2. Supporting the implementation of primary care networks
- Date: 2024-10-24
- Concurrent Session: Concurrent Session A
- Time: 2:45– 3:30 pm
- Room:
- Style: Presentation (information provided to audience, with opportunity for audience to ask question)
- Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
- Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations
Learning Objectives:
Participants will learn to:
- Apply co-design to bring partners together across organizations to deliver integrated care within a Family Health Group by leveraging Specialized Geriatric Service providers;
- Learn about how the Electronic Frailty Index can help automatically flag frail patients in a primary care EMR who might benefit from specialized geriatric supports; and
- Use their OHT member organizations, and Primary Care Networks, to identify team members from existing staff who can work together, in a new way, to provide comprehensive care to older adults living with multiple chronic conditions.
Summary/Abstract:
The North Toronto Ontario Health Team (NT OHT) used the Electronic Frailty Index (eFI) to automatically identify older adults living with frailty in the EMR of a Family Health Group (FHG). These patients often require a team-based approach to care. So now what? In NT OHT, only 7% of patients have a primary care provider who has access to an interprofessional team. Geriatricians provide expertise to care for the most frail older patients. Systemic challenges of information flow between primary care and specialists, wait times, and variation in specialists’ inter-professional teams frustrates the optimal use of geriatricians’ expertise for both geriatricians and family doctors. The NT OHT convened partners across the continuum of care to meet the need for integrated collaborative team-based care for older adults using existing resources. The group: - Tested an algorithm, based on the eFI, that automatically screened a family physician’s practice, stratified older adult patients into mild, moderate, and severely frail categories; - Leveraged OHT partnerships among hospital teams, home care, primary care, and geriatric specialists to develop one team to wrap around older adults with complex needs; - Co-designed a Primary Care and Geriatric Medicine Team model that allows providers to work to full scope and collectively optimize patient and care-partner experience; and - Improved care efficiency through a process that supports the patient at the FHG practice – the patients’ medical home – documents a comprehensive care plan in the primary care EMR, and strengthens relationship-based care by centering care processes with the family physician.
Presenter:
- Jagger Smith, BHSc, MHA, Baycrest Hospital and NTOHT
- Kaitlin Siou, MD, MSc, CCFP (COE), Department of Family and Community Medicine, University of Toronto, Sunnybrook Health Sciences Centre and Baycrest Health Sciences
- Carla Rosario, MD PhD FRCPC, Geriatric Medicine, Department of Medicine, University of Toronto and Baycrest Health Sciences
- Adam Morrison, MSc, North Toronto OHT