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Family Health Teams and Family Health Teams and Public Health: Public Health: A new partnership A new partnership

Nick KatesNick KatesLead : Quality Management CollaborativeLead : Quality Management Collaborative

Family Health Teams

152 approved146 business plans approved126 hired some or all staff2.75 million patients

50 more proposed

Vision for Family Health Teams

Excellent Primary Health Care for Ontarians

Family Health Teams

2-25 physicians (some larger)Comprehensive primary health careInterdisciplinary teamsChronic disease prevention and managementHealth promotion and disease preventionSelf-management supportRound the clock coverageIT support

Escaping“The Tyranny of the Urgent”

Thomas Bodenheimer 2002

“Here is Edward Bear,comingdownstairs now, bump, bump, bump,on the back of his head, behindChristopher Robin. It is, as far ashe knows, the only way of comingdownstairs, but sometimes he feelsthat there really is another way, if onlyhe could stop bumping for a momentand think of it”

A.A. Milne 1926

Illustration E.H.Shepard 192614

“Insanity is doing things the way we’ve always done them, and expecting different results”

CHANGING THE PARADIGM

Focus on populationsFocus on longitudinal care / closing the loop (a system of care)Care co-ordinationPatients as partnersAddress all determinants of healthWell-linked with community partners

Everyone is working hard but in isolation

Address quality as well as quantity

Creating a culture of improvement and innovation

Breaking out of our traditional ways of doing things

Take the leap…. we will build our own wings on the

way down.Donald Berwick

Like trying to cross a bridge while we’re still building it

Role of the Quality Management Collaborative

To assist FHTs with

developing and evaluating programsintegrating additional health professionals and building teamsbuilding links with community partnerscreating organisational frameworks to support theseThe Improvement and Innovation agenda

Negotiating the transition to a new model of care

3 Steps for FHTs

Foundation tasksHR / RecruitmentOrganisational frameworks / governanceITSpace

Building teams

Improving the quality of care we provide

How to get there : The approach

A framework / model

Processes and supports to make it work

How will we get there : The Framework / Model

The Care Model

The Improvement Model

The Learning Model (Collaboratives)

INDIVIDUALS AND FAMILIES

Improved clinical, functionaland population health outcomes

HEALTH CAREORGANIZATIONS

Informed,activated

individuals& families

Prepared, proactivepracticeteams

Activated communities &

prepared, proactivecommunity

partners

HealthyPublicPolicy

SupportiveEnvironments

CommunityAction

DeliverySystemDesign

ProviderDecisionSupport

InformationSystems

Ontario’s CDPM Framework

Productive interactions and relationships

PersonalSkills & Self-Management

Support

How will we get there : The Framework / Model

The Care Model

The Improvement Model

The Learning Model (Collaboratives)

How to get there : The Processes

Set up a Quality Improvement Team

Get to know your FHT

Improve access and office efficiencies

On site support

Health promotion and illness prevention in FHTs

Mission

Ontario’s CDPM Model – role of community, populations

Traditional activities

Self management support

Enhanced 18 month baby visit

A community resource

Collaboratives

How to encourage it

Gradual

Change the culture

1 clinician vs all

3 steps

Risk factors (ie obesity)

Antecedents (ie adverse childhood events)

Pre-natal / early cohort

Link with community partners

IT

Incremental

Links with public health

Personal contacts

Presence in FHTs

Formal links

Collaborative programs

Sharing community data

Joint needs assessments