This document discusses a new partnership between Family Health Teams (FHTs) and Public Health in Ontario. There are currently 152 approved FHTs serving over 2.75 million patients. FHTs aim to provide excellent primary health care through interdisciplinary teams of 2-25 physicians providing comprehensive care, chronic disease management, health promotion, and round-the-clock coverage with IT support. The document outlines steps for FHTs to improve quality of care through developing organizational frameworks, building interdisciplinary teams, and building links to community partners. It presents a framework involving a care model, improvement model, and learning model to guide this transition, with the goal of improving clinical, functional and population health outcomes.

2. Family Health Teams and
Public Health:
A new partnership
Nick Kates
Lead : Quality Management Collaborative

3. Family Health Teams
152 approved
146 business plans approved
126 hired some or all staff
2.75 million patients
50 more proposed

4. Vision for Family Health Teams
Excellent Primary Health Care for Ontarians

5. Family Health Teams
2-25 physicians (some larger)
Comprehensive primary health care
Interdisciplinary teams
Chronic disease prevention and management
Health promotion and disease prevention
Self-management support
Round the clock coverage
IT support

6. Escaping
“The Tyranny of the Urgent”
Thomas Bodenheimer 2002

7. “Here is Edward Bear,coming
downstairs now, bump, bump, bump,
on the back of his head, behind
Christopher Robin. It is, as far as
he knows, the only way of coming
downstairs, but sometimes he feels
that there really is another way, if only
he could stop bumping for a moment
and think of it”
A.A. Milne 1926
Illustration E.H.Shepard 192614

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

9. CHANGING THE PARADIGM
Focus on populations
Focus on longitudinal care / closing the
loop (a system of care)
Care co-ordination
Patients as partners
Address all determinants of health
Well-linked with community partners

10. Everyone
is
working
hard but
in
isolation

11. Address quality as well
as quantity

12. Creating a culture of
improvement and
innovation

13. Breaking
out of our
traditional
ways of
doing
things

14. Take the leap…. we will
build our own wings on the
way down.
Donald Berwick

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

16. Role of the Quality Management
Collaborative
To assist FHTs with
developing and evaluating programs
integrating additional health professionals and
building teams
building links with community partners
creating organisational frameworks to support these
The Improvement and Innovation agenda
Negotiating the transition to a new model of care

17. 3 Steps for FHTs
Foundation tasks
HR / Recruitment
Organisational frameworks / governance
IT
Space
Building teams
Improving the quality of care we provide

18. How to get there : The approach
A framework / model
Processes and supports to make it work

19. How will we get there : The
Framework / Model
The Care Model
The Improvement Model
The Learning Model (Collaboratives)

20. Ontario’s CDPM Framework
INDIVIDUALS
AND FAMILIES
Healthy
Public Personal
Policy Skills & Self-
Management HEALTH CARE
Supportive Support
Environments
ORGANIZATIONS
Delivery Information
Community System Provider Systems
Action Design Decision
Support
Productive interactions and relationships
Informed,
Activated Prepared,
activated
communities & proactive
individuals
prepared, proactive practice
& families
community teams
partners
Improved clinical, functional
and population health outcomes

21. How will we get there : The
Framework / Model
The Care Model
The Improvement Model
The Learning Model (Collaboratives)

22. 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

23. 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

24. 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

26. Links with public health
Personal contacts
Presence in FHTs
Formal links
Collaborative programs
Sharing community data
Joint needs assessments