Theme 2. Optimizing capacity of interprofessional teams
Presentation Materials (members only)
Collaborative Practice - Messy, Time-Consuming and Worth It.
Learning Objectives
To describe our Family Health Team experience developing and implementing a new interprofessional team process for complex medical patients identified through Health Links and older adults within the TAPESTRY study. We will show the participants how new eyes on a patient can develop new solutions and strategies and expand the ability to provide a preventive health care plan.
Summary
McMaster Family Health Team is an Academic Family Health Team located in Hamilton, Ontario with two sites serving over 31 000 patients. Our broad-based interprofessional team collaborates to maximize primary health care delivery and educational opportunities. We currently provide placements for 81 family practice residents and interprofessional learners. TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a twelve-month randomized control trial that fosters optimal aging for older adults living at home using an interprofessional primary health care team delivery approach centering on meeting a person’s health goals with the support of trained community volunteers, system navigation, community engagement, and use of technology. We are the lead organization for one of three Hamilton Health Links. Health Links targets individuals who use the health care system the most, particularly the use of the emergency department and frequent hospital admissions. The intent of the program is to change the way this population receives health care, driven by the development and implementation of coordinated care plans, and utilizing the insights learned to advocate for system-level change. By targeting specific at-risk populations for more intensive care planning, we uncover significant health and social issues. When these issues are addressed by the interprofessional team before they become crises, we can shift our focus to health promotion and prevention. The energy created when like-minded professionals work collaboratively is amazing and motivating. Through this process, we have developed greater insight into the scope and skills of our team members to enhance the quality of care of our patients.
Presenters
- McMaster FHT:
- Kiska Colwill, Clinical Pharmacist, Assistant Clinical Professor
- Martha Bauer, Occupational Therapist
- Michael Spoljar, Nurse Practicioner, Assistant Clinical Professor
- Dan Edwards, RSSW, System Navigator
- Laura Cleghorn, Research Coordinator TAPESTRY, School of Nursing and DFM
Authors and Contributors
- McMaster FHT/McMaster University Department of Family Medicine:
- Betty Delmore, Nurse Practictioner, Assistant Clinical Professor
- Dale Guenther, MD, co-director, Professor
- Doug Oliver, MD, Associate Professor
- Glenda Pauw, Registered Dietitian, Assistant Clinical Professor
- Jessica Peter, MSW, Research Coordinator, TAPESTRY & MedREACH