Conference Abstracts - BUKSA Strategic Conference ServicesConference Abstracts Table of Contents 1)...

Conference Abstracts

Table of Contents

1) Sabrina Akhtar MD, CCFP, Toronto Western Hospital Integrated Home‐Based Primary Care: Improving access to care for a complex elderly population Poster Presentation

2) Stephanie Baker BA, Calgary Foothills Primary Care Network Improving Access to Primary Care: Pan‐PCN Calgary and Area unattached patient registry Poster Presentation

3) Misty Bath BSN, RN MPH, Vancouver Coastal Health Authority Integrated Care for High Users of the Emergency Department Poster Presentation

4) Bachir Belhadji PhD, Health Canada Inventory of CDM (Chronic Disease Management) Programs in Canada in PHC (Primary Health Care) settings Oral Presentation

5) Michael Brand BA, The Taber Clinic The Continuous Improvement Journey at the Taber Clinic Oral Presentation

6) Jacqueline Chaisson BA, RN, BN, Palliser Primary Care Network Palliser Primary Care Network: A learning organization Poster Presentation

7) Elaine Chow Baker MSc, MBA, Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary 'You and Your Patients': Using billing data to facilitate reflective thinking Poster Presentation

8) Lisa Cook PhD, Chinook Primary Care Network Ambulatory Care Sensitive Conditions Indicator as a Measure for Primary Care Performance Oral Presentation

9) Shagnaz Davachi PhD, Alberta Health Services Patient Centred Care Through a Diversity Lens: Alberta Health Services approach Poster Presentation

10) Yogeeta Dosanjh BSHA, Vancouver Coastal Health VCH Primary and Community Care Integration: Leading from behind Oral Presentation

Banff, Alberta – Nov. 18 – 20 – Conference Abstracts – Accelerating Primary Care 2012 Conference of 90

11) Rebecca Dunne MCS, Wood Buffalo Primary Care Network Collaborative Practice in the Development of Organizational Team Covenants: Creating a foundation and an environment for interdisciplinary team openness and responsiveness to change Poster Presentation

12) Judith Dyck BA, MA Student (MACT), University of Alberta eHealth and Chronic Disease Management: The patient perspective Poster Presentation

13) Brandi Engbert BA, Palliser Primary Care Network Enhancing Primary Care Access: Improving access and reducing unnecessary emergency visits Oral Presentation

14) Jim Fleming, Palliser Primary Care Network Visualizing the Team Poster Presentation

15) Jodeme Goldhar MSW, RSW, MHSc, Toronto Central CCAC Advancing an Integrated System of Care: Integrated client care for older adults with complex needs Poster Presentation

16) Jodeme Goldhar MSW, RSW, MHSc, Toronto Central CCAC Creating a Primary Care Integration Strategy: Working hand‐in‐hand with primary care Poster Presentation

17) Michele Hannay BSc, Toward Optimized Practice Group Medical Visits: An innovative approach to clinical care Poster Presentation

18) Sarah Hassall RN, IBCLC, Bow Valley Primary Care Network The Growing Need for Breastfeeding Support and Education in the Bow Valley Poster Presentation

19) Robert A. Haubrich MSW, Boyle McCauley Health Centre, Pathways to Housing Program Primary Health Care and Housing First: Interdisciplinary teamwork yields successful outcomes Oral Presentation

20) Nina Hirvi RD, Copeman Healthcare Centre Care Gap Analysis and Improving Outcomes for Patients with Type 2 Diabetes in Primary Care Oral Presentation


21) M. Janet Kasperski RN, MHSc, CHE, The Ontario College of Family Physicians Evaluating Measurements in Primary Care Poster Presentation

22) Nick Kates MBBS, FRCPC, MCFP(Hon), McMaster University A Framework for Transforming Primary Care and Supporting Quality Improvement Oral Presentation

23) Nick Kates MBBS, FRCPC, MCFP (hon), McMaster University Building on the Effective Integration of Mental Health Services: New opportunities and better care Oral Presentation

24) David Keegan MD, CCFP(EM), FCFP, University of Calgary Making Change Happen: Increasing the percentage of students choosing family medicine as a career Poster Presentation

25) Holly Kennedy‐Syonds RN, MHSc, Copeman Healthcare Optimizing Quality of the Patient Experience in Primary Care: The Copeman Healthcare way Poster Presentation

26) Ross Kirkconnell MSc, Guelph Family Health Team Integrated Hospice Palliative Care: Bringing family physicians back into the team Oral Presentation

27) Scott Klarenbach MD, MDs, FRCPC, University of Alberta Rethinking Self‐Monitoring of Blood Glucose in Non‐Insulin Treated Type 2 Diabetes Oral Presentation

28) Holly Knight RD, MEd, PhD, Alberta Health Services Health Coaching as a Self‐Management Support: Introducing a paradigm shift in patient care Poster Presentation

29) Judith Krajnak PhD, Charis Management Consulting Inc. Effort to Bridge the Gap Between Emergency Department and Primary Care Service in a Young Urban Patient Population: Embedding evaluative processes to guide clinic development Oral Presentation

30) Markus Lahtinen PhD, Health Quality Council of Alberta Primary Healthcare in Alberta: A HQCA perspective Oral Presentation


31) Bonnie Lakusta BSc, PhD, Alberta AIM The Impact of Alberta AIM at the PCN Level Oral Presentation

32) Allison Larsen HBA, MA, Alberta Health Services Provincial Primary Care Clinical Pathway for Adult Depression Oral Presentation

33) David Letourneau BCom, Alberta AIM The Impact of Panel Management on Patient Access to Care Oral Presentation

34) Anthony Levinson MD, MSc, McMaster University Online Quality Improvement and Innovation Programs for Family Physicians in Ontario Poster Presentation

35) Shariq Lodhi MD, CCFP, William Osler Health System Bridging the Gap: An innovative collaboration between Brampton’s family physicians and Brampton Civic Hospital Poster Presentation

36) Marlee MacDonald MN, NP, Red Deer Primary Care Network Street Clinic: Working together to meet the health needs of vulnerable population in a primary care setting Oral Presentation

37) Sharon Macklin RD, Edmonton Oliver Primary Care Network Transformational Change: Measurement of patient satisfaction with dietitian supports in a primary care network setting Poster Presentation

38) Bev Madrick RD, CDE, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone Online and Email Diabetes Education Increases Knowledge, Confidence and Reach Poster Presentation

39) Ann Makin BPE, Bow Valley Primary Care Network Get Smart with Panel Management: From chaos to control Poster Presentation

40) Donna Manca MD, CCFP, FCFP, University of Alberta, Dept. of Family Medicine The BETTER Project: Qualitative study Oral Presentation


41) Donna Manca MD, CCFP, FCFP, Department of Family Medicine, University of Alberta Finding a BETTER Way: Facilitating chronic disease prevention and screening in primary care Oral Presentation

42) Raelene Marceau MN, NP, Peace River Primary Care Network Evaluation of a Nurse Practitioner in a Rural Alberta Primary Care Network Poster Presentation

43) Yolanda Martens vanHilst RN, Calgary Foothills Primary Care Network An Integrated Shared Referral Model with Specialty Partners Within Primary Care Poster Presentation

44) Carol Maskowitz RN, Red Deer Primary Care Network Optimizing Chronic Disease Management in Primary Care through Program Integration and Teamwork Oral Presentation

45) Bev Matthiessen, Alberta Committee of Citizens with Disabilities Barrier‐Free Health and Medical Services in Alberta: Communicating need Poster Presentation

46) Lorna Milkovich RN, BN, MBA, Red Deer Primary Care Network Health Basics: An innovative team approach to healthy lifestyle promotion and management Oral Presentation

47) Gillian Mulvale PhD, McMaster University How Social, Political and Economic Factors Shape Formation and Integration of Interprofessional Primary Healthcare Teams Oral Presentation

48) Sharon Nelson RN, BScN, Edmonton West Primary Care Network Shared Mental Health Care Poster Presentation

49) Pauline Pariser MD, CCFP, FCFP, Taddle Creek Family Health Team WRAP: A self‐management recovery program for and by patients with mental health challenges Poster Presentation

50) Pauline Pariser MASc, MD, CCFP, FCFP, Taddle Creek Family Health Team It Takes a Team: An interdisciplinary clinic to treat patients with complex conditions Oral Presentation

51) Pauline Pariser MASc, MD, CCFP, FCFP, University Health Network Within the S.C.O.P.E. of Patient Care: A primary care integration project Oral Presentation


52) Pauline Pariser MASc, MD, CFP, FCFP, University Health Network The Art of Persuasion: Engaging physicians in primary care integration Oral Presentation

53) Sandra Pelchat BSc Kin, CEP, Edmonton Southside Primary Care Network Moving for Health: Bridging the exercise gap between primary care and community Poster Presentation

54) Thuy‐Nga Pham MD, MSc, CCFP, South East Toronto Family Health Team Supporting the Patient with Complex Needs in a Virtual Ward Program: A collaborative to improve the patient experience Poster Presentation

55) Paul Philbrook MD, CCFP, Credit Valley Hospital and Trillium Health Centre Peel Regional Primary Care and Cancer Network Poster Presentation

56) Paul Philbrook MD, CCFP, Credit Valley Hospital and Trillium Health Centre "Do What You Know" Cancer Screening Toolkit for Primary Care Providers: A quality improvement initiative Poster Presentation

57) Michele Poirier BKin, CAT c, MPAS, CCPA, University of Calgary, Department of Family Medicine Physician Assistants: Adding value To primary care In Alberta Poster Presentation

58) Marion Relf RN, BScN, MHSA, Alberta Health Services What We Can Learn From Others: A scan of primary health care service delivery models Oral Presentation

59) Julie Shemanchuk BA, Alberta AIM Alberta AIM: Continuing the access and efficiency journey Poster Presentation

60) Shannon Spenceley RN, PhD, University of Lethbridge Back to the future: What Taber has to teach us 10 years on Poster Presentation

61) Tamara Stecyk, Edmonton Southside Primary Care Network Improving Access to Primary Care Physicians for Unattached Patients Poster Presentation

62) Lindsay Steward, Edmonton North Primary Care Network Orthopedic Triage at the Primary Care Level at the Edmonton North Primary Care Network Oral Presentation


63) Jennifer Tilbury Registered Psychologist, Red Deer Primary Care Network Coping with Anxiety: An innovative and responsive group method Poster Presentation

64) Danielle Tone BA, BSW RSW, Chinook Primary Care Network Understanding our Practice to Change our Practice Oral Presentation

65) David Topps MD, University of Calgary Data Informed Self‐Evaluation and Collaborative Knowledge Translation (DISECKT): Primary care on the cutting edge Poster Presentation

66) Christine Vandenberghe MEd, Emergency Medicine, University of Alberta Uptake of Addiction Assessment Resources by Primary Care Physicians Poster Presentation

67) Lorna Warkentin RN, Edmonton Oliver Primary Care Network Review of INR Protocols for Registered Nurses at the Edmonton Oliver PCN Poster Presentation

68) Sasha Wiens RN, BN, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone Online and Email Obesity Education Increases Knowledge, Confidence and Reach Poster Presentation

69) Shea Wilks BESc, Palliser Primary Care Network Improving and Evaluating Physical Examination Attendance Through Use of Recall Letters and EMR Data Extraction Poster Presentation

70) Margot Wilson RN, MSN, Providence Health Care Shared Care: Specialist support for community‐based patients – doing more for less Oral Presentation

71) Kate Woodman PhD, Charis Management Consulting Inc. Evaluating Teamwork in Primary Care: Edmonton North Primary Care Network's Resources in Clinics Pilot Project Oral Presentation

72) Lisa Wozniak MA, University of Alberta, School of Public Health, ACHORD Importance of Patient Registries for Implementing Quality Improvement Interventions in Primary Care Poster Presentation


1. Integrated Home‐Based Primary Care: Improving access to care for a complex elderly population Sabrina Akhtar MD, CCFP, Toronto Western Hospital Thuy‐Nga Pham MSc, MD, CCFP, South East Toronto Family Health Team Context The health care system in Ontario will be increasingly challenged in the coming decades to meet the needs of an ageing population. Innovative models are required to meet the complex inter‐related health and social problems faced by marginalized frail and homebound older adults. Objective We will present our home‐based primary care model (IHBPC) with the intention of building capacity within the Canadian context for this model of interprofessional team based care that integrates primary and specialty care as well as community and acute care. Methods Qualitative studies will explore patient and caregiver experiences, interprofessional team integration, key stakeholder analysis on how to develop effective partnerships with other professionals and agencies in the home‐based care field, as well as how to leverage resources that may be harnessed in the design and implementation of an integrated home‐based primary care program. Quantitative analysis using a matched cohort design will measure hospital and emergency room admission rates for patients receiving IHBCP versus routine care, and ongoing Quality Improvement process and outcome measures are being monitored during the study period. Results This study will establish a registry of frail older homebound adults in Ontario; compare costs of IHBPC relative to the status quo; evaluate the health trajectories of patients receiving IHBPC to those receiving usual care; and consider the perspectives of relevant stakeholders, including patients and caregivers, to better understand issues related to accessibility and satisfaction, and to identify the facilitators/barriers to IHBPC service delivery. Conclusion The health needs of an aging frail homebound population require new innovative models of care that are interprofessional and traverse the health continuum between community and acute care, in order to reduce avoidable emergency room visits and institutional care.


2. Improving Access to Primary Care: Pan‐PCN Calgary and Area Unattached Patient Registry

Stephanie Baker BA, Calgary Foothills Primary Care Network Rick Ward MD, Calgary Foothills Primary Care Network Karen Seigel MD, Calgary Foothills Primary Care Network Carol Anne Schitthelm, Mosaic Primary Care Network Petra Okeke, South Calgary Primary Care Network Lisa Froehlich, Highland Primary Care Network Alison Morton, Calgary West Central Primary Care Network Les Cunning MD, Calgary Rural Primary Care Network Yvette Penman BPE, MEd, Bow Valley Primary Care Network Sheena Clifford BSW, MSW, RSW, CPM, Alberta Health Services ‐ Calgary Zone Context The Unattached Patient Registry is an online tool designed to attach patients who do not have a doctor to the first available physician in their local residential area on a first come, first served basis, as well increase access to primary care services for patients while they wait for attachment. Launched in 2009, the registry began as a pilot program through Calgary Foothills PCN. In September 2010, 7 PCN's partnered together to offer this service to residents in Calgary and area. Participating PCNs: Calgary Foothills, Mosaic, Calgary West Central, South Calgary, Calgary Rural, Highland and Bow Valley. Objective The registry serves to increase capacity by identifying patients who do not have a family doctor and connecting them with physicians taking new patients. The registry also directly supports physicians looking to establish or expand a practice by facilitating access to unattached patients in their PCN’s catchment area. Methods Unattached patients register on the website www.needadoctorcalgaryandarea.ca or through HEALTHLink Alberta, a 24‐hour telephone advice and health information service. The information is collected on a secure website by PCN assigned postal codes, and participating PCNs log in to download their registrations on a monthly basis. Results From Sept 2010 to March 2012: 12,104 unattached patients in Calgary and area were connected with a family physician 56% of registrants were without a family doctor for over a year 44% of registrants were without a family doctor for under a year 37% of registrants had one or more chronic conditions Conclusion This is an example of how PCNs are facilitating change to improve patient access to primary care services. Working as a team, this initiative is an opportunity for PCNs in Calgary and area to better understand the


health needs of the unattached population and address them on a local level. It has also built stronger relations with community stakeholders such as AHS/HEALTHLink Alberta. With the successful implementation of this program the team has developed project guidelines and lessons learned that can be used by the pan‐PCN Operations Committee for other quality improvements initiatives.


3. Integrated Care for High Users of the Emergency Department Misty Bath BSN, RN MPH, Vancouver Coastal Health Authority Vernie Dettmers BS, MA, DPA, Vancouver Coastal Health Authority Laurie Ringaert BSc, BMR‐OT, MSc, Vancouver Coastal Health Authority Stan deVlaming MD, Vancouver Coastal Health Authority Val Munroe BSN, RN, MS, Vancouver Coastal Health Authority Anne McNabb BBA, RN, Vancouver Coastal Health Authority Scott Harrison RN(C), BScN, MA, CCHNC, Providence Health Care

Context Vancouver’s Downtown Eastside (DTES) is characterized by a high incidence of poverty, homelessness, open air drug trade, commercial sex work and crime. Due to the complex interactions of these and other social determinants of health, residents of the DTES experience significant morbidity from all causes and higher use of health services compared to the general population. One high profile issue is their frequent use of the inner city Emergency Department (ED). Eight nine clients in the DTES have accessed ED services 10 or more times during the period April 2011‐February 2012. However, these clients are also engaged with and access clinical services from primary care clinics in the DTES.

Objective The integrated care initiative aims to address problems such as fractured communication and interaction among ED and community care providers as well as the costly use of EDs as a source of primary care. The goal is to implement an integrated system of primary and community care with ED transition support to provide proactive, coordinated, and efficient community‐based care for complex clients frequently seeking ED services.

Methods Six primary care sites are implementing a pilot integrated care process from July 2012‐June 2013 that includes:

Creating a registry of high ED users/site.

Identifying a key health care provider for each client.

Identifying other clinical teams associated with the client.

Reviewing the ED care plan if available for each client.

Meeting with clients to better understand their reasons for frequent ED visits.

Case conferencing among care providers including the client.

Co‐developing, sharing and implementing new care plans.

Results Preliminary results currently under collection from the evaluation plan will be shared (pre/post test surveys, administrative data and tracking of successes, challenges and lessons learned) . Outcomes include:

1. Reducing ED use. 2. Reducing average cost of care. 3. Improved patient and provider experience. 4. Improved health and social functioning. 5. Improved coordination and integration of care.


Conclusion Based on findings from the evaluation, the integrated care process may develop into standard practice for community clinical services to strengthen coordination and integration of care for clients with chronic and complex needs.


4. Inventory of CDM (Chronic Disease Management) Programs in Canada in PHC (Primary Health Care) settings Bachir Belhadji PhD, Health Canada Louise Rosborough BA, Health Canada Jordan Sauer MSc, Health Canada Dale McMurchy MA, Dale McMurchy Consulting Context Chronic conditions place significant pressures on the health care system. Research indicates that a small proportion of the population accounts for the largest percentage of total provincial health spending. People with chronic conditions are relatively heavy users of health care services and are significantly more likely to be admitted to hospital or use the emergency department and are also more likely to experience longer (and costly) hospital stays. These factors suggest that skilled, timely and appropriate management and treatment of these patients is required to reduce their often heavy use of hospital services. Objective There is a wealth of CDM programs in Canada but little information is being exchanged across provincial and territorial program and policy officers. The objective of the present work was to develop an inventory of CDM programs as a means to share information about these programs with all of the provinces and territories. Methods The information contained in this inventory has been collected from federal, provincial and territorial governments, regional authorities, local providers, health care organizations, and non‐governmental health organisations. The survey templates were emailed to as many contacts as possible as a means of gaining a broad of representation of CDM programs from across Canada. Representatives from these authorities were asked to provide standardized information on their programs related to the following chronic conditions: Diabetes, Hypertension, Congestive Heart Failure, Asthma / COPD, Arthritis, and Depression Results Each completed inventory template provides key program information, including: the contact information of the program leader, the target disease(s), key program objectives, a description of the work being done within the program, key lessons learned, and any available information in relation to health and economic outcomes. This report is a ‘snap‐shot picture’ of 157 CDM programs from across Canada. There are details on 12 (7.6%) national chronic disease strategies, 54 provincial programs (34.4%)4 and 91 (58.0%) regional programs. Most of the CDM programs in Canada addressed Diabetes care (66.9%), while 49.0% addressed Hypertension, 36.3% Congestive Heart Failure, 36.3% Asthma/COPD, 30.6% Arthritis, and 35.7% Depression.


Conclusion The contents of this inventory indicate that there are multiple CDM initiatives taking place across Canada and that there is a wealth of experience and examples of promising models for care.


5. The Continuous Improvement Journey at the Taber Clinic Michael Brand BA, The Taber Clinic Audrey Wiebe RN, The Taber Clinic Robert Wedel MD, The Taber Clinic Context Over the past seven years, The Taber Clinic has been implementing office redesign improvement strategies resulting in increased access to a family physician and higher screening rates for chronic disease and cancer. When this journey began, the screening for various health conditions was inconsistent and clinical outcomes were not measured. Objective We will demonstrate the importance of collecting and analysing data for long term success. The Electronic Medical Record (EMR) played a critical role in our information management needs. Team members used this data to educate patients, promote preventative medicine and implement the care patients need. Methods The EMR allowed for the efficient collection of aggregate data and provided personalized alerts of patient screening needs, to all our team members. Team‐based care allowed us to involve all team members of the clinic, regardless of role, in the care of our patients. When a patient contacted the clinic (either by phone or through an appointment), all members of the team assume the responsibility for ensuring the medical needs of the patient were met. In addition, we proactively contact those patients at risk to ensure screenings are completed. With this shared responsibility, we are able to provide more comprehensive primary health care for our patients. Results Our improvement strategies have significantly improved in several clinical outcomes such as cancer screening, diabetes and asthma management as well as a substantial reduction in Emergency Room visits. With increased access to the clinic and the team‐based care, our patients are provided with the tools to better manage their own health conditions. Conclusion This has been an on‐going journey for us, our clinic and the community we serve. Our patients have grown along with us and have come to appreciate the level of care we provide. After seven years of continuous improvement, we have the data to show this is the best way to provide accessible, comprehensive, patient focused care with excellence and compassion.


6. Palliser Primary Care Network ‐ A Learning Organization

Jacqueline Chaisson BA, RN, BN, Palliser Primary Care Network Treena Klassen RN, BN, Med, Palliser Primary Care Network

Context A learning organization is the term given to a company that facilitates the learning of its members and continuously transforms itself. Learning organizations develop as a result of pressures facing modern organizations & enables them to remain competitive in the business environment. A learning organization has 5 main features; systems thinking, personal mastery, mental models, shared vision and team learning. It encourages organizations to shift to a more interconnected way of thinking. Organizations built like communities have committed employees that work harder for them (Senge, 1994).

Objective To demonstrate the successful development, implementation & continuous improvement of processes which have been utilized to develop a learning organization.

Methods

Individualized learning assessments leading to individualized orientation and lifelong professional learning.

Site visits with process and a clinical assessor. Follow‐up site visits as needed.

Individualized mentorship opportunities both in house and visiting clinics.

Individualized ongoing coaching.

Ongoing integrated performance appraisal system.

Telephone/text/email connectivity of central office staff with clinic employees.

Mobility of central office.

Monthly mandated networking team meetings.

Community of Practice developed through secure website.

Evaluation Completed through anecdotal feedback, orientation and workshop evaluations, employee surveys and exit interviews. PCN Employees report a sense of interconnectedness, influence and meaningfulness within a decentralized system disbursed over a large geographic area. “When you ask people about what it is like being part of a great team, what is most striking is the meaningfulness of the experience. People talk about being part of something larger than themselves, of being connected, of being generative” (Senge, 1990).

Results ‘I appreciate the annual evaluation process. I look forward to knowing I am meeting the needs of this position [fr patient to coworkers, M.D and central office staff]’. Abbie Skrove PCN R.N 2011 2011 Employee survey key satisfaction questions rated in the range of 86‐93%.

Conclusion Palliser PCN continues to strive to be a learning organization. Implementation of this model has lead to successful development of a significantly geographically disbursed team. Launched in August 2006 with 0 employees and presently in August 2012 with 61 employees in 29 clinics whom collaboratively continue to develop the organization.


7. 'You and Your Patients': Using billing data to facilitate reflective thinking

Elaine Chow Baker MSc, MBA, Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary Grace Button RN, Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary Ingrid Vicas MDCD, FRCPC, Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary Jocelyn Lockyer PhD, Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary

Context The Physician Learning Program (PLP), a collaborative initiative, provides Alberta physicians with access to practice‐based information for learning, reflecting and improving patient care. This project is a unique opportunity for family physicians to review individual practice‐specific data and in‐depth analysis previously unavailable to them.

Objective This pilot is an observational study to 1) gauge the utility of practice data extracted from physician claims database, 2) evaluate the opportunity for expansion to a larger Alberta‐wide offering.

Methods Calgary family physicians were invited by mail to participate in the pilot by providing consent. Alberta Health identified panel patients using the AIM four‐cut methodology and provided PLP with 13 months of physician billing claims data. Individual reports were sent to physicians for self‐review. Physicians were subsequently invited to participate in a semi‐structured telephone or in‐person interview to evaluate the data's validity and utility. Each report provided: 1) patient panel information, including panel size, panel visits to the physician, clinic and outside clinic, work day analysis, and panel continuity, 2) patient panel age and gender distribution, and 3) top 10 diagnostic codes stratified by age.

Results Invitations were sent to 140 family physicians, 15 of whom consented to participate. Several themes emerged from the 13 interviews conducted: 1) variability between physician practices, 2) variable concordance between data validity and internal physician perception 3) unexpected value of the data, e.g. identification of coding variations due to clinic operational processes, 4) perception of limited value in using data for identifying learning needs, 5) limited analysis of the data by physicians prior to the interview and 6) recommendations for useful data modifications. Further examples and details will be provided.

Conclusion These reports have the potential to promote reflective thinking for family physicians. A limitation of the reports is the reliance on primary diagnostic codes to describe the scope of diseases/conditions managed by the physician. Facilitated interviews appear to allow for more in‐depth reflection versus individual review. The next step is to repeat with rural family physicians, modifying the reports provided based on physician recommendations. Rural physicians may have differing practices and perceptions than their urban counterparts.


8. Ambulatory Care Sensitive Conditions Indicator as a Measure for Primary Care Performance Lisa Cook PhD, Chinook Primary Care Network Charles Cook PhD, Chinook Primary Care Network Rob Wedel MD, Chinook Primary Care Network Context The Ambulatory Care Sensitive Conditions (ACSC) indictor focuses on a core of 7 chronic conditions: asthma, angina, congestive heart failure, hypertension, epilepsy, diabetes, and chronic obstructive pulmonary disease. Hospitalization for an ACSC is considered to be an indirect measure of access to appropriate primary care. Objective To determine if ACSC conditions presenting in the emergency department are correlated to primary care access throughout the Chinook PCN. Methods The data from the nine emergency department (ED) throughout the Chinook PCN region from 2008‐2012 was data‐matched to the physicians’ panel. The number of visits to the ED, as well as the number of hospital admissions for the ACSC conditions was compiled for each year. The visits and admission data was correlated to clinic access, function and composition of multidisciplinary teams, implementation of electronic medical records, and clinic billing data. Results The number of patients with an ACSC conditions presenting in the ED decreased in 2012 when compared to the previous years. Preliminary data suggests that those patients without a previous ACSC diagnosis were more likely to present with symptoms in the ED, and subsequent hospital admission. Follow‐up analysis with validated patient registries of these conditions will be used to evaluate the ED utilization throughout the Chinook PCN over a number of years. The clinic access, multidisciplinary teams, use of electronic medical records and billing data will be applied as covariates to further elucidate the reason for the presentation of ACSC conditions in the ED. Conclusion The ACSC indicator is used to evaluate access to appropriate primary care. Clinic specific information is required, however, if this indicator is to be used for quality improvement.


9. Patient Centred Care Through a Diversity Lens: Alberta Health Services approach Shagnaz Davachi PhD, Alberta Health Services Context Alberta is rapidly becoming more diverse in its population. The increasing prevalence of chronic health conditions among Albertans is a key challenge for the province, however, there are strong indications that compared with the general population, vulnerable segments of diverse populations such as Aboriginal People, immigrants, refugees, specific visible minorities and people experiencing homelessness are disproportionately impacted by chronic disease and other health conditions. Despite high needs, access to appropriate primary health care and resources is a major concern for vulnerable populations, particularly for Aboriginal and non‐Aboriginal people living in remote parts of Alberta due to multiple factors: geographic remoteness, socio‐cultural, financial, environmental and systematic factors. Objectives Limited number of Alberta Health Services programs and Primary Care Networks (PCNs) have successfully adopted and implemented modified elements of the Expanded Chronic Care Model to address access challenges and achieve enhanced access and improvements in the quality of chronic disease care for diverse and vulnerable populations. Overall, these services are fragmented and the unique needs of the diverse and vulnerable populations in Alberta have not been effectively reflected in provincial planning, policy/decision making and service provision. The objective of this presentation is to introduce an innovative Service Delivery Framework and Action Plan that we have developed for addressing needs of diverse and vulnerable populations in Alberta and discuss the applicability of this framework in the primary care settings. Methods The Framework /action plan for Alberta is developed in response to the broader Social Determinants of Health that impact the health and access of Alberta's diverse and vulnerable populations to primary health care and proposes specific strategic directions and concrete action plans to support health care planners and providers in addressing these service gaps and needs. Strong patients, family and community engagement is foundational to this framework. Conclusion Differences across the province related to population diversity and level and nature of vulnerability suggest that primary health care services need to be tailored to match the local needs of each geographic and diverse community to ensure equitable access and outcomes for Alberta’s diverse and vulnerable populations.


10. VCH Primary and Community Care Integration: Leading from behind Yogeeta Dosanjh BSHA, Vancouver Coastal Health Joanne Douglas RD, MA, Vancouver Coastal Health Laurie Ringaert BSc, BMR‐OT, MSc, Vancouver Coastal Health Venie Deettmers MA, DPA, Vancouver Coastal Health Authority Carol Park PEng, Vancouver Coastal Health Authority Cheryl Rivard, Vancouver Coastal Health Authority Parkash Sahota BSc, BEd, BSN, Vancouver Coastal Health Lori Beach, Vancouver Coastal Health Context Vancouver Coastal Health (VCH) is one of the 5 Health Authorities taking part in a five‐year plan with the BC Ministry of Health Services to develop an integrated system of primary and community care. The goals of Integrated Primary and Community Care (IPCC) are to improve health outcomes and quality of life for our complex/chronic care and frail elderly patients; lower healthcare costs; and enhance the provider/patient experience. Objective A regional IPCC change management team has been formed to provide support and leadership in building an integrated health care system in all of VCH CoC’s by 2015. The work of the team includes coaching, project management, GP engagement, patients as partners involvement, care management support, QI, LEAN methodology and a robust evaluation framework. We have learned that an effective strategy is adopting a ‘leading from behind’ philosophy that encourages local staff to become engaged, generate new possibilities and change ideas and in time, take ownership of the integration process. Methods We have developed a process framework to guide our change team as they support each CoC. This structure focuses on engaging key stakeholders, identifying current issues, improving work flow and efficiencies and embedding the voice the “customer” including the patient as well as family physicians and frontline staff. A provincial evaluation framework has been developed with a developmental evaluation focus as a key aspect. This approach to evaluation ties in well with “leading from behind” as the evaluator serves as a coach, critical friend and helps empower the communities to embrace evaluation and to become players in the evaluation process themselves. Results Our “leading from behind approach” has created several challenges including slower progress with projects than a traditional “top down” approach. However, we are also seeing that there is more sustainability in this approach as the CoC’s are now taking ownership of what was once was thought of as “corporate” ideas. Conclusion Lessons learned have been important to transferability to new CoC’s coming on board and will be important for others outside of VCH to consider in their health transformation work.


11. Collaborative Practice in the Development of Organizational Team Covenants: Creating a foundation and an environment for interdisciplinary team openness and responsiveness to change Rebecca Dunne MCS, Wood Buffalo Primary Care Network Jill Sporidis PhD‐DHA Candidate, Wood Buffalo Primary Care Network Context Research on collaborative practice argues that team involvement, defined as being given the opportunity to provide direct feedback in decision making processes is integral to team cohesiveness and positive culture (Clawson, 2006). Based on this, the WBPCN executive team began a change movement with the intent to build a foundation ensuring team resiliency in times of change. Objective To review an existing mission statement and to guide the process of involving team members throughout a journey of creating a new vision, mission, and team covenants. A key process question was; What needs to take place for an organization’s vision and mission to be effective and for the team to support it? The result of this process would be put into practice with an organizational re‐location requiring team buy‐in at every step. Methods The team came together for a biannual team retreat and team building session on February 28, 2011 so each individual member of the organization would not miss the opportunity to engage in the process with others. The process was considered by all team members to be effective in creating a list of team covenants that is representative of the lived values of the organization and is described in the steps below. Step 1: Review of current mission statement – this process was conducted in smaller groups and involved an in depth discussion of the current mission statement followed by group consensus to create a vision statement, as one had not been created for the organization previously. Step 2: Review of team values – This process was done in a small group setting followed by review by all members of the organization. The intent for this exercise was to have open dialogue centered on the lived norms and values of the group as each member goes about his or her daily work. Step 3: Introduction of team covenants – Upon completion of Step 2, the team values were realigned and wordsmithed in the development of a concrete list of team covenants that represent, to the team and external stakeholders, the culture of the organization. Step 4: Finalization and approval of the newly developed WBPCN Mission, Vision, and Values occurred during the preceding Annual General Meeting. Team covenants were approved by consensus by all. Results An outcome of the covenants was the creation of a clinical leadership role whereby a senior nurse would oversee the daily resolution of clinician concerns and then report back to the management team. This role has been proving to exemplify the covenants as demonstrated in a successful re‐location whereby the team drew on values in the covenants to embrace challenges.


Conclusion Collaborative practice in the documentation of team covenants guides mentoring and coaching at all levels throughout the organization, which has ultimately lead to the sustainability of a positive culture that is open to individual roles and responsibilities and continuous change resulting in quality patient care.


12. eHealth and Chronic Disease Management: The patient perspective Judith Dyck BA, MA Student (MACT), University of Alberta Context eHealth is the use of information and communication technologies in health care. It encompasses treatment, research, health care provider education, disease tracking and public health monitoring (World Health Organization, n.d.). eHhealth shows promise in the support of improved health outcomes, particularly for individuals with chronic conditions. Objective Facilitate the development of effective eHealth interventions by examining adult use of consumer‐focused eHealth applications in managing their chronic disease condition for effective practices and consumer preference. The focus will be on interventions aimed at people with Type 1 and 2 diabetes. Methods Monitor popular websites and social media sites which focus on diabetes self‐care and analyzing how people are using the sites i.e. posting, gathering information, asking questions, developing relationships with other users, etc. Conduct a literature review to identify practices and gaps in knowledge in the use of eHealth to assist people in their management of chronic conditions, including:

social media sites that have community building as an objective

sites which primarily focus on the provision of information

the use of information technology to monitor chronic conditions Results

People with diabetes engage with other diabetics online to gather and share information and encourage one another through social interactions.

Online apps represent a growing aspect of eHealth and provide people with convenient tools to monitor their conditions, track food, blood sugar levels and exercise.

eHealth interventions may be particularly beneficial to the chronic care sub‐population of people with Type Two diabetes, as this condition requires a complex set of actions to support successful management, including diet and exercise, ongoing medication adjustments and the need to monitor blood glucose levels, all of which can be supported by information technology. Their success also requires ongoing feedback from and support from health care providers responding to clinical information gathered and reported by patients. This interaction and information sharing also can be facilitated by information technologies, including texting and web‐based interaction.

Conclusion Electronic interactions and eHealth applications are increasingly important tools in chronic disease management and hold promise in the primary care setting for improved effectiveness of self‐managed care and patient‐provider interactions.


13. Enhancing Primary Care Access: Improving access and reducing unnecessary emergency visits Brandi Engbert BA, Palliser Primary Care Network Shivonne Berger BA, MEd, Palliser Primary Care Network Context Practice improvement is becoming the norm in health care and aims to modify the current system into one that is more efficient and that delivers a higher standard of care. The Palliser PCN Practice Improvement Program extends to the community of Brooks, Alberta. This community has been able to achieve their goal of improving health care access. The PCN in Brooks consists of four clinics which have all completed the Alberta AIM program and are continually implementing new practice improvement strategies, and maintaining excellent access for their patients. Objective To improve patient access to family physicians and other healthcare team providers (RN, dietitian, counselor). Methods The physician access was measured through the process of collecting their third next available appointment once per week, which measured the average number of days any patient would have to wait for an appointment. The first measure (time one), is an average of the first month of data collection, at the beginning of a practice improvement collaborative. The second measure (time two), is an average of the last month of data collection, at the end of a practice improvement collaborative. The PCN in Brooks has focused on community education to help patients get care from the right provider at the right time. Posters have been used in the Emergency Department and in the clinics to remind patients to contact their primary doctor before going to the ER for non‐emergent problems. Other initiatives include routinely collecting and measuring data as well as collaborating with specialty care (e.g. mental health, home care and the CDM program). Results The time one (Pre‐practice improvement) third next available appointment average for all participating physicians in Brooks was 9.8 days. The time two (Post‐practice improvement) third next available appointment average for the same physicians was 1.8 days, therefore showing a tremendous improvement in patient access. Conclusion These components have greatly improved healthcare access in Brooks and we are confident the effort will decrease the number of unnecessary ER visits in the future.


14. Visualizing the Team Jim Fleming, Palliser Primary Care Network Context Promotion of the Palliser PCN and the teams providing primary care services to its patient population. Objective According to the 2009 Malatest report, public awareness of PCNs was low in Alberta—only 36% of Albertans surveyed could give an accurate definition of the term “primary care” and only 38% had heard the term “primary care networks”. At January 2010 little had been done, other than verbal communication, to promote the Palliser PCN and the teams providing primary care services to its patient population. Methods To address the identified educational/promotional needs, Palliser PCN communication plans have included these initiatives over the past three years:

1. Exterior clinic signage indicating PCN membership 2. Consistent messaging and design for patient informational handouts/brochures 3. Interior print/televised messaging explaining team member roles and services provided within

specific clinics 4. Promotional items (e.g. water bottles, pedometers and mugs bearing clinic‐specific and health‐

related information) Result Physician buy‐in was slow initially but picked up significantly once they began speaking amongst peers taking advantage of this communication strategy. Practice Improvement Facilitators also introduced physicians to these messaging concepts and their benefits. Today, 76% of clinics belonging to the Palliser PCN have used this tool in some way or another to help patients visualize the team and services offered. Conclusion While we have no reliable measurement tool to determine any statistical increase in the aforementioned Malatest results, we do have significant anecdotal evidence in the form of patient feedback. This feedback, which tells us we are definitely on the right track, ranges from statements such as, "I didn't know you had a counsellor at this clinic… how do I get an appointment with her?", to, "I make sure I arrive 20 minutes early for an appointment so I can watch your TV messages and learn more about my health and your team." We have also received several written testimonials from patients who not only understand the individual roles of health professionals at their clinic and how they function as a team, but also know that they, as patients, play a significant role on the health care team.


15. Advancing an Integrated System of Care: Integrated client care for older adults with complex needs Jodeme Goldhar MSW, RSW, MHSc, Toronto Central CCAC Dipti Purbhoo RN, MHSc, Toronto Central CCAC Context The Toronto Central CCAC is leading a collaborative LHIN‐wide multiyear strategy and change initiative to implement and evaluate practical models of integrated care for clients with complex needs. The basic premise of this strategy is the belief that despite their complex circumstances, most people can remain in the community with the right support system in place. In the year since its inception, a number of key innovations have demonstrated significant value and are driving sustainable solutions across the TC LHIN. Objective The strategy addresses the gaps where the system fails people and their families most and leverages and aligns existing resources by bringing together sectors from across the health system to build capacity and be more responsive to these populations. Methods The approach is focused on functional integration at the point of care and is designed to improve quality while ultimately bending the cost curve for some of the system’s most complex and costly clients. With a strong emphasis on a Quality Improvement approach to evaluation, health system data has been collected and analyzed. Key lessons learned have been identified and will be shared in relation to: the Critical success factors for health system integration and the Key components for successful integration at the point of care. Results Noteworthy innovations include: Care Coordinators Providing Intensive Case Management focused on System Navigation, Inter organization, inter disciplinary care team and shared care model development to ensure wrap around care and smooth transitions; Primary care Engagement with Physicians and CCAC Care Coordinators working hand in hand; EMS‐ CCAC Partnership to support smooth transitions with the creation of the ED Transfer Package and team communication flagging systems and acute care repatriation; Acute Care with new flagging systems for high risk clients and virtual case conferences between the community and acute care; Engagement with community pharmacists by building relationships to move to a single pharmacy for each client and dedicated training to support caregivers based on experienced based problem solving techniques. Conclusion ICCP in its first generation has successfully transitioned the local health system into a level of readiness for transformative change and has embarked on a large scale expansion. As Ontario continues to face significant challenges in achieving value and sustainability through system‐wide integration, this Toronto‐based model is moving the local health system towards a scalable model for integration while also delivering grassroots impact. The presentation will focus on both the strategy and the on the ground work and will be told through the eyes of clients, their caregivers and members of the integrated care team.


16. Creating a Primary Care Integration Strategy: Working hand‐in‐hand with primary care Jodeme Goldhar MSW, RSW, MHSc, Toronto Central CCAC Dipti Purbhoo RN, MHSc, Toronto Central CCAC Pauline Pariser MAsc, MD, CCFP, CFCP, Taddle Creek Family Health Team Context The Toronto Central Community Care Access Centre is working in partnership with primary care physicians to garner an understanding of how an integrated framework can be developed, tested and advanced. One of the central tenants is a belief that integrated models of care support people to live at home and in their communities successfully. Objective To work hand in hand with primary care to better support clients to live successfully in the community, to achieve goo health outcomes, and for both clients and caregivers to experience seamless care from an integrated care team. Methods With an emphasis on new models of care, fundamentally changing the “way we do business” at the point of care, the Toronto Central CCAC is testing on the ground innovations by embedding Care Coordinators in Family Health Teams, a Community Health Centre and in neighbourhood communities with solo‐primary care physicians. The learnings from these new models are informing scalable and sustainable solutions across Ontario adapted to context and populations Results Early learning’s point to the critical importance of working alongside primary care to most effectively support clients and caregivers in the community. The degree and intensity of that relationship varies depending on the client population being served. For many clients with low needs the role of the Care Coordinator is simply to ensure the client has primary care and to facilitate that linkage and communicate with primary care when there are challenges in the client's care. For the very complex clients, the care coordinator engages more intensely with the primary care physician with a goal to develop an integrated, shared care plan for support Conclusion The strategy, conceptual framework, and key innovations occurring on the ground will be highlighted, along with early lessons learned to inform this multi‐year strategy. The ‘lived’ experience of this strategy will also be told through the eyes of primary care physicians.


17. Group Medical Visits: An innovative approach to clinical care Michele Hannay BSc, Toward Optimized Practice Robert Wedel MD, CCFP, FCFP, Associate Medical Centre Context Current demand for healthcare necessitates innovative strategies to meet the needs of increasingly complex patients. Group Medical Visits (GMVs) offer teams the opportunity to work together to provide efficient, effective care that promotes patient self‐management and community support. Objective For healthcare teams in Alberta, the group visit concept is often intriguing, but many are unsure about how to begin. Toward Optimized Practice (TOP), in association with Dr. Robert Wedel of Taber, Alberta, can provide customizable tools, information and training to support teams in developing processes and skills to successfully offer GMVs. Methods To guide healthcare teams who are interested in offering GMVs, TOP provides:

A customizable toolkit for primary care physicians and teams, specifically developed for Alberta users

Support with step‐by‐step processes for the introduction of GMVs, utilizing the Model for Improvement and measurement strategies

Assistance with tailoring tools to suit a variety of patient groups and diagnoses

Training and support for team members who may be new to the “facilitator” role Results During Group Medical Visits, patients interact with physicians, RNs, pharmacists and other healthcare professionals who are providing information and care together. This enhances trust and familiarity with the "team". As well, strong bonds develop among the patient group, and they often form secondary support systems. Patients become educated and empowered members of the healthcare team. Conclusion Evidence supports that Group Medical Visits are beneficial. They have been shown to improve clinical outcomes and patient/provider satisfaction, and are appropriate for many patient populations. They also enhance patient self‐management and increase access by reducing return visit rates and enhancing overall productivity.


18. The growing need for breastfeeding support and education in the Bow Valley Sarah Hassall RN, IBCLC, Bow Valley Primary Care Network Context With the opening of a “low risk” obstetrical clinic in September 2011, the Bow Valley has seen a 100% increase in the number of births in the community. When a community sees a sudden increase in a specific population, services and support must be implemented to ensure maximum quality of care. Successful inter‐professional collaboration has ensured that breastfeeding issues are referred and dealt with quickly. The more support and access these mothers have the greater the outcomes for breastfeeding success. Objective As a Lactation Consultant (LC) with the Bow Valley PCN I provide support to mothers and babies struggling with breastfeeding concerns. My goals are to create timely access for all mothers, to educate health care professionals so they may provide a consistent approach with mothers and to create support networks within the community. Methods The comprehensive needs of a lactation consultant consist of:

Education/training support staff and volunteers

Initiation of a monthly BF support group

Trial and support of a collaborative “Buddy” volunteer support system

1:1 patient consultation, support and education for issues such as pain, infection, infant weight gain, congenital deformations, low milk supply etc.

Equipment support‐ rentals of books, breast pumps etc.

Close collaboration with PCN nurse L. Nickerson from the OBS clinic to identify further education needs

Results 2011‐LC provided 155 consultations (63.8% Canmore; 25.9% Banff; 10.3% other). Referral sources: hospitals (28.6%), PCN MDs & nurses (41.4%) and Public Health (24.3%). Most consultations are same day access or patient is seen within 2 days of the referral being received. 2012 We have thus far seen a steady increase in the number of initial consultations and follow‐up. The PCN continues to meet same day access for urgent referrals and 72 hours for non‐urgent cases despite the rapid growth of this particular population. Education is provided to RN's and LPNs at the Banff and Canmore Hospitals 1‐2 8 hour seminars, each 1‐2 Months with an attendance rate of 5‐10 nurses per session. Conclusion In summary the Bow valley Primary care network has developed a flexible and innovative LC program that provides consultations, support and education to mothers of the Bow Valley, while increasing the ability of local nurses to also provide a higher level of support in hospital.


19. Primary Health Care and Housing First: Interdisciplinary teamwork yields successful outcomes Robert A. Haubrich MSW, Boyle McCauley Health Centre, Pathways to Housing Program Tracy Mercier MA, Boyle McCauley Health Centre, Pathways to Housing Edmonton Context The Boyle McCauley Health Centre (BMHC) has provided primary health care to Edmonton’s inner city for 30 plus years. In 2009, it launched Pathways to Housing Edmonton (P2H), a housing support and treatment program for people with a history of chronic homelessness and severe mental illness. It is a Housing First model, where housing services are implemented immediately and are not contingent on treatment services. Services are delivered, 24/7, through an interdisciplinary Assertive Community Treatment (ACT) team. It is a team case‐management model where each professional provides a balance between specialist and generalist case‐management for every client. Specific recovery services are based on clients’ needs. Examples of support and treatment include medical and psychiatric care, addictions/concurrent disorders treatment, living skills training/coaching, employment skills training, financial management skills training, and housing and landlord/tenant relations. Objective Project Objective: Conduct a formative evaluation of early program outcomes. Success indicators for Housing First programs commonly include housing retention rates ≥ 85%, client retention rates ≥ 95%, cost avoidance for emergency and acute hospital care, and reduced symptom severity on the Health of the Nation Outcome Scales (HoNOS). Methods Pre and post HoNOS scores, emergency room visits, and days spent in hospital were tabulated for 68 clients after one year of program participation. Hospital usage was then translated into dollar figures. Tenure of housing and client retention rates were measured as indicators of client engagement for the same time frame. Results Total emergency room visits were significantly reduced from 274 to 120 (p<.05). Emergency room cost avoidance was approximately $45,430.00. Similarly, the total number of days spent in hospital was reduced from 2,186 to 658 days. Cost avoidance for days spent in hospital was substantial, at an estimated $2,192,680.00. Tenure of housing and client retention were high at 82% and 92%, respectively. HoNOS total scores were reduced by a mean average of 6.82 points, indicating clinically significant change for many clients. Conclusion BMHC’s P2H program has successfully engaged this traditionally underserved population in treatment, improved their symptom severity, and substantially reduced associated costs of using acute health care in Edmonton.


20. Care Gap Analysis and Improving Outcomes for Patients with Type 2 Diabetes in Primary Care Nina Hirvi RD, Copeman Healthcare Centre WP House MD, Copeman Healthcare Centre Boaz Saffer BA, Copeman Healthcare Centre Michael Koehle PhD, MD, Copeman Healthcare Centre, University of British Columbia Context Diabetes costs the Canadian healthcare system over $6 billion each year. Facilitation of self‐management in patients is the cornerstone to achieving better health outcomes. The documentation of parameters such as blood pressure, Hemoglobin A1c, and blood lipids is part of Canadian Clinical Practice Guidelines for Diabetes Care. Objective To gather data on current practise parameters and use the data as a tool for clinicians to engage clients in self‐management of Type 2 Diabetes within a primary practice. Methods All patients in a primary care practice diagnosed with Type 2 Diabetes were enrolled in our dietitian‐run program. Data were collected at the beginning and every 3 months thereafter over 18 months. The data collected included: HbA1c, blood pressure, LDL cholesterol, and random urine ACR. Based on these data, targeted patients with values outside of the target range and steps were taken to improve parameters through both lifestyle measures and/or medication adjustments. A team approach to care was used including the dietitian, nurse and physician. Results Sixty patients with Type 2 Diabetes were followed over an 18‐month period. The mean (±SD) HbA1c, LDL, systolic and diastolic blood pressure at baseline were 7.2±1.2%, 3.18±1.1mmol/L, 141±23mmHg and 85±8, respectively. Eighteen months later, the mean values were 7.1±1.3%, 2.2 ±1.0 mmol/L (p <0.001), 122±15 mmHg and 74±12 mmHg, respectively. At follow‐up, systolic and diastolic BP and LDL were significantly lower than at baseline (p<0.001) The frequency of testing HbA1c increased from 41% to 60% (an HbA1c at target) and the percentage of patients achieving a target HbA1c < 7.0% rose from 50% to 68%. The percentage of patients achieving a target blood pressure <130/80 was 16% at baseline and 60% at target after 18 months. The percentage of patients with LDL readings at target (< 2.0 mmol/L) rose from 7% to 50%. Conclusion A simple quality assurance program leads to significant improvements in key health outcomes in patients with Type 2 Diabetes. Quality assurance and data collection are important motivational tools to help clinicians identify and address unmet targets with their patients with Type 2 diabetes in a primary care setting.


21. Evaluating Measurements in Primary Care M. Janet Kasperski RN, MHSc, CHE, The Ontario College of Family Physicians Context Ontario has invested heavily in the primary care sector in recent years. Province‐wide statistics, such as emergency visits, were being used as the basis for judging whether or not, the province was obtaining "value for money". Quality indicators were identified with the power to segregate family practices into high performing, high quality and innovative practices from those that were still "evolving". The practices were then evaluated on the basis of their impact on the cost per patient and the potential for long term impacts on the health of the population. A second arm of the project identify the factors leading to high performing practices. Objective

1. To identify a reliable set of measurement indicators that can differentiate between high performing, high quality and innovative practices.

2. To analyse the differences in service use and costs of practice characters and provincial patterns across the health system to identify short‐term cost‐avoidance savings and long‐term health impacts amongst the different practices.

3. To identify the attributes leading to high performance. Methods Qualitative and quantitative analysis amongst 20 practices was used to differentiate the practices and to identify the factor leading to high performances. Administrative data bases were used to identify short‐term cost avoidance savings. Results On site evaluations of the practices reveal the variety of ways in which practices have been organized to provide the expected results. Practices that are high performing may show long term results without necessarily demonstrating short‐term cost avoidance savings. Conclusion The factors that influence the development of high performance, such as physician leaderships and team performance are predictions of both short‐term cost‐avoidance savings and long‐term savings resulting on a concentration in health promotion/chronic disease management.


22. A Framework for Transforming Primary Care and Supporting Quality Improvement Nick Kates MBBS, FRCPC, MCFP(Hon), McMaster University Brian Hutchison MD, FCFP, McMaster University Brenda Fraser BSc (OT), MSc, Cancer Care Ontario Trish O'Brien RN, BA, CNeph(C), Health Quality Ontario Susan Wheeler RN, BA, Health Quality Ontario Cheryl Chapman RN, BScN, MEd, MHSc, Health Quality Ontario Context A consistent feature of effective healthcare delivery systems is a strong and well‐integrated primary care sector. In the absence of well‐organized primary care systems, practice‐level transformation is essential but remains a challenge. Objective To describe a) changes required at a practice and provider level, b) ways to introduce those changes and c) the supports required at a practice and system level to enable primary care transformation to happen. Methods The authors propose an evidence‐based framework that incorporates the key elements of high‐performing primary care practices, demonstrates how quality improvement can become part of the fabric of a practice, and outlines the supports required to attain it, and achieve IHI’s Triple Aim of improving the health of a population (better health), improving the patient experience of care (better care) and reducing per capita cost (better value) and present examples from QI work in Ontario. Results The framework was developed by Ontario’s Quality Improvement and Innovation Partnership (now Health Quality Ontario) to guide the transformation of primary care and the integration of quality improvement approaches. It has three elements: 1) the major constituencies that primary care serves – patients, families and local communities; 2) the desired outcomes of primary care, based upon IHI’s Triple Aim; and 3) practice attributes that will enable primary care organizations to attain these outcomes ‐ a population focus, patient engagement, partnerships with health and community services, innovation, performance measurement and quality improvement, and team‐based care. Strategies to support these changes include: building system capacity for improvement; providing quality improvement coaching support; and employing effective spread and sustainability strategies. System‐level structures and policies needed to sustain a high‐performing primary care sector include: common goals; a comprehensive approach to performance measurement; funding incentives aligned with quality outcomes; a local primary care organization; support for inter‐professional teams; patient enrolment; and mechanisms to support coordination and integration. Conclusions This framework can guide and support primary care transformation at both the practice and system level towards a primary care sector that is patient and family centred, well‐linked with other health and community resources, addresses community and population health needs and continuously improves.


23. Building on the Effective Integration of Mental Health Services: New opportunities and better care

Nick Kates MBBS, FRCPC, MCFP (hon), McMaster University Context While the last 10 years has seen major advances in collaboration between mental health and primary care providers including the integration of mental health teams in primary care settings, such models offer new opportunities to address challenges that face most health care delivery systems. Objective To present 5 new opportunities created by the integration of mental health services in primary care that address major challenges facing Canada’s primary health care systems. Methods The presentation synthesizes a review of the current literature about collaborative mental health care, an analysis of trends and challenges in mental health care delivery, and lessons learnt from Canadian projects to identify 5 opportunities for primary care to address these challenges more effectively and achieve IHI’s Triple Aim of improved health for the population served, an enhanced experience for the patient and reduced per capita costs. It illustrates these opportunities with examples from the Hamilton FHT mental Health program, which has integrated mental health teams in primary care settings for over 18 years. Results The 5 opportunities are

increasing the capacity of primary care to deliver effective mental health services (primary mental health care), by using screening tools, on site , integrating treatment protocols and support for new provider roles

focusing on quality improvement and safety as major drivers of change, including the development of a quality improvement plan for the practice

developing new partnerships with patients and families, through self‐management support, person‐centred care and individualized care plans

addressing the needs of individuals with complex medical conditions by integrating physical and mental health care

Using all resources more efficiently, by redesigning office practices and supporting staff to work to full scope of practice

Conclusions Integrating mental health services within primary care is an effective way of improving access, coordination of care, communication between providers and reducing waiting times as well as enhancing the patient’s experience. The examples from the Hamilton program demonstrate new ways in which framing collaborative care within IHI’s Triple Aim can take advantage of the potential that better collaboration offers. Lessons learnt are applicable to most other medical specialties and health professions.


24. Making Change Happen: Increasing the percentage of students choosing family medicine as a career David Keegan MD, CCFP(EM), FCFP, University of Calgary Bruce Wright MD, FCFP, University of Calgary Cathy MacLean MD, MCISc, MBA, FCFP, University of Calgary Wayne Woloschuk PhD, University of Calgary Context Canadians continue to struggle to find a family physician, despite increases in the numbers of medical students and residents in training. As of 2008, 25% of Calgarians were unable to find a family physician. At the same time, the percentage of students choosing Family Medicine as a career continues to be lower than a broadly accepted ideal of 50% nationally, reaching as low as 18.4% at the University of Calgary in 2008. Objective This presentation will describe the comprehensive program of interventions that have been implemented at the University of Calgary to increase the percentage of students choosing family medicine as a career. These interventions include the Task Force on this issue, a new course in Family Medicine, and new informal curricular innovations (such as MedZero for incoming medical students, Massive Impact research night) and other strategies (including thinkfm.ca) aimed at dispelling the hidden curriculum against family medicine as a career. Methods Outcome data types include immediate program evaluations by participants, delayed program impact evaluation, and, most importantly, the data from the 2012 residency match process which will include the percentage of students choosing family medicine as their first choice of career. Results Early exposure to family medicine – both in the formal curriculum and through informal curricula – increases medical students’ awareness of and interest in the specialty. Students report one year after participating in MedZero that it has made a lasting impression upon them. Most importantly, this presentation will focus on the lessons learned through the ongoing implementation and evaluation of this program. In particular, the learned‐the‐hard‐way importance of theme‐congruency by “champions” of the specialty will be reviewed. Conclusion Consistent with the literature, our program has incorporated a layered strategy of multiple types of interventions to illuminate the career of family medicine and sustain those who are interested in it as a career. Crucial to our success has been having a tight program mission of illuminating the career option, not “convincing” people it’s the right choice for them.


25. Optimizing Quality of the Patient Experience in Prmary Care: The Copeman Healthcare way Holly Kennedy‐Syonds RN, MHSc, Copeman Healthcare Michelle Kaarto CSEP, CEP, BScK, Copeman Healthcare Boaz Saffer BA, Copeman Healthcare Michael Koehle MD, PhD, Copeman Healthcare Peter House MD, Copeman Healthcare Chris Nedelmann MBA, Copeman Healthcare Context An innovative approach to primary care was developed to increase patient's access to a highly skilled, multidisciplinary team and to increase the quality of the experience of healthcare for both patients/clients, their families and their care team. Copeman Healthcare (CHC) opened its doors in 2005; as a blended funding healthcare model, with uninsured services provided by the multidisciplinary team. The team composition is unique to CHC; with family physicians, psychiatrists, family nurse practitioners, family health nurses, dietitians, psychologists (general & neuropsychologists), kinesiologists, physiotherapists and clinical care coordinators. Objective To review published peer reviewed scientific literature for evidence to select a rigorous evidence based patient/client tool to measure quality of general practice/family medicine, reflecting patients' perspective on the quality of care. Methods The literature review provided three categories of documents: Status of patient satisfaction, guidelines for developing patient satisfaction questionnaires and specific measures and their respective psychometric properties. In at least 50% of studies, the most common aspects of care measured was humanness, competency/accuracy, patient involvement in decisions, time for care provision and availability/accessibility. The EUR0PEP, validated in 23,892 patients, > 16 Countries was chosen and delivered to CHC patients by email. Results Survey was completed on patients in Spring 2012. The response rate was 665 of a total 3700 surveyed, a 18% response rate. Response means were 4.44 ‐ 4.82 out of a maximum of 5. Full details with SD will be presented. There were surprisingly few differences between Provinces and centers. Conclusion The scores reflecting high quality & consistency were encouraging. Study limitations: the response rate, the lack of comparative data and with scores so high, it is challenging to benchmark higher levels for future years. Because the data is consistently high at both centers in two Provinces, this is reassuring the CHC way is effective in achieving our goals of consistency & quality.


26. Integrated Hospice Palliative Care: Bringing Family Physicians Back into the Team Ross Kirkconnell MSc, Guelph Family Health Team Andrea Martin RN, Waterloo Wellington Community Care Access Centre Context The Guelph Family Health Team, with 71 family physicians and interdisciplinary care teams provides primary health care to 100,000 residents of Guelph. Over the past decades, changes in provincial health policy and funding has enhanced the network of services providing hospice palliative care (HPC) in the Guelph community but with one negative and unanticipated result: family physicians have become increasingly disengaged from the network of services. Recognizing the critical role played by Family Physicians in caring for patients at the end‐of‐life, local stakeholders collaborated to re‐integrate primary care in the provision of HPC care in Guelph. The practical application of this concept is not easy. In Guelph, the partners looked beyond these barriers to create a viable and sustainable option that is in the best interest of patients at end‐of‐life and their families at a very sensitive time of life. This integrated approach being implemented in Guelph respects patients' end‐of‐life care wishes while supporting families into bereavement all while maintaining the trusted patient ‐ family physician relationship. Objectives In this 30 minute presentation participants will have a further understanding of:

strategies to ensure primary health care providers remain actively involved with patients living with a life‐threatening illness in the last 12 months of life

approaches to local hospice palliative care (HPC) system design, implementation and analysis aimed at providing integrated care for patients.

Methods

Family Physician surveys

Physician Forums

Provider Education ‐ Learning Essentials Approach to Palliative Care

Community Palliative On Call Group funding

Shared understanding of Community HPC "basket of services" including primary care

Expansion of the function of case management and broad system navigation in the home care sector

Results As this initiative is in its implementation phase, the preliminary results will be shared with participants. Participants will hear challenges, lessons learned and future opportunities. Conclusion This community approach aims to achieve improved HPC support to patients and families through:

Improved communication among team members during the last 12 months of a patient’s life

Sustained engagement of the family physician in patient’s care until death

Stronger team care approach for dying patients


27. Rethinking Self‐Monitoring of Blood Glucose in Non‐Insulin Treated Type 2 Diabetes Scott Klarenbach MD, MDs, FRCPC, University of Alberta Context Type 2 diabetes is a growing epidemic with significant implications for health and Canada’s health system. Self‐monitoring of blood glucose (SMBG) is thought to improve glycemic control, but evidence of effectiveness has only been examined recently. Further, spending on test strips for SMBG comprises one of the largest drug plan expenditures associated with diabetes, costing the Canadian public and private plans more than $500 million per year. Objective To develop evidence‐based recommendations for the optimal use of blood glucose test strips, considering both clinical benefit and the sustainability of Canada’s health care system. Methods The Canadian Agency for Drugs and Technologies in Health (CADTH) performed a systematic review of the clinical evidence, assessed the cost‐effectiveness of SMBG, and performed a budget impact analysis. Through an expert review committee, CADTH developed recommendations to guide test strip use. Results SMBG in patients with type 2 diabetes who do not take any antidiabetes drugs did not result in clinically or statistically significant differences in glycemic control, as measured by haemoglobin A1C (WMD in A1C [95% CI] = ‐0.05% [‐0.33, 0.23]). SMBG in patients who use non‐insulin antidiabetes drugs (e.g., metformin) resulted in statistically significant, but clinically modest improvements (WMD in A1C [95% CI] =‐0.25% [‐0.36, ‐0.15). Routine use of SMBG was associated with an additional 0.02385 quality‐adjusted life years (QALYs) and increased costs by $2,711, resulting in an incremental cost‐utility ratio (ICUR) of $113,643 per QALY gained. CADTH recommends that most adults with type 2 diabetes not using insulin do not require routine SMBG. Periodic testing may be indicated for select patients, such as those with unstable glucose levels, acute illness, changes to drug therapy, pregnancy, or those at high risk of hypoglycemia or situations where hypoglycemia poses danger. Evidence‐based use of test strips could free $450 million to $1.2 billion between 2012 and 2015 for spending on other needs. Conclusion If SMBG practice changes to reflect the evidence, health care dollars will be saved, and patients will be able to focus on other, more effective diabetes self‐management actions.


28. Health Coaching as a Self‐Management Support: Introducing a paradigm shift in patient care Holly Knight RD, MEd, PhD, Alberta Health Services Judith Britten MSc, Alberta Health Services Context Supporting patients to self‐manage is fundamental in chronic disease management. Evidence indicates that good self‐managers have increased self‐efficacy, better symptom management, less health distress, less physical disabilities and some decrease in health care utilization. Self‐management support can include Health Coaching as a patient‐centred approach. Objective The AHS provincial Chronic Disease Management program recently hosted a visioning session ‐ bringing people together to identify an action plan for Health Coaching for health care providers working with clients. Health Coaching is a practice in which health providers apply evidence‐based health behaviour change principles and techniques to assist their patients to adhere to treatment and lifestyle recommendations, for the purpose of achieving better health outcomes or quality of life. Methods Participants were invited from across AHS representing strategy teams as well as chronic disease management and primary care operational groups. Additional invitees included physicians and academia. Day one of this event updated the participants about existing initiatives within AHS to support patient behaviour change ‐ e.g., motivational interviewing. Additionally, guest speakers from Ontario and Nova Scotia profiled health coaching programming and education in place in these jurisdictions. Day two led participants through a facilitated session to provide direction on a vision for health coaching for Alberta. Results Based on the outcomes of the visioning exercise, specific priorities were identified for action planning. Priorities were refined over the course of work group discussions and goals and actions were identified to support these priorities. Identified goals and action items included: supporting a system‐wide cultural shift; developing a marketing/communication strategy; curriculum development (health coaching continuing education); patient preparation for the shift; development and implementation of an evaluation strategy; alignment of a health coaching approach with other initiatives, and sustainability/dissemination. Conclusion Following the two day visioning session, an evaluation survey was sent to participants. Feedback about the session was overwhelmingly positive. In addition, participants provided insight into existing behaviour change programming available across the health system as well as suggestions for next steps. Key take aways included support for moving forward with a health coaching model for Alberta health care providers, a need for a system wide transformational approach and opportunities for collaboration in building and implementing the model. Participants strongly advised to establish a steering committee with representation with sectoral representation from across the organization.


29. Effort to Bridge the Gap Between Emergency Department and Primary Care Service in a Young Urban Patient Population: Embedding evaluative processes to guide clinic development Judith Krajnak PhD, Charis Management Consulting Inc. Leanne McGeachy MBA, Edmonton North Primary Care Network Context Alberta Health Services Northeast Community Health Centre (NECHC) and the Edmonton North Primary Care Network (PCN) identified a common interest to improve access to and delivery of primary care for patients who attend the emergency department (ED) at the NECHC and who are not currently attached to a family physician (FP). Objective The purpose of the Bridge Clinic is to follow unattached patients after a visit to the ED with a view to link or “bridge” them to a FP, with an ultimate aim to improve patient care and reduce unnecessary or inappropriate repeat ED visits. Methods A developmental evaluation strategy was used to guide decision making in the pilot phase of the clinic. Data was collected from the tracking tool used by the Bridge Clinic staff. Feedback was gathered from project stakeholders, including patients. Aggregate ER data was also reviewed to examine visit patterns of patients pre‐and post‐visit to the Bridge Clinic. Results A total of 161 patients were referred to the clinic (September 2011 ‐ May 2012), with 110 patients being seen by the Nurse Practitioner. Fifty‐seven percent (57%) of patients were between 20 to 39 years of age. More than half of patients seen at the Bridge Clinic had at least one previous visit to the ER in the six months prior to their ED visit resulting in their referral to the Bridge Clinic. Forty‐one percent (41%) of prior ED visits of Bridge patients were categorized with a CTAS score of 4 or 5. Conclusion This pilot attempted to dispel the myth that it is "impossible to find physician in Edmonton" and had both ER and PCN staff play an active role in providing patients with referrals to physicians known to be accepting new patients. Proactively assisting young patients between the ages of 20 and 39 to reduce their use of the ER while engaging them to take an active role in their care required trying new engagement strategies. Further evaluation is needed to understand the needs of this younger demographic of patients, often neglected by the current focus on chronic disease management.


30. Primary Healthcare in Alberta: A HQCA perspective Markus Lahtinen PhD, Health Quality Council of Alberta Tim Cooke BSc, Health Quality Council of Alberta Jody Pow MA, Health Quality Council of Alberta The province of Alberta recognizes the importance of healthcare through its funding and support, and has additionally taken on a leadership role by developing primary care networks (PCNs). In 2011‐12, the province is expected to spend over $14 billion of its $38.4 billion budget on healthcare, of which over $170 million is estimated to be spent on PCNs. Primary healthcare providers, including PCNs, serve as a point of contact; acting as gatekeepers to the broader health care system, they help to facilitate continuity and coordination or care across providers, programs, settings and over time. Additionally, primary healthcare providers have the potential to address the needs and requirements of patients with chronic illness earlier on in their healthcare continuum. This is a significant and substantive contribution which could improve the health outcomes for people with chronic illness in a sustainable manner; especially important since 61% of healthcare expenditures are consumed by 30% of Albertans (i.e. those with chronic disease). In 2009, the HQCA piloted a primary healthcare measurement initiative which included collaboration and input from Alberta Health, Alberta Health Services and 17 PCNs throughout Alberta. This initiative resulted in the production of PCN and physician level reports, and additionally a meta‐report regarding primary healthcare in Alberta. The following presentation is based on “lessons learned” by the HQCA and its primary healthcare collaborators. Key issues are identified and summarized; additionally, recommendations and required actions are identified where possible.


31. The Impact of Alberta AIM at the PCN Level Bonnie Lakusta BSc, PhD, Alberta AIM David Letourneau BCom, Alberta AIM Julie Shemanchuk BA, Alberta AIM Steven Clelland MA, Alberta AIM Cheri Ell LPN, Edmonton West Primary Care Network Context Alberta AIM delivers a learning collaborative model across the province with a focus on improving access to and efficiency in healthcare service delivery, particularly in primary care. Participating in Alberta AIM requires the formation of an improvement team, development of improvement aims, mapping of current processes, testing of changes and reporting and tracking of key quality measures. Alberta AIM emphasizes measuring for improvement, not for judgment. The Edmonton West Primary Care Network (EWPCN) has had 13 participating clinics between 2007 and 2011. Objective The objective of this investigation is to demonstrate PCN‐level success in reducing delays to primary care after participating in an Alberta AIM collaborative. Methods Third Next Available (TNA) is a measure of system capacity. TNA is the time between the demand for an appointment by a patient and the third next available appointment in the provider’s schedule. Reducing the time to the TNA appointment reflects an increased access to care. Data are tracked at the level of a primary care provider and are aggregated and reported at the clinic level. Data are analyzed using the SPSS V. 19 program. Linear regression was used to analyze the data, with an alpha level of .05. Results Thirteen unique clinics have participated in Alberta AIM from the EWPCN. Collectively, participating clinics from the EWPCN demonstrated a significant drop in TNA from an initial average of 12 days to 4 days (‐67%) after 1 year. Other measures (e.g., no shows) of importance showed similar improvements. Conclusion The data show that clinics in the EWPCN that participated in Alberta AIM showed a significant reduction in TNA. This indicates that over the duration of time participating in Alberta AIM, clinics were able to improve access to primary care within their clinics. Although there are common components to the Alberta AIM program, each clinic’s experience in applying Alberta AIM principles, practices and strategies can be different. The results describe in this report show that the EWPCN has been successful in meeting the primary goal of the collaborative model – to reduce delays to primary care providers. This directly aligns with the overall goals of the Primary Care Initiative and demonstrates access improvements at the PCN level.


32. Provincial Primary Care Clinical Pathway for Adult Depression Allison Larsen HBA, MA, Alberta Health Services Richard Phillips BSW, RSW, Alberta Health Services Christopher Carvalho BSc, PMP, TELUS Health Context There has been a growing awareness in health care circles that high frequency, high cost mental health disorders may be best addressed via the systemic adoption of clinical pathways. A clinical pathway is defined as “a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes” (Middleton, Barnett & Reeves, 2001). A clinical pathway helps bridge the gap between research and practice by incorporating guidelines, protocols and evidence informed best practice into everyday clinic use. Objective Alberta Health Services (AHS) Provincial Addiction & Mental Health is collaboratively working with Primary Care Networks (PCNs) and Zone partners to develop, implement, and evaluate an adult depression clinical pathway in primary care. Work is also underway to develop templates and reports in the primary care Electronic Medical Record (EMR) systems to support the clinical pathway. Methods AHS zone based working groups have been created to review the latest research, customize the clinical pathway to meet local conditions, and pilot the pathway. A variety of stakeholders are involved in the process, including: family physicians, psychiatrists, psychologists, pharmacists, registered nurses, social workers, PCN leaders, as well as AHS provincial and zone leaders to ensure that all aspects of patient care are considered. Results Data collection, client outcome monitoring, and analysis of variances are built into the clinical pathway. Variance analysis helps identify areas of innovation which can then be spread across the province. A formal evaluation has not yet taken place; however, initial analysis shows positive results. Conclusion The depression clinical pathway in primary care is currently being piloted in a number of sites and a model for provincial rollout has been developed. Numerous lessons learned have been documented that will aid in future implementations to ensure a positive experience by all sites involved.


33. The Impact of Panel Management on Patient Access to Care David Letourneau BCom, Alberta AIM Bonnie Lakusta BSc, PhD, Alberta AIM Julie Shemanchuk BA, Alberta AIM Steven Clelland MA, Alberta AIM June Austin RN, Alberta AIM Context Effective panel management leads to better access for patients. Alberta AIM delivers a learning collaborative model across the province with a focus on improving access to and efficiency in healthcare service delivery, particularly in primary care. As in business, success in timely access to care depends on an in‐depth understanding of demand. An essential part of understanding patient demand is an understanding of the provider’s panel. The panel is the primary source of demand for services that are being generated, so understanding the panel is one of the most effective tools to anticipating the patients’ needs. Objective To demonstrate the importance of managing the patient panel and to increase access to care through the balancing of the panel equation. Methods A sample clinic was drawn from the AIM database. A ratio of demand and supply was calculated and charted over time against Third Next Available (TNA) values for the same clinic. TNA is the time between the demand for an appointment by a patient and the third next available appointment in the provider’s schedule. PANEL EQUATION: Provider scheduled visits per day × Provider days per year = Panel size × Visits per patient per year The left side of the equation is SUPPLY, reflecting the number of appointment times a provider can offer in a given year; the right side of the equation is DEMAND, reflecting the number of patient requested appointments. When providers are able to balance both sides of the equation, access, expressed as third next available, declines. Alberta AIM teaches strategies for focusing on each side of the equation independently to achieve a balance. Three essential steps for panel management include:

1. Identify the panel to determine demand 2. Verify the panel to ensure accuracy 3. Maintain accuracy to ensure accurate system balance over time

Results The data show that as the Demand over Supply ratio fluctuates, TNA mimics the fluctuation causing delays in the system.


Conclusion As Demand and Supply are stabilized, through an understanding of a provider’s panel, TNA stabilizes and increased access to care can be achieved for patients.


34. Online Quality Improvement and Innovation Programs for Family Physicians in Ontario Anthony Levinson MD, MSc, McMaster University Jan Kasperski RN, Ontario College of Family Physicians Cheryl Chapman, Health Quality Ontario Tricia Wilkerson, Health Quality Ontario Susan Wheeler, Health Quality Ontario Satacey Bar‐Ziv PhD, Health Quality Ontario Sarah Garside MD, PhD, McMaster University Lisa Colizza MEd, McMaster University Context Family physicians get little instruction in concepts of quality improvement throughout their training. Face‐to‐face continuing education sessions have rarely broached the topic, and are constrained by limits on the ability to scale up the education for large numbers of physicians. Objective We have developed online continuing education programs related to quality improvement initiatives, to improve dissemination and uptake of innovative approaches in family practice. Methods The programs were developed in partnership amongst key provincial stakeholder organizations. A mixed methods approach utilized Instructional Systems Development theory to inform the program development, including the ADDIE instructional design model of Analysis, Design, Development, Implement and Evaluate. Best practices in multimedia learning informed the design of the online programs. Iterative review and formative evaluation incorporated stakeholder feedback throughout the development process. The programs were disseminated through the machealth.ca online continuing education platform. The online content is supplemented by social networking tools in the hopes of developing a community of practice related to quality improvement. Results Two main multi‐component online programs were developed: quality.machealth.ca consists of an overview of the Quality in Family Practice project; and advancedaccess.machealth.ca consists of a primer of Health Quality Ontario's innovative Advanced Access & Efficiency initiative. In addition to accredited interactive, multimedia presentations, the programs also consist of blogs, discussion forums, and a database of relevant resources. A mentorship network on the topic is currently in development. Conclusion Primary care providers may benefit from having access to online continuing education resources related to quality improvement. Additional innovative delivery methods such as mentorship networks and the use of online social networking platforms may enhance the communities of practice around quality improvement in primary care. The use of e‐health administrative tools, such as automating reports of practice information such as 'Third Next Appointment' are also being investigated to facilitate evaluation of outcomes.


35. Bridging the Gap: An innovative collaboration between Brampton’s family physicians and Brampton Civic Hospital Shariq Lodhi MD, CCFP, William Osler Health System Frank Martino MD, CCFP, William Osler Health System Context Discharge is a high risk transition. Documented risks include discontinuation of previous routine medications, poor understanding by patients of the reason(s) for admission, not to mention the treatment received and follow‐up care planned after discharge. As community physicians continue to withdraw from inpatient care, they are increasingly forced to rely on the patient’s own recollection of the circumstances of their hospital admission and follow‐up instructions, with a formal discharge summary often arriving several weeks after the patient was discharged. Note very helpful in a busy practice when a patient arrives in the office a few days after discharge, clearly in need of reassessment. Objective To improve the chances of successful discharge following hospitalization for an acute episode by facilitating direct communication between the GP Hospitalist managing the patient in hospital and the patient’s primary care physician. Methods In an attempt to address this gap in care, the William Osler Health System GP Hospitalist Service at Brampton Civic Hospital developed Bridging the Gap: a first‐in‐Ontario initiative where streamlined protocols using pre‐printed discharge order sets and dedicated switchboard resources were employed to connect hospitalists with primary care GP’s at the time of discharge. Result Over the course of the 6 month pilot, 723 calls were placed to community physicians to review course in hospital and discharge patients. Conclusion This innovative program demonstrates a practical approach to improve the safety of discharge of complex medical patients not cared for in hospital by their primary care physician. Due to the amount of positive community physician and patient feedback, the program has now been included as part of the hospitals’ corporate strategic plan


36. Street Clinic: Working together to meet the health needs of vulnerable population in a primary care setting Marlee MacDonald MN, NP, Red Deer Primary Care Network Context Interventions inclusive of primary care and housing for the vulnerable population result in better health outcomes and reduced health care costs (D. Fitzpatrick et al., 2011). Objective To serve the vulnerable population in an accessible drop‐in downtown street front clinic through an intersectoral partnership between Red Deer Primary Care Network (RDPCN) and Alberta Health Services and PCN interprofessional team. Methods The RDPCN, with support of family physicians, established a primary care street clinic by collaborating with partner agencies in resourcing facility; medical supplies; and staffing, including a team of Nurse Practitioner (NP), nurse, mental health counsellor and administrative support. Street Clinic team members are employees of the RDPCN. Working to full scope of practice, the NP provides same day basic medical services, prescribes medications, and orders laboratory testing. Disease prevention and navigation are key elements of care provided by the team. The Street Clinic works with AHS in offering flu immunization and city of Red Deer in a Housing First initiative. Seasonal health fairs provide vulnerable clients, including the homeless, with health information and personal aids e.g. haircuts and mittens. Traditional methods don’t always work with this population, thus the Street Clinic team uses innovative approaches to engage clients. Results As the primary health care provider for this population (n= 140, 2011), the Street Clinic team addresses non‐urgent medical concerns, wound care, minor injuries, addictions, communicable and chronic diseases. The Street Clinic team supports the broader determinants of health such as hunger, poverty, housing, transportation etc. to promote better health, disease management and prevention. Average number of street clinic client visits was 8.0 with clients connected to health professionals, medical specialists, and multiple community organizations for additional services (2011). In particular, mental health concerns and pain, which exacerbate chronic conditions and are frequently experienced by this population, have been addressed. Patient, staff and partner feedback indicates a positive response in meeting client needs from obtaining an Alberta Health Care card through to treatment for mental illness. Conclusion RDPCN Street Clinic reflects evidence‐ based, integrated and accessible team approach in improving health and reducing costs for the vulnerable population.


37. Transformational Change: Measurement of patient satisfaction with dietitian supports in a primary care network setting Sharon Macklin RD, Edmonton Oliver Primary Care Network Alison Crag RD, Edmonton Oliver Primary Care Network Pierrette Elias RD, Edmonton Oliver Primary Care Network Miranda Chan RD, Edmonton Oliver Primary Care Network Marion Relf MHSA, Edmonton Oliver Primary Care Network Racha Sabha MPH, MD, Edmonton Oliver Primary Care Network Jessica Schaub BA, Edmonton Oliver Primary Care Network Context The overall goals of the dietitian services at the Edmonton Oliver Primary Care Network project include: Improving patient health and/or preventing further deterioration of health including mental well‐being, functioning, confidence and clinical markers, Improving access to nutritional counselling by reducing financial and other barriers, offering service close to community physician practices, and Increasing patients’ self‐management of chronic conditions Objective An evaluation framework was developed with the business unit and clinical team. Eight common outcomes were developed including immediate‐level (patient satisfaction, access to services, care continuity by the team), intermediate‐level (improved self‐management, improved linkages, improved clinical markers) and final outcomes (improved health status, cost effectiveness). To collect information on patient experience outcomes, a survey instrument was developed by the clinical team of dietitians and support from the evaluators. The objectives of the patient experience survey included:

1. Patients’ level of satisfaction with their last family physician visit 2. Patients’ level of satisfaction with their last visit with the dietitian 3. Experience with and perceptions about access to services 4. Self‐reported confidence and positive changes in self‐management as a result of physician and

dietitian support Methods Over the five week survey period between May 28 to June 29, 2012, patient surveys were collected. The data was analyzed by the evaluation team using the SPSS 19.0. The open ended comments were explored for emerging themes. Results Patients indicated an overall high level of satisfaction; those who had seen the dietitian for two or more visits were asked about the impact of the program. The majority of returning patients reported making a positive change in managing their health as a result of working with the dietitian. The percentage of patients who strongly agreed increased as the number of visits with the dietitian increased. Overall, returning patients reported improvements in their energy levels or ability to move around and controlling appetite.


Conclusion Overall, Edmonton Oliver Primary Care Network patients were highly satisfied with services received from their family physician and their dietitian.


38. Online and Email Diabetes Education Increases Knowledge, Confidence and Reach Bev Madrick RD, CDE, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone Sasha Wiens RN, BN, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone Julie McKeen MD, FRCP(C), Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone University of Calgary Context An online diabetes educational series with automated email delivery was created to address the barriers associated with traditional in‐person education. Objectives Objectives were to provide an audio/PowerPoint diabetes educational series that was: accessible online to overcome potential barriers to traditional in‐person education; comparable to in‐person diabetes education; deliverable through automated sequential emails; available for use by primary care to build capacity for diabetes education; and cost effective. Methods Twelve online diabetes audio‐PowerPoint education sessions were developed, each available through a unique URL. Content covered basic knowledge and self‐management skills. Clients accessed these sessions directly or through email links pushed out weekly after signing up at a micro‐website http://wcmprod2.ucalgary.ca/cdm/. An online service, AWeber, was used to automate sequential email deliveries. Surveys assessing knowledge and confidence in performing self‐management skills were administered pre and post in‐person classes and each online session. Satisfaction with the online modality was also assessed. Results Survey results for in‐person class respondents (111 pre/128 post) and online respondents (250‐283 pre/post for online sessions) showed gains in knowledge and confidence measures for both forms of education. When compared to in‐person classes, the online participants were younger (26% were 45 years or younger vs. 14%), more likely to have attended previous diabetes classes (38% vs. 18%), more likely to not have diabetes (41% vs. 10%), and scored higher in confidence gains after education (16% vs. 8.4%). Over 92% of online participants surveyed were satisfied with the online modality. Many accessed their unique emails from more than one computer, suggesting individuals used more than one computer or forwarded emails. In‐person participants were from Calgary, Airdrie and High River. Online participants were from these locales plus, Grande Prairie, Edmonton, Vermillion, Red Deer, Acme, Redcliff, Medicine Hat, Battleford (SK), Okotoks, Milo, Barons, Taber, Canmore, Cochrane, Nanaimo (BC), Burnaby (BC), Surrey (BC), Kamloops (BC), Truro (NS), Oregon and Virginia states Conclusion Online classes are well‐received, show knowledge and confidence gains, and reach a broader geographical area compared to in‐person classes. The surprising number of online participants without diabetes needs to be further investigated.


39. Get Smart with Panel Management: From chaos to control Ann Makin BPE, Bow Valley Primary Care Network Michelle Hannay BSc, Toward Optimized Practice Mark Watt RN, BN, Toward Optimized Practice Context The Bow Valley Primary Care Network (PCN), in partnership with Toward Optimized Practice (TOP), offered a guided program to assist primary care practices in a rural setting with identification of patient panels and common chronic diseases within the panel. Expanding on identification, the practices designed processes and procedures for ongoing management of the physician panel needs. Lessons on moving from panel identification to panel management will be shared. Objective The focus of this presentation is to share lessons from a guided project to assist primary care practices with identification and ongoing mechanisms to understand current and future panel care needs. Specifically, the project sought to:

Optimize the power of the EMR in the management of the PCN’s five most prevalent chronic diseases: Diabetes, Hypertension, Obesity, Dyslipidemia and Tobacco use

Identify and manage patient panel information

Develop standardized terminology, coding, problem lists and processes

Utilize evidence‐based tools and techniques to measure accomplishments and areas for improvement in clinical care delivery

Assess and review clinical reporting, and plan clinical care using this information Methods Practice facilitators and PCN staff used EMR‐based measurement to guide customized clinic interventions for identifying panel composition and care delivery needs. Results The following points summarize the lessons learned to date:

Establishment and maintenance of validated, manageable panels is critical for effective care

Knowing the panel enables the PCN and clinic members to provide a care team that is optimized to meet the ongoing needs of the identified populations

Common nomenclature (i.e. demographics, health problems and diagnoses), coding and standardized data entry processes are essential for reliable and relevant EMR data

Identified value of a Panel Manager role Conclusion Improved familiarity with panels ultimately results in effective panel management. Moving from “panel data” to accessing valuable panel information allows PCNs and clinic members to realize EMR potential, design the right care teams, and facilitate proactive patient care.


40. The BETTER Project: Qualitative study

Donna Manca MD, CCFP, FCFP, University of Alberta, Dept. of Family Medicine June Carroll MD, CCFP, FCFP, University of Toronto, Dept. of Family and Community Medicine Michelle Greiver MD, CCFP, FCFP, University of Toronto, Dept. of Family and Community Medicine Ginetta Salvalaggio MD, CCFP, MSc, University of Alberta, Dept. of Family Medicine Andrew Cave MD, CCFP, FCFP, University of Alberta, Dept. of Family Medicine Jess Rogers BA, Centre for Effective Practice James Pencharz MD, CCFP, MSc, Credit Valley Family Health Team Carolina Aguilar MA, MSc, University of Alberta, Dept. of Family Medicine Eva Grunfeld MD, PhD, FCFP, University of Toronto, Dept. of Family and Community Medicine

Context Family practice is the setting for most chronic disease prevention and screening (CDPS) maneuvers offered by the health care system. The BETTER project developed and tested an approach that builds on existing evidence applying it to the family practice setting. This mixed methods project included a pragmatic cluster randomized controlled trial in 8 practices. The interventions involved practice level facilitation and patient level facilitation. The patient level facilitation intervention utilized a prevention practitioner (PP), trained by BETTER, who prepared a prevention prescription tailored to each patient. A qualitative sub‐study was conducted to assess the patient level facilitation intervention.

Objective To better understand the patient level facilitation intervention including the development of the necessary skills, perceived barriers and facilitators, and to explore the feasibility and sustainability of the BETTER approach to CDPS.

Methods A modified grounded theory methodology was used to explore the Prevention Practitioner’s role. Purposeful sampling included participants involved in any capacity with the BETTER project. Two physicians and one coordinator at each city conducted 8 individual semi‐structured interviews and 7 focus groups, which were taped and transcribed. An interview guide ensured all areas were covered and helped to standardize the interview process. An audit trail documented the research activities. Journals, field notes and memos were also captured and shared by the researchers. Coding involved constant comparisons and theoretical coding followed open coding.

Preliminary Results The BETTER approach introduced a framework for CDPS through a proactive, personalized approach tailored to the individual patient that facilitated the development of relationships with patients and clinicians. The PP role developed linkages with CDPS resources inside and outside of the practice, increased CDPS awareness and facilitated change at the patient and practice level. Participants perceived the unique and distinct properties of the approach as beneficial, viewed the BETTER approach to CDPS as adaptable and described how they intended to integrate the approach into their practice settings.

Preliminary Conclusion The BETTER approach to CDPS provides a framework to transform from organ and disease focused approaches to a personalized integrated approach, which may be adapted to different practice settings to address CDPS.


41. Finding a BETTER Way: Facilitating Chronic Disease Prevention and Screening in Primary Care Donna Manca MD, CCFP, FCFP, Department of Family Medicine, University of Alberta Carolina Aguilar MA, MSc, Department of Family Medicine, University of Alberta Denise Campbell‐Scherer MD, PhD, CCFP, Department of Family Medicine, University of Alberta Christopher Meaney MSc, Department of Family and Community Medicine, University of Toronto Eva Grunfeld MD, PhD, FCFP, Context Primary care is the ideal setting for Chronic Disease Prevention and Screening (CDPS); however, evidence‐based approaches are inconsistently applied and physicians lack the time to adequately address CDPS. The BETTER coalition, informed by Ontario’s Chronic Disease Prevention and Management Framework, demonstrated the effectiveness of an approach to CDPS. Objective To improve CDPS for cardiovascular disease, diabetes, cancer and their associated lifestyle factors in patients aged 40‐65. The desired long‐term goals of this program are improved clinical outcomes, reduction in the burden of chronic disease and improved sustainability of the health care system through improved CDPS in primary care. Methods The BETTER program brings together primary care providers, policy/decision makers, and researchers to work towards improving CDPS in primary care. The program aims to transform practice using practice facilitation through a patient‐level intervention by a healthcare professional within the practice, the Prevention Practitioner (PP) (e.g. RN, dietician, etc.). Using the BETTER toolkit, the PP will determine which CDPS maneuvers each patient is eligible to receive and through shared decision‐making and motivational interviewing, develop a unique personalized “Prevention Prescription”. This proactive intervention is: 1) individualized, 2) addresses multiple conditions, 3) integrated with linkages to local, regional or national resources, and 4) longitudinal ‐ assessing patients over time. Results Internal practice facilitation for CDPS at the individual patient level through the use of a Prevention Practitioner trained in the BETTER approach has demonstrated effectiveness in eight Alberta and Ontario urban practices. The BETTER program will expand to new jurisdictions and feasibility will be evaluated. A composite measure of CDPS effectiveness will be made using the summary quality index (SQUID). The SQUID consists of the number of CDPS maneuvers that were met divided by the number a patient is eligible to receive. The RE‐AIM framework will also be used to evaluate the program. Conclusions The BETTER project is a collaborative approach grounded in practice and building upon existing work, that is, ‘integration NOT creation’. The findings to date provide an understanding of an approach that is effective for CDPS within primary care and may be adapted to become sustainable in the non‐research setting.


42. Evaluation of a Nurse Practitioner in a Rural Alberta Primary Care Network Raelene Marceau MN, NP, Peace River Primary Care Network Brieanne Rogers BHSc, Peace River Primary Care Network Michael Kolber MD, CCFP, MSc, University of Alberta Context In rural Canada, the shortage of family physicians has resulted in initiatives to improve patient access. One potential solution in improving access is to utilize Nurse Practitioners (NPs) within existing health care teams. However, limited research exists on the utilization of NPs in rural primary health care teams. This study will evaluate utilization of the NP in a rural Primary Care Network . Objective To explore the experiences and activities of a new NP program in a rural Primary Care Network, and to potentially to identify barriers, successes and possible future directions for NPs in rural Primary Care Networks. Methods Retrospective collection and analysis of patient encounter data between April 30th, 2011 and April 30th, 2012 in Peace River, Alberta, Canada. Upon analysis, results were represented dichotomously or categorically as summative values and proportions (%). Results Of the 1356 NP encounters, 63 patients were “no shows” leaving 1293 visits on 799 different patients to be analyzed. Regular clinic NP encounters totaled 785, Heritage Towers clinic encounters totaled 89 and STI/Teen clinic encounters totaled 419. Overall mean age was 31.2, 82.6% of patients were female, 55.4% of patients did not have a family physician and 41.8% saw only the NP during the year. The most frequent reason for visit was reproductive health discussion (25.7%), followed by pregnancy or prenatal care (11.1%) and other visit, defined as follow up (11.1%). Walk‐in visits comprised 47.0% of all NP encounters. 54.9% of encounters had follow‐ups, primarily with the NP (28.0%). Conclusion NP role in a rural Primary Care Network may be one reasonable solution to improve patient access in areas with physician shortages.


43. An Integrated Shared Referral Model with Specialty Partners Within Primary Care

Yolanda Martens vanHilst RN, Calgary Foothills Primary Care Network June Bergman MD, Calgary Foothills Primary Care Network Lorraine Bucholtz RN, Calgary Foothills Primary Care Network Rick Ward MD, Calgary Foothills Primary Care Network Allan McDonald RN, Calgary Foothills Primary Care Network Agnes Dallison MSc, Calgary Foothills Primary Care Network

Context The CFPCN has implemented an innovative Integrated Shared Referral Model (ISRM) with specialty partners within our Medical MSK and Chronic Pain programs. The pilot projects have demonstrated successful results in the first year.

Objective Traditional referral processes between primary care and specialty areas have resulted in frustrated providers and patients, but most critically, unacceptably long queues that potentially compromise patient safety and may result in increased costs of investigation and health care utilization. The objective of the ISRM is to develop a strong integrated service for CFPCN patients with specialty partners while keeping patients within their medical home.

Methods The Medical MSK clinic operates with an extended team and focuses on assessing, diagnosing, and educating the patient and providing them with a self‐management plan. The Chronic Pain Management program was developed in partnership with the Calgary Chronic Pain Centre and provides accessible interdisciplinary and strong integrated primary care service for patients with MSK chronic pain while increasing the support to family physicians’ practices. The implementation of the ISRM within these two programs has paved the way for a paradigm change within the specialist referral process and will be discussed in depth.

Results During the pilot phases, we have demonstrated improvement in health outcomes, satisfaction and system efficiencies. Specifically:

Reduction in wait times ‐ following the fourth quarter of operation, the wait time for Medical MSK was 90 days in comparison to the control ‘routine patient’ population in the Department of Rheumatology’s average wait time of 608 days

Improved Health Assessment ‐ Improved quality of life, functioning, decreased pain levels

Satisfaction – Survey information indicates high levels of satisfaction by referring physicians, patients, and specialty partners

Conclusion Long waits for services are still commonplace and result in costly delays in patient care. CFPCN’s ISRM maximizes communication, multidisciplinary care and a closer connection between consultant specialists within the patient’s medical home. As a result of the success of this pilot project, our PCN is exploring expanding this ISRM to our mental health and GI programs, as well as expanding the Medical MSK program to a Pan‐PCN initiative within the Calgary zone.


44. Optimizing Chronic Disease Management in Primary Care through Program Integration and Teamwork Carol Maskowitz RN, Red Deer Primary Care Network Context It is estimated that 30% of the population with chronic disease use 60% of direct health care costs in Alberta (AHS, 2010). Objective Responsive to population data and family physician (x78) needs, Red Deer Primary Care Network (RDPCN) set the course in implementing integrated chronic disease management strategies. Methods Adapting the Expanded Chronic Care Model (S. Barr et al., 2003), chronic disease management programs are integrated with health promoting strategies. Physician‐referred patients are seen by inter‐professional practice teams (Family Nurse, Mental Health Counselor, Pharmacist) co‐located in physician offices to facilitate collaboration, patient continuity and coordination. Evidenced‐based care algorithms e.g. diabetes, smoking cessation were developed emphasizing a patient centred self‐management approach. The team navigates patients to community/health resources for help with income support, diabetes care, housing etc. Patients are referred to PCN group programs i.e. Health Basics CHOICES – a lifestyle management program; Happiness and Anxiety Groups; Strong and Steady –falls prevention. Inter‐professional staff teams lead group programs e.g. Health Basics team comprises nurses, kinesiologists and dietitians. Patients who attend group programs are followed through family physician clinics. Patients and their families, along with staff, are encouraged to participate in PCN health promotion activities e.g. virtual treks and outdoor gyms. Results In 2011‐12, 90% of referred complex chronic care patients (n=1579) were coached by team members. On average, patients presented with four chronic conditions; each patient received six interventions including navigations to community resources. Case consultations between PCN staff and physicians doubled and over 50 % were cross referred to multiple programs. Patient feedback was positive regarding attributes of self‐management i.e. involvement in action/care planning (>90%), confidence in improving health (>80%) and awareness that PCN staff were collaborating in their care (90%). Physician and staff feedback reflect high satisfaction level with team approach regarding access and helpfulness of inter‐professional team care. From 2007‐09, there was a reduction in emergency department visits and hospitalizations evidenced in RDPCN patient panel (AHS). Conclusion RDPCN recognizes that health is a partnership among individuals, families, communities, health professionals that deliver health care and services. Together, these integrated PCN services promote better health and chronic disease management.


45. Barrier‐Free Health and Medical Services in Alberta: Communicating need

Bev Matthiessen, Alberta Committee of Citizens with Disabilities Melita Avdagovska MA, Alberta Committee of Citizens with Disabilities

Context In 2011, ACCD completed "Barrier‐Free Health and Medical Services in Alberta", a research project that increased our understanding of the barriers to health and medical services experienced by Albertans with disabilities. The project involved a literature review, consultations with consumers/health care professionals, online surveys, and accessibility audits. In 2012, ACCD launched "Barrier‐Free Health and Medical Services: Communicating Need," a project to implement our strategic communications plan to share our research findings and raise awareness for improved access to doctors' offices, diagnostic clinics, and medical equipment for Albertans with disabilities.

Objectives The following objectives were developed for ACCD's "Communicating Need" project: 1) increase health professionals understanding of the barriers people with disabilities face; 2) ensure health and medical access are included in the revised Alberta Building Code, Section 3.8; 3) enhance the Standards of Practice for physicians and surgeons under the Health Professions Act; 4) ensure the proposed Family Care Centres are accessible; 5) partner with and mobilize consumers and stakeholder groups; and, 6) increase public understanding of the barriers that people with disabilities face when accessing doctors' offices, diagnostic clinics, and medical equipment.

Methods ACCD developed a creative strategic communications and advocacy plan to convey key messages to primary/secondary target audiences (health system, health professionals, government, and the public sector) to support the necessary critical institutional change. ACCD's key messages are conveyed through social media (Interactive Website, Twitter, Facebook), print media, presentations, and journal articles. ACCD has an on‐line petition. ACCD is developing, with the U of A, templates for accessible doctors' offices, diagnostic clinics, and medical equipment.

Results ACCD has created and distributed key messages, identified and engaged target audiences, launched a revised web page, Twitter (300 followers), and Facebook page. Letters were sent to government officials, ongoing meetings are taking place with MLAs, MPs, public servants, and community organizations. Brochures are printed. The media has responded to our press release. The online petition is gathering names. A barrier‐free working group has begun. We are evaluating our processes and outcomes.

Conclusion ACCD acknowledges the complexity of the issues and that many of the solutions require financial investment; however, implementing our recommendations will create an inclusive equitable health care system for persons with disabilities.

Albertans with disabilities are passionate about healthcare issues; they contributed to the recommendations for barrier‐free health services in Alberta. The intent of ACCD's projects has been to assist decision‐makers to produce policies that will have the greatest impact on the health and safety of people with disabilities.


46. Health Basics: An innovative team approach to healthy lifestyle promotion and management Lorna Milkovich RN, BN, MBA, Red Deer Primary Care Network Context A Health Basics program was designed and implemented (2009) for physician‐referred patients in response to: 1) higher rates of physical inactivity and obesity among the population served by Red Deer Primary Care Network (RDPCN) compared to the provincial rate (CCHS, 2009), and 2) a gap in addressing obesity and inactivity associated with chronic disease management/prevention for PCN patients as indicated by member physicians (78). Objective The Health Basics CHOICES program is focused on healthy eating, exercise, life balance and incorporates health promotion principles. Physician‐referred participants are empowered to make healthy choices the “simple and easy choices “. Methods Program consists of an introductory class, eight interactive workshops and monthly follow‐up classes. An inter‐professional coaching team comprised of nurses, kinesiologists, and dietitians is guided by a physician‐led Committee of Practice. PCN staff including family nurses, mental health counselors and pharmacists co‐located in physician clinics facilitate continuity of care for group participants. PCN also invests in virtual treks, outdoor gyms and disc golf in city parks, and safe biking activities, with staff support, to create supportive healthy environments for patients, family and greater community. Results Since 2009, over 2000 patients participated in the Health Basics CHOICES program with a completion rate of 75%. Participants reported positive changes in physical activity, eating habits, and medication use. BMI score and waist circumference decreased over the course (p<.05), with continued decreases noted up to 12 months post group. Increased mean scores were evidenced in quality of life metrics (physical and mental health) three months after program. Health Basics responds to physician, staff and participant feedback in making program changes. Over 4500 people have participated in seven treks; ten outdoor gyms and one disc golf course have been placed in city parks in partnership with city of Red Deer. Conclusion Inter‐professional team work has contributed to program success. Further study and integrated follow‐up is planned for Health Basics participants through Alberta Obesity Strategy and Primary Care Interprofessional Team Study (AHS). Weaving health promotion principles of Health Basics into PCN programs and community initiatives fosters a unique team approach in putting “health” back into health care.


47. How Social, Political and Economic Factors Shape Formation and Integration of Interprofessional Primary Healthcare Teams Gillian Mulvale PhD, McMaster University Ivy Bourgeault PhD, University of Ottawa Context Despite calls to expand interprofessional team‐based primary health care delivery in Canada, little is known about the factors that shape collaboration among professions in existing teams. In Ontario, 200 Family Health Teams (FHTs) have been established since 2005, which include family physicians, nurse practitioners, registered nurses, social workers, dietitians, and other health professionals working together to provide primary care for their community. Objective The objective was to explore how the social, political and economic context matters in the formation and functioning of interdisciplinary primary health care teams with a view to making recommendations to policy makers and individual teams to enhance interprofessional collaboration. Methods A conceptual framework developed in earlier work on collaborative mental health care delivery in Ontario was applied to this qualitative case study. A maximum variation sampling approach was used to select 12 FHTs that differed with respect to a number of features (e.g. governance, geography, history of collaborative practice, co‐location of allied health professionals) for in‐depth analysis. A total of 50 telephone interviews were carried out early in the teams’ development (i.e., between January and April 2007) with administrators and providers of different disciplines (e.g. family physician, nurse practitioner, social worker, dietitian, pharmacist, psychologist). In addition, 30 patients were interviewed to gain their perspective on team collaboration. The study received approval from the McMaster Research Ethics Board. Results The results suggest that a number of political and economic factors (e.g. funding, remuneration of professionals, scope of practice regulations, professional liability) that are under the purvey of provincial governments can influence team integration and quality of collaboration in FHTs. Others social were important at the level of the individual team such as, communication, degree of hierarchy, professional culture/practice style, team vision, co‐location, and personal factors. Conclusion There is much that policy makers and individual teams can do to foster team integration and effective collaboration in interprofessional primary health care teams. The conceptual framework which identifies these factors and the associated recommendations will be helpful in improving integration and team functioning in FHTs and to decision‐makers and teams in other jurisdictions.


48. Shared Mental Health Care Sharon Nelson RN, BScN, Edmonton West Primary Care Network Lori Deverdenne RN, Edmonton West Primary Care Network Charmaine Parameswaran MD, CCFP, Alberta Health Services Myrna Isaac MSW, Alberta Health Services Amie Dowell MPH, Edmonton West Primary Care Network Context 1 in 5 Canadians will experience a mental illness in their lifetime. The remaining 4 will have a friend, family member or colleague who will (Health Canada. A Report on Mental Illness in Canada, 2002). Many family physicians feel ill‐equipped to properly diagnose and treat mental illness. The Shared Mental Health Care (SMHC) program builds on pre‐existing family physician‐patient relationships with additional mental health expertise in order to provide unique learning opportunities to the family physician and improve the level of care provided to the patient. Objective SMHC is a pilot program between the Edmonton West Primary Care Network (EWPCN) and Alberta Health Services' Addiction and Mental Health (AAMH) program ‐ Edmonton Zone. This consultation program, started in December 2011, partners family physicians with a psychiatrist and a mental health therapist (MHT)in order to enhance mental health services delivered by family physicians at the primary care level. The goals of the program are to: provide timely specialized mental health access for patients in the EWPCN Network; build capacity of primary care providers in providing mental health support to their patients; promote early detection and intervention for mental health concerns by bringing services to clients; enhance communication between EWPCN and AAMH services; and create structures including a Business Agreement that would assist in the processes of providing AAMH services within the EWPCN. Methods The family physician selects patients who will benefit from shared mental health care. The family physician and the SMHC team see the patient together with the intent of meeting both the clinical needs of the patient and the professional learning objectives of the family physician. The one hour consultation appointment typically includes an assessment, intervention, and treatment for the patient, and an opportunity for feedback and discussion regarding the family physicians' specific learning and care objectives. Results Success of the program is measured using pre/post physician surveys (to measure improved capacity to deliver mental health service), patient satisfaction surveys, and statistical data referencing the reason for referral, no show rate, and patient demographics. Of the patient satisfaction surveys that have been completed, 100% of the patients have reported either "mostly satisfied" or "delighted" with the services that they received. Early feedback from physicians indicate that the program is helping them to better meet the needs of their mental health patients and that the mentorship of the SMHC team is providing them with a great learning opportunity.


Conclusion To date, there are two EWPCN clinics consisting of 12 family physicians participating in the SMHC pilot program, with more EWPCN clinics interested in accessing the program. The EWPCN will continue to promote and expand this program as resources become available.


49. WRAP: A self‐management recovery program for and by patients with mental health challenges Pauline Pariser MD, CCFP, FCFP, Taddle Creek Family Health Team Nadiya Sunderji MD, FRCP, St. Joseph's Health Centre Sherry Kenndy B Health Admin, Taddle Creek Family Health Team Context Wellness, Recovery, Action Plan (WRAP) is the most disseminated model of mental health recovery‐oriented peer support interventions. Generic self‐management interventions for chronic medical conditions can improve health outcomes and is empirically proven. Similarly mental health self‐management aims to increase problem‐solving skills and self‐efficacy. A mix of patients, physicians and residents introduced WRAP to a primary care setting, Taddle Creek Family Health Team ,( TCFHT) for the first time in Ontario. WRAP is an 8 week program that facilitates the identification of strategies to maintain wellness, to recognize triggers and early warning signs, and to create an action plan helping patients navigate through times of crisis. Objective To create an understanding of the basic tenets of the Recovery model of mental health and reflect on lessons learned by a family health team in the implementation of this peer‐support imitative and to present measures of impact. Methods Two focus groups with WRAP participants were conducted 1 week post‐session. The evaluation model was in keeping with the recovery model which relies on personal narrative to guide decision‐making. Open‐ended and exploratory questions were drawn up by a mix of stakeholders ; a psychiatrist, family physician, two patients, and a psychiatric resident who had participated in WRAP. Results Two focus groups of 10 participants answered questions about their experience. Answers were collated and grouped into the following themes: Hope and Empowerment, Connection between Physical and Mental Health and Attitudes towards the sponsoring Health Organization, TCFHT. Patients overall reported feeling less helpless, having a much better appreciation of linkages between their physical and mental health and not needing as much medical support because of the skills they had acquired. Five participants went on to formal training as WRAP facilitators and subsequent groups became self‐sustaining with TCFHT patients leading the groups. Conclusion With peer‐lead groups, WRAP offers a powerful alternative to traditional models of mental health treatment in its emphasis on self‐management, empowerment and focus on the social determinants of health. At TCFHT, we have demonstrated that these groups can be implemented in partnership with patients, become self‐sustaining and reduce health care costs.


50. It Takes a Team: An interdisciplinary clinic to treat patients with complex conditions

Pauline Pariser MASc, MD, CCFP, FCFP, Taddle Creek Family Health Team Christina Biancucci MD, CCFP, Taddle Creek Family Health Team Howard Abrams Beng, MD, FRCP, Division of Internal Medicine, University Health Network Nadia Sunderji MD, FRCP, Department of Psychiatry, University of Toronto Brandi Brozell RN, NP, Taddle Creek Family Health Team Cathy O'Toole MSW, Taddle Creek Family Health Team Megan Omstead BSc Nutrition, Taddle Creek Family Health Team Leslie Nickel MD, CCFP, Taddle Creek Family Health Team

Context Patients with chronic multiple co‐morbidities are the fastest growing sector of the Ontario population and account for more than 40% of health care costs. Currently they are treated with serial visits to disconnected providers using single disease management models, inadequate in addressing complex conditions. Taddle Creek Family Health Team (TCFHT), in collaboration with Sunnybrook Health Sciences Centre (SHSC), has developed a team model of simultaneous inter‐professional consultation (IMPACT clinic) that brings together patients with complex disease, the primary care provider (PCP), the inter‐disciplinary team and secondary consultation from an internist and psychiatrist in real time at the primary care site. Studies have shown that intensive and integrated inter‐professional care reduces costs while offering at least equivalent care for this population.

Objective The goal is the realization of a fully integrated patient and family centered care plan for patients at risk for ED visits and hospitalization with consequent reduction in those visits. Secondary goals include a reduction in total healthcare utilization, enhanced patient and PCP satisfaction, and improved efficiency and skills acquisition by the inter‐professional team.

Methods Patients with 3 or more complex conditions or taking >5 medications are identified in the electronic medical record and randomly assigned to the IMPACT clinic or to usual care over a 6 month period. ED visits between the groups will be compared over the next year. Secondary outcome measures include overall healthcare utilization, patient, caregiver and provider satisfaction as well as measures of team functioning.

Results SHSC assessed 120 patients with qualitative interviews indicating high patient satisfaction and enhanced confidence on the part of caregivers. Team members scored high on a 56 item measure of teamwork. Qualitative interviews of 20 TCFHT patients also indicated high patient satisfaction with overall reduction in medication use, diagnostic imaging, and medical visits. Interviews with PCPs confirm they experience support and renewed confidence in managing complex patients.

Conclusion The IMPACT clinic has comprehensively treated our most complex patients, engendering high degrees of patient and provider satisfaction. Its impact on health care cost will be studied. This concept has been peer‐modeled at four family health teams and a training video has been produced. FHTs have he capacity to offer this service as consultation to other MDs in their regions.


51. Within the S.C.O.P.E. of Patient Care: A primary care integration project Pauline Pariser MASc, MD, CCFP, FCFP, University Health Network Kathy Sabo, University Health Network Gillian Hawker MD, FRCP, Womens' College Hospital Dipti Purhboo, Toronto Central Community Care Access Centre (CCAC) MaryKay McCarthy, University Health Network Context Individuals with chronic conditions are at increased risk for emergency department (ED) visits and hospitalization and account for the majority of Ontario’s hospital and home care costs. Solo primary care practitioners (PCPs) are challenged in meeting these patients' needs because of lack of infrastructure, and difficulty accessing hospital and community resources. Seamless Care Optimizing the Patient Experience (S.C.O.P.E.) is a two‐year collaborative primary care integration project that aims to improve care transitions and linkages between solo PCPs and hospital and community resources. Objective To facilitate prevention and management of ambulatory care sensitive conditions by improving access to resources, better aligning PCPs with acute care and community services resulting in fewer ED visits and avoidable hospitalizations. Methods A sample of PCPs identified as having patients with high rates of hospital admission and ED utilization will be given access to: 1) A single point of access to hospital and community resources (Navigation Hub); 2) General Internist ‘on‐call’ for timely phone/email consultation; 3) Patient Results Online (PRO) and secure email to enable timely review of hospital results. Iterative Plan‐Do‐Study‐Act (PDSA) cycles will be used to adapt interventions to fit local resources and practice routines. Success will be defined by an overall 25% reduction in ED visits; we have >90% statistical power to detect such a reduction. Other measures include rates of interaction with the navigation hub/internist on‐call and patient and provider satisfaction. Results An early measure of success is PCP engagement in system transformation, overcoming clinical inertia and facilitating investment in the project. To date almost 70 % of the PCPs indicated interest in participation and 60% have agreed to participate. From two engagement events, 95% of respondents ranked the events above average or excellent. Ninety one percent felt the project would be relevant to their practices. Conclusion Early evidence suggests PCPs are interested in improved linkages to hospital and community resources and that this project has relevance in addressing high ED use and hospitalization. The model has the potential to identify key components in improving care transitions to be disseminated to other settings.


52. The Art of Persuasion: Engaging physicians in primary care integration

Pauline Pariser MASc, MD, CFP, FCFP, University Health Network Mandeep Gaidhu PhD, University of Toronto, School of Medicine Hayley Panet MHSc, University Health Network MaryKay McCarthy, University Health Network Jodeme Goldhar MSW, RSW, MHSc, Toronto Central Community Care Access Centre Laura Pus MBA, Women's College Hospital

Context The success of quality health improvement programs depends on a high degree of physician engagement defined as ‘involvement which is two‐way, influences decision making, occurs early and is integral to the decision making process" (NHS 2008). Seamless Care Optimizing the Patient Experience (S.C.O.P.E.) is a 2‐year collaborative primary care integration project that aims to improve care transitions and linkages between solo primary care providers (PCPs) and hospital and community resources. Consistent with literature reports, key strategies to influence engagement include a project lead with clinical credibility and capacity for transformational leadership, early involvement of physician champions, support by senior management, responsiveness to PCP priorities, and clarity regarding mutual obligations.

Objectives 1. To initiate and maintain a significant level of PCP engagement in the implementation and ongoing

evaluation of the project, and 2. To report on the results of incorporating rapid Plan‐Do‐Study‐Act (PDSA) cycles in enhancing key

engagement strategies.

Methods Fifty‐one PCPs were identified from rates of high patient visits to the emergency department and hospitalization. Pre‐project implementation, thirteen PCP interviews were conducted to identify priorities in improving transitions of care. Data were collected via evaluation forms post engagement sessions and through documented communications between PCPs and the project team. Iterative changes were made to engagement strategies on the basis of these communications using rapid PDSA cycles.

Results Of the 51 PCPs approached, 30 (60%) agreed to sign on. Five physician champions were identified and all are actively engaged. Physicians endorsed involving their front‐line staff in engagement events and focus groups. Regarding the engagement events, ~95% of respondents ranked them as above average or excellent, with an average of ~90% indicating that organizers should hold this type of event quarterly. Importantly, ~91% of respondents indicated that the project would be relevant to their practices. Key communications influenced real‐time changes in engagement strategies and promoted marked improvement in physician contributions to S.C.O.P.E.

Conclusion An early measure of success in an integration project is the ability to engage PCPs in system transformation. Iterative changes to key engagement strategies have enabled significant early involvement, two‐way collaboration, and robust contributions to S.C.OP.E. development.


53. Moving for Health: Bridging the exercise gap between primary care and community Sandra Pelchat BSc Kin, CEP, Edmonton Southside Primary Care Network Kate Masters BScN, RN, Edmonton Southside Primary Care Network Context Moving for Health is a class designed to help bridge the gap in exercise services between primary care and the community. Our target population is people with, or at risk of developing, chronic health conditions who are currently inactive. The class is meant to be a gentle interactive introduction to moving through education and physical experience. Objective Cardio‐respiratory fitness has been deemed one of the greatest markers of morbidity and mortality. For many people living with chronic health conditions staying active can be very challenging. This program helps facilitate a transition back to an active healthy lifestyle at home or in the community. Methods Over the past year, more than 200 patients from the Edmonton Southside Primary Care Network have attended this two month supervised group exercise program. Once per week a CSEP Certified Exercise Physiologist and a Registered Nurse facilitate a simple progression to activity. All patients are encouraged to track their steps using a pedometer and individualized activity goals are set weekly. Patients also have the option of meeting the Exercise Specialist at a community fitness facility one day per week. Results Over the course of the past year we have tracked incidence of chronic health conditions. The majority of attendees have one or more of the following: obesity, arthritis or joint pain, diabetes, hypertension, dyslipidemia and mental health concerns. A quality of life survey (SF‐12) was completed by patients prior to completing the first class and at the last class. We are conducting a phone follow up survey with all patients who attended more than 60% of classes to see if they have continued with the habits learned during Moving for Health. This data will be presented. Conclusion Physical activity is an integral part of any comprehensive approach to health. It should, therefore, be a central component in the prevention, treatment, and maintenance of our patient’s health. Group environments can be an ideal way to provide impetus and motivation to get moving and foster holistic lifestyle changes.


54. Supporting the Patient with Complex Needs in a Virtual Ward Program: A collaborative to improve the patient experience

Thuy‐Nga Pham MD, MSc, CCFP, South East Toronto Family Health Team

Context Many older adults with complex health needs experienced higher than average re‐admission rates to a community hospital in Toronto. To better serve the needs of this population, a Virtual Ward (VW) was developed by the South East Toronto Family Health Team (SETFHT) as a novel collaborative between primary, acute and community care, targeting patients at high risk for readmissions to hospital.

Objective The goal of the Virtual Ward is to improve continuity of care and reduce avoidable emergency department visits and hospital readmissions for elderly patients who are deemed at high risk. With a focus on a team‐based approach to care for patients with complex needs, VW patients are supported by an interprofessional team at SETFHT. With a focus on increasing capacity in primary care and ensuring seamless communication, a case management approach has been taken, including weekly team based case conferences that include a community care (CCAC) case coordinator and physicians involved in both acute and primary care.

Methods Evaluation is a priority for not just the virtual Ward model by expanded initiatives that are supporting the team’s patients with complex needs. The ‘lived’ experience of this model of care through the eyes of the care team and the patients/caregivers have been collected. Formal qualitative evaluations are in progress and funded by the Ontario Ministry of Health and Long‐Term Care to evaluate the Virtual Ward, and BRIDGES funding from the University of Toronto to evaluate the Home Visit component of the program both qualitatively and quantitatively. CCAC will also be undergoing a multi‐year evaluation on the partnership between the various sectors. Quality Improvement methodology has been employed in tracking program success.

Results Early learnings point to the critical importance of working alongside primary care to most effectively support patients and caregivers in the community. For the complex patients, a case manager engages intensely with the primary care interprofessional team in the community with the goal to develop an integrated, shared car3e plan for support. Building an electronic communication platform for exchange across care sectors has improved communication and alignment of care provided. Larger changes in health policies, in Ontario specifically the Excellent Care for All Act, have aided greatly in establishing a care team across differently funded sectors by focussing on the patient’s experience.

Conclusion Our work is focused on wrap around care in the community top prevent unnecessary admissions to acute care. However, when the hospital admissions are unavoidable, VW patients are followed between the community and the hospital by a care team that knows their needs. This has been achieved by building a team across sectors, spanning primary, acute and community care, and thereby improving the patient experience by ensuring more seamless transitions.


55. Peel Regional Primary Care and Cancer Network Paul Philbrook MD, CCFP, Credit Valley Hospital and Trillium Health Centre Praveen Bansal MD, CCFP, Credit Valley Hospital and Trillium Health Centre Alexandra Boasie HBSc, MSC, Central West Mississauga Halton Cancer Program Mark Gaskin BSc, ART, Central West Mississauga Halton Cancer Program Julie Lessard HBSc, MPH, Central West Mississauga Halton Cancer Program Kristi Phillips HBSc, MHA, Central West Mississauga Halton Cancer Program Context To recognize the vital role of Primary Care in the regional cancer system and to provide an opportunity for Primary Care to actively contribute to the planning of care across the cancer continuum, with a focus on prevention, screening, diagnosis, and survivorship. Objective Currently, there is a gap in the integration of primary care in the cancer system. From cancer screening through diagnosis and onto treatment, a patient's cancer journey is fragmented. Often, there is a disconnect in communication and lack of awareness of regional programs and initiatives in which primary care engagement is integral. Research indicates that improvements in health care require direct and meaningful involvement of physicians. Engaging, integrating, and working in collaboration with primary care providers is a valuable tool for the evolution of cancer screening programs (i.e. integrated cancer screening, diagnostic assessment programs and survivorship programs). To address this gap and to align with Cancer Care Ontario's (CCO) 2011‐2015 Ontario Cancer Plan, the Mississauga Halton & Central West Regional Cancer Program has developed a Peel Regional Primary Care and Cancer Network (PRPCCN). Methods A PRPCCN has been established for the Mississauga Halton & Central West LHINs and is comprised of two Regional Primary Care Leads, 13 Primary Care Network members (family physicians), as well as, the regional Integrated Cancer Screening team. In addition, a Primary Care Database has been established to enhance, improve and streamline communication between this Network, CCO and other stakeholders. Results Expected outcomes of the this Network are as follows: increased primary care leadership capacity, as well as increased primary care involvement in cancer screening, diagnosis, and survivorship initiatives. The Network will also provide opportunities for primary care physicians to provide meaningful input and an opportunity to collaborate within the cancer system. Conclusion Effective and efficient integration of primary care into the cancer system will enhance best practices and facilitates a sustainable solution to provide high quality services to the community regarding cancer prevention, screening, diagnosis and survivorship.


56. "Do What You Know" Cancer Screening Toolkit for Primary Care Providers: A quality improvement initiative

Paul Philbrook MD, CCFP, Credit Valley Hospital and Trillium Health Centre Praveen Bansal MD, CCFP, Credit Valley Hospital and Trillium Health Centre Alesandra Boasie HBSc, MSc, Central West Mississauga Halton Cancer Program John Day MD, The Erie St. Clair Regional Cancer Program Mark Gaskin BSc, ART, Central West Mississauga Halton Cancer Program Julie Lessard HBSc, MPH, Central West Mississauga Halton Cancer Program Kristi Phillips HBSc, MHA, Central West Mississauga Halton Cancer Program

Context The goal of Cancer Care Ontario’s (CCO) Integrated Cancer Screening Program is to increase breast, cervical, and colorectal cancer screening participation in order to reduce cancer causing deaths. Cancer screening rates in Ontario remain low. Interventions to Increase the Uptake of Cancer Screening: Guideline Recommendations (2009) recommends that primary care providers should be 1) evaluated on their performance in delivering or offering screening to clients and, 2) presented with information regarding current resources and guidelines.

Objective Reducing structural barriers has been determined to be an effective intervention to increase community participation and overall screening rates. This pilot project is currently being conducted over an eight month period to identify and address the issues related to low cancer screening rates. In collaboration with the Erie St. Clair Regional Cancer Program, a “Do What You Know” toolkit was developed to provide primary care offices with new and existing screening resources for physicians, administrative staff and client waiting room areas aimed at promoting cancer screening participation.

Methods 300 primary care providers within the Central West and Mississauga Halton LHINs will be invited to participate in the pilot. Recruitment will be through cold calling and referral. To measure the effectiveness of the toolkit as a provider‐ and client‐ directed intervention to influence cancer screening practice at the primary care level, pre‐ and post‐implementation surveys will be administered to pilot participants (primary care providers, administrative staff, and patients). During a future phase of this study, these qualitative data will be correlated with quantitative data gathered via provider OHIP billing codes to determine the screening participation rates of pilot primary care provider participants.

Results This pilot project is currently underway, and results are not yet available. Early anecdotal feedback has been positive and adoption by primary care providers is expected.

Conclusion This initiative will provide the information required to establish a successful quality improvement toolkit for primary care providers, supplying them with cancer screening resources and guidelines, resulting in an increase in primary care engagement in the cancer journey. Future considerations for this initiative include toolkit translation into languages that serve under‐never screened populations.


57. Physician Assistants: Adding value to primary care In Alberta Michele Poirier BKin, CAT (c), MPAS, CCPA, University of Calgary, Department of Family Medicine Context Physician Assistants (PAs) are highly skilled health care professionals who provide a wide range of medical services with physician supervision. They are physician extenders and not independent practitioners. Certified PAs need not be in the same physical space as supervising physicians but reachable by phone or other means. Consequently, PAs are able to provide medical services in areas lacking physicians, thus improving access to quality patient care. Objective It is well understood that ongoing shortages of physicians and residents in Alberta and across Canada are creating challenges in the health regions efforts to provide patients with access to continuous, comprehensive patient care (CMA 1999, Mazankowski 2002, Romanow 2002). A growing population and an increase in chronic illnesses such as diabetes and heart disease means more people will need ongoing monitoring and management of their conditions. We are seeing the development of interprofessional teams of health care providers who work collaboratively, apply knowledge and skillsets, and provide comprehensive care to more people than practitioners working alone. Many states and provinces are already seeing the value PAs provide to demanding patient loads. Methods PAs in Canada are trained through a CMA accredited program or through the Canadian Military. Trained within the medical model, PAs are able to take detailed patient histories, conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, perform small procedures, assist in surgery and write prescriptions. Their scope of practice is determined on individual basis and formally outlined in a contract agreement between the supervising physician(s) and the PA. The Physician–PA relationship is essential for patient centered medicine. Results A number of studies have concluded that the quality of care a patient has received from PAs is equal to that provided by physicians in a comparable situation (Mittman, Cawley & Fenn, 2002). Working in collaboration with physicians, PAs have shown a substitution ratio of 0.86 meaning they see the same type of patient and deliver the same care 86% of the time. With a compensation to production ratio of 0.36, there are significant economic benefits to practices where PAs are employed (Grzybicki DM et al, 2002). Most importantly, patient satisfaction with care delivered by a PA consistently rates high in many areas of practice, including Primary Care. Conclusion Physician Assistants began practicing in the US 50+ years ago due to a shortage of physicians in Primary Care. They are strongly supported in the US and the Canadian Military, as well as by the provinces of Manitoba, Ontario and New Brunswick. The CPSA has a voluntary, non‐regulated membership for PAs.


As Alberta looks in the direction of access to quality, patient centered care, Physician Assistants are an innovative and cost effective way of accelerating primary care.


58. What We Can Learn From Others: A Scan of Primary Health Care Service Delivery Models Marion Relf RN, BScN, MHSA, Alberta Health Services Shannon Erfle MScRD, MBA, Alberta Health Services Paul Childs BA (Hon), MPH, Alberta Health Services Brenda Regehr RN, BScN, MBA, Alberta Health Services Scott Oddie PhD, Alberta Health Services Context The Primary Care Integration & Innovation (Alberta Health Services) team working with Alberta Health has prepared background on recommended enhancements to the province's system for Primary Health Care delivery. This includes a more wholistic view of factors that impact health and may contribute to a Primary Health Care approach. A literature review and interviews were completed to understand current best practices internationally. The interviews were conducted as part of an environmental scan of successful primary health care organizations and jurisdictions. Objectives

1. Assess successful PHC service delivery models in other jurisdictions. 2. Interview key stakeholders in select organizations to gain additional insight on promising

practices. 3. Analyze and synthesize findings to identify potential practice elements for Alberta.

Methods In conducting the environmental scan of organizations and jurisdictions demonstrating “best‐practices” in Primary Health Care, the group identified approximately 25 organizations/jurisdictions which were thought to have made progress in planning and/or implementing exceptional primary health care service delivery models. From this, a “long list” of 13 organizations/jurisdictions were identified that appeared most promising; and a final list of five organizations/jurisdictions selected for interviews. The five organizations/jurisdictions were 1) Veterans Health Administration, USA, 2) NorWest Community Health Centre, Ontario, 3) Southcentral Foundation, Alaska), 4) Netherlands, and 5) Australia – Remote/Rural & Aboriginal Initiatives. Results The key findings are grouped into eight value categories:

1. Individual and Family Focused: A focus on relationships and case management 2. Wellness: Self‐management and promotion of health as a community effort 3. Access: Access and team composition tailored to the needs of the community 4. Integration: Use of electronic medical records by the entire team; integration within the health

care system and with other sectors that impact primary health care 5. Quality and Safety: Owning the quality process; use of clinical guidelines as a resource 6. Continuous Improvement: Use of performance measures; focus on workplace training; innovation

supports for staff 7. Accountable: Community‐driven management; metrics to inform teams and leaders 8. Sustainable: Sustainable practices such as compensation of providers, use of highly functioning

interdisciplinary teams and attention to measurement of progress


Conclusion During interviews, a recurring theme was the “culture” of the organization; one that focuses on relationships with individuals, families and staff, as well as a culture of measurement to guide improvement. The challenge of moving beyond episodic care to addressing the determinants of health was commonly cited. These and other insights will be important aspects to consider as the dialogue on Alberta's future in primary health care.


59. Alberta AIM ‐ Continuing the Access and Efficiency Journey Julie Shemanchuk BA, Alberta AIM Steven Clelland MA, Alberta AIM Bonnie Lakusta BSc, PhD, Alberta AIM John Lester BSc, Alberta AIM June Austin RN, Alberta AIM

Context Alberta AIM is a made in Alberta quality improvement initiative which supports physicians and teams in primary care and specialty care as well as AHS programs to improve access, efficiency, and clinical care. Including work that started in the Chinook PCN in 2005, AIM has reached 170 primary care clinics and 79 specialty and/or AHS program teams. These 249 participating teams represent 809 General Practitioners, 411 specialists and 1304 health care providers across Alberta.

Objective Objectives of the AIM program are to spread opportunities for clinic participation province wide, increase capacity for AIM in Alberta, and support teams who have graduated from the program.

Methods Alberta AIM uses a principle driven evidence‐based approach to improvement. The learning process is based largely on the work of Mark Murray and Associates and utilizes the IHI (Institute for Healthcare Improvement) Break Through Series (BTS) collaborative model. AIM concepts are based on a number of improvement theories and methodologies including The Model for Improvement, Demming’s lens of profound knowledge, Queuing Theory, Theory of Constraints, and LEAN. Three change packages are utilized during the collaborative learning process to meet participating clinic objectives:

reducing delays for and at appointments

increasing operational team efficiency and clinical team effectiveness

improving clinical care practices and outcomes Clinics participating in an AIM Collaborative are provided with support to collect the following measures to guide their improvements:

Delay: the number of days to the third next available appointment.

Demand: The number of appointments booked today.

Supply: A prospective measure of provider capacity.

Activity: A retrospective measure of provider productivity.

Panel Size: The number of unique patients for whom a provider is accountable.

Continuity: The probability that patients see their own provider when requesting care.

No Shows: The number of patients who fail to keep their appointment.

Cycle Time: The time from when a patient enters the clinic until the patient leaves.

Results Collaborative level results will be presented for AIM 10‐15. Statistically significant improvements to the time to third next available (TNA) appointment, clinic cycle time, and no show rates were found across multiple collaboratives and for many teams / clinics participating in AIM.


Conclusion Teams that have participated in AIM have demonstrated improvements to access, efficiency, clinical care, teamwork, and patient and provider satisfaction. Balancing measurement for improvement and evaluation is an important consideration in this work.


60. Back to the future: What Taber has to teach us 10 years on Shannon Spenceley RN, PhD, University of Lethbridge Janet Lapins RN, BN, University of Lethbridge Cheryl Andres MHSc Student, University of Calgary Linda Janz MSc, University of Lethbridge Lisa Halma Med, Alberta Health Services Context Primary care reform has been on the international, national and provincial agenda for over two decades. There have been many innovative projects and models implemented across Canada and an evidence base is growing around the factors that support success in improving primary care. We suggest that while some areas of Alberta have made great strides in primary care improvement, there continue to be many areas where struggles persist in implementation. In too many cases, we still struggle to implement reforms and best practices. The purpose of this presentation is to introduce preliminary findings of a longitudinal, qualitative review of a primary care practice that has successfully navigated this difficult process of reform. Methods The research design is qualitative and descriptive in nature; it involves secondary analysis of original interviews of participants in the Taber Integrated Primary Care Project (2000‐2004), as well as primary and comparative analysis of recently collected interviews of individuals currently involved with the practice (many of whom were interviewed in the original project) . Primary analysis also includes focus group data gathered from the current clinic teams. Conclusion We identified a unique opportunity to examine how change unfolded over time, and glean the lessons learned over the last 10 years of primary care reform in the Taber primary care practice. We believe that these lessons will be valuable as we ponder the next iteration of primary care reform in Alberta.


61. Improving Access to Primary Care Physicians for Unattached Patients Tamara Stecyk, Edmonton Southside Primary Care Network Len Frank, Leduc Devon Beaumont Primary Care Network Candra Tinis, Leduc Devon Beaumont Primary Care Network Sarah Vilay, Primary Care Initiative Cheri Ell, Edmonton West Primary Care Network Johanna Dietrich, Primary Care Initiative Karen Yukes, Alberta Heartland Primary Care Network Context In response to the growing need to connect patients to a family physician, nine Edmonton area Primary Care Networks have teamed up to develop the Find A PCN Doctor website and phone application. These tools (or this website) provides the public with an up‐to‐date and comprehensive list of all PCN member physicians in the Edmonton area who are accepting new patients. Objective To create a simple website and mobile phone platform that lists PCN physicians who are accepting new patients. To increase the ratio of pageviews (to entire website pageviews) for each PCNs’ Physicians Accepting New Patients web page by 10 per cent. Methods A five‐member committee was formed to facilitate the project from April 2012 until the website launch in June 2012. Each committee member was given a role ‐ development of the website and mobile platform, engaging the nine participating PCNs to update their information about physicians accepting new patients, communications and media relations for the website launch, reaching out to community organizations to raise awareness about the website, and development of a participatory agreement. Results Within 24 hours of the website's media launch, 3,000 unique hits occurred to view the 119 Edmonton area family doctors who were accepting new patients at that time. The website raised public awareness about access to family physicians and the importance of continuity of care. As of the end of July, there were 133 PCN family physicians accepting new patients. This website project improves access to patients to family physicians and ultimately to PCN services. It also helps increase awareness of PCNs. Conclusion The project demonstrates how well nine PCNs within a geographic area can collaborate on a common goal. A similar website could be developed for other groups of PCNs or expanded to become a provincial resource.


62. Orthopedic Triage at the Primary Care Level at the Edmonton North Primary Care Network Lindsay Steward, Edmonton North Primary Care Network Boris Boyko MD, Family & Sports Medicine Clinic Context Since its inception as a Primary Care Network (PCN) in 2007, one of the Edmonton North PCN's top priorities has been to find ways to improve the links between primary and specialty care. Referrals to Orthopedics traditionally have had the longest wait times for patients in Alberta. In 2011, our PCN created an ortho triage program to help address this issue. Objective The objective of this triage program is to determine, at the primary care level, how many orthopedic patients are surgical and how many can be treated with conservative measures and taken off a surgeon's waiting list, thereby reducing the waiting time a surgical patient will wait to see an orthopedic surgeon. This will help determine contributory factors as to why waiting lists for this specialty are so long and how access and overall waiting times can be improved with additional screening by a family physician with additional training and specialization in orthopedics and MSK. Methods Patients referred to the ortho triage program are generally seen within two weeks (as opposed to a 90 day median wait time for an orthopedic surgeon) and are assessed. If appropriate, they are treated conservatively by the ortho triage doctor, therefore eliminating the need to see an orthopedic surgeon and further add to the excessive wait time for patients requiring surgery. If a patient is deemed to be surgical, their referral is forwarded on to an ortho surgeon, ensuring that all applicable conservative measures have been exhausted first. Results A front page story about this program ran in the Edmonton Journal on June 14 and we were subsequently contacted by patients all over Edmonton wanting to participate in this program, making it clear there is a desire for support. Currently, of the 621 patients seen through the program: 162 (26%) have been deemed surgical 448 (72%) have been deemed non‐surgical and managed conservatively 6 (<1%) have been deemed non‐surgical although a referral to a surgeon was insisted by the patient 5 (<1%) have been deemed inappropriate referrals and forwarded to a different specialty Conclusion There is much work that can be done at the primary care level that can be done to provide more timely care to patients that also helps reduce the burden on specialists. We are currently in discussions with the orthopedic specialists in the Edmonton area to engage with them to develop this program further either by expanding this program and/or fast tracking those that have been identified as surgical.


63. Coping with Anxiety: An innovative and responsive group method Jennifer Tilbury Registered Psychologist, Red Deer Primary Care Network Context Anxiety was one of two primary presenting problems for mental health clients with Red Deer Primary Care Network (RDPCN) 2009‐2011. Objective This situation provided the impetus to develop and offer a psycho‐educational group (Anxiety to Calm) in the treatment of anxiety for physician‐referred patients. Methods Research identifies that cognitive behaviour therapy is the most effective therapy for the treatment of anxiety. An eight week interactive program is facilitated with trained instructors. Interventions are designed to address techniques to change feelings, thought and behaviours associated with anxiety. A booklet is being developed of educational material and interventions. To date, 390 patients have been referred to the program; 75% female, 25% male, average age – 40 years. Results Program completion rate is 72% with an average of 5.2/8 classes attended by 100 participants. Qualitative evaluation indicates that people are experiencing a reduction in anxiety symptoms, an increase in management skills and reduction of specific phobias resulting in improved quality of life. They also report a strong positive impact from being in the group and connecting with other's struggling against anxiety. Quantitative evaluation reflects positive changes in feelings, thoughts and physical symptoms using the Burns Anxiety Inventory tool. Quality of life measures (SF12v2®) show improvement in mean scores associated with mental health, physical functioning, ability to cope and social interactions from beginning to end of program. Conclusion The development of this program has been a dynamic process of reflective practise and ongoing evaluation with positive results.


64. Understanding our Practice to Change our Practice Danielle Tone BA, BSW RSW, Chinook Primary Care Network Becky Marshall RN, Campbell Clinic Chinook Primary Care Network Context To help us better understand who was doing what work we used a Care Team Work Load Analysis (CTWLA). The purpose of the CTWLA was to inform us about what tasks were that the team was doing, and provide information about how much time they spent on these tasks. This data can be used to assist us in making an informed decision regarding who the right person is to do the right work, help us to optimize team roles, and determine what work could be delegated and distributed to various team members. Objective Our goal was to maximize the teams’ capacity to work at full scope of practice and provide optimal care for patients. Methods A CTWLA was completed by 6 physician, 3 RN’s, 5 LPN’s, and 2 MOA’s. The CTWLA requires team members to track the different tasks that they do on a daily basis, over a specific time‐period. The team collected data over ten days, using 10‐minute intervals. The team defined the different tasks and used these definitions to create consistency during the measurement period. The CTWLA provides more details for the overarching categories of: direct, indirect, and non‐patient care. Individual and aggregate results were collected for each participant and will be used to inform current allocation and delegation of tasks. Results It was determined that there were redundancies in practice and that various health professionals were doing work that could be better suited to other team members. Conclusion We will share a breakdown of the aggregate results and share examples for the physician CTWLA. A comparison of roles and discussion of how we utilized the results of the WLA to implement changes in team structure, roles, duties and physical location within the clinic, as well as future plans and next steps.


65. Data Informed Self‐Evaluation & Collaborative Knowledge Translation (DISECKT): Primary care on the cutting edge David Topps MD, University of Calgary Janet Corral PhD, University of Calgary Karen Sullivan PharmD, University of Calgary Heather Armson MD, University of Calgary Context The Alberta Physician Learning Program (PLP) aims to enhance physician performance through self‐assessment, informed by health services data. PLP has made great strides in making aggregate and correlated data available from a variety of data sources. However, data alone will not promote reflection or transformational change, no matter how rich or extensive the source. Objective This project aims to provide context and comparative peer data, through a series of data‐based virtual patients, allowing physicians and their teams to explore their decision making, use of resources, and clinical care processes. Methods Based on established quality improvement principles, the project leads physicians through a PDSA‐like cycle of reflection and provides them with Personally Linked Analyses of Networked Educational Sources (PLANES) – a template‐driven plan based on data derived from multiple services. At the beginning and end of each cycle, participants try a virtual patient scenario (VP), built in open source software called OpenLabyrinth. The VP is purposely designed like a script concordance test in order to test judgment, insight, and tacit knowledge. The VPs are also designed to include simple game scores and feedback mechanisms, as well as further links to evidence‐informed sources. Physicians complete the VPs individually or in small groups, the latter facilitated by online collaboration tools. Individual PLANES data is integrated into the VPs, increasing impact and relevance of the VPs. Results Challenges to date include the difficulties of meaningful data aggregation from multiple sources; exploring new approaches to mining EMR data; and the redesign of OpenLabyrinth to accommodate external data sources. A variety of statistical approaches are being explored to analyze concordance of experts’ navigation within the virtual patient narrative pathways. Conclusion This project is still in its earlier phases. Initial feedback and face validity testing on the learning designs have been very positive and have iteratively refined VP case designs. Using VPs as an applied, reflective activity has provided great insights into cognitive processes, along with detailed metrics about the steps taken in case management. In parallel projects, virtual patients have been used to great success in promoting team function and quality improvement.


66. Uptake of Addiction Assessment Resources by Primary Care Physicians Christine Vandenberghe MEd, Emergency Medicine, University of Alberta Ginetta Salvalaggio MD, CCFP, MSc, Family Medicine, University of Alberta Kathryn Dong MD, FRCP(C), DABEM, MSc, Emergency Medicine, University of Alberta Scott Kirkland MSc, Emergency Medicine, University of Alberta Greta Cummings PhD, Nursing, University of Alberta Bob McKim MSc, Evaluation, Alberta Health Services Ryan Cooper MD, FRCPC, MPH, Infectious Diseases, University of Alberta Cam Wild PhD, School of Public Health, University of Alberta Context Screening, Brief Intervention, and Referral for Treatment (SBIRT) is an evidence‐based primary care approach to addiction assessment. Unfortunately, implementation in practice has been suboptimal, and little is known about best implementation practices. Objective The goals of this project were to develop and evaluate a set of SBIRT and patient engagement knowledge translation (KT) resources designed to enhance the capacity of physicians to effectively intervene with low‐socioeconomic position patients with substance use problems. Methods The study used a nonrandomized two‐group pre‐post quasi‐experimental intervention design. Participants included family and emergency medicine physicians and residents. Physicians were provided with electronic educational modules, accompanying presentations, point of care resources, addiction medicine champions, and provider orientations to the inner city. Self‐reported frequencies of SBIRT use, perceived proportion of patients who suffer from addiction, and physician attitudes (Short Understanding of Substance Abuse Scale (SUSS) and Attitudes Towards Injection Drug Use Scale (ATIDU)) were measured at baseline and 12 months. Results 131 physicians were assigned to the intervention (78) or control (53) condition according to their usual location of practice. 39 intervention and 25 control participants were available for follow up at 12 months. Uptake of KT resources ranged from 25% for e‐modules to 63% for point‐of‐care reminders; when used, the majority found these resources useful. Intervention physicians reported a trend toward higher frequency of SBIRT behavior (F(1,60) = 2.97, p < 0.10). There were no significant differences across time in physicians estimates of the proportion of their patients with addictions (F(1, 51) = 2.21, p = ns) or in their attitudes toward injection drug use (F(1, 61) = 0.06 p = ns) on ATIDU. However, there were attitudinal changes across time on the SUSS Eclectic Orientation (F(1,62) = 59.33, p < 0.01) and Disease (F(1,62) = 112.38, p < 0.05) subscales. Conclusion A multipronged SBIRT KT strategy was favorably received by physicians and was associated with a trend towards increased addiction assessment behavior and improved attitudes towards substance use.


67. Review of INR Protocols for Registered Nurses at the Edmonton Oliver PCN Lorna Warkentin RN, Edmonton Oliver Primary Care Network Jube Laruan RN, Edmonton Oliver Primary Care Network Madalyn Abella RN, Edmonton Oliver Primary Care Network Lillian Sissons RN, Edmonton Oliver Primary Care Network Lori Radmaovich RN, Edmonton Oliver Primary Care Network Rochelle Graham MS RN, Edmonton Oliver Primary Care Network Kris Skov Rackette RN, Edmonton Oliver Primary Care Network Donna Weiss RN, Edmonton Oliver Primary Care Network Marion Relf RN, MHSA, Edmonton Oliver Primary Care Network Context This abstract presents a recent review of the therapeutic window of Warfarin, a drug used in the care of patients with atrial fibrillation by the Physicians and Registered Nurses at the Edmonton Oliver Primary Care Network. Objective Atrial fibrillation is one of the biggest factors in the incidence of stroke. Until recently Coumadin/Warfarin has been the drug of choice. This abstract reviews the recent changes in the management of INRs. Methods Physicians' review of acceptable INR ranges based on input from evidence‐based research. Registered Nurses' input based on the 20+ years of combined experience of managing INRs since 2007. Information was also gleaned from a 2012 patient satisfaction survey and from the Health Quality Council of Alberta (HQCA). Results Stroke risk is drastically reduced when INRs are greater than 2.3. The risk of bleed, specifically, intercranial hemorrhage, does not outweigh the risk of stroke until the INR reaches 4.0. The standard range of INRs is 2.5‐3.5 for all patients unless otherwise indicated by the physician. Results greater than 3.5 are treated with less aggression since small changes in dose can result in significant changes in results. Doses are evaluated with greater caution and aberrant results are treated with smaller changes in dose to achieve better outcomes. INRs are checked every two weeks for greater safety of drug levels. Wide fluctuations or long term high or low INRs are caught early. The personalized care that the Registered Nurses provide has led to more accurate adjustments of medication, less frequent ER visits and shorter hospital stays. Patients are telling their physicians and the nurses just how much they appreciate the care and education provided. Conclusion Physician and nurses approach INRs with improved skills for the management of INRs which leads to better outcomes for our patients. Physicians and nurses are always working together to continually improve our knowledge base and our service to our patients.


68. Online and Email Obesity Education Increases Knowledge, Confidence and Reach Sasha Wiens RN, BN, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone Bev Madrick RD, CDE, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone Wendy Shah BSc, RD, Endocrinology & Metabolism Program, Alberta Health Services, Calgary Zone University of Calgary Context Online obesity education was developed and emailed to clients to address the barriers to traditional in‐person education. Objectives Objectives were to provide an audio/PowerPoint weight management education series that was: accessible online to overcome potential barriers to traditional in‐person education; comparable to in‐person diabetes education for weight outcomes; deliverable through automated sequential emails; available for use by primary care and community partners; and cost effective. Methods Twelve online weight management audio/PowerPoint education sessions were developed, each available through a unique URL. Online sessions were accessed directly or through email pushed out weekly after signing up at a micro‐website http://wcmprod2.ucalgary.ca/cdm/. An online service, AWeber, was used to automate sequential email deliveries. Clients registered in an obesity management program self‐selected to receive either emailed online education or in‐person classes. Both online and in‐person education was delivered over 6 months. Weight was measured pre and post education in both groups. Online participants completed pre and post education surveys assessing knowledge and confidence in performing self‐management skills. They also participated in a focus group. Results When compared to in‐person class participants (42), the online participants receiving emailed education (10) were older (49.8 vs. 46.9 yrs average), were more likely to reside outside of Calgary (60% vs. 20%), and lost more weight (7.13 kg vs. 5.29 kg). Online survey results reflected responses from online participants receiving emailed education, as well as an unknown number of direct URL accesses from the general public (992 accesses). These combined online respondents agreed that the online format was user friendly (94%) and they would recommend this program to others (90%). They also reported an increase in knowledge and confidence after viewing sessions. Focus groups and survey comments identified strong assets of the online education to be convenience, the ability to start and stop presentations as desired and the ability to repeat sessions as needed. Conclusion Online and emailed weight management education sessions result in weight loss, are well‐received, show knowledge and confidence gains, and reach a broader geographical area compared to in‐person classes. There is a role for emailed online education to support obesity management programs.


69. Improving and Evaluating Physical Examination Attendance Through Use of Recall Letters and EMR Data Extraction Shea Wilks BESc, Palliser Primary Care Network Shivonne Berger BA, Med, Palliser Primary Care Network Vince Elgersma MD, South Shore Medical Clinic Context The Palliser Primary Care Network (PCN) employs 54 nurses, dietitians, counselors and pharmacists who provide direct patient care in 29 PCN clinics. The PCN performs a quarterly data extraction from clinic Electronic Medical Record (EMR) systems. This activity is undertaken to facilitate and evaluate clinical outcomes for patients interacting with physicians and PCN staff, and to measure staff productivity and inform education activities. Panel analysis includes efficiency measures (e.g. number of visits, distinct patients, visits per hour), chronic disease distribution (e.g. number and proportion of patients with obesity, diabetes, hypertension, dyslipidemia, COPD, number of active diseases per patient) and other clinical measures (e.g. percentage of patients with a recent blood pressure reading, percentage of hypertensive patients with a controlled blood pressure reading, percentage of patients with a measured weight in the last year). The method of data extraction permits complete patient lists to be provided to clinics for all measures taken, indicating, for example, the specific patients overdue for a certain test, procedure or exam, or the patients not "on target" for a specific benchmark. Objective To measure clinical improvement by leveraging the PCN's data extraction and providing clinically relevant information to PCN clinic physicians and PCN staff. A specific PCN pilot project involved the South Shore Medical Clinic mailing recall letters to patients over fifty years of age, reminding them to schedule a yearly physical examination. Methods The PCN evaluation analyst extracted data from the 2008 to 2011 EMR records of all patients over fifty years of age to determine if a physical examination had occurred during those years, and compared the percentages of completed physicals of eligible patients who were mailed a recall letter with those who were not mailed a letter. Results 81% of patients who were sent a recall letter completed a physical within the next 365 days; 47% of patients who were not sent a recall letter had a physical within that time period. Conclusion Recall letters are an effective method for improving annual physical exam attendance.


70. Shared Care: Specialist support for community‐based patients – doing more for less Margot Wilson RN, MSN, Providence Health Care Robert Levy MD, FRCPC, Providence Health Care Garey Mazowita MD, CCFP, FCFP, Providence Health Care David Thompson MHSc, Providence Health Care Clay Barber BSc, BC Ministry of Health/BC Medical Association Context In 2010 Providence Health Care partnered with the Shared Care Committee and Vancouver Coastal Health (VCH) to facilitate the collaboration of FPs and specialists to develop and implement tools and processes to streamline care for patients with complex chronic conditions. The Partners in Care initiative aims to increase access to specialists through telephone advice prototypes and to expedite referral and re‐referral processes, with a focus on improving communication, knowledge translation and role clarification for FPs and specialists. A team of specialists, FPs, patient representatives, clinical/administrative leaders, and quality improvement and change specialists was created to develop processes to address the identified areas of work. Objective Pressures and increasing challenges in the healthcare system call for transformation and system redesign. Shared care models present opportunities for collaborative and innovative solutions allowing patients to benefit from specialist expertise in “real time” while maintaining the benefit of continuity of care from their family physicians (FPs). Prototypes were developed and implemented in the VCH region using the “PDSA” model for improvement. While these prototypes were designed to address the urban environment, the objective was to develop strategies to scale throughout British Columbia (BC) in differing medical contexts. Methods Guided by the Institute for Health Care Improvement’s “Triple Aim”, evaluation of the work was performed using qualitative/quantitative measures. Evaluation included surveys and interviews involving FP users, specialists, and decision makers. Results Findings indicate there have been fewer unnecessary face‐to‐face specialist consults (60%) and fewer emergency department visits (32%) within the VCH region. 77% of FPs report the new referral process improved care, 81% felt the shared care planning tool improved care and 83% state the telephone advice line improved care for their patients. Broad uptake of prototypes exists at sites elsewhere in BC funded by the Shared Care Committee as part of its Partners in Care initiative. Conclusion This work addresses a critical challenge and is viewed as a model that reduces costs, streamlines patient care, supports FPs, and utilizes specialist services more appropriately. The Shared Care project demonstrates how the combination of QI approaches, collaboration, and partnerships can address critical challenges faced between specialists and FPs.


71. Evaluating Teamwork in Primary Care: Edmonton North Primary Care Network's resources in clinics pilot project Kate Woodman PhD, Charis Management Consulting Inc. Donna Lien‐Willcott RN, Edmonton North Primary Care Network Context Edmonton North Primary Care Network (PCN), with over 130 member family physicians, is one of the largest PCNs established in Alberta tasked with helping to enhance primary care delivery in the province. One objective for this enhanced care involves establishing multi‐disciplinary care teams to contribute to the improved health of Albertans. The Resources in Clinics (RICs) Pilot Project was developed by Edmonton North PCN to inform changes to clinical practice, in this case through the development of high functioning, formalized dyads. Objective Team formation & function: the RIC model addresses the over‐arching concerns of improving physician workplace satisfaction and increasing patient satisfaction with the care they receive. The model embeds a physician‐led dyad within the practice, to:

Increasing efficiencies in the use of physician time;

Increasing physician workplace satisfaction;

Increasing unattached/orphan patient access; and,

Decreasing patient wait times. Methods In spring 2010, RICs were recruited, hired, and trained by the PCN. RICs were then assigned to a physician who had volunteered to participate in the pilot, based on the type of work support requested by the physician (e.g., MOA or LPN).

In coordination with the physician and in alignment with their roles the RICs’ core responsibilities included assisting with administrative tasks; patient triage; clinical supports and patient education provision; and patient follow‐up. Patients had access to a coordinated, collaborative primary care team supporting them from pre‐visit through to follow‐up. Daily interaction between the dyad ensured continuous and ongoing consultation, to the patient’s benefit. The PCN facilitated on‐going meetings, trainings and data gathering for RICs and meetings with the physicians to discuss the pilot’s progress. This intentional monitoring allowed “just in time” adjustments to be made. Results A solid, coherent, and consistent pattern of findings was discovered. Of note is the level of satisfaction with the RICs project: physicians (98%); RICs (93%); and, patients (93%). The data indicated that over time, the relationships between the three stakeholders evolved into trust‐based collaborations that supported results in each of the four objectives. Key findings:

physician direct patient care productivity increased and RIC contribution in patient engagement

physicians increased work/life balance

fourfold increase in new patients being seen

decreased patient wait times


high patient satisfaction with team awareness of health condition Conclusion The dyad model for delivering team care in the primary care sector has disclosed trends of interest, including the importance of evaluation (measurement). This encourages family physicians to be responsive to practice changes that are inclusive of other health care providers. This inclusion leads to increased satisfaction for themselves, the RICs, and their patients.


72. Importance of Patient Registries for Implementing Quality Improvement Interventions in Primary Care

Lisa Wozniak MA, University of Alberta, School of Public Health, ACHORD Allison Soprovich BScN, MPH, University of Alberta, School of Public Health, ACHORD Sandra E. Rees BPharm, University of Alberta, School of Public Health, ACHORD Steve T. Johnson PhD, Athabasca University, Centre for Nursing and Health Studies, ACHORD Sumit R. Mujamdar MD, MPH, Department of Medicine, University of Alberta Jeffrey A. Johnson BPS, PhD, University of Alberta, School of Public Health, ACHORD Context Patient registries are a foundation of the Chronic Care Model and are associated with better processes and outcomes of care for conditions such as type 2 diabetes. Nevertheless, there has been limited implementation of registries in primary care settings. The Alberta’s Caring for Diabetes (ABCD) project seeks to improve the quality and efficiency of diabetes care in Alberta. It includes piloting quality‐improvement interventions in four Primary Care Networks (PCNs) for people with type 2 diabetes. As there is no existing provincial patient registry, it was anticipated that potential participants would be identified and recruited into the ABCD interventions through PCN patient registries. Two participating PCNs had existing patient registries, and two requested support with registry development. Objective Using a mixed‐methods approach, our team adopted the RE‐AIM framework to evaluate the ABCD interventions. One goal was to document the development and use of registries as an organizational strategy to identify and reach target populations that might benefit from the ABCD interventions. Methods Semi‐structured interviews (n=7) were conducted with directors and chronic disease managers of the participating PCNs. Registry development processes and maintenance issues were explored. Data were analyzed using content analysis. In addition, recruitment response rates and eligibility data were used to derive PCN (regional) rates of type‐2 diabetes and compared to Alberta Diabetes Surveillance System (ADSS) data, an external reference standard of population‐based rates of type‐2 diabetes. Results Two broad themes emerged regarding the ability to reach target populations at the organization assessment level: (1) the varying ability of the participating PCNs to estimate and identify the target populations in usual care; and (2) the individualized PCN approaches to registry development or enhancement. Both themes were found to influence PCN‐specific recruitment rates. Compared to ADSS data, the registries tended to under‐estimate the expected rates of diabetes. Specific challenges and potential solutions in identifying patient populations were provided by respondents. Conclusion Through our evaluation, we observed challenges in the development and application of patient registries, thus affecting the "reach" of the ABCD interventions. We outline several policy implications related to the development and quality of registries based on our findings.

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