New Vision Family Health Team is a busy primary care practice in Kitchener, Ontario. On average, outcomes for patients in the practice who had been diagnosed with type 2 diabetes were not meeting clinical best practice guidelines. The team realized it needed to redesign its chronic disease management system to improve care for these patients.
The Athens District Family Health Team (FHT), located within the South East LHIN, serves 3,500 rostered and 300 unrostered patients. In November 2008, the team was experiencing a wait time of 27 days, as measured by the time to the third next available appointment. As a result, the registered nurse had to do telephone triage to fit patients into an already doublebooked schedule or offer telephone advice.