Theme Description: Interprofessional comprehensive primary care is the foundation of a sustainable responsive health care system in Ontario. Primary care teams work with patients to develop clinical services that respond to the expectations and needs of their patient population. This theme is focused on the comprehensive aspect of primary care. Presentations in this stream will showcase programs and services that integrate the interprofessional team and focus on a continuum of care for patients on everything from health promotion, illness prevention through chronic disease management to palliative care.
A7 Closing the primary care loop following hospital discharge – The Markham FHT Medication Reconciliation Program
The Markham FHT Medication Reconciliation Program serves to prevent medication related issues post hospital discharge and the potential for readmission through a standardized documentation process whereby patients and physicians will be able to know with 100% certainty what medications the patient is currently taking. The goal of the program is to obtain the “best possible medication list” when patients are discharged from the hospital and facilitate seamless transition from the tertiary care setting back to primary care.
B7-a The Health Promotion 6Pack (Hp6): Motivating Patients to Change Unhealthy Behaviours in Clinical Practice
How can healthcare practitioners effectively address chronic disease prevention with their clients? This dynamic workshop is designed to help practitioners improve their skills in screening, assessing and intervening with even the most complex or “resistant” clients. The “6Pack” approach (smoking, alcohol, diet, physical activity, stress tolerance and sleep) will be introduced as a novel method of addressing chronic disease prevention in an integrated way.
B7-b Respiratory Care: From Case Finding to Rehab and Comprehensive Partnerships
3. Case Finding and Managing Chronic Obstructive Pulmonary Disease
4. Exercising the Option to help those with COPD- a Family Health Team approach to Pulmonary Rehab
5. Comprehensive Regional Respiratory Care Program
The aim of the London Family Health Team (LFHT) was to improve outcomes for patients with COPD, while ensuring our care is patient-centered. To achieve this, the LFHT developed a program centered on evidence-based guidelines for case-finding and management of individuals with COPD.
The Stratford Family Health Team Respiratory Clinic, is a nurse-led program, providing four basic work streams: spirometry testing (to confirm diagnosis of a lung condition and assist in management), patient education regarding self-management of a lung condition (COPD, Asthma), Smoking Cessation counselling, and Pulmonary Rehab – to provide a monitored, community supported exercise and education program in an area where access to pulmonary rehab is very limited. The specific benefits in this area will be the focus of the presentation.
The third presentation will showcase the creation of a successful collaboration with 6 FHTs (Windsor, Amherstburg, Harrow, Leamington, Tilbury, Chatham- Hent) and Asthma Research Group (ARGI) within Erie St. Clair LHIN with community based physician leaders, utilization of the CIHR knowledge-translation (KT) framework to contribute to multi-level health system innovation, facilitate guideline implementation, and improve health outcomes, with modest program expenditures in community primary care practices.
C7 Treating Insomnia in a Family Health Team
Chronic insomnia does not disappear on its own. Left untreated, it continues for years, contributing to poor quality of life, increasing the risk of major depression, compromising glucose metabolism and increasing the risk of type 2 diabetes. The Family Health Team is the ideal place to treat insomnia shortly after it is reported to the family physician. There are very effective treatments; the first-line recommended one in medical guidelines in North America and the UK is Cognitive Behavioural Therapy for Insomnia, or CBT-I.
D7 Advances in Mental Health Care: Telepsychiatry Collaborative Care Model/Anxiety Group
5. Integrative Telepsychiatry Collaborative Care: Increasing Patient Access and Provider Confidence for Adult Mental Health
6. Ten Years of Anxiety Group at a FHT-What Have We Learned
People are more likely to consult their family physician about mental health than any other provider”. Mental health commission of Canada advised that one of their priority recommendations is to therefore “expand the role of primary health care in meeting the mental health needs”. With a needs assessments proving a lack of mental health consultants we qualified for increased sessional funds. It was evident that an innovative approach would be needed to address this gap in care. Our presentation will establish how telemedicine effectively and efficiently enhances the comprehensive care for patients with mental health concerns.
E7-a Patients supporting patients: self- management in Chronic Pain
The evidence suggests that patients experience poor quality of life and deterioration in their condition during this waiting period. The Chronic Pain self- management program, a six week group workshop facilitated by 2 leaders 1 or both of whom are volunteers living with chronic pain themselves, provides participants with support, self-management and coping skills to help manage their pain. The positive reaction to the program across Ontario suggests that it can make a valuable contribution to the management of chronic pain.
E7-b Identifying and Managing Challenging Complex Chronic Conditions: A FHT/Health Link Initiative to Address Frailty, Complex Geriatric Conditions, and High Health System Resource Use. (presentation to follow)
The “C5-75” (Case-finding for Complex Chronic Conditions in seniors 75+) program has been developed by the Centre for Family Medicine (CFFM) FHT to address frailty in primary care by systematically screening for frailty amongst all persons 75 years of age and older and addressing potential underlying causes using pro-active, evidence-based interventions. Similarly, the “Community Ward” project has been developed to address the unmet needs of community- based patients who are high users of health system resources.
F7-a Advanced Care Planning: practical implementation tools and reflections from two Family Health Teams (presentation to follow)
1. Advance Care Planning: A Quality Improvement Plan Toolkit for Primary Care Teams
This presentation will showcase the Advance Care Planning (ACP) quality improvement (QI) toolkit developed by Cancer Care Ontario to support Primary Care Teams who wish to include ACP as part of their QIP.
2. Advance Care Planning: What we can learn from the experiences of primary care providers in the East Toronto Health Link.
The East Toronto Health Link has developed an interdisciplinary facilitator model of the ACP process. The session would provide an overview of the interdisciplinary model, approaches to common barriers to ACP in primary care and an approach to incorporating ACP into routine care of patients within a family health team.
F7-b Finding a BETTER Way to Chronic Disease Prevention and Screening: The BETTER 2 Program
The BETTER Program aims to transform practice and brings together primary care providers, policy/decision makers and researchers to work towards improving CDPS in primary care. Using the BETTER toolkit, the PP determines which CDPS maneuvers the patient is eligible to receive and through shared decision-making and motivational interviewing, develops a unique, individualized “Prevention Prescription” with the patient.