Championing Integrated Care: Primary and Community Care Response Teams

Primary and Community Care (PCC) Response Teams is an integrated care planning program focused on supporting system navigation and service connection for vulnerable adults living in East Toronto. The virtual interdisciplinary teams are comprised of health care and social services providers and volunteer community health ambassadors who participate in the localized, cross organizational, cross-sector care planning. Prior to COVID-19, health care and social service providers had recognized the need to come together across organizations to coordinate care for adults with complex needs (with an initial focus on homebound clients unattached to primary care). With the onset of COVID-19 in March 2020, health and social needs were exacerbated by increased isolation and pandemic-related changes to health and social services. This program began as an urgent response in April 2020 to strengthen collaboration among primary care, other local health care providers and social services workers to pool knowledge, expertise and resources to develop coordinated care plans for the people who needed them most.

Integrated, team-based care provided with the appropriate care partners ensure optimal care outcomes for patients. The North York Family Health Team (NYFHT) is a large, academic, multi-site family health team (FHT). In the treatment of diabetic foot ulcers, a team of NYFHT providers collaborate in the patient’s care plan.  The NYFHT physicians and nurses are distributed throughout the North York area providing their expertise in assessing and educating their patients. The NYFHT chiropodist is responsible for providing assessments, treatment and education for patients with high-risk foot conditions including those that are limb threatening.    3 to 4 case studies of patients with diabetic foot ulcers seen by the NYFHT physician, nurse, and chiropodist will reflect how integrating providers both within and outside the FHT improve patient outcomes, including the wound size and the patient’s overall DM status. Patients were then referred to internal FHT providers such as the Diabetes Education Program (DEP) and pharmacy team, and external organizations such as the Home and Community Care Support Services for nursing support in providing regular dressing changes and the Centre for Complex Diabetes Care (CCDC) for offloading devices. By building a team around the patient’s needs, this led to wound closure in all cases and improved a1c.   

The number of Canadians diagnosed with diabetes is on the rise each year, with 1 in 3 Canadians living with gestational diabetes, diabetes or prediabetes. Our team realized the need to enhance our program to ensure all eligible patients are screened for diabetes, and if diagnosed, have access to prompt education, pharmacology, physical assessment and laboratory follow up, as needed. Our Diabetic Program demonstrates the importance of having multiple Inter-Health Professionals involved. Prevention in Primary Care is key, and our program was built to prevent the many adverse outcomes that can accompany a diagnosis of diabetes. Not only can our Diabetic Program positively affect glycemic control, it can also have a direct lipid lowering affect, and assist in blood-pressure management. Virtual and in-person appointments are scheduled as needed for blood pressure review, insulin starts, proper glucometer use, and continuous glucose monitoring, along with foot exams and retinal exams as recommended. We encourage all DM patients to attend our Diabetes 101 online class, Carbohydrate Counting and food label reading education as well as our interactive Eating the Mediterranean Way class to ensure our patients feels empowered to manage their diabetes and prevent complications.   

Leveraging Primary care Ontario Practice based Learning and Research (POPLAR) Network to Improve Quality in Primary Care: the SPIDER study
 

Building Resilience Individually and as a Team 

This poster will look to highlight the importance of resiliency and team support.  It will highlight the key areas that SETFHT has implemented in order to support the staff both individually and as a team.  This will help out teams to customize these strategies to help support their own teams.     By supporting the individual person, they are better equipped to work together as a team, which in turn has allowed for consistent in person and virtual care during the pandemic, as well as improved team dynamics.  The goal it to carry these lessons and strategies through to the other side of the pandemic and build momentum to grow our team strength, resilience and dynamic.    Poster will also look at the outcomes and evidence including lower absenteeism, even during a time when there is greater risk of sickness, lower staff turn over, higher productivity rates and higher staff morale and team spirit!      

Primary Care Occupational Therapy: The Value of Access for Patients

Occupations, or daily activities, bring meaning to people’s lives. Using the full scope of  occupational therapy services, clients can  optimize their ability to participate  in meaningful activities, thus reducing disability and improving health.     The scope of practice of occupational therapy is well aligned with the objectives of Primary Care. “There is growing evidence that occupational therapists’ unique lens (focus on occupation) supports individuals with or at risk of disability in a primary care environment. The scope of occupational therapy goes well beyond traditional rehabilitation to include health promotion, disability and disease prevention, and community development..” (Donnelly et al 2022).    Occupational therapists in FHTs provide services longitudinally, providing comprehensive and coordinated care .     We will review the evidence about the benefits of the broad range of interventions that occupational therapists provide and how this improves patients’ participation in meaningful activities with impacts on overall health outcomes. Examples include: Aging in place, brain health, falls prevention, driving retirement, support to stay at work/ return to work, managing pain and/or  mental health conditions, chronic disease management, and developmental screening for young children.     Occupational therapists have worked in Family Health Teams for 12 years.  With OTs in approximately 65 of Ontario’s 184 FHTs , approximately 65% of Ontarians rostered with FHTs are left without access to Primary Care Occupational Therapy services. Opportunities to increase occupational therapy’s presence in FHTs will be discussed.  

7.63 million Canadians suffer from chronic pain. Opioid medications can help relieve chronic pain and improve health-related quality of life. Canada ranks third globally for prescription opioid use. During 2016-17, Ontario witnessed 73% increase in hospitalizations attributed to opioid misuse. Team-based primary care, of which pharmacists form an integral part, serves nearly 25% of Ontarians. This project explores pharmacists’ perspectives on team-based opioid stewardship in Ontario. Pharmacists working in team-based primary care settings across Ontario who participated in a provincial survey about chronic pain management and opioid stewardship (N=88) were invited to follow-up individual semi-structured interviews that explored pharmacist perspectives on the functioning, challenges, opportunities, and best practices in team-based opioid stewardship. Understanding these factors can optimize team dynamics and lead to more effective use of the pharmacist as a resource in opioid stewardship.  

Project ECHO is a guided practice model that increases workforce capacity to provide best-practice specialty care and reduce health disparities. It is well-suited to rheumatology care delivery in Ontario, as the number of rheumatologists in the province has remained static despite the growing prevalence and burden of rheumatic disease. Consequently, there remain striking disparities in access to care, particularly in rural and remote areas across the province.     ECHO Ontario Rheumatology began in 2017 and facilitates knowledge sharing and the evolution of a community of practice for rheumatic disease care. In doing so, ECHO fosters and supports rheumatic disease care champions within a Family Health Team (FHT), impacting the access and management of these diverse rheumatologic presentations – often with high morbidity, mortality, and decreased quality of life. ECHO not only impacts the direct participant and clinician, but also offers rich learning opportunities for colleagues within clinics and improved care delivery across organizations.     In this session, we present experiences of ECHO Rheumatology participants from FHTs to demonstrate how the Project ECHO model is adapted to effectively share knowledge and support complex rheumatic disease management. We also highlight the development of a virtual community of practice (VCoP) through ECHO Rheumatology and present metrics regarding uptake and effectiveness of the program.   

From Silos to Success: Collaboration of Primary Care Models Tackling Community Needs 
 

 - Well developed relationships are the foundation of innovative work  - Through covid work 1) testing 2) respiratory assessment 3) vaccines 4) treatments (antivirals - oral, IV) primary care has worked cohesively to be the only primary care based model in the province  - Close working partnerships with hospital, public health, lab, pharmacy, municipalities, even a fire department,  Ontario Health and our newly formed Sarnia-Lambton Ontario Health Team; our community has been able to successfully respond to the needs throughout the last 2.5 years and still going strong.   - Daily reporting of stats (7 days a week) has provided data to support our model and show our success  - Rural and urban partnerships translated into coverage across the entire county   - Overlap of teams and care created one team, no matter the primary care model (ie. FHT vs CHC) in which partners co-lead sites utilizing staffing from both models as one team - it can be done!   - Our model was showcased on Ontario West region meeting May 25, 2022

Our small community-based family practice is part of the large, distributed North York FHT.  Our practice participated in a large-scale provincial QI initiative, the Quality Improvement and Innovation Partnership in 2009; we have had QI meetings and ongoing activities since then.  Our QI team includes physicians in the practice, Interprofessional Healthcare Providers (IHPs), our Office Manager, a Front Staff member and a Patient Partner.     The QI Team is ably led by the NYFHT RN in the practice.  Central NYFHT IHP members (clinical pharmacist, dietician, social worker) join remotely. Meetings became fully virtual during the Pandemic and are currently hybrid.    The meetings are structured and include agendas and minutes.  Data by physician practice are collected ahead of each meeting, presented, reflected on and discussed at each meeting.  PDSAs have been used for many years to drive improvement, with measurable and measured impact.    We measure quality of care for several conditions, including diabetes and asthma.  Findings and activities of interest are communicated back to the NYFHT, which then decides whether to spread to multiple other practices.  The entire practice meets to discuss practice management once a month, and selected activities and results are shared by the QI team with all physicians and staff.    We conclude that QI activities in small community practices can be sustained over long periods of time.  Successful QI work can be spread and scaled beyond the practice.  We will present examples of data that is measured, examples of agendas and minutes, and discuss how we sustain QI efforts.   

Recognizing homelessness as a significant barrier for maintaining or improving health, the Dufferin Area Family Health Team - over the past two years - ‘stepped forward’ to take a lead in our community by focusing on ‘housing as a health need’.  This vision to provide care for health needs created by chronic homelessness through actively supporting and prioritizing housing stability presented new ways of working in community and new partnerships with social care organizations. Funding through a federal program (Reaching Home), supported by a local Community Advisory Board and additional Covid relief support, allowed for the hiring of 2 Housing Support Workers from June 2020 to May 2022.      During this challenging time and through the impact of Covid on access to resources, including affordable permanent housing, 93 individuals struggling with chronic homelessness (defined as at 6 months of homelessness over the past year or recurrent experiences of homelessness over the past 3 years) were supported by this project.  Of these individuals, 58 (or 62.4 %) individuals were successful in acquiring and maintaining housing.      Throughout the project, as a health care organization, we became much more aware of the barriers to accessing affordable housing, the significant impact of mental health and addiction for homeless individuals in seeking housing, and the challenges faced by community partners working to address homelessness and poverty.  
 

"This project was conducted between September 2021 and March 2022 with VHA’s Toronto Central rehab team in a community care setting. Opportunity to engage with interventions was made available to all members of the team which included approximately 80-90 providers.  Client partners and community organizations who work with 2SLGBTQI+ populations and provide education in this area were consulted. These stakeholders reviewed the content developed through literature review and an environmental scan of available training in the community.   The interventions developed during this project included:   1.    An educational intervention 30 minutes to one hour in length delivered virtually and recorded.  2.    A resource hub launched on VHAs intranet containing community resources, access to wider training resources, and the recorded educational session.  3.    Practice tools in the form of pronoun buttons to be worn by providers to serve as a visual representation of openness to provide an accountable space for clients.  4.    Weekly emails delivered in February and March sharing practical tips to incorporate into daily practice.    This project has increased awareness of unique needs of 2SLGBTQI+ clients, and has improved provider knowledge, skills, and attitudes. Attitudes are very challenging to change, however in this project with an improvement in knowledge there appears to be an improvement in attitudes too.   Resources are now readily available for providers to consult. There is still a significant opportunity for more frequent education opportunities. This project has highlighted that VHA providers would like to continue learning so that they can provide inclusive, equitable, and safer care.     "

Serving the Underserved: Bringing Interprofessional Primary Care to High Needs Communities

The Taylor Massey neighbourhood has very little access to primary care services. This “high-needs” neighbourhood currently has a scarcity of family physicians paired with a high number of poorly served individuals with multiple emergency department visits and return inpatient admissions.   The proposed services provided to this population will build upon the success of the South East Toronto Family Health Team (SETFHT) by expanding into a neighbourhood with an immediate need for investment in primary care. By responding to the specific population needs of these communities, the expanded SETFHT services will ensure that those individuals who are complex and poorly served have improved access to team- based primary care that is integrated across the care continuum.  The service will focus on providing program-based care that will provide a higher level of service to a greater number of complex and at-risk patients.  Furthermore, this proposal will evolve the FHT model by incorporating learnings from the initial investment in FHTs and responding to the specific needs of each community and the emerging mandate of our Ontario Health Team (OHT). Development of this service represents significant collaboration with partner organizations in the East Toronto Health Partners OHT and the residents of the communities that will be served. This collaboration and co-design represents the future of efficient and effective primary care reaching priority populations in underserved geographies.     
 

Promoting Smoking Reduction and Cessation with Indigenous Peoples of Reproductive Age and their Communities: A Best Practice Guideline
 

Equity, Diversity and Inclusion (EDI) work at the Guelph FHT is in its infancy. As a Best Practice Spotlight Organization, the Guelph FHT works hard to continue to provide best quality care to patients. In 2022, EDI has become a strategic focus, and this poster presentation will provide a snapshot of the planning phase of EDI related work. The content will be divided into three categories: 1) identification of current state and future state, 2) development of an EDI Council and 3) strategies toward creating cultural competency in healthcare.   Early work has included a needs assessment through an employee opinion survey process using the Global Diversity, Equity and Inclusion Benchmarks. As a partner organization to the Canadian Centre for Diversity and Inclusion (CCDI), using resources to help develop an effective and sustainable EDI Council has been instrumental in this process. Finally, moving toward creating cultural competency has been broken down into both individual and organization recommendations that will be highlighted in both current and future state examples.    In summarizing learnings from the above healthy equity activities, applied against the GDEIB framework, the Guelph FHT aims to offer recommendations and general directions on practical and impactful applications of EDI work in a primary care setting.   

Road to Recovery: A Multi-Pronged Approach to Support COVID-19 Vaccinations and Beyond in North York
 

The disproportionate impact of HIV/AIDs in African Caribbean and Black (ACB) communities in Canada remains a problem that requires targeted efforts. In this session, we present qualitative findings from the African Canadian (AC) study of HIV behaviours, knowledge, and barriers to healthcare among ACB communities in Ontario. The study meaningfully engaged ACB community members in the interpretation of quantitative study findings and in the generation of best practices.  Qualitative data sources included a two-day World Café event where study findings were presented and 12 Focus Group Discussions (FGDs) involving over 107 ACB individuals from Toronto and Ottawa were held.  FGDs were transcribed verbatim and thematic analysis guided data interpretation. Credibility of data was established through data validation strategies.  Five key themes will be discussed:  1) Community perceptions of research importance and challenges, 2) Factors associated with HIV vulnerability, 3) Experiences with HIV testing, 4) Use of PEP and PrEP, and, 5) Community perspectives on how to address HIV in ACB communities. Fear and stigma remain one of the most frequently cited reasons why ACB community members don’t access HIV testing. Many participants were not aware and /or did not have direct experience with use of PrEP/PEP prevention treatments; one of the main reasons being because these treatments are marketed for white gay men. Participants identified numerous strategies to address the HIV needs in ACB communities, including education, community-level strategies and health provider capacity building strategies. We conclude that community based participatory research, co-led by community members, is an important strategy for identifying the multi-level individual, interpersonal, community, institutional and structural factors that increase HIV vulnerability in ACB communities, notably anti-Black systemic racism.

Cannabis is the most commonly consumed substance during pregnancy; it is estimated that consumption will increase among pregnant individuals following legalization and the growing recognition of its health benefits. In healthcare contexts, cannabis consumption can be framed as risky for the fetus and infant. Limited research evidence available to understand the impact of cannabis consumption during the perinatal period has left health and social care providers grappling with how to adequately support those seeking care. Ongoing research centering the lived experiences of people who consume cannabis has highlighted numerous ways cannabis supports harm reduction and positive physical and mental health outcomes thereby redefining conventional conceptions of risk and expanding how cannabis is understood during the perinatal period and while parenting. An evidence brief outlining the current state of research and practice knowledge about cannabis, pregnancy, and parenting will be shared to highlight opportunities for practice and policy improvements that respond to the lived experiences of people who consume cannabis. Through dialogue sessions with health and social care providers and parents who consume cannabis, local and system-wide solutions have been identified that can support improvements in care for pregnant, lactating, and parenting people who consume cannabis through addressing practice and policy barriers. Through this session, interprofessional primary care organizations, with considerations for collaboration with service recipients, allied health and social service organizations, will be able to improve service delivery by employing approaches informed by harm reduction and anti-oppressive principles, and social justice-oriented community practice. 

In this presentation, Rainbow Health Ontario will support your team in learning the clinical and culturally competent practices to provide welcoming and inclusive services to 2SLGBTQ patients.   
 

Background: Segmentation, or the division of populations based on specific characteristics, is a common technique applied in marketing, but not fully explored in healthcare. New approaches to patient segmentation might help tailor primary care interventions and communication needs. Access to primary care electronic medical record (EMR) data repositories provides an opportunity to implement personalized primary health care solutions.   Objectives: To develop a virtual peer-to-peer workshop intervention for patients with type 2 diabetes (T2D) by segmenting participants based on medication use.    Methods: This mixed-methods pilot study used data from the Eastern Ontario Network, a practice-based research network and repository of EMR data drawn from primary care practices across south-eastern Ontario. Patients aged 40 and older with T2D were identified (n=825) and segmented based on medication data using k-means clustering. Patients with good and bad control of disease were classified based on A1c, LDL, and blood pressure. Moderated virtual peer-to-peer workshops were held with patients with good and bad control from within and across segments. Patient-reported outcomes were collected at baseline, immediately post-workshops, and at one-week and one-month follow-ups to assess patient T2D experiences, engagement, self-efficacy, motivation, and planned behaviour change. Thematic analysis will be conducted using recordings from workshops.  Outcomes: Results from six workshops will be reported (n=25). This pilot study will provide preliminary evidence to support the development and implementation of a data-driven intervention for patients with T2D in the form of virtual peer-to-peer support, based on patient segmentation on medication-taking behaviour.   
  

With the rise in the occurrence of post-partum depression and isolation during COVID, along with the positive feedback from our pilot Baby and Me program, our team felt it essential to continue to improve resources for our families with new babies. Data mining was done within our EMR to compile a list of families with newborns 0-6 months and 6-12 months. They were personally contacted and invited to join our program via Zoom. Our program was developed during the height of COVID, but it was quickly recognized that the format needed to continue post pandemic, realizing that Primary Care can be provided virtually, and actually improve our resources and supports. We reached out to our community partners to allow increased access to pelvic floor physiotherapy, mental health support as well as basic first aid and CPR training. We ask for feedback after each session, and update our information and delivery method as needed. Each session is a 4-part series hosted by the NP, RN, RD, SW and OT, and handouts are emailed to each participant after each session. Outside community participation is encouraged and advertised on our website and social media platforms to offer access and support to members of our community that may not otherwise have this collaborative approach available to them.

With no linkage between primary care data and hospital data, there is currently a disconnect in continuity of care. Creating a consolidated data repository could result in an improved understanding of the care journey and reduction of siloes in healthcare, supports for the healthcare needs in OHT priority populations, continuity of care improvements across sectors, and decreased burdens on emergency departments and primary care providers.     The primary objective of the project is to merge two key data sets, combining primary care electronic medical record (EMR) data from the Eastern Ontario Network (EON) with acute care, post-acute, community mental health and addictions, home care, and community support services data from the Shared Health Integrated Information Portal (SHIIP). This robust dataset will provide opportunities for quality improvement (QI) projects that can be undertaken by Ontario Health Teams (OHTs) to improve the approach to population health management.     To test the utility of a merged data set, a QI pilot project will aim to apply a physical health risk register to support the early identification of cancer screening opportunities in those with mental health concerns to improve the quality and continuity of care. Alignment with the Mental Health and Addictions working group of the FLA OHT will be central to see how this merged dataset supports population health management at the primary care level. Findings from this project can be applied to future QI work and can be shared with other OHTs interested in adopting a similar approach.         

Background: Advanced Practice Providers (APPs) have improved equitable, evidence-based access to care for over 30,000 patients with hip and knee arthritis since the introduction of Sunnybrook’s Hip and Knee Rapid Access Clinic (RAC) in 2007.  Up to 40% of RAC patients do not proceed to surgical consultation, but benefit from an additional specialized touch-point to review management of their osteoarthritis. A RAC 3-month follow-up visit is offered to patients who require would benefit from evaluation of initial RAC treatment outcomes and re-assessment of their readiness for joint replacement.     A gap in care was created during the first wave of the COVID-19 pandemic, when 88 patients scheduled for in-person RAC 3-month follow-ups were cancelled or postponed.      Aim: The purpose of this quality improvement project was to conduct virtual RAC follow-up visits via telephone to identify patients who: did not require further care, felt ready for surgical consultation, or required urgent surgical consultation.   We also wanted to evaluate patient experiences in this context.    Methods: Two APPs attempted to contact patients (n=88) booked for a RAC follow-up visit. Telephone visits were conducted with patients who consented to a virtual visit and follow-up (n=82). After the visit, we emailed an anonymous, optional four-question survey to each patient. The survey contained three Likert-scaled questions and one open-ended question to gather further impressions about the patient experience. Those that could not be reached via email were sent a print version of the survey via Canada Post with a stamped return envelope.         

Traditionally, in-person supervised rehabilitation has been the standard of care following total knee arthroplasty (TKA). During pandemic restrictions, our ability to offer in person postoperative treatment to our patients after knee replacement at the Holland Centre was significantly impacted. Thus, quick adaptation was needed in order to expand our rehabilitation services and provide reliable access to care. Technology such as Zoom provided us with an opportunity to deliver quality care to patients within the comfort of their home, while keeping them safe. Although virtual care was becoming a standard of care at the Holland Centre, it also had its own unique challenges that patients and rehabilitation team were confronting.  To better understand the patient’ perspective and address their needs; we modified an existing patient virtual care experience survey (developed by AFHTO), in collaboration with our patients and patient partners with an aim to develop mitigation strategies and provide patient focused care. Patient-related outcomes were: Patient Specific Functional Scale (PSFS) and P4-pain scale. Flexion and extension ranges were measured before and after treatment. A modified Primary Care Patient Experience Virtual Care Survey was used to examine barriers for virtual care and evaluate patient’s satisfaction. A well-designed post-operative virtual physiotherapy program continues to be an important part of our model of care as we normalize our activities. Clear understanding of barriers to virtual care and mitigation strategies will help us create virtual care standards, meet our patient needs and facilitate continuous postoperative care to patients despite pandemic restrictions and limitations in resources.

VPC has become more popular since the COVID-19 pandemic hit. As healthcare providers, we have had to adapt to the challenges that the pandemic brings while making sure that patients could still get the care that they need for their well-being. During the times when people were encouraged to stay at home, we have relied on either phone or video appointments in order to provide care that did not require an in-person consultation.  We also ensured that adequate in-person appointments were available for those who required a physical exam.   We do not anticipate VPC going away even after the pandemic as it has shown its effectivity in making healthcare more accessible to the population.  In addition, home visit program has also helped the vulnerable people who are no longer capable of leaving their homes get the care and support that they need which also includes COVID-19 vaccination. This is one way for us to show that we, as a healthcare facility, will find ways to provide continued care and support to our patients who are in need.    

In 2020 Haldimand FHT began to focus on more targeted data collection as Schedule A was often onerous for IHPs, and the data collected did not help to inform the IHPs on the programs they were running. Time was spent identifying and understanding program pathways, program delivery, and gaps in data entry and analysis. Clearly defined program parameters have allowed more relevant data capture that better reflects the IHP work and capacity as well as the populations served.  This has allowed for IHPs to be more informed about their programs and has made the process of developing measures for Schedule A a significantly easier task. Clearly defining the numerator and denominator for process and outcome measures within the context of the program pathway has resulted in cleaner data that better reflect the care patients receive.  Additionally, IHPs now have a better understanding of their aggregate data, as it is more relatable to their delivery of care.  With the use of false billing codes it has made it easy and convenient to enter and track data without it being onerous or reducing clinical time. This implementation is fostering a culture of Quality Improvement amongst the IHPs as they have shifted the processes of program development to include a focus on data and improvement. 

The Registered Nurses Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners and nursing students in Ontario, and the Best Practice Guideline (BPG) Program is a signature RNAO program. In partnership with Humber River Hospital, RNAO is developing the first BPG to address clinical practice in a digital health environment. This BPG will include evidence-based recommendations for nurses, organizations and health systems to foster nurses’ ability to maintain, advance, and strengthen professional practice in the context of a digital health environment. This BPG will be relevant to nurses practicing in all clinical settings, including primary care. RNAO assembled an interprofessional expert panel that included persons with lived experience and individuals with experience with digital health in the areas of clinical practice, education, research and policy. The expert panel identified priority recommendation questions for the BPG which focused on: integrating digital health competencies into the professional practice roles and responsibilities of nurses at all levels within an organization; leveraging predictive analytics; practical or hands-on professional development education; education about relational care and interpersonal communication skills; active involvement of nurses in all stages of the technology lifecycle; and, embedding digital health competencies into nursing entry-to-practice exams. RNAO’s research team is currently conducting systematic reviews on these questions that will inform the recommendations included in the BPG. Consideration is also being given to digital health equity and sustainability while developing the BPG. In this session, RNAO will describe the guideline development process and the recommendation areas of focus. 

The Ontario Standards for Care (OSC) program, developed by the Centre for Effective Practice, the eHealth Centre of Excellence, and North York General Hospital, will translate evidence-based clinical and quality standards into decision support tools, digitally embedded into frontline clinical information systems. This program is part of Ontario Ministry of Health’s (MOH) Digital First for Health Strategy. The program will initially be delivered through a series of Use Cases, piloted in acute and primary care sites. Program deliverables will be met through stakeholder engagement, translation of quality standards into the Electronic Medical Record (EMR) and Hospital Information System (HIS), alpha and pilot testing, continued feedback gathering and tool modification. The first Use Case for the OSC program is a heart failure tool to be piloted in 1 EMR and 1 HIS, with targets of 125 primary care clinicians and 100 acute care clinicians across two Ontario Health Teams (OHTs). Subsequent confirmed Use Cases will be anxiety disorders, major depression, and diabetes within other OHTs.  In 2015, Ontario had roughly 250,000 people diagnosed with heart failure, approximately 1.8% of the province’s population. Heart failure is one of the five leading causes of hospitalization and 30-day readmissions, the most common cause of hospitalization for people over age 65. Opportunities to improve care for people with heart failure in Ontario and reduce the health system burden, include improving variations in clinical outcomes, reducing costs to healthcare systems, addressing adoption barriers and challenges, improving care coordination and patient care, which are rooted in quality standards.
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The Technology Equitable Collaborative Care (TECC) model aims to engage patients and leverage technology to provide equitable access to holistic care. The use of the digital care pathway enables accessibility and bridges systemic gaps in healthcare providing clients with evidence-based treatments to support physical and mental health. By employing technological tools (e.g., REDCap and Cisco Webex), current challenges in primary care, including geographical barriers, time pressure, disjointed care, and a lack of local expertise can be addressed to improve client wellbeing.    The TECC model has two main components. The care coordinator functions as the cornerstone of this model and connects clients and their associated care providers (family, primary care, community services, etc.) with expert guidance to streamline the treatment process. The care coordinator works closely with clients to co-create goals, enhance motivation, and create and implement treatment plans. The virtual care team (VCT)  which may include physicians, mental health professionals, registered nurses, dietitians and peer mentors, works collaboratively to provide ongoing treatment recommendations.     The TECC model creates a feasible and scalable care solution that empowers clients to take an active role in improving their physical and mental health. For clients with limited digital literacy or limited internet access, the TECC model can be adapted to provide care over the phone. For clinicians, this model facilitates access to an interdisciplinary team of experts and provides an opportunity to learn evidence-based approaches to physical and mental health care.