FHT Vision
The Minto-Mapleton FHT (MMFHT) will demonstrate excellence in delivering comprehensive, patient-centred rural primary care.
FHT Mission
The MMFHT is a collaborative, interdisciplinary team of providers located in Minto (Palmerston, Harriston and Clifford) and Mapleton (Drayton). Our mission is to efficiently provide high quality, accessible, patient-centred primary care with a particular focus on chronic disease management and disease prevention to maximize health and well-being.
FHT Guiding Principles
The work of the MMFHT is guided by the following principles:
The Minto-Mapleton FHT (MMFHT) will demonstrate excellence in delivering comprehensive, patient-centred rural primary care.
FHT Mission
The MMFHT is a collaborative, interdisciplinary team of providers located in Minto (Palmerston, Harriston and Clifford) and Mapleton (Drayton). Our mission is to efficiently provide high quality, accessible, patient-centred primary care with a particular focus on chronic disease management and disease prevention to maximize health and well-being.
FHT Guiding Principles
The work of the MMFHT is guided by the following principles:
- Teamwork: We work in interdisciplinary teams of health care professionals to meet the needs of our patient population.
- Community partnerships: We work in collaboration with our community partners including other health care organizations and professionals.
- Realistic and Responsive: We strive to develop MMFHT programming and services based on the changing needs of our patients.
- Evidence-based practice: We are committed to developing and using evidence-based practice and continuous re-evaluation to guide our services and measure our results.
- Innovation: We use creative solutions that respond to local community and provider needs to achieve the MMFHT objectives.
- Research and education: Research and education opportunities are embraced and encouraged for all staff.
- Patient-centred: We encourage patient self-management by providing direction, education and support. Through this partnership we promote a culture of mutual trust and accountability.
MMFHT Revised Strategic Plan: 2017 - 2020
The following 7 revised strategic goals will guide the work of the MMFHT over the next few years. The goals were developed through the following process steps: environmental scanning, board/staff strategic planning workshop, feedback from board and staff on draft goals and objectives.
The following 7 revised strategic goals will guide the work of the MMFHT over the next few years. The goals were developed through the following process steps: environmental scanning, board/staff strategic planning workshop, feedback from board and staff on draft goals and objectives.
2018-2019 Quality Improvement Plan (QIP)
Overview
The Quality Improvement Plan (QIP) has been developed to meet the requirements of the Excellent Care for All Act and to demonstrate to the community our commitment to quality, responsive, and accountable rural primary health care. The QIP aligns with the Minto-Mapleton Family Health Team's (MMFHT's) strategic directions and Annual Plan. The QIP, in addition to other quality improvement strategies, continues to play an important role in helping the FHT better understand our patients' experiences at the FHT with the goal of improving the quality of care and overall experience.
The Minto-Mapleton FHT's 2018/19 QIP will focus on four (4) quality dimensions: Effective Care, Equitable Care, Patient-Centred Care and Timely Care.
The Effective Care quality dimension aims to improve our transitions of care for our patients from hospital back into community through working in partnership with our local hospital. We are going to particularly focus on patients with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). We are also going to assess the impact of e-notifications into our Electronic Medical Record (EMR) on our patients discharged into the community from the Homewood Health Centre.
In terms of the Equitable Care quality dimension, we are going to continue to focus our efforts on cancer screening and diabetes care. Over the past year, we have begun to see some improvements to our preventative care screening targets. The 2018/19 Plan aims to maximize our use of an electronic Preventative Care Toolbar in our EMR and ensure that our new physicians are able to access and use the Toolbar. Later this year, we plan to test a new colorectal screening test called the FIT with an eye on improving our screening rates with this more user friendly screening test. Continual focus on our diabetes patients is also planned for 2018/19. We will be using our EMR to generate information that targets patients with diabetes, aged 40 or over, and who are not up to date with their diabetes screening. The goal is to improve the number of patients with diabetes who have at least two (2) HBA1C tests in the past 12 months. We have a number of FHT staff involved with diabetes and pre-diabetes programs, and our goal in 2018/19 is to more regularly share information with these staff on diabetes screening statistics so that they can assess their progress with their patients more consistently.
The 2018/19 Plan continues to value input from our patients about their experiences with their primary care practitioner with the objective of maintaining our high performance of primary care involving patients in decision making about their care. We have been trialing different ways to get input from our patients and plan to expand the ways that patients can provide us with feedback. Our plan for this year is to select one or two sites and display survey results to patients, such as developing and displaying a patient poster, in addition to sharing survey results with our physicians, nurse practitioners and staff.
The fourth quality dimension involves offering Timely access to primary care when patients need an appointment. In addition to asking patients in our patient survey about the number of days it takes to get an appointment, we are including an additional patient survey question that asks "Do you consider the amount of time you usually have to wait to get an appointment with your health care provider reasonable?" We will be collating responses for both of these questions and including in our results. We are also requesting and documenting email addresses for our patients in their patient record with the goal of beginning to do email reminders to patients for their appointments.
The MMFHT has 5 practice sites where primary care is offered: Drayton, Palmerston (2 sites), Harriston and Clifford.
The overall objectives of our Quality Improvement Plan include:
The 2018/19 QIP is the 6th QIP that the Minto-Mapleton FHT has developed. We continue to remain committed to tracking our progress and working towards achieving our QIP objectives with the overall goal of improving patient care.
Describe your organization's greatest QI achievements from the past year
Two of our greatest QI achievements from the past year include:
1) Working in partnership with our local hospital to help our COPD patients access up-to date testing, specialist consults via telemedicine, and FHT programs including pulmonary rehab with the goal of improving our patients' overall quality of life.
2) Our sub-Region (Rural Wellington) system work where we are working together to 1) better align our Community Care Coordinators with primary care physicians and NPs so that communication is improved and our patients' home and community care needs are met and 2) improve mental health and addiction supports for rural residents including the identification of the most appropriate Mental Health and Addiction services through the creation of a Tiered Model of Care.
Resident, Patient, Client Engagement
The main vehicle where we engage our patients and their caregivers in our Quality Improvement work is through our patient surveys in each of our physicians' and NPs' offices. We will continue with patient survey distribution in 2018/19 at each of our practice sites. In 2018/19, we are going to further our use of tablets for patient survey distribution and trial providing survey feedback to our patients, such as through a patient poster. Results from the patient surveys are discussed at our Quality Committee meetings, FHT Board Meetings, FHO User Group Meetings and FHT Staff Meetings.
Collaboration and Integration
This year's QIP continues to recognize the importance of health care partners working together to create smoother transitions for our patients. The FHT will continue to monitor our performance on the percentage of patients who saw their primary care provider (physician or nurse practitioner) within 7 days after discharge from hospital. We are now capitalizing on a more consistent use of the e-Notification feature of Hospital Report Manager (HRM) to track our patients who are admitted and discharged from hospital, and who need a primary care visit within seven days. Recently, Homewood Health Centre (psychiatric hospital) began using HRM and we will be interested to see how HRM notification in our EMR, will facilitate smoother transitions for our patients being discharged back into the community from Homewood Health Centre. We also will continue to monitor the use of the EMR tracking process we developed for our patients who see their Nurse Practitioner post-hospital discharge. Through a partnership with our Rural Wellington partners (local hospitals), LHIN's Home and Community Care, Canadian Mental Health Association Waterloo Wellington, Homewood Health Centre and three other neighbouring FHTs, we plan to develop a 2018/19 collaborative QIP (cQIP).
Engagement of Clinicians, Leadership & Staff
The Family Health Team has an active Quality Committee that meets regularly to review progress on the Quality Improvement Plan (QIP) and to participate in the development of the annual QIP. The Committee is comprised of clinical and administrative staff, management, and two physicians including the FHT's Medical Lead. Members of the Committee worked together to establish quality improvement initiatives, goals and commitments for the organization for 2018/19. Throughout the year, members of the Quality Committee keep FHT Staff and practice sites up to date by providing progress reports in the FHT-bit newsletter and verbal updates at meetings. The Medical Lead and Executive Director regularly report progress on our QIP to the FHT Board.
Population Health and Equity Considerations
Our quality improvement efforts focus on working collaboratively with our community partners to ensure that our residents have full and equal access to opportunities that enable them to lead healthy lives. Through our Rural Wellington Health Advisory Committee and Health Links funding, a Community Health Needs Assessment for Rural Wellington has recently been completed. The purpose of the report is to identify the strengths and needs of Rural Wellington, which will enable the establishment of wellness and health priorities that will improve the health status of our population. Based on agreed upon priorities, improvement initiatives will be developed with the overall goal of improving the health of rural Wellington residents. A Rural Wellington Community Conversation will be launched in spring/2018 that brings a broad range of community partners together to discuss the health and well-being of Rural Wellington residents and collectively move the Community Health Needs Assessment to action.
Access to the Right Level of Care - Addressing ALC
Minto-Mapleton FHT is helping to ensure patients have access to the right level of care by supporting Alternative Level of Care (ALC) initiatives in our community. For example, the FHT is an active participant in Health Links/Community Outreach Initiative which includes various partners working together to develop coordinated care plans for complex patients. Through the development and sharing of coordinated care plans, programs and supports are being put in place to help residents stay in their own homes.
Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder
Physicians and Nurse Practitioners working in the Family Health Team have taken a number of active steps to support the effective treatment of pain including opioids treatment practices and promoting alternatives to treatments. Some of the steps include:
1) Our Low Back Pain and new Hip/Knee Programs in particular capitalize on the use of the FHT pharmacist to review analgesic regimens.
2) The FHT offers a variety of programs such as Chronic Pain, Fibromyalgia Groups that provide interdisciplinary education and support with the goal of assisting patients to be better able to deal with the physical and emotional problems of living with chronic pain.
3) Our physicians and NPs use a stepwise approach (e.g. WHO ladder) for pain management in acute settings.
4) Our Medical Lead has joined the McMaster Mentoring in Pain Management Program where he is provided with a pain management expert who offers support for complicated patients.
5) We collaborate closely with our community partner (CADS) who offers specialized addiction counselling for our patients.
6) Over this past year, all of our Nurse Practitioners have completed their certificates in controlled substance prescribing.
7) Providers are able to refer our patients to pain clinics where the clinics reinforce interdisciplinary care and offer alternative options.
8) Our EMR contains practice documents to allow our providers to continue to have safe and effective prescribing for patients who have controlled substance use.
9) Our providers have access to Stonehenge which has residential addiction programs for both men and women.
10) We have recently had some conversations with Dr. Yelena Chorney of the Rapid Access & Addiction Clinic to better understand thoughts and challenges related to the development of a Rapid Access and Addiction Clinic (RAAC)-supported range of services for our patients in rural Wellington.
Workplace Violence Prevention
The Minto-Mapleton Family Health Team is committed to building and preserving a safe working environment for its staff. The FHT assesses risk factors in the workplace to identify workers who may be exposed to violence. In conjunction with staff, the FHT's health and safety representatives regularly review our Violence Policy and Program to minimize or eliminate the risks of violence in the workplace. Any incidents of workplace violence are reviewed by the FHT's health and safety representatives to ensure concerns have been dealt with and to make recommendations to reduce or eliminate risk of violence. The FHT is also committed to training and informing staff on the contents of the Violence Policy and Program to ensure that staff are knowledgeable of the risk factors and how to eliminate or respond to violent situations. A health and safety update including any Workplace Violence incidents is provided to the FHT Board at least annually by the FHT's Executive Director.
Contact Information
Shirley Borges, Executive Director, Minto-Mapleton FHT; sborges@mmfht.ca
The Quality Improvement Plan (QIP) has been developed to meet the requirements of the Excellent Care for All Act and to demonstrate to the community our commitment to quality, responsive, and accountable rural primary health care. The QIP aligns with the Minto-Mapleton Family Health Team's (MMFHT's) strategic directions and Annual Plan. The QIP, in addition to other quality improvement strategies, continues to play an important role in helping the FHT better understand our patients' experiences at the FHT with the goal of improving the quality of care and overall experience.
The Minto-Mapleton FHT's 2018/19 QIP will focus on four (4) quality dimensions: Effective Care, Equitable Care, Patient-Centred Care and Timely Care.
The Effective Care quality dimension aims to improve our transitions of care for our patients from hospital back into community through working in partnership with our local hospital. We are going to particularly focus on patients with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). We are also going to assess the impact of e-notifications into our Electronic Medical Record (EMR) on our patients discharged into the community from the Homewood Health Centre.
In terms of the Equitable Care quality dimension, we are going to continue to focus our efforts on cancer screening and diabetes care. Over the past year, we have begun to see some improvements to our preventative care screening targets. The 2018/19 Plan aims to maximize our use of an electronic Preventative Care Toolbar in our EMR and ensure that our new physicians are able to access and use the Toolbar. Later this year, we plan to test a new colorectal screening test called the FIT with an eye on improving our screening rates with this more user friendly screening test. Continual focus on our diabetes patients is also planned for 2018/19. We will be using our EMR to generate information that targets patients with diabetes, aged 40 or over, and who are not up to date with their diabetes screening. The goal is to improve the number of patients with diabetes who have at least two (2) HBA1C tests in the past 12 months. We have a number of FHT staff involved with diabetes and pre-diabetes programs, and our goal in 2018/19 is to more regularly share information with these staff on diabetes screening statistics so that they can assess their progress with their patients more consistently.
The 2018/19 Plan continues to value input from our patients about their experiences with their primary care practitioner with the objective of maintaining our high performance of primary care involving patients in decision making about their care. We have been trialing different ways to get input from our patients and plan to expand the ways that patients can provide us with feedback. Our plan for this year is to select one or two sites and display survey results to patients, such as developing and displaying a patient poster, in addition to sharing survey results with our physicians, nurse practitioners and staff.
The fourth quality dimension involves offering Timely access to primary care when patients need an appointment. In addition to asking patients in our patient survey about the number of days it takes to get an appointment, we are including an additional patient survey question that asks "Do you consider the amount of time you usually have to wait to get an appointment with your health care provider reasonable?" We will be collating responses for both of these questions and including in our results. We are also requesting and documenting email addresses for our patients in their patient record with the goal of beginning to do email reminders to patients for their appointments.
The MMFHT has 5 practice sites where primary care is offered: Drayton, Palmerston (2 sites), Harriston and Clifford.
The overall objectives of our Quality Improvement Plan include:
- Provide an organizational focus across all practice sites on quality improvement;
- Identify measures/indicators and set targets for the organization to monitor and track process over time;
- Propose and implement planned improvement initiatives;
- Obtain meaningful input from our patients regarding their experiences with primary care; and,
- Communicate findings, quality improvement progress and lessons learned.
The 2018/19 QIP is the 6th QIP that the Minto-Mapleton FHT has developed. We continue to remain committed to tracking our progress and working towards achieving our QIP objectives with the overall goal of improving patient care.
Describe your organization's greatest QI achievements from the past year
Two of our greatest QI achievements from the past year include:
1) Working in partnership with our local hospital to help our COPD patients access up-to date testing, specialist consults via telemedicine, and FHT programs including pulmonary rehab with the goal of improving our patients' overall quality of life.
2) Our sub-Region (Rural Wellington) system work where we are working together to 1) better align our Community Care Coordinators with primary care physicians and NPs so that communication is improved and our patients' home and community care needs are met and 2) improve mental health and addiction supports for rural residents including the identification of the most appropriate Mental Health and Addiction services through the creation of a Tiered Model of Care.
Resident, Patient, Client Engagement
The main vehicle where we engage our patients and their caregivers in our Quality Improvement work is through our patient surveys in each of our physicians' and NPs' offices. We will continue with patient survey distribution in 2018/19 at each of our practice sites. In 2018/19, we are going to further our use of tablets for patient survey distribution and trial providing survey feedback to our patients, such as through a patient poster. Results from the patient surveys are discussed at our Quality Committee meetings, FHT Board Meetings, FHO User Group Meetings and FHT Staff Meetings.
Collaboration and Integration
This year's QIP continues to recognize the importance of health care partners working together to create smoother transitions for our patients. The FHT will continue to monitor our performance on the percentage of patients who saw their primary care provider (physician or nurse practitioner) within 7 days after discharge from hospital. We are now capitalizing on a more consistent use of the e-Notification feature of Hospital Report Manager (HRM) to track our patients who are admitted and discharged from hospital, and who need a primary care visit within seven days. Recently, Homewood Health Centre (psychiatric hospital) began using HRM and we will be interested to see how HRM notification in our EMR, will facilitate smoother transitions for our patients being discharged back into the community from Homewood Health Centre. We also will continue to monitor the use of the EMR tracking process we developed for our patients who see their Nurse Practitioner post-hospital discharge. Through a partnership with our Rural Wellington partners (local hospitals), LHIN's Home and Community Care, Canadian Mental Health Association Waterloo Wellington, Homewood Health Centre and three other neighbouring FHTs, we plan to develop a 2018/19 collaborative QIP (cQIP).
Engagement of Clinicians, Leadership & Staff
The Family Health Team has an active Quality Committee that meets regularly to review progress on the Quality Improvement Plan (QIP) and to participate in the development of the annual QIP. The Committee is comprised of clinical and administrative staff, management, and two physicians including the FHT's Medical Lead. Members of the Committee worked together to establish quality improvement initiatives, goals and commitments for the organization for 2018/19. Throughout the year, members of the Quality Committee keep FHT Staff and practice sites up to date by providing progress reports in the FHT-bit newsletter and verbal updates at meetings. The Medical Lead and Executive Director regularly report progress on our QIP to the FHT Board.
Population Health and Equity Considerations
Our quality improvement efforts focus on working collaboratively with our community partners to ensure that our residents have full and equal access to opportunities that enable them to lead healthy lives. Through our Rural Wellington Health Advisory Committee and Health Links funding, a Community Health Needs Assessment for Rural Wellington has recently been completed. The purpose of the report is to identify the strengths and needs of Rural Wellington, which will enable the establishment of wellness and health priorities that will improve the health status of our population. Based on agreed upon priorities, improvement initiatives will be developed with the overall goal of improving the health of rural Wellington residents. A Rural Wellington Community Conversation will be launched in spring/2018 that brings a broad range of community partners together to discuss the health and well-being of Rural Wellington residents and collectively move the Community Health Needs Assessment to action.
Access to the Right Level of Care - Addressing ALC
Minto-Mapleton FHT is helping to ensure patients have access to the right level of care by supporting Alternative Level of Care (ALC) initiatives in our community. For example, the FHT is an active participant in Health Links/Community Outreach Initiative which includes various partners working together to develop coordinated care plans for complex patients. Through the development and sharing of coordinated care plans, programs and supports are being put in place to help residents stay in their own homes.
Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder
Physicians and Nurse Practitioners working in the Family Health Team have taken a number of active steps to support the effective treatment of pain including opioids treatment practices and promoting alternatives to treatments. Some of the steps include:
1) Our Low Back Pain and new Hip/Knee Programs in particular capitalize on the use of the FHT pharmacist to review analgesic regimens.
2) The FHT offers a variety of programs such as Chronic Pain, Fibromyalgia Groups that provide interdisciplinary education and support with the goal of assisting patients to be better able to deal with the physical and emotional problems of living with chronic pain.
3) Our physicians and NPs use a stepwise approach (e.g. WHO ladder) for pain management in acute settings.
4) Our Medical Lead has joined the McMaster Mentoring in Pain Management Program where he is provided with a pain management expert who offers support for complicated patients.
5) We collaborate closely with our community partner (CADS) who offers specialized addiction counselling for our patients.
6) Over this past year, all of our Nurse Practitioners have completed their certificates in controlled substance prescribing.
7) Providers are able to refer our patients to pain clinics where the clinics reinforce interdisciplinary care and offer alternative options.
8) Our EMR contains practice documents to allow our providers to continue to have safe and effective prescribing for patients who have controlled substance use.
9) Our providers have access to Stonehenge which has residential addiction programs for both men and women.
10) We have recently had some conversations with Dr. Yelena Chorney of the Rapid Access & Addiction Clinic to better understand thoughts and challenges related to the development of a Rapid Access and Addiction Clinic (RAAC)-supported range of services for our patients in rural Wellington.
Workplace Violence Prevention
The Minto-Mapleton Family Health Team is committed to building and preserving a safe working environment for its staff. The FHT assesses risk factors in the workplace to identify workers who may be exposed to violence. In conjunction with staff, the FHT's health and safety representatives regularly review our Violence Policy and Program to minimize or eliminate the risks of violence in the workplace. Any incidents of workplace violence are reviewed by the FHT's health and safety representatives to ensure concerns have been dealt with and to make recommendations to reduce or eliminate risk of violence. The FHT is also committed to training and informing staff on the contents of the Violence Policy and Program to ensure that staff are knowledgeable of the risk factors and how to eliminate or respond to violent situations. A health and safety update including any Workplace Violence incidents is provided to the FHT Board at least annually by the FHT's Executive Director.
Contact Information
Shirley Borges, Executive Director, Minto-Mapleton FHT; sborges@mmfht.ca