Poster Displays

Information & Resources For Posters:


2019 Key Dates:

  • June 19, 2019: Confirm intent to submit poster
  • September 4, 2019: Early-bird registration deadline - payments must be received by this date
  • September 5, 2019: Deadline to submit poster PDF
  • September 19 & 20, 2019: AFHTO 2019 Conference
    • Install poster: 7:00 AM to 7:45 AM, Wednesday September 19, 2019
    • Remove poster: 3:00 to 4:00 PM, Thursday September 20, 2019

Poster Display Guidelines:

  • The maximum size for posters is 46” (vertical) x 70” (horizontal)
  • Posters are to be put into place before 7:45 AM on Wednesday, September 19, 2019, and removed at 4:00 PM on Thursday, September 20, 2019

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 to members through AFHTO’s website after the conference. To participate, please upload a PDF of your poster to your presenter management portal by September 5, 2019.

Poster Board #





Flu Shots +…… Integrating Cancer Screening into flu shot clinics

1. Access to care: improving access to team-based care

This quality improvement project aimed to increase our practice screening rates for cervical, breast and colorectal cancer.  Currently cancer screening occurs during preventive health visits and opportunistically during regular patient visits if noted to be overdue. Nevertheless, average screening in the practice has not met the provincial targets and is currently 60 % for cervical cancer, 64 % for colorectal cancer and 67 % for breast cancer.  Our practice organizes annual fall flu vaccination clinics which attracted over 1000 patients.  We have previously utilized these clinics to update pneumococcal vaccinations.  In 2018 we incorporated an intervention to promote cancer screening.  We informed flu clinic attendees aged 21-74 years about their cancer screening status (up to date/overdue) and offered those who were overdue with an appointment for a Pap smear, mammogram and/or FOBT kit.  Incorporating other preventive health activity like cancer screening into flu immunization visits has the potential to effectively reach large numbers of patients who may be interested and open to these other interventions to improve their health.


 Examining differences in mental health support and symptom reduction across rural, urban, and suburban sites in the CAMH PARTNERs Integrated Care Project

1. Access to care: improving access to team-based care

The CAMH PARTNERs Project is a randomized controlled trial that supports adult primary care 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 (INT) for 12 months. Patients in EUC receive comprehensive telephone assessments at baseline 4, 8, and 12 month intervals, the results are shared with their primary care providers (PCPs). Additionally, patients in the intervention receive regular telephone support from Mental Health Technicians (MHTs), who monitor symptoms, treatment adherence, and provide education on lifestyle changes. Primary care providers of patients in the intervention condition also receive updated medication recommendations from the project psychiatrist.     PARTNERs has collaborated with 186 physicians, nurse practitioners, and social workers through implementation at 27 sites including; family health teams, family health organizations, community health centres, a university health centre and solo physician practices across Ontario.     The data explored in this poster will examine differences in the reduction of symptoms of depression and anxiety (using scores from the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 scales) in both the EUC and INT conditions, as compared across our 27 unique participating sites. This analysis will explore whether our integrated care model of telephone based mental health support and monitoring is more effective at providing support and thus reducing symptoms of depression and anxiety in patients receiving care at either: FHOs, FHTs, CHCs, or with solo physicians at sites across rural, urban, and suburban locations.


Antidepressant Utilization in the CAMH PARTNERs Project

1. Access to care: improving access to team-based care

The CAMH PARTNERs Project is a randomized controlled trial that supports adult primary care 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 telephone assessments at baseline 4, 8, and 12 month intervals, the results are shared with their primary care providers (PCPs). Patients in the intervention receive regular telephone support from Mental Health Technicians (MHTs), who monitor symptoms, treatment adherence, and provide education on lifestyle changes. Additionally, PCPs of patients in the intervention, receive medication recommendations from the project psychiatrist. PARTNERs has collaborated with 186 physicians, nurse practitioners, and social workers via implementation at 27 sites including; family health teams, family health organizations, community health centres, a university health centre and solo physician practices across Ontario.   The data explored will examine how closely medication recommendations are followed by primary care providers, as well as, the length of time taken to implement these recommendations. Furthermore, trends in antidepressants will be assessed via baseline data. Factors will be measured in the following: suboptimal vs optimal dose, percentage of study population not prescribed an antidepressant, and brand of antidepressant prescribed.   Antidepressants are a major treatment used by primary care providers. Identifying practices in antidepressant prescriptions, as well as, proclivity to implement recommendations provided through integrated care can inform future treatment planning.


The Triumphs and Trials of Collaborative Mental Health Care: Our Journey 

1. Access to care: improving access to team-based care

Collaborative care integrating primary and specialist mental health care has been increasingly highlighted as a way to improve psychiatric services in Canada and internationally. The ‘Shared Care’ Program at Sunnybrook Academic Family Health Team (SAFHT) is a inter-departmental initiative that links family physicians and family medicine residents with timely support from psychiatrists and psychiatry residents in the form of on-site consultations and just-in-time advice, as well as support over email/phone by psychiatrists to help manage patients with complex mental health conditions. In addition to providing excellent and timely patient care, this unique program provides family medicine and psychiatry residents with the opportunity to learn about collaborative care together in real-time. It helps to build capacity for future family physicians to manage psychiatric illnesses in a primary care setting. In addition to providing direct patient-related advice and support to family physicians, residents, social workers and care navigator, the Shared Care Program help build more mental health care capacity within our team; as part of the program a staff psychiatrist delivers case-based rounds at the SAFHT twice per month. This model is transferable to any primary care practice setting that facilitates collaborative care. 


Access to care: A primary care nurse practitioner led home visiting program for homebound individuals

1. Access to care: improving access to team-based care

The Ontario seniors (65 years and over) population is the fastest growing group of individuals in Ontario and this is projected to have a 25% increase by the year of 2041 according to the 2016 Canadian census. With this in mind, primary health care will have to adapt their models of team-based care accordingly in order to create greater accessibility Ontario seniors to receive health care needs.    There are many barriers whom individuals encounter when seeking primary care. This includes receiving care in a timely manner for an episodic health condition which is often not attainable due to long wait times; increased frailty and ambulation restrictions in the elderly that inhibits portability and transportation to medical buildings where their health care providers are located; and lastly,  earlier and more acute discharge planning occurring due to over capacities of emergency departments from tertiary care hospitals whom individuals require closer monitoring in the primary care setting when discharged back to home.     The North York Family Health Team (NYFHT) NP home bound program provides a service for home bound individuals affiliated within the FHT who are unable to see their primary care providers for episodic health conditions due to barriers mentioned above. This program allows for increased access for individuals to attain health care in a timely manner, prevents unnecessary visits to the emergency departments, and in due course a decrease in readmission to hospitals.     Using the team-based model of care, the NP works collaboratively with the primary care physician, allied health members and community services to develop a plan of care for these individuals to ensure that they are assessed and treated for their acute episodic illnesses, thus ensuring supportive measures to continue living healthily and safely in the comfort of their home.  


Physical Disabilities in Ontario: How the Mobility Clinic is Levelling the Playing Field

1. Access to care: improving access to team-based care

Objective:  Physicians report that patients with physical disabilities are often more complex in their healthcare and clinic visits require more time. Many physicians lack appropriate training to address these conditions in primary care. There is an opportunity to address these barriers through development of a network of clinics outfitted with specialized equipment and staff trained to respond to the needs of these patients.    Background:  The Centre for Family Medicine Mobility Clinic started in 2010 and currently provides primary care to over 70 individuals with spinal cord injuries (SCI). Our Mobility Clinic is an innovation to support and empower individuals with SCI. We have since expanded the scope of our work in the Mobility Clinic to include other physical disabilities, including multiple sclerosis, Parkinson’s, spina bifida, stroke and cerebral palsy.    Intervention:  The Mobility Clinic has established success in providing care to individuals with physical disabilities at the Centre for Family Medicine Family Health Team. Building on this momentum and success, we have established three additional Mobility Clinics in Ontario to expand primary care for patients with spinal cord injuries.     Summary:   Through establishment of additional Mobility Clinics, we are helping to provide knowledge translation and dissemination among PCPs across Ontario. Successful engagement of PCPs helps to level the playing field for individuals with physical disabilities, ensuring that they have access to high-quality primary care. 


Getting the Discussion Going – Advance Care Planning for the Community

1. Access to care: improving access to team-based care

About 6 in 10 Canadians believe that it is extremely important to talk to someone about their end-of-life (EOL) care wishes and preferences and yet 55% of Canadians have not had these discussions (CHPCA, 2014).   When Canadians were asked about beliefs and values for EOL care, most indicated that they would prefer to die at home in the presence of loved ones, and yet nearly 70% of Canadian deaths occur in a hospital (CIHI, 2007).  With this in mind, members from the North York Family Health Team (FHT) and North York General Hospital Palliative Care Team have come together to offer information sessions within the community that focus on ACP. These sessions provide practical information and real-world examples related to the importance of planning ahead, how and when to begin planning, as well as identifying one’s specific wishes, core values and trade-offs for EOL care.  For quality improvement purposes, participants complete a survey before the session which helps assess their current knowledge and level of comfort in discussing ACP. A second survey is administered after the session to determine if their knowledge, confidence and readiness to begin planning has improved. Finally, a telephone follow-up is completed 3-months post-session to assess the progress and/or barriers towards completing an ACP.  


Bronchiectasis: Self-Management Education starts in Primary Care

1. Access to care: improving access to team-based care

Chronic Disease Self-Management education is part of our FHT's curriculum. After developing RN led patient self-management programs for hypertension, heart failure and chronic non-cancer pain, we used this experience to build an innovative nurse-led self-management program for bronchiectasis with the goal of improving the quality of care and patient experience.     While bronchiectasis is not rare it is currently a neglected disease which poses a significant burden to the health care system.  Learning to counsel patients regarding the modifiable factors can affect prognosis and improve patient quality of life.   Patient self-management education is needed to reduce symptoms, prevent recurrent lung infections, prevent emergency department visits and hospital admission.     In this RN-led self-management program, patients learn skills to prevent the deterioration of their lung function, and actively participate in their daily therapeutic treatments.    An initiative is now underway to offer a bronchiectasis education workshop for health care professionals in the greater Ottawa area. 


Improving access to specialist advice: incorporating eConsult into Family Health Teams

1. Access to care: improving access to team-based care

Excessive wait times for specialist care are a serious issue in Canada and are associated with patient and provider frustration, poor health outcomes, and dissatisfaction with care. eConsult is a secure web-based tool that allows physicians or nurse practitioners timely access to specialist advice for all patients, often eliminating the need for an in-person specialist visit. New technologies and changing workflows can negatively impact primary care provider workload. We will discuss ways to minimize this including incorporation of eConsult into Family Health Team referral workflow through the use of existing clinic staff and a delegate feature.     The Ontario eConsult Program has been created to enable timely and equitable access to specialist advice for all primary care providers in Ontario. The program integrates two successful initiatives: the BASE™ Managed Specialty model and the Ontario Telemedicine Network’s (OTN) Direct to Specialist model. The program includes four services: Champlain BASE™ regional service, Ontario eConsult service, Teledermatology and Teleophthalmology.     Building on the success of the BASE™ model and the evidence that eConsult demonstrates, the eConsult service has been implemented as a provincial program across Ontario with a regionally focused program model. We will highlight how this service has expanded to provide specialist advice across the province and the key success factors to successful uptake of the eConsult service.        


Sleep:  We all need it.  Starting an Interdisciplinary Sleep CBT-I Group in Primary Care - Worth The Effort

1. Access to care: improving access to team-based care

Insomnia is a one of the more common complaints that Health Care Practitioners hear from patients in the Primary Health Care setting.    Health Practitioners have long known about educating patients about sleep hygiene principles and providing pharmacological treatments. Since approximately 2005, CBT-Insomnia (CBT-I) has been recommended as first-line treatment for insomnia.  However, CBT-I treatment for insomnia has been available only through privately funded practitioners and not accessible for the majority of patients in our Primary Care setting.  In addition, more recent research has identified the negative short and long term side-effects of pharmacological treatments. One of the Family Physicians, the Pharmacist and the Occupational Therapist at McMaster Family Practice decided to start a CBT-I program. This program combined both Dr. Colleen Carney’s approach to CBT-I and the Occupational Therapy approach to managing activity in the context of insomnia. Our program has had excellent initial results.    

#11 System Navigation Made Easy

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

Family Health Teams see patients from multiple populations, and they need to connect those patients with services available in their communities that will help them get well, stay healthy, and use resources wisely.    You don’t need to know every single program, support group, and service provider out there – you just need to know where to look. is Ontario’s digital health and community information network – a free, publicly-accessible managed database that provides you with the comprehensive inventory of health and community services available in every region of the province. It provides you with accurate and up-to-date information in a standardized, easy-to-read format that you can share with your patients.    After attending this presentation, clinical providers and administrative staff will know how to use tools like catchment mapping displays, postal code searches and the clipboard function to give your patients specific, personalized information about services, taking into account the person’s location, accessibility needs, and language preferences, among other criteria.    You will be able to visualize opportunities for integration within your team’s business model, and also with other teams and external partners – using the website itself, regional tools and resources, or even by using, our unique online communication and collaboration platform. 


A Best Practice Guideline on Supporting Adults who Anticipate or Live with an Ostomy – Recommendations for Interprofessional Evidence-based Practice.

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

The Registered Nurses’ Association of Ontario’s (RNAO) Best Practice Guideline (BPG) Program is recognized around the world as a knowledge movement composed of rigorous guideline development and transformational approaches that are contributing to implementation science and robust evaluation methodology. The BPG development process follows a  rigorous methodology which includes a comprehensive systematic review process, integrating both Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and Confidence in Evidence from Reviews of Qualitative Research (CERQual) methods. In April 2019, RNAO published the second edition BPG: Supporting Adults who Anticipate or Live with an Ostomy. The BPG was developed with an interprofessional panel of experts, which included persons with lived experience.  The expert panel prioritized four recommendation questions and priority outcomes. A key area of focus was to explore the effect of an interprofessional standardized ostomy care program on organizational and individual outcomes. A systematic review was completed to identify relevant studies and formulate recommendations. The systematic review findings suggest benefits to implementing an internal expert-guided, standardized ostomy care program within health service organizations. Further, evidence suggests benefits when the following components of an interprofessional ostomy care program are included: perioperative education and counselling; discharge planning; scheduled home visits and telephone follow-up; and ongoing access to nurses specialized in wound, ostomy, and continence. The recommendations provide important guidance for the interprofessional team to enhance quality care for persons transitioning through the ostomy care continuum. 


NP-Led Adult ADHD Program within the FHT – Identifying and managing adults with ADHD and Transitioning Adolescents with ADHD back to primary care from pediatricians

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

ADHD is often overlooked in the adult population and can have numerous social implications if untreated. It can affect one’s success in their education, careers, and relationships. It is also associated with an increase in risky behaviour. Adults often present with a major mood or anxiety disorder, addictions, and a family history of ADHD. Our rural family health team has initiated a Nurse Practitioner-Led Adult ADHD Assessment/Management Program which patients are referred to if there is a suspicion of ADHD. Young adults that are discharged from pediatric care with an ADHD diagnosis are also referred into the program. The nurse practitioner provides all ADHD and comorbid assessments, initiates and manages their treatment if positive for ADHD, and follows the patients with regular periodic follow-up appointments. The program’s nurse practitioner consults with psychiatry as needed through OTN and with a local pediatrician specialized in ADHD management. The potential impact of this pilot program include timely access to ADHD assessments and management, more patients being diagnosed with ADHD that were previously undiagnosed and untreated, and the ability to ensure regular follow-up appointments and close monitoring of patients being treated for ADHD.


How to create an Ontario Health Teams Integrated Hub

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

Using Canadian implementations across the country, we will showcase how they have been successful in implementing an integrated, sustainable, innovative platform for their coordinated care needs.  These lessons learned will show how other jurisdictions like Ontario can leverage the integrated hub approach taken by other provinces to help deliver patient-centric solutions like eReferrals, Remote Patient Monitoring, EMR to EHR integration (from hospital to community), and mental health assessments.


 Optimizing Care for Individuals with Schizophrenia in an Urban Academic Family Health Team

3. Comprehensive team-based care

From the chart review, it was evident that patients in this demographic population have very low cancer screening rates and high rates of cigarette smoking.  In contrast, it was nice to note that 90% of the patients had the standard metabolic monitoring completed in the last 6 months. This, in addition to the HQO guidelines on community care for schizophrenia, helped to establish the questions on the survey.  The surveys were offered to patients, who met the inclusion criteria, by nurses at 3 clinics and a$10 honorarium was offered to complete the survey. In order to recruit patients for the interviews, the patients were then asked if they were interested in taking part in an interview about their physical and mental health. It would take 30 minutes and there would be a $20 honorarium.  From the 11 patients who completed the survey, 6 agreed to have this interview at their next appointment. From the survey, it was evident that patients in this demographic do not want more information concurrent smoking cessation programs. However 100% of the respondents wanted to speak to a pharmacist about their medication. In addition, 60% of the respondents wanted to get more information on diet and exercise and 40% on income security and budgeting. Information from both the chart reviews and surveys helped to inform the questions on the patient Interviews.  The interviews took place in conjunction with the patient’s regular visits with the Clinical Leader Manager and the local Quality Improvement Specialist. The patients all offered consent and were given Information about the project and the Quality Improvement Process. All of the respondents in the survey felt they were receiving excellent care in the Family Health Team and they all reported therapeutic relationships with their providers. In addition, the majority ranked their physical and mental health as being good or excellent. The interviews also corroborated that patients are very interested in having more information about their medication and, in particular, about side effects and new advances in antipsychotic medication. When asked about their thoughts on the low rate of cancer screening in this demographic, themes from patients were that they felt they required more time and resources to understand the screening process and time to discuss their questions and concerns. They also thought that print material to take home would be helpful. In relation to smoking cessation, themes from patients were that we should take a positive, proactive approach, for example how much money can be saved as opposed to COPD risk, etc. 


“Specialized Senior’s Clinic”: An Interprofessional Assessment Clinic to Improve Coordinated Care for Frail Older Adults

3. Comprehensive team-based care

The needs of frail older adults are more complex, often involving coexistent medical, functional, psychological, and social needs.  Comprehensive geriatric assessment (CGA) has become the standard of care for frail older adults.  With this in mind, the SSC was developed to improve the collaboration and coordination of care for frail older adults living in the community. The clinic was designed using a CGA and interprofessional collaborative model of care.  The interprofessional team runs the clinic one half day a month.  A maximum of 3 patients are booked per half day clinic.  Patients undergo a 2-hour assessment in which they rotate among the physiotherapist, occupational therapist, nurse and social worker.  The assessment includes various domains: patient’s concerns/goals, balance, mobility, cognition, ADL’s, IADL’s, elder abuse, advance care planning, home and social situation, mental health, nutrition, medication, vaccines, and physical health. The team develops an individualized coordinated care plan for each patient outlining the issues and recommendations. The recommendations may include referrals to other hospital clinics, community programs/services, recommendations for the family physician, or scheduling individual appointments with one of the SSC team members for specific interventions. The patient and physician receive a copy of the report.  The nurse provides a 2 week follow-up phone call to review the contents of the report and address any questions/concerns.  Clinical implications may include decreased emergency visits/hospitalization, decreased healthcare costs, improved patient experience with primary care services, improved quality of life for older adults, and optimizing interprofessional collaborative practice in primary care.


Helping Seniors Age Well

3. Comprehensive team-based care

With more and more seniors calling into clinic with questions about aging well, food choices, supplementation and how to prevent falls and maintain independence, our small primary care team decided it was time to offer a monthly practice-based group for seniors to address their concerns.  Our nurse, dietitian and physician decided to start with the topic of Eating Well- Aging Well using a novel patient centered, conversational approach.  Instead of using a traditional power point, didactic format, questions and answer cards were developed that stated the questions we commonly hear from our older patients. Cards were spread out over the table and participants were asked to pick one question they would like to talk about during the session.  We then went around the table, asking participants to read out each question and the group would have a conversation about what they think the answer might be. Evaluations were so positive the team decided to offer monthly topics.  Healthy Eating for the Holidays, Preventing Falls with Protein and Strength Training, Nutrition-Medication Interactions, Bowels and Bladder are some of the topics discussed with more than 25 seniors attending all sessions. Nutrition screening using SCREEN II AB has also been added to the sessions and seniors screening positive are booked for an individual followup nutrition visit.  Our Health Aging Series has been a win-win for patients and providers, giving seniors piece of mind and cutting down on non-urgent visits to the nurse and family physician.


The Benefits of a Nordic Pole Walking Program for Type 2 Diabetics in a Family Health Team

3. Comprehensive team-based care

This program encompassed weekly programs in which patients in the family health team with Type 2 diabetes and nurse practitioners participated in Nordic Pole walking within community settings in Milton Ontario. We recruited one hundred patients between January 1, 2014 and December 31, 2018.The program consisted of an intake medical assessment, weekly thirty minute Nordic pole walking sessions, anthropometric measurements, blood glucose monitoring, and self-reported mental health questionnaires. Feasibility was ascertained by assessing program delivery, program participation, on-site attendance in weekly clinics, and completion of survey questionnaires. Patient's provided informed consent. This study was approved through the Halton Healthcare Services Research Ethics Committee.


Integrating Depression Treatment into Smoking Cessation Programming: A Virtual Approach to Encourage Practice Change among Ontario Family Health Teams

3. Comprehensive team-based care

Individuals with depression are almost twice as likely to smoke cigarettes, achieve lower long-term abstinence rates and experience greater addiction severity and negative mood changes when making a quit attempt. Evidence has shown that integrating a self-help mood management component into standard smoking cessation counselling increases long-term quit rates by 12-20% in smokers with current and past depression. Family health teams (FHTs) are at an advantage to implement concurrent mental health and addictions treatment, as they can utilize the unique skills and services offered by interprofessional care team staff to provide holistic care. However, it remains unclear which knowledge translation (KT) strategy would be most effective for encouraging practice change among primary healthcare providers (HCPs).    The Smoking Treatment for Ontario Patients (STOP) program works in partnership with 80% of Ontario FHTs to provide cessation treatment to smokers making a quit attempt. In this study we randomly allocated 123 FHTs 1:1 to receive either virtual KT strategy: generalized monthly emails or a personalized knowledge broker, to promote the delivery of a brief mood intervention and self-help resource to patients presenting depressive symptoms. Through our work, we hope to address the knowledge gap in implementation approaches for integrating depression treatment into smoking cessation programming. We will also examine the potential impact of both strategies on patient quit outcome at 6-month follow-up and depression status. This initiative could result in system-wide implementation among FHTs, and has the potential to reach over 19,300 patients enrolled in STOP primary care settings across Ontario, per year.


Why Weight: Recognizing and Integrating Weight Management in a Chronic Disease Model

3. Comprehensive team-based care

Not only does the WHO now recognize obesity as a chronic disease, but it is also a treatment for other concurring chronic diseases. In anticipation of the release of updated Best Practice Guidelines for obesity management, we have taken the initial steps to address a systemic gap in obesity health care. As there is no such thing as a “healthy weight”, we propose to replace the term “obesity” with “weight-health”, to reduce bias and stigma. Based on research in program development and evaluation, and professional collaboration, our change model builds comprehensive, collaborative, evidence-based and patient co-designed capacity into our Guelph FHT and primary care model for weight-health management. Our change model utilizes the Edmonton Obesity Staging System (EOSS) to identify our target patient population of those with EOSS stage 1 or higher. Therefore, when weight becomes pathological, we absorb these patients into our chronic disease model of care, and specifically and intentionally offer weight loss as a treatment option.   Unfortunately, there are not a lot of structured programs than support weight loss for this population. Patients often turn to external medical or surgical bariatric programs; however, once the program is completed, there is no structured support available in primary care after their discharge. Evidence shows that patients regain weight with the cessation of treatment. We have developed a clinical pathway detailing local and community system navigation, patient care and measurable outcomes. We have collaborated with community partners to develop a strategy that enables primary care to support these patients before, after and/or throughout their weight loss journey and an EMR tool to facilitate the delivery of evidence based care to this patient population. 


Put your best foot forward: An interprofessional approach to implementing innovative diabetes care tools through adaptation of a validated foot assessment

3. Comprehensive team-based care

Background:  Evidence shows that foot complications, including ulcers, infection, peripheral neuropathy, peripheral arterial disease and amputation, are a major cause of morbidity and mortality in people with diabetes, and contribute to an increased burden on the health care system. In Canada, only 50% patients with type 2 diabetes have a foot assessment done annually; our primary care team was not far off with an estimated 40% completion. Patients receiving an annual foot assessment with a validated evidence-based tool as part of their routine diabetes care is an important component in the prevention of secondary complications and overall diabetes care.    Methods: An interprofessional primary care team was assembled to address the status of annual foot assessments being done in patients with type 2 diabetes in our Family Health Team (FHT).  Through an environmental scan it became apparent that more than just a validated foot assessment tool was required for team buy-in, implementation, adoption and quality patient care.  Thus, the team decided to develop a standardized evidence-based diabetes visit stamp, adapted validated foot assessment tool, and a comprehensive diabetes care toolbar within our EMR. Key stakeholders were engaged to test prototypes and refine the tools prior to implementation. Multiple forms of unit-wide communication were undertaken to disseminate and demonstrate the developed tools. 


Getting Fit with the FHT – Exercise Programs in Primary Care

3. Comprehensive team-based care

The Guelph FHT recognizes that the development and implementation of exercise programs play a key role in improving and maintaining the health of its patients, staff and community. Since 2009 the Guelph FHT have utilized Registered Kinesiologists and Health Promotors to develop exercise programs within a primary care setting. These programs have grown to address key areas, including; chronic disease management, chronic pain management, staff health and engagement, as well as community outreach and involvement. These programs provide a model frame work for health care organizations to implement exercise as part of their primary care strategy.     The chronic disease and chronic pain management exercise components have grown into a multifaceted primary care approach to exercise prescription. Patients receive personalized assessments and ongoing appointments with Registered Kinesiologists as well as have access to, in clinic, daily group exercises classes tailored to address chronic diseases and chronic pain.     The Guelph FHT addresses staff health and engagement through a city wide exercise initiative titled “The FHT to Move”. This program brings together staff throughout the organization as well as other community organizations to promote health through physical activity challenges and events.     The role of community partnerships and community outreach also plays an integral role in the success of the various programs. These include community partnerships for walking programs, Kinesiology led peer support groups, and referrals to population specific community programs.  


Dissemination and Evaluation of the "Direct Oral Anticoagulant (DOAC) Monitoring Tool”  in Family Health Team Pharmacy Practice

3. Comprehensive team-based care

The emergence of direct-acting oral anticoagulants (DOACs) has drastically changed the landscape of anticoagulation therapy. Although DOACs eliminate the need for regular INR measurements, monitoring is still essential – and ambulatory pharmacists can play a key role. This study involves the dissemination and evaluation an electronic-based monitoring tool in a family health team setting. The “Direct Oral Anticoagulant (DOAC) Monitoring Tool” was implemented at the Sunnybrook Academic Family Health Team in an effort to improve the documentation and involvement of pharmacists in the monitoring of patients on DOACs. The utility and acceptability of the tool will be assessed hereafter.


It takes a Village: Allied Health Team’s comprehensive approach for individuals with Chronic Pain

3. Comprehensive team-based care

Chronic pain is now well known to affect approximately 20-30 % of the population.  Multidisciplinary pain management programs are known to be the gold standard treatment. Most of these are very expensive and until recently were not available through OHIP funded clinics.  Our clinic began a group program over 8 years ago to address chronic pain.  We have expanded this over the years to include the addition of the exercise program. Allied health team members work together to offer group and individual intervention in our FHT to address the needs of the patients. When the classes are completed in sequence it provides the individual with 4 months of comprehensive weekly therapy and treatment and access to the team ongoing as needed. Three case studies will be presented following the trajectory of failures and successes on the journey to improve function and return to occupations of most importance to the individual .


Team based approach to Opioid management: a case for physiotherapy

3. Comprehensive team-based care

In order to address the ongoing problem of opioid management/addictions within our patient population the South East Toronto Family Health Team hypothesized that the provision of physiotherapy supports to address pain management would be effective in reducing patient reliance on opioid dependency to manage their chronic pain and/or mobility. This launched our planning efforts in how best to provide access to this important patient support with limited resources.   Working with our community partners at East York Physio (EYP) co-located on the 3rd floor at our 840 Coxwell clinic site, we drafted a memorandum of agreement (MOA). Under this arrangement SETFHT patients receive access to PT service within the confines of EYP premises from our part time physiotherapist who is job shared between EYP and SETFHT. We started the pilot 6 month PT service in fall 2018 with 2 days/week to our patients who met one or more of the following criteria: patients were between 19 and 65 years, have no or low private health insurance to access PT; and/or are currently prescribed opioids for pain management.  It was envisioned PT service would enhance their access to pain management & rehabilitative supports housed within a primary care environment. SETFHT physicians and other allied health providers could refer patients for 4-6 sessions. With the initial program success, this pilot and our MOA was extended.  


Obesity as a Chronic Disease Program: A Physician-Supervised, Centralized Inter Professional Model

3. Comprehensive team-based care

Obesity has been officially declared a disease by the the CMA since October 2015.  It is a significant risk factor for a wide range of disease, including T2DM.  Recent Canadian and American obesity guidelines are clear that obesity management be a team-based approach.   Primary health teams have the benefit of interdisciplinary care. However, recent analyses reveal challenges with interdisciplinary weight management, including lack of communication between team members, disparate messaging to the patients and lack of role-clarity.  (Asselin J et al. Challenges in interdisciplinary weight management in primary care: lessons learned from the 5As Team study. Clinical Obesity. 2015). There is a lack of training to medical students and residents in obesity medicine. Currently, clinical time is only provided to residents pursuing selective time.  Further, the billing construct in Ontario is a barrier to referral for expert consult.     North York Family Health Team (NYFHT) endeavored to address this community need by implementing an innovative Obesity as a Chronic Disease Program, a patient centered, multidisciplinary program lead by a physician and registered dietitian in collaboration with FHT pharmacists and social workers.  This lifestyle management program utilizes diet and behavioral management interventions, and is tailored to each individual’s metabolic disease and personal preferences. The program consists of a group session followed by individual follow up visits by the team.   


A collaborative team-based approach to diet and exercise in primary care: Experiences from primary care teams and patients in the CHANGE Program

3. Comprehensive team-based care

Effective collaboration within interprofessional primary care teams is essential to provide optimal patient care. The CHANGE program, Canadian Health Advanced by Nutrition and Graded Exercise, is an evidence-based diet and exercise program aimed at reversing metabolic syndrome and reducing cardio-metabolic risk in primary care settings. Unlike other lifestyle programs, the CHANGE program utilizes the complimentary skills of a family MD/nurse practitioner, dietitian and exercise specialist to take care of the whole patient. Given the lack of exercise specialists and the need for weekly/monthly diet and supervised exercise visits, many FHTs have been able to create innovative collaborations with community partners. Since 2018, more than 240 patients from 9 FHTs have been placed on the CHANGE program. Patient experiences of those participating in the program will be shared as well as experiences from staff offering the program. Evaluation metrics on diet, physical activity and outcomes relevant to cardio-metabolic risk over 12 months will also be presented.


Medication Reconciliation in a Rural Family Health Team

3. Comprehensive team-based care

At the beginning of our project, we sought to create a standard medication reconciliation process to decrease chances of medication errors, as we have many patients who access outside clinics and inpatient hospital care. Often, there is a communication breakdown between those institutions and the Family Health Team, resulting in medication lists within patient charts which are not up to date. Our aim was to ensure accurate medication information within the EMR for 70% of our cohort (adults diagnosed with diabetes and/or hypertension rostered to a specific Family Physician), ensure patients understood the purpose of each medication they took, and identify challenges experienced by providers attempting to reconcile patient medications within the EMR.  We utilized various tools including checklists and scripts for members of the health care team to establish a consistent process. Patients within our cohort identified with appointments between January – March 2019 were encouraged by receptionists to bring in their medications in a brown bag; they were given a Medication Reconciliation Form to complete upon arrival for their appointments. During their appointment with a Physician, Registered Nurse, or Nurse Practitioner, patients and the provider had a chance to go over the Medication Reconciliation Form together.   As we refined the process, we came to the realization that we would not meet our goal of having the EMR reconciled for 70% of our patients; we shifted our focus to understanding why this wasn’t possible.


Enabling Active Patient Self-Management of Stress through Group Workshops

3. Comprehensive team-based care

We identified stress as a common reason patients are booking mental health counselling appointments with their physician or nurse practitioner and one of the leading reasons the mental health counsellors are receiving referrals for counselling. In order to reduce staff workload for stress-related appointments and improve health outcomes for patients with a health condition affected by stress, we offer a group stress management workshop. The goal is to enable active patient self-management of stress by offering a group workshop that promotes health and supports that self-management. The course is skills-oriented and interactive and teaches patients a variety of techniques to better manage stress and reduce its impact on patients’ health. Patients benefit from the interactive nature of the workshop while they learn breathing and muscle relaxation techniques, improve their assertive communication, uncover and change negative automatic thoughts and thinking errors and explore the interaction of stress and sleep.


Community Care Health and Care Network Telepsychiatry Program: AN INTEGRATED CARE MODEL

3. Comprehensive team-based care


Narrowing Gaps in Health Services Through Collaboration: Introduction of a Social Worker Specializing in Children, Youth and Families in a Family Health Team.

4. Patient and family-centred care

One in five children in Ontario have a mental health disorder and there is an increase in children and families requiring mental health services. Early intervention and identification is key for stronger outcomes in children.     When working with children, one must address a person’s psychological needs. North York Family Health Team (NYFHT) adopted a collaborative approach when working with children and families.  A community needs assessment and feedback from NYFHT physicians and clinicians indicated a need for specialized services for children and youth. To address this gap, the NYFHT implemented a centralized child and youth social work role to support continuity of service for this this specialized population.     Through a case study we will demonstrate the streamlining of services, allowing us to take a client centered approach when working with children and families. Together, we worked towards a young man’s goals for recovery. The family did not need to access a navigator, or wait to access mental health services.  We addressed his medical and mental health needs when he needed it, allowing for early intervention.     Research suggests that early intervention is key for the long-term success of a person’s physical and emotional wellness. If we want to continue to provide quality care to our patients, we must be able to do this in a timely manner. NYFHT aims to reduce barriers to accessing mental health services for children and families. We will explore the data collected to date and what it is telling for future planning.  


The role of the Kinesiologist in the Family Health Team: A collaborative approach to patient care

4. Patient and family-centred care

There is currently a disconnect between individuals who require guidance in physical activity and the role that kinesiologists can play in health care. In primary care, despite the evidence that exercise promotion by family physicians can positively affect participation in physical activity in patients, the medical community seems to struggle with prescribing exercise due to lack of time and training. Registered Kinesiologists (RKins) are trained specialists in exercise programming and health promotion and have the ability to support the primary care teams by transforming exercise recommendations into actions for patients.   As health professionals, RKins understand the importance that exercise plays in the management of chronic disease and how to individualize exercise programming to minimize the risk of injury. The CHANGE program, Canadian Health Advanced by Nutrition and Graded Exercise, developed by professionals at Metabolic Syndrome Canada is a program that brings the expertise of the RKin to work with the Family Physician/Nurse Practitioner and the Registered Dietitian to provide a collaborative and interdisciplinary approach to patient health and well being.    In this session, you will learn how RKins across several FHTs have been successful in improving patient outcomes related to physical activity and experiences within the CHANGE Program. Key performance indicators measured include percentage of patients by low, moderate and high physical activity levels and physical activity in minutes per week by level of activity. Having a RKin on the interdisciplinary team can prove to be very effective in guiding, supporting and empowering patients to adopt a more active lifestyle.    


Integrating patient voices into primary care: co-creation of the Guelph FHT Patient & Family Advisory Committee

4. Patient and family-centred care

In an effort to bring a stronger patient voice to our FHT, we began to explore the idea of a patient and family advisory committee.   We attempted to ask and answer questions such as “What will this committee look like?”, “What will they do?”, “What will they be accountable for?”. We quickly realized that these questions should not, and could not, be answered without the voices of patients. As we began to form the committee, in an effort to avoid a “dictative” approach, recruitment efforts only provided a high level notion of what the PFAC would involve: identifying and offering suggestions on opportunities to incorporate patient perspectives in initiatives to improve primary care in the Guelph area.     We will share our journey launching the committee, where we worked together to create an individual style, structure, and mission that reflected, in some part, each members interests and ideas. We will share how specific goals and accountabilities were identified during early meetings to ensure members would have a strong connection with the committees work influencing primary care. We will share strategies used to promote accountability from FHT staff wanting PFAC feedback, an essential process to eliminate tokenism.     There is no doubt that our PFAC continues to mature and with this process our FHT is committed to continuously learning how to better support patient and family advisors in improving health care. Through sharing our lessons learned with other FHTs, we hope to promote embracing patient voices early in the launch of PFACs. 


Aurora-Newmarket Family Health Team Preventative Screening Blitzes

4. Patient and family-centred care

Cervical Cancer Screening Blitz Month October 2018  Breast Cancer Screening Blitz February 2019    Data search in EMR was performed to capture due and overdue patients for cervical and breast screening.     We contacted patients and scheduled them to see GP/BP/RN for cervical screening.    A personal letter, requisition and a list OBSP locations was mailed to patients aged 50-55 with no mammogram on file and followed up with a phone call.


Strengthening Collaborative Mental Health Care: Integrating the Perspectives of People with Lived Experience of Mental Health Challenges

4. Patient and family-centred care

Collaborative mental health care (CMHC) has been identified as a national priority because of its well-documented efficacy to improve clinical outcomes, cost-effectiveness of care and patient experience. A critical element of CMHC is the active leadership of patients to establish and act on care plans; optimally in CMHC, patient engagement occurs individually, and at the organizational level. As health systems implement CMHC more widely, it is critical to integrate client perspectives on what experiences and outcomes matter to them into CMHC design, delivery and evaluation. However, at present, client perspectives are wholly absent from CMHC literature, and people with lived experience (PWLE) have not been meaningfully consulted on these subjects. We conducted a qualitative study with PWLE as co-researchers and participants to explore the challenges and successes that PWLE face when accessing and/or using CMHC. Study findings were reviewed with multiple stakeholders including PWLE, primary care and mental health care providers, mental health advocates and CMHC researchers; these engagement and knowledge mobilization efforts generated numerous practice and policy recommendations to improve CMHC. Project learnings were also transformed into a toolkit that includes two workbooks and will be distributed to conference attendees. One workbook is aimed at healthcare providers in primary care and community-based organizations that support people with mental health concerns and can be used during client appointments. The second workbook offers some guiding questions and tips for people who have questions or concerns about their mental health and are interested to speak with their primary care provider.


Cannabis, Marijuana or Weed? – Developing health education for community needs

5. Community and social accountability

Research suggests that recreational cannabis use has negative health implications, especially for mental health and brain development in young adults under the age of 25 (Health Canada, 2019, & CAMH, 2018). There is still much room for further research on its effects on health and mental health (Hill et al., 2017, & Colizzi and Murray, 2018). This leads to further knowledge gap on the topic for health care providers, social service providers and general public alike.     Since the federal announcement of legalization of Cannabis, Toronto Western Family Health Team developed and delivered several education talks for a variety of audiences such as high school students, local residents, and mental health agency staff regarding the health and mental health effects of recreational cannabis use. Other inter-professional primary care teams have since approached Toronto Western Family Health Team to develop strategies for community health promotion regarding this topic.     In this presentation we will share how we identified this health education need in the community, how we effectively partnered with community organizations to discuss the effects of cannabis on the mental health and brain development of young adults under the age 25, and developed the workshop to meet the needs of each audience. While walking through this example we will share tips and resources you can use to implement in your health promotion programming in the community.


A journey of a thousand miles begins with a single step: A collaborative approach to knowing our community and filling the gaps

5. Community and social accountability

Understanding and meeting the needs of the community is a never-ending journey that requires thorough planning and skillful navigation. Completing a proper needs assessment and utilizing population demographics data can benefit the health needs of the community and guide practice, program and service planning; and even hiring practices.     Since Toronto Western Family Health Team opened the Garrison Creek site two years ago, we have intentionally focused on population health data for our outreach and programming. We actively engaged with the community, and built strong relationships and partnerships with numerous service providers and local resident groups.     In this process, we identified insufficient coordinated care in the community and co-founded (with Toronto public health) Mid-West Service Network, a health care and social service providers’ network in our catchment area. By the end of Year 1, over 30 inter-sectoral member organizations in the network met 6 times to share community resources, identified needs in the community, and collaborated on projects and capacity building as a team.     This presentation will walk you through the initial journey on which the Toronto Western Family Health Team – Garrison Creek embarked. We will share our obstacles and triumphs, and the lessons we learned along the way. This session will include community building principles that can be applicable to your target population, location, and partnership history with the community.


Fitness- Not just for falls prevention

5. Community and social accountability

Research tells us the multiple benefits for exercise including better sleep, digestion, more energy, improved mood, reduced risk of many chronic diseases, enhanced cognitive function, and more. At the OSFHT, we wanted to give our patients a safe place to participate in exercise under the lead of a health care professional not only for the above mentioned health benefits but also to address the high rate of falls and the growing waitlists for free exercise programs for older adults in our area. We started with one-fitness class 2x/week and have grown to 3 classes 2x/week in one year. Our patients complete 3 simple standardized tests for balance, leg strength, and mobility at the beginning and end of each 12 week session. Every patient has shown improvement on one or more of the tests, majority show improvements on all 3. The patients can tell you it is not the objective numbers that matter to them, it is all the other benefits they see in their lives: ADLs are easier, they can do more IADLs around the house, they are more confident walking, and best of all is the community that they have built- a group of strangers brought together by fitness. Our fitness classes are demonstrating the impact that fitness and socialization can have on patients lives- improved overall health- physical, emotional, mental, and spiritual.


Toward Trans Affirming Primary Care: An Interdisciplinary Toolkit to Improve Access to Services for Transgender People

5. Community and social accountability

Literature identifies that 73% of trans people in Ontario feel unsafe in a medical office and 30% avoid medical offices altogether. Forty three percent of trans Ontarians who have no family or social supports will attempt suicide; when supported solely by a health care practitioner, suicide attempts drop to 4%. These statistics call primary care stakeholders to action! As such, we have adopted quality improvement methodology to develop an interdisciplinary approach to build capacity within the GFHT to provide trans affirming primary care in our community.  Our work began with the formation of an LGBTQ+ health committee and arranging education events for staff. The committee and Guelph FHT leadership team hosted a panel discussion with members of the local trans community, which provided an opportunity to hear real experiences about primary health care access as a trans person. Notably, panellists identified a strong preference to receive trans health care within a primary care model.     We are piloting a project with 5 interdisciplinary providers (MD, RN, R.Pharm, NP, Registered Psychotherapist) to develop a practical and evidence based toolkit to improve access to and quality of trans primary care within our clinic. We identified prescribers (MDs and NPs) as a starting point for our change efforts with the aim to increase access to preventative health care and hormone therapy for our trans patients. To date, activities have included a survey of prescribers and the development of a TransHealth EMR tool to promote an evidence-based approach to clinic encounters and documentation.


Improving equity of access through electronic consultation: a case study of an eConsult service

5. Community and social accountability

Patients with complex circumstances pertaining to geography, socioeconomic status, or functional health often face inequities in accessing care, which can have serious consequences. Electronic consultation (eConsult) is a secure online application that allows primary care providers (PCPs) and specialists to communicate regarding a patient’s care. eConsult has demonstrated an ability to improve access to specialist care, and may be of particular use in cases of inequitable access. In this study, we examined how eConsult is used to improve equity of access for patients in complex circumstances by conducting a multiple case study of eConsults from seven patient groups: addiction, frail elderly, homeless, long-term care (LTC), rural, special needs, and transgender. Cases from these groups were selected from all eConsult cases completed between January 1 and December 31, 2017 using a data collection strategy tailored to each group. An access framework by Levesque et al. was applied to the data to examine different dimensions of access. By offering an in-depth exploration of select eConsult cases for patients from various complex populations, we explored some of the key benefits eConsult can provide to potentially improve equity of access. While our findings are encouraging, more research is needed to understand why patients in low equity areas face a longer wait time compare to the general population, and the impact that eConsults can have in improving health outcomes and wait times for this population is needed.


Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation

6. Enabling high -performing primary health care

Electronic consultation (eConsult) services can improve access to specialist advice. Little is known, however, about whether and how often primary care clinicians adhere to the advice they receive. We evaluated how primary care clinicians use recommendations conveyed by specialists via the Champlain BASETM (Building Access to Specialists through eConsultation) eConsult service and how eConsult affects clinical management of patients in primary care. This is a descriptive analysis based on a retrospective chart audit of 291 eConsults done between January 20, 2017 and August 31, 2017 at the Bruyère Family Health Team, located in Ottawa, Canada. Patients’ charts were reviewed until 6 months after specialist response for the following main outcomes: implementation of specialist advice by primary care clinicians, communication of the results to the patients, method, and time frame of communication. We found little evidence of barriers to implementing specialist advice with use of eConsult, which suggests recommendations given through service were actionable. With a high primary care clinician adherence to specialist recommendations and primary care clinician-to-patient communication, we conclude that eConsult delivers good-quality care and improves patient management.


A targeted approach to mitigating opioid risks for high—risk patients experiencing chronic non-cancer pain

6. Enabling high -performing primary health care

Summerville Family Health Team QI Committee is undertaking an extensive, phased approach to opioid risk management. The first phase of work involved the identification of patients who may be at greater risk of adverse effects from opioid use for CNCP.  This involved an immense amount of work to validate EMR data and determine high-risk patients. High-risk, CNCP patients were identified using the following demographic criteria: high dose opioid use, concurrent benzodiazepine use, mental health diagnosis, history of substance abuse and patients who were over the age of 65 years. The 2017 Canadian Guidelines for Opioid Use in Chonic Non-Cancer Pain were used to support the directions of this initiative.     Establishing a baseline of our ‘at risk’ opioid patient cohort across all sites of Summerville FHT enabled us to then move into the second phase of work whereby individualized patient reports were generated for each physician. The final phase of work will leverage this data to increase the use of opioid risk mitigation strategies and was included as a goal in the FHT’s 2019-2020 Quality Improvement Plan.  Strategies that will be implemented over the coming year include decreasing the number of CNCP opioid patients with modifiable risk factors (such as number of high dose opioid patients) and increasing the implementation of risk mitigation strategies (such as opioid contracts, academic detailing and patient education). Finally, Health Quality Ontario recommends all FHTs evaluate newly prescribed opioid patients and design a plan of action to maintain appropriate prescribing of new opioids. By coordinating our efforts to improve quality care using the Health Quality Ontario framework and taking the time to understand the FHT’s rostered opioid patients better, we anticipate the success of our opioid initiatives. This presentation may set in motion ideas for other FHTs to adopt a structured approach to opioid risk management.


Practice Lead-The launch of a new role to enhance IHP practice 

6. Enabling high -performing primary health care

Prior to this role implementation the team often hoped many improvements would occur but without dedicated time and resources shift in practice was slow and not always coordinated. As the Practice Lead role was implemented this allowed resources to be dedicated to ensuring the IHP roles at the FHT are utilizing best practices for primary care.     This poster will review how the launch of a Primary Care Practice Lead for IHPs at the Toronto Western FHT enhanced team based care by;     - enabling nurses at the FHT to work to scope,      -increasing knowledge of primary care topics with nursing      -creating a forum for IHPs to discuss practice concerns.      -worked with the IHP team to create a standardized appointment tracking system     -created a point of contact for educational resources and practice concerns     This has enabled the team to standardize and streamline well baby visits/physicals, review concerns with IHP referrals, implement new tracking tools for wound care, and develop new workload tracking tools with the input of the IHP team      


Performance data as a driver of quality improvement: Implementation and key learnings in a large, multi-site primary care organization

6. Enabling high -performing primary health care

Engaging healthcare providers in Quality Improvement (QI) activities are imperative to population health and enhancing patient care outcomes. Amidst clinical priorities in the practice setting, engaging providers continues to be one of the main barriers related to the success of QI endeavours. Performance feedback can be a practical and cost-effective strategy used in healthcare to support evidenced-based decision-making, enhancing the clinician’s ability to provide quality patient care.    Towards our broader organizational strategy and commitment to quality improvement, the North York Family Health Team (NYFHT) has implemented the use of performance data as a QI mechanism to improve patient care. The NYFHT’s internal QI plan has adopted strategies that include performance feedback reports as a driver to achieve annual patient care targets.     With support from the NYFHT QI Committee and leadership from the Quality Improvement Decision Support Specialist (QIDSS), priority indicators were identified:  1) De-prescribing geriatric patients on Sedative Hypnotics and Proton Pump Inhibitors (PPIs),   2) Improving follow-up rates for patients with diabetes requiring HbA1C testing,   3) Screening for geriatric falls risk, and   4) Preventative screening rates for cervical and colorectal cancer.   Performance feedback reports are generated by the NYFHT Data Manager, specific to each office location, and updated on a quarterly basis. Such reports include a list of patients requiring clinical intervention by the interdisciplinary team. Frequent reports from the Data Manager allows clinicians to receive feedback on the impact of their care, with the most up to date data available. As a collective, each FHT office works towards the annual targets identified in the QI plan. This initiative provides insight into the impact and sustainability of a performance feedback intervention in a multi-site healthcare organization.   


Demystifying EMR Technology Agreements: Reducing the burden of privacy due diligence

6. Enabling high -performing primary health care

Digital health technology is increasing in leaps and bounds and offers amazing tools to improve patient care.  Integrated health information is a key focus of this government and our patients need us to be technological savvy to continue to respond to their health needs.  When presented with new EMR technology opportunities, FHT leaders respond in one of two ways: (1) we hold our breath and sign agreements without fully understanding them; or (2) we separately invest scarce time and resources into legal contract and privacy reviews. When we sign without understanding agreements, we fail to identify risks to our patients and organizations.  When we decide to do privacy reviews, we sometimes miss out on time-sensitive opportunities or we may be told the process takes too long or we are the only ones concerned.      All FHTs struggle to balance opportunities with risk.  Privacy risks have become increasingly concerning to FHT boards as privacy litigation across the country has resulted in expensive settlements and high-priced damage awards for poor information management practices in all industries including health.      With the support of AFHTO, we identified the most common EMR technologies used by FHTs across Ontario and developed streamlined privacy checklists to explain the technology in lay language, identify the main risks, and prompt FHTs to ask the right questions of their clinicians and Board members. These checklists assist FHT leaders to understand common digital health technology tools and better explain the impact of those tools in their environments.     


Tips & Tricks for Being a Preceptor for Health Care Professional students

6. Enabling high -performing primary health care

Taking on students is a daunting a task for many Interprofessional Health Care Providers (IHPs).  However, the experience can be rewarding and enriching for both student and preceptor.  A little bit of preparation can go a long way to ensuring a worthwhile experience.  Through years of acting as preceptors, the Registered Dietitians at the South East Toronto Family Health Team (SETFHT) have developed a pre-, during and post rotation routine to help optimize the placement for all. We have had many challenges, including having three Dietitians at two different sites acting as preceptors.  We would like to share our experiences with the hopes of encouraging other FHTs and IHPs to take on this valuable, educational task which supports the development and growth of future healthcare professionals in our field.  We also hope that other IHPs will share their experiences, successes and resources


Tackling the Opioid Crisis through Academic Detailing

6. Enabling high -performing primary health care

The academic detailing service brings together a family physician and a trained academic detailer (clinical pharmacist) for a one-on-one discussion of ways to best address therapeutic challenges. Academic detailing strives to bring the best in balanced, evidence based and clinically relevant information. The first service visits focused on three areas key to addressing the opioid crisis, a) managing opioids, b) treating chronic pain, and c) managing opioid use disorder.  Academic detailing is somewhat unique as a best practice educational intervention in that a skilled detailer is able to customize information and recommendations to the clinician’s needs and practice setting. Academic detailers also equip family physicians with clinical tools and help them navigate local supports and resources.    Offering academic detailing by an embedded clinical pharmacist within the family health team (FHT) context is an innovation specific to the local Ontario context. Potential advantages include the already established relationships and the ability to support practice change beyond the initial visit. Since the service became available to physicians in March of 2018, over 338 visits related to opioid use have been conducted with family physicians across two large FHTs (Hamilton FHT and Thames Valley FHT). Based on the success of various academic detailing initiatives around the world, the embedded academic detailing service is expected to receive positive feedback, see measurable improvements in opioid management, and identify increased knowledge and confidence in the area of opioid prescribing among participating family physicians. 


Quality Improvement and Information Management Specialists in Ontario Nurse Practitioner-Led Clinics – Demonstrating excellent outcomes and patient-centred care in a team-based model

6. Enabling high -performing primary health care

There were three key initial steps to ensure that this new initiative could move forward across the province:     1) Creating collaboration and data sharing agreements (including access to the EMR) between each QIIMS and their respective NPLCs within each of the three regions;   2) Organizing and consulting with Steering Committees within each region to set priorities and harmonize quality indicators that will align with the strategic priorities of the NPLCs; and   3) Improving data standardization, performance measurement and enhanced reporting priorities both within and across each of the three regions.     To date, collaboration and data sharing agreements have been created and each of the three regions has an established Steering Committee composed of the administrative and clinical leads from each of the NPLCs in the region. This work is also supported by regular meetings among the QIIMS, as well as consultation with representatives from Health Quality Ontario and the members of the Quality Community from AFHTO. The main priorities from each of the three regions include:    1) Focusing on standardization of diagnostic codes;  2) Capturing more robust social determinants of health and patient complexity information;  3) Measuring a cross-NPLC Quality Improvement Plan (QIP) indicator on interdisciplinary health care delivery within NPLCs;   4) Developing standardized/customized queries/searches for quarterly reporting and QIP indicators; and   5) Creating an outcomes dashboard or story of the Ontario NPLC model.     Future work of the QIIMS will also focus on standardizing the reporting of the QIP indicators, questions asked within the patient experience surveys and quarterly reporting.


The Electronic Asthma Management System (eAMS) Improves Primary Care Asthma Management

6. Enabling high -performing primary health care

International asthma guidelines have recommended written asthma action plans (AAPs) for over 20 years, yet AAPs are seldom provided to patients. Similarly, assessment of asthma control using guideline criteria is rarely performed and asthma controller therapies are under prescribed. Multiple barriers underlie these evidence-practice gaps. Point-of care computerized clinical decision support systems (CDSSs) that provide complex patient-tailored decision support may address many of these barriers.   We developed the Electronic Asthma Management System (eAMS) to address care gaps and sought to measure impact on care. eAMS consists of: 1) a touch tablet patient questionnaire completed in the clinic waiting room; and 2) a point-of-care CDSS that receives and processes questionnaire data to produce real-time, electronic medical record system-integrated decision support (control status, medication recommendations, auto-populated AAP).   Various components of the tool were developed through qualitative studies and systematic literature reviews.  We then tested the eAMS in a 2-year interrupted time series study of usual care (year 1) versus eAMS (year 2) at 3 Canadian primary care sites. We included asthma patients aged >16 years. The study demonstrated that the tool improves assessment of asthma control, the quality of medication prescriptions, and delivery of self-management asthma action plans to patients by primary care clinicians.  We are now exploring strategies to scale the technology in order to provide access to providers across Ontario.