Poster Displays

A list of poster displays is now available below.

Information & Resources for Poster Presenters:

If you are unsure of the status of your poster presentation, please contact

2017 Key Dates:

  • October 2, 2017: Early-bird registration deadline – payments must be received by this date
  • October 11, 2017: Deadline to submit poster PDF
  • October 25 & 26, 2017: AFHTO 2017 Conference
    • Install poster: 7:30 to 8:30 AM, October 25, 2017 (updated)
    • Remove poster: 2:00 to 4:00 PM, October 26, 2017 (updated)

Poster Display Guidelines:

  • The maximum size for posters is 46” (vertical) x 70” (horizontal)
  • Posters are to be put into place before 8:30 AM on Wednesday, October 25, 2017, and removed at 4:00 PM on Thursday, October 26, 2017.

Online Poster Gallery

In order to share your initiative with as many of your peers as possible, an online gallery of posters will be made available here after the conference. To participate, please email a PDF of your poster to by October 11, 2017.

Poster Board NumberTitleTheme 1Summary / Results
#1A Centralized Approach to Standardize Electronic Medical Record Tools and Templates in a Multi-Site Family Health Team: Formation of a Data Standardization Committee1. Effective leadership and governance for system transformationBackground: Improving the quality of care and reducing medical errors are critical factors influencing patient outcomes. Embracing the use of EMR to provide evidence-based medicine readily available at the point of care has had a major impact on achieving these goals. Incorporating evidence-based information into patient care requires making the right information available at the right time. In addition, consistent and standardized clinical data are key in measuring and monitoring the quality of healthcare delivery. Purpose: We identified the need to create a centralized process to review and update all existing EMR forms and templates, particularly the chronic disease management forms and templates across our multi sited organization. Approach: To improve consistency of patient care, data sharing and quality of reports, the NYFHT has formed a data standardization committee responsible to promote and support standardization of EMR data entry. Terms of reference were developed to define the goals and objectives, responsibilities and the scope of work. The committee meets every other month and reports to the Information Management/ Information Technology Committee at the FHT. Findings: Currently, the committee has accomplished the task of reviewing and updating several EMR templates against most current best practice guidelines. These forms have also been standardized and released for use across the FHT. Implications: Data governance and management are the cornerstone of effective data optimization. Involving the right team members and ensuring effective implementation and adoption across the team are the foundation for building a successful process that will help improve patient care through standardization.
#2Workplace Violence Prevention in Primary Care: Reflections from the 2017-2018 Quality Improvement Plans1. Effective leadership and governance for system transformationAn epidemic of violence within the health care setting is undermining the safety of not only those who provide care, but also patients and their families. Violence in settings like primary care is often persistent and ubiquitous, yet under-reported. In fact, a survey of Canadian physicians (2010) found that 98% of 720 family physicians indicated they had experienced one incident of minor abuse. Roughly one third were exposed to some form of aggressive behaviour from a patient or patient’s family. Similarly, over 4,000 nurses were assaulted nationally between 2008 and 2013. According to the Association of Workers’ Compensation Boards of Canada, these incidences of violence were serious enough to keep the nurses away from the bedside. This presentation will provide participants with valuable information on how primary care organizations, hospitals, long term care homes and Community Care Access Centres are safeguarding their staff and organization from abuse, assault and harassment. This year, team-based inter-professional primary care organizations submitted data regarding “Staff Safety and Workplace Violence” in their 2017/18 Quality Improvement Plans. Themes from these submissions reflect prevention and response strategies, as well as the measurement of workplace violence in these organizations. Early findings focus on the importance of leadership’s commitment to prevention of workplace violence, and frequently implemented strategies such as policies and procedures, and educational programs will also be discussed.
#3Acceptability of Telephone-Based Mental Health Support for Patients in Primary Care 2. Planning programs for equitable access to careThe CAMH PARTNERs Project is a randomized controlled trial that supports patients with depression, anxiety, and at-risk drinking using a telephone-based integrated care model. Patients are randomized to one of two groups: Enhanced Usual Care (EUC) and intervention for 12 months. Patients in EUC receive comprehensive quarterly telephone assessments, the results of which are shared with their primary care providers. In addition to the quarterly assessments, patients in the intervention arm also receive regular telephone support from a Mental Health Technician (MHT), who monitors symptoms, treatment adherence, and provides education on lifestyle changes. Currently, the project is implemented across Ontario at 18 primary care sites with 189 physicians and nurse practitioners, including rural, urban, and suburban settings. Although it is commonly believed that patients prefer to receive their mental health care in face-to-face settings, telephone-based care can serve as an effective, low-cost, and acceptable alternative. Telephone-based care can increase access to individuals who live in remote areas with scarce resources or have mobility limitations/busy schedules. In addition, telephone models can be cost-effective for both patients and providers as travel to appointments is not required. Furthermore, the relative “anonymity” of the telephone calls allows some patients to feel more comfortable discussing sensitive issues such as suicidal ideation, self-harm, and past trauma. Available data to date support the high acceptability of the telephone-based model. To illustrate the acceptability of telephone-based care, the following data will be presented: reasons provided for declining consent and withdrawals, retention rate, and 12-month satisfaction survey responses.
#4Health Equity Curriculum in Family Health Team2. Planning programs for equitable access to careThe presentation will describe the development and evaluation of a health equity curriculum created at Women’s College Hospital Academic Family Health Team (WCHAFT). This program was developed in order to better service complex patients in our practice. A multi-disciplinary team developed a project outline through the creation of a project charter. We conducted an environmental scan to assess the demographics and needs of our community, and the types of curriculums and resources currently offered in other family practice settings. We surveyed our staff to assess their knowledge and confidence with health equity topics, to determine which topics to include in the curriculum. Once we outlined the key sessions to deliver, we worked with community leaders who delivered sessions on 11 diverse topics such as Indigenous, Refugee, LGBTQ health and other topics. Sessions are delivered once per month and attendance is mandatory for all staff. We are surveying the attendees before and after each session to assess their knowledge and confidence in providing equitable patient care to assess the efficacy of individual sessions. The curriculum we developed is being considered as a model to the implementation of health equity curriculums among other departments at Women’s College Hospital. We hope to show that, through the development of our health equity curriculum, other family health teams can create similar curriculums in order to provide equitable care to patients.
#5Collaboration with Community Partners for Equitable Access for Low Back Care and Services 2. Planning programs for equitable access to careLow back pain is said to affect over 80% of Canadians in their lifetime, with many of these people experiencing persistent or recurring low back pain. While 93% of Family Physicians treat LBP, more than half report finding it challenging to treat LBP on their own, and 75% feel their patients could benefit from involvement of other AHPs in treatment. By filling the gap of access to treatment and providing referrals to appropriate treatment and education, LBP can be effectively treated. This poster presentation will cover the strategies used in executing a program that allows access to multi-disciplinary services for all patients. The program is set-up for individuals that would not otherwise have access to multidisciplinary care, such as Physiotherapy, Chiropractic or rehabilitation services funded through private health benefits. By incorporating an allied health care provider into the primary care facility, the patients’ have access to education and self-management strategies, along with referral to other health providers as needed, to effectively manage their low back issues. The program utilizes community partners for pre-existing allied health services, and fitness facilities for rehabilitation programs to eliminate the cost of implementing new and redundant services.
#6Go To Sleep! Group Cognitive Behaviour Therapy for Insomnia (CBT-I) with the Family Physician, Mental Health Counsellor and Pharmacist – A Pilot Project at the Hamilton Family Health Team (HFHT)2. Planning programs for equitable access to careIn primary care, Cognitive Behaviour Therapy for Insomnia (CBT-I) is not always readily available and patients may take sleep medications for longer than 4-5 weeks as per guideline recommendations. Objectives: The primary objective of this project is to determine the feasibility of having group CBT-I sessions in primary care. The secondary objectives are to determine if patients with insomnia improve their sleep and reduce their sleep medications after receiving CBT-I. Methods: Patients with chronic or acute insomnia with or without sleeping medications and willing to commit to 5 sessions to learn about CBT-I were invited to attend the group CBT-I sessions. The intervention consists of five group CBT-I sessions, approximately 2 hours long (baseline, 2 weeks, 4 weeks, 6 weeks, 3 months) with opportunity for patients to meet individually with the family physician, mental health counsellor and pharmacist. The intervention (5 group sessions) will be repeated three times over a two-year period at one primary care site. Preliminary Results: After 2 group interventions, 12 patients with insomnia (6 patients in each group) received CBT-I treatment. Overall, most patients' sleep efficiency improved within 3 months. One patient did not take any sleeping medications. The other patients (11/12) took prescription (e.g., benzodiazepines, trazodone, zopiclone, zolpidem) and/or Over-The-Counter medications (e.g., melatonin, diphenhydramine) to help sleep. After 3 months, 10/11 patients were able to decrease or stop the sleeping medications. Summary: Based on the preliminary results, the group CBT-I facilitated by the family physician, mental health counsellor and pharmacist is feasible in primary care.
#7From Prenatal to Antenatal: How to Maximize Your Capacity for Comprehensive Care for Mothers and Babies2. Planning programs for equitable access to carePrenatal Care in the community is often disjointed, with women bouncing back and forth between clinics and practitioners, often not seeing much of their Primary care Provider until after delivery. Community Obstetricians and Midwives typically have many more patients that a Family Practitioner, and are therefore also not as available on short-notice to their patients. The outcome of this relationship is often unnecessary and inappropriate visits to the ER. Family Health Teams are in a unique position to fill in the gaps that are left in the current landscape of prenatal and antenatal health care delivery. By maximising our use of IHP staff, and delivering care both over the phone and after-hours, we can increase pregnant women and new mother’s abilities to access their care team. In order to support the Province’s vision for health care delivery that is highly integrated across the continuum, we have also identified a target population that extends beyond our own enrolled patient population, and includes all Pregnant women and their children in the East Toronto sub-region.
#8Mind Over Mood: A CBT Approach to Anxiety and Depression2. Planning programs for equitable access to careThe large number of SW referrals for patient’s suffering with anxiety, depression, stress and relationship issues led us to looking for a better way to provide the evidence based CBT skills that patients could learn and use to better manage their symptoms and lives. As research has shown, there are numerous benefits to treating depression and anxiety through the CBT model. This led to the development of the Mind over Mood program. This is a 7-8 week Cognitive Behavioural Therapy group that is offered across the Thames Valley FHT (TVFHT) and is based on the CBT workbook Mind over Mood by Padesky & Greenberg. The program has shown great success, recently being expanded across the FHT to better serve our patients. The program is targeted to patients that are dealing with mild to moderate depression and/or anxiety and has become our main mental health group. Mind over Mood provides IHPs the opportunity to redirect patients that require mental health services away from individual appointments and into a more appropriate setting, thus decreasing our wait time for individual and new patient assessments. The presentation will outline the description as well as the weekly schedule of the program (how the book has been broken into weekly sessions), the results of the program to date, as well as participants’ testimonials.
#9A Transition in Primary Healthcare – An Interdisciplinary Model of Providing Transgender Care 2. Planning programs for equitable access to careThe transgender community has gained increased visibility in society, however it represents one of the most marginalized and underserved populations in healthcare (Alegria, 2011; Roberts & Franz, 2009). Yet transgender individuals in Ontario are still denied health care, are treated with disrespect, or “referred out” for basic health care needs. Many transgender individuals in Ontario still struggle to find a primary care provider who is knowledge in transgender health care issues. In response to this need, a gender clinic was developed at the Wise Elephant Family Health Team in Brampton, Ontario. This clinic currently serves over 90 transgender patients, with many patients traveling from other cities to access these services. This presentation will address barriers and facilitators to accessing care within the transgender population, including making your facility a ‘safe space”. Exploring the concepts of social, medical and surgical transition. The interdisciplinary approach to transgender healthcare will be examined, including the role of psychotherapy. Strategies to further improve the provision of transgender primary health care in Ontario will be explored. The aim of this presentation is to highlight the implementation of the gender clinic, lessons learned and demonstrate the vital role interdisciplinary teams have in transgender primary healthcare.
#10Feedback on a Self-Management Booklet from Individuals Who Have Been Prescribed OP Medication for Low Bone Mass3. Employing and empowering the patient and caregiver perspectiveIntroduction Self-management was identified as a key component of health care for Ontarians. As a result, the Ontario Osteoporosis Strategy created a self-management booklet: My Bone Health Journal: Managing osteoporosis for a full and active life. The booklet includes sections on creating an action plan, fracture risk, bone health treatment, exercise, diet, falls reduction, and sources of support. The study purpose was to examine individuals’ experiences of the booklet and explore the influence of the booklet on their beliefs and actions regarding bone health. As well, we solicited input on the booklet to ensure clarity, approachability of layout and relevance of information presented. Method Eligible individuals were those who had been prescribed osteoporosis medication. A total of 50 telephone interviews were conducted from June 2015 to December 2016. Participants were interviewed for approximately one hour and asked to provide their feedback on the booklet and describe what they were doing with respect to the recommendations in the booklet. Conclusion We found that the booklet could be used to engage patients in discussion about bone health. As well, the booklet motivated individuals to make changes to their existing routines to achieve better health outcomes. Providing a tool like this to people recently diagnosed with a bone health issue may prove to be beneficial. The feedback elicited will be incorporated into the final version of the booklet to ensure readability and utility for this population. The next steps are to pilot this booklet in primary care settings and develop an online version.
#11Partnering with Patients to Improve After-Hours Care3. Employing and empowering the patient and caregiver perspectiveDespite providing 24-hour urgent care to its patients, the St. Michael’s Hospital Academic Family Health Team (SMHAFHT), found that only 68% of surveyed patients reported that it was easy to access care in the evening, on the weekend, or on holidays, the last time they were sick and needed care. The objectives of this quality improvement (QI) initiative were as follows: first, understand the root causes of patients reporting difficulty accessing urgent after-hours care; second, improve such care at SMHAFHT; and third, determine whether patients with different income levels, genders, ages, and health statuses are similarly able to access after-hours care. The team combined the Model for Improvement with Experience-Based Design methodology in an effort to incorporate the patient voice into this work. To understand the root of the problem, the team reviewed patient comments; tracked awareness of after-hours care; determined how many patients accessed after-hours care; and interviewed patients to better understand their experience with accessing after-hours care. This work revealed a lack of awareness of after-hours services, leading to difficulty accessing such services. To improve awareness, the team worked with patients to understand how they would like to become informed of these services; suggestions included improving our posters and handouts, and emailing patients. The team re-designed their posters and handouts with patient input, and sent an email to patients detailing how to access services when they are sick after-hours. The team also analyzed ease of accessing after-hours care by gender, income, and health status to better understand equity.
#12Healthy Lifestyle Journeys: Highlighting Patient Success Stories Through Experience Based Design3. Employing and empowering the patient and caregiver perspectiveThe Healthy Lifestyle Journeys patient experience project marries Quality Improvement and Health Promotion in a primary care setting. The Maitland Valley FHT has begun to focus on the depth of the patient experience though this initiative. The intention is to focus on the intricate details of a patient’s successes, challenges, and observations in our local healthcare system. By understanding these detailed experiences, we are able to understand the role of primary care in a rural community more clearly. While the focus of the project is to highlight the significant health behaviour changes achieved by an individual patient, it has also highlighted the benefits of an interdisciplinary care team wrapping care around the patient. It also highlights the role of community organizations such as service clubs, support groups, and healthcare partners. By illustrating these systematic experiences in a health promotion display, we are highlighting the areas of our healthcare system that work well together to help patients achieve their goals. Additionally, we more fully understand the obstacles that are encountered by the patient. This information becomes invaluable when designing meaningful Quality improvement work and allows for the patient to become directly involved in continuous improvement efforts.
#13Barriers and Facilitators in Primary Care Follow-Up Upon Hospital Discharge: Patients’ and Caregivers’ Perspectives3. Employing and empowering the patient and caregiver perspectiveThe transition period from a hospital inpatient setting to an outpatient setting is a vulnerable time for patients. To reduce this risk, a care plan needs to be arranged before the patient leaves the hospital. Part of the care plan includes booking a follow-up appointment with the patient's primary care provider (PCP) (e.g. family doctor) promptly after the patient leaves the hospital. A delay in follow-up or no follow-up at all, however, can put patients at risk of going back to the hospital and a longer hospital stay. In our experience, many patients do not follow up with their PCP in the recommended amount of time. We do not fully know why this happens. The purpose of this study was to explore patient and caregiver experiences with how easy and/or difficult it was for patients to follow-up with their Primary Care Provider (PCP) upon discharge from hospital. This study followed a qualitative descriptive research design. Semi-structured individual interviews were carried out with a total of thirteen participants (eleven patients and two caregivers) and were held on site at the Toronto Western Family Health Team (TW FHT) or over the phone. The purposive sampling technique was used to select patient participants who were: discharged home from the Family Inpatient Service unit of the TW FHT in the last thirty days; had an identified Ontario PCP at the time of discharge; Suffered from one or more of Chronic Obstructive Pulmonary Disease (COPD) exacerbations, Congestive Heart Failure (CHF), Gastrointestinal disorders (GI), Pneumonia, or Acute Myocardial Infarction (AMI); and be able to speak English, Portuguese, or Mandarin (interpretation was made available).
#14Advance Care Planning: Facilitating Conversations Between Patients and Families Before It’s Too Late3. Employing and empowering the patient and caregiver perspectiveThe detailed communicative work of Advance Care Planning is best done before the first onset of any major illness or injury; it is the self-reflective task of deciding who you would want to speak up for you if you were unable to speak for yourself. Unfortunately these discussions are too often had in the emergency department or in other settings where an individual’s cognitive ability has already begun to decline. The Bridgepoint Family Health Team is re-defining the Primary Care Setting as the ideal place for facilitating and engaging patients and their families toward having ACP discussions and to have clinical staff available that are trained to engage and follow-up with patients. With more time to focus on having these important discussions, and a higher capacity to work with patients on an ongoing basis, we believe that Family Health Teams are uniquely positioned to provide patients with the best chance of reducing some of the challenges and complications that come from major unplanned illness/injury.
#15Walk Your Way To Better Health – Enhancing the Patient Experience One Step at a Time3. Employing and empowering the patient and caregiver perspectiveThis presentation will focus on both the researched backed benefits of this form of fitness and rehabilitation as well as a hands on portion that will allow participants to apply what they have learned and actually feel within themselves how the program will be received by their patients. Every doctor and healthcare professional recommends walking as a way of staying active and managing/preventing chronic disease. Many family health teams and nurse practitioner clinics currently offer walking programs to their patients as a means of engaging them in regular physical activity as well as providing a supportive social outlet for them. By incorporating the Urban Poling, fitness and rehabilitation program, family health teams will be able to offer something new and innovative to their patients, which also offers improved benefits over walking alone. This interactive program can be conducted in combination with other programs and can be facilitated through a walk & talk program as well geared towards improved mental health. Examples will be provided through the programs that have been conducted through: 1) The Fit For Life project team at eight different community health centers 2) The Couchiching Family Health Team 3) The Walk Away Stress wellness program launched at The University Of Guelph Humber. Practical applications of the program as well as tips on how session participants can launch their own program will be covered.
#16Strengthening Partnerships: What Our Running Group Taught Us4. Strengthening partnershipsThis presentation is to showcase the success of a running group within the small First Nation community of Curve Lake. The running group started as a way for the FHT Nurse Practitioner to share her enthusiasm of physical activity with the Curve Lake community members of whom she provides primary care to. This was made possible thru the coordination and cooperation between the FHT NP-PHC and several Curve Lake First Nation employees . A partnership was formed with the Community Health Representative and the Community Aboriginal Recreation Activator and the NP-PHC. Together utilizing several different methods of advertisement, including a community newsletter invite, social media, personal invites/"prescriptions", and video footage/information regarding the benefits of exercise, a running group was formed. Using the popular "From Couch Potato to 5K" running plan, a group of novice runners successfully completed a 10 wk prep course and went onto running two separate 5K runs. 17 runners participated in a Color Run in Kingston, and 22 runners participated in a night Neon Run in Montreal. This very successful program highlights that with innovation and partnerships primary care can include motivating and supporting our clients into healthy lifestyle changes.
#17Coordinating Complex Paediatric Nutrition in the Medical Home Model4. Strengthening partnershipsChildren with complex medical conditions who receive nutrition through tube feeds require dietitian support. When children in this unique population are home-bound, dietitian services are provided through the Community Care Access Centre (CCAC) until the child becomes stable. Primary care is the most appropriate place for these stable patients to continue to access dietetic care. The Guelph Family Health Team (Guelph FHT) dietitians have collaborated with the CCAC to take on the care of stable enterally fed paediatric patients who require care, but no longer qualify for CCAC dietitian services. In this presentation, the Guelph FHT dietitians share their journey into partnering with an outside organization to pilot a sustainable program and increase scope of practice to ensure a seamless transfer from homecare into primary care. We hope that other FHTs will be able to build off of our success and continue to truly support as many patients through the primary care, medical home model.
#18Challenges in Collaborative Mental Health Care Research: Understanding Primary Care Providers’ Participation in the PARTNERs Study4. Strengthening partnershipsCollaborative care is one of the most empirically supported approaches to achieving good outcomes in primary mental health care. However, it has not been implemented in Ontario for reasons that remain poorly understood. We are conducting a mixed methods study of primary care providers’ (PCPs) perspectives on collaborative care interventions and on participation in the PARTNERs study, to better understand low referral rates and delayed uptake of specialist treatment recommendations in the study. The PARTNERs Study is a pragmatic randomized controlled trial to assess the implementation and effectiveness of an integrated care model vs. enhanced usual care for people experiencing depression, anxiety, and/or alcohol use disorders. The study aims to improve treatment initiated by the primary care provider, symptom severity, and quality of life or functioning. The intervention introduces the new role of Mental Health Coach providing telephone-based support, monitoring and evidence based recommendations. This study is guided by the Consolidated Framework for Implementation Research and the Theory of Planned Behaviour, and explores PCP opinions, preferences and behaviour related to collaborative care components (e.g. measurement-based care, population-based care, care management, and specialist decision support) and RCTs. We will concurrently conduct approximately 50 individual semi-structured telephone interviews and a grounded theory analysis until reaching informational saturation. It is important to understand PCPs’ experience of participating in collaborative care research, their perceptions of interventions, and individual or local contextual characteristics that limited participation. This understanding will be crucial to advancing the study of collaborative care, and ultimately its widespread adoption and implementation.
#19Days of Taste: A FHT-Community Partnership for Promoting Nutrition Education in a Local School4. Strengthening partnershipsThis poster presentation will describe an innovative partnership championed by the Registered Dietitian (RD) at the Jane Finch FHT to pilot a nutrition education program in a local elementary school. The Jane Finch FHT is located in a highly diverse neighbourhood, with a high proportion of immigrant and low-income families who experience significant barriers to accessing health services. The FHT encourages a culture of local outreach among its team members to: strengthen connections with community organizations, deliver health promotion beyond the walls of the primary care office, and foster relationships with hard-to-reach and underserved members of the local community. Recognizing that many of her young patients lacked an understanding of the power of food in enhancing health and preventing disease, this RD partnered with staff from the Culinary Arts Program at George Brown College to bring Days of Taste to a nearby school. Days of Taste is an interactive, discovery-based program that empowers grade five students to learn about the elements of taste and the journey of food from farm to table. The RD co-facilitated the program and integrated key elements of nutrition education through-hands on learning. This innovative method of service delivery addresses an identified gap in care while promoting the role of the FHT dietitian and providing crucial health education services to patients in their own milieu.
#20Be Well Community Collective: Healthy Kids, for a Healthier Tomorrow4. Strengthening partnershipsAs a direct result of strategic planning sessions and existing external partnerships, Georgian Bay Family Health Team collaborated with Healthy Kids Community Challenge and Simcoe Muskoka District Health Unit to develop an innovative approach to what physicians describe as a “Tsunami of unhealthy children” on the health care horizon. The Be Well Community Collective has four initiatives that are relevant to inter-professional primary care organizations. 1. Health behaviour & poverty screening tool 2. Consistent health messaging throughout the communities 3. Streamlined referral pathways 4. An innovative website Using evidence based recommendations from various health fields and leveraging the Healthy Kids Community Challenge, Be Well Community Collective is working collaboratively to embark on an initiative to improve child health in our region. Building on the LIVE 5210 initiative developed by BC Children’s Hospital (SCOPE), the Collective has developed and marketed an interactive web-based map to assist in connecting patients/community members to information, tools and resources that enable, support and enhance their health and well being. The map further highlights the role all sectors play in supporting and enhancing health. Health behaviour messaging focuses on: sleep, fruits & veggies, screen time, physical activity, parenting, mental health and finances. In addition a screening tool has been adapted for use in physicians’ offices to initiate health behaviour conversations and identify families and children struggling to attain the healthy habits guidelines and/or those affected by the SDoH. Patients are then connected to the most appropriate community resources through streamlined referral pathways.
#21A Pilot Program to Determine the Feasibility of Organizing a Walking/Healthy Lifestyle Program for Seniors in a Rural Community4. Strengthening partnershipsFamily Health Teams are encouraging patients to follow healthy lifestyles, including participating in physical activity, but many patients are faced with barriers such as distance and cost of programs. In rural areas, these barriers become even more pronounced. This pilot program determined the feasibility of offering patients the opportunity to participate in a free walking/healthy lifestyle program in a rural area. The Fit Walk was created by an interprofessional group involving the registered dietitian and a nurse practitioner. The team partnered with the Central Huron Community Center and the YMCA to provide the location and staff to assist with the program. At the time of the program, participants have access to the walking track and to the workout stations along the track. A weekly nutrition and lifestyle information discussion along with resources are given by the RD and NP to further encourage healthy living. Ten to 12 participants attend the class regularly. Participants reported having favorable health outcomes such as having more energy. Participants reported also having looked into other fitness programs on other days of the week. Setting up a no cost to the participant fitness program that includes a healthy living education component is effective in reducing barriers to healthy lifestyle choices in a rural area. While one day per week may not lead to substantial changes in one's health, it gives participants the initiative and the direction to pursue more physical activity per week and attain healthy lifestyle goals.
#22Partnerships to Promote Diet and Exercise: The CHANGE Program4. Strengthening partnershipsMetabolic syndrome (MetS) is a group of conditions (high blood pressure, high blood lipids, high blood sugars, insulin resistance, large waist size) that increases the risk of heart disease, stroke and diabetes. Diet and exercise trials have shown the potential to improve clinically relevant outcomes and lifestyle modification is being emphasized as key therapy in primary care. However, the uptake of a team based diet and exercise preventive care is limited in Canadian primary care. An efficacious diet and exercise intervention aimed at improving MetS that also involves the Family MD is needed. The CHANGE program, is an evidence based program designed by Metabolic Syndrome Canada to reverse MetS in primary care settings. Based on a feasibility study, the CHANGE program may halt the progression of metabolic syndrome to diabetes, stroke and heart attacks, hence it’s adoption in primary care has the potential to have a major impact on well-being and healthcare. By the creation of new partnerships and strengthening current ties, the CHANGE program is being expanded across several Primary Care Networks in Alberta and to the Pacific Northwest Division of Family Practice in BC. Current efforts in Ontario include the piloting of the program at 2 FHTs with others to follow. In order to deliver the CHANGE Program within the complex environment of primary care, participating FHTs have been able to develop unique partnerships and will share their experiences with the implementation of the CHANGE program within the team environment.
#23Maximizing Collaboration in an Interprofessional Outreach Team: Contributions of Implementation Science, Relational Coordination, and Interprofessional Competencies 4. Strengthening partnershipsAn inter-professional outreach team based in the KW4 sub region (Kitchener-Waterloo-Wellesley-Wilmot-Woolwich) received 400+ patient referrals over three years from healthcare providers and social service agencies. Founded through a partnership between the Centre for Family Medicine and Waterloo Wellington Community Care Access Centre (CCAC), the team includes 2 CCAC Coordinators, a physician assistant, a nurse practitioner, a chiropractor, a community outreach worker, a pharmacist and a consulting physician who work collaboratively to conduct home assessments and tailor interventions for patients according to risk level. The team uses a case management approach to support patients with complex medical conditions and social circumstances, and to help patients connect, or reconnect with health and social service resources. This includes patients who have previously felt disenfranchised from healthcare or faced barriers to accessing care. Managing complex patients, and facilitating health and social system negotiation for these patients requires ongoing collaboration within the team, between the partner organizations, and with primary care and social service providers across the sub-region. To better understand and maximize their collaboration efforts, the team has drawn on ideas from implementation science, relational coordination and inter-professional competencies to develop a conceptual model and stakeholder map. Along with an analysis of patient outcomes over three years, these tools will support future planning and help the team to prioritize within its dual roles of care and system navigation.
#24Referring Patients to Community Exercise Programs: A Cost-Effective Approach to Continuity of Care4. Strengthening partnershipsEveryone needs to exercise! Exercise is perhaps even more critical for persons with disabling conditions such as stroke, MS or arthritis to mitigate the risk of a sedentary lifestyle, functional dependence, or reduced overall health and well-being. To address the need for access to exercise, Toronto Rehab-UHN developed a cost-effective community exercise program for patients with balance and mobility limitations in collaboration with Toronto Parks, Forestry and Recreation in 2007. The result was Together in Movement and Exercise (TIME™), an evidence-based, group exercise program which has since expanded to 50 locations across Canada, with 35 locations in Ontario. Designed by physiotherapists (PTs) and delivered by certified fitness instructors, with safe and effective exercise as the priority, participants experience the health and social benefits of exercising together at their local community recreation centres. Education, training and ongoing support for the fitness instructors is provided by healthcare providers, usually PTs, who visit the program periodically to ensure program quality and integrity. The TIME™ program is easily replicated with an implementation toolkit including roles of the partners, the exercise guideline and fitness instructor training. TIME™ provides the Family Health Team (FHT) with a credible patient referral option to a community program for chronic disease management through ongoing exercise. PTs in the FHT can expand their impact on more patients by training and mentoring fitness instructors to lead classes in collaboration with community centres. For patients, TIME™ meets their need to be active, improve their health, fitness, and self-management in the community.
#25Home Based Primary Care Program; Quality Improvement in Palliative Care4. Strengthening partnershipsHome based Primary care was initiated with three goals; 1. Increase # of residents doing home visits with sustainability to do home visits in independent practice. 2. Increase involvement of the primary care physician in palliative care to ensure patient and their care givers play an active role in the shared decision making in their care especially end of life. 3. Improve access to health care for patients, frail elderly, multiple comorbidities, rural community and mental health issues. Primary Drivers/ secondary Drivers Strong RN coordinator role: enhance relationship with community supports, introduction to patients, ability to independent practice in home setting, Improved Resident participation: initial visit with staff and RN, home cased resident follow patients, feedback Improved Patient/care givers identification and communication: early identification, ease communication, introduction of team. Program Overview Patient identified for HBPC based on access, palliative, frail elderly, multiple comorbidities. RN contacts patient / family performs safety screening, sets up initial visit, compiles list of support people. Home visit done may be one off i.e. post discharge or may be ongoing. RN coordinate f/u visits and provides contact information for point of contact for families, community care givers. This has led to partnership with CCAC and joint CCP completion.
#26Switching to FIT: Strengthening Partnerships and Relationships to Improve a Population Based Screening Program in Ontario4. Strengthening partnershipsCancer Care Ontario’s ColonCancerCheck (CCC) program will be transitioning from the guaiac fecal occult blood test (gFOBT) to the fecal immunochemical test (FIT) for colorectal cancer screening of average risk individuals in Ontario. This presentation will review the joint partnerships and collaborations that are being utilized and strengthened throughout Ontario to help ensure a successful roll out of FIT amongst primary care. Following this, participants will learn about the details surrounding the implementation of FIT in Ontario and the impact this will have on their colorectal screening practices. They will be able to understand the significance of partnerships with Cancer Care Ontario, the central distribution lab for FIT, their colleagues in primary care and gastroenterology and most importantly, how this will effect relationships with their patients. This includes information on how primary care teams can leverage these partnerships and relationships to ensure FIT kits are being distributed to eligible Ontarians, that kits are being completed and returned, and that FIT positive patients are receiving appropriate follow up.
#27"Getting it Right"—A Model for a Center of Excellence in the Delivery of Hospice, Palliative Care in the Development of a 10-Bed Hospice in Stratford, Ontario 4. Strengthening partnershipsIn an effort to deliver high quality palliative care to patients facing terminal illness and end-of –life, there is opportunity for innovative supportive care delivery focusing on best practice and utilizing the skills of an interdisciplinary team/and important partners to create of center of excellence which “gets it right” in supporting patients and families. Goal # 1 The first goal of the Hospice Palliative Care Program is to provide quality, seamless care for Huron Perth County and Area patients and their families. To meet this goal the program focuses on six main components: • Patient-centred care - We work closely with the patient to meet individual needs. • Excellence in Addressing Physical, Emotional and Spiritual Suffering • Family support - The family/caregivers are an essential part of the care plan. • Advanced planning - Everyone needs to plan ahead, to reflect on choices. For example, "Where do I want to die?", "Who can speak for me if I am unable to speak for myself?" • Interdisciplinary care - A team of doctors, nurses and allied health care professionals provide comprehensive, compassionate care for palliative patients and their families. Care is based on best-practice guidelines supported by provincial and national standards. • Local community partners - To meet the Palliative Care Program goal we work closely with community-based organizations. Stratford Family Services Perth-Huron Hospice VON - Perth-Huron Palliative Care Program Woodstock VON Oxford Sakura House Residential Hospice Waterloo Hospice of Waterloo Region Listowel North Perth Community Hospice Goderich Wingham/Seaforth Huron Hospice Volunteer Service London Southwest Palliative Pain and Symptom Management Consultation Program Other South West Hospice Palliative Care Network - an alliance of community agencies, hospitals, long-term care homes, and other stakeholders who are all committed to continuously improving hospice palliative care services. Canadian Virtual Hospice - provides support and personalized information about palliative and end-of-life care to patients, family members, health care providers, researchers, and educators. By working together, the Palliative Care Team: • Aims to care for the body, mind and spirit • Provides seamless transition through the health care system • Offers a choice of settings for final days • Supports those grieving the loss of a loved one Helpful information about Hospice Palliative Care Speak Up Advance Care Planning Website Speak Up Advance Care Planning Toolkit Speak Up Advance Care Planning Workbook Canadian Hospice and Palliative Care Association (CHPCA) Canadian Virtual Hospice Goal # 2 The Centre of Excellence leads the Hospice’s teaching, learning and research initiatives, to ensure we are a leading national facility for those dealing with life-altering diagnoses. The Centre of Excellence is committed to improving the quality and accessibility of programs, services, and patient care by continually updating the standards of practice for all departments in the Hospice. We continually strive to advance both the art and the science of palliative hospice care. Working with the all Hospice staff in interdisciplinary teams, the COE ensures that academic knowledge is put into practice in our clinical settings. The Centre of Excellence is focused on four core areas of improvement: 1. Quality Management 2. Education 3. Research 4. Innovative Projects Goal # 3 STAR Family Health Team will be a teaching center in Hospice Palliative Care for the Western Ontario University. The goals and objectives for this project are that students training in nursing, medicine and ministry will: 1. Improve their knowledge of palliative care and symptom management. 2. Improve their knowledge and appreciation for the spiritual needs of patients with terminal cancer. 3. Improve their cultural sensitivity and appreciate the role of culture in influencing a patient’s experience of dying. 4. Enhance their appreciation for a team approach to patient care, especially for the terminal patient. 5. Appreciate the contribution of all health care professionals to the care of the terminal patient.
#28Partnering in the Community to Help Eliminate Opioid Overdoses4. Strengthening partnershipsThe results have been very significant and pain reduction has allowed the pharmacist to taper a lot of the opioid medications in their clientel. It has even provided a complete elimination of opioid medication and over the counter pain medication for their patients. Definite improvements can be seen with the use of the Oswestry and Roland Morris Pain questionairres as well as a visual pain analogue. The project has allowed for increased communication and dialogue between the centres to the point that one of their programs is now going to be availaable to the BNPLC.
#29Taking HealtheSteps™ to Reducing Chronic Disease Risk through Partnerships with Family Health Teams 4. Strengthening partnershipsThe HealtheSteps™ Lifestyle Prescription Program is aimed at reducing three main risk factors for chronic disease: physical activity; sedentary behaviour; and healthy eating. Participants are provided with in-person healthy lifestyle coaching, an individualized fitness score (VO2 max.), personalized lifestyle prescriptions for exercise, physical activity, and healthy eating and access to long-term support through the free HealtheSteps™ smartphone app. Through delivery of HealtheSteps™ at different community sites we have been able to create a network of HealtheSteps™ coaches, supporting organizations, and participants. An area of success and focus for delivering HealtheSteps™ has been in the primary care/family health team space as the program can be incorporated into the regular flow of a work day and patients at risk for chronic disease are more easily accessible through health care provider referrals. HealtheSteps™ has also been integrated into quality improvement plans ensuring those at risk or diagnosed with a chronic disease receive timely access to preventative/lifestyle management programs. Marathon Family Health Team (MFHT) services a community of 3,900 in Marathon, Ontario as well as neighbouring Biigtigong and Pic Mobert First Nations. MFHT became interested in HealtheSteps™ program as it targets adults at risk for chronic disease complementing their work on self-management for several domains of care and can be easily adapted to meet participant needs from a health promotion program. MFHT have been a strong partner in delivering the HealtheSteps™ program in Marathon and also delivering the program in the neighbouring community of Biigtigong First Nation at a satellite site.
#30Effective Diet and Exercise Programs in Primary Care? Lessons from The CHANGE Study4. Strengthening partnershipsMetabolic syndrome (MetS) is a cluster of risk factors related to increased insulin resistance that increases the risk of developing cardiovascular disease, stroke, diabetes and cancer. Controlled studies have shown that diet and exercise can reverse MetS and improve outcomes related to these diseases. We designed an evidence based diet and exercise program aimed at reducing the components of MetS in primary care, i.e. The Canadian Health Advanced by Nutrition and Graded Exercise, The CHANGE Program. The results of the recently published CHANGE feasibility study conducted in 3 primary care clinics will be presented. Our work confirms that structured lifestyle programs are feasible and effective in primary care. Unlike other lifestyle programs in primary care, the CHANGE program includes regular follow up by Family MD, dietitian and exercise specialist and evaluation of outcomes relevant to cardio-metabolic risk. Such programs should be available to all Canadians with metabolic syndrome from their family doctor’s offices. The CHANGE program is being expanded across several Primary Care Networks in Alberta and to the Pacific Northwest Division of Family Practice in BC. Efforts aimed at creating several partnerships to aid in the dissemination of the of the program will be reviewed.
#31Partnering with the Baby-Friendly Strategy for Ontario: A Getting Started Story4. Strengthening partnershipsThe implementation of best practices can often be a challenge for smaller organizations with their limited resources. This presentation will describe how a family health team and a small community hospital have partnered with each other and with the BFI Strategy for Ontario, to introduce Baby-Friendly best practices in their organizations. The presentation will outline the changes implemented to date and how the BFI Strategy has assisted in building capacity to ensure sustainability. Key Success factors and lessons learned will also be described.
#32Pharmacist-Led Medication Reconciliation to Improve Transition of Care from Hospital to Home5. Optimizing use of resourcesOur IDEAS project was to look at improving the transition from hospital to home with the overall aim of decreasing 30 day hospital readmissions and Emergency Department Revisits. The Northumberland Family Health Team and the Northumberland Hills Hospital worked together to develop a discharge notification process in order to improve the transition. Once this process was in place, we began testing change ideas involving the integration of medication reconciliation by a pharmacist into the 7-day post-hospital discharge process. The pharmacist was able to access the hospital's EMR records and book appointments with the patients prior to their visit with their primary care provider. We also partnered with the Central East Health Links Project Management Office to use this project as an opportunity to identify patients who would benefit from the Health Links approach. Being involved with the IDEAS Advanced Learning Program allowed us to use Quality Improvement Methodologies to facilitate change and improvement.
#33A Web Based Conference Series on COPD for Healthcare Providers in Ontario5. Optimizing use of resourcesSince its inception, PEP has engaged subject matter experts, academic, and clinical leads in the development and delivery of its training programs. In an effort to follow a rigorous, evidence-based approach to the development of its training programs and tools, PEP engaged experts in the field of educational technology, instructional design, and program evaluation. As a result, the ADDIE framework for instructional design was used to develop a web-based program on COPD. In 2014, The Lung Association partnered with the Ontario Association of Community Care Access Centers (OACCAC) and the Ontario Telemedicine Network (OTN) to develop a series of expert- led web conferences for health professionals working with individuals living with COPD. Through the use of focus groups, healthcare professionals across Ontario were invited to share their learning needs and interests as well as their opinions with regard to the training needs across the continuum of care. Core topics were identified through this process and incorporated in to the program’s development. A series of five, expert-led educational web conferences were developed with input from OACCAC, expert faculty, and members of the PEP program and committee. The five sessions included case examples and covered the core topics identified by the focus groups. To promote participation of health care providers across the province, the educational series was offered via OTN. The focus of the training program was on best practice patient care and transition management. This is known to be relevant to the reduction and prevention of avoidable Emergency Department visits and hospital re-admissions for patients with COPD. The sessions were extremely well received with a total of 548 participants and an average of 110 participants per session located across Ontario. The sessions were archived on the OTN site and have been accessed by 486 individuals to date.
#34Improving the Quality of Care for Depression and Anxiety in Ontario Family Health Teams: Incentives and Disincentives Influencing Access within the Interprofessional Context 5. Optimizing use of resourcesOver the past two decades, significant efforts have been made to improve the quality of care for patients with depression and anxiety in primary care contexts. Barriers to optimal prevention and management of depression and anxiety in Canadian primary care services may lie in the misaligned incentive systems currently in place. There has been insufficient attention directed towards the incentives and disincentives that influence care for anxiety and depression, especially for interprofessional team-based settings. The aim of our study is to develop an incentives model to help guide providers and policymakers in their efforts to improve prevention and management of patients with depression and anxiety in FHTs. This is especially important in Ontario, where a regional strategy for primary health care resources, including the availability and role of mental health workers, is being planned. We are currently in year two of a three-year study. Individual interviews are being conducted with a diverse group of FHTs across Ontario and with healthcare professionals working in these settings, which can help us understand how various financial and non-financial incentives and disincentives influence their ability to provide evidence-based collaborative care for patients with depression and anxiety. We are also recruiting other stakeholders knowledgeable about mental health funding and service delivery in FHTs. We will have approximately 100 individual interviews at completion of this project.
#35Integration of Social Workers in Primary Health Care: Findings from a Provincial Survey with Social Workers in Family Health Teams in Ontario 5. Optimizing use of resourcesSocial work can respond to a broad range of clinical needs that emerge in primary health care (PHC). Despite expansion of social work into PHC, few studies have examined the integration of social work into this expanding area of the health care system. We conducted an online survey between August and November 2015, and invited all social workers employed in the 184 Ontario FHTs to participate. The survey consisted of twenty-four questions. The range of domains included in the survey were: respondent demographics; social work role and scope of practice; access; collaboration; and, barriers and facilitators to integration of social work in FHTs. One hundred and twenty-eight (N=128) respondents completed the online survey with a response rate of 31%. There was broad geographical representation given that responses were received from social workers from each of the 14 Local Health Integration Networks located in the province of Ontario.
#36Sharing is Caring: Our Model for Dividing FHT Patients Among Diabetes Services in Barrie5. Optimizing use of resourcesThe presentation will review the programs available within Barrie for diabetes education and care. We will review dispersion of patients amongst the programs, and our Triaging Algorithm for patients newly diagnosed with type 2 diabetes will be shared.
#37Improving Telephone Traffic Control: The Transition from a Decentralized Phone Management System to a Centralized Phone Centre6. Using data to demonstrate value and improve quality of care • The St. Michael’s Academic Family Health Team (SMH AFHT) consists of six family medicine sites. Each site independently manages their incoming calls to the clinic with 2-3 full time clerical staff. • A review of phone data across the FHT and patient satisfaction surveys shows that patients are left on-hold for long periods of time. • Consultations with the clerical managing the phones brought to light the inconsistent approaches to managing the access needs of patients. • In this poster presentation the authors will detail the process of transitioning the SMH AFHT from a decentralized phone management system to a centralized phone centre using a quality improvement approach. • We anticipate that centralizing phone calls within the SMH AFHT will improve the triage of phone calls, improve patient satisfaction, reduce wait times on hold and promote efficient use of human resources.
#38Using Screening Activity Report (SAR) Data to Increase Cancer Screening Rates6. Using data to demonstrate value and improve quality of careAt South East Toronto Family Health Team (SETFHT), we had noticed that those physicians who reviewed their SAR reports regularly, had higher cancer screening rates than the FHT average (14% more than the FHT mean of 74% for cervical screening rates, and 10% higher than the FHT mean of 70% for colorectal screening rates). Since all 23 doctors at SETFHT had access to SAR cancer screening data, which is currently more accurate than our EMR data, we wanted to find a way to use this data to increase cancer screening rates. By assigning the Quality Improvement- Information Management Coordinator to be the SAR delegate, the delegate could have access to the doctor’s individual SAR reports and provide this data to the physicians. Every 6 months, each physician will be provided their monthly screening rates compared to the FHT median and the data of the highest and lowest performer (with no identifiers), in hopes that this will increase the likelihood of the doctor’s reviewing their SAR reports. Physicians will also be asked before and after about their frequency of using the SAR reports.
#39Taking Stock: Cleaning One of Ontario's Largest Primary Care Databases6. Using data to demonstrate value and improve quality of careThe Barrie and Community Family Health Team (BCFHT) is one of the largest FHTs in Ontario. The BCFHT is partnered with a single FHO, representing 84 physicians, with a single Board of Directors in Barrie. This unification with a single FHT and single FHO under a single EMR provides the BCFHT with one of the largest primary care databases in the Province: with 137,043 rostered patients and 24,361 fee-for-service patients. With the establishment of a Quality Improvement Team at the BCFHT and the setting up of a sandbox EMR environment, the BCFHT now has the tools to evaluate the quality of its entire database and improve clinical information for patients, providers and researchers. At the initial stage of the project it was identified amongst participating physicians that the average error rate between Ministry of Health roster lists and those in our EMR was 25%, with some practices having over a 75% error rate. The BCFHT is not only conducted ex-post cleanups of its data; it established guidelines and tools to ensure accurate input of information moving forward. This data quality improvement initiative is lead by a multi-discipline team with the focus of improving baseline data quality for all physician practices that participate. This project has not only improved performance measurement, but has helped us better identified practices and patients that can benefit from enhanced quality improvement resources. In addition, as BCFHT is move to become a leader in primary care research, this has helped ensure accurate results.
#40Improving Patient Outcome One FHT Pharmacist at a Time6. Using data to demonstrate value and improve quality of carePharmaceutical care is a professional model of pharmacy practice that provides medication management services to patients. It involves the identification and resolution of drug therapy problems (DTPs), with the goal of optimizing pharmacotherapy and improving patient outcome. Using this model, we characterized pharmacist services within our family health team, and provided a benchmark of the clinical outcome of pharmacist interventions. Data over a two-year time period was collected using an electronic online portal (maintained by FHT Stats: with a pre-set form adapted from the pharmaceutical care practice model. Information collected included the disease conditions that the pharmacist was consulted on, the category of DTPs identified, the interventions taken by the pharmacist to address the DTPs, and the patient outcome at follow-up. The outcome status at follow-up was assessed according to the definitions of the pharmaceutical care model to be “resolved”, “stable”, “improved”, “partially improved”, “unimproved”, “worsened”, “failure”, or “expired”. (Further details may be found in the publication: Lui E, Ha R, Truong C. Applying the pharmaceutical care model to assess pharmacist services in a primary care setting. Canadian Pharmacists Journal 2017; 150(2): 90-93 ( )
#41Measuring Collaboration: Performance Indicators for Interprofessional Primary Care Teams6. Using data to demonstrate value and improve quality of careDespite the focus on interprofessional primary care (IPC) models little is known about performance indicators that contribute to collaboration in IPC teams. One challenge is determining how to measure the value of interprofessional collaboration. A qualitative study was completed to examine performance measurement in IPC teams. This study was conducted at a pre-conference workshop for IHPs at the Association of Family Health Teams of Ontario Annual Meeting in 2016. Our presentation will describe the results from these focus groups with the aim of engaging important stakeholders in the discussion of how to meaningfully measure IPC. Our findings demonstrated that participants identified practices supporting interprofessional collaboration however had more difficulty identifying performance indicators to measure the impact of collaboration on the team or population. Findings reflect the ongoing challenge of determining performance indicators that capture IPC.
#42An EMR Advance Care Planning (ACP) Tool for Talking with Patients About End of Life6. Using data to demonstrate value and improve quality of careA palliative care physician in our community noted that many patients he came in contact with had not had a conversation around ACP. As these conversations most appropriately begin at the primary care level, he wanted to offer support to primary care providers in starting the conversation. The palliative care physician, QIDSS and a clinical nurse educator in cancer care from our local hospital collaborated to design an EMR tool to help facilitate these conversations. The tool was developed for 2 EMRs (TELUS PS Suite and Accuro) and utilizes various resource materials created by Speak Up Ontario. The tool was designed as a means to get started and as such it’s intentionally short and simple. The tool is structured to take place in 3 parts: part 1 as an addition to an existing patient visit, part 2 as a scheduled visit specific to ACP and part 3 as an addition to a subsequent visit that the patient is already having with their primary care provider. The tool was deployed to all EMRs and presented by the palliative care physician and clinical nurse educator at each of our FHO meetings. The tool was also presented at our annual FHT continuing medical education day. ACP is important and everyone should have conversations about their wishes. These conversations become even more important when someone has a serious illness or chronic condition. Research has shown that if patients engage in ACP they are more likely to have their end of life wishes known and followed, family members will have less stress and anxiety because they know their loved one’s wishes, patients and families are more satisfied with care and patients have a better quality of life and death.
#43Reconnecting Health Link Patients from Hospital to Primary Care6. Using data to demonstrate value and improve quality of careWithin the Central West Health Links, there was an inconsistent exchange of information and follow up support for existing Health Link patients as they transitioned from one care provider to another. Specifically, in the Dufferin Area Health Link this problem was evident in the transition from hospital to PCP. Our aim was to have a 20% increase in the number of existing Dufferin Area Family Health Team (DAFHT) Health Link patients that were reconnecting in-person with DAFHT within seven calendar days of discharge from Headwaters Health Care Centre (HHCC). To date we have tested the following change ideas: 1. Use of HHCC brochure inserts and CCAC hospital Care Coordinators to educate and remind patients of the importance of reconnect and DAFHT communication reminding PCPs to reconnect with patients. 2. DAFHT Patient Services Coordinator calling patients post discharge to do an assessment and book reconnect appointments if patients have not done so already. 3. PCPs being reminded that they can use E080 billing code for post discharge follow up appointments within 14 days.
#44Translating Knowledge into Action: Integrating Best Practices for CHF and COPD Management into EMR Decision Support Tools for Primary Care Providers6. Using data to demonstrate value and improve quality of careAdoption of best practice guidelines in primary care is often suboptimal. Advancements in health technology allow for integration of evidence-based guidelines at the point of care through decision support tools in physicians’ Electronic Medical Records (EMRs). Complex and multidimensional decision support tools, which capture patient-specific information such as medical history, physical examination and laboratory data, have been shown to be promising in supporting primary care providers’ decisions surrounding patient diagnosis, prognosis and treatment. Since January 2016, the eHealth Centre of Excellence (eCE) in Waterloo, Ontario has been leading a project called QBIC (Quality Based Improvements in Care) to enhance quality of care through EMR decision support tools that facilitate best practices in chronic disease prevention and management (CDPM). The eCE partners with other organizations that lead research on relevant best practices, to ensure that EMR decision support tools apply the best available evidence for CDPM. Physician engagement guides the tool development process to establish support and ensure the tools meet physician needs. The Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) EMR tools are such examples. This presentation focuses on the CHF and COPD decision support tools for primary care providers and presents early findings on benefits.
#45Pregnancy Risks and Women’s Future Cardiovascular Health: A Missed Primary Care Opportunity?6. Using data to demonstrate value and improve quality of careCardiovascular disease (CVD) is the leading cause of death of Canadian women. The development of common pregnancy complications (gestational diabetes, obesity, excessive gestational weight gain, hypertensive disorders of pregnancy, intrauterine growth restriction and idiopathic preterm labor) are harbingers of women and their children’s risks of premature CVD and type 2 diabetes. These complications impact up to 20% of women in Ontario, Canada2. • A prospective cross sectional patient-recall validated survey was sent to 2102 female patients (18 to 50 years) of the Sunnybrook Academic Family Health Team. • The survey asks questions about socio-demographics, self-rated health, recent pregnancy obstetrical care provider, cardio-vascular risk factors and pregnancy history. This data will be presented • Similar data from patient electronic medical records was extracted and will also be presented Future directions to improve capturing and documenting this information will be discussed
#46Moving Beyond Performance to Supporting Primary Care Improvement Efforts through Vascular Health Quality Improvement Toolkits6. Using data to demonstrate value and improve quality of careAcross Ontario there are variable high rates of vascular diseases and variation in the prevention and management of those diseases. These challenges are associated with the lack of integrated evidence-based resources at point-of-care. For example, few vascular health quality improvement (QI) templates exist to support primary care (PC) teams to implement QI activity. There is a lack of simple and standard vascular health QI resources that augment current QI activity for screening, identification, management, and/or monitoring of patients. The Ontario Vascular Health Primary Care Work Group (PCWG) oversees development of practical patient-centred resources to enhance implementation of best practices. Vascular Health QI Toolkits are designed to support small PC QI activities or larger program implementation. The PCWG has developed foundational vascular health QI elements within a QI toolkit design. The Toolkits have been framed around patient engagement and include key features such as QI elements for contextualization to practices, teams, and patients. Web-based QI Toolkits for hypertension, tobacco use, abdominal aortic aneurysm, and chronic kidney disease have been developed so far. It is anticipated that simple QI initiatives can lead to effective and meaningful changes in practice management such as identification of high risk patients without record of blood pressure measurement or smoking status to target efforts. A survey (n=3) and focus group interviews (n=6) were conducted to understand the feasibility, usefulness, and implementation ability of the Toolkit. PC team respondents commented on the usefulness and relevance of the Toolkits emphasizing the importance of moving from performance measurement to improvement.
#47Channeling Positive Deviance: A New Approach for Improving Timely Access for Patients in Primary Care 6. Using data to demonstrate value and improve quality of careFor the last five years, our multi-site academic FHT has been measuring and trying to improve timely access to care for patients. We have had some improvements but as of last year, many patients still reported long waits to see a physician and the Third Next Available appointment for physicians ranged from 0 to 39. In this interactive workshop, we will share our recent efforts at improving timely access in our FHT using “positive deviance” – an approach used in other health care sectors to tackle complex systems issues. We will discuss our methods, findings, and reflections using positive deviance to improve access. We interviewed a few physicians with consistently timely access, as measured by TNA, to understand their attitudes and practice patterns. We identified common themes in their responses and then surveyed all physicians to see if these themes consistently correlated with timely access. Our findings have informed our understanding of local best practices that we intend to share widely among the FHT to improve timely access. During the workshop we will share our data and ask for the audience’s help in interpretation and advice on next steps. Positive deviance is a promising approach to addressing seemingly intractable health care problems. Attendees will learn how they can apply positive deviance to their own setting and health system challenge. We will simultaneously reflect on the challenges unique to improving timely access in primary care.
#48“One-Stop Shop” Charting Approach to Interdisciplinary Diabetes Management Using Standardized Template Embedded with Advanced Features 6. Using data to demonstrate value and improve quality of careors, allied health professionals and medical specialists. To address the gaps identified from a needs assessment initiated and conducted by the inter-disciplinary clinician group, in-house Information Technology specialist and Quality Improvement Decision Support Specialist (QIDSS), two Plan-Do-Study-Act (PDSA) cycles were implemented to improve the clinic workflow and optimize the utilization of EMR data in performance measurement. Methods: The use of multiple charting templates (i.e. text-based note, custom form and encounter assistant) in Telus Practice Solution Suite (PSS) by different disciplines (i.e. physicians, nurses, dietitians, social workers and pharmacists) in the Diabetes Education Program has significantly reduced the efficiency, effectiveness and data quality in outcome measurement. A universal PSS customized charting template (i.e. custom form) is designed to guide clinical workflow in diabetes consultation, facilitate transfer of clinical data among the clinician group, and capture outcome data to support performance measurement and quality improvement. Results: A universal standardized custom form embedded with commonly used features (including adding diagnostic code, generating lab requisition form, inserting neuropathy screening instrument, performing psychological symptom screening, conducting ODB formulary search, submitting OHIP billing, prescribing pneumococcal vaccine, completing trillium drug benefits and assistive device program application, and printing patient education handout) is developed and adopted by all clinicians in April 2017. Implication: This newly developed “One-Stop Shop” custom form enables integrated diabetes care and seamless communication among the inter-disciplinary clinician group. Analysis using data extracted from this custom form is aligned with provincial outcome indicators highlighted in the FHT annual operating plan (AOP), primary care indicators recommended in the Quality Improvement Plan (QIP) and Diabetes composite indicators included in the AFHTO D2D project. A complete package of this “One-Stop Shop” custom form has been uploaded to the Telus Community Portal and disseminated with the QIDSS network in May 2017.
#49Power in Numbers: Unlocking the Potential of the Diagnostic Data in Your EMR6. Using data to demonstrate value and improve quality of care The Bridgepoint Family Health team strives to achieve health impact at the population level by examining our practice though a holistic and chronic disease perspective. Our EMR (Practice Solutions) has the potential to allow for quite a robust and ground breaking analysis of medical complexity in the Primary Care setting; however, this is largely dependent on the availability of reliable, high quality data inputted by clinicians. By taking steps to improve the quality of EMR data we have access to, including standardizing processes for coding medical diagnoses, we will be in a better position to support more accurate and meaningful quality improvement projects.
#50Examining Growth Monitoring Practices for Children in Primary Care Practices 6. Using data to demonstrate value and improve quality of careBackground: Growth monitoring of infants and children is the basis for assessing healthy growth and development. Surveillance of children’s growth measures, specifically age and sex standardized body mass index, has been proposed as a preventive public health strategy for childhood obesity. However, adherence to recommended growth monitoring protocols is unknown. Objective: To assess whether primary care practices are using accurate measurement practices for height/length and weight in children. Methods: A descriptive study of current measurement practices in pediatric and family physician primary care practices in Ontario was conducted from December 2016 to February 2017. A detailed electronic survey was sent to members of the Association of Family Health Teams of Ontario and the Ontario Medical Association Pediatrics Group. Questions focused on three main areas: growth monitoring equipment and techniques, adherence to growth monitoring guidelines, and use of growth charts in electronic medical records (EMR). Descriptive statistics were performed and chi-squared or Fisher’s exact test was used to determine any statistically significant differences among practice type.
#51A Data-Driven Decision: Culturally-Specific Mini Health Link Among the Carefirst Family 6. Using data to demonstrate value and improve quality of care“Timely care coordination for patients with multiple chronic complex medical conditions” is identified as one of the strategic directions of Carefirst Family Health Team (FHT). The inter-disciplinary team at Carefirst FHT has collaborated with Carefirst Seniors and Community Services Association (SCSA) to identify patients who were concurrently receiving care from different departments of the Carefirst Family (including FHT, Assisted Living or Supportive Housing Service, Adult Day Program and Specialist Clinic). Data extracted from multiple health information systems have served as a powerful resource to empower the design, implementation and outcome evaluation process of this coordinated CDM model. Combining the utilization of in-house EMR data (captured from customized charting templates) and centrally stored coordinated care plans in Client Health Related Information System/Health Partner Gateway (implemented by the CE LHIN), the effectiveness and efficiency of care coordination have significantly improved. Positive feedback received from clinicians (Carefirst FHT) and client service coordinators (Carefirst SCSA) acted as a driving force to expand the scope of this coordinated CDM model to include patients living with diabetes, hypertension and congestive heart failure. This model encompasses primary care interventions delivered by clinicians of Carefirst FHT, personal support and home-making services provided by Carefirst SCSA, adult day programs operated by Carefirst SCSA and medical specialist care offered by geriatrician, cardiologist, nephrologist and endocrinologist affiliated with Carefirst FHT. Carefirst is committed to provide quality wrap-around home and community care to residents within the Central East Local Health Integration Network (LHIN) and Central LHIN through its care coordination hub located at Carefirst One-Stop Multi-Services Centre. *Semi-annual evaluation supported by in-depth data analysis pending in July 2017.
#52Determining Prevalence of Malnutrition in North York Family Health Team Geriatric Population at High Risk7. Clinical innovations for specific populationsThe 2008/2009 Canadian Community Health Survey—Healthy Aging results determined that the estimated prevalence of geriatric malnutrition to be 34% amongst community-dwelling citizens 65 and older. The Nutrition Care in Canadian Hospitals study found that 45% of seniors admitted to Canadian hospitals are malnourished, stay 2-7 days longer in hospital and cost the health system 60% more than well-nourished seniors. As an interdisciplinary quality improvement effort utilizing FHT RN’s and RD’s in a collaborative approach, the NYFHT RD’s have targeted the 75+ population for malnutrition risk screening, assessment and therapeutic nutritional interventions. To identify this population, the FHT RD’s have imbedded the Canadian Nutrition Screening Tool (CNST) as a component of routine office visits for this population. Upon a positive CNST score, RN’s refer patients to the RD for further assessment using Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREENII) tool, medical nutrition therapy, ongoing RD follow up and referrals to other FHT and community-based services as needed. This poster presentation will review the systems and processes put in place to identify, screen, treat and follow this nutritionally at-risk population and highlight any additional allied health or community resources that are incorporated into the patients care plan. We will also share findings around the effectiveness and sustainability of the referral process, outcomes from RD interventions and improved patient outcomes using SCREENII and patient weight gain/stabilization. In the end, we will identify and treat geriatric malnutrition and improve overall nutritional health using an interdisciplinary approach.
#53Introduction of a Multidisciplinary Program to Deprescribe Sedative Hypnotics (SH) in Patients >65 Years of Age in a Large Multi-Site Family Health Team (FHT). 7. Clinical innovations for specific populationsLarge scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. A multidisciplinary program to deprescribe SH among older adults was created in our FHT. Patients were referred to either a pharmacist, the Cognitive Behavioural Therapy-Insomnia (CBT-I) program (or an individual social worker (SW) to do CBT-I) or both. Pharmacists provided initial assessments, recommendations and follow up. The CBT-I program ran over 7 weeks (on average about 1-2 hours/week), and was led by a SW, with a 1 hour presentation each from the pharmacist and dietician. The pharmacists evaluated pre and post SH use. The CBT-I program evaluated pre and post measures for depression (PHQ-9 scores), anxiety (GAD-7 scores), and sleep quality (ISI scores). Preliminary data was assessed over 12 months.
#54How Equine Facilitated Wellness Enhances Mental Health Social Work Programs7. Clinical innovations for specific populationsEquine facilitated wellness (EFW) in conjunction with the clinical counselling model of mental health care starts when patients are referred by their physician either directly to the EFW aspect of the social work program, or afterwards by the social workers (2). Usually the patient presents with mood disorders, often anxiety with poor somatic awareness and areas of depression, grief, boundaries, childhood neglect/ sexual abuse. The trauma focus is benefited by the equine engagement in the areas of attachment, self-esteem and self soothing strategies. EFW provides results due to the experiential process and the immediate support provided. Clinical engagement time is often reduced. Collaboration between physician, social workers, and patient, with the potential to reduce emergency room visits. Because of the experiential nature of the work, patients express a sense of reconnection to self and others which in turn can assist with the healing process for mental health. Integration often follows as patients focus more on the present physiological symptoms of their issue. This work is enhanced by the dual awareness and mindfulness approach found in the “bottom up” process and engagement with the horse. Motivation is sparked and enhanced with the opportunity to leave the office setting and draw from the free medicine of nature. The client expresses a sense of autonomy immediately and their collaboration within their own mental health process is evident. This opportunity is usually only available in private practice therefore excluding large segments of the community without financial means.
#55Preventing Chronic Disease in a Vulnerable Population - Implementation of a Community Kitchen with an Emphasis on Chronic Disease Prevention for Bengali Newcomers in Regent Park Community7. Clinical innovations for specific populationsAs a public health strategy, community kitchens (CK) have been implemented to prevent food insecurity through reducing social isolation, improving food and cooking skills and empowering participants. Demographic statistics in City of Toronto (2011) indicate the highest number of immigrants residing in Regent Park are from Bangladesh. The Christian Resource Centre (CRC) provides several cost-free food/cooking programs for the Bengali community, but none have a Registered Dietitian (RD) facilitating to provide nutrition expertise. This gap provided an opportunity for the St. Michael’s Hospital Academic Family Health Team (SMH FHT) and CRC to collaborate to allow RDs to facilitate a CK once a month. The aim of the pilot program was to assess whether RD-facilitated community kitchen can improve the social and nutritional health of participants and their families. Using SMH FHT’s electronic medical record, Bengali patients at our Sumac Creek practice site with diabetes (DM) and or cardiovascular (CVD) risk factors were identified. Patients who met inclusion criteria of > 18 years old, Bengali ethnicity and one or more CVD or DM risk factors were called to assess interest in participating in a pilot CK at CRC. 10 patients provided consent to participate in the CK with focus on cooking traditional Bengali recipes. RDs used healthy substitutes to improve the nutritional content of the recipes and provided a formal presentation focusing on nutrition strategies to manage chronic disease. An 11-question survey, using the stage of change (SOC) construct was disseminated to measure dietary behaviour change and satisfaction.
#56Breathe Easy: An Interdisciplinary Approach to COPD Care in Vulnerable Populations 7. Clinical innovations for specific populationsChronic Obstructive Pulmonary Disease (COPD) is the 4th leading cause of death worldwide (1). COPD Is considered to be a leading cause of morbidity, mortality, and decreased quality of life among Canadians nationwide (2). In Ontario, COPD prevalence increased 65% from 1996-2007 (3). Prevalence rates are thought to be highly underestimated (2). COPD has the highest rates of hospital admissions and re-admissions among chronic diseases in Canada (4). The Primary Care setting can off-set the burden of COPD in Ontario and nationwide. COPD management is optimized through patient education, health promotion, prevention, and early treatment of exacerbations. Our team examined and identified common gaps and barriers to COPD care. Among the vulnerable populations that we serve, we identified health literacy, co-morbidities, malnutrition, poly-pharmacy and multiple medications, low income, poor housing, and smoking as barriers to care. Due to the complexity of the disease and multiple factors affecting its management, we decided to employ a team-based approach to COPD care within our Family Health Team (FHT). Our inter-disciplinary team utilizes multiple providers including, but not limited to, physicians, registered nurses, a pharmacist, dietician, and social workers. Our goal is to provide comprehensive health visits to all of our patients with COPD. These visits provide patient education, medication reconciliation, treatment optimization, smoking cessation counseling (including free access to nicotine replacement therapy), and nutritional interventions. By employing this approach, we have enhanced patient self-management and empowerment, improved patient outcomes, prevented unnecessary emergency room visits, and increased vaccination rates. (References available in separate document and upon request)
#57Enhancing Preventative Care Visit through a Shared-Care Model7. Clinical innovations for specific populationsten delivered in variance due to providers ‘time and the lack of involvement from other interdisciplinary healthcare professionals. In the team-based preventive care model, nurses play a primary role in performing preventive screening, counselling and also making the appropriate referrals to other interdisciplinary healthcare professionals. The team also developed a standardized documentation template specific to health screening performed by nursing. This is to promote consistency in the health screening, documentation and enhance team communication. The implementation of a shared-care model in adult preventive care is showing to increase health promotion opportunities, capture missed screenings, and connect patients to the appropriate healthcare professionals.
#58An Innovative Smoking Cessation Program for Cancer Survivors Within the Primary Care Setting7. Clinical innovations for specific populationsIn collaboration with North York General Hospital (NYGH), the North York Family Health Team provides a unique Colorectal Cancer Survivorship program within a primary care setting. This Nurse Practitioner-led clinic works collaboratively with other healthcare providers to meet cancer survivors’ needs. In the past year, we provided a smoking cessation program in conjunction of our pharmacy team. The current research demonstrates a high smoking prevalence (23%) and high relapse rate among cancer survivors (Karam-Hage, 2014); therefore, we endeavored to determine how this population differs from the general smoking population. The literature reveals that cancer survivors face unique psychosocial factors, such as pain, reduced physical functioning, anxiety, depression, stress, distress and stigma. In addition, smokers have a higher prevalence of comorbid mental health disorders and alcohol or substance use (Karam-Hage, 2014; Westmass, 2014). Smoking cessation interventions tailored to the unique struggles that cancer survivors face are likely to help them succeed in quitting (Westmass, 2014). At this point, our smoking cessation program is tailored to the general smoking population, however, our program does include standardized screening and incorporates smoking cessation best practice guidelines for cancer survivors. Currently, our program does not incorporate the psychosocial needs of this population. We are in the process of expanding our services to include social work involvement and access to additional community resources (e.g. Registered Dieticians, Smoker’s Helpline, Centre for Addiction and Mental Health Nicotine Dependence Clinic) to best meet the needs of our unique population.
#59Caring for Vulnerable Patients Leaving Hospital – Transition to Home7. Clinical innovations for specific populationsFollowing patients that are admitted and discharged from hospital is difficult. Despite the connection between the St. Michael’s Hospital Academic Family Health Team (FHT) and St. Michael’s Hospital, our FHT still faced challenges with respect to being notified when patients were admitted and discharged, following up with those patients to ensure that they are receiving high-quality follow-up care, and tracking outcomes efficiently. To alleviate these concerns, the Transition to Home program was implemented. Each day, St. Michael’s Hospital sends a list of FHT patients who have been admitted or discharged to FHT staff. Each list is imported into a database which streamlines workflow so that administrative duties and minimized and it is less likely for patients to fall through the cracks. Patients are contacted during those first vulnerable days – both as a valued check-in, and to book them for timely follow-up with the appropriate provider. In order to track results, each chart is audited one month after discharge to determine when the patient was contacted by a clinician, and by what method (eg. in person, home visit, phone, email, etc.). With this mechanism in place, providers are given an effective model that can be used in daily practice, and that minimizes their administrative duties. Moreover, this has also sparked collaboration with General Internal Medicine (GIM), whereby they now book follow-up appointments before the patient leaves hospital. Finally, it also provides a platform we have been using to streamline care for patients who are particularly vulnerable, such as those with COPD.
#60Addressing Social Determinants of Health in a Culturally Sensitive Manner for Karen Refugees in Primary Care- A Nurse Practitioner (NP) Practice Model 7. Clinical innovations for specific populationsThe NP role is centered on the principals of accessibility and health promotion. We are ideally positioned to observe the patient’s health as the product of their socioeconomic environment in addition to culture, lifestyle, and physiologic factors. Our capacity to schedule longer appointments allows adequate time for addressing acute health concerns as well as health promotion, disease prevention and chronic disease management. Understanding the patient’s perception of balance between health and illness has been facilitated by access to a cultural interpreter. With his support, time is dedicated to recognize their past experience which then allows the delivery of services in a manner that is relevant to their needs and expectations. By employing practice panel management principles and EMR recall capabilities continuity of care is facilitated. Recognizing patients’ needs for help navigating the system and taking the time to assist them has been paramount to ensuring adequate provision of care throughout their lives in Canada. Some patients due to complex psychosocial and medical conditions will require ongoing additional support beyond the first years of resettlement. The NP practice model in primary care is an opportunity for the MOHLTC to further support NPs. Addressing the social determinants of health in a culturally sensitive manner for our refugee population is an example of how NPs provide care in Ontario.
#61Collaborative Care for Serious Mental Illness7. Clinical innovations for specific populationsAccess to mental health care, particularly for individuals with more severe mental illness, is often problematic both in Ontario and generally in Canada. Psychiatrists prefer to provide consultative care rather than ongoing care, necessitating patients to receive their care from their primary care provider (PCP). While a variety of programs exist, they are not integrated or coordinated with PCPs. Patient care may suffer as a result. To deal with this problem of access and ongoing care for patients with more severe mental illness, our team integrated this program into the FHT. Which manage the patient’s psychiatric, medical and social needs, while providing access to established programs and health care providers within the FHT. The case manager additional coordinates care with outside agencies and consulting psychiatrists as needed. PCPs and a part-time psychiatrist are consulted and available for advice as needed. The case manager maintains a patient population of approximately 175 patients.
#62Income Rx: A Novel Income Security Health Promotion Service at St. Michael’s Hospital Academic Family Health Team 7. Clinical innovations for specific populationsAn innovative and timely project, Income Security Health Promotion Service attempts to engage and stabilize people’s financial wellness in order to positively impact their overall health. Through an engaging panel discussion with two income security health promoters, and a nurse practitioner, we will discuss income security as a medical risk factor. During this discussion, we will explore ways to screen and intervene in poverty. We will also discuss how income security fits within the broader context of intervening on the social determinants of health. By examining how poverty intervention works within a primary care setting, participants will engage in new ways of thinking about possible risk factors related to income and their patients’ health; as well as providing new tools for screening and intervention. You will hear from our income security health promoters on how they engage with patients, the various interventions, and modalities, used as well as how to engage health providers in conversations around poverty, and their role in effecting change on a micro-, meso- and macro- level. By the end of this presentations participants will be better versed in poverty, poverty related illness and practical ways they can engage and make real change in their patients’ financial health.
#63OPTIMUM: Optimizing Outcomes of Treatment-Resistant Depression in Older Adults7. Clinical innovations for specific populationsStatement of Purpose: Treatment-resistant depression (TRD) is a major health problem for the aging population: in most older adults, depression fails to remit with first-line antidepressant pharmacotherapy. Older adults with persistent depression experience significant medical consequences, place high burdens on caregivers, and suffer high suicide rates. Making it worse is the paucity of evidence-based treatments at a stage in life when medications benefit vs. risk ratio is crucial. OPTIMUM is a five city (4 US and 1 Canadian) large study that will use both quantitative and qualitative methods. It includes a pragmatic, adaptive randomized controlled trial (RCT) to evaluate the comparative benefits and risks of antidepressant strategies (augmentation versus switching medications) and how aging changes this balance of benefits and risks. Methods: OPTIMUM will randomize 1500 older adults aged 60+ to 10 weeks of one of three treatment strategies: aripiprazole augmentation, bupropion augmentation, or switch to bupropion. Participants who complete acute treatment will be followed for one year. This pragmatic RCT will be carried out in real-world primary care clinical settings and psychiatric clinics in Ontario. Primary care providers will provide treatments, with decision support from the study team. Stakeholder engagement including patients and professionals or family caregivers will ensure the study methods and results are relevant to both patients and providers. Results: We will report on the challenges and results of operationalizing OPTIMUM with respect to REB and Health Canada approval, physician and patient recruitment strategies, partnerships and progress to date. Conclusions: Operationalizing pragmatic studies in primary care require attention to a variety of barriers and enablers which will be discussed during the presentation.
#64Prescribing Books for Kids: A Two-Year Review 7. Clinical innovations for specific populationsThis is good evidence regarding relatively high rates of low literacy across Canada. Low literacy is associated with higher rates of unemployment and directly and indirectly to poorer health. In an effort to ameliorate this, Reach Out and Read was introduced by pediatricians into the United States 25 years ago and has good support from the literature regarding efficacy. This is an early literacy program, delivered to children ages 0 to 5 years at well-baby visits by family physicians and pediatricians. This workshop will review the 2 year data from a large inner city FHT regarding success and challenges with program introduction, implementation, logistics, partnership formation, and fundraising. Preliminary data will include the income of the population served, the number of visits, parental reading behaviour and literacy resource connections. The presentation will include contacts for partnerships, EMR templates, and resource materials to include.
#65Treating Opioid Use Disorder in Primary Care7. Clinical innovations for specific populationsOpioid Treatment programs are relatively inaccessible to many individuals who are facing the challenges of Opioid dependence. By bringing Opioid treatment programs to primary care, more patients can access the care they need, in a familiar place. The Thames Valley FHT Opioid Program assist patients with both chronic disease and/or addictions through the Suboxone program. The programs collaborates with the patients’ community pharmacy to ensure optimal success both in clinic and at home. The team mainly consists a physician and registered nurse, however the program can be successfully implement with an NP.
#66Frailty Five Checklist for Family Practice: Enhancing Care and Teaching in the Home or Office7. Clinical innovations for specific populationsCaring for frail elderly is often complex and can be overwhelming for learners and even seasoned practitioners. Checklists have been shown in other areas of medicine to improve care. The Frailty Five Checklist for Family Practice identifies five domains of care to be addressed in a home visit with a frail senior. The five domains are: Falls and Function (falls, mobility, ADLs) Feelings (mood, cognition, pain) [F]armacy (medication review) Flow (bladder/bowel) Future (goals of care, advance directives, substitute decision maker/POA) Applying this cheeky checklist can assist primary care providers in providing comprehensive care and identifying opportunities for interdisciplinary collaboration in the home. The checklist will act as a reminder for clinicians to initiate discussions around goals of care and advance directives in care of the frail patient.
#67Treponema Be Gone: An Interprofessional Approach to Increasing Serologic Testing After Syphilis Treatment7. Clinical innovations for specific populationsThe St. Michael’s Family Health Team (FHT) is an inner-city multi-site practice in Toronto, ON, comprised of over 40,000 patients, many of which who are under-housed and poor, and who live with multiple medical and psychiatric co-morbidities. The FHT also sees a high prevalence of syphilis infections among Men Who Have Sex with Men (MSM), including MSM who are living with HIV. Toronto Public Health guidelines recommend several calendared post-syphilis treatment screens, as follow-up serological testing is an important health care practice that reduces the burden of active syphilis disease in the community. We conducted multiple PDSA cycles to improve follow-up serological testing for patients treated for syphilis. Our aim was to increase the rate of follow-up syphilis testing three months post treatment by 10% within a one year timeframe (September 2016 – September 2017). We began by conducting a chart audit to understand our baseline rates of follow-up testing after syphilis treatment. We then collaborated with a Toronto Public Health nurse to implement a formalized tracking system, which allowed for the introduction of reminder calls to patients due for follow-up testing. We then conducted a more in-depth chart review to identify common causes for lack of follow-up serological testing. The results of the thematic analysis allowed for further opportunities for change to target underlying contributors for failure to perform follow-up testing. Our success illustrates the potential for applying QI methods to vulnerable populations.
#68Cancer Screening in Trans and Gender Non Binary Persons – Patient and Provider Perspectives on Barriers to Screening and Strategies for Quality Improvement7. Clinical innovations for specific populationsCancer screening rates are significantly lower for trans and gender non binary (GNB) persons. Research suggests that reasons for this phenomenon are multiple and nuanced. In this quality improvement project, we quantified screening rates for trans/GNB patients in our practice and discovered that disparities in screening rates persisted for cervical, colon, and breast cancer, with the cervical screening disparity remaining when other variables were adjusted for. In order to better understand why this disparity exists, we reviewed current literature to determine strategies for improving cervical cancer screening rates in trans/GNB populations. We then interviewed both patients and providers in our clinic to understand how we might best apply this information to our practice setting. Our qualitative data is presented with accompanying reflection about how providers might more effectively approach cervical cancer screening for trans/GNB patients. Our results emphasize the patient perspective and include a summary of anonymized patient stories and suggestions. Given that the risks and benefits of screening may be very different for trans/GNB persons than for cis-gendered women, it would be useful to examine screening data in more nuanced ways, for example by accurately documenting when patients have made an informed decision to decline screening and by approaching screening as a process in which the patient plays a central collaborative role. There is ongoing need for provider education regarding special considerations in cervical cancer screening for trans/GNB patients. Effective, empowering communication and shared decision making is especially crucial in this setting.
#69HERstory: Lessons Learned from a Women’s Trauma Therapy Group7. Clinical innovations for specific populationsIn 2014 the Family Health Team engaged in a series of focused discussions with patients and IHPs around the theme of trauma therapy. The goal behind these discussions was to identify the gaps in the existing trauma therapy delivery framework, and to develop a process for filling in those gaps. Namely, we identified that a lack of availability of trauma therapy groups in the community was due to significant waitlists. At the culmination of these discussions, HERstory was born; a trauma therapy group in a Primary Care setting, with a target population of women who are survivors of domestic and/or sexual violence. As per the recommendations that emerged from community consultation, the group initially ran with one peer facilitator and one therapist. It is currently facilitated by one therapist, two hours in duration, and can accommodate no more than 9 members. To support the creation of the trauma therapy group, we also developed a set of measurement indicators that borrow from existing clinical frameworks for measuring anxiety, depression, self-observation, and trauma recovery
#70Optimizing Smoking Cessation Efforts Within the St. Michael’s Hospital Academic Family Health Team7. Clinical innovations for specific populationsAn EMR search conducted in October 2011 revealed that approximately 22% of our ~40,000 rostered patients were identified as smokers, slightly higher than the Ontario average of 19%. With the exception of the Nicotine Dependence Clinic at CAMH and the STOP on the Road program offered through Toronto Public Health, there were limited smoking cessation programs available to our patients at the St Michael's Hospital Academic Family Health Team (SMHAFHT) that offered both ongoing behavior change counseling support and cost-free nicotine replacement therapy. AIM: To reduce cigarette smoking among patients of the SMHAFHT by identifying and documenting smoking status, and offering current smokers who are ready to quit with ongoing counseling support and pharmacotherapy This presentation will highlight efforts made by the SMHAFHT to achieve this aim and how other Primary Care centers can adopt these changes into their environments. Specifically, the presentation will focus on the utility of an interprofessional Smoking Cessation Task Force to develop a specific Smoking Cessation program that offers a structured approach to identifying smokers and those ready to quit via the Ottawa Model for Smoking Cessation[OMSC]), along with provision of pharmacotherapy and counseling support via the STOP Study. Additionally the presentation will demonstrate how to generated an ideal process map that allows all staff to integrate smoking cessation into their regular work flow and how to enhance EMR tools to facilitate delivery of smoking cessation activities, such as: documenting smoking status of patients >14 years at all appointment types at defined intervals, providing smokers with brief advice to quit and assessing their readiness to quit for referral to group workshops/smoking cessation counselors. The presentation will additionally review how to spread change of the program to the entire FHT through iterative PDSA cycles of piloting the program at one site, receiving feedback from providers, use of innovative methods such as email marketing, creation of an EMR toolbar and representation of all stakeholders to provide feedback.
#71Making the Coordinated Care Plan (CCP) Work: Chronic Disease Management that Matters7. Clinical innovations for specific populationsWith a goal of increased integration across the health care continuum, Ontario HealthLink’s introduction of the Coordinated Care Plan (CCP) was a right step and in the right direction. Subsequent work to further develop this tool however, has slowed. This has left many teams without much support on how to implement a multipage care coordination tool that is available only as a .pdf or word document, and more importantly, without an understanding of how CCP can be included in the existing business processes. Many health care provider voices from across the province have echoed the need for an electronic care coordination tool that allows for EMR integration and greater ease of use. Both in anticipation of the creation of such a platform, and in the interest of supporting decreased system utilization, IHPs at the Bridgepoint Family Health Team have come together to create a pathway for care coordination that also leverages our existing EMR technology to create a more user-friendly care coordination tool. Both Provider and Patient satisfaction with care coordination and continuity has been statistically less than their satisfaction in other areas of care. Common complaints include specialists not having received a patients complete and accurate information prior to an assessment, providers not having been made aware that their patient was assessed/treated elsewhere in the community, and patients feeling like there are cases where the emergency room is the most accessible health care facility to them, regardless of the level of urgency of their concern.
#72Opioid Use in Primary Care - New Tools & Resources to Support Collaborative Care7. Clinical innovations for specific populationsPrimary care plays a significant role in pain management and Family Health Teams are well positioned to support people with complex needs. As part of Ontario’s comprehensive opioid strategy, HQO is undertaking the creation of a number of tools and resources to assist both patients and health care providers in tackling this issue. This sessions will profile work that HQO is undertaking as it relates to opioid use and prescribing, which include the following: • Primary Care Practice Reports: Starting in the fall 2017, opioid prescribing will be added as a new topic to the primary care practice reports, available to all family physicians in the province of Ontario. The practice reports represent one component of a broader implementation plan to support the adoption of HQO Quality Standards. • Opioid Quality Standards: HQO is developing 3 opioid-related quality standards scheduled for public release in March 2018: opioid prescribing for chronic and acute pain and opioid use disorder. Cutting across all sectors, these standards will look at the evidence and best practice for adolescents and adults across care settings, receiving all forms of opioids for either pain or use disorder, and will also touch on consideration of harm reduction strategies. • Opioid Specialized Reports: HQO will be producing reports intended for the general public as well as people working in the health system, to highlight the current state of variation in how and to whom opioids are being prescribed and some of the complex issues associated with opioid prescribing. The report features stories from patients and providers that highlight some of the challenges and benefits of opioids from different perspectives.