Theme 3. Strengthening collaboration within the interprofessional team
Presentation Details
- Date: 10/18/2016
- Concurrent Session E
- Time: 10:45am - 11:30am
- Room: Metropolitan Ballroom West
- Style: Presentation (information provided to audience, with opportunity for audience to ask question)
- Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
- Target Audience: Clinical providers, Representatives of stakeholder/partner organizations
Learning Objectives
- Attendees will understand how they can implement best practices in quality improvement initiatives
- Attendees will learn about gaps during transitions of care that highlight needs for further system integration
- Attendees will understand how members of the multidisciplinary team can be efficiently involved in the post-hospitalization phase to reduce complications at this stage
Summary/Abstract
Data collected from the CVFHT EMR shows an 84% reduction in patient readmissions and a 16% improvement in post-hospitalization follow-up rates using various members of the multidisciplinary team from Jan 2015 to March 2016. The HDP only considers follow-up rates with physicians; in contrast, the CVFHT considered a valid follow-up as one where a contact is made with an MD, NP or RN. This method optimizes the role of various team members, facilitates a sustainable process and supports patient access to primary care. Re-hospitalizations were prevented and home visits were made same day as needed, consistent with patient-centered care.
Presenters
- Gordon Canning, Nurse Practitioner, Credit Valley Family Health Team
- Heather Hadden, Pharmacist, Credit Valley Family Health Team
- Inge Bonnette, Registered Nurse, Credit Valley Family Health Team
- Claudia Mazariegos, Registered Dietitian, Credit Valley Family Health Team
- James Pencharz, MD, Credit Valley Family Health Team
Authors & Contributors
- Hilal Syed, Quality Improvement Decision Support Specialist at the Credit Valley Family Health Team
- James Pencharz, Family Physician, Credit Valley Family Health Team