Health Links: Bringing the Pieces Together: The Patient s Medical Home

Transcription

1 Health Links: Bringing the Pieces Together: The Patient s Medical Home Respectfully Submitted to: The Honourable Deb Matthews Minister of Health and Long Term Care Contact: M. Janet Kasperski, RN, MHSc, CHE Chief Executive Officer Ontario College of Family Physicians 340 Richmond Street West Toronto, Ontario M5V 1X2 Tel: Fax: jk_ocfp@cfpc.ca Website: 1

2 Table of Contents Executive Summary ) Introduction: Strengthening the Missing Link ) Bring the Pieces Together: ) The Collaborative Care Networks/Mainpro C Workshops: Coaching, Mentoring... 8 and Capacity Building in Family Practices ) Complex Assessment Resource Centres: Developing Care Plans and... 9 Establishing Virtual Teams ) The Virtual Ward/Hospitals-in-the-Home: (People-to-People Connects supported by Telehomecare) ) Advanced Access to Care/Chronic Disease Management: Providing Patients and their Families with High Quality Care When Needed ) The Quality Measurement and Improvement Program ) Primary Care Councils ) Summary: APPENDIX A: A Vision for Canada: Family Practices The Patient s Medical Home Appendix B: Centre for Excellence in Coaching and Mentoring: The OCFP s Collaborative Care Networks Appendix C: The Two Memory Clinic Proposals: Appendix D: The TEGH Virtual Ward Appendix E: Advanced Access and Efficiency/Chronic Disease Management Appendix F: Evaluating Measurements in Primary Care Appendix G: LHIN Primary Care Councils

3 The Pillars of A Medical Home Promoting the quality of family medicine in Ontario through leadership, research, education and advocacy. A Vision for Canada: Family Practice The Patient s Medical Home ( The Ten Pillars of Patient s Medical Home Pillar I: The Patient s Medical Home will be Patient-Centred. Pillar II: The Patient s Medical Home will ensure that every patient has a personal family physician. Pillar III: The Patient s Medical Home will offer healthcare to its patients and their family delivered by teams or networks of providers. Pillar IV: The Patient s Medical Home will ensure timely access to care. Pillar V: A Patient s Medical Home will provide each patient with a comprehensive scope of family practice services. Pillar VI: A Patient s Medical Home will provide continuity of care, relations and information. Pillar VII: A Patient s Medical Home will maintain electronic medical records (EMRs) for each patient. Pillar VIII: Patient s Medical Homes will serve as the ideal training sites for medical Learners, as well for family practice and primary care research. Pillar IX: A Patient s Medical Home will carry out ongoing evaluation of the effectiveness of its services as part of its commitment to continuous quality improvement. Pillar X: Patient s Medical Homes will be strongly supported internally through governance and management structures defined by each practice and will be externally supported by all stakeholders. 3

4 Every person in this province should have access to a family physician that affords them the benefits of each of the ten Pillars of the Patient s Medical Home. Family Health Teams are Canada s best examples of the Model in action. Now, we need to build upon the model, starting with virtual teams. The Five Point Program is the starting point for a healthcare system that affords every Ontarian an opportunity to be served in his or her Patient s Medical Home. Executive Summary: The Five Point Program Family physicians are often referred to as the canaries in the mineshaft they know immediately when the system is not responding adequately to the needs of their patients. They are in the best position possible to identify practice and system problems, to identify the possible solutions and to work with local healthcare providers to implement them. The Canadian College of Family Physicians (CFPC) relied heavily on the primary care renewal efforts in Ontario to create the discussion paper A Vision for Canada: Family Practices The Patient s Medical Home. Some of Ontario s most evolved Family Health Teams are on the brink of being able to offer their patients most of the benefits of the Patient s Medical Home. Indeed, they are being seen as Canada s best example of the Patient s Medical Home model. Health Links provides an opportunity to create and/or strengthen linkages in local health service delivery systems. The missing link in many communities is family practices. The establishment of Health Links in communities throughout the province should be used to foster the development of programs that will support all primary care practices to develop into the Patient s Medical Home. This document provides an overview of the individual innovative programs that have been developed separately over the course of time. Each Health Links has the potential to bring them together into an integrated program of supports for family practices to serve their patients, especially their most complex and vulnerable patients. Over the course of time, this integrated program of supports will provide each practice with the resources needed to become a Patient s Medical Home. The integrated program is anchored in a virtual team that should model the results of Family Health Teams in providing excellent care for their patient populations, especially their most complex and vulnerable patients. The Five Point Program: This paper builds upon the separate and complimentary innovative programs that have been created by the OCFP with the support and the guidance of the MOHLTC and our many partners. It documents the key components of an integrated program that brings the pieces together to create the framework for the services that need to be available in each Health Link to support family practices/primary care sector and the community and hospital sectors to link together to deliver the care that complex, high resource patients need and want. The five point program that brings the pieces together is as follows: The Collaborative Care Networks/Mainpro C Workshops linking family physicians, specialists and hospitals strengthening primary care through coaching, mentoring and capacity building; supporting the dissemination of the HQO bestpaths; 4

5 The Complex Assessment Resource Centres linking family physicians, CCACs and other community-based service providers supporting the development of evidence-based and practice informed Care Plans for complex patients; establishing virtual care teams; The Virtual Ward and Hospital-in-the-Home linking hospitals, specialists, CCACs and family physicians supported by tele-homecare, patients would be admitted and discharged to a level of care in the community that provides the same level of care and monitoring in the home as they would receive in a hospital inpatient bed; the model includes patient and family education in self-care and rapid access to expert nursing and medical care; Advanced Access and Efficiency and Chronic Disease Management Program linking OCFP, HQO and machealth.ca supporting easy access to quality care in their own family practice for high resource patients with complex conditions and multiple co-morbidities; and, The Quality Measurement and Improvement Program linking the OCFP, HQO, OntarioMD, E-Health, Ontario s research and quality improvement community and the LHIN Primary Care Councils to provide supports needed to implement the Excellent Care for All Act in primary care including the development of Quality Improvement Plans, Quality Measurement and Evaluation and Continuous Quality Improvement Programs anchored in the Triple Aims: Better health outcomes Enhanced patient experience of care Cost-containment/bending the cost curve. Supporting this initiative is 40 Decision-Support experts to assist FHTs to develop their quality initiatives, as well as, HQO s bestpath program. LHIN Primary Care Councils linking the family physician leads in each Health Link in a LHIN with the LHIN Primary Care Leads, Diabetes Lead, and CCO Leads etc. to support quality improvement activities at the level of the individual family practices, within each Health Link and within each LHIN. The Patient s Medical Home The Patient s Medical Home will support a best start for each child in the province and allow seniors to remain healthy and stable as long as possible. It is the vehicle for delivering the right care, at the right time and in the right place for all Ontarians. The OCFP and our partners will use our educational infrastructure to work with family practices to assess and improve their abilities to provide the 10 Pillars of the Patients Medical Home. A health system, anchored in a strong and vibrant primary care sector, will produce the Triple Aim outcomes that Ontarians expect and need. Health Links is the vehicle for establishing the Five Point Program that will ensure that every person in the province has access to a family physician providing all ten Pillars of the Patient s Medical Home. (A Vision for Canada: Family Practice - The Patient s Medical Home) 1.0) Introduction: Strengthening the Missing Link 5

6 The Members of Ontario College of Family Physicians (OCFP) have benefitted greatly from our partnerships with the Ministry of Health and Long Term Care (MOHLTC), the Ontario Medical Association, the Ontario Association of Community Care Access Centres, the Ontario Hospital Association, Health Quality Ontario, Cancer Care Ontario, Public Health Ontario, the Departments of Family Medicine at the six Ontario medical schools and many others. The OCFP has developed the ability to bring together the right people with the right ideas at the right time to build consensus on the right solution and to create the right climate through our partnerships for the implementation process to be successful. 1.1) The Patient s Medical Home Together, we have undertaken the following to establish the Patient s Medical Home model in Ontario: Pillar I: Recognized the importance of the family medicine, anchored in the Patient- Centred Clinical Method, as the foundation of our healthcare system and supported the development of patient self-management tools. Pillar II: Supported the drive to provide every Ontarian with a personal family physician by addressing the shortage of family physicians in the province. Supported our Academic Departments of Family Medicine to train more medical students and family medicine residents and to train them in the realities of family practice in distributed learning sites; created the Northern School of Medicine; invested in competitive funding models and increased the interest of medical students in family medicine from an all-time low of 24% to the current 40%; Pillar III: Supported team-based care; envisioned and established Family Health Teams ; created the Collaborative Care Network model that is transforming the specialty referral model into a cost-sparing coaching and mentoring model that is building capacity in family practices to deliver high quality care to Ontario s most complex patients; developed the Memory Clinic/Complex Assessment Resource Centres and Virtual Wards to create virtual teams; Pillar IV: Supported practices to provide timely access to care ; supported HQO, OCFP and machealth.ca to provide the Advanced Access and Efficiency Program to FHTs and non-fht practices alike; supported CCO to develop Diagnostic Centres to reduce diagnostic wait-times; Pillar V: Supported practices to deliver a comprehensive basket of services ; supported knowledge transfer to provide family physicians with the skills to serve patients in their practices; developed multiple Mainpro C Workshops anchored in small group facilitated learning opportunities to transfer clinical best practices into practice change; ensured their success by making them practice-informed and reflective of the realities of family practice; developed the Memory Clinic/Complex Assessment Resource Centre model to provide evidenced-based and practiced informed care to patients and their families with dementias; created the Palliative Care Strategy to offer more patients hospice palliative care in the setting of their chose; Pillar VI: Recognized the importance of continuity of care, relationships and information by supporting the rostering of patients to family doctors; supported them to provide care regardless of the care setting by providing innovative CME/CPD 6

7 programs that brought knowledge and skills to the practices; fostered the development of EMRs/EHRs; Pillar VII: Supported family physicians to acquire EMRs as a key communication and quality improvement tool amongst practice providers and to set the stage for EHRs to connect family practices to the broader healthcare system; Pillar VIII: Assisted academic Departments of Family Medicine, distributed learning sites and community-based family physicians to develop the practice environment to be the ideal teaching sites for a wide variety of healthcare professionals and the sites for family practice and primary care research ; supported the development of Primary Care Health Service Research Networks and Community-based Research Network; Pillar IX: Supported the development of the Quality in Family Practices program, the Quality in family practices Book of Tools, the Quality Improvement and Innovation Partnership and the Evaluating Measurements in Family Practices research project to assist family practices to commit to a continuous quality improvement program anchored in Quality Improvement Plans; Pillar X: Supported leadership development programs to build knowledge and skills in practice governance and management ; supported the development of external supports for family practices; encouraged the integration of primary care and the broader healthcare system through Health Links and the evolving role of LHINs in the primary care sector; encouraged the development of LHIN-based Primary Care Councils led by Primary Care Leads; engaged in the system changes to integrate the Cancer Care System and family practices to improve the cancer patient s journey from prevention to end-of-life; supported the integration of public health and the primary care sector. 1.2) Developing a World-Class Healthcare System Ontario has all the building blocks in place to move forward with the development tof a world-class healthcare system. As the first point of contact for patients and their family members, family physicians understand the needs of their individual patients and family members and are the first to know when the broader healthcare system is not meeting their needs. Ontario s healthcare system is performing comparatively better that most other provinces; however, we lag behind countries that have invested heavily in their primary care system. The two most important attributes of a healthcare system capable of achieving the Triple Aims of quality improvement are: Continuity ( including continuity of care, relationships and information); and, A comprehensive basket of services delivered in family practices. These attributes are intertwined. Given sufficient knowledge, skills and practice supports, family physicians are capable of delivering comprehensive services. The reduction in referrals and use of the broader health care system provides opportunities that result from providing as much care as possible in primary care settings for continuity of care. Both are viewed as essential in meeting the needs of their practice population, especially for those patients with advanced chronic conditions that require high quality complex care. The Canadian College of Family Physicians document: A Vision for Canada: Family Practice the Patient s Medical Home, describes the attributes of family practices that are fully capable of delivering the care that each patient needs and wants. Many 7

8 of our Family Health Teams (FHTs) have evolved into high performing, high quality and innovative practices that are the best examples in Canada of the Patient s Medical Home. Unfortunately, the use of the broader healthcare system increases expedientially in practices where knowledge and skills and especially, adequate practice supports are lacking. Under these circumstances, patients are referred to consulting specialists. If the patient has one major health problem, the specialty model of care is effective in providing the patient with care anchored in evidencebased best practices. The patient population that is of primary concern for the providers who will be assembled under the auspice of the Health Links (the 1 to 5% of the population that use the most healthcare resources) tends to have complex conditions and/or multiple co-morbidities complex multiple conditions that are not amendable to simple solutions and requires new approaches to care, including interdependent teams of healthcare professionals that view the patient in a holistic manner. For several years now, hospitals and CCAC have worked together to try to address the Emergency/ALC problem. Family medicine has tended to be the missing link in the model in many communities. Health Links provides an opportunity for the voice of family medicine to be heard. The canaries in the mineshaft need to be front and centre in the development of each Health Link. As the various Health Link leads develop their business plans, they need to be cognizant of the innovative programs that have been developed in the primary care sector. This is the right time to bring the pieces together to create a new way of addressing the needs of patients and their family members. Together, we can ensure that every person in Ontario, especially our most vulnerable patients have access to their own Patient s Medical Home. 2.0) Bring the Pieces Together: The OCFP is recommending that each of the following components of an integrated and comprehensive program be available in each Health Link to strengthen each family practice so that it can deliver the 10 Pillars of the Patient s Medical Home. The program components are as follows: 2.1) The Collaborative Care Networks/Mainpro C Workshops: Coaching, Mentoring and Capacity Building in Family Practices The Ontario College of Family Physicians (OCFP) has received literally thousands of dollars over the course of the last 15 years to develop expertise in the delivery of an innovative educational model that is transforming the costly specialty referral model into the cost-sparing shared-care/collaborative care model that relies on coaching and mentoring to build capacity in family practices to deliver a comprehensive basket of services. Collaborative Care Networks/Shared-care models have been singularly successive in bringing knowledge and skills to family practices to assist with the care of their most complex patients. This is the model that will underpin the directions that Health Links are expected to take a reduction in the use of the more expensive parts of the system. Collaborative Care Networks combined formal and informal CME/CPD to assist family doctors, the right care providers, to delivery the right care, in the right place at the right time. Some of the strategies are quite straightforward. The Western Hospital s Emergency Department was inundated with patients that could have been handled in the community through a simple conversation or a direct referral to a consulting specialist. A focus group meeting between the community-based family physicians and the emergency medicine physicians revealed that the family doctors were sending patients to the ED because they could not get timely access to specialty guidance and advice or timely referrals. The ED was the stop-gap in the system that 8

9 provided access to care that was needed to prevent a continued downward spiral in the health status of the patient. A simple solution was developed anchored in a component of the OCFP s Collaborative Care Network a consulting specialist at the hospital devoted to providing telephone consults on complex patient conditions; thereby, avoiding ED visits. The OCFP is proposing to support the transformation of the healthcare system by engaging with each Health Link: to establish local/regional Shared-Care/Collaborative Care Networks to provide the linkages between consulting specialists and family physicians to transfer knowledge and skills and to build capacity for complex care in family practices. to provide a concentrated series of workshops on specific topic areas to support knowledge transfer and capacity building. The workshops will assist family physicians to address patient conditions, such as: Cognitive Impairments (Alzheimer s Disease and Related Disorders); Cardiovascular Diseases (Congestive Heart Failure and Atrial Fibrillation - primary and secondary stroke prevention and management); Asthma/COPD and Spirometry; Insulin Starts in Type II Diabetes; Falls/neurological conditions; Severe persistent mental disorders; Chronic intractable pain and addictions; Children s Developmental Delays/Infant, Child and Adolescent Mental Health and Addictions; Rheumatoid and other musculoskeletal conditions leading to joint replacements; and, Other conditions and topical areas as requested. to provide our Leadership Development for Family Physicians workshop to provide family physicians with the skills they need to actively participate in system and practice planning and improvements and the Best Practices: Don t Just Do Something Stand There to assist family physicians to address the ordering of tests, treatments/medications, procedures, etc., that have little or no evidence of a positive impact on health outcomes. This component links specialty/hospital care with family practices. See Appendix B: The Centre for Excellence in Coaching and Mentoring The OCFP s Collaborative Care Networks 2.2) Complex Assessment Resource Centres: Developing Care Plans and Establishing Virtual Teams The Memory Clinic model was developed as an intermediary step in the assessment of patients with cognitive disorders, such as Alzheimer s Disease and Related Disorders. 83% of patients in Toronto with a dementia diagnosis were seen by consulting specialists in their offices or in the Regional Geriatric Clinics. The Memory Clinics cost-sparing model has reduced this use of precious RGP resources to 7 to 9 %, providing better access for complex patients. Patients with other conditions and a 9

10 dementia overlay are the most likely candidates for early ALC designation. They are amongst the heaviest users of the healthcare system. The CARC s model depends on a standardized assessment of patients at the earliest stage in the development of dementias when mild cognitive impairments first appear. The components of the model are as follows: An inter-professional team (a family physician, a nurse or nurse practitioner, a social worker, a CCAC case manager and a pharmacist) undertakes a complete cognitive and functional assessment. The team assesses for driving capabilities and processes the necessary forms if the patient s license needs to be removed. This protects the patientphysician relationship that is often disrupted when the patient s own family physician undertakes this task. The team helps the patient and family to develop an advance care plan while the patient is still competent to make their own decisions about the care they want as their condition(s) increase in severity. The family physician develops a medical care plan for the patient. The care plan is anchored in the best available evidence. The clinic s family physician receives ongoing expert coaching and mentoring by geriatric medical and psychiatric specialists to ensure evidence-based practice. The medical care plan is practiced-informed since it is developed by a family physician who fully understands the nature of the family practices in his/her FHT and community. The pharmacist reviews all of the medications the patient is on to ensure that the medical care plan reduces the likelihood of drug interactions and complications. The social worker and the CCAC case manager work together to develop a virtual team for the patient and family members. They are connected to the services that the patient and family needs now, including those in the FHT and the community. Team members may include those from homecare organizations (nurses, personal support worker, physio and occupational therapists, etc), as well as supports from various community-based agencies such as the Alzheimer s Society. In addition, patients and family members are introduced to the services that will be needed in the future as the condition(s) begins to deteriorate. This component is especially important for non-fht practices in creating the supports that are required in the absence of a teambased practice model. The clinic family physician provides mentoring and coaching for the patient s own family physician who oversees the implementation of the care plan that encourages a patient and caregiver self-care strategy. As the family physician provides ongoing patient and family care and the patient s condition changes, easy access to the clinic family physician and/or the consulting specialist and to other services provides the supports that are needed to keep the patient stable and in the community. This component builds capacity in family practices to provide care for Ontario s most complex patients. Thirty-one Memory Clinics have been established in Family Health Teams, Community Health Centres and in Family Health Organizations across the province. As the clinics gain a high degree of comfort in addressing dementias, they are being supported to become Complex Assessment Resource Centres. The Memory Clinic model is being expanded with the assistance of cardiologists, respirologists and neurologist to 10

11 provide assessments and the development of medical care plans for patients with multiple co-morbidities, including a dementia, depression or anxiety overlay. The OCFP has submitted a proposal to expand the number of Memory Clinics and to transform the current Memory Clinics into Complex Assessment Resource Centres. In addition, a second proposal entails the research into the best way to establish the Memory Clinic/Complex Assessment Resource Centre model in non-fht practices and evaluating the value-for-money proposition of the model with ICES. The OCFP and the Centre for Family Medicine will: Identify the location of current Memory Clinics, and under the direction of the LHINs, will identify the appropriate location for the establishment of the next 30 Complex Assessment Resource Centres to ensure that they align with the Health links; Work with the MOHLTC to ensure the best way to proceed to ensure that current Memory Clinics are converted into Complex Assessment Resource Centres, and that new Memory Clinics/Complex Resource Assessment Centres are developed in each Health Link; Will test the broad use of the Hamilton-Niagara Patient Identification tool to identify patients in primary care practices (predominately those over the age of 75) who are at risk of becoming one of the 1 to 5% of the high needs population if they are not identified and surrounded by a virtual team as early as possible in their disease trajectory; and, Will work with ICES and McMaster University to ensure that a rigorous value for money evaluation process is undertaken. This component links family practices with the CCACs and various communitybased service providers with family practices. (See Appendix C: Overview of the Memory Clinic/Complex Assessment Resource Centre Proposals - Doc1, Doc2) 2.3) The Virtual Ward/Hospitals-in-the-Home: (People-to-People Connects supported by Telehomecare) Within each Health Link, hospitals and CCACs would be supported to link with the Patient s Medical Homes to develop Primary Care Virtual Wards/Hospitals-in-the- Home. The Family Practice Virtual Ward model was established successfully at the Toronto East General Hospital and is seen as the ultimate model for the Home First program. The model utilizes both a people-to-people connect, as well as technology to ensure safe and effective discharges and oversight during the critical few weeks postdischarge. The Toronto East General Hospital s Virtual Model is anchored in the primary care sector to ensure safe discharges from the hospital for patients deemed to be at risk for re-admission. The model can be used as a Hospital-in-the-Home to avoid admissions in the first place. The Virtual Ward is a people-to-people connect that uses technology to its best advantage. A Physician Assistant is actively involved in the care of the patient while in hospital. On the day of discharge, the PA brings telemedicine equipment into the home, introduces the patient and the family to the use of the technology and ensures that the connection to the CCAC and the family doctor is made. With technology in 11

12 place, the hospital-based physicians and nursing staff are able to monitor the patient s key vital signs (weight, as an example, in Congestive Heart Failure). They are able to make medication adjustments prior to the patient even developing symptoms. If left unchecked, the results would be a visit to the ED and subsequent readmission. The immediate interaction of the PA with the family doctor ensures that information is shared in a timely and meaningful way to promote ongoing medical care. The alignment with the CCAC provides adequate supports are available for the patient and family members to transition safely from hospital to home. The Department of Family Medicine at the University of Western Ontario provided a highly regarded Virtual Hospital for patients for several years. The model included the direct admission to the Virtual Hospital and avoided the use of inpatient beds by providing care in the home comparable to the care that would be delivered on a hospital ward. This model of care would be incorporated into the Virtual Ward model to serve patients with acute problems. In addition, the model lends itself to supporting Palliative Care teams to deliver care in the home to patients and their family members at the end-of-life. Three of the LHINs are now involved in a pilot projects to utilize telehomecare for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). This nurse led model is demonstrating early wins in those communities where the linkage between the patient s family physician and the RN is robust. This component links consulting specialists/hospital, CCACs and family practices and demonstrates the value of people-to-people connects, supported by telehomecare. See Appendix D: The Virtual Ward 2.4) Advanced Access to Care/Chronic Disease Management: Providing Patients and their Families with High Quality Care When Needed Each high needs patient served by Health Links will require a family physician working in practice that is able to provide easy access to care, when required. The program will help family practices to organize their practices so that they will be able to see each patient within 7 days of discharge and to offer routine access to care when the patient or family member determines that they need to be seen for an urgent problem or for routine care of their chronic conditions. The model has been shown to decrease emergency room visits and subsequent inpatient admissions. The OCFP has been working with Health Quality Ontario and the e-learning Innovation Division at McMaster University (machealth.ca). We have modified the QIIP program on Advanced Access and Efficiency that was originally developed for FHTs to provide non-fht practices with the knowledge and skills they need to change their practices to accommodate patients on the day they require or desire to be seen. The program is a combination of a one day workshop on Advanced Access and Efficiency with on-line interactive web-based learning opportunities and mentoring by a family physician QIIP Champion. Health Links are required to involve a minimum of 65% of the family physicians within the Link s geographic boundaries. If patients or family members are not able to access care or guidance and advice when they need it the most, the system will fail. This program ensures that they have access to urgent care when they need it and routine care is planned, team-based and effective. Ensuring that discharged patients 12

13 are seen within seven days of discharge is one of the main benefits of a program that provides today s work today. The program is transforming the processes used by patients to request clinics visits into one that is customer-friendly for the majority of patients. The model uses a proactive approach to reach out to patients with chronic disorders to ensure that they have access to care, tests and self-management education they need to better control their own chronic disorder. The program is heavily anchored in an effective teaching model to help family practices understand the principles of continuous quality improvement. The OCFP, HQO and machealth will provide the following: The Advanced Access and Efficiency/Chronic Disease program will be offered to the family practices in each Health Link to ensure that patients and their family members have easy access to care. Hospital rounds will be used to introduce family practices to the program and the various resources available to them on line at machealth.ca and at HQO. Practices will be encouraged to include the Advanced Access and Efficiency Program in their Quality Improvement Plan. The OCFP partnership with HQO will facilitate discharge coordination between the hospital-based Most Responsible Physician (MRP) and the patient s family doctor to bridge the gap between the hospital and community practices. In addition to forwarding discharge summaries to the family doctor within 24hours of discharge, patients will be booked to see their family doctors within 7 days of discharge. This component will link family practices with the OCFP, HQO and macheath.ca to ensure that family practices have local access to a practice change methodology that will afford patients with access to their family physicians and their practice team members when they need or want care. (See Appendix E: Advanced Access and Efficiency and Chronic Disease Program) 2.5) The Quality Measurement and Improvement Program: (Developing Quality Improvement Plans, Initiating Continuous Quality Improvement Programs and Measuring Successes) Over the course of the past ten years, the MOHLTC has supported the OCFP and the Department of Family Medicine at McMaster University to develop, demonstrate and evaluate the Quality in Family Practice Program. Our quality work began in 2003 with funding for an international study of quality improvement/voluntary accreditation programs in family practices. The purpose of the research was to develop consensus amongst the various associations representing front-line primary care providers regarding the best of the breed of available programs. Our objective was to identify ones that could be adapted to Ontario s evolving primary care environment. This study led to an ongoing relationship with our peers in the United Kingdom, Europe, Australia, New Zealand and the United States. The research project resulted in the identification of the indicators and criteria to address each indicator that have more recently been developed into the Quality in family practices Book of Tools. The voluntary accreditation program anchored in the Book of Tools has been tested and is ready for province-wide roll-out. The HQO QIIP program has been singularly successful in training family practices in CQI methodology. The Quality in family practices Book of Tools identifies what needs to be improved and provides the basis for accrediting practices to ensure patients and funders that practices are providing the level of care that patients and their families need and want. 13

14 The University of Toronto s Department of Family Medicine has developed an intensive education in quality improvement methodologies for their residents in family medicine. The resources developed for this program are applicable to the community practice arena and will be combined with the work of the HQO/OCFP/machealth.ca work to result in a comprehensive quality improvement program for family practices. Since CQI tends to be data driven, the OCFP has been leading a process to identify the barriers to effective CQI activities. In consultation with e-health and OntarioMD, vendors are being requested to find ways to make the data available in EMRs readily available to family practices. In collaboration with HQO, PHO, CCO, OMA-OntarioMD, e-health and MARs, the OCFP is assisting the MOHLTC to develop a Think Tank on the strategies to determine what should go into our EMRs to ensure that good data comes out and identify the decision-support tools and care prompt that will foster high quality at the point of care. In addition, the OCFP is the fund-holder and project manager for a project entitle Evaluating Measurements in Primary Care. In collaboration with HQO, CIHI, ICES and the Departments of Family Medicine at McMaster University, University of Western Ontario and Queen s University, the OCFP has identified a number of indicators that are able to differentiate between high performing, high quality and innovative practices and those that are still evolving. The research included an investigation into the factors that lead to high performance and the short-term and long-term impacts of the investments in time and resources in developing high performance, high quality and innovative practices. This project has identified a robust number of indicators that practices can use as the basis for the starting point in developing their Quality Improvement Plans. This component links HQO, OCFP and the Departments of Family Medicine at McMaster University and the University of Toronto to support effective quality improvement programs in family practices. It also supports the further evolution of EMRs to support CQI activities and high quality at the point of care. (See Appendix F: Evaluating Quality In Family Practices Doc1, Doc2) 2.6) Primary Care Councils The OCFP was pleased that the call for LHIN Primary Care Leads included a requirement that the applicants must be Members of our College. As the Leads have been developing their Primary Care Councils, in addition to the LHINs, they have been accessing supports from OMA, CCO, CCACs and the OCFP. The OCFP has been supporting them to continue the work that the OCFP began with the establishment of the Leadership Connect. The Leadership Connect is a communication system that allows the OCFP to access every family physician in the province that hold a leadership position in Ontario (Academic leaders, Hospital Chiefs of Family Physicians, FHO, FHN, FHG and FHT leads and the OCFP Board members). The list is organized by LHIN and contact information is updated on an annual basis on each member of the Leadership Connect. The Leads are using the Leadership Connect to identify the family physician leaders in their LHIN and outreaching to them to establish the membership of Primary Care Councils to support local and regional quality improvement activities. 14

15 This component is linking family physician leaders and the Leads in each LHIN to address local and regional quality issues. See Appendix G: LHIN Primary Care Councils 3.0) Summary: The Health Links provide an opportunity to support each practice to develop into a practice that can offer each of the 10 Pillars of the Patient s Medical Home. The components of this comprehensive series of programs will enable the Health Links to anchor their local health system in high performing, high quality and innovative practices in keeping with the tenets of the Excellence Care for All Act. 15

16 APPENDIX A: A Vision for Canada: Family Practices The Patient s Medical Home 16

17 Appendix B: Centre for Excellence in Coaching and Mentoring: The OCFP s Collaborative Care Networks 17

18 Appendix C: The Two Memory Clinic Proposals: The Five Day Education Program to Establish Memory Clinics and Complex Assessment Resource Centres in Family Practices: The Missing Link in Diabetes/Chronic Disease Care Building and Evaluating Memory Clinics in Non-FHT Practices: Providing an Impact Analysis of the Memory Clinics on Health System Utilization 18

19 Appendix D: The TEGH Virtual Ward 19

20 Appendix E: Advanced Access and Efficiency/Chronic Disease Management 20

21 Appendix F: Evaluating Measurements in Primary Care (Doc. 1) (Doc. 2) 21

22 Appendix G: LHIN Primary Care Councils 22