Hawkesbury Family Health Group Shared Care Pilot Project 20072009

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• Hawkesbury Family Health Group Shared Care Pilot
  Project 2007-2009

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• May 2006
• The Ontario Ministry of Health and Long-Term
  Care announced funding for 6 shared Care Pilot
  sites for Family Health Groups.

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Shared Care or Collaborative Care

• Family Physicians working together with
  interdisciplinary
• health care providers
• Team Based collaborative environment
• Target Population for high need
  patient/population
• Chronic Disease Management /Prevention
• Health Promotion
• Mental Health

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What does the Hawkesbury FHG look like?

• 23 Family Physicians (on fee-for-service)
• 17,000 18,000 Ontario Patients
• Francophone majority, high prevalence of
  chronic disease,
• low social economic status
• Comprehensive Care
• On-Call After Hours Care
• In Hospital Care Including
• ER
• Seniors Care
• Anesthesia
• Palliative Care
• Maternal Child Care

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Hawkesbury FHG Affiliations
Public Health
Hospital
Hawkesbury FHG
Community Mental Health
Diabetes Stroke Prevention Smoking
Cessation Cardiac Rehabilitation Geriatric
Services Palliative Services
CCAC Geriatric Assessments Memory Disorder
Clinic RISC
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What did we hope to accomplish?

• Create a community of professional practice
• Use Population Health Approach
• Our Goal To address gaps in care and maximize
  the health
• potential of our patients
• Interdisciplinary teams in family practices
  working together
• to help patient in self management programs.
• What we also discovered? intense case
  management

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Proposed enhancements

• Allied Health Professionals
• Chronic disease Nurse (Registered Nurse)
• Health Promoter (Kinesiologists)
• Mental Health Worker
• Administrative Position
• Manager (Mme Sylvie Lemaire CMHA)
• Physician Team Leader (Dr. Renée Arnold)

Governance Physician Led
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Shared Care Team

• Health Educator/Kinesiologist
• Linkage to community resources
• Facilitator in health promotion and illness
  prevention activities
• Accent on individualized, goal oriented
  physical activity
• Programs for patients with and without chronic
  diseases
• Evaluate lifestyle and give counseling to
  patients on areas
• needing improvement (increase well-being and
  confience,
• eating habits, sleep, stress)
• Innovation
• Partnership with the Hospital Diabetes Program
• Community Engagement Walk With It and Heart
  Wise

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Shared Care Team

• Chronic Disease Nurse/ Registered Nurse
• System Navigator
• Intense Case Management
• Linkage to community resources
• Accent on individualized and group self
  management programs
• Education and counseling to patients and
  families
• Arthritis Self Management Program
• Lung Health Progam
• Asthma Educator
• COPD( living well)
• Spirometry

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Shared Care Team

• Mental Health Worker/ Mental Health Counselor
• Navigator /Advocate role to existing services
• Individual Group therapy for patients with
  chronic disease
• Chronic Pain Clinic
• Lung Health, diabetes, obesity fibromyalgia
• Individual Group therapy for anxiety and
  depression,separation
• and divorce, sleep disorder, stress management
  and addiction
• Children and youth mental health

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Patient Participation through self management
Programs
Arthritis Self Management Programs Asthma
Educator COPD (living well with COPD)
Healthy Lifestyle (prevention) Healthy
Lifestyle in chronic disease management
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Patient Participation
Enhances knowledge Eliminates wrongful
perceptions Increases Self esteem Improves
adherence to therapy Increases well being and
confidence
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We established a Pain Clinic in
collaborationwith Hawkesbury District General
Hospital

• Assessments and follow-up by a team of
• professionals, which includes a Medical
  Director,
• a registered nurse and a mental health worker
• Referrals to other specialist consultants as
  needed
• Assist patient in learning to live with chronic
  pain
• Relieving pain and improving functional
  activities
• and quality of life

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Lesson Learned

• Administrative Issues
• Support from OMA was greatly appreciated
• CMHA administrative assistance was a plus
• Office space separate from physician had
  positive
• benefits and disadvantages

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Lesson Learned

• Focus on patient centered care
• Shared mutual goal
• Inter-reliance interdependance
• High trust climate
• Build Programs on Healthy Lifestyle, Mental
  Health and Chronic
• Disease with a strong self management
  component
• Establish effective communication and role
  clarity between team
• members is important
• Newsletter
• Referral and report forms
• Daily and monthly Interdisciplinary meetings
• Well defined accountabilities

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Our vision for the future

• The Lower Outaouais Family Health Team (LOFHT)
• Phase One
• Primary care access for a geographic area
• (Urgent care advanced access, care to
  housebound, orphan and difficult to serve)
• Strenghten and Expand Programs
• High Risk Vascular Program, Drug Program
  including an anticoagulation clinic,
• Child and Youth Program, Care of the elderly
  and end of life care, shared care
• with specialists
• Phase Two primary care hub for education,
  training and research
• Phase Three Primary care division of Champlain L
• (Quality improvement
  initiatives and system innovations)
• will need Nurse Practitionners,
  Dietician and pharmacist

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Calls for Collaboration

• SALUTE
• TO
• COLLABORATIVE CARE