F2 - Developing an integrated care plan through collaborative relationships

June 12, 2018

Theme 2. Healthy relationships, healthy teams

  • Date: Thursday, October 25, 2018
  • Concurrent Session F
  • Time: 12:00-12:45pm
  • Room: Pier 5
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives Through the application of a multidisciplinary approach, learn how we implemented the chronic disease management and prevention framework to adapt the principles of the ICCP into a plan to help improve at risk patient’s co-ordination of care and improve continuity of care.  We will illustrate how we have been able to improve first contact, and intervene before issues arise.  The inclusion of client appropriate allied health has helped to stream line the intervention so that it is designed to meet the needs of the individual client, and address any unmet social/mental health needs arising from or exacerbated by illness Summary/Abstract Our FHT initiated the Multi-D appointment approach to utilize the key concepts of the ICCP, but in a more efficient manner with a broader criterion including psychosocial issues.  Sullivan et al (2016) suggest that building successful professional teams includes “re-envisioning goals, promoting shared decision making, communicating effectively and interprofessionally, clarifying roles, learning from failure, and using organizational structures to support multidisciplinary teams.”   Our process is to encourage staff to use their professional judgement in initiating a referral for any “at risk” patient who might benefit from this contact.  This maximizes the coordination and comprehensiveness of care by meeting together with the patient, their significant others, and the involved primary care providers.    Our vision is to improve health outcomes and the self-efficacy necessary to manage chronic or acute conditions.  We are striving to promote a culture of client centered, safe, multidisciplinary care.  “Even in the best healthcare systems, patients most remember their individual encounters.  We must ensure that the teams we create sustain our common goal of providing high-value care for every patient, every time (Handel, 2016). Presenters:

  • Mandy Weeden, CEO, Kirkland District Family Health Team
  • Christina Woollings, NP-Clinical Lead, Kirkland District Family Health Team
  • Julie Moody, RPN, Co-Ordinator Multi D Meetings, Kirkland District Family Health Team
  • Sandra Dal Pai, NP-PHC, Kirkland District Family Health Team
  • Lauren O'Connor- Byer, Pharmacist, Kirkland and District Hospital
  • Christine McBean, Pharmacist, Kirkland Family Health Team


  • Woollings, Christina NP-PHC, KDFHT
  • Dal Pai, Sandra NP-PHC, KDFHT