Annual Report FY 2011/12 1 P age
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Message from Dr. Geordie Fallis, SETFHT Chair of the Board This fifth year of operation is one of celebration. Our facility on the Danforth [1871] opened in March 2012. This is a wonderful testament to those who believe in improving the health of our community through service, teaching, outreach and research. The Carswell Family in particular brought this new site to fruition with their support. Allan and his wife, Helen, have been very proud advocates of the Toronto East General Hospital and its community. Helen received her training at the hospital and believed it was important to support those that were less fortunate than us. The Carswell Foundation, which strives to support service and health education, chose this project as their first significant contribution. Our work with virtual medicine continues to expand under the leadership of our team of providers. This innovation in technology allows patients to stay in their homes while being treated. The team has been recognized for their hard work and successes with the virtual ward, this year being granted project innovation dollars by the Ministry to evaluate the program. We as an organization are fortunate to have many hard working individuals. In particular, our executive director Kavita Mehta and our assistant Stephanie Pimentel continue to do incredible things to enhance the South East Toronto Family Health Team s vision..a leading academic family health team that improves the health of our community.. Message from Kavita Mehta, SETFHT Executive Director It is hard to believe how quickly another year has flown by! This last year was one of our busiest years as our family health team opened our second clinic site at 1871 Danforth Avenue on March 27, 2012. With the introduction of six brand new physicians who have trained in the family health team model, we have been quickly enrolling new patients into our FHT at a rapid pace. Over the next several years our FHT will be focusing our innovative energies on creating increased access to primary care for our patients as they negotiate their way through the health care system, starting with our clinics being open to our patients not only on Saturdays but Sundays as well. As is the case with everything, change is the only constant and this year we saw a change in leadership of our lead physician I would like to personally thank Dr. Marcus Law for his strong leadership, dedication and hard work as our inaugural Lead Physician and look forward to the next chapter of SETFHT under the very capable guidance and leadership of our new Lead Physician, Dr. Tia Pham. And as always, I remain in awe and am so very proud of all our team members as they continue to work hard in developing programs and services that centres around the patient and their family. We look forward to continually providing excellent primary care to our patients, their families and our community. Message from Dr. Thuy Nga (Tia) Pham, SETFHT Lead Physician It continues to be an exciting time to be involved in primary care, and particularly as one of SETFHT s first board members since 2007. Our work reaches far and wide into our local community by now through novel partnerships with Toronto Public Health, as well as very strong relationships with our local Toronto community care service agency and our community hospital, Toronto East General Hospital. Our Virtual Ward and the new Home Visit Program, both now funded as research projects by the Ministry of Health and the University of Toronto, puts our FHT into a leading position in the Minister s Health Care Action Plan, and we are actively involved in how primary care can be a key player in health care planning for the future in Ontario. The next five years will bring new opportunities for further growth and they also will bring new challenges as we strive to remain leaders and innovators of healthcare delivery. Our second clinic site has opened at 1871 Danforth Avenue and one of the objectives of our clinic expansion is to reach out to marginalized sections of our community and to improve the health of some of the poorer socioeconomic populations in our neighborhood through increased community outreach. Access to timely medical care will be improved for our patients with our two clinics now being able to provide after-hours care on weekday evenings, as well as both Saturdays and Sundays starting June 2012. All the work that we have accomplished thus far and that lies ahead of us truly has been made possible because we have an outstanding team working incessantly to provide better care and I am honoured to continue to build on my predecessor, Dr. Marcus Law s outstanding leadership as the new lead physician for SETFHT. 3 P age
TEACHING The South East Toronto Family Health Team (SETFHT) is an academic Family Health Team affiliated with the Department of Family and Community Medicine (DFCM), University of Toronto. The DFCM at the University of Toronto is the largest Family Medicine training program in North America and our teaching unit, through a partnership with Toronto East General Hospital (TEGH), continues to be ranked as the number one choice for Family Medicine Residents. With the expansion of SETFHT, the teaching program in family medicine at TEGH is expected to increase to 36 residents. Teaching is not limited to just family medicine residents. SETFHT Interprofessional health care providers (IHPs) all participate in teaching peers in their own disciplines. Participating in an interprofessional approach to education, the students learn together during all or part of their professional training with the objective of promoting collaborative practice for providing patientcentered health care. In the last year alone, SETFHT IHPs have taught students in pharmacy, nursing, Nurse Practitioner, dietetics, addictions and physician assistant programs and we look forward to continually educating health care providers of the future. Diversity and Outreach Through Family Medicine Education As a second year family medicine resident I could not ask for a better family practice with which to be associated. There are a number of reasons this is so. First is the group of skilled clinicians that are part of this team. Coming from a wide range of backgrounds including emergency medicine, palliative care, obstetrics and research they bring their diverse set of skills and apply it to the equally diverse population that they serve. These skill sets allow them to provide true community based care. A one day a week prenatal care clinic situated in a high risk neighborhood and staffed by SETFHT physicians exemplifies this type of care. Chosen for its high immigrant population and lack of access to basic prenatal care the woman in this area are followed throughout pregnancy, up to and including their delivery, by the family physicians who practice obstetrics at SETFHT. Dr. Aaron Harris Similarly, the initiation of a Virtual Ward home based care program allows for management of complex patients in their own home, improves their quality of life and reduces the frequency of visits to the emergency room. Such initiatives not only allow increase collaboration with other health organizations but also take into account the health determinants of the practice population and cater to the needs of specific high needs groups. As a resident at SETFHT I feel lucky to be a part of the above initiatives and see firsthand the ability of a family practice to move out into the community to provide individualized care. Aaron Harris, MHSc, MD; Co-Chief Resident TEGH Family Medicine, Department of Family and Community Medicine, University of Toronto 4 P age
Christine Leong Interprofessional Teaching with our Pharmacy Students During the 2011-12 academic year we each had the opportunity to complete a 4-week Doctor of Pharmacy (PharmD) patient care rotation with Jennifer Lake at the South East Toronto Family Health Team (SETFHT). One of the most impressive attributes about working with the staff at SETFHT was their commitment to interprofessional collaboration and patient-centered care. This rotation provided us with a unique opportunity to integrate with learners of all levels in the medical community while delivering patient care. One of the most rewarding aspects of our rotation with the SETFHT was the ability to provide individualized patient care and have the opportunity to be an independent practitioner. This not only strengthened our clinical decision making skills, but also enhanced our confidence in making drug therapy interventions. In the multitude of educational opportunities provided during each of our rotations, we were able to improve our knowledge and skills as pharmacists and pharmacy educators. Each member of the SETFHT team played an important role in enhancing our ability to practice as competent and dedicated healthcare professionals. We are extremely grateful to the staff at SETFHT for their support during each of our rotations, as well as to the patients who provided us the opportunity to develop our clinical skills. We would also like to express our gratitude to Jennifer Lake for her time and dedication to our learning. With sincerest appreciation, Aleesa Carter, Neal Irfan, & Christine Leong, Doctor of Pharmacy Students, University of Toronto 5 P age
PARTNERSHIPS & OUTREACH Keeping People at Home To support older adults with complex needs, SETFHT has been working actively with the Toronto Central Community Care Access Centre (TC CCAC), in order to provide continuous and seamless care from the community into hospital and back out again. We have been fortunate to work with CCAC on three different initiatives that focus on the 1% of the population that accounts for 30% of hospital and home care costs: Our Virtual Ward program is a collaboration between SETFHT, TEGH, TC CCAC, and Ontario Telemedicine Network (OTN) that reaches out to patients at high risk for admission and readmission to hospital, in order to decrease avoidable hospitalizations. The Integrated Client Care Program (ICCP) model is leveraging and aligning existing system resources by bringing together sectors from across the health system to create processes and structures to build capacity in the system to be more responsive to this population. The goal is to enhance the quality of their care, improve value and address sustainability less siloed care, more collaborative care. The ensuing partnership between CCAC and SETFHT has been so productive that it has given rise to a new initiative that is committed to providing home visits to patients who have barriers to seeing a primary care provider in office. Protecting Our Community Toronto Public Health (TPH) and our FHT have developed a close collaborative relationship since the beginning of our FHT. We were the first agency to partner with TPH during the H1N1 pandemic in late summer 2009, developing the longest and most successful flu assessment clinic (FAC) for the City of Toronto. Through our partnership, we were the link between TPH, TEGH emergency room, and the local family practices in our East York neighborhood, diverting traffic from our local emergency room to our FAC, as well as serving as a dedicated assessment centre for our family physician colleagues in the community who did not have the respiratory protection equipment, and who could divert their patients over to our centre. Last year our Family Health Team took the initiative to collaborate with TPH to start the Toronto Public Health Toronto Family Health Teams (FHTs) Partnership. We brought together 21 FHTs working within the TPH borders and staff from TPH to start a dialogue on common programs and services that public health and primary care share it has now lead to the development of five (5) different working groups (immunization surveillance, diabetes strategy, smoking cessation, child health including breastfeeding & immunizations and emergency planning & preparedness) where we hope we can highlight that integration and communication can lead to less duplication of resources and programming and more patient-centred care. Outreach to marginalized populations remains a strong commitment by our FHT. Our family physicians have provided outreach to local Homeless Shelters, the local Withdrawal Management Centre and a teen pregnant women shelter in the past. In this year, we aim to serve this population even better with the opening of our new clinic within a neighbourhood that has traditionally been a very low income community and hope to start a homeless drop-in clinic in collaboration with the Inner City Health Associates (ICHA) and the TEGH Withdrawal Management Centre. This is also a very good learning experience for our residents who will learn how to manage the care of a vulnerable and often transient population. 6 P age
Home Visit Team working collaboratively and action planning for a homebound patient Providing Care at Home Mr. Z is an elderly gentleman in his 80s who has severe Parkinson's and was enrolled in the SETFHT Virtual Ward because of frequent admissions to TEGH. The wife, who is the patient's sole caregiver and who is elderly and disabled from her own stroke, was struggling to care for her husband. In the end the patient was referred to rehabilitation for 6 weeks but the family knew that they should contact us as soon as the patient was discharged back home. The daughter describes the moment of discharge back home as the following: "My father was now back home, my mother who cleans him, washes him, cooks for him, checks his sugar for him, was struggling, since my father did not want any outside help at all in his house, and we children live too far away to help with those daily chores. I tried to call the old family doctor whom my father has not seen in over 2 years since he cannot move out of the house because of his severe Parkinson's, and my mother is too frail to somehow carry him into a wheelchair and into a taxi to bring him to the doctor, but there was no way that old family doctor could provide home visits. In that same moment, Hala, who is the physician assistant in charge of the Home visit and Virtual Ward Program together with Marianne, the Nurse Practitioner, called my mother and asked how my father was doing and what she could do to help. Hala was like an Angel that appeared out of nowhere. She arranged for a home visit by the clinical team under Dr. Pham and Maureen, SETFHT's care navigator and Hala managed to convince my father to accept help by CCAC to provide assistance with bathing and diabetes education, which has been a tremendous relief for my mother Home and Visit us children. Team working Jen the pharmacist in collaboration provided to medication action plan assistance for our to patients get better control over the new diagnosis of diabetes for my father. I cannot express enough how much I appreciate the care that has been provided by the Home Visit Program at SETFHT." 7 P age
IT TAKES A TEAM Finding your way through the health, community and social service systems can be a challenge. And for many of our patients, they are left on their own to navigate through the complexity of their health condition to find the resources and services they need in order to get back on track. Fortunately for our patients, we have an exceptional team of providers that will work in collaboration with the patient and family to support them in their health and social services journey. Commonwealth Fund and the seminal work done by Dr. Barbara Starfield really stress that countries that invest in primary care as the foundation of their health care system have better outcomes: their citizens live longer and have a better quality of life. And if the care can be delivered by a team, it frees up the physician s time to truly see patients who are sick. Together, all the members of the FHT will empower our patients to build skills for healthy living and engage them in being more involved in their health care planning. You Need to Start Being Awesome... This is the advice Judy has for anyone in her life that she sees still struggling with their addictions. Judy has been a patient with South East Toronto Family Health Team for almost four years and she feels strongly that, although this has been a journey all her own, the staff at South East Toronto FHT have made that journey smoother and given her the support she needed, when she needed it. Judy came to the South East Toronto Family Health Team with a long history of drug abuse. She gave up one son to his paternal aunt and when she delivered her second child more than seventeen years later, as part of her recovery she began a search for a family physician. Judy have made After a short time with her SETFHT doctor she opened up about her new lease on life and how she was committing to raising her son and starting a new chapter in her life. Judy s doctor suggested that she speak with our Addictions Counsellor. She walked down the hall and made an appointment that same day. Judy began seeing our counsellor twice a week and working hard at keeping herself clean and off drugs. She enrolled in school and began working on getting her driver s licence back. That was harder than she expected. Her doctor worked with her to get all the medical clearances she needed and our care navigator stepped up and worked with Judy to find the right Ministry of Transportation information to get her file cleared and her licence back. It s been a long three years and the hard work Judy has done is paying off. She and her son are living in their own place, Judy just bought a car and she s finishing College to be a Computer Technician. But all the successes still make Judy nervous and excited for the future. Right now she is working with the SETFHT Dietitian on a new challenge: to be fit and lose a few pounds. 8 P age
INNOVATION & RESEARCH Quality improvement work and research are highly encouraged at our academic FHT and there are multiple research projects presently undertaken by our physicians, funded by the Ministry of Health and Long- Term Care and the Departments of Family Medicine and Medicine at the University of Toronto through their BRIDGES: Building Bridges to Integrate Care funding grants. SETFHT s virtual ward was chosen as an innovation in primary care that the Ministry wanted to see a full qualitative evaluation on. As such, the program evaluation is being funded by the Ministry through the Primary Health Care System (PHCS) Program. Although we have been delivering the virtual ward model for a few years, we have not been able to do a full scale evaluation on the program. These research dollars will involve an evaluation of this primary care virtual ward program piloted at SETFHT with objectives including: the impact of the program on patients experience; the virtual ward health providers experience; patient attachment to a primary care physician and hospital utilization (readmission and emergency department visits); and its scalability to other family health teams (FHTs) in Ontario. As a co-principal investigator for the BRIDGES funded Bridging Care for Frail Older Adults: a Study of Innovative Models Providing Home-based Care in Toronto, we are working in collaboration with other organizations interested in home based care. The study being undertaken will look at three objectives: 1. Improve access and build capacity for the provision of primary, specialty and community care for homebound older adults. 2. Study the effectiveness of different innovative homebased primary care models at improving patient, caregiver, team and system outcomes. 3. Inform the development of toolkits to support scalability and dissemination of best practices and to build system capacities and networks that support home-based care and training opportunities therein. As a co-investigator of another BRIDGES project, our team will also be participating in the IMPACT Plus: The Integrated Complex Care Clinic project which is a team model of simultaneous interprofessional consultation and planning that brings together patients with complex or multiple chronic diseases, significant others/ caregivers, the primary care team, community care providers and specialists in real time at the FHT with the goal to create and implement a fully integrated patientcentred care plan for the patient who are at high risk of ED visits and hospitalization This year, we took a new approach to patient-centred care by implementing concepts developed by the Picker Institute in delivering the optimal patient experience. With the roll out of Excellent Care for All Act in primary care in the not so distant future, there is increasing attention that has focused on the importance of measuring and improving the health care experience of patients and families. Instead of asking patients to provide simple satisfaction ratings, as had been standard practice for measuring care, we will be asking patients whether or not certain processes and events occurred during the course of a specific care episode. This work was started with the assistance of a University of Toronto Institute for Healthcare Improvement Open School student group as mentors to this group of students (a Masters of Health Research student, nursing student, engineering student and two medical students), SETFHT is proud to be coaching an Interprofessional team in this crucial quality improvement initiative that will provide patients with an optimal patient experience when they visit the FHT. The hope is that we can use lessons learned (which is being done through focus groups with patients and online/hard copy surveys) and continue to work to develop the optimum patient experience each and every time our patients visit us for care. 9 P age
PROGRAMS AND SERVICES Roughly 15% of our clinic population is over the age of 65 and many of them suffer from multiple chronic illnesses. But chronic illnesses happen to individuals of all ages. To support our patients self-manage their health and encourage health promotion, we have developed a number of self-care and self-management programs in order to educate and enable patients to manage their own health: PATH (Personal Action Towards Health for patients managing chronic illnesses), Mind over Mood (for patients with depression and/or anxiety), Craving Change (for patients looking at influences to eating behaviours), Healthy Weights (for patients interested in weight management), Hypertension Management Program (for patients with high blood pressure), Healthy Heart Classes (for patients with high cholesterol), Memory Clinic (for patients experiencing memory problems) all of these programs are backed up with the health coaching approach to self-management. In this upcoming year, we will be starting Well Baby Group visits for parents and family members. These group visits will provide a supportive network to share parenting tips, knowledge and experiences and allow parents with babies the same age to learn together. Programs and services continue to develop as the FHT continues to grow from offering Nicotine Replacement Therapy (NRT) to our evolving diabetes program, our health care providers are working hard at supporting the health care needs of our patients. By promoting primary prevention and health promotion and utilizing Interprofessional Care through the creation of a number of quality primary health care relationships and programs, SETFHT is changing the face of primary care provision and meeting the four (4) measures of Primary Care (Access, Continuity, Comprehensiveness and Coordination) set out by the late Dr. Barbara Starfield. Quitting Smoking With Assistance Fred is a 75 year old patient with SETFHT. He has smoked a pack of cigarettes every day since he was 17 years old. Fred mentions on more than one occasion how costly that has been to him over his life. He decided that it was time to quit as more doctors were telling him how bad it was for his health. Once he quit Fred noticed that even after all those years of smoking his chronic smokers cough was gone in about two weeks. When Fred asked his doctor to help him finally quit, his doctor prescribed a pill. Fred tried it for a while but found it did not work for him at all. He went back to the doctor. After a conversation with his doctor Fred was referred to the SETFHT Addictions Counsellor for the Nicotine Replacement Therapy (NRT) program. Fred found the program to be just what he needed. It has been a year since he started the program and he finds that although his cravings are still there, he has no desire to actually smoke. And he proudly states: I haven t even put on any weight. Fred also has some advice for anyone who thinks attempts to quit smoking: The first thing you have to know is you don t want to smoke anymore after that it s only success! Fred also has some parting thoughts for the South East Toronto Family Health Team. He says This program was fantastic; there are slews of people who would like to quit if only they knew it was available. My counsellor being in the same office as my doctor made it easier for me and I highly recommend the patch. 10 P age
Gord Efficiency Through Team-Based Care The last day of April 5 years ago, Gord wasn t feeling well. His family doctor had retired and some of his patients had transferred over to the South East Toronto Family Health Team. Gord was one of them. He walked into the clinic telling the front desk he wasn t feeling well; his new doctor came to see him and walked him across the road to the Hospital. Gord was suffering from Congestive Heart Failure. Once out of hospital, Gord was introduced to the SETFHT OTN program, where his CHF (congestive heart failure) was monitored at home and he met with the pharmacist, doctor and nursing staff to keep a close watch on his health while he recovered. Once Gord was feeling better, he worked closely with one of the FHT s dietitians to begin a weight loss program and began to find ways to control his hypertension. Through the help of the FHT Gord feels that he is in a place where transitions are smooth; in his words referrals happen quick here; if my doctor isn t sure what it could be, there are people here who can help get the answers Gord has also been seeing our Pharmacist on a regular basis to have his medication managed. He feels this program at the clinic is far better than what he used to go through: it used to be I had to have blood taken from my arm and wait a week for the lab results, then come in and see the doctor for follow up. Now I see the pharmacist and she pricks my finger; the only time I have to come back is if my levels are off, other than that, it s see you next month. One thing that Gord feels sets SETFHT apart, is that when he comes into the clinic, staff know his name. I feel that it works here, it s just more efficient 11 P age
1871 DANFORTH AVENUE Finally! After over three years of planning, development and construction, our new clinical site at 1871 Danforth Avenue opened on March 27, 2012. Welcoming a group of nine physicians, six of the physicians are former medical residents who trained in the FHT interprofessional model of care and enrolling patients in their practice. With a team of health care providers including nurses, Nurse Practitioner, dietitians, social worker, psychologist, mental health addictions counsellor, care navigator, pharmacist and chiropodist, we look forward to providing the same exceptional care at 1871 Danforth Avenue that you have come to expect at our flagship clinic at 840 Coxwell Avenue. Purchase of 1871 Danforth May 2009 The Demolition July to October 2010 12 P age
Construction November 2010 to March 2012 We are Open! 13 P age
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The South East Toronto Family Health Team (SETFHT) is an academic Family Health Team affiliated with 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 services and programs to the residents of South East Toronto. Many members make up our team: Administrative/Clerical Team Care Navigator Chiropodist Family Doctor Family Medicine Residents Internal Medicine Specialist Mental Health/Addictions Counsellor Nurse Practitioner Pharmacist Physician Assistant Psychologist Psychiatrist Registered Dietitian Registered Nurse Social Worker Each of these health care workers plays a different role in our patients health care so that they and their family can benefit from a total approach to health. Right care by the right provider at the right time in the right place! 15 P age
A leading academic family health team that improves the health of our community Administration Office: 833 Coxwell Avenue, Toronto, ON M4C 3E8 Tel: 416 423 8800 Fax: 416 423 8803 Clinic Sites: 840 Coxwell Avenue, Suite 105, Toronto, ON M4C 5T2 Tel: 416 469 6464 Fax: 416 469 6164 1871 Danforth Avenue, Toronto, ON M4C 1J3 Tel: 416 699 7775 Fax: 416 699 7776 www.setfht.on.ca @SETorontoFHT 16 P age