2016 COMMUNITY REPORT

Transcription

1 2016 COMMUNITY REPORT

2 MAKING A DIFFERENCE IN OUR COMMUNITY The Thames Valley Family Health Team s board chair and senior leadership sat down to reflect on our family health team s accomplishments in 2015/16. What do you consider to be the Thames Valley Family Health Team s biggest achievement this year? Tom: Over the past year, we have really stepped forward as a system partner. We are proud to be the lead organization for the London Middlesex Health Link, and to participate in the implementation of the Oxford and Elgin Health Links. We support patients in meeting their health goals; initiatives such as Health Links allow us to focus on that. Keri: Our highly skilled and dedicated employees are the key to our success. They believe in what we do, and are committed to supporting people throughout their lifespan. Our employees provide people with self-management skills for ongoing life challenges, treatment when needed, and proactive health supports. In addition, the quality and commitment of the physicians we partner with are definitely something to be proud of. Norm: I m always pleased to receive feedback from someone regarding the care they received from us. In this fast-paced world, when someone takes the time to let us know how much they appreciated our service, we know we have definitely made an impact on them. What message do you hope readers of this report come away with? Tom: One of the major themes of this report is Making a Difference in Our Community. I think I speak for the entire Board of Directors when I say how impressed I am with the variety of programs our family health team offers. These programs are based on people s requests and assist in improving quality of life. Keri: We want our patients to know they can count on us to work with them in support of their health care needs. We want to acknowledge our system partners, with whom we have accomplished much this year. We look forward to strengthening these relationships to benefit the communities we all serve. Norm: I hope people will see the value we place on constant improvement of our processes and programs to enhance the support of patients and communities. That thinking led to the Physician Advanced Access initiative, which you will read about later in our Community Report. I hope people get a flavour of who we are as an organization and what we believe in. As primary care providers, we are a trusted part of people s lives; we are with them through both joyful and challenging times. We take that role seriously and everyone in the Thames Valley Family Health Team is honoured to be part of this journey with you. Dr. Tom Freeman Board Chair Dr. Norm Furtado Medical Director Keri Selkirk Executive Director

3 Between December 2015 and April 2016, 900 Syrian refugees arrived in London, triple the number the city normally receives annually. When the South West Local Health Integration Network (SW LHIN) asked for assistance in delivering health care to the refugees, the Thames Valley Family Health Team (TVFHT) stepped forward. TVFHT registered nurses Sandra Ansems and Lizanne Bertrand-Holley embraced the chance to work with the London Intercommunity Health Centre. Despite challenges along the way, both say it was a worthwhile experience. Working alongside other health care professionals from across the city, Sandra and Lizanne triaged and treated refugees at makeshift locations at local hotels. That environment was soon found to be inefficient and operations were moved three blocks away to the London Cross Cultural Learner Centre (CCLC). Things got smoother as the new facility meant easier access to equipment, desks, printers and even a laptop. Dianna Cleland, a nurse practitioner who had been retired for two months and Nour Al-Farawi, a nurse practitioner at TVFHT s Whitehills site who speaks Arabic, also volunteered to help. Some days we d see ten patients; other days, we d see 30, Sandra remembers. Working with newborns to seniors, they saw everything from pregnancies to Post- Traumatic Stress Disorder (PTSD). Even with Nour s help, there was a language barrier between Arabic-speaking refugees and Englishspeaking medical staff. Every conversation required an interpreter supplied by the CCLC. While all were excellent, they were especially impressed by one translator, Nefertari, She even interpreted our jokes, Lizanne said. The TVFHT staff learned much from the experience. From L to R: Lizanne Bertrand-Holley, Nour Al-Farawi, Sandra Ansems. Absent: Dianna Cleland. I have a better understanding of the war in Syria and how it affects families, Sandra says. They also learned about the Syrian medical system. I realized just how fortunate we are in Canada to have the medical system we have, Lizanne says. They were touched by the Syrian children they treated, who were always giving the staff hugs and high-fives. The nurses came away with the fond memory of leading all of the children in singing Head, Shoulders, Knees and Toes. Syrian people are just like us, Lizanne says. They want to look after their families and live a normal life. Sandra agrees and states, I m glad I did it, and I would do it again. Some days we d see ten patients; other days, we d see 30, Sandra remembers. Working with newborns to seniors, they saw everything from pregnancies to Post-Traumatic Stress Disorder (PTSD). 3

4 QUICK ACTION AND TEAMWORK Four months after Janice quit smoking, life hadn t gotten any easier. Instead, she was becoming quite ill and felt more and more tired. I was out of breath going from my house to the barn, she remembers. It was terrifying. Any activity with any type of exertion and I was huffing and puffing. Having been placed on nicotine replacements, she assumed she was experiencing a side effect of the drug. Janice was about to call the paramedics. Instead, she reached out to Elizabeth Smith, nurse practitioner at the Thames Valley Family Health Team s Old South location, and was immediately seen. Her vitals were stable, and she did not need emergency care, but she did need urgent care, Elizabeth discovered. Janice was soon to leave for Florida and the family health team staff knew she needed to be taken care of before leaving on her trip. Suzanne Bainbridge, registered respiratory therapist, was working at the Old South location that morning. She administered a breathing test called spirometry to better understand how Janice s lungs were functioning. HELP JANICE ENJOY A NORMAL LIFE She saw Janice had significant lung damage and immediately notified Elizabeth. As a nurse practitioner, Elizabeth was able to diagnose Janice with Chronic Obstructive Pulmonary Disease (COPD) and provide her with the medication she needed to improve her breathing. Janice was offered support in the form of the family health team s smoking cessation program to continue her efforts of remaining smoke-free as well as a COPD teaching program to provide education that could help prevent a lung flare up. Four days later, Elizabeth saw Janice again. She was relaxed and delighted. She was using her puffers and her breathing had returned to normal. 4 TVFHT 12% more TVFHT patients report that they receive same day/next day appointments than patients of other PEER AVERAGE 66.3% 54.3% family health teams in Ontario.

5 Janice admits it s been a slow way back but within a matter of days I was able to resume my daily activities. She is pleased to report she is now riding her horses twice a day. She estimates she quickly returned to between 70%-80% of what I normally do in a day. When Janice spoke to us, she was enjoying her time in Wellington, Florida, and feels confident that she will continue to manage her illness effectively with the help of the Thames Valley Family Health Team. She has high praise for the staff, especially Elizabeth and Suzanne. They were wonderful. They listened to me and took care of me. I m really happy with the service they provided. It s great that everything lined up the way it did, Suzanne says. We all worked to make sure everything was in place for Janice s departure for Florida. We made full use of many of our health care providers to do this on such short notice. I believe quick intervention by the family health team may have saved her life or at least a hospital admission, Elizabeth says. When you can improve the quality of life for a patient, it makes the job even more rewarding, Suzanne says. This experience shows that interdisciplinary collaborative care provides many benefits to the patient. It s been a slow way back but within a matter of days I was able to resume my daily activities. SUCCESSFUL TREATMENT OF COPD 65% of people referred for COPD education from the family health team completed the program. Of those: reported improved use of inhaler(s) and improved effectiveness on medication. identified increased understanding of the chronic nature of their illness. noted improved symptom self-management during follow-up appointments. Of COPD patients who received COPD education from a family health team respiratory therapist. Of COPD patients who received COPD education and set an action plan. 5

6 A WIN WIN SITUATION FOR PATIENTS AND PHYSICIANS 6 While the number of Ontarians who do not have a regular family doctor or nurse practitioner decreased from 8.2% in 2006 to 6.5% in 2009, the challenge to get timely appointments (the same day or the next day) has remained. The Advanced Access and Efficiency for Primary Care initiative supported by Health Quality Ontario (HQO) is all about doing today s work today. Dr. Sonny Cejic from Byron Family Medical Centre took advantage of HQO s offer to analyze the Centre s appointment booking process. The result has been a more efficient workflow, incorporating a mixture of pre-booked appointments and daily open appointments. Gone are the days of what Dr. Cejic calls squeezed-in booking, which left patients and physicians unhappy and frustrated. Dr. Saadia Hameed from St. Joseph s Family Medical Centre and Dr. Cejic agree the Advanced Access initiative has led to increased satisfaction for physicians and patients. Physicians can provide better care when they are not rushed, Dr. Cejic says. Patients like it because we are able to spend more time with them... we re getting a lot of positive comments. It s a win/win situation, Dr. Cejic says. It s wonderful to see patients when they really need it. Patients can be diagnosed right away instead of having to go to (a hospital s emergency department). Year over year, 95% of TVFHT patients report feeling involved in the decisions being made about their health. Patients can check what works with their schedule. They can often be seen the same day or they can set up appointments two to three months in advance. Dr. Cejic says medical students also like the set-up, as it allows them more time to seek out pertinent information and get advice from physicians. Dr. Hameed says she has heard of cases where, because physicians are able to open up spots on their schedule, they are able to take on new patients. Meanwhile, Dr. Cejic says, Patients are happier. They are very appreciative of being seen.

7 LOOKING AHEAD: TRANSFORMING OUR HEALTH SYSTEM VISION As leaders in the provision of primary health care, we will enhance the wellbeing of the people of Thames Valley. MISSION We are a dynamic primary health care network providing exceptional care. VALUES Patient and Family Centred Care: We make a difference in people s lives by providing comprehensive, compassionate care that responds to the evolving needs of our patients and their families. Trust and Respect: Trust for each other and mutual respect for the unique roles we play as colleagues and professionals is critical to our inter-disciplinary model of patient care. Collaboration and Teamwork: In order to help our patients and families, we value working together as a team of professionals where the contribution of each team member is optimized in a professional atmosphere of camaraderie and collegiality. Honesty and Open Communication: We value open and honest dialogue which promotes information sharing and supports collaborative problem solving. Accountability: We accept our individual and team responsibilities and we meet our commitments. We take responsibility for our actions, our decisions and our performance as both team members and individual professionals. In late 2015, Minister of Health and Long Term Care Eric Hoskins announced changes in our health system with a particular focus on primary health care, home care and public health. There is no doubt that the topic of system transformation will remain one of the most talkedabout topics throughout medical and health care offices for the remainder of 2016 and may still be such by the time we provide you with our 2017 Community Report. Over the past several months, the Thames Valley Family Health Team (TVFHT) board of directors and leadership has paid full attention to this process. We have looked for opportunities to provide input into the direction of this work to improve the health care system and more importantly, increase access to teambased health care for all Ontarians. In harmony with our vision enhancing the well-being of the people of Thames Valley we will remain focused on being at the forefront of developing methods to best meet the most significant patient needs. We are committed to constantly transforming our own efforts in order to more effectively provide the best level of care possible to our patients, as this year s Community Report showcases. We will keep looking for new ways to work even more closely with our community partners, as highlighted by initiatives such as Health Links. Together, we are even greater than the sum of our parts. 7

8 Thames Valley Family Health Team BOARD OF DIRECTORS: Tom Freeman (Chair) Rose Domenicone David Dougherty Sandy Jansen Lauren Kopechanski Silvie MacLean Shamidah Noorani Karen Perkin Tracy Smith-Carrier Stephen Wetmore SENIOR LEADERSHIP: Keri Selkirk, Executive Director Norm Furtado, Medical Director Michael Oates, Director of Operations and Quality North Routledge Park London, ON N6H 5N5