PDF Version - South East Toronto Family Health Team

2009/10 Annual Report1

CONTENTS OF REPORTMessage from the Chair and Executive Director …………………………………………………………………………… 3A Snapshot of South East Toronto Family Health Team ………..………………………………………………………. 4Our Team MembersOur Community PartnersPrograms and Services Highlights …………………………………………..……………………………………………………. 5‐8Interprofessional Diabetic Foot Wound Healing ClinicCelebrating Innovations in Health Care Expo 2009Healthy Weights ProgramCollaborative Change Leadership CoursePoint of Care Anticoagulation ClinicHealthy Work Environments Innovation Grant Fund ProgramJoint visits for Diabetes Care by dietitian and pharmacistFlu Assessment Centre …………………………………………………………………………………………………………………. 9Commitment to Quality Improvement ………………………………………………………………….…………………… 9Growth of the South East Toronto Family Health Team ………………………………………………………….……. 10The South East Toronto Family Health Team (SETFHT) is an academic Family Health Team affiliatedwith the Department of Family and Community Medicine, University of Toronto.We are a team of health care professionals that provide a full range of primary health care servicesand programs to the residents of South East Toronto. The South East Toronto FHT includes a team ofdoctors, medical residents, nurse practitioners, nurses, dietitians, social workers, pharmacist, carenavigator, mental health/addictions counsellor, physician assistant, chiropodist, health careprofessional students/interns and a full administrative team.OUR VISIONA leading academic family health teamthat improves the health ofour community.OUR MISSIONWe provide comprehensive primaryhealth care services to our communitythat are innovative, collaborative andinterprofessional.We commit to excellence in traininghealth care professionals of the future.SETFHT Board of DirectorsFrom L to R: Dr. Kevin Workentin (Treasurer),Dr. Geordie Fallis (Chair), Dr. Tia Pham (840 Coxwell FHOrepresentative), Dr. Marcus Law (President &Lead Physician)2

Dr. Geordie FallisChair of the BoardMESSAGE FROM THE CHAIR AND EXECUTIVE DIRECTORThis past year has been one of outreach, innovation, and education. The South East TorontoFamily Health Team has evolved from a small doctor group with a very small administrative staffto well over fifty personnel. Entrepreneurs consider this a “medium‐sized business.” However,business at SETFHT is far from being “usual”.This last year saw a terrific organization challenge and service with the worries of an impendingH1N1 flu epidemic. SETFHT was instrumental in inoculating several thousand worriedconsumers. It also served as one of six Flu Assessment Centres for the City ofToronto. Our staff was recognized by Toronto Public Health for their work and compassion.New initiatives within the Family Health Team allow us to go beyond the traditional ways ofdelivering care. A memory clinic to assist our families with loved ones who find it exceedingly difficult to cope withthe loss of their independence due to their forgetfulness is recently opened. This is an Interprofessional teamapproach composed of many of our health providers including nurses, pharmacists, social work, dietitians, andphysicians.Patients encouraged to take control of their own health with assistance from trained health worker has hadencouraging results. This Stanford University initiative is called PATH (Personal Action Towards Health).With the advent of telemedicine and our abilities to care for patients in the home, SETFHT is involved in creating morehome based care. This involves going to where the patient is rather than bringing them to the hospital for definitivetreatment. The creation of a “virtual ward” program in conjunction with the Toronto East General Hospital is anexciting innovation. This program has been selected to present at a national conference in Montreal this fall.As we look forward to the opening of our satellite clinic at 1871 Danforth Avenue, it is gratifying to have several of ourtrainees rejoin us at our new site. This ensures rejuvenation and a robust succession plan. These physicians havebeen trained in an Interprofessional atmosphere which bodes well for the future of patient and family‐centered care.Much of the success and forward thinking of the SETFHT is due to the commitment of its staff to accept thechallenges of change with aplomb. We are very fortunate to have a group of health care providers who trulyembellish the vision of being one of the leading academic family health teams that improves the health of ourcommunity.In 2009/10, the South East Toronto Family Health Team (SETFHT) continued to build upon thefoundations that have been set in place since the commencement of the FHT initiative withthe focus on continuing to improve access to comprehensive patient‐centric team‐basedprimary health care. As we continue to grow and our programs continue to develop, we getcloser to realizing our vision and being a leader amongst our peers.This year, we saw a lot of focus on quality improvement with the integration of conceptsthat were learned through the QIIP Learning Collaboratives. As we start moving into anenvironment of accountability and ensuring Excellent Care for all Ontarians, measuring patient outcomes and workingat office practice redesign becomes very important in ensuring we are providing the best care we can to our patientsand our community.With 2010/11 upon us, we look forward to developing and implementing new programs and services, embarking onnew initiatives, and building new partnerships that will enable us to further work towards a more accessible andhigher quality of primary health care in our community. We also look forward to continuing to develop our secondsite on the Danforth and watching our successes continue to grow!3Kavita Mehta,Executive Director

A SNAPSHOT OF SOUTH EAST TORONTO FAMILY HEALTH TEAMThe South East Toronto Family Health Team is committed to meeting the Ontariogovernment's strategy to improve access to comprehensive primary health care forOntarians by: Reducing the number of unattached patients in South East Toronto; Keeping Ontarians healthy; Reducing wait times; and Providing better access to primary health care services.Your Team MembersFamily DoctorMental Health/AddictionsCounsellorChiropodistClinical PharmacistNurse PractitionerMedical ResidentPatient andFamilyCare NavigatorRegistered DietitianAdministrative TeamSocial WorkerRegistered NursePhysician AssistantOur community partners working together for our patients4

PROGRAM AND SERVICES HIGHLIGHTSDiabetic Foot Wound Healing ClinicThere are limited services fordiabetics requiring foot care in thecommunity. Most patients at risk fordiabetic ulcers are seen by aspecialist for treatment or end up inemergency departments with foot infections increasingtheir risk of amputations. In January 2009, South EastToronto Family Health Team opened a Diabetic FootWound Healing Clinic with assistance of aHealthForceOntario grant. The clinic’s focus was todevelop an interprofessional wound care team in order toprovide comprehensive assessment and treatment forpatients with diabetic foot ulcers in a primary care setting.Clinics were held for a ½ day biweekly initially and thendue to demand, increased to weekly. Patients werebooked to see a Registered Nurse and Chiropodist fordiabetic foot assessment, treatment and education.Subsequently, patients also saw a Dietitian, Pharmacist,Care Navigator and Mental Health Addictions Counsellorfor issues related to their diabetes diet, medications,community resources and mental health/smokingcessation (as required).The clinic ran fromJanuary to September2009 with a total of 57patients seen – 50 werereferred from thecommunity byspecialists such asEndocrinologist, Plasticsurgeons andcommunity physicians. Ajai Rooprai, SETFHT ChiropodistThe rest were existing SETFHT patients.The impact on patients was significant as most patientswere not receiving regular foot care in the community norhad many received diabetic foot education. The majorityof patients had their wound healed within 3 months. Welearned that diabetic foot care can be provided in primarycare at a significant cost savings by avoiding costlyspecialist care in hospital.Some examples of feedback from patients are: “The clinic has been very helpful in getting my woundsunder control and getting me on my way to walkingproperly.” “If it weren’t for this clinic, I may have lost my feet!”An educational workshop was held for community nurses,diabetic educators and CCAC coordinators.Educational modules were also developed for medicalresidents and physicians in the community on diabeticfoot assessment and treatment.The launch of the Interprofessional Diabetic Foot Wound Healing ClinicCelebrating Innovations inHealth Care Expo 2009Both the Interprofessional Diabetic FootWound Healing Clinic and the HealthyWeights Program were invited to showcasethe programs at the November 2009 HealthCare Expo at the Metro Convention Centrein the Meeting Community Needs ThroughIntegrated Care category. This Ministry of Health and Long‐Term Careprogram celebrates and recognizes innovation in health care and provides anopportunity to showcase the hard work of Ontario’s health care providers.5

Healthy Weights ProgramThe Healthy Weights program is a program designed to help patients makehealthy lifestyle changes to facilitate a weight loss of 5‐10% of their bodyweight. This will lead to a lowering of their risk of developing chronic diseaseconditions. The program is an innovative partnership between SETFHT and theCity of Toronto Parks, Forestry and Recreation.SETFHT patients who are identified by their health care provider to meet the criteria for the program areoffered a combination of services including: Individual counseling with a Dietitian and Registered Nurse. A Dietitian meets regularly with patients tohelp patients learn about healthy eating and set goals. The nurse discusses health implications relatedto unhealthy weights and follows the patient while in the program. Individualized activity program developed by a recreationist from the City of Toronto. A PhysicalActivity and Recreation Specialist meet individually with patients to find out their interests and developa unique program including physical activity as part of their daily life. 8 weeks of Cognitive Behavioral Technique (CBT) group sessions with a Social Worker. These groupshelp patients learn more about their own thoughts, feelings and actions and share their challengeswith others facing the same issues.In 2009/10, 66 patients were enrolled into the program. The average weight loss was 13.2 lbs or 5.4% of theirbody weight. Three CBT groups were held over the course of the year and due to their success, has lead to thedevelopment of an advanced group for those attending the initial CBT group. The advanced group providespatients with the chance to develop further techniques to support healthy living choices.Collaborative Change Leadership CourseThe collaborative change leadership course is a certificate coursefor health care professionals offered through University ofToronto and University Health Network in which participants areexpected to select and complete an initiative using changeleadership knowledge and skills to enable interprofessional carein the participant’s organization. The initiative that Jennifer Lake,Julie Seale and Tiffany Carroll focused on was the creation of acommunication framework for new programs and services. Toaid in the development of this framework a pre‐survey, assessinginterprofessional collaboration (IPC) in SETFHT, was created anddisseminated and a post survey will follow. In addition, avoluntary IPC workshop was developed and facilitated by Jen,Julie and Tiffany, and delivered to SETFHT employees. Thisworkshop focused on a patient case to demonstrate current andbest practices in IPC, to define IPC and its context in Ontario’sprimary healthcare system. Since this, many examples of IPChave been spread throughout the clinic in various programs suchas the Case Conferencing, The Healthy Weights Program, TheDiabetes Program and the Memory clinic. The communicationframework is in its final stages of editing and we look forward topiloting the framework on future programs and services.IPC WorkshopCreative Map of CCL Journey6

Point of Care Anticoagulation ClinicProviding services to patients since April 2008The Point of Care (POC) Anticoagulation Clinic has been providing clinical services to the patients at SETFHTsince April 2008. Since it has started, 166 different patients have been managed by the Anticoagulation Clinic;currently there are 97 active patients (out of 159 warfarin patients at SETFHT).Since integrating anticoagulation management into a clinic format, we have been able to follow statisticsmonthly (see graphs below) about the patients achieving target INR (defined as latest INR, within 6 week,between 2‐3.5) and those missing their INRs within the past 5 week period.This clinic has allowed patients to have efficient and timely access to their INRs and warfarin management.This has led to a high rate of INRs within target, which should translate to better care and less adverse effects.At an organization level, the clinic has allowed an opportunity for medical residents to have practicalexperience managing patients on warfarin. There are 4‐6 residents trained every 8 week Family medicine blockat SETFHT.Healthy WorkEnvironmentsInnovation Fund GrantProgramIn December 2009, SETFHT received a grant from theHealthForceOntario Healthy Work Environments Innovation FundGrant Program 2009/10. This project also included the collaborativeefforts of a number of FHTs ‐ CANES FHT, Credit Valley FHT, EtobicokeMedical Centre FHT, Markham FHT, North York FHT, Sherbourne FHT,Summerville FHT and Upper Grand FHT. As part of the deliverablesfrom the “Creating a Healthy Workplace Culture to SupportOrganizational Wellness for the Interprofessional Family Health TeamMembers” project, a number of health and safety resources weredeveloped and a DVD was sent to all the FHTs and Nurse Practitioner‐Led Clinics in the province. QIIP also hosted the materials on theirwebsite (http://www.qiip.ca/healthyworkplace.php).7

Joint visits for Diabetes Care by dietitian (Tiffany Carroll) andpharmacist (Jennifer Lake)Presented at the Ontario Interprofessional Health Collaborative IPE Ontario January 2010Late in 2009, we trialed a health care delivery system forpatients with diabetes to provide care simultaneouslywith the dietitian and pharmacist to promote and modelinterprofessional collaboration. We thought that sincepatients in our clinic having insulin adjustments aretypically seen by the dietitian & the pharmacist that bycombining the visits, the patients would spend less timein the clinic, the dietitian and pharmacist would learnfrom each other, care plans would be bettercommunicated and there would be less duplication ofservices.We piloted on four patients & presented a poster with theresults of these 4 visits at the IPE Ontario conference heldin Toronto, January 2010.OutcomesSpecifically surrounding diabetes care, the patients whowere seen by the 2 providers all had improved blood sugarcontrol over time, but as important, patients felt that theycould manage their diabetes better.From an organizational standpoint, this was a newhealthcare service delivery for our patients and has beenused by other providers for other diabetes visits, includingRN and dietitian and for other healthcare providers withdifferent patient populations.8

From November 16 th to December 1 st , 2009 SETFHTonce again lived our vision when the front half ofthe clinic at 840 Coxwell Avenue became a FluAssessment Centre for the City of Toronto. As partof the City’s pandemic response, the Centreprovided health assessment, treatment and referralsfor people with flu‐like symptoms. At noted byToronto Public Health, the SETFHT site was the mostsuccessful and had the best operations of the 5Centres that rolled out in the city. Collectively, wesaw 319 individuals in the community that may haveused the emergency room at Toronto East GeneralHospital for their symptoms and treatment. Thiswas a great example of how primary care DOESmake a difference in the community. To thankeveryone that participated in the FAC, we received aplaque of appreciation by Toronto Public Health.The fall of 2009 was also busy with H1N1vaccination—over 4,100 people in the communitywere vaccinated over a short 2 months.FLU ASSESSMENT CENTRECOMMITMENT TO QUALITY IMPROVEMENTQIIP Learning CollaborativesThe focus of the QIIP Learning Collaboratives was tosupport the introduction of a quality improvementagenda within FHTs. The three main areas of focus were: Chronic Disease Management (Diabetes) Preventive Care (Colorectal Cancer Screening) Office Practice Redesign.With the support of a Practice Facilitator, SETFHTdeveloped a QI team and implemented a number ofpractice improvements using the model of Plan, DoStudy, Act (PDSA). Outcome measures were used andmonthly reports were run to see whether these smallchanges in practice resulted in improved clinicalmeasures. The QI team attended three Learning Sessionswith action periods in between.92009/10 saw the following improvements implementingwith the FHT: Simplified version of the FOBT instructions forpatients requiring testing and translation of theseinstructions into 5 different languages. Mapping out the process within the clinic for cancerscreening. Development of a diabetes planned visit approach forType II Diabetes. Development of a self management tool fordocumenting patients self management goals. Development of a clinical foot assessment tool forhealth care providers to used with patients withdiabetes Creation of same day appointments for eachphysician to improve access for patientsFuture quality improvement work involves SETFHT beinginvolved in six QIIP Learning Communities related toAsthma, COPD, Hypertension, Diabetes, IntegratedCancer Screening and Office Practice Redesign.

GROWTH OF SETFHTOver 40 individuals from the community attended our Pre‐Demolition Open House at 1871 Danforth Avenue on June 11 th ,2010. We had speeches from two of our closest communitypartners, Rob Devitt (President and CEO, Toronto East GeneralHospital) and Dr. Lynn Wilson (Chair, Family and CommunityMedicine, University of Toronto). With a number of unexpecteddelays, we are still hopeful that we will be able to open this newsite in late spring/early summer 2011. Demolition of the propertyis occurring in Summer 2010 and it is hopeful that construction ofthis 5‐storey (basement included) building will commence shortlyafter.Rob DevittDr. Lynn Wilson2009/10 was a very eventful year – we have had a lot of activities and should be very proud of all of ouraccomplishments. 2010/11 will be just as busy and will bring with it many challenges but some greatopportunities to be leaders amongst our peers. Some activities we already have engaged in or areanticipating to participate in include:Integration of a physician assistant in a Family Health Team (HealthForceOntario grant programinitiative);Development and roll out of the virtual ward program, initiated to provide care to unattachedpatients that are most medically and socially complex in their home setting alongwith Interprofessional case management;Deployment of Ontario Telemedicine Network Telehomecare equipment to monitor vitals of patientsat home with COPD, CHF and/or diabetes;The SETFHT Memory Clinic which is composed of an Interprofessional team that provides earlydiagnosis and treatment for people experiencing problems with their memory;The participation in the QIIP Learning Sessions in the areas of diabetes, COPD, Asthma, hypertension,integrated cancer screening and office practice redesign; andPATH (Personal Action Towards Health), a six‐week self‐management workshop that empowerspeople to live well while dealing with conditions like diabetes, heart disease, arthritis, lung disease,and other health issues.SETFHT will also be undergoing its very first strategic planning session in the Fall of 2010 which will help usget even closer to living our vision. Keep informed of our activities by visiting our website on an ongoingbasis – www.setfht.on.ca. Collectively with our patients and community, we are working towards our visionof becoming a leading academic family health team that improves the health of our community.10