Concurrent Sessions

D3-b – Guelph Residents’ Health Matters: Guelph FHT teams are embedded in the community

Theme 3. Expanding your reach

Presentation Details

  • Date: Thursday October 25, 2018
  • Concurrent Session D
  • Time: 9:45-10:30am
  • Room: Pier 9
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff

Learning Objectives

Patients frequently tell us they like the team-based approach to care at Guelph FHT. They tell us they appreciate not only their physician AND their health care team, including nurse practitioner, mental health counsellor, pharmacist, nurse and dietitian. Improving access to care is a central mandate to our FHT.  For many years, Guelph FHT has offered team-based primary care to 90% of local residents (vs. 25-30% of Ontarians). But that wasn’t good enough!  Participants will gain insight into how the Guelph FHT extended team-based care to the remaining 10% through community partnerships, operational efficiency and resource optimisation.


The Board of the Guelph FHT has been very clear: it is imperative that we understand and target the needs of our community.  Every patient deserves access to comprehensive team-based primary health care, and primary care providers support their patients through integrated interprofessional teams.   Since 2012, we have evolved, becoming an organization that provides better care for our whole community. Change has been incremental  and includes:

A) Strong Community Partnerships:

1- Relocation of the Gestational Diabetes Management (GDM)program from Guelph General Hospital to the Guelph FHT
2- Implementation of Post -Partum Mood Disorder program supporting high risk populations in partnership with Guelph CHC
3- Provision of medical nutrition therapy to HIV/AIDS/Transgender patients through ARCH clinic
4- Initiation of the Rapid Access Addiction Clinic and Overdose prevention site in partnership with Guelph CHC and Stonehenge Therapeutic community

B) Operational Efficiency to Enable Community-Wide Access to FHT Programs Schedule optimisation, efficient triage processes, structured discharge, and addressed no show rates are some strategies that led to built capacity to extend existing FHT programs to all Guelph residents. Programs including Primary Care at Home, Diabetes Care, exercise, INR, foot care, chronic pain, smoking cessation, wellness workshops, and geriatric psychiatry are available and accessible to the entire community.  C) Resource Optimization to Support Associate Practices  Through care assessment of efficiency, population need and practice workflows, we integrated 3 dedicated FTEs in non- FHT practices educator to support additional 17,000 patients beyond our 105,000 Guelph FHT rostered patients.


  • Laura Adam, MSc., RD, CDE, Clinic Coordinator, Guelph Family Health Team
  • Sam Marzouk, MB BCh MBA, Director Business Services, Guelph Family Health Team