Theme 1. Population-based primary health care: planning and integration for the community
Presentation Materials (Members only)
Learning Objectives
The purpose of this presentation is to share the knowledge we have gained through our Medically Complex Patient Pilot Program and the changes in practices that have resulted in reaching out to more patients and their caregivers.
- How to identify patients.
- How to determine which partnerships can best serve the patients.
- How to provide health care when those most in need don’t show up.
- How Mental Health, addictions, physical health and crime can be tackled together with success.
Summary
The Family Health Team interdisciplinary model has increased accessibility and revolutionized primary care. However, complex patients with significant medical and social problems require a different approach to providing care. During our Medically Complex Patient Pilot Program (MCPPP) some of the most complex patients identified by our partners did not come to appointments and were frequently unreachable. These were often folks with no phone, no fixed address or had mental health and addiction problems which made travelling to appointments and or making appointments near impossible for them. The Innovation Centre is an organization in Sault Ste Marie which uses data to drive innovation. They identified an area of the city where a significant number of residents are marginalized and economically and socially disadvantaged. It indicates that this area of the Sault has the highest poor academic performance and poor health, the highest crime rates and mental health and addiction issues. The police had already initiated a Neighbourhood Resource Centre (NRC) located in the heart of the identified region where frontline Mental Health workers work side by side with police officers to serve the population in a better way. We identified a lack of primary care through a community engagement survey funded by NELHIN and with support from Police Services, the Resource Centre was equipped with an examination room and a weekly drop in clinic was started. Through our MCPPP and the NRC, we have forged collaborations with various agencies to identify and address a broad spectrum of concerns, including medical and social issues. Regular case conferencing that may include the patient keeps everyone involved connected. Thus far there have been plenty of anecdotal reports of better chronic disease management and emergency room diversion and these stats will be followed.
Presenters
- Dr. Alan McLean, MD, CCFP; Physician Lead, Superior FHT
Authors and Contributors
- Superior FHT
- Dr. Alan McLean, MD, CCFP, Physician Lead Superior FHT
- Michelle Brisbois, Interim Executive Director, Superior FHT
- Susan McLean, RN; Director, Clinical Services and Program Development, Superior FHT