element to be elaborated during our presentation is ongoing communication with stakeholders including face–to- face meetings, shadowing of care, training of staff and sharing of knowledge. Appropriate training of DCG staff was supported by GGH, DCG and ongoing devotion to professional development. DCG’s close working relationship with the Endocrinologists in Guelph also promoted collaborative patient care and inter-professional development. In addition, we are also fortunate to have Registered Kinesiologists and Mental Health Counsellors on our DCG team to help support women with GDM, which is unique to community programs.

Presentation highlights will include program flow process, resource allocation, educational strategy and expansion. The results of our one-year transitional evaluation outcomes will be shared and of course would not be complete without a review of lessons learned and next steps.




Chantelle Cecile, Registered Nurse, MN, BScN- Manager of Quality, Experience and Patient Safety, Windsor FHT

Summerville FHT:

Nadya Zukowski, Health Promotion Specialist


This presentation will demonstrate a strategic, population-health approach to program planning and QI initiatives. Participants will gain an increased knowledge of how to develop an evidenced- based, patient-informed, comprehensive health promotion plan. They will understand and take home practical tools that help to systematically identify needs, inform decision-making, and support program planning and evaluation processes. This presentation will discuss the benefits of embracing patient feedback, creating community partnerships, and developing meaningful evaluation tools. Participants will be able to identify aspects of building collaboration, and gaining buy-in and support from key stakeholders. Also, it will highlight the importance of utilizing this approach when creating the health promotion plan and for FHT wide organizational improvements.

Summary:

FHTs face many competing priorities and interests for program planning. How can they respond to the needs of FHT patients and the broader community, while considering an evidence-

based approach to planning in an efficient and effective manner? This presentation will highlight systematic approaches to the annual health promotion plan and QI initiatives within a small and medium sized FHT. There will be two approaches and tools presented to assess community needs and identify top priorities for action.

Windsor FHT will review the steps they take throughout the annual program planning process including: reviewing evaluations from the previous year, analyzing targets met and unmet, gaining and incorporating patient feedback regarding program and service wants and needs, fostering existing partnerships and creating new ones, examining and comparing chronic condition priorities and statistics across the country, province, locally, and within individual FHT’s, and developing evaluation tools.

Summerville’s Chronic Disease Management Committee (CDMC) developed a systematic tool that considered the top 10 chronic conditions within the FHT against various criteria: 1) prevalence of condition, 2) health care providers’ perspective, 3) patient feedback, 4) complexity of care for patients and providers, 5) probable impact of a program on health outcomes, 6) existing resources and care gaps, at Summerville and in the community, and, 7) feedback from the MOHLTC which helped inform the population health measures within Summerville FHT’s QIP.

At Family Health Teams we work in interdisciplinary teams; Health Promotion planning and activities should be no different. It is crucial to engage the team, community members, organizations and businesses, in order to make health promotion activities successful and sustainable. Drawing on internal resources, statistics, and utilizing external partners is key in developing a plan that meets the needs of your FHT and local community.

F1-b Presenting an Improved Tool for Meaningful Program Planning and Reporting



Bryn Hamilton, Provincial Lead, Governance and Leadership Program, The Association of Family Health Teams of Ontario (AFHTO)

Representative from Primary Health Care Branch, Ministry of Health and Long-Term Care (MOHLTC)

Representative from AFHTO members on the joint MOHLTC-AFHTO working group

Summary:

Both FHT/NPLC Executive Directors and staff in MOHLTC’s Primary Health Care Branch have identified the need to improve the ministry’s template for reporting on program plans (known as “Schedule A” in the FHT contract and “Schedule E” in the NPLC


contract). A joint working group from the MOHLTC Primary Health Care Branch and AFHTO will be working over the summer to improve this Schedule as a useful tool for program planning and reporting.

This workshop will include tips from the working group on how to do effective program planning and evaluation, ministry needs for reporting, and how to use the reporting tool effectively.


Theme 2 – Optimizing capacity of interprofessional teams

Interprofessional primary care teams are being called upon to provide high-quality, comprehensive, well-integrated care to all patients who need it. This requires high functioning teams able to provide healthy working environments, optimize capacity and allow all team members to work to full scope of practice. This stream focuses on how teams have overcome barriers to engage all team members in providing care, leverage the team to meet community needs, change behavior from solo to group practice, manage conflict within the team, strengthen care coordination internally and in the community, and expand access. Sessions:

A2 Developing Principles for Family Practice: Sharing a Common Approach to Care

AB2 Bettering Mental Health Outcomes through Optimized Team Care

B2 "Welcome to your new reality - you have diabetes this week!"




F2 Integrated Care Planning for Complex Patients

A2 Developing Principles for Family Practice: Sharing a Common Approach to Care Theme: 2. Optimizing capacity of interprofessional

teams Length: 45 Minute Presentation

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


By the end of the presentation, participants will:

1. Reflect upon the four principles of family medicine and its relevance within Ontario’s FHT’s.

2. Consider the meaning of Shared Accountability and its impact on team-based care.

3. Re-evaluate personal perspectives on willingness to provide collaborative patient-centred care.

Summary: Further information to follow.

AB2 Bettering Mental Health Outcomes through Optimized Team Care

Theme: 2. Optimizing capacity of interprofessional teams Length: 90 Minute Presentation

Many primary care patients present with mental health issues. CAMH and McMaster FHT share how they have optimized care for these patients through interprofessional collaboration.

I. Integrated Care for Better Outcomes: Supporting Primary Care Patients with Mental Health and Addictions Issues – Centre for Addiction and Mental Health

II. Optimizing Capacity of the Mental Health team. Triaging the patient: who is the right provider?

– McMaster FHT

III. Responding to the Needs of Patients with Anxiety-Developing a Comprehensive Group Program at a FHT – McMaster FHT

(I) Integrated Care for Better Outcomes: Supporting Primary Care Patients with Mental Health and Addictions Issues

Centre for Addiction and Mental Health:

Athina Perivolaris, RN, MN, Project Manager

David Rodie, Project Psychiatrist, MD, FRCPC

Benoit Mulsant, Principal Investigator, MD, MS, FRCPC

Diana Noel, Executive Director, BCOMM, MHSC, CMC, Village FHT

Bachir Tazkarji, Director, Postgraduate Family Medicine Program, MD, CCFP, ABFM, Summerville FHT

Learning Objectives (I):

At the end of this session, the learner will understand:

Factors that influence the implementation of evidence-based integrated care in addressing mental health and addictions issues in the primary care settings.

The role of a Mental Health Care Technician in supporting and enhancing the interprofessional collaboration between primary care and mental health providers.

The experiences of primary care providers, at participating Family Health Teams working within the context of the integrated care model

Challenges and strategies for successful implementation.

Summary (I):

Depression, anxiety, and at risk drinking are among the most common health problems for patients receiving general medical care. The majority of patients are seen exclusively in primary care, and never see a mental health or addictions provider.


Undetected, untreated or under-treated these conditions create a significant public health burden. This interactive presentation will overview a three-year research project partnering with Ontario Family Health Teams (FHTs) evaluating an innovative integrated care model of telephone-based, computed aided care management to support the mental health care of primary care patients. The project will compare enhanced usual care (EUC) and a telephone-based intervention -- including psychoeducation, regular monitoring, and support from a Mental Health Technician (MHT) and team supervision from a psychiatrist.

Demands in primary care make it difficult for physicians to obtain needed information, follow-up as frequently as needed, and use best practices effectively. The proposed model addresses these gaps by facilitating collaboration with PCP and new MHT role, to provide screening and symptom monitoring, follow-up calls, access to on-line psychotherapies, while enhancing patient self-management and supporting adherence to treatment and medication management. Clinical updates and specific recommendations are sent to PCP to facilitate initiation of evidence-based pharmacotherapy or psychotherapy, and referrals to specialty mental health services when indicated.

Within the context of primary care and an integrated care model, partnering FHTs will speak to their experiences identifying and referring patients, utility of recommendations, and communication and collaborating with MHT role. The presentation will discuss challenges and strategies for successful implementation.

(II) Optimizing Capacity of the Mental Health Team. Triaging the Patient: Who is the right provider?

Anne Childs, Co Lead/Coordinator, McMaster FHT

Kathy De Caire, Clinical Director, Stonechurch FHC; McMaster FHT

Jill Berridge, Clinical Manager, McMaster Family Practice; McMaster FHT


Primary care is often the first place a patient with mental health concerns present. These presentations are varied in complexity and urgency and require expert care. How does one decide the best way to support this patient? Understanding the skills mix of the Mental Health Team is essential. At McMaster FHT, a Mental Health Summit was organized and all staff who was interested in mental health services was invited to attend. This meeting revisited the priority and focus of the FHT; the skill set required to meet that focus and the direction of new programming, including a commitment to the interprofessional triage team comprised of the system navigators, occupational therapists, administrative support, leadership, psychology and psychiatry. Outcomes were predicted (and achieved) with regard to wait times, provider and service delivery times.

Summary (II):

This presentation will describe the interprofessional team, the challenges and successes of the triage process and the successful outcome achievement of reduced wait times. The interprofessional mental health team is committed to supporting the various needs of the patient with mental health concerns.

Role definition and clear understanding of that role are important in the triaging of referrals appropriately. Identifying the most appropriate provider/professional supports patient centered care by aligning that patient with the profession best suited to meet their needs. This has reduced wait times and resulted in timely and effective care planning that includes the patient.

The one hour weekly triage meeting reviews all new referrals, closes files as appropriate, and manages patients who have missed appointments. Complex cases are reviewed as a team and recommendations for ongoing care (patient and provider) are shared.

Community Resources are an essential part of the extended interprofessional team. Seeking out appropriate community resources and employment supports is an important strategy within the FHT.

The importance of process measures and timely reporting of those measures has worked to keep the team focused on excellence in patient care and effective triaging to the most appropriate team member. Ongoing training was recommended and supported by the Mental Health and the Leadership teams and to that end, DBT training opportunities have been levered.

Next (ongoing) steps include further reducing the wait times to within 2 weeks, gathering patient feedback and strengthening the relationships with community partners (i.e. Teen services).

(III) Responding to the Needs of Patients with Anxiety – Developing a Comprehensive Group Program at a FHT

McMaster FHT:

K. Lynn Dykeman, Social Worker

Colleen O'Neill, Occupational Therapist

Learning Objectives (III):

In the last 12 years the McMaster Family Health Team has developed a three part group treatment program to address the ever increasing numbers of clients being referred for treatment of anxiety. This presentation will focus on the development of the core anxiety treatment group, a teen group and the aftercare group. It will follow the challenges and sucesses of our groups and help participants develop some practical ideas about how to develop interprofessional group leadership, how to publicize groups, how to structure group sessions and tips about when to move from offering the core anxiety group to offering more specialized programming.


Summary (III):

Patients presenting with anxiety use a signficant amount of many primary care givers time. Skills for managing anxiety can be taught and practiced in a group setting. Learning the skills for managing anxiety in a group can be a normalizing experience and can provide a sense of peer support. Treatment groups provide the opportunity to utilize the skills of numerous health care providers including the pharmacist, dietitian, occupational therapist, psychologist, physicians and social workers.

In this presentation, we will begin with a discussion of the structure of our group programs, group resources, treatment modalities, publicity, interprofessional networking, and common mistakes. We will then examine the outcomes of the client satisfaction sureys. Finally, we will provide time for participants to ask questions about their specific clinical experiences.

We now have several hundred people referred to our anxiety groups each year. Groups are offered 5-6 times a year so the wait is much shorter for group programming than the wait for individual counselling. We are able, through an interdisciplinary collaborative appraoch, to provide quality care to many more patients than could be served in 1-1 sessions.

Client feedback indicates that many clients prefer group sessions to individual counselling particularly in some age groups. Teens, a challenging population to network with, have routinely indicated that they prefer group to individual treatment. The aftercare group provides ongoing clinical support to patients who might otherwise be taking individual appointment spaces.

Group programming is an effective response to a signficant mental health need and may be part of the solution to the signficant numbers of patients seeking mental health care through Family Health Teams.

B2 "Welcome to your new reality – you have diabetes this week!"


Sunnybrook Academic FHT:

Leigh Caplan, RN, BSc, MA, CDE, Diabetes Nurse Educator

Judith Manson, RN, BScN, NCMP, Executive Director


By the end of the session, participants will be able to:

1. Describe an innovative educational process to understand the patient experience of living with a chronic condition.

2. Reflect on their own clinical practice related to working with patients with diabetes.

3. Explore the possibility of implementing this program in their own clinical setting.

Summary:

The Diabetes Education Team at the Sunnybrook Academic Family Health Team believed that exposing professionals to the tasks involved in the day-to-day management of the diabetes would increase their understanding of the complexity and time associated with self-management. This session will describe a program developed and offered to the interprofessional team including family medicine residents, faculty physicians, nurses, pharmacists, social worker, OT, and support staff to provide them with the opportunity to live with diabetes for a week. Learning objectives were developed and the nurse educator and dietitian provided the participants with a health history and scenario entitled "Welcome to Your New Reality". Through the course of the week, they progressed through ~ 8 years of living with diabetes. Self glucose monitoring, insulin "dry" injections, paging the participant informing them they were experieincing low blood sugar and medication changes were all part of the program. The team met every morning to debrief expereinces, consider how they would counsel patients in a similar situation and to provide new scenarios and challenges. By going through the program team members learned about the patient experience of living with diabetes (i.e. how to fit diabetes into one's life) and about each other's roles and perspectives around caring for patients with chronic conditions. The program is now offered ~ every 2 months.


Theme: 2. Optimizing capacity of interprofessional teams


Guelph FHT:

Sam Marzouk, Director, Operations and Finance

Sylvia Scott, Director, Clinical and Professional Services


In an effort to be patient-centred, the Guelph FHT since inception adopted the decentralized model/approach in allocating IHPs across all 22 practices where every practice gets its share from FHT funded IHPs depending on # of physicians, population served and roster size. In other words each practice is a “patient medical home. Attendees will gain understanding of how this model works, how to allocate, manage resources, promote ownership and accountability, tailor services according to population needs and embrace collaborative team approach to population health. It is important to note that there is no perfect structure fits all organisations but it crucial to understand your stakeholders and plan your approach to organisational structure accordingly.

Summary:

We broadly agree on the core objectives that health care systems should pursue. The list is strikingly straightforward: universal access for all people, effective care for better health outcomes, efficient use of resources, high-quality services and responsiveness to patient concerns. It is a formula that resonates across the spectrum but the diversity of health system


configurations that has developed in response to broadly common objectives leads quite naturally to questions about the advantages and disadvantages inherent in different arrangements, and which approach is “better” or even “best” given a particular context and priorities. The logic of a decentralized model is based on an intrinsically powerful idea. It is, simply stated, that smaller organizations, properly structured and steered, are inherently more agile and accountable than are larger organizations. With ownership, delegation and autonomization often implemented, decentralized GFHT structure provides efficiency in terms of reducing the risk of bottlenecks and improving access at practice level, thus increasing the overall throughput capacity of Guelph primary care system

Objectives of decentralization: • To improve clinical efficiency through developing skills and

knowledge of practice based IHPs to manage more diversified patient portfolio.

• To increase allocative efficiency through better matching of FHT services to practice preferences for improved patient care.

• To empower individual practices through taking the lead in planning and initiating services that meets patients needs.

• To increase team accountability through collaborative and holistic approach to patient health.

• To increase quality of health services through integration of services and improved IM systems and access for vulnerable groups.

• To increase equity through allocating resources to better meet the needs of particular groups.


Theme: 2. Optimizing capacity of interprofessional teams Length: 45 minute Presentation

University of Toronto, DFCM:

Dr. Philip Ellison, MD MBA CCFP FCFP

Ms. Patricia O'Brien, RN BA CNeph(C)


The University of Toronto (U of T) Department of Family and Community Medicine (DFMC) Quality Improvement (QI) Program has launched an 18-month “teaming” project. Teaming refers to the collective actions or processes associated with an interprofessional primary care team performing optimally. This session will introduce the results of the environmental scan and how they have framed a blueprint that will guide interprofessional primary care teams to function effectively, and with ultimate outcomes leading to improved health of populations, improved patient and provider experiences, and improved value.

Summary:

A significant provincial investment has been made in Ontario in family health teams and inter-professional models of care. Significant work has also been done in Ontario on improving team governance and leadership. There has been a large transformation from solo practitioners to teams yet there has been very little structured team function guidance and support. The opportunity exists for change and improvement; teaming will promote the best possible function from interprofessional primary care teams, leading to better patient care and improved outcomes. The development of a conceptual framework has been derived from the environmental scan, guided a research design and blueprint to be tested at the Trillium Health Partners affiliated Credit Valley FHT, Family Medicine Teaching Unit. Change ideas, tools, instruments and qualitative and quantitative measurement related to team performance and patient outcomes have been defined to support team effectiveness improvement. The teaming project will enable individuals and teams to embark on a journey of thinking and working differently in order for them to drive change and improvement.


Theme: 2. Optimizing capacity of interprofessional teams


McMaster FHT:

Kiska Colwill, Clinical Pharmacist / Assistant Clinical Professor

Martha Bauer, Occupational Therapist

Michael Spoljar, Nurse Practicioner / Assistant Clinical Professor

Dan Edwards, RSSW / System Navigator

Laura Cleghorn, Research Coordinator TAPESTRY, School of Nursing and Department of Family Medicine


To describe our Family Health Team experience developing and implementing a new interprofessional team process for complex medical patients identified through Health Links and older adults within the TAPESTRY study. We will show the participants how new eyes on a patient can develop new solutions and strategies and expand the ability to provide a preventive health care plan.

Summary:

McMaster Family Health Team is an Academic Family Health Team located in Hamilton, Ontario with two sites serving over 31 000 patients. Our broad-based interprofessional team collaborates to maximize primary health care delivery and educational opportunities. We currently provide placements for 81 family practice residents and interprofessional learners.

TAPESTRY (Teams Advancing Patient Experience:


Strengthening Quality) is a twelve-month randomized control trial that fosters optimal aging for older adults living at home using an interprofessional primary health care team delivery approach centering on meeting a person’s health goals with the support of trained community volunteers, system navigation, community engagement, and use of technology. We are the lead organization for one of three Hamilton Health Links. Health Links targets individuals who use the health care system the most, particularly the use of the emergency department and frequent hospital admissions.

The intent of the program is to change the way this population receives health care, driven by the development and implementation of coordinated care plans, and utilizing the insights learned to advocate for system-level change. By targeting specific at-risk populations for more intensive care planning, we uncover significant health and social issues. When these issues are addressed by the interprofessional team before they become crises, we can shift our focus to health promotion and prevention. The energy created when like-minded professionals work collaboratively is amazing and motivating. Through this process, we have developed greater insight into the scope and skills of our team members to enhance the quality of care of our patients.

F2 Integrated care planning for complex patients


(I) Telemedicine IMPACT PLUS (TIP): Bringing Inter-Disciplinary Team Resources to the Community

Pauline Pariser, Co-lead Taddle Creek FHT, Lead, Mid-West Toronto Health LInk, Taddle Creek FHT

Sherry Kennedy, Executive Director, Taddle Creek FHT

One of Shazmah Hussein, Victoria Charkow or Karen Finch, Registered Nurse, Taddle Creek FHT

Jessica Lam, Pharmacist, Taddle Creek FHT

One of: Jocelyn Charles, Chief of Family Medicine, Sunnybrook; or Tia Pham, Physician Lead, South East Toronto FHT


1. Demonstrate how Telemedicine complex care clinic can provide high-quality comprehensive care for medically complex patients and support community primary care

2. Model how to leverage FHT inter-professional skills to promote working to full scope of practice

3. Outline the efficiencies needed to offer this service via protected video-conferencing

4. Describe the opportunities and risks in extending FHT resources to community primary care

5. Demonstrate the value of this approach in coordinated care planning.

Summary: Telemedicine IMPACT PLUS is an innovative, proactive interdisciplinary model of care for serving complex patients and supporting their solo primary care providers (PCPs). TIP has been implemented across the Toronto Central LHIN offering clinics since 2013. Through TIP, both the complex patient and family physician are connected to an interdisciplinary care team over a one-hour consultation via secure videoconferencing technology. The teams leverage inter-disciplinary support from FHTs to focus on critical issues identified by patient, family and PCP. A dedicated TIP nurse facilitator, as care coordinator, provides pre- and post-clinic follow-up supports to all stakeholders.

The model recognizes the “perfect storm” created by an aging demographic within a health care system founded on treating acute illness. Currently, disconnected serial consultations based on single disease entities do not reduce the burden of chronic illness for these patients nor provide coordinated care planning for their PCPs.

TIP built upon the success of IMPACT PLUS, a Bridges evaluated inter-professional care model. By marrying the power of a skilled inter-professional team, including general internist and psychiatrist, to telemedicine technology, TIP provides one stop coordinated real-time care planning in the PCP office or at home.

Evidence from the literature found that intensive inter-professional care succeeds in reducing health care costs with at least equivalent outcomes for complex populations. Preliminary results demonstrate high patient, provider and caregiver satisfaction with this model of care. Already the model has shown itself to be scalable with plans to spread TIP to 2 other teams within the Toronto Central LHIN.

(II) Blitzing Integrated Care for the Super Complex Patients

Thuy-Nga (Tia) Pham, MD, Assistant Professor, University of Toronto DFCM; Physician Lead, South East Toronto FHT

Richard Doan, MD, FRCPC, Psychiatrist, South East Toronto FHT/East Toronto Health Link


1. Recognizing the need for an inter-professional and primary care led team to address patients' medical and social complexities.

2. The importance of starting a coordinated care plan with the patient physically present at the case conference with the inter-professional team.

3. The importance of having primary care, community agencies (CCAC and CSS), and specialists such as Psychiatrists working collaboratively towards patient's care coordination and follow-up, and for the patient to have an individualized care team.


4. The impact of using Hospitalization Admission Risk Monitoring System (HARMS-8) to identify complex patients in primary care, and who are then recipients of an electronic coordinated care plan. 5. Share results of patient/caregiver experiences via patient/caregiver stories.

Summary:

East Toronto Health Link has developed an innovative approach to address the needs of 1-5% complex patients who have significant social and medical concerns. ETHeL is trying to demonstrate that high risk hospitalization (using HARMS-8) justifies increased use of resources such as Complex Care Plan Management (intensive care management with dedicated follow-up and requiring an inter-professional team approach maximizing scopes of practice, and integration of multiple sectors) .

CCT is composed of a small core team of hospital based programs currently operating within ETHeL (Virtual Ward, Geriatric Emergency Medicine (GEM) Nurse, Telemedicine Impact Plus (TIP)-RN, Primary Care Physicians, specialists, as well as a CCAC care coordinator), AND a community-based team consisting of multiple sectors including community support services, mental health, addictions, housing, and Toronto Paramedics.

Primary target population for CCT intervention is the frail elderly

with complex medical/social needs residing in ETHeL’s catchment area; however, any individual identified by CCT members as complex and in need of coordinated care planning, is supported, though a case conference might not be the desired or effective mechanism in all cases. Some of the key primary characteristics that qualify an individual as ‘complex’ and who would require care coordination via CCT’s case conference are as follows:

• At least one (preventable) hospital inpatient admission and/or multiple (preventable) emergency department visits in the last 12 months (mandatory requirement) and at least two of the following:

• 55 years and older (65 years old and over is ideal except when individuals have conditions that deem them to be frail and elderly)

• Unattached to primary care or ‘poorly’ attached to primary care

• Physical immobility including staying upright, maintaining balance and walking resulting in falls, immobility or delirium

• Multiple/chronic co-morbidities including dementia

• Mental health and addiction complexities leading to barriers to access care

• Polypharmacy

• High caregiver burden and stress


Theme 3 – Transforming patients and caregivers experience and health

Healthcare in Ontario is moving towards an integrated, population-based health care system; it’s about what’s important to the patient and evolving our health care system to match that. Interprofessional primary care teams work with patients and caregivers to develop services that respond to their expectations and needs. This stream focuses on the programs, initiatives and changes that include the patient and caregiver voice in strategic and program planning, and care delivery. Sessions:

A3 Patient Councils: Experiences Within the GTA

B3 Tips for Capturing and Understanding Patient Experience

C3-a Well-Baby Visits in Primary Care

C3-b Measuring the Patient Experience: How to Select a Delivery Method for Best Results and Minimal Effort

DE3 The Power of the Collective: FHT Experiences with Group Medical Visits


A3 Patient Councils: Experiences within the GTA

Theme: 3. Transforming patients’ and caregivers’ experience and health


(I) Community Engagement - Mississauga Halton Share CCAC Share Care Council

Nancy Gale, Associate Vice-President, Strategic Communications and Partnership Advancement, Mississauga Halton CCAC


1. Define the key elements of a Patient and Caregiver Bill of Rights

2. Identify benefit of forming a Share Care Council and how it benefits families and caregivers

3. Describe how a patient and family advisory forum provides a direct voice to inform service development and funding priorities

4. Learn how to develop strong relationships with families and caregivers in the circle of care

5. Identify best practices of a family patient advisory forum – watch a video interview with a Share Care Council member as she explains the importance of having a patient voice in the development of new programs/services.

Summary (I):

Mississauga Halton CCAC established the Share Care Council to give patients and caregivers an authentic engagement forum and direct voice in service development and funding priorities. Mississauga Halton CCAC recognizes the most important partners in caring for patients are patients and their informal caregivers. It recognizes that an inclusive approach to the circle of care will improve quality of care and outcomes. Authentic engagement is not a strategy; it is part of care. The Patient and Caregiver Bill of Rights is an important milestone as Mississauga Halton CCAC and service providers along with patients and caregivers as it articulates how

they will work together to attain an exceptional patient experience. Launched in 2014, the Council meets quarterly.

Members of the Council proactively identified the need to articulate patients and caregivers priorities to ensure consistent care guidelines. In a truly collaborative approach, the Mississauga Halton CCAC engaged front-line staff and contracted service providers to determine how these priorities could be realized with the intention of creating a single charter for patients, caregiver and care providers across the region.

The Council is a patient and caregiver forum that gives them a direct voice to inform service development and funding priorities.

This Council strengthens that partnership between Mississauga Halton CCAC and its patients and caregivers. The forum’s name also recognizes the role of primary care and other health service providers, and reflects Mississauga Halton CCAC’s inclusive approach to developing programs and services that deliver an exceptional patient experience.

(II) Patients' Perspectives: Getting Patients Involved and Engaged to Participate in PAC (Patient Advisory Council)

Sonia Mastroianni, Patient, South East Toronto FHT


How to get patients involved in PAC

Relevant recruiting methods and process to recruit and select patients to be on PAC

Patients' experiences with the recruitment and selection process

What to look for/qualifications in patients that should or want to be on PAC

Types of patients who get involved/volunteer

Patient motivations/hot buttons to get them involved


What patients want to get out of being on PAC

Benefits/expectations/outcomes/improvements

Summary (II):

Will discuss how to get patients involved and the recruiting methods and selection process used to establish a PAC

Patients' experiences with the recruitment and selection processes

Key attributes/qualifications to look for in patients that should or want to be on PAC

Types of patients who get involved and why - Key motivations/hot buttons for patients to get involved in PAC

Patient Expectations/ Benefits/ Outcomes/ Improvements of being on PAC

Key impact of presentation: to help FHT's across Ontario implement a PAC in their centre by providing some patient insights that could help them recruit patients

B3 Tips for Capturing and Understanding Patient experience Theme: 3. Transforming patients’ and caregivers’

experience and health Length: 45 Minute Presentation

(I) Tips and Tools to Capture the Patient’s Experience in Primary Care using the NHS’s Experience-Based Design (EBD) Methodology

Partnering for Quality Program, South West CCAC:

Rachel LaBonte, Program Lead

Jennifer Jackson, Quality Improvement Coach


Attendees will :

• receive an introduction to the tools and techniques developed in the NHS to capture and understand patient’s experiences.

• experience some of the tools in action

• leave with the foundational knowledge of the ebd approach in hopes they consider application back at their own team/site.

Summary (I):

Patient experience - what's it all about? Differentiating between and understanding our patient's experiences of care from their level of satisfaction are essential in the delivery of high quality patient care. Experience Based Design (ebd) is a methodology developed by the NHS in the United Kingdom. It is comprised of four phases: Capture, Understand, Improve, and Measure, all designed to assess and improve patients' experiences.

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. The objective of this presentation is to

build capacity in primary care and community organizations to lead and implement patient experience improvement work in their teams.

(II) What are they thinking? Approaches, Ideas and Tools to Measure Patient Experience in Your Practice

Sharon Johnston, Family Physician, Clinician Investigator, University of Ottawa, Department of Family Medicine, Bruyère FHT

Gail Dobell, PhD, Director, Performance Measurement, Health Quality Ontario

Susan Taylor, Director, Quality Improvement, Health Quality Ontario

Elizabeth Muggah, MD, MPH, Family Physician, Director of Quality Improvement, University of Ottawa, Department of Family Medicine, Bruyère FHT

Ellie Kingsbury, MLT, QIDSS, Équipe de santé familiale académique de Monfort


Session attendees will learn about primary care patient experience measurement activities at the health system level (provincial, regional) as well as the practice-level. Participants will acquire knowledge about the tools and resources available to them to support practice-level patient experience measurement and gain insight into practical ideas for how to design, implement, interpret, and then translate patient experience data into meaningful quality improvement in their practice environment. Summary (II):

Including the voice of the patient in our efforts to improve primary care quality has become a key objective of policy makers, primary care organizations, and patients themselves. However, it has not always been clear how best to measure and then use data on the patient experience. This session will present the new primary care patient experience survey developed and tested through a collaborative project that included HQO, AFHTO, OMA, OCFP, and the AOHC. Presenters from across the primary care health system will highlight the provincial and regional resources available to assist organizations with patient experience measurement and approaches for translating patient feedback into practice improvement.

The collaborative approach of the Champlain LHIN’s FHT patient experience measurement partnership project, which developed and supported a common patient survey across 19 FHTS, reported results back to the FHTS for benchmarking performance, identifying priorities for improvement, and enabling sharing of experiences and strategies across FHTS, will be presented. Practical ways to design, implement, and then act upon patient experience data in a primary care practice will be presented. The alignment of patient experience measurement to broader performance measurement strategies such as quality improvement plans, data to decisions, the provincial primary care performance


measurement framework, and the primary care practice reports will be discussed.

C3-a Well-Baby Visits in Primary Care


(I) Well-Baby/Well-Child Care Groups: The Bridgepoint FHT Report Five Years Later

Bridgepoint FHT:

Lora Cruise, Medical Director

Alice McDermott, Administrative Assistant

Meghan Rule, Registered RN, NP Candidate Ryerson, Bridgepoint FHT


The Bridgepoint FHT has been providing well baby care in a group model since 2010. Well baby groups optimize the scope of nursing practice, primary provider time and create a community of support for new parents. In this workshop we will explain how to get groups started, discuss pitfalls and successes and how to automate your processes to keep this model sustainable.

Summary (I):

Well-baby groups were started at the Bridgepoint FHT due to the overwhelming demand for well child appointments. Since 2010 we have utilized and revised our model for well baby group visits. This model of care optimizes the nursing scope of practice, improves primary provider efficiency while meeting the needs of the growing young community our FHT serves. In this workshop we will provide the practical perspective from nurses, administration and primary providers of what works and what does not in the well baby and child care model. We will provide tools to get your team started, discuss how to optimize your team roles to keep this model sustainable and how to spread this model within and across teams.

(II) Baby Friendly Initiative (BFI): Leveraging the EMR to Capture Breastfeeding Statistics

Kim Lichty, RN, International Board Certified Lactation Consultant, Two Rivers FHT


Using the Newborn Support and Breastfeeding Program as a case example, presenters will demonstrate how breastfeeding data collection has evolved from paper-based surveys distributed at group classes, to retrospective data collection through the Healthy Beginnings Program, to custom forms integrated into encounter assistants using the EMR. Presenters will describe the team-based approach taken to ensure consistent and reliable data collection for Baby Friendly Initiative (BFI) reporting. Participants will learn about the challenges in accurately capturing breastfeeding statistics and tips and tricks to promote organization wide data collection.

Summary (II):

In pursuing Baby Friendly Initiative (BFI) accreditation, Two Rivers Family Health Team is required to monitor breastfeeding rates, duration and exclusivity. Since 2010 when the breastfeeding program was first developed we have struggled to find an accurate method to capture breastfeeding statistics. Although breastfeeding status is collected at each well-baby visit, extracting data from the Rourke is a challenge due to inconsistencies in documentation. We initially started with paper-based surveys distributed at breastfeeding classes, but found a bias as we were only reaching those patients who attended the sessions. Data collection then evolved to a retrospective approach extracted from the 3-year old Healthy Beginnings appointment. Finally, through taking a team-based approach, breastfeeding rates are now recorded at each well-baby visit using a breastfeeding status custom form. Medical office assistants input a breastfeeding status form at patient each encounter- 2 months, 4 months, 6 months, 9 months, 12 months, 15 months and 18 months. Through taking a consistent and team-based approach, BFI data collection has progressed to a more accurate, reliable and meaningful process.

C3-b Measuring the Patient Experience: How to Select a Delivery Method for Best Results and Minimal Effort Theme: 3. Transforming patients’ and caregivers’

experience and health Length: 45 Minute Presentation

Ellie Kingsbury, MLT, QIDSS, Équipe de santé familiale académique de Monfort

St. Michael’s Hospital Academic FHT:

Tara Kiran, Family Physician, QI Program Director

Sam Davie, QIDSS

Morgan Slater, PhD, Senior Research Associate

Lisa Miller, EMR Administrator


Observe the benefit of centralizing the development, implementation, collating, and reporting of a standardized patient experience survey that would require limited resources from FHTs.

Compare response rates, responses, and respondent demographics from different survey methods including waiting room, web-based, and emailed surveys.

Reflect on how patient experience surveys can be used to differentiate patients’ experience within different clinics and/or for different physicians/clinicians.

Reflect on challenges with feeding back survey data to staff to drive improvements in quality of care. Reflect on the best method of delivering a patient experience survey in your FHT context.

Summary:

First, FHTs from the Champlain LHIN will describe the implementation of their second annual Patient Experience Survey, the goal of which was to understand the key elements of patient’s


experience in the Champlain LHIN according to key performance indicators. While each FHT is distinct and cares for a unique population, the results of the survey should help FHTs establish their own priorities for improvement. The FHTs are provided with a report, which aims to provide information for the Quality Improvement Plan, initiate action within the FHTs, enable FHTs to learn from each other, and perform benchmarking within a FHT year over year; it is not intended to compare FHTs. We will describe the creation of the survey, the various methods of delivery, and the questions asked. Second, the St. Michael’s Hospital Academic Family Health Team will describe their experience with two different survey delivery methods – emailing a link to an online survey and approaching patients in the waiting room to complete a survey using tablet computers. They will share how response rates, respondent characteristics, and responses differed between the two survey methods. This interactive workshop will engage participants in a discussion around how to administer surveys using few resources, how survey responses can be used to improve quality of care, and what survey delivery methods can sustainably produce generalizable, meaningful results in your setting.

DE3 The Power of the Collective: FHT Experiences with Group Medical Visits



Group medical visits, including peer-led and peer-facilitated exercise groups, and care-based focus groups, are emerging as an efficient and effective way to care for patients with complex needs. Four teams describe how they have implemented group visits and share their results.

I. HERSTORY: An innovative group model for mental health care using peer facilitation and patient co-design – Bridgepoint FHT

II. Shared Medical Appointments: the why, the how, the impact – Hamilton FHT

III. Peer Directed Group Exercise Programs Improving Clinical Outcomes – Guelph FHT

IV. Group Medical Visits (GMV) for Primary Care Diabetes. The McMaster FHT Experience – McMaster FHT

(I) HERSTORY: An Innovative Group Model for Mental Health Care Using Peer Facilitation and Patient Co-deisgn

Bridgepoint FHT

Lora Judge, MSW,RSW

Sharon Van Manen, Peer Facilitator

Dr. Lora Cruise, Medical Director

Patient - TBD


WHAT MAKES A PATIENT COMPLEX? The Bridgepoint FHT would like to present an approach for dealing with a complex and underserved population- those with a past history of sexual childhood trauma. In this interactive presentation you will learn about the impact of this model, be provided with the tools to spread this model to your FHT and hear directly from the voice of patients and peer facilitator.

Summary (I):

The Bridgepoint FHT in partnership with our patients have developed a cutting edge women's trauma program entitled "HERSTORY". The current community wait times for referral to trauma therapy are measured in YEARS. In order to respond better to our patient needs we developed an inter professional group model of care using focus groups, peer leadership and ongoing patient and provider feedback. This presentation will illustrate our process, review our outcomes both qualitative and quantitative, provide insights into the challenges and victories of this unique group and allow the audience to hear directly from our patient representative and peer facilitator.

(II) Shared Medical Appointments: The Why, the How, the Impact

Hamilton FHT:

Anneli Kaethler, MSc, RD, CDE

Cornelia Mielke, BSc, MD, CCFP


Summarize SMAs - what they are, evidence for their use.

Describe our process to initiating and adapting SMAs in busy practices -listen to/hear experiences of SMA participants (practitioners and patients).

Summary (II):

Shared Medical Appointments are an exciting and innovative way to provide care to patients with chronic diseases. Our interdisciplinary teams introduced Shared Medical Appointments (SMAs) to patients living with diabetes in 2012. An SMA is a 90 min appointment held simultaneously with 5-10 patients and 2 providers in an interactive visit. All parameters of diabetic care are monitored as with any individual diabetic visit, patient questions are addressed by both peers and providers and true collaboration is encouraged between


patient and health care professionals. Participants (providers and patients) experiences will be highlighted in this presentation.

(III) Peer-Directed Group Exercise Programs Improving Clinical Outcomes

Krista Crozier, R.Kin, CDE Diabetes Care Guelph, Guelph FHT


Attendees will learn about how building group exercise programs with peer co-leaders and patient directed educational discussions not only cn affect A1c, BMI, BP and MaxMETs in a population with metabolic syndrome or diabetes, but also improves patient attitude towards being physically active. The program leaves participants confident and prepared to maintain activity levels after completion. This model increases patient independence and thrives off of group cohesion and the support of peer co-leaders. In addition, attendees will learn how to implement similar programs with varying resources in their own community.

Summary (III):

Supervised group exercise programs have been proven effective in improving outcomes in patients with diabetes. At the Guelph FHT we have implemented group exercises classes that incorporate peer co-leadership and patient directed educational discussions. The program runs on a rotating basis twice per week for 12 weeks. Participants complete cardio, strength, balance, and flexibility activities during each session. Upon completion, patients have the option of undergoing training to become peer co-leaders.

The program’s goal is to improve outcomes (a1c, BP, BMI, WC, lipids, MaxMET) for people with diabetes and metabolic syndrome and increase physical activity levels and leave patients confident with their ability to maintain after program completion. Results are collected and analyzed in an ongoing basis. As of April 2015, average days completing cardio exercises increased from 1.8 to 4.5 and resistance training from <1 to 3.5 days. Perception of exercise improved during the program and 90% of graduates believed they had attained the necessary confidence, skills, and strategies to maintain their activity levels. Average a1c decreased 0.3%. Estimated MaxMETs increased approximately 20%. Both WC and BMI showed decreasing trends.

Using a highly peer directed group exercise program can increase physical activity levels and improve outcomes. Similar programs could be created using partnerships with community gym facilities or with minimal equipment. This model also places the focus on the patient and empowers them make positive and hopefully lifelong changes in their perception of and motivation to be physically active.

(IV) Group Medical Visits (GMV) for Primary Care Diabetes: The McMaster Family Health Team Experience

McMaster FHT:

Inge Schabort, MB ChB CCFP FCFP

Michele MacDonald Werstuck, RD MSc CDE

Learning Objectives (IV):

1. To gain knowledge about how to organize and implement a group medical visit

2. To learn the value of using group medical visits effectively within primary care

3. To hear positive patient accounts about their experience with group medical visits

Summary (IV):

The increasing prevalence of diabetes poses a threat to the sustainability of Canada’s health care system. Group medical visits (GMVs) are emerging as an efficient strategy to deliver care to multiple patients and have been shown to improve glycemic control, patient satisfaction and patient self-efficacy in disease management. The purpose of this study was to examine a number of process and quality of care outcomes measures to compare GMVs to traditional care and a diabetes clinic model that existed within the McMaster Family Health Team. This was a cohort study comparing GMVs to traditional care and a diabetes clinic model over the period 2008-2012. During each visit, patients saw a family physician and registered practical nurse with foot care certification and one of the following diabetes educators: nurse practitioner, dietitian or pharmacist. Group visit content included physical exam, medication review, group diabetes education review, question and answer time and goal setting. The numbers in each group were small so data was analyzed descriptively. The benefits and challenges of GMVs as compared to conventional care will be highlighted during this presentation and suggestions on how GMVs can be used effectively for diabetes care within primary care will be provided.





McMaster FHT:

Michele MacDonald Werstuck, RD MSc CDE Registered Dietitian and Diabetes Educator

Colleen O'Neill, OT Reg (ONT) Occupational Therapist

Miriam Wolfson, SW Mental Health Counselor


Participants will:

• Become familiar with a interactive lifestyle program for overweight or obese (BMI 26-40) patients facilitated by an interprofessional team including a RD, OT and SW with a focus on health and well being vs. weight alone

• Gain an appreciation of a patient-centered approach to program content and delivery

• Identify key outcome measures of success for a lifestyle program in primary care

• Access tools and resources to offer a similar program in your family health team setting.

Summary:

With 25% of Canadian adults classified as overweight or obese and recent systematic reviews emphasizing the importance of offering structured behavioural interventions in primary care aimed at weight loss and adding small amounts of exercise to reduce risk of chronic disease, the Vitality Healthy Lifestyle program nicely aligns with current best evidence while meeting the needs of our patients. The 11 week lifestyle program offered at the McMaster Family Health Team uses a non-diet approach to educate and empower patients on healthy lifestyle choices to improve health outcomes and promote a small weight loss in a healthy, realistic way.

Facilitated by a Registered Dietitian, Social Worker and an Occupational Therapist, participants have the opportunity to learn what influences their food, mood and activity patterns and practice cognitive behavioural strategies to manage emotional eating, eat more mindfully, reframe negative self talk, become more active, try different physical activities, develop action plans and achieve health goals. Patients choose topics of interest and activities they would like to engage in. Linkages with local community resources are explored to assist with managing future relapses.

Patients are highly satisfied with this interactive, patient-centered approach that affords opportunities to access specialized advice from the right provider at the right time along with opportunities to learn from each other and become empowered to make positive life-style changes.


Theme 4 – Building the rural health care team: making the most of available resources

Rural health care teams face unique challenges in providing care across large areas with small teams, isolated patients and limited access to resources. These teams find innovative solutions to reach remote patients and specialist care using technology, creating teams and community partnership across significant distance to provide care in a timely manner. This streams focuses on the lessons and innovations that maximize the use of resources in these environments which can be applied in wider team-based primary care settings. Sessions:

A4 Community Quilt – The Story of How our FHT has been Woven into the Fabric of the Community

B4 Innovative Service Provision in a Rural Underserviced Community: The Virtual Visit, Shared Innovations, Patient Centered Service Delivery

C4 Organizing the Community around the Patient – Rural and Remote Regions of Ontario


EF4 Project ECHO (Extension for Community Healthcare Outcomes) - Managing Complex Chronic Conditions without Sweating Bullets

A4 Community Quilt – the Story of How our FHT has been Woven into the Fabric of the Community

Theme: 4. Building the rural health care team: making the most of available resources


MMFHT:

Vicky LaForge, Chronic Disease Prevention and Management Nurse

Jenny Harrison, Registered Dietitian

Sandy Turner, Health Promoter


Feeling overwhelmed by your rural residents’ needs for accessible, team-based programs? Is it practical to creatively tap into existing community resources to offer programs in the rural areas with fewer resources? Minto-Mapleton FHT is a multi-sited, rural team that services 15,000 patients in a geographical area of close to 850 square kilometres. Learn about our unique partnerships that have allowed us to do more with less. Explore the possibilities of potential community partners and how to foster productive relationships to meet some of your harder to reach patients. Understand the role/importance of program ownership and champion development for program sustainability.

Summary:

In 2011, Canada’s Health Minister quoted: “3 of 5 Canadians, older than 20 years of age, have a chronic disease and 4 out of 5 people are at risk”. In total, chronic diseases cost the Canadian economy at least $190 billion a year. The Minister noted that commitment to collaboration is a cornerstone of Canada’s approach to chronic disease prevention and control. Despite considerable effort, FHTs working in solo, find it impossible to meet the needs of all patients and their health conditions. This presentation will cover the journey our rural

FHT has taken to secure sustainable community partnerships and viable programming while maintaining integrity of program objectives.

MMFHT reached out to community partners, assessed existing programs and identified gaps that could easily be met by creating strong, symbiotic relationships. From humble beginnings, to the successes of today, and plans for tomorrow, we will share innovative approaches aimed at cost sharing, avoiding duplication, seeking out additional venues, staffing and programming. Partnerships have spread current, evidence-based information, to patients that normally do not access FHT services at our typical venues.

Clear, specified navigation guidelines have resulted in the right patients now being seen by the right practitioners at the right time. By including telemedicine, we have expanded our reach while decreasing patient costs of transportation, parking and extended work absences.

The power point presentation will include patient and community partnership testimonials. In conclusion, we will discuss the importance of well-defined roles within the partnerships and the need to identify individual responsibilities.


B4 Innovative Service Provision in a Rural Underserviced Community: The Virtual Visit, Shared Innovations, Patient Centered Service Delivery


Length: 45 Minute Presentaton

Kirkland District FHT:

Christina Woollings, NP-PHC, Clinical Lead

Julie Moody, RPN, Telemedicine Coordinator

Mandy Weeden, Executive Director

Sandra Dal Pai, NP-PHC, Kirkland District FHT; Adjunct Professor, Laurentian University


Participants will learn:

• How a Northern FHT maximizes service delivery to expand available technology and minimize travel through OTN for shared care where there are no obstetrical services. A woman not traveling an hour for prenatal follow- up has made a difference in the lives of families experiencing a normal life event.

• How the FHT fostered collaborative relationships with the local hospital sharing IHP’s in order to maximize outpatient services.

• How collaborative partnerships maximized delivery of collective resources before Health Links inception. As a member of Timiskaming Health Link, our FHT led establishing and developing ICCPs (Integrated coordinated care plans).

Summary:

The Kirkland Lake Family Health Team is located in Northeastern Ontario, serving a population of approximately 10,000 with demographics skewed towards the elderly and complex patients. The doctor shortage was severe, and reliance on locum physicians was high. Nurse Practitioners and IHPs have been the most stable part of our delivery team, at times being the main service providers in our community. Managing patients with complex care, multiple specialists, home care, and high demand for services caused frustration and fragmentation in care delivery for patients and providers.

The integration of individual coordinated care plans (Health Links) has alleviated stress and demand on workload and enabled clients to better self-manage. Part of facilitating this has been involving the whole team as part of the process so that the delivery can be shared. We make extensive use of OTN. That has saved money and thousands of kilometers in travel, and hs avoided significant lost time at work for patients. We are currently participating in a research project to examine how to better prepare NP students for the challenges of managing patients with multiple comorbidities.

The abstract for this paper has been accepted for presentation at the Canadian Association of Advanced Practice Nurses annual conference in Winnipeg in October, 2015. We provide placement for NP, RN and medical students. We hope to be setting the stage for professionals to return to practice in a facility which is proud to offer a truly integrated team approach. We are proud to discuss the innovations we have made to enhance service delivery as well as provider satisfaction and team integration at the AFHTO conference.

C4 Organizing the Community around the Patient – Rural and Remote Regions of Ontario Theme: 4. Building the rural health care team: making

the most of available resources Length: 45 Minute Presentation

Rural Health Hubs Framework for Ontario

Randy Belair, Executive Director, Sunset Country FHT

Dr. Adam Steacie, Physician, Upper Canada FHT


By the end of the presentation, participants will:

1. Review the rural health hub framework and the context for its creation

2. Identify existing health hubs and pilot projects – what makes them work? What are the elements of community partnership that are relevant for primary care across Ontario

3. Discuss issues and opportunities for implementation in primary care

Summary:

Rural communities face unique challenges in delivering high-quality care due to lack of critical mass and economies of scale. Some communities have worked hard to overcome these challenges through innovative local solutions and are well-positioned to continue to improve access to care as part of health system transformation. Rural health hubs and improved health and social service integration are important to all local providers, including physicians in rural and remote practice. Therefore, the OHA and the OMA agreed to establish a Multi-Sector Rural Health Hub Advisory Committee with broad stakeholder representation to develop a framework for implementation of rural health hubs in Ontario.





Espanola and Area FHT:

Susan Clarke, RN, Certified Diabetes Educator, Telemedicine Coordinator

Renee Desjardin, BA, RN, PTS (Personal Training Specialist), OAS(Older Adult specialist)


1. Learn how to access this free program via OTN and the “how- to’s” for implementing.

2. Learn the rationale and benefits in offering an arm-chair based exercise program to the citizens of a community.

3. Participate in a demonstration of the three programs “From Soup to Tomatoes” offers.

4. Be inspired to offer “From Soup to Tomatoes” exercise programs in your own community.

Summary:

The session begins with a 15-minute PowerPoint presentation outlining "From Soup to Tomatoes"; from inception, growth, current programs, future plans and brief reports of studies and statistics. Presented information will include the following:

In 2006 From Soup to Tomatoes was conceived by Susan Clarke who believed that in order to help patients become active, a new approach was needed. A free program that addressed accessibility, nutrition, financial constraints, and transportation was the answer. Inspiration was found from quoting Dr. Ian Blumer, who once told an audience “studies have proven that using two cans of soup to exercise just ten minutes a day is beneficial”. So Susan started a patient out with two cans of soup with instructions to slowly increase reps and weight. The patient quipped that one day, she may just advance to cans of tomatoes. From this conversation came an armchair-based exercise program named From Soup to Tomatoes, consisting of three non-consecutive days of armchair-based resistance exercises that would meet the CDA guidelines.

The three classes offered (basic, gentle, and yoga) are viewed "live" via the Ontario Telemedicine Network (OTN) at many locations. All webcasts are archived and available free of charge to anyone with internet access. Many hundreds view via the web. Participants report enhanced physical, mental and social well-being.

After the PowerPoint presentation, Renee Desjardins will lead the audience to participate in a 15-to-20-minute demonstration of the basic, gentle and yoga programs. 10 minutes of Q and A will follow.

EF4 Project ECHO (Extension for Community Healthcare Outcomes) - Managing Complex Chronic Conditions without Sweating Bullets Theme: 4. Building the rural health care team: making the most of available resources Length: 90 Minute Presentation

Ruth Dubin, PhD, MD, CCFP, FCFP; Project ECHO Co-Chair, Asst Professor (adj), Dept of Family Medicine, Queens University; ECHO Ontario

Leslie Carlin, PhD, Medical Anthropologist, University of Toronto

Allison Crawford MD, FRCP, Medical Director Northern Psychiatric Outreach Program | Telepsychiatry Centre for Addiction and Mental Health, Centre for Addiction and Mental Health

Other co-presenters TBD


1. Understand the basic ECHO principles: • Leveraging telemedicine to move knowledge, not

people and create a community of practice for continuing professional development

• Multiplying specialist expertise by connecting an expert team (HUB) with multiple primary care providers (SPOKES)

• Using case-based learning • Sharing best practices to improve quality of care for

complex patients. 2. Identify how ECHO addresses specialist shortages in rural

and urban settings, raises primary care providers’ skills to their maximum scopes, and enhances interprofessional team performance.

3. Review the MOHLTC-funded ECHO Ontario Chronic Pain/Opioid Stewardship demonstration project and other ECHO’s under development (Mental Health/Addictions, Hepatitis C, Rheumatology).

Summary:

In 2003, Dr. Sanjeev Arora, a New Mexico hepatologist, developed ECHO (Extension for Community Healthcare Outcomes) to reach > 30,000 hepatitis C patients requiring treatment. By holding weekly video-conferencing rounds, distant primary care providers (SPOKES) managed their own hepatitis C patients with the support of an interprofessional expert team (the HUB). Cure rates were identical in both groups (NEJM 2011 364:23).

There are now >20 complex chronic disease ECHO projects throughout the US and other countries. In April 2014, the MOHLTC announced funding for the first Canadian ECHO replication: ECHO Ontario chronic pain/opioid stewardship.


ECHO sessions start with brief didactics on chronic pain management. Next, a de-identified case is presented by a community SPOKE following a standard template. Their “virtual” colleagues ask questions and provide advice first, with HUB experts acting as “guides on the side.” SPOKES’ knowledge and comfort levels rise and HUB experts also learn from the SPOKES. Hands-on “boot-camps” teach specific skills (the chronic pain sensory exam, myofascial pain, challenging conversations, and managing mental health problems or aberrant opiate behaviours). Curriculum themes include pain fundamentals, opioids and addictions, management (mind, movement, self-management, and medical) and special topics (e.g. medical marijuana).

This presentation will educate attendees on the basic principles of ECHO, demonstrate how the model works, and discuss promising ECHO programs under development in Ontario for other complex chronic conditions such as Mental Health/Addictions, Hepatitis C, and Rheumatology.


Theme 5 – Advancing manageable meaningful measurement

Primary health care is growing its capacity to use data for improvement and give measurable evidence of the value of interprofessional primary care. This stream will share experiences of teams collecting and using data, improving access to patient health records while maintaining privacy, and maximizing use of EMRs. Sessions:

AB5 Optimizing EMR Use: Merging Data, Managing Patients and More

C5 Boiling Multiple Measures down to a Single Indicator: The Queen Square FHT and Patients Canada Experiences

D5-a Tools to Enhance and Track Patient Experience


EF5 Dragon’s Den: Pitching Real-Life Innovations in EMR Queries

AB5 Optimizing EMR Use: Merging Data, Managing Patients and More

Theme: 5. Advancing manageable meaningful measurement Length: 90 Minute Presentation

Lisa Ruddy, RN, Clinical Program Manager, Markham FHT

Tony Pallaria, IT Manager, Markham FHT


1. Learn how to access Cancer Care Ontario’s Screening Activity Report (CCO SAR) for all family health team (FHT) physicians and merge it with EMR data.

2. Describe how to use postal code to understand variation in cancer screening rates by neighbourhood income quintile and the impact of interventions on equity.

3. Learn how use of physician billing codes, and the creation of IHP tracking codes have helped to account for the work produced by Markham FHT, as well as enabled the creation and evaluation of clinical programs.

Summary:

1. How to Optimize EMR Use for Maximum Data Usability: EMR search capability and data extraction has moved beyond the “keyword search” and into the next level of meaningful management. With the introduction of Quality Improvement Plans, Ministry of Health and Long-Term Care reporting requirements, and now the Association of Family Health Team’s Data to Decisions, Markham FHT has had no difficulty extracting the data necessary for submission, due in large part to the careful planning and attention to how EMR data is entered and interpreted.

2. Managing Patient Rostering: Patient rostering data is an important area that could be optimized within EMR systems. Patient rostering is central to a high-performing primary health care system. Rostering can enable the practice to better define its panel size, manage access to care, track health indicators and outcomes. In 2014, North York FHT reviewed and updated 3,864 (4%) patient records, and mailed out 1,758 roster invitation letters to patients. Similarly,

Queen Square FHT reviewed and updated nearly 4,000 (11%) patient charts, and invited 2,000 (50%) patients by telephone to roster. We will discuss roster management and cleanup processes in Queen Square and North York FHTs.

3- Merging data sources to understand and improve cancer screening rates and related inequities Last year, Cancer Care Ontario made it easy for physicians to download an integrated summary of their patients eligible and overdue for cervical, breast, and colorectal cancer. We will describe how we accessed this data for the majority of our FHT physicians and merged it with our own EMR data. We noted a large variation in cancer screening rates between our physicians as well as significant disparities in screening related to patient income. Our FHT used the merged cancer screening data to deliver a multifaceted, evidence-based quality improvement intervention that included patient recall letters signed by their physician, physician audit and feedback, and enhanced point-of-care reminders. The intervention improved overall screening rates and improved rates for most physicians. We noted a narrowing of income-related inequities for colorectal cancer but not cervical or breast. The results of our intervention have spurred further work on how to improve disparities in cancer screening in our FHT.


C5 Boiling Multiple Measures Down to a Single Indicator: The Queen Square FHT and Patients Canada Experiences


(I) Indicator Management: Weighted Indicator Selection Matrix (QSFHT Experience)

Queen Square FHT:

Abel Gebreyesus, BA, MHI, Quality Improvement Decision Support Specialist (QIDSS)

Heba Sadek, Executive Director

Lindsey Thompson, RN, BScN, MPH - Health Services Planner/RN


The objective is:

1. Why indicators matter to primary care performance

2. Mastering prioritization of indicators efficiently

3. Exercising objectivity in indicator selection evidenced through Six Sigma Tool.

Summary (I):

The presentation showcases the Weighted Indicator Selection Matrix a complementary tool to the Accountability Management System (AMS) (“QIDSS Innovation Fund”). Since indicators are key part systemic system performance, they need a uniform and robust approach for selection and measurability. The AMS, manages and organizes indicators by linking them through goals, objectives and activities. But, how should we select the best indicators to highlight an organization’s performance? We need to have an objective system; and that is why we developed the “Weighted Indicator Selection Matrix”. The presentation will deal with the process of how a FHT team can develop their own customized Matrix and translated it into a practical decision-making process to enhance data gathering and collection tools.

(II) Measuring What Really Matters to Patients

Patients Canada

Alies Maybee, Patient Advisor, Patients Canada

Brian Clark, Patient Advisor, Patients Canada

Puja Ahluwalia, Project Coordinator, Quality Improvement Decision Support, QIDS, AFHTO


The partnership between AFHTO and Patients Canada on the Patient/Doctor survey to find out what matters to patients in their relationship with their doctor and clinic, led to two important areas of learning:

• About why patient/caregiver collaboration in developing the survey led to better uptake and results

• About the value and process of the partnership itself

You will learn why partnering with informed patients can help target and improve a survey and increase the response rate. You will also learn what makes an effective partnership and how to develop the partner relationship.

Summary: The presentation will look at the development and results of the Patient/Doctor survey and why and how the successful partnering of AFHTO and Patients Canada impacted the quality of the survey and increased the response rate. The goal of the survey was to determine what is important to patients and how important each question was in how patients evaluated their relationship with their primary care provider. The results of the survey will inform clinicians which are the most important questions to include in their own surveys to determine the quality of the care they deliver.

The Key Performance Targets (KPTs) developed by Patients Canada from patient experiences helped identify questions important to patients. Initially, the survey design was complex, with levels of questions framed in research speak. The challenge was how to make the survey goal, its structure and language understandable to patients. It took several rounds of work with AFHTO researchers and informed patients from Patients Canada to rework and streamline the survey. After all, if patients cannot understand the need for the survey, its questions and how to answer, what value can come of it?

So what did we learn? The nature of the patient partnership determines the depth of value patients can bring to the project. Measuring what is important to patients from their perspective and acting on the results can lead to better experience of primary care for patients in Ontario.

D5-a Tools to Enhance and Track Patient Experience



Collecting meaningful data on patient experience can be a time-consuming and challenging, but it can have invaluable results. Four different approaches that have proven successful are explored in this session.

I. Extending the EMR with Patient Tablets: Using Interactive, Point-of-Care Patient Surveys in the Waiting Room to Generate Clinical Content and Save Time – North York FHT

II. Transforming Primary Health Care Delivery through Innovative Patient Experience Tool – Wise Elephant FHT

III. Using an automated patient reminder service and survey to collect information on patients’ experiences – Cliniconex

IV. Add some SaaS to your patient experience surveys – Women’s College Academic FHT


(I) Extending the EMR with Patient Tablets: Using Interactive, Point-of-Care Patient Surveys in the Waiting Room to Generate Clinical Content and Save Time

Dr. Douglas Kavanagh, MD, Founder of CognisantMD, North York FHT

Dr. Robert Davis, MD, Happy Valley FHT


Learn how mobile devices and a cloud-based platform can unlock and extend your EMR, enhance patient communication, and save time. In this session, you will hear how primary care clinics are using mobile tablets and a large library of clinical content with their existing EMRs to allow patients to securely update contact information, provide a detailed patient history, or complete forms like the Nipissing Well-Baby Screen. Data entered by the patient can be automatically used to calculate scores, recommend treatment based on clinical guidelines, add a clinical note to the EMR, and even generate customized patient educational materials and handouts.

Summary (I):

In this presentation, you will see firsthand how one physician is using tablets to transform his practice. Learn how online patient questionnaires - completed on tablets in the waiting room, or from home before the appointment – are reducing appointment time requirements by as much 65%, while allowing more time spent face-to-face with the patient. By automating administrative tasks like email consent and demographic updates, you will also hear how clinics are becoming more efficient and reducing the burden on front-desk staff. Finally, you will see how replacing the scanning of paper forms with digital data entry, patient records can become more structured, more accurate, and minable. Learn how Ocean’s EMR-agnostic, integrated support for mobile tools and the largest library of openly available clinical questionnaires is transforming primary care across the province. With over 300,000 patient record EMR updates completed by patients in waiting rooms and exam rooms in just under two years, this technology is making it possible to access and share crucial healthcare resources in a whole new way.

(II) Transforming Primary Health Care Delivery through Innovative Patient Experience Tool

Wise Elephant FHT:

Sanjeev Goel, Lead Physician

Virgiliu Bogdan Pinzaru, Health Informatics Analyst, QIDSS

Lopita Banerjee, Physician


1. Importance of obtaining Patient Feedback on primary health care services delivery

2. Value of Real Time innovative Patient Feedback tools in aiding analysis and relevance

3. Removing Communication Barriers between patients and health care team

4. The value of patient feedback tools on measuring quality improvement of patient experience.

Summary (II):

This innovative tool of collecting patient feedback has resulted in removing barriers for patients to provide feedback to their health care team about their experience due to the ease of use and accessibility. Furthermore, we are now using the provincial QIP patient questions in our survey for the past 1 month. This will allow our tool to be leveraged across primary care teams to compare patient experience in different settings and ensuring our alignment with provincial strategy.

(III) Using an Automated Patient Reminder Service and Survey to Collect Information on Patients’ Experiences

Anthony Mar, President, Cliniconex Inc.

Sharon Johnston, Family Physician, Clinician Investigator, University of Ottawa, Department of Family Medicine, Bruyère FHT


This session will inform participants about how to use an automated patient reminder service to survey patients on their experiences seeking and receiving care at their FHT. Participants will learn about the cost and minimal burden of this approach as well as the patients it can reach and which survey questions can be used.

Summary (III):

In order to improve the care we deliver, FHTS need to understand patients’ experiences in seeking and receiving their health care. FHTs are also required to survey their patients annually to contribute to their quality improvement plans. At the same time, many FHTS are seeking ways to improve their care through automated reminder systems such as appointment reminders. This session will present an overview of a new approach to surveying FHT patients using automated surveys similar to patient reminder calls, emails, or texts. It will present the results and experiences from FHTs which have used this technology. The strengths and weakness of this technology including the patients it reaches and whom it may not, the burden on practices, and the cost will be shared with participants.


(IV) Add some SaaS to your Patient Experience Surveys

Women’s College Academic FHT:

Nicole Bourgeois, Dietitian and Health Promoter

Holly Finn, Program Coordinator

Susie Kim, Family Physician and FHT QI Lead

Craig Thompson, Director of Digital Communications, Women's College Hospital


Participants will learn novel strategies for coordinating and collecting patient experience surveys that reduce FHT staff and patient burden.

Summary (IV):

While the collection of patient experience data is mandated by HQO, there is little guidance around how to collect this data with existing resources. Strategies are needed to support survey distribution that minimize burden on both FHT staff and patients.

To address this challenge, the Women’s College Hospital Academic FHT has developed an automated system to collect patient experience data. We designed 3 short surveys, each focussed on a different domain of patient experience. Each survey includes:

1. the questions mandated by HQO,

2. questions related to chosen domain, and

3. demographics questions.

Patients receive an email with survey link during their birth month, so that each patient only receives one survey annually. Our process, which involves use of SaaS (software as a service) solutions, allows us to:

1. Minimize data entry and analysis burden by automating distribution, data entry, and analysis

2. Minimize patient burden, while still collecting feedback on a wider variety of issues (3 short surveys)

3. Monitor improvements over time (the 3 surveys are rotated throughout the year, allowing for quarterly analysis on all domains)

4. Semi-automate qualitative analysis of patient comments

5. Adopt best practices in electronic survey distribution, including via mobile devices

6. Minimize privacy and confidentiality issues related to the US Patriot Act

7. Be compliant with Canada’s anti-spam legislation (CASL) which came into effect July 1, 2014.

While subscription costs for SaaS solutions are not inexpensive, economies of scale may be achieved if a system is adopted and shared across FHTs.



Markham FHT:

Dr. Allan Grill, MD, CCFP, MPH, Lead Physician

Lisa Ruddy, RN, Clinical Program Manager


1. Review the clinical signs and symptoms associated with Measles and the appropriate tests to confirm the diagnosis.

2. Outline the infection control steps to prevent measles exposure as well as other airborne infections to patients and staff present in the office setting.

3. Emphasize the importance of collaboration with local public health for contact tracing after an office measles exposure.

4. Discuss the recommendations by the Markham FHT Occupational Health & Safety Committee to collect immunity data on staff and providers with respect to vaccine preventable diseases (e.g. MMR, varicella, Hep B) and institute baseline TB skin testing.

Summary:

Measles is a viral infection that classically presents with fever, rash and the 3 “Cs” - cough, coryza and conjunctivitis. While most people with measles are sick for a few days and recover completely, it can lead to complications and even death. In Canada, due to high immunization rates, measles is rare. However, several factors have contributed to recent outbreaks including patients who only received one immunization against measles, those who refuse to be immunized due to a discredited claim that there is a link to developing autism, and unintended exposures in countries endemic to measles.

Given the virus spreads through respiratory droplets, multiple exposures can occur when an infected patient presents to a primary care practitioner’s office. Providers need to be comfortable responding to such a scenario and this session will provide a practical approach on how to manage a measles exposure based on our FHT’s experience from earlier this year. Consistent with the theme of “Advancing manageable meaningful measurement”, we will highlight the importance of leveraging one’s EMR system to access patient health records for contact tracing.

Topics including collaboration with public health, and the importance of transparent messaging to patients and staff will be reviewed. Providers will also be imparted with valuable lessons learned such as the importance of infection control practices to prevent spread, and knowing the immunization status of office staff/providers to ensure protection in the event of a measles outbreak. A review of the diagnostic tests for measles will also be provided.


EF5 Dragon’s Den: Pitching Real-Life innovations in EMR Queries


How do you make the most of your EMR? Six teams pitch their methods for optimizing custom queries to gather precise, meaningful data. Join moderator/”dragon” Darren Larson of OntarioMD as he presides over this lively, fast-paced session.

I. Quality Based Improvements in Care (QBIC): How EMR data can transform care – CFFM FHT

II. Data Tracking: Creating Your Own Path – Burlington FHT

III. Beyond an electronic paper file - Optimizing your EMR for population-based measurement – South West CCAC

IV. Leveraging convergence of healthcare delivery, business dynamics and technology advancements to advance collection and utilization of meaningful COPD patient data – Couchiching FHT

V. Leading Edge Custom Queries and their Applications Across Ontario – East Wellington FHT

VI. Optimizing EMRs to Accurately Identify COPD and other Chronic Disease Patients – Windsor FHT and QIDSS partners

(I) Quality Based Improvements in Care (QBIC): How EMR Data can Transform Care

Centre for Family Medicine FHT

Dr. Mohamed Alarakhia, Director, eHealth Centre of Excellence, Family Physician, CFFM FHT eHealth Centre of Excellence

Kathryn Flanigan, Nurse Practioner, Centre for Family Medicine FHT

Ted Alexander, MA, Research Associate, CFFM FHT eHealth Centre of Excellence

Masood Darr, Technical Specialist, CFFM FHT eHealth Centre of Excellence


1. Attendees will learn how to use EMR templates with simple clinical decision support tools to facilitate care of patients

2. Attendees will increase awareness of enhanced use of EMR to identify patients with chronic conditions

3. With the use of structured data in EMR, attendees will be introduced to a model that can help predict at-risk patients in need of additional support.

Summary (I):

Quality Based Improvement in Care (QBIC) is based on the understanding that optimizing primary care’s use of electronic medical records (EMRs) is essential to supporting improvements in our health care system and achieving positive health outcomes at the patient, practice and population levels. With support from an eHealth coach and Information Technology expert, 91 primary care clinicians in 6 primary care organizations were able to enhance quality improvement, chronic disease management best practices and information management. Furthermore, after clinicians were encouraged to document chronic diseases in a structured way, reminders were created in 2 pilot Family Health Teams. After six months, data was evaluated linking workflow to patient outcomes using these reminders. Furthermore, a model was created using structured EMR data to identify at-risk patients who require further support. This advanced use of the EMR will be critical as primary care organizations use system-level strategies to achieve higher quality care while reducing costs (e.g. Health Links patients)

(II) Data Tracking: Creating Your Own Path

Burlington FHT:

Melonie Mawhiney, Clinic Manager

Caitlin Grzeslo, Program Co-ordinator


The key learnings are how to approach data tracking to work around EMR limitations. With some ‘out of the box’ thinking, you can customize data measurements based on unique programs and services, IHP roles etc. This improves program management as well as eliminating manual tracking for Ministry reports. It provides efficient and effective reporting of statistics and performance measures for the AOP, QIP and quarterly reports. Chronic Disease Management also benefits from queries and other reports developed through QIDSS support by identifying specific health issues in patient charts. Data integrity is also improved through comparative analysis. Summary (II):

“You can’t manage what you can’t measure” That was our mantra in developing our data tracking system. We will describe how we used ‘fake’ billing codes and unused data fields to measure patient encounters by type and by program. Through innovative thinking, we found ways to extract data from our EMR (Oscar) that did not have the specific functionality we wanted, allowing us to measure what we wanted, not just what was available.

With support from our QIDSS, we developed specific queries for programs based upon the performance indicators in our QIP. We can measure time spent by IHP on various tasks and programs with the next step being a ‘Return on Investment’ analysis with the return being measured by patient outcomes. We are able to better manage our Chronic Disease preventions and target patients that would benefit from one of our programs.


Our QIP has significantly improved through allowing us to set realistic targets that can be justified by statistics. We can now measure the QIP performance indicators efficiently, effectively and most importantly, accurately. Given the Ministry’s emphasis on providing “solid evidence of the value of FHTS/NPLCs and team-based care” our FHT can demonstrate this is a quantifiable versus qualitative manner.

(III) Beyond an Electronic Paper File – Optimizing Your EMR for Population-Based Measurement

Partnering for Quality, South West CCAC

Rachel LaBonte, Program Lead

Gina Palmese, eHealth Coach


Participants will:

• gain a shared understanding of challenges that exist in optimizing the use of EMRs in primary care settings;

• gain an understanding that improving the use of basic/intermediate functionality is often a prerequisite for using intermediate/advanced features (e.g. queries and reports depend on good data integrity, structured and searchable data) and;

• learn a few tips/tricks to help them optimize the current use of their EMR and next steps to population-based care (multiple EMRs will be discussed).

Summary (III):

With 80% of health care encounters occurring in primary care settings the vast majority of patient data is collected and managed at the primary care level and the transformative change to be undertaken will be reliant on information management supports and tools. Not all users are using their EMR to its fullest potential. Through the results of the Primary Care EMR Needs Assessment, primary care physicians, nurse practitioners and physician assistants have demonstrated that they are comfortable using EMRs for episodic care, however challenged to shift EMR use for practice level management.

Through the optimization of EMR use for practice level management, primary care practices will be positioned to achieve positive health outcomes at both individual and population levels, leveraging the full benefits of EMR adoption. This further provides a significant opportunity to optimize the use of EMRs for chronic disease prevention and management and delivery of quality patient care. This presentation will not only outline high level results of the EMR needs assessment but will also highlight the rest of the journey towards population-based care.

NOTE: This presentation will cover multiple EMR systems.

(IV) Leveraging Convergence of Healthcare Delivery, Business Dynamics and Technology Advancements to Advance Collection and Utilization of Meaningful COPD Patient Data

Couchiching FHT:

Stephanie Kersta, MSc, Health Promoter

Greg Armstrong, MD, Lead Physician

Stephen Graper, President, Healthcare Together Ltd

Doug Kavanagh, Founder, Cognisant MD


1. Become aware of an optimal healthcare delivery method and process to:

a. Integrate a multi-disciplinary, cross functional team into a QI initiative that will optimize COPD population management (prevention and treatment)

b. Use patient generated health data to identify patient needs and resource requirements

2. Understand key insights into developing strategic business partnerships with complimentary core competencies and resources to enable FHT’s to achieve CDM (chronic disease management) goals

3. Increased awareness of technology advancements to enable rule based processes to optimize efficient and timely collection of patient self-reported clinical insights with direct Telus PSS EMR integration.

Summary (IV):

Couchiching FHT (CFHT) insights demonstrated a need to enhance screening of its COPD population to achieve prevention and management goals. It sought an innovative way to engage patients, efficiently collect key COPD clinical insights that could be leveraged in the EMR. CFHT also recognized the need for an internally aligned team, to leverage strategic partnerships and to adopt new technology to ensure success. Through the use of a cloud-based clinical platform, the CFHT is now enabled to use rule-based technology to collect smoking status information, promote smoking cessation programs, inquire about the patient’s desire to quit smoking, complete the Canadian Lung Health Test screening tool and the MRC dyspnea scale. Additionally, email consent and address collection occurs. All of this data is self-reported by the patient, can occur in just a few minutes and is immediately integrated directly into the patient’s EMR.

This standardized data entry can be used to identify patient’s needs, direct internal resources (ie. program referral, spirometry required, bill for smoking cessation…) and communicate cross functionally through customized clinical notes.

This presentation will:

1. Describe current vs desired status of the CFHT COPD population registry and management


2. Present an overview of the current COPD data collection processes and gaps compared to processes utilizing new technology

3. Identify the value of developing strategic partnerships with private industry that can leverage technology advancements, therapeutic insights, project management and critical resources.

4. Highlight the benefit of a multi-disciplinary, cross-functional team with physicians and staff aligned on the QI initiative.

(V) Leading Edge Custom Queries and their Applications Across Ontario

Hope Latam, QIDSS, East Wellington FHT

Windsor FHT:

Brice Wong, QIDSS

Sara Dalo, QIDSS

Other QIDSS TBD

Learning Objectives (V):

Participants will gain an understanding of the different types of data in the EMR, and learn how structured data leads to higher data quality. They will be able to take home knowledge of different data extraction tools, in particular the Telus PS custom queries for extracting data from the custom forms. Participants will also learn the various ways FHTs are using the extracted data to guide program development, track staff utilization, and improve patient care. Finally they will gain knowledge about the AFTHO QIDSS program and how it facilitates the development and sharing of data management concepts and tools to FHTs across the province.

Summary (V):

The presentation will introduce the various types of data in EMRs; free text, stamps, encounter assistants and custom forms. It will have a focus on custom forms and how they are ideal for entering structured data into the EMR. We will then discuss the challenges we faced getting data out of the custom forms. This lead to the development and deployment of the custom queries across Ontario with the funding, guidance, and support from AFTHO. The presentation will then review how East Wellington FHT has used the queries to pull valuable data for a wide range of applications. Other QIDSS will then discuss how they have implemented the queries at their FHTs, and what they are using them for. We’ll conclude with the impact this new data has had on the FHTs, and what others can do to use and apply this same methodology.

(VI) Optimizing EMRs to Accurately Identify COPD and other Chronic Disease Patients

Sara Dalo, QIDSS, Amherstburg | Central Lambton | Chatham-Kent | Harrow Health Centre | Leamington & Area | Rapids | Thamesview | Tilbury District | Windsor FHTs

Brice Wong, QIDSS, Amherstburg | Central Lambton | Chatham-Kent | Harrow Health Centre | Leamington & Area | Rapids | Thamesview | Tilbury District | Windsor FHT

Thiv Paramsothy, QIDSS, East GTA FHT | Scarborough Academic FHT | West Durham FHT | Carefirst FHT

Learning Objectives (VI):

This initiative will allow EMR users to reliably generate a list of patients with COPD. Patients already coded/documented as having COPD can be filtered out, so those patients unclearly identified can be reviewed by the primary provider and properly documented in the EMR. EMR- specific instructions and other resources are available for FHTs as they undergo the process of making data quality improvements in their EMRs. Although this presentation is specific to COPD, the development of additional comprehensive queries, for top chronic conditions (ie. diabetes, hypertension, dementia…), are currently underway and will be available in the near future.

Summary (VI):

Approximately 12% of Ontarians have COPD and is a leading cause of hospitalization and death in Canada. Primary Care is continuously looking for ways to identify patients living with COPD and linking them with appropriate services that will help them manage their health to reduce ED visits and hospitalizations, and improve overall quality of life. The presentation would include a live demonstration and clearly outline processes around data clean-up initiatives that will optimize the EMR. There will also be next steps around which stakeholders in the community setting can provide services or support for patients identified with having COPD, such as OLA. The Algorithm Project Team is currently in the process of working on the next search for Diabetes and there will be more to come. The data generated could also assist with improving the accuracy and ease of Ministry reporting. This initiative has been broadcasted on several weekly QIDSS calls and professional development sessions, but the AFHTO conference would be an ideal opportunity to share it with members abroad since many can benefit from this search. A significant number of FHTs across Ontario have reported they do not have a reliable COPD registry, which is a drawback since registries allow for identification and tracking for patients with specific conditions, facilitate delivery of health care and track their progress. This solution can allow FHTs to manage their patients effectively and help overcome fragmented care and improve coordination services.


Theme 6 – Leadership and governance for accountable care

Boards hold their organization’s management accountable for performance. In turn, boards are accountable to their “shareholders” – for FHTs and NPLCs, this is the Ministry of Health and Long-Term Care. Accountability in primary care is evolving -- it includes patients, the local community, community partners, Health Links, and increasingly, LHINs. Primary care boards and leaders must have the means to track performance, quality of care and value delivered, take action when needed, and meet the expectations of those to whom the organization is accountable. This stream focuses on the practices, tools and tips to support boards and leaders in good governance, strategic population-based planning, performance measurement, making evidence-informed decisions and supporting the development of leadership within the team. Sessions:

A6 Quality Improvement Leadership Team (QuILT): Hearing Everyone's Voice


C6 Solutions for Managing Patient Privacy Across Clinics and Community Partners


EF6 Navigating by the stars? Try GPS. How Two FHT Leaders Used Brain Research to Increase Team Collaboration and Physician Engagement

A6 Quality Improvement Leadership Team (QuILT): Hearing Everyone's Voice Theme: 6. Leadership and governance for accountable

care Length: 45 Minute Presentation

Thames Valley FHT:

Natalie Clark, Program Administrator

Jill Strong, QIDSS

Tim McDonald, Physician


Participants will gain the knowledge of the benefits of bringing together a passionate group of individuals whose main objective is to improve the quality of care for patients of the TVFHT. Other FHT will see the benefits to their organization by having a committee comprised of each profession, administrative staff, and a family physician. The presentation will touch on why TVFHT believes that this group is integral to its operations, and why other FHT may find a similar committee beneficial to their organization.

Summary:

The TVFHT Quality Improvement Leadership Team (QuILT) works to better understand the responsibilities TVFHT as an organization holds to the Ministry of Health and Long-Term Care (Ministry) and Health Quality Ontario (HQO), and has worked towards creating plans and processes to meet those responsibilities from various clinical perspectives to make these efforts meaningful. QuILT also works to assure the TVFHT Board that processes are in place to continuously improve the care, health and well-being of the population we serve. This will include processes to demonstrate outcomes of a high performing organization as defined by HQO’s attributes of a high-performing health system: Accessible, Effective, Safe, Patient-Centered, Equitable, Efficient, Appropriately Resourced, Integrated and Focused on Population

Health. Membership includes interdisciplinary team representation recruited through an expression-of-interest invitation. QuILT will ensure an organization-wide approach to: 1. Annual quality improvement plan (QIP) submission to Health

Quality Ontario (HQO) that aligns with the organizational Strategic Directions and the Ministry of Health and Long Term Care (MOHLTC) health care strategic priorities.

2. A coordinated quality improvement work plan to achieve QIP deliverables.

3. Consistent application of evidence informed practices.

4. Timely access to information by providers and team members for informed decision making.

5. Building a culture of, and capacity for, a collaborative, integrated and systematic approach to quality improvement that include standardized data collection tools.

6. Ongoing accountability and reporting timelines.

7. Ongoing advising related to professional practice such as policies and implementation of evidence informed practice.



Theme: 6. Leadership and governance for accountable care


Markham FHT:

Dr. Allan Grill, MD, CCFP, MPH, Lead Physician

Dr. Parm Singh, MD, CCFP, Family Physician & Chair, Governance Committee

David Marriott, B.A., Executive Director


1. To outline the steps required in creating a performance review with a focus on the FHT Lead Physician role.

2. To explore the function of the Governance Committee and the FHT Board of Directors with respect to implementing the LP performance review.

3. To discuss the importance of a transparent process when designing a performance review and its influence on accountability.

Summary:

The MOHLTC, a key “shareholder” of FHT Boards of Directors, expects accountability to be linked to performance. In order for FHTs to succeed in this regard, strong leadership is required. Therefore, evaluating the performance of individuals holding leadership positions within FHTs is crucial. Furthermore, from a professional standpoint, advice from peers and colleagues creates the opportunity for leadership growth and in turn organizational maturity. Constructive feedback also holds a leader accountable by determining if s/he meets their stated deliverables. In this regard, the Markham FHT recently designed a performance review process for their Lead Physician. This presentation will outline the various steps taken by the Governance Committee including updating the LP job description, developing an evaluation survey, selecting FHT members of various roles to partake in the survey, choosing an on-line method to gather and analyze feedback, and communicating the results to the FHT Board and members of the organization. Perspectives from the Chair of the Markham FHT Governance Committee, Executive Director and Lead Physician will be shared. It will also provide a step-by-step practical outline of how to initiate a process to measure the performance of the Lead Physician, and other staff, for FHTs who have not yet participated in this exercise. Furthermore, this presentation falls within the AFHTO theme of “Leadership and governance for accountable care” by focusing on tools to support leaders in good governance and supporting the development of leadership within the team.

C6 Solutions for Managing Patient Privacy across Clinics and Community Partners Theme: 6. Leadership and governance for accountable

care Length: 45 Minute Presentation

(I) A Stewardship Privacy Model for a FHT and its Clinics

Kirk Miller, Director of Performance and Accountability, Guelph FHT

Justin St-Maurice, Privacy Consultant, St-Maurice Consulting Services


As the province's third largest FHT, the Guelph FHT has 76 doctors and is operationally broken down into 17 clinics. While privacy is always a challenge, privacy in the Guelph FHT's environment is especially challenging and requires a purposeful privacy governance structure to ensure consistency across clinics, to support FHT staff and to meet legal obligations. Participants will learn about the Guelph FHT's approach to privacy governance, how the model was implemented and how other FHTs may take a similar approach.

Summary:

FHTs are continually asked to provide leadership in data. This leadership often involves searching, accessing and summarizing data about clinics. Often, however, the relationship between a FHT and its clinics from a privacy perspective is ambiguous, and questions of custodianship, responsibility and training are unclear. As FHTs are strategically moving to play a even stronger role in data, the question of privacy and privacy governance needs to be formally resolved.

As the province's third largest FHT, privacy in the Guelph FHT's environment is especially challenging and requires a purposeful privacy governance structure to ensure consistency across clinics, to support FHT staff and to meet legal obligations. The Guelph FHT's privacy model is based on the concept of privacy stewardship, and sharing privacy roles and responsibilities between the Guelph FHT and its clinics. The goal of this model is to allow the Guelph FHT to participate in regional data programs, while simultaneously giving individual clinics appropriate control and responsibility for their privacy responsibilities.

The Guelph FHT's approach is broken down into two parts: the first part of this governance model is based on a common set of privacy principles that are adopted by all clinics. This "Harmonized Privacy Policy" establishes universal privacy policies for all clinics and clearly outlines the role of the FHT and the role of the clinic regarding privacy responsibilities and obligations. The second part of the governance model is a Stewardship Agreement, which formalizes the relationship between the FHT and its clinics from a data and privacy perspective.


The presentation will conclude with a review of lessons learned through the process of negotiating this privacy model, and an update on its current status.

(II) Quality-Based Reporting and PHIPA Compliance

North York FHT:

Susan Griffis, Executive Director

Jennifer Leung, Clinical Manager

Marjan Moeinedin, Quality Information Decision Support Specialist


Increase overall awareness of privacy, security and confidentiality of data.

Review current PHIPA regulations and the relevance to Family Health Teams in quality-based reporting.

Provide an overview of the current challenges faced by Family Health Teams in meeting PHIPA requirements

Share useful and practical ideas that may be adopted by other FHTs in terms of contract negotiations with internal and external partners, implementation of processes, policies and procedures, and internal quality monitoring through audits.

Summary:

Quality-Based Reporting and PHIPA Compliance. No one would argue that information from data is key to improving efficiencies within the healthcare system, influencing public policy development and administration and supporting research to advance patient care. At the same time, information security and privacy in the healthcare sector is an issue of growing importance, where breaches can incur serious consequences for both the individual and the organization involved. The adoption of electronic patient medical records and the increasing need for providers and funders to access and utilize patient data all point towards the need for a better understanding and adoption of policies and protocols regarding information security.

The main threats to patient privacy and information security are those that arise from inappropriate access of patient data either internally or by exploiting disclosed data, including big data, beyond its intended use. Compliance with provincial regulations governing privacy and security of health information is mandatory (PHIPA, 2004) and yet, many Family Health Teams and other healthcare organizations are failing to comply and struggling to understand the risks they face by not meeting these requirements.

This presentation will highlight some of the challenges faced by the North York Family Health Team in meeting PHIPA requirements as we continually strive to implement best practices in addressing quality-based reporting both internally and with our external partners. The importance of a data flow chart; end-user agreements; staff training and education; privacy, security, data breach and confidentiality policies and procedures; audits; and other necessary checks and balances will be discussed.


Theme: 6. Leadership and governance for accountable care Length: 45 Minute Presentation

Dave Courtemanche, Principal and Founder, Leading Minds Inc


This workshop will invite participants to rethink the importance of team culture by:

1. Understanding ‘whole-mind’ thinking

2. Leading inter-professional collaboration

3. Shifting the leadership culture of their teams.

Summary:

Team-based primary care in Ontario is driven by a ‘left-brain’ approach to healthcare. Accountability, fiscal restraint, governance, policy, structure, patient statistics- these are the things that drive Ministry-funded primary care organizations. But for the people leading these teams, the need to embrace ‘right-brain’ thinking brings a healthy balance to the experience. Purpose, collaboration, trust, creativity, relationships and patient stories- these are the things that inspire a high performance team culture. Participants will be invited to reflect on their own team’s ethos and identify new ways of balancing the demands of accountability with the desire for a thriving team environment. They will hear how taking a ‘whole-brain’ approach to leadership can create a healthier high performance team culture. And they will be invited to consider how they might shift the leadership culture of their team by unleashing the leadership potential of all team members.

EF6 Navigating by the stars? Try GPS. How two FHT Leaders used Brain Research to Increase Team Collaboration and Physician Engagement

Theme: 6. Leadership and governance for accountable care Length: 90 Minute Presentation

Penny Paucha, Principal, Instincts at Work

Mary Atkinson, Executive Director, North Perth FHT

Barb Major McEwan, Executive Director, North Huron FHT

Elyse Savaria, MD, Lead Physician, Owen Sound FHT


Identify leadership and governance challenges that derail the effectiveness of FHT’s Identify hidden, structural barriers that prevent effective collaboration Highlight key leadership skills Learn about the social drivers of team behaviour. Learn new strategies to reduce conflict and increase engagement. Develop an action plan to more effectively engage others.

Summary:

An essential challenge of leaders within Family Health Teams is to create the conditions for high functioning individuals to reorganize into higher functioning, complex and adaptive teams. To do that successfully requires navigating the invisible barriers to engaging


others. In this workshop we will demonstrate how understanding the social wiring of the brain can lead to powerful strategies to motivate and engage others. We will present examples of how targeting these social drivers of behaviour led to increased physician engagement

and improved team performance in 2 Family Health teams. You will leave with practical and simple tools that you can use to lead your team to a more collaborative and effective level of functioning.


Theme 7 – Clinical innovations keeping people at home and out of the hospital

A sustainable health system must meet the triple aim of better health, better care and better value. Primary care teams have comprehensive programs focused on everything from health promotion, mental health, illness prevention through chronic disease management to palliative care. These programs engage the whole team in providing care where and when patients need them in order to help them stay home and out of the hospital. This stream focuses on successful examples and lessons learned in program planning and delivery for teams to use in their own community. Sessions:

A7 Reducing the Revolving-Door Syndrome: Hospital and Primary Care Working Together to Reduce 30 day Re-admission Rates for COPD and CHF Patients

B7 Community Paramedicine – Review of a Dedicated Model in Primary Care (FHT)


D7 Aging at Home: Interprofessional care to keep seniors at home and out of hospital

E7 Integrated LTC: An Innovative Initiative to Reduce Potentially Avoidable Hospitalizations for Seniors Living in East Toronto Long-term Care Homes


A7 Reducing the Revolving-Door Syndrome: Hospital and Primary Care Working Together to Reduce 30 day Re-admission Rates for COPD and CHF Patients

Theme: 7. Clinical innovations keeping people at home and out of the hospital


Tricia Wilkerson, Director, Quality and Evaluation, Guelph FHT

Sylvia Scott, Director, Clinical and Professional Services, Guelph FHT

Jackie Beaton, Inpatient Flow Coordinator, Guelph General Hospital


Attendees will:

• Understand the benefits from hospital and primary care perspectives of working together to address hospital readmissions versus working in silos

• Explain how care transitions impacts avoidable and unavoidable readmissions for populations at risk

• Understand why COPD /CHF populations were targeted

• Discuss how hospital utilization data informed the initiation of improvement activity

• Describe tests of change undertaken by each organization and in collaboration

• Discuss expected outcomes, system gaps and current mitigation strategies.

Summary:

To respond to a growing readmission rates and hospital length of stay for COPD and CHF populations, Guelph General Hospital (GGH) implemented clinical pathways to ensure best practice. A key intervention in the clinical pathway was to establish a follow up

appointment with primary care, for the patient prior to discharge. This intervention was implemented via a fax to provider’s office. Collaboration between GGH and GFHT was initiated to explore the uptake and rates of scheduled appointments received before patients were discharged. This initiative resulted in the following changes:

1. Primary care involvement in hospital discharge planning (including where needed, phone calls from the charge nurse to discuss patient discharge needs)

2. Primary care calling patients at risk of readmission within 48 hours post hospital discharge

3. Shared lists of practice based primary care contacts to facilitate scheduled telephone appointments prior to discharge

4. Electronic notification of primary provider of hospital patient admission and or discharge to facilitate patient centred and effective transition planning

5. Regular collaborative meetings to explore what is working well and what needs to be improved

Our test efforts have occurred within three pilot practices within the Guelph Family Health Team. Regular practice team meetings with the QI facilitator to review team improvement progress. Lessons learned will be integrated shared and tested for implementation across all practices.


B7 Community Paramedicine Models for Primary Care



(I) Community Paramedicine – Review of a Dedicated Model in Primary Care (FHT)

Medavie EMS Ontario:

Steve Pancino, General Manager

Ken Langlois, Community Paramedic

Dr. David LaPierre, Family Physician, CK-CHC


At the end of this presentation, attendees should be abIe to identify the types of patients who would benefit from visits from a Community Paramedic in (CP) their own home or community setting, understand the role that CP’s can play in community health systems including Family Health Teams, understand how the unique paramedic skill set can augment and support existing community health supports without duplicating service, and decrease reactive system utilization (9-1-1, ED visits) by taking a proactive approach to providing care for specific, at risk, patient populations.

Summary (I):

Medavie EMS Ontario, Chatham-Kent (MEMSO-CK) is the contracted service provider for the provision of land ambulance services for the single tier municipality of Chatham-Kent. MEMSO-CK was an active stakeholder in the development of the Chatham-Kent Health Link (HL) as where directors with the Thamesview Family Health Team and Chatham-Kent Family Health who together have aproximately 60,000 rostered patients in the municipality. In a collaboration with the HL partners, MEMSO-CK was successful in receiving one time funding from the Ministry of Health and Long Term Care to develop and examine CP programs. Medavie EMS has extensive history and experience with CP programs in Atlantic Canada and the north eastern US and sought to bring some of that experience to our Ontario operations. This novel program was developed in consultation and collaboration with the the FHT’s in the region in addition to the CCAC, CHC, CKHA and medical oversight physicians from the South West Ontario Regional Base Hospital Program. Three specific referral sources feed patients into the program: HL high users as determined by a care cooridinator at CKHA, waitlisted cardiac rehab patients, and CCAC rapid response RN patients. The 2 CP’s selected for the program attended an 8 week custom CP program developed by Fanshawe College. Working in a non response vehicle, 5 days per week, the CP’s provide supportive care, health coaching using the NHS wellness index, advanced assessment and diagnostics (eg. 12 lead ECG, POC testing), fall education, end of life care planning, and consultative/advocacy link for the patient population being served.

(II) Community Paramedicine in a Rural FHT

Bev Atkinson, Quality Information Decision Support Specialist, West Carleton FHT


At the end of this presentation, attendees should be abIe to identify the types of patients who would benefit from visits from a Community Paramedic in their own home, understand how to integrate Community Paramedic into a Family Health Team, understand the benefit to physicians of having a Community Paramedic visit patients on behalf of the Family Health Team, understand the importance of identifying all medications that patients may be taking including prescription medications, over the counter medications and herbal supplements, understand the limits of technology in rural communities and how to integrate community care and advocate on behalf of patients.

Summary (II):

West Carleton Family Health Team (WCFHT) is one of the few medical service providers in Rural Northwest Ottawa, and is located in the Village of Carp, within the amalgamated City of Ottawa. The largest portion of this practice population resides in this area, a sparsely populated region that traditional home services find difficult to service. In 2014 the Ministry of Health and Long Term Care distributed $6 million dollars in Ontario to expand paramedicine programs. WCFHT was chosen to pilot a paramedicine program where extensively trained and experienced Community Paramedics (CP) are integrated into the FHT to provide patient services in their own home. This novel program was developed in consultation and collaboration with the two regional providers of Paramedical Services in Rural Northwest Ottawa. Patients accepted into this program were chosen by physicians in the FHT . The patient population includes patients with chronic diseases, co-morbidities, palliative care, mental health concerns, recently discharged from hospitals or any patient identified as at risk. The program focuses on reducing the stress on limited health services, while at the same time, improving patient’s quality of life and assisting patients to live independently in their own home. CPs provide services that are normally provided within the FHT to patients, such as but not limited to; blood pressure checks, blood glucose testing, suture removal, immunizations and a thorough identification of medications. Most importantly the CP acts on behalf of the patient as an advocate in coordinating care from community partners.





Dr. Ed Brown, CEO, Ontario Telemedicine Network

Co-presenters TBD


Participants will learn about the value, effectiveness and availability of Telehomecare, which connects patients to their healthcare teams in real time for monitoring and coaching. Data will highlight how Telehomecare is helping to shift resources from hospital-based acute and ER care to a more proactive, community-based model. Participants will gain an understanding of how Telehomecare helps patients remain independent and optimize their health using self-management skills, bridging the gap between appointments, increasing access to care and making better use of healthcare resources. Participants will also learn how to refer patients or start their own Telehomecare program in their FHT.

Summary:

The evolution of Telehomecare will be the focus of the panel presentation, led by Ontario Telemedicine Network (OTN) CEO Dr. Ed Brown. Telehomecare brings together specially trained clinicians and simple technology to coach patients with chronic obstructive pulmonary disorder (COPD) and/or congestive heart failure (CHF) to monitor vital signs and manage their health at home.

Offered in eight LHINs in Ontario through hospitals and Community Care Access Centres, Telehomecare has been delivered to more than 5,000 patients to date. It enhances patient confidence and self-management skills significantly, avoiding unnecessary ER visits and reducing inpatient hospitalizations. Telehomecare is now expanding to target patients with COPD and/or CHF with diabetes as a comorbidity, as well as patients with chronic complex needs. To enhance accessibility, the program is now being offered in a format that can be tailored to smaller, individual sites, to accommodate particular needs and resources.

The panel will feature a Telehomecare physician “champion”, a representative involved in the diabetes pilot and a representative from a Family Health Team involved in a pilot for patients with chronic complex needs. They will highlight how expansion of Telehomecare across Ontario can offer the community supports to manage chronic disease and prevent exacerbations, promoting improved access to care for enrolled patients and reduced healthcare resource utilization.

D7 Aging at Home: Interprofessional Care to Keep Seniors at Home and out of Hospital



Burlington FHT:

Shawna Cronin, Occupational Therapist

Theresa Hubley, Nurse Practitioner

Caitlin Grzeslo, Program Coordinator


Our Aging at Home program’s focus is to provide interdisciplinary home care to seniors and reduce unnecessary emergency department visits. We will share our experience with team building, physician engagement as well as collaboration with CCAC and Joseph Brant Hospital.

Our team were participants in the IDEAS program. We will discuss how the resources made available assisted in developing tangible goals and performance indicators and how this carried over into our QIP.

The goal for our presentation is to have the attendees benefit from our learnings in:

• Program Development

• Team Building

• Internal and External Collaboration

• Embedding QI into a program.

Summary: The LHIN’s Aging at Home Strategy identified that a wider range of homecare and community support services will be needed. They project that the population of seniors will double in the next 16 years. Approximately 40% of the population of Burlington is over the age of 50.

For our aging population, the Burlington Family Health Team has developed a program through clinical innovations to keep seniors at home and out of hospital. The Aging at Home program aims to reduce preventable emergency department visits and helps to promote optimal health for our patients in the community. This is achieved through assessment and intervention by the FHT Occupational Therapist and Nurse Practitioner for patients who have difficulty accessing services, and who are at high risk for repeat emergency department visits and hospitalizations.

Several aspects of the program will be highlighted, including monthly rounds with physicians and members of the interprofessional team as well as ongoing monitoring of emergency department data for quality improvement purposes. A key feature of the program is the ongoing collaboration and integration with our local CCAC and Joseph Brant Hospital. The Burlington FHT will also continue to build on our close relationship with Burlington Health Links. Future goals include utilization of emergency department data to screen for high risk patients who may benefit from the program.


E7 Integrated LTC: An Innovative Initiative to Reduce Potentially Avoidable Hospitalizations for Seniors Living in East Toronto Long-Term Care Homes



Candy Lipton, MD, East Toronto Health Link; Vice President, Operations, Sienna Seniors

Irene Ying, MD, Palliative Care Consultant, Sunnybrook Health Sciences Centre; Assistant Professor, University of Toronto DFCM


The objectives are to share lessons learnt from the pilot project including:

1. Establishing shared milestones/goals with stakeholders in acquiring real-time data to inform rapid-cycle changes and perform program evaluation.

2. Diversifying activities decreases risk of over-relying on a particular strategy - Program resilience is a key requirement for success. Accordingly, we have developed parallel activities (i.e. Nurse Practitioner support, telemedicine case conference rounds, knowledge translation materials, and quality improvement), in order to support our pilot LTC homes.

3. Impact of pilot: • Potential for healthcare sustainability – Estimated cost

savings approx $70K (In the first 10 clinical days, the NP was able to change LOC for 6 of 13 residents, eliminating future ER transfers for the subsequent 6 months).

• Resident outcomes – improved pain and symptom management, in-house palliation (avoiding stressful transfers at the end of life, respect for wishes and best interests

• Support for families – goals of care enables proactive care plan development.

Summary:

Seniors suffer from increased morbidity and mortality when transferred to hospital versus receiving care in their place of residence. In long-term care (LTC) 25-55% of transfers to the Emergency Room (ER) are potentially avoidable and a 15% reduction in Ontario could save over $76 million per year. US & UK QI initiatives have shown 17-25% reduction in ER transfers. The Integrated Long Term Care (ILTC) program, recently featured in the Ontario Medical Review (April 2015), is composed of 3 pillars – capacity building, access to specialist consults, and acute care provision.

Juxtaposed to the supporting evidence for the program, there have been some challenges in the first year of implementation. These include identification of a target population, nurse practitioner recruitment and retention, competing demands for staff on the floor, need for palliative care training for front line staff and family's insistence of ER transfer. Each of these challenges has an

associated mitigation strategy which will be discussed during the presentation, as will next steps for the program.




Henry Siu, Physician, MedREACH Evaluation Lead, McMaster FHT; McMaster University, Department of Family Medicine

Laurel Cooke, BES, BScN, RN, Nursing Program Manager, Hamilton FHT


At the end of the session, participants will be able to:

1. Describe the health care needs and barriers of medically complex patients (MCP) being addressed by the MedREACH project

2. Describe the different components of the MedREACH project and how they work together to support the medically complex patient

3. Describe the preliminary results of the MedREACH project.

Summary:

The MedREACH pilot project (Medical Rapid Education and Assessment for Complete Health) is a demonstration pilot funded jointly by the Ministry of Health and Long-Term Care and the Ontario Medical Association. The goal of MedREACH is to improve the overall health of the medically complex patient (MCP) by seeking to re-forge the therapeutic relationship between the MCP and their family physician and interprofessional team.

MedREACH consists of three distinct yet coordinated health care delivery models:

1. Primary MedREACH involving clinical nursing outreach to MCPs;

2. Specialist MedREACH involving integrated health care delivery by specialists and allied health professionals at McMaster University Medical Centre; and

3. Mobile MedREACH involving facilitated interaction between specialists and primary care providers enabling direct and timely consultation for patients with barriers to health care access in their family practice setting or home environment.


The MedREACH project aims to address current gaps in the following areas:

1. Medical service provision for MCPs in the primary care and tertiary care setting in order to ensure more timely and coordinated care

2. Existing silos of operation in primary and specialty care by building bridges for communication and partnership between primary care and specialty care.

This session will familiarize participants to the MedREACH project framework, how each component of the project was operationalized, and the program evaluation strategy with preliminary results.

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