Vascular Health in Southeastern Ontario 2012

Vascular Health in Southeastern Ontario A Focus on Primary Care

September 24, 2012 A report prepared for the Southeastern Ontario Health Collaborative

Special thanks to:

All the members from primary care organizations in Southeastern Ontario who participated in the Environmental Scan and the Primary Care Think Tanks The Southeastern Ontario Health Collaborative including Dr. Adam Steacie, Dr. Hugh Langley, Maureen McIntyre and Julie Gordon for their assistance with this review and active participation in the Primary Care Think Tanks The planning committee for the Primary Care Think Tanks: Dr. Jonathan Kerr, Marg Alden, Stafford Murphy, Lynne Poff, Mary Woodman, Colleen McMahon, Sherri Fournier-Hudson, Dr. Adam Steacie, Dr. Hugh Langley, Mike Bell and Ron Shore

This report was prepared by: The Stroke Network of Southeastern Ontario

For further information, please contact: Colleen Murphy, Regional Stroke Best Practice Coordinator ([email protected])

Vascular Health in Southeastern Ontario 2012

Table of Contents

Executive Summary…………………………………...... 1

Introduction……………………………………………………………………………………………………..... 5 Environmental Scan……………………………………………………………………………………………. 9

Literature Review…………………………………………………………………………………..... 10 Internal Survey………………………………………………………………………………………... 15

External Questionnaire………………………………………………………………...... 15 Face-to-Face Visits………………………………………………………………………………….... 15

Opportunities Identified During Environmental Scan……………………………………………. 22

Think Tanks………………………………………………………………………………………………………… 26

Think Tank Plan……………………………………………………………………………………….. 27

Vision for a Robust Vascular Service……………………………………………………..…… 29

Tools, Resources or Programs that are Working Well…………………………………. 30

What Tools, Resources or Programs are Needed?.……………………………………… 31 Common Elements Related to Top Three Needs…………………………………………. 37

Action Planning………………………………………………………………………………………………...... 38 Conclusion…………………………………………………………………………………………………………… 44

Recommended Next Steps……………………………………………………………………………………. 46

References…………………………………………………………………………………………………………… 47

Appendix A FHTs, CHCs, NP-Led Clinics in Southeastern Ontario………………………….. 52

Appendix B Primary Care Questionnaire……………………………………………………………... 53 Appendix C Environmental Scan of FHTs, CHCs, NP-Led Clinics………………………...... 54

Appendix D Planning Committee for Primary Care Think Tanks…………………………… 58

Appendix E Invitation & Agenda Templates for Think Tanks………………………………... 59

Appendix F Needed Tools, Resources or Programs…………………………………………...... 61 Appendix G 3 Action Plans for 3 Local Areas……………………………………………………….. 69

Vascular Health in Southeastern Ontario 2012

separate Think Tanks involving many Executive Summary different primary care health A recent health profile of Southeastern professionals, administrators and support Ontario continues to report higher than staff from different urban and rural provincial rates for vascular diseases such locations. The main objectives for the ES as diabetes and stroke. The report also and Think Tanks were to discover the reveals higher rates of vascular disease tools, resources, or programs currently in risk factors such as hypertension, obesity place and to help identify primary care and smoking (Statistics Canada, 2012). The needs in relation to vascular health. vascular health profile of the south east Despite the variation in services, region provides the rationale for further programs or systems because of the exploration and review that is detailed in diversity of the community primary care this subsequent report. The solution to serves, there were some commonalities improving vascular health largely lies identified including issues and needs. with primary care and in collaboration with others such as the Southeastern Findings Ontario Health Collaborative (SEO Health Most primary care organizations have at Collaborative), speciality clinics and least one to two vascular disease public health. prevention services on-site. The The SEO Health Collaborative recently consistent services offered include formed in January 2011 as different smoking cessation and diabetes health organizations decided to come education. Many during the ES and the together and determine how best to work Think Tanks indicated their wish to in collaboration with primary care. The expand the services or programs they first priority of the newly formed SEO provide and apply relevant components Health Collaborative was to determine of smoking cessation and/or diabetes how best to further support primary care services to preventing other vascular to improve vascular health. disease risk factors such as hypertension.

First Steps Simplicity and user-friendliness were mentioned over again during the visits Primary care is perceived by many to be and Think Tanks in reference to having fairly complex and is changing at a one integrated electronic medical record remarkable rate. The many new and (EMR) and one evidence-based different functions and services within harmonized vascular disease prevention primary care related to vascular health guideline (i.e., C-CHANGE: Canadian may not be fully understood. In order to Cardiovascular Harmonization of National better understand the nuances within Guidelines Endeavour). primary care it was decided to perform an environmental scan (ES) and host three

Vascular Health in Southeastern Ontario 2012

The common vision for a robust vascular Integration: health service program identified would 6. Develop a user-friendly integrated be one that is patient-centred, equitable, system that incorporates improved accessible, team and community-based access (e.g., EMR) and has one valid with emphasis on self-management. vascular health-related guideline; one Common Needs & Opportunities vascular disease risk assessment tool Identified in the ES and Think Tanks that everyone can agree to use; one clinical flow sheet that captures all Communication & Collaboration: relevant health indicators. 1. Increase sharing of information Determine what vascular health between primary care organizations indicators should be tracked such as lessons learned and tips for consistently. Regular training for all success to initiate, sustain and expand staff to increase comfort with the vascular disease prevention services functions within the EMR system. or programs; and how others Increase access to other clinical tools effectively utilize their EMR (e.g., such as point-of-care blood testing. generate reports and referrals). 7. Develop a person or patient-centred 2. Facilitate consistency such as integrated vascular health service or documentation practices within the program within each primary care EMR. organization encouraging self- 3. Examine innovative ways for sharing management, physical activity, a up-to-date vascular health-related healthy diet and smoking cessation. information, tools, and resources A vascular health program, service or such as a common web site. system should be flexible in order to 4. Continue to improve connections be applicable to a local setting. with groups interested in vascular Components of a vascular health health such as the SEO Health program, service or system could be Collaborative, Public Health Units and modelled after established programs specialty clinics. such as the Global Risk Reduction 5. Increase awareness and promotion of program in the Upper Canada Family established vascular disease Health Team. prevention community services or Given the interest to improve vascular programs to reduce duplication of health, the time seems right to work efforts. Further development of collaboratively and start addressing some partnerships and plans to increase of the prioritized needs identified during physical activity and safe exercise the ES and Think Tanks. Acknowledged programs. advice by some primary care providers was to start with smaller and potentially more doable action plans. Some feasible 2

Vascular Health in Southeastern Ontario 2012

plans to begin with in relation to the 2. Local Action Plans will be followed up needs identified could include: 1) by those engaged and self-identified in collaborative education sessions in developing the preliminary action relation to common interests such as plans made at the Primary Care Think blood pressure management and Tanks. motivational interviewing; 2) support for shared work experience opportunities to 3. The SEO Health Collaborative will enhance information sharing about review this report to guide the focus vascular health programs or services that for a collaborative and supportive are working well; and 3) consideration for partnership with primary care in developing or enhancing local vascular addressing regional concerns and health community resource directories. proposed actions. The SEO Health Collaborative will lead a process to Ultimately, primary care plays a critical identify a consolidated regional action role in ensuring the success of an plan that will guide its ongoing activity integrated and collaborative vascular for the coming year. The intent would health strategy. be to carry on the momentum for Recommended Next Steps improving vascular health by translating the identified prioritized 1. This report will be shared with: needs into actionable plans. This will a. Primary care providers across the be initiated in partnership with the region – including all who Primary Care Lead for the SE LHIN, the participated in the environmental SE Primary Health Care Council and scan and the Primary Care Think associated local primary care leads. Tanks; The Primary Health Care Council will b. The Southeastern Ontario (SEO) validate actionable plans and Health Collaborative including the collaborate on implementation through Primary Care Lead for the SE LHIN its primary care hub network. and each of the Regional Steering Committees of its represented 4. Consideration may need to be given to chronic disease networks; the development of community c. The SE Primary Health Care Council; vascular health tables to support d. The SE LHIN; primary care locally in relation to e. The leads for the Cardiovascular proposed actions in vascular health. Clinical Services Roadmap of the SE This consideration would need to be LHIN and made in alignment with the ongoing f. The Project Manager for the Ontario work of the SE Primary Health Care Integrated Vascular Health Strategy. Council.

Vascular Health in Southeastern Ontario 2012

5. The SEO Health Collaborative is well positioned to become the Regional Vascular Collaborative as described in the August 2012 release of the Integrated Vascular Health Blueprint for Ontario. This will be discussed with the SE LHIN.

6. The SEO Health Collaborative will build communication with the Ontario Integrated Vascular Strategy Project Manager to ensure that areas outlined in this report that align well with the provincial strategy be referred on.

Vascular Health in Southeastern Ontario 2012

Introduction Type 2 Diabetes (Ontario MOHLTC, 2010). Many are predicting our children may see Many of us know someone who has had a a reduction in life expectancy that has not stroke or a heart attack. It is also well- been present for over two centuries (Lee et known that cardiovascular disease is al.). Some people develop new vascular linked to high rates of death, disability disease(s) and experience repeated and health-related costs (Carter et al., 2009). hospital admissions (Hall et al., 2012). A An estimated 1.6 million Canadians are common combination is heart disease and living with heart disease and stroke (Public diabetes (Ontario MOHLTC). Hypertension is Agency of Canada, 2009). Globally about the most common reason for a visit to 29.2% of deaths result from different primary care providers. forms of cardiovascular disease; many of

them are preventable (WHO, 2010). Vascular diseases affect blood

vessels. They can include What is hopeful is despite vascular certain heart diseases such as disease being such a burden on coronary artery disease, kidney society it is largely amenable to

positive change through prevention disease, stroke, diabetes and

(Passey et al., 2012) dementia. These diseases are

different but are linked by

For the purpose of this report, it was common risk factors such as decided to move beyond what is known hypertension, physical as cardiovascular disease and include all inactivity and poor nutrition. vascular-related diseases such as stroke, kidney disease, diabetes and certain heart Reports indicate that Southeastern diseases such as coronary artery disease. Ontario (SEO) has higher than provincial Vascular diseases affect the body rates for many vascular diseases such as differently but share common risk factors. diabetes (SEO: 8.7%; Ontario: 6.8%) and It’s the related risk factors that have led related risk factors such as hypertension many to working together to prevent (SEO: 19.8%; Ontario: 17.4%) (Baines et al., 2005; vascular disease. Kapral et al., 2011; Hall et al., 2012; Statistics Canada, 2012). Lee et al. (2009) indicated that risk factors such as hypertension and obesity Table 1 from Statistics Canada (2012) are on the rise for all ages and ethnic highlights the incidence and regional groups in Canada. Young people are at variations in vascular diseases and risk increasing risk for vascular diseases (Lee factors. These results have provided the et al.). One disturbing trend is an increase main impetus for this report. in the number of children diagnosed with

Vascular Health in Southeastern Ontario 2012

Table 1 Vascular Health Indicators (Statistics Canada, 2012) Indicators HPE KFL&A LLG South East Ontario LHIN Health Condition/Health Behaviour Obesity % 23.6 22.6 20.2 22.0 18.0 Diabetes % 8.0 8.9 8.5 8.7 6.8 Hypertension % 23.0 18.7 18.4 19.8 17.4 Current daily 23.0 15.7 21.6 20.0 14.5 smoker % Heavy Alcohol 18.6 17.1 19.5 18.3 15.9 drinking % Perceived life 24.8 26.9 25.0 25.8 24.0 stress % Physical Activity: 57.8 63.4 59.6 60.5 50.5 Moderately Active or Active % Hospitalized 241 210 212 218 207 Myocardial Infarction (per 100,000 population) Hospitalized 140 108 133 127 125 Stroke (per 100,000 population) Health System Coronary Artery 101 101 94 103 68 Bypass Graft (per 100,000 population) Percutaneous 214 202 224 207 174 Coronary Intervention (per 100,000 population) Mortality Circulatory 179.1 162.3 178.1 174.7 155.6 Diseases (per 100,000 population) Community Age > 65 % 16.9 15.2 17.2 16.4 12.7 Rural Area 48.2 36.9 58.7 45.9 14.9 Population Note: Vascular-Related Health Profile adapted from “Health Profile, June 2012: South East Health Integration Network Ontario” by Statistics, Canada, 2012. Retrieved from www.statcan.gc.ca

Note: HPE: Hastings & Prince Edward Counties; LLG: Lanark, Leeds & Grenville Counties; KFL&A: Kingston, Frontenac, Lennox & Addington Counties

Vascular Health in Southeastern Ontario 2012

Lately there is a shift in focus from Primary care is considered the first point hospital care to primary health care. of entry into the health care system and Primary care is in the spot light with the addresses many health care needs threat of a “storm” brewing in light of an including chronic disease prevention and ageing baby boomer generation and management (Khan et al., 2008). reported increase in physical inactivity Much has been written about chronic and poor diets. More attention is being disease prevention. This report will placed on health promotion and concentrate on one related group of prevention initiatives within primary care chronic diseases known as vascular to help weather this storm. More can be diseases. It is anticipated that some achieved by prevention than treatment lessons learned can be applied to efforts alone as noted in the1974 Lalonde report. related to chronic disease prevention. In 2002, Roy Romanow recommended more emphasis on promoting a healthy Over time primary care has become more lifestyle and disease prevention in order complex, changing and expanding rapidly to improve health outcomes and decrease (Australian Institute for Primary Care, 2008). the burden on health care. A local Stroke Self-management initiatives are front and Prevention Clinic report indicated that center as the system moves away from 30% of patients presented with diabetes disease-centred care to person-centred and of those, 30% were undiagnosed with care. One such initiative is the launch of diabetes. The latest INTERSTROKE study the Ontario Diabetes Strategy to help (2010) indicated that five risk factors empower patients (Ontario MOHLTC, 2010). (hypertension, physical inactivity, current The Excellent Care for All Act (2010) smoking, poor diet and abdominal emphasizes that patients and caregivers obesity) account for 80% of the global have a significant role. It is the patient risk for stroke (O’Donnell et al., 2010). who has the greatest role to play in the prevention of vascular diseases. The Health promotion and disease prevention evidence suggests a “partnership” of individuals are considered important between patient and provider leads to parts of primary care (Hogg et al., 2009). A better outcomes (Walker, Swerissen & strong primary care component in health Belfrage, 2003; Weeks et al., 2003). care has a positive effect within health Improvements within primary care can care systems including lower costs only benefit others along the continuum (Starfield & Shi, 2001; Australian Institute for of care. Primary Care, 2008). Primary care is essential as it provides early identification and management of “Everyone is a preventable diseases and improves access to health services (Starfield, Shi & Macinko, 2005). patient”

Vascular Health in Southeastern Ontario 2012

The Ontario Ministry of Health & Long Collaborative in January 2011 includes all Term Care (2010) lists successful the Southeastern Ontario regional chronic characteristics for health promotion and disease programs including primary care disease prevention programs: representation (e.g., the primary care physician lead for the Local Health “Addressing measurable and Integration Network of Southeastern modifiable risk factors Ontario). The purpose of this Being pro-active Collaborative is “to provide a forum for Using multiple strategies utilizing knowledge exchange and joint planning in best evidence best practice implementation among the Integrating and collaborating on South East regional networks and planning delivery of services groups associated with various chronic Empowering people in relation to diseases” (SEO Health Collaborative, 2011). The self-management first priority the SEO Health Collaborative Evaluating programs for identified was to work with primary care effectiveness” to reduce vascular disease risk factors. Initial “steps” include: Recognizing common related risk factors for vascular disease, many have been Identifying tools, resources, working together including primary care programs and systems currently in providers and other health care providers place across Canada to integrate their efforts Discussing how to enhance these for disease prevention (Change Foundation, tools, resources, programs and 2010; Wolbeck Minke et al., 2006). Pooling systems and determine together expertise and different collaboratively what is needed to perspectives and ideas leads to a synergy further support vascular health in that can achieve more effective results primary care than working alone within a single Identifying from primary care organization or group (Wolbeck Minke et al.). initial steps for local and regional Essentially through integration and action collaboration of efforts duplication and costs are reduced and positive outcomes This integrated approach is patient or are achieved. person- focused and aligns with many other plans such as the Ontario Integrated Health organizations in Southeastern Vascular Health Blueprint, Canadian Ontario decided to come together and Heart Health Strategy Action Plan, the determine how best to work in Ontario Stroke Network Strategic Plan, collaboration with primary care to the Ontario Chronic Disease Prevention support vascular health locally and and Management Framework and the regionally. The newly formed World Health Organization’s priorities Southeastern Ontario (SEO) Health

Vascular Health in Southeastern Ontario 2012

(Bacon et al., 2009; Garcia & Riley, 2008; OSN, “what’s really going on” (Katz 2011; WHO, 2005). The ongoing work of the SEO Health Collaborative including & Mishler, 2003; Pillay, 2003). Primary health primary care and public health will care is complex and when caring for inform and advise the Ontario Integrated clients and working with many health Vascular Health Strategy. care professionals within different health systems, one needs to consider unique The many different functions, services and different cultures, behaviours and and programs within primary care as it perceptions. An environmental scan (ES) relates to vascular health promotion and is a useful tool for health decision-making disease prevention may not be fully by increasing awareness and predicting understood. Two initial “steps” have been trends (Graham, Evitts & Thomas-MacLean, taken to better understand the nuances 2008). To help organize the ES, the Choo within primary care and to begin to 2001 framework was chosen. The Choo determine how best to work with primary (2001) framework recommends an active care to support their efforts. The first step and “intrusive” search mode in order to in understanding the complexity within fully assess for disparities, similarities primary care related to vascular health and needs (Choo). An ES of primary care was to perform an environmental scan organizations would be the springboard (ES). An ES was conducted as a first step to increase awareness and understanding in providing direction for future plans of vascular disease prevention activities related to vascular health. The within primary care. environmental scan consisted of a literature review, an internal survey, Ultimately, the knowledge obtained about external questionnaire and on-site visits. vascular health promotion and prevention within primary care practices The second step involved hosting three would be beneficial for the SEO Health separate primary care Think Tanks to Collaborative in generating action plans explore collectively vascular-related for collaborative opportunities with services that are working well and to primary care. further identify local needs. The identified needs were ranked according to The Environmental Scan a voting system and participants involved: discussed some possible strategies to address those prioritized needs. Literature review Internal Survey Environmental Scan External Questionnaire

In order to understand more about Semi-structured diversity, complexity, truths and realities interviews at primary within healthcare it helps to determine care organizations 9

Vascular Health in Southeastern Ontario 2012

In order to prepare for the on-site visits, a Primary Care & Delivery Models literature review was conducted to help understand the general functions of the Primary Health Care is considered the different delivery care models, to increase main point of contact between the patient knowledge about vascular disease and the health care system (Health Force prevention activities within primary care Ontario, 2007). There are different delivery and to explore possibilities of others models of primary health care within integrating their efforts in relation to Ontario such as Solo practices, Family prevention. Health Organizations (FHO), Family Health Teams (FHT), Family Health The literature review mostly Groups (FHG), Nurse Practitioner (NP)- involved a review of “grey” literature. Led Clinics, Community Health Centres Reports, plans and websites were (CHC) and Family Health Networks reviewed from Canada, the United States, (FHN). For practical and logistical reasons the United Kingdom and Australia (e.g., FHTs, CHCs and NP-Led clinics were The Change Foundation, Canadian Health visited. Council, Ontario Ministry of Health and LTC, the Ontario Chronic Disease A review of various websites including Prevention Alliance, Chronic Disease the Ontario Ministry of Health and Long Prevention Alliance of Canada, British Term Care (MOHLTC) was conducted to Heart Foundation, National Health understand the various associated Services (UK), American Heart and Stroke functions. Associations and the Department of FHTs were developed to improve access Health and Ageing from the Australian to primary care, help patients navigate Government). through the health care system and offer The literature review also involved one entry point to meet complex needs. searching for evidence-based practices FHTs are groups of health care related to vascular health; related professionals such as physicians, nurse environmental scans conducted; and practitioners, nurses, dietitians and social integrated vascular health strategies. workers who work collaboratively to This involved a search of the Cochrane provide patient-centred primary care. Library, CINAHL, PubMed and Ovid One of the roles of FHTs identified by the MEDLINE databases for additional Ontario MOHLTC (2010) is to develop and information about prevention practices provide chronic disease management within primary care. programs including the promotion of self- care. A “Family Health Team Guide to Chronic Disease Management and Prevention” provides general prevention strategies and suggested resources.

Vascular Health in Southeastern Ontario 2012

Currently, there are fifteen FHTs in the care delivery groups is to provide care region of Southeastern Ontario (see closer to home and to adapt health care Appendix A). according to the current needs of the local communities. All provide, to some extent Community Health Centres (CHCs) are system navigation, health promotion, organizations providing comprehensive prevention of chronic diseases, facilitation primary care and health promotion of self-management and improved access programs and services in diverse such as offering extended hours of communities (Ontario MOHLTC, 2001). They practice. are important for their contributions to a healthy community. One of the main roles There will be variance in services and of CHCs is to improve equal access to programs because of the diversity of the health services for all people and link population each primary care clients to community and social services organization serves. (Ontario MOHLTC). One of the principles of Prevention CHCs is for the client to take responsibility for their own health. CHCs The literature review also involved a offer a broad range of community support search for vascular disease prevention services such as the “Good Food Box” practices within primary care. The review program. There are five CHCs currently in began with a search for stroke prevention operation (see Appendix A). initiatives within primary care. The review of the literature revealed a paucity Nurse Practitioner-Led Clinics are of information specifically about stroke operational in Belleville and Smiths Falls prevention programs within primary care (see Appendix A). With the Nurse organizations in Canada. One Irish study Practitioner (NP) led model, the NP is the (2009) looked at primary care ensuring lead provider of primary health care. optimal stroke prevention (Whitford et al., However, the NP-led clinic operates as a 2009). The researchers hypothesized that team with other health care professionals effective primary prevention strategies such as pharmacists, dietitians, nurses such as treatment for hypertension and and collaborating physicians. The NP-led atrial fibrillation are well understood but Clinic improves access to primary and may not be implemented fully in general family health care for those who do not practices (White, Feely & O’Neill, 2004). have a primary care provider. Whitford et al. claimed that general These different types of primary care practitioners could implement secondary delivery groups are person or patient- prevention measures for stroke. The centred and bring together different study reported on an environmental scan health care professionals to provide a (ES) of general practices to determine team approach for enhanced coordinated stroke prevention programs in place. The services. The goal of the different primary ES revealed that most general practices

Vascular Health in Southeastern Ontario 2012

had good access to nurses and with successful interventions. For physiotherapists but not to dietitians, example, in South Korea, there is social workers, speech language emphasis on promoting local foods and pathologists, psychologists and traditional cooking methods; in Japan occupational therapists (Whitford et al., their campaign on sodium reduction has 2009).The majority of barriers identified helped lead to stroke rates decreasing by for primary care to implement stroke more than 70%; and in Mauritius, prevention were “inadequate time, cholesterol levels were reduced with a resources, funding and lack of risk factor switch in cooking oil from palm to soya protocols” (Whitford et al.). Many general bean (WHO, 2010). practices in the UK have a stroke/TIA In 1999, Joseph et al. indicated that to registry and engage in annual audits that achieve control of vascular risk factors an have revealed a steady improvement in introduction of incentives and a team prevention (Simpson et al., 2006). approach may be helpful. A study by With regards to cardiovascular disease Schutze et al. (2012) relayed that a prevention within primary care, research lifestyle modification program in general indicates that certain factors can lead to a practice is feasible for the prevention of prevention program’s success (e.g., local vascular diseases but requires a flexible expertise, engagement of physicians, format to be adapted to the local setting. presence of a pharmacist and a balance High risk patients with already identified between flexibility and standardization) vascular diseases benefit by combining (Carter et al., 2009). Cardiovascular disease multiple prevention approaches such as risk can be reduced with primary care medications, diet and exercise (Hackam & interventions based on a Spence, 2007). multidisciplinary approach (Colle & Integrated Vascular Disease-Related Brusaferro, 2008). One study indicates that Prevention Programs in Primary Care strong primary care is associated with improved cardiovascular disease Other regions in Ontario are starting to prevention (van Lieshout et al., 2009). Some invest in integrated and collaborative studies have identified nurse–led vascular disease prevention strategies programs as playing an important role in such as the Central East and Champlain cardiovascular disease prevention in LHIN areas. Lessons learned from these primary care (Voogdt-Pruis et al., 2011). initiatives are to involve all vascular- related organizations, other team The WHO Global Strategy for members and effective utilization of the Cardiovascular disease prevention and control focuses on “diet, physical activity electronic medical record. and tobacco consumption” (WHO, 2010). The Peterborough Networked Family The WHO Global Strategy lists countries Health Team developed a “Comprehensive

Vascular Health in Southeastern Ontario 2012

Vascular Disease Prevention and The Centre for Rural and Northern Health Management Initiative” (CVDPMI). The Research at Lakehead University goal of CVDPMI is to streamline care, conducted an environmental scan for the prevent vascular-related diseases, North West Local Health Integration improve outcomes and lower costs (Central Network (LHIN) on chronic disease East LHIN, 2008). The proactive and prevention and management initiatives. collaborative initiative involves the One program the reviewers examined Peterborough Networked FHT, was the prevention initiative from the Cardiologists, Nephrologists and many 1972 “North Karelia” project (Finland) other partners including industry. The involving cancer, diabetes and heart initiative complements the disease. The program had smoking recommendations of the “Canadian Heart cessation, dietary and rehabilitation Health Strategy Action Plan”. support. Results of the integrated Karelia Project showed a 50% reduction in The Champlain Cardiovascular Disease cardiovascular and cancer mortality in (CVD) Prevention Network has the community (Minore, Hill & Perry, 2009; implemented the “Improved Delivery of Puska, n.d.). The ES discusses challenges for Cardiovascular Care (IDOCC)” program to Ontario in developing integrated models help primary care providers with in relation to geography and diversity. prevention. The program relies on The ES of the North West found that the facilitators who act as resources for majority of FHTs and CHCs have chronic primary care practices. These facilitators disease prevention and management help primary care providers integrate programs in place. There were many into their practice the Champlain Primary examples of primary care organizations Care CVD Prevention & Management creating a chronic disease network Guideline for Coronary Artery Disease, working with others such as community Peripheral Vascular Disease, Stroke and agencies and cardiac rehabilitation. The Diabetes (Champlain CVD Prevention Network, northwestern primary care organizations 2009). The guideline includes a risk factor assist their patients to navigate the health screening tool, recommended targets, and care system and refer clients to management strategies for hypertension, appropriate community resources for dyslipidemia, detection of chronic kidney further management of their chronic disease, smoking, weight and physical disease such as diabetes education. In inactivity. The guideline also includes tips some areas, nurses were educating for self-management and a list of themselves on chronic disease community resources such as a management such as asthma and would Hypertension Clinic. share this knowledge with their Other Environmental Scans on colleagues (Minore, Hill & Perry, 2009). Most Prevention within Primary Care of the primary health care areas that were scanned in the North West have

Vascular Health in Southeastern Ontario 2012

implemented “The Stanford Chronic The Ontario Chronic Disease Prevention Disease Self-Management” program Alliance conducted an environmental (Minore, Hill & Perry, 2009). The ES also noted scan in 2005. Lyons and Kugl (2005) that many of the electronic record noted nine strategies as a result of their keeping systems were unable to scan: planning, policy development, “communicate” with each other. communication, enabling system, research and development, human In 2002, an environmental scan “Health resources development, Promotion and Chronic Disease Prevention dissemination/deployment, monitoring Collaborative Initiatives” was completed and surveillance and provincial for the Canadian Diabetes Association to indicators. Some observations related to support an integrated chronic disease barriers were made such as a lack of prevention strategy for Alberta (Blair & consistent social marketing, competing Chenier, 2002). At that time, it was noted research priorities and a lack of a healthy that cardiovascular disease, cancer, public policy. chronic obstructive pulmonary disease and diabetes are connected by common An environmental scan was also preventable lifestyle risk factors (Blair & conducted of public health and primary Chenier). One integrated initiative care in Ontario in 2009 (Valatis et al., 2009). highlighted in the ES was the global WHO, The ES discovered processes required to “Countrywide Integrated Non- enhance collaboration between public communicable Disease Intervention” health and primary care. Valatis et al. also (CINDI) program. CINDI was initiated in discovered that collaboration was taking 1982 and currently includes 20 countries. place (e.g., HPE Health Unit and the Prince This program looks at reducing common Edward FHT related to smoking risk factors such as smoking, poor diet, cessation). alcohol abuse, physical inactivity and The Change Foundation (2010) noted that stress. Blair & Chenier noted in their ES a there is collaboration of primary care and disconnection between specialist groups, other health care providers in many primary health care, public health and communities across Ontario. If the vision health promotion systems. The review is clear and staff are made to feel part of noted that a successful integrated system the decision-making process and had involves wide representation with some responsibility for some component commitment to partnership, realistic of prevention, staff would be willing to timelines, doable plans, affordable adapt and integrate prevention into their functions, good communication links, daily practice (Nemeth et al., 2008). Nemeth shared and sustainable resources, a et al. claimed that “translating research common purpose and vision, and an into practice has been difficult to achieve evaluation and monitoring process (Blair & Chenier) by many health services leaders, despite

Vascular Health in Southeastern Ontario 2012

tools such as benchmarks and clinical The external questionnaire was guidelines”. The electronic medical record developed by different health care (EMR) is a tool that might help. EMRs are professionals on the Stroke Network SEO useful for recording notes, internal team. The questionnaire is found in messaging, reminders and tracking Appendix B. The questions were tailored patients (e.g., EMRs can identify clients to increase knowledge and awareness of with hypertension that have not been the functions and services of CHCs, FHTs seen in the prior 6 months) (Ornstein, 2001). and NP-led clinics. The questionnaire EMRs can have evidenced-based clinical helped guide the site visits and was not guidelines or algorithms embedded in totally adhered to at times as the their systems. conversation may have led to more meaningful information. The literature review supports an integrated strategy for risk factor Face-to-face visits reduction of vascular diseases. Face-to-face site visits were essential in

order to gain a more in-depth perspective. Internal Survey Visits to 13 FHTs, 5 CHCs and 1 NP-Led An internal survey was conducted with a clinic and three informal discussions with small number of members of the Stroke primary care providers contributed more Network SEO team (n=8) and determined details for the environmental scan (ES). the feasibility for conducting the Visits are planned for the remaining two environmental scan. The survey results FHTs and one NP-Led Clinic. The visits also supported the objective of increasing awareness of the functions and services began in June 2010 and took place over within primary care as it relates to two years. One to ten members from each vascular health. team participated based on their availability on the day of the visit. The External Questionnaire visits involved broad representation from various organizations such as family Location Electronic Record Contact (s) Links with physicians, nurse practitioners, dietitians, community/rehab nurses, social workers, administrative Team Members Community support staff, administrative leads, resources system navigators and pharmacists. One Functions and Links with specialty services clinic to two members from the Stroke Network Vascular disease Motivational SEO team visited the organizations. prevention services Interviewing Risk Assessment Education needs Depression Screen Issues

Vascular Health in Southeastern Ontario 2012

contact volunteered responsibility for the dissemination of educational opportunities, guidelines and other pertinent information to the rest of their team. One to five contacts were established at each primary care organization.

Team Members

All of the primary care organizations visited have at least an administrative lead, support staff, physicians, nurse practitioner(s) and nurses. This group of The face-to-face visits captured several professionals is the constant throughout elements including meeting the objective the various different primary care to increase awareness of the various delivery groups. For many of the services, programs or systems related to organizations, there was noticeable vascular health (e.g., smoking cessation, variation in the number and type of diabetes education, hypertension health professionals and ancillary staff. In management and depression screening). addition to the variability of the number The following is an overview of the visits and different team members per and is also summarized in Table 2. A more organization, many organizations detailed description is found in Appendix mentioned being in “transition” with staff C. For this report, “patient” and “client” leaving. Some voiced the challenges are used interchangeably. experienced in maintaining their “usual” Location quota of different staff (e.g., dietitians, physicians). Besides the “usual” Each primary care organization visited complement of staff (e.g., physician, has at least two satellite locations in nurse, receptionists, support staff, nurse addition to the “main” site with a range of practitioner, dietitian and social worker) one to six locations. Some staff “cross- one might discover at a primary care cover” and work in all locations such as organization, some other members allied staff (e.g., social workers and depending on the community and clients’ dietitians). needs (e.g., pharmacists, system Contact navigators, occupational therapists, physiotherapists, psychologists, data It was necessary to establish at least one coordinators, kinesiologists, respiratory contact at each primary care organization therapists, physician assistants, practical in order to sustain ongoing assistants, nutritionists, health promoters communication and collaboration. The

Vascular Health in Southeastern Ontario 2012

and health educators). Some primary care Care, Well Woman program, Memory organizations share human resources Clinic, Wound Management Clinic, Asthma (e.g., psychiatry) and some physicians Clinic and a Falls Prevention Clinic). have partnered with a local CHC and In addition to the many services offered arrange visits with their clients and utilize by different primary care organizations, the space and services provided. some services are related to chronic Functions disease management such as “Living well with Diabetes” and “Living Well with a The functions of the various organizations Chronic Condition”. Both programs are appear to align with those previously offered for six weeks and include outlined by the Ontario Ministry of Health medication “how-tos”, relaxation & Long Term Care. These functions techniques and tips on eating well. include primary health care, health promotion and chronic disease Some primary care organizations have a prevention and management. Many to television in their waiting room set-up nearly all of the organizations referred to with health promotion messages and servicing a large geographical territory information about on-site prevention and many people with a lower programs. During one of the visits, socioeconomic status. Some expressed arthritis and asthma information was challenges encountered with apparent displayed. Most primary care high illiteracy rates. Mental illnesses (e.g., organizations have a web-site displaying suicide rate) appear to be one of their on-site services and programs for clients. main issues and staff present during the Many of the websites have a link to a visits expressed appreciation for having calendar of upcoming prevention-related social worker(s) on-site and the support events. Some of the web-sites have of a psychiatrist or a psychologist. One of recommended links for clients to the primary care organizations reported organizations such as the Heart & Stroke having a “collaborative mental health Foundation. model”. Vascular Disease Prevention Many of the primary care organizations To assess for client’s risk for provide a variety of support services. cardiovascular disease, most to nearly all Some CHCs offer an extensive list of are utilizing the Framingham risk services for their clients and families (e.g., assessment tool. For the environmental Living Well with Pain, Managing Powerful scan, inquiry about depression screening Emotions, Senior’s Wrap Around-helps was included given the relationship with seniors stay at home longer, Mindfulness, vascular health. Some of the staff (e.g., Well Woman, Community Kitchens and social workers and NPs) referred to using Good Food Box programs). FHTs are also the PHQ-9 (Patient Health Questionnaire) offering some services on-site (e.g., Foot

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to screen for depression. One social organizations provide all what is worker indicated that this tool is considered to be essential vascular embedded in their EMR. Most primary disease prevention services (e.g., care organizations claimed to have at hypertension, diabetes, smoking cessation least one to two services, programs or and anticoagulation management). In clinics related to vascular disease some primary care organizations, one prevention (e.g., smoking cessation and “chronic disease” prevention nurse diabetes education). Those that did not manages or leads all of these services. have organized services or programs Despite being led by a nurse many were usually the “newer” organizations. expressed that it is a “team” effort with These organizations expressed their the various vascular health related intentions of providing vascular disease services. Two primary care organizations prevention services once staff received indicated that their anticoagulation clinic required training (e.g., smoking cessation is led by a pharmacist in collaboration and diabetes education). Two “smaller” with other members of the team. Many organizations reported not having a have indicated in relation to healthy separate service or program devoted to lifestyle programs being offered, it’s a prevention but having a “system” in place. combination of group and individual They indicated incorporating vascular counselling that is perceived to produce disease prevention within their individual optimal results. One primary care everyday practices. organization’s vascular health program is linked to their “Global Risk Reduction” Nearly all of the primary care program with services led by different organizations have a diabetes education members of the team. program led by a nurse or a nurse and dietitian. In one organization a nurse A few primary care organizations works in collaboration with a pharmacist particularly the CHCs offer on-site to lead the diabetes program. exercise programs. Many of these organizations have walking programs Many of the staff in all of the primary (e.g., pole walking). Some organizations care organizations have had training in have combined nutrition counselling with motivational interviewing and some have exercise into a “healthy lifestyle” program undergone the “Choices and Changes” and have utilized the “Eat Well and be training. Some primary care providers Active” educational toolkit from Health expressed great support for self- Canada. These programs are led by a management programs and one FHT nurse and dietitian and one FHT reported indicated that their clients have access to positive outcomes as a result of this parts of their electronic record and program. update their blood work levels themselves (e.g., lipid levels). Some

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“It’s great to hear that primary care is pressure monitoring with ambulatory offering weight control and exercise devices and others provide more of a programs. Of particular concern lately is “program” including education led usually that many people I see are overweight and by a nurse. The program is linked to are not active. These two health related other lifestyle programs such as behaviours should be at the top of a list of relaxation programs and nutrition priorities” (Local Specialist, June 2012) counselling and to other health care professionals depending on client needs Most of the primary care organizations (e.g., financial difficulties and poor diet). visited have at least one staff member One noted successful primary prevention trained in smoking cessation. Two newer program related to hypertension is led by organizations were planning to send their an RPN. Primary care providers refer staff for training. Some of the primary patients with one elevated blood pressure care organizations are involved in the reading to the RPN who provides blood STOP study. Many staff participated in the pressure monitoring and health Ottawa Heart Institute Smoking Cessation promotion education for a period of time. training program and some have She refers to other health professionals completed the CAMH (Centre for such as a dietitian or nutritionist for Addictions and Mental Health) Smoking nutrition counselling and a social worker Cessation T.E.A.C.H. program. Two FHTs for stress management. have expressed that they put their emphasis on smoking cessation and have Some primary care organizations have noted good results. However, they indicated success with their on-site expressed an interest in developing other anticoagulation service utilizing point-of- services besides smoking cessation. Some care testing (INR monitoring). One FHT stated that they could apply the principles studied their service and noted a 13.7% and lessons learned in relation to increase in the number of clients in the smoking cessation to other vascular risk therapeutic INR range. With traditional reduction strategies. Many smoking methods, people would have to wait for cessation programs are led by a nurse but their results increasing their risk and one of the FHTs has a social worker possible loss to follow-up. The FHT that leading the program. Some have reported positive results had to abandon mentioned partnering with their local their program related to lack of funding Public Health Unit in relation to smoking support for the test strips. cessation especially regarding high-risk Two rural FHTs reported specialists clients such as pregnant women. outside of their community providing on- Some of the primary care organizations site regular visits for clients (e.g., internist provide a hypertension clinic or blood and a cardiologist). pressure program. Some offer blood

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Of interest in relation to cardiovascular organizations in this region in relation to disease is a dental service being provided tracking chronic diseases. at CHCs. Some offer oral hygiene to clients including children that are unable to Referrals to Speciality Clinics cover the associated costs of receiving Most organizations are aware of and refer this service. their clients to speciality clinics closest for the client (e.g., Congestive Heart Failure A few primary care organizations indicated they were able to abstract their and Stroke Prevention Clinics). data and tracked health outcomes. Two Links with Community Agencies and FHTs reported the ability to generate pre- Rehabilitation populated referral forms containing the client’s demographic and relevant clinical Some of the organizations visited refer information. One FHT has many of the their clients to support services off-site referral forms embedded into the EMR within their local communities (e.g., including the required destination contact physiotherapy clinics, community support information. A few organizations have agencies, YMCA, pools, Fitness Gyms, provided their clerks with directives to Recreation Centres, “Wellness Clinic” and order repeat blood work that is a “Get with It” walking program). Some automatically prompted through the EMR. organizations have partnered with What has generated great value in community agencies particularly relation to the EMR is a result of recreation centres to provide education organized annual training and refreshing sessions about prevention. One staff for all staff members. Some staff members member has proposed utilizing space un- have taken initiative due to their own used in their local community to support interest and have helped built reports an exercise program. Some have that can be generated by other team partnered with local gyms, pools and members (e.g., HbA1c and blood pressure recreation centres in relation to readings of their clients). Some improving physical activity for their organizations have a “data coordinator” clients. Some also are linked and refer to who helps manage the EMR and facilitates the closest cardiac rehabilitation centre. the abstraction of pertinent data. One CHC

indicated their ability to monitor data for Emergency Department visits and are able to identify any possible gaps in their services. One FHT mentioned the “Canadian Primary Care Sentinel Surveillance Network” or CPCSSN study that seems relevant for primary care

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Table 2 Overview of Regional Face-to-Face Visits

Team Members Functions Vascular Health Programs/Services Client ▪Primary health care ▪Hypertension (e.g., HIM/H&S Foundation) Administrative Lead ▪General family practice ▪Anticoagulation (e.g., program coordinated Physician ▪Improve access (e.g., extended by a pharmacist) NP Nurse hours & telephone advice) ▪Diabetes Education +/-Dietitian ▪Health Promotion ▪Diabetes Services(e.g., Rideau Valley +/-Nutritionist ▪Chronic Disease Prevention & Diabetes) +/-Health Promoter Management ▪Smoking Cessation +/-Health Educator ▪Dental Health +/-PT +/-OT ▪Provide support services- ▪Exercise (e.g., Senior’s Fitness) +/-SW +/-RT Examples: “Senior’s Wrap ▪Healthy Nutrition (e.g., “Craving Change”) +/-Psychiatrist Around”, “Living Well with ▪“Healthy Lifestyle” (adaption of Health +/-Psychologist Chronic Conditions”, “Well Canada’s Eat Well & Be Active education +/-Pharmacist Woman-Take 5”, Community Toolkit) +/-Kinesiologist Kitchen”, “Memory Clinic”, +/-Data Coordinator “Managing Fatigue”, “Aboriginal +/-Practical Assistant Health”, “Understanding Comment: “would like to integrate +/-Physician Assistant Depression” programs prevention into their practice with less +/-Clinical Resource emphasis on referral out to programs” Referral to Specialty Links with Community Agencies Educational Interests Clinics & Rehabilitation ▪Most aware of Examples: Wellness Clinic, ▪Hypertension speciality clinics walking programs such as “Get ▪Depression ▪Request to link more With It”, local recreation centre, ▪Behaviour Change & Motivational with speciality clinics Land-O-Lakes Community Interviewing Services, Cardiac Rehabilitation. ▪Current evidence-based guidelines related A couple of comments: to prevention “effectively manage Comments: “rural area does not CDPM on their own” have adequate community exercise or recreation program”; “would like to know more about community support services ”

Note: Visits took place 2010-2012; see Appendix C for more detailed information; Request for further details: contact [email protected]

Note: NP: Nurse Practitioner, OT: Occupational Therapist, PT: Physiotherapist, SW: Social Worker, RT: Respiratory Therapist, HIM/H&S Foundation: Hypertension Management Initiative from the Heart and Stroke Foundation, CDPM: Chronic Disease Prevention and Management

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Opportunities Many especially reported that they Some of the barriers and enablers perceive an increase in the number of identified during the on-site visits to older clients with multiple issues. In this implementing vascular disease situation, many expressed the need for prevention strategies within primary care improved linkage with others in relation align with the literature review. Time and to secondary prevention (e.g., speciality resources were recounted over again clinics and community support services). during the visits. One of the barriers Some expressed that they are seeing more identified in relation to resources seems obese clients, especially young obese to occur when organizations are in clients and more clients with diabetes “transition” or staff are “coming and especially young clients with diabetes. going”: Some requested guidance about what “We’d really like to have more prevention program or service should be their focus services but struggle with just keeping up in relation to vascular disease prevention with the day-to-day routine and don’t given their limited resources. really have extra time to fit in health Enablers identified also correspond with promotion activities” the literature such as more reliance on One unexpected barrier perhaps to different team members, collaboration of consolidating or integrating efforts efforts and better use of one’s electronic expressed was the inherent lack of trust medical record. toward “outside” organizations that wish One main opportunity to explore is an to help. Another barrier identified idea raised that rang consistent bells in repeatedly was “too” many evidence- other organizations is less reliance on based practice guidelines and not having outside organizations for services that the time to keep up with all the latest can be provided on-site. Many expressed evidence. interest in a global vascular disease Many expressed that the social prevention service within their own determinants of health are an important primary care organizations. Working consideration in relation to prevention. together can support efforts to bring The recent “POWER” study continues to vascular health closer to home for people reaffirm consideration of socio-economic in local communities. status when planning prevention “Our patients are not willing to travel programs (Bierman et al., 2009). down the road a short distance as many “The cost of ASA is an issue for our patients. cannot afford gas and have limited Some of our patients just stop taking their finances and really they just won’t go” (NP medications because they can’t afford from FHT) them” (NP from FHT)

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If the program is simple and How to expand or grow their integrated, there is more chance of prevention programs to be able to successful delivery that would offer their prevention services to ultimately lead to building capacity and more clients. less reliance on outside distant How others are able to attract and organizations. Some feel that they are sustain the number of participants in able to manage well but are looking for their programs. Some programs get more innovative ways to improve started but “fizzle” out due to lack of prevention services that they provide. interest from the community.

Another main opportunity identified was “I wonder what the best method is for to share lessons learned and tips for reaching patients or gaining their interest success from other primary care in relation to prevention. What do others organizations. Sites visited were find works-newsletters, a website or do particularly interested in knowing: many things help?” (Executive Director, The number and type of professionals Primary Care) involved in prevention programs. How to initiate vascular disease How some primary care prevention services such as a blood organizations are able to effectively pressure service (find out more about utilize their EMR to track important outcomes of participating in the Heart health indicators, abstract data, run and Stroke Hypertension relevant reports and generate Management Initiative study), an automatic pre-populated referral anticoagulation service and an forms with required clinical and exercise program within primary demographic information. care. How some organizations are able to How to sustain prevention programs. trigger reminders or prompts within Many expressed an interest in their EMR (e.g., reminders in relation starting a safe exercise program on to blood pressure measurements or their site or collaborating with a needed blood work). community exercise program but Many other common reported want to know the particulars about opportunities for collaboration regarding “how to make this happen”. areas to be addressed were identified Some expressed they have had such as: success but struggle with sustaining their programs such as an Utilization of the EMR to anticoagulation service due to the systematically identify patients at cost of the test strips for the point-of- high risk for a vascular disease. care blood work. Improved communication processes by having a more consistent way of

Vascular Health in Southeastern Ontario 2012

entering information. Would like to One integrated global vascular have one integrated vascular disease prevention program as health flow sheet such as expanding noted at some of the primary care the existing diabetes flow record to organizations. include other risk factors. When and how to partner with Many would like to know what others if needed as seen with the health indicators would be most successes identified with working important to track given limited with the Alzheimer’s Society and the resources and time. Arthritis Society. The ability to link clients to Improved linkage with speciality community resources electronically clinics and an easier referral process. through the EMR. For those that do Many expressed an interest in not have an EMR, develop a way to clinicians from speciality clinics link them to community resources. providing on-site or OTN education sessions regarding current guidelines. “We have many good resources in our Many indicated that they have OTN community. The problem lies in equipment and admitted that it recognizing the need; then making the could be utilized more. connection. We have to be more aware of the resources in our community” (family “Just keep working away and don’t give up physician, FHT) trying to work together in relation to prevention. More can be accomplished this Some rural organizations indicated way!” (family physician, FHT) that they have limited community recreation services. Some staff members thought it would Request for one consolidated be great to have a hypertension vascular risk identification tool. workshop closer to their local Request for one evidence-based community. practice guideline related to Continue efforts around the vascular disease prevention such as promotion of self-management utilizing the “Canadian Cardiovascular learning opportunities. Harmonized National Guidelines Endeavour” (C-CHANGE). C-CHANGE “We need to engage our patients in is one of the recommendations of the understanding their risks and being able to Canadian Heart Health strategy action be a part of the solution” (family physician from FHT) plan (Tobe, 2011).

“There is too much duplication and I One FHT member indicated the would like more consolidation of efforts importance of thinking more toward one user-friendly guideline” (staff regionally in order to improve member, FHT) equitable access to services

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(e.g., if a diagnostic test is not available in one community, should

have equitable access to this service in another community).

Table 3 Summary of Environmental Scan Themes and Opportunities for Planning o Global Integrated Vascular Disease Prevention Program within primary care o What would be the vascular-related indicators that should be tracked consistently o Improve functionality of the EMR /Improve knowledge of application: -pre-populated referral forms -generate reports -data evaluation -link to community resources -consistent way of documentation among providers -one data flow sheet -reminder prompts for clinic visit and tests (clerk can facilitate with directives) -include all staff in regular EMR refresher training o One vascular health integrated guideline o Improved linkage with speciality clinics o More sharing of lessons learned from initiating programs or services (e.g., how to attract clients and keep them engaged; how to prepare for an on-site exercise program) o Sustaining programs or how did others maintain successes o How to expand successful programs or services o Educational updates for related vascular topics via on-site or OTN(e.g., behaviour change/motivational interviewing) o Fund test strips for point of care blood work (e.g., INR level) o Further collaboration by working with others; more partnering and sharing of resources (e.g., public health, health networks) o Consideration of socioeconomic barriers to prevention services (e.g., transportation costs)

Note: Information corroborated with the on-site visits by presenting an overview of the environmental scan results at the Think Tanks.

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Think Tanks

One consistent theme that surfaced from the environmental scan was that many primary care staff would like to learn about vascular health services or programs from other primary care organizations.

To delve more deeply and explore further primary care needs in relation to vascular health, Think Tanks were held in three different Southeastern Ontario areas: Belleville, Brockville and Kingston. The objectives for the Think Tanks were to: 4) Begin to examine the prioritized 1) Discover tools, resources and needs together and begin thinking programs already in place that about innovative, feasible and seem to be working well. sustainable ideas for planning. 2) Identify other tools, resources and 5) Begin to discuss how to build on programs that are needed. those resources, tools and 3) Determine priority needs per area programs already in place to across organizations. determine collaboratively what is needed to support vascular health.

The Think Tanks were an opportunity to begin discussions about enabling the prevention of vascular disease and to figure out how to easily apply some of the identified tools, resources or programs into practice.

Planning for the Think Tanks

A small planning group for the Think Tanks met twice with member representation from the SEO Health

Collaborative and Primary Care consisting of different professions from different rural and urban locations (see Appendix

D for a list of the planning committee members). The role of the planning group

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was to help plan for the open discussion Ontario Renal Network, Diabetes Strategy Think Tank event. and Heart and Stroke Foundation forming the Ontario Integrated Vascular Health The 3-hour Think Tanks were planned to Strategy group and Regionally – SEO follow the environmental scan and in Health Collaborative. The recognition at anticipation of the pending every level for the need to work together announcement of the Ontario Integrated in partnership with primary care and Vascular Health Blueprint from the build collaboration was emphasized. Ontario Integrated Vascular Strategy group. The three Think Tanks were The Think Tank Plan designed to give people an opportunity to: Details of the Think Tanks (templates of learn from each other Invitation and Agenda are found in determine together what the Appendix E) included: priority needs are in relation to 1) A brief overview of preliminary vascular health environmental scan results to set the decide collectively what is needed stage. to make it happen 2) Presentation about the Ontario The planning template for the Think Integrated Vascular Strategy. Tanks also involved determining the 3) Groups were divided into 6-8 people. target audience. The invitations included: 4) First discussion involved what a primary care representation from robust vascular health program different primary care organizations (e.g., would look like. A few minutes were CHCs, FHTs, FHO and solo practitioners), dedicated to speaking to the person different locations and different next to them about describing a case professions (e.g., administrative leads, or a situation where they saw physicians, nurse practitioners, nurses, vascular health being managed or health promoters, nutritionists, delivered at its best. An additional pharmacists and dietitians); public health period of time was set aside for the leads; and representation from the entire table to discuss and a Ontario Integrated Vascular Strategy. dedicated scribe consolidated the ideas onto flip chart paper. Introductions would emphasize the 5) Looking at the flip chart paper notes critical role that primary care plays in about the ideal vascular health vascular health. The introduction of the program, members discussed the Think Tanks would also include tools resources or programs that are information about various networks in place and are working well. The working together: Nationally-C-CHANGE scribe transcribed the ideas onto flip guidelines, Provincially-Cardiac Care chart paper. Network, Ontario Stroke Network,

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6) Participants then wrote on coloured the enablers, barriers and post-its (colour designated delivery sustainability needs; who would be groups- CHC, FHT, Solo/FHO, involved; possible time lines; and Other/NP-led clinic) their individual thoughts about how to measure ideas about what is needed to make it success. happen (what tools, resources or 11) Focus groups reported back on their programs are needed). Time would action plan and discussion occurred be allotted for the table to discuss for a brief period of time with the these individual ideas. The table larger group. participants then organized their 12) Closing notes included notice of a post-its on large flip chart paper. short survey to be completed and 7) Time was allotted for each group to possible plans for follow-up. It was report to the larger group their mentioned that the intent for follow- “grouped” ideas in rotating fashion up is to continue to work together to until all ideas were brought forward. keep the momentum going from the 8) Collectively the ideas related to the Think Tanks. “needs” were grouped into common themes. 9) Participants were given 6 “dots” and they were asked to place their dots on what matters most (e.g., could place 1 dot on 6 themes or 6 dots on one theme). During the ranking, participants were asked to consider: Feasibility Impact Evidence Applicability Sustainability OR Should DO Want to DO Can DO

10) After the needs were ranked and the top three needs were revealed, participants then chose one of the top 3 needs to begin an action plan. A dedicated scribe transcribed possible local, regional and provincial action plans. Discussion involved: some of

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Think Tank Overview Lanark, Leeds & Grenville Counties (LLG): Vision A robust vascular health program would What does a robust Vascular Health be community-based, accessible and program, service or system look like? integrated and include services such as smoking cessation, blood pressure Hastings & Prince Edward Counties management, mental health, diabetes (HPE): education, safe exercise and nutrition A simple, collaborative, proactive, and counselling. Ideally this program would accessible approach would be ideal that is include children and making activities patient-centred and community-based accessible for children. The program where different health care professionals would include components from other can openly share resources. Accessibility successful prevention models (e.g., would involve more access to the Champlain cardiovascular disease electronic medical record (EMR). The prevention programs). The Ottawa Heart EMR should be utilized more (e.g., Institute Smoking Cessation program triggers for clinic visits and diagnostic design could be applied to other vascular tests). A robust program would have one disease risk factors. The EMR could be integrated clinical pathway, standardized utilized more to enhance consistent metrics and incorporate applicable and communication and generate referrals. transferable components that are Improved quality of data and vascular working well in other organizations (e.g., health standards to follow were listed as the Peterborough Comprehensive elements for a robust vascular health Vascular Disease Prevention Initiative). program. Collaborating with others was Included in the program would be regular identified including cardiac rehabilitation, vascular health checks for people the Stroke Prevention Clinic, Brockville including blood pressure measurement General Hospital, community support on everyone including young people. A services, Public Health and Community robust vascular health system involves Care Access Centre. partnering more (e.g., public health and Kingston, Frontenac, Lennox & YMCA) and engaging solo practitioners in Addington Counties (KFL&A): vascular health planning or programming. A proactive, interprofessional, predictive, “We need to work with our local cost-effective, sustainable program that is communities. Vascular health means patient-centred, recognizes cultural people taking ownership for wellness and diversity and is community-based would having the support they need to do that. It’s be ideal. Adopting elements within the about working together” Ottawa Heart Institute Smoking Cessation program for other risk factors should be

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considered. Included in this robust established programs or services in place vascular health service or program would can be adapted such as the Peterborough be an organized screening system, CVDPMI and the Upper Canada FHT’s prevention and management of obesity, Global Risk Reduction program. smoking cessation, treatment and the Continued use of the “vascular” term and development of long-term plans. integrated vascular services on-site. Starting early in schools for smoking Common elements among all three cessation has helped and group diabetes areas (HPE, LLG & KFL&A) related to a visits have been successful. Developing Vision for a robust Vascular Health partnerships such as with the YMCA has system, program or service been effective. Increasing patient’s Person or Patient-Centred knowledge of various prevention Accessible programs and ensuring that the patient Pro-Active feels that they are being heard helps to make the vascular program more Working together successful. Having access to an Community-based information technologist and alerts built Utilize other established vascular into the EMR for overdue tests or disease prevention programs appointments contributes to a successful Standardized tools program. Evidence-based guidelines are Program with: screening, useful tools (e.g., C-CHANGE) that could prevention including self- be embedded in the EMR. management education and a plan for follow-up “I like having ease of access that is quick with no hoops” What Tools, Resources, Programs contribute to optimal vascular health? LLG: What is Working Well? A concise list of tools, resources and HPE: programs that are working well was relayed with an emphasis on patient self- The various primary care delivery group management: models (CHCs, FHTs and NP-Led Clinics) have many tools/resources in place such Framingham tool as dedicated staff, administration, team Living Well program approach and follow-up procedures. Seniors Fit activity program Graduated programs foster engagement Rideau Valley Diabetes and are easier to apply when it is a step- Vascular Protection Clinic (Perth & by-step approach. Consistent messaging Smiths Falls District Hospital-Perth Site) in the media, on-line social networking Smoking Cessation, Diabetes combined with face-to-face encounters, Education, Blood Pressure Clinic are effective influential tools. Already

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Get with It walking program Partnering, connecting or linking Community Centre walking facility with other groups, clinics, Cooking programs such as networks or community groups community kitchens. Good Food (e.g., Vascular Protection Clinic, Box program cardiac rehabilitation, YMCA) Cardiac Rehabilitation (Brockville What Tools, Resources or Programs General Hospital) are Needed? KFL&A: Many ideas were generated related to Similar tools, resources and programs what is needed to support vascular health were identified at the Kingston think tank. in the local areas. The comprehensive lists The EMR was identified as a tool when displaying all of the participants’ programmed properly is effective for contributions are listed in Appendix F. reviewing relevant tests and patient The following is a review of the top three information. Being knowledgeable of the needs in each local area identified in the EMR’s capabilities and having information “think tanks”. technology support is very beneficial. Another helpful technology identified was The Top Three Needs point-of-care blood testing such as HbA1c HPE: and INR levels. Having a responsive system in place when the patient requires 1-EMR certain services such as diabetes 2-Engage Practitioners not Associated

management and being able to connect with Multidisciplinary Teams 3-System Navigation with other community programs such as

cardiac rehabilitation is advantageous. Effective programs identified were the Further development of a reliable, “Global Risk Reduction” program, the effective and user-friendly EMR was Chronic Disease self-management identified as a top priority in the HPE area programs, the Better Beginnings program, to help improve quality, communication, After-School programs encouraging access and safety. healthy living and the Ottawa Heart Development of shared tools such as Institute Smoking Cessation program. flow sheets that populate the Common Elements across all three patient’s clinical information and locations related to: What is Working screening tools to provide a Well? consistent method for communication among different Smoking cessation program health care professionals. Diabetes education and services An integrated health information Self-Management programs system with improved flow between

Vascular Health in Southeastern Ontario 2012

all involved with the patient’s care. from different health care professions Embed evidence-based guidelines. including rural areas (e.g., Increased access to reports and videoconference, telephone, and relevant aspects of the patient’s chart. computer link). A suggestion to facilitate A patient portal could be created system navigation was to have a directly for hospitals, diagnostics and dedicated person coordinate vascular provincial programs. services or programs. This would help Develop a user-friendly system for reduce duplication and improve tracking identification of patients at high risk of vascular health outcomes. for vascular disease. LLG: Develop useful templates and prompts within the EMR (e.g., 1-Public Policy (Funding & Resources) triggers for overdue diagnostics & 2-Healthy Lifestyle clinic appointments and risk factor 3-EMR screening).

The next priority relates to having a The top priority in the LLG area process in place to engage primary concerned public policy including providers not currently practicing in a adequate funding and resources. Of CHC, FHT or NP-Led Clinic. Of interest interest, this seemed to generate interest in relation to this priority is that only one from both CHC and FHT participants. participant’s identified need received Advocacy for programs as a result of gaps many votes. This demonstrates support in public policies especially for family from group delivery models (e.g., CHCs) centred-initiatives was discussed. as they identified this as a high priority need. This “need” tied for second place Equitable access related to improving with system navigation. access to care (e.g., transportation) and addressing social determinants of “I really appreciate being part of this think health (e.g., ensuring medication tank experience and it was interesting to coverage for all vascular disease- see that although we come from different related medications such as smoking primacy care organizations, we are alike in cessation; helping the working poor). not only some of the services we provide Accessing easily the cost of but in what we want in relation to ideal medications. Access to physiotherapy, vascular health” dental health care, mental health care. System navigation for improved Provide funding for exercise. collaboration could be facilitated by Improvements related to seniors (e.g., having one streamlined referral process care in the home to include (e.g., one form) for vascular-related monitoring of nutrition, blood diseases. Ease of access was mentioned pressure and blood work).

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Ambulatory primary care for seniors. Develop on-site primary care Improve seniors’ community services programs coordinated by a nurse (e.g., community centre and walking involving lifestyle change by working groups). on goals of treatment together, Develop innovative programs to motivation and education. increase activity such as gardening in “A community-based healthy lifestyle local schools. program is not just for people who have Improved worker-friendly schedules. had events; primary prevention should be The next priority need identified involves the focus” healthy lifestyle improvements. Some of “If something is happening down the street the needs in this section seemed to why do we need to do it. We need to avoid overlap with public policy (e.g., working duplication of efforts” collaboratively to improve nutrition and physical activity in communities, primary EMR and eventual electronic health care and specialty clinics). An extensive record (EHR) was the third priority list was generated under the healthy discussed at the LLG think tank. This lifestyle theme: priority seemed more popular with the FHT participants that were present and Healthy youth programs with funding centred around integration and for equipment. communication improvements. Healthy lifestyle plans could include schools, after-school programs, One integrated EMR across the entire community exercise programs, continuum of care with improved organized sports and volunteer flow with hospital, diagnostics, programs. Community Care Access Centre and Providers provide prescriptions for specialists. physical activity/exercise. Could Embed validated tools and guidelines provide prescriptions for lifestyle within the EMR. recommendations for clients with Establish alerts or triggers based on hypertension. best evidence. Coordinated vascular health centre in System identification of clients at risk local communities offering exercise, for vascular disease embedded into healthy food advice, weight EMR. management, smoking cessation and Consistent documentation including medication assistance for secondary assessment. Embedded flow sheets. prevention. This community-based Improve ability to extract relevant centre could provide recreational quality data and generate useful activities. reports. EMR can be utilized to

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evaluate progress in relation to Determine one or two measures to client's health outcomes. start as a guide for assessing process Improve access for the patient to and quality. their EMR and eventual EHR. Infrastructure for quality Provide a link to social media and improvement related to involving the provide “photo” capability. patient and building effective Need time for training and increasing processes for improved vascular one’s knowledge related to health. functionality of the EMR. The next priority need identified was to “If we had a systematic way of develop an integrated vascular health identifying those at risk and then program close to home and improve streaming them to effective programs, community partnerships. that would be a great start” Develop on-site vascular programs KFL&A including: diet, exercise, smoking cessation and “psychosocial” services.

1-Quality Improvement (Data/EMR) Free community activities to promote 2-Integrated Vascular Health exercise and health for all ages. Program & Community Partnership Family-based activity and nutrition 3-Clinical Tools (EMR, Guidelines) programs. Adequate staffing of health programs The first priority need identified for with designated “coordinators” who participants from the KFL&A area was would also provide program quality improvement specifically in evaluation. relation to abstracting quality data and analyzing the information. Adequate resources such as health promotion materials. Time to analyze the data and obtain Include self-management, feedback from the team. motivational interviewing, and Ability to link or have one integrated healthy behaviour change programs EMR across the continuum. involving designated team members. User-friendly EMR. Adapt OHI smoking cessation tool for Improve everyone’s knowledge of the healthy living program including EMR’s functions/capabilities and exercise. have information technology or data Include youth programs. coordinator provide support. Increase accessibility from “cradle to Improve accessibility for any health the grave” for prevention programs; care provider and the patient. improved access to transportation, healthy food and nicotine replacement therapy.

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Better partnerships in relation to Prompts or triggers for providers. food security, other community User-friendly EMR. organizations for life skills training Develop a health information such as cooking classes, exercise network. facilities, schools, public health, other Embed evidence- based guidelines primary care organizations and within EMR (e.g., guidelines for chronic disease networks. antiplatelet therapy for secondary Sustain partnership for vascular prevention). health. Utilize a “virtual” team approach for sharing where no vascular health programs or services are in place.

The third prioritized need identified was clinical tools such as point-of-care testing. Again some common needs were discussed in relation to the EMR such as screening tools and integrated evidence- based guidelines.

Point-of-care testing such as INR and HbA1c blood test monitoring. Funding for the test strips. Systematic method for identifying clients at risk for vascular disease.

Screening for patients at risk (e.g., screen for hypertension: check blood pressure and record measurement at least every 3 years). Embed validated risk screening tool such as the Framingham Risk Assessment tool within the EMR. Need consensus about what validated tool to use and

then consistently utilize the tool. One universal flow sheet. Develop a registry of patients with risk factors (e.g., learn more about the Canadian Primary Care Sentinel Surveillance Network-CPCSSN).

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Table 4 Top 3 Needs Identified at Primary Care Think Tank HPE LLG KFL&A 1. EMR (e.g., user-friendly 1. Public Policy 1. Quality Improvement system ID of high risk Funding & Resources Data/EMR (e.g., start with 1-2 patients; shared tools such (e.g., equitable access measures; increase training; data as clinical flow sheets) such as dental health coordinator) and transportation; access to smoking cessation meds

2. Engage Practitioners not 2. Healthy Lifestyle 2. Integrated Vascular Health associated with (e.g., coordinated Program & Community multidisciplinary teams vascular health Partnership (e.g., on-site vascular (e.g., develop partnerships centre) health programs; better with other organizations) partnerships )

3. System Navigation (e.g., 3. EMR (e.g., embed 3. Clinical Tools EMR, Guidelines one vascular health referral validated tools & (e.g., POC testing; registry of form; dedicated person) guidelines; consistent patients with risk factors) documentation)

Note: Details of participants’ identified needs are found in Appendix F. During the Think Tanks participants grouped their needs and ranked the needs according to a voting system.

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Common Elements across all three Innovative ideas were raised: locations related to the top 3 Priority prescriptions for lifestyle interventions- Needs perhaps could be automatically generated from EMR; more use of social media, a Some common themes surfaced when Health Information Network, reviewing the top three needs (Table 5). development of a community resource Similar themes were also noted among directory for prevention including an the lower “ranked” or priority needs. electronic version related to vascular health prevention.

Table 5 Summary of Think Tanks and Opportunities for Planning o EMR seemed to be the common thread between all three locations. Many hope for one integrated EMR to become a reality. Ongoing training to improve local knowledge of the EMR is required. Expand functionality of the EMR to include such elements as reminder prompts for visits and testing (more medical directives); ensure new applications or improvements are user-friendly. Embed agreed upon evidence-based guidelines and validated tools within the EMR. o Integration related to a vascular health prevention program. Aim for one- integrated vascular disease prevention guideline. o Key lifestyle priorities within programs or services related to vascular health: smoking cessation, physical activity and a healthy diet. Include people who have not had an event; include all ages. o Improved access to prevention programs (e.g., accessible transportation). o Continue to build partnerships and improve collaboration between primary care organizations, networks, hospitals, public health and other members involved with the circle of care and prevention. o Exercise seems to be a priority on all the lists including engaging youth. Starting early seems to ring a familiar bell.

Note: Information summarized from participants’ contributions during all three Primary Care Think Tanks (HPE, LLG and KFL&A). Details are located in Appendix F.

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Action Planning provider to send necessary clinical information to improve the continuity Many needs were identified in relation to of care. vascular health as a result of the Think Improving the electronic patient data Tanks (see Appendix F). This will be very flow between organizations (back helpful for planning purposes when and forth). others such as members of the SEO Health Improving collaboration between Collaborative and primary care providers organizations related to sharing begin to collaboratively determine how patient information including the best to support vascular health locally patient’s health profile or history and and regionally. The Think Tanks also flow sheets. provided an opportunity to initiate Sharing of tools such as planning in relation to the top three documentation and forms’ templates. priority needs. Transcriptions of the Obtaining measurements related to Action Plans are located in Appendix G. effectiveness of the system could This is only the beginning of the include access (e.g., examining “planning” phase to address the demographics and number of clients), prioritized needs. patient satisfaction (use of surveys) HPE Action Plans and timing (e.g., when reports are received and processed). EMR Provincial Action Plan- Two barriers to implementation of the EMR were identified: lack of system Implement a consistent integrated integration with different EMRs between electronic medical record and carry primary care organizations and across the out plans for an electronic health continuum of care; and lack of an up-to- record (EHR). date billing system related to different Support EMR initiatives (funding). scopes of practice within the primary care Reduce barriers for other health teams. A collaboration of efforts between professionals such as NPs (e.g., different partners would be required to referrals and diagnostic requests). help facilitate integration (e.g., information technology, hospital Primary Care Engagement administration, specialists and primary Some of the barriers identified reflect care provider representation). health care professionals working within Action plans would involve: their own “silos” of care. Many could feel threatened by change even positive Local/Regional Action Plans- change as it is something new and given busy practices, health care professionals Hospitals working with primary care would designate one primary care

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don’t necessarily have the time to adapt Network will attend meetings with changes to their practice. other chronic disease networks (e.g., Cancer Care Ontario). Local Action Plan- Provincial Action Plan- One recommendation was easily accommodated related to physician Continue to improve access issues availability to attend the SEO Health such as human resources in relation Collaborative. The time change was to primary care. acceptable to other members of the Primary Care Physician Lead SEO Health Collaborative. participates in provincial primary Circulate surveys to other primary care initiatives. care providers to obtain their feedback about vascular health System Navigation prevention needs and possible action An identified enabler is to have assistance plans. with navigation in health promotion Examine methods to facilitate activities. A system navigator would also collaboration such as utilizing CHC identify acute care occurrences occur and space after-hours and receiving notify primary care providers involved in access to programs and services the client’s care. provided by interprofessional members of the team (e.g., Living Local Action Plan- Well with Chronic Conditions-6 week Begin to streamline internal referral program). processes, perhaps designate team Primary Care Physician Lead for the members to be responsible for South East LHIN to continue on-site certain programs or services. visits with other primary care A system that generates automatic providers to obtain feedback for referrals depending on health improvement in relation to indicators. efficiencies and quality. Improve communication among Suggestion to “re-brand” CHCs as a primary care providers. “community program provider”. Ensure referrals are sent to the Regional Action Plan- appropriate external person or organization. Require up-to-date SEO Health Collaborative should referral information (e.g., specialist continue to meet and work with list). primary care to determine how best Utilize the EMR to pre-populate to support vascular health regionally. referral forms with necessary clinical Primary Care Physician Lead of South and demographic referral East Local Health Integration information.

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Increase and improve vascular Local Action Plan- disease prevention services for Promote better utilization of already clients with mental health conditions. existing resources (e.g., Public Health Provide or adapt applicable programs and students) through collaboration for this patient population. Need to and communication extend collaboration for this population and utilize mental health Continue to break down existing silos “friendly” strategies. and develop more partnerships. Develop an inventory of current Regional Action Plan- services, programs and resources for all providers in relation to vascular One integrated vascular health clinic health prevention. (e.g., integrate Stroke Prevention Link the vascular health inventory of Clinics with Diabetes Services). programs and services to the EMR. Integrated Electronic Health Discharge Summary. Healthy Lifestyle

Provincial Action Plan- Locally a barrier was identified in continuing lifestyle change self- Wait time strategy to include referral management programs as a volunteer-led time from primary care provider to program. Discussion for action included when seen by specialist. youth programs. Effective healthy lifestyle Support funding for system programs for youth in relation to navigators within health care prevention would have a greater impact organizations (e.g., hospitals, FHTs, with support from local school-boards. CHCs, Clinics). Local Action Plan- LLG Action Plans Adapt lifestyle change programs to Public Policy include defined goals with The group indicated that public policy measurable outcomes. would be a challenge as it encompasses a Encourage more self-management much larger scale for change including groups and training around self- political and social. It was expressed by management and motivational the group to start with “smaller” local interviewing within primary care. issues as there would be a chance for More recognition that rural areas more success with local policy require appropriate and applicable development. program planning. More consideration of collaboration and coordination of lifestyle programs within communities (e.g., physical activity).

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Regional Action Plan- providers. Measurements could be obtained in the number of errors Implement the provincial Ontario related to consistency. Chronic Disease Prevention plan. Agree upon valid screening tools and Provincial Action Plan- integrate the validated tool within the EMR for all providers. Focus on programming at all levels to Provide regular training and help plan for funding and “refresher” training in relation to the sustainability. EMR (e.g., how to extract relevant Adopt and apply a Patient-Centred health indicators). model. Measure and track costs (e.g., MD, Regional Action Plan- imaging and allied health). Facilitate the integration of EMR with Measure wait times for specialists other organizations (e.g., hospitals). from time of referral from primary Privacy issues would have to be care provider to time seen by a explored. specialist. Measure indicators-vital signs such as Provincial Action Plan- blood pressure readings (could also Continue sharing knowledge transfer apply to a local action plan). between organizations (could be a EMR regional plan). A barrier identified with implementing a provincial action Local barriers were identified in relation plan was related to software to different practice patterns and a lack of licensing. Success would be the consistent documentation. Enablers implementation of the planned discussed were the engagement of electronic health record (EHR). different primary care providers and determination by consensual agreement KFL&A Action Plans of evidence-based guidelines to adapt Quality Improvement/EMR within the EMR. Another local enabler identified in relation to the EMR was Multiple EMRs and a lack of useful and effective software applications interoperability is a significant barrier to and qualified staff who are comfortable quality improvement. A barrier identified with the functions of their EMR. by the KFL&A group discussing a local and regional action plan for their EMR Local Action Plan- was due to a system with multiple Improve documentation practices by providers with many different patient inputting required information in a record systems. Another barrier was consistent manner by all health care some utilize a “paper” system and there

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are different organization systems within Utilize a common quality the EMRs (inconsistent documentation improvement methodology. processes). One enabler identified would Track common and relevant health be to have the system force data entry indicators. Establish evidence-based (e.g., can’t move on in the system unless benchmarks. this is completed or recorded) and provide automatic cues or prompts to Integrated Vascular Health Program help navigate through the electronic Local Action Plan- record. Provincially, funding could be a barrier (e.g., the province does not fund Emphasize increase awareness of data collection, abstraction and analysis available recommended community of reports). resources and if applicable refer to the already established community Local Action Plan- resources first. If not available, then Develop infrastructure in relation to utilize other resources such as CHCs the EMR and increase training for all and Diabetes Education Centres. primary care providers and support Increase exposure of other valuable staff. Improve upon the quality of and recommended resources (e.g., data entry and capture information Diabetes Education Centres). within the EMR in a consistent way Group patients with similar vascular- and in a consistent location. health related issues and collaborate Examine what health elements are with others to provide appropriate essential for data collection. evidence-based services. Share flow sheets, tools and other Designate team members to relevant data templates across coordinate services and programs organizations (could be a regional related to vascular health (e.g., plan). designate one team member to be responsible for leading self- Regional Action Plan- management groups and programs). Define roles and responsibilities of LHIN to collect and share quality different team members involved in a improvement information with local and integrated health strategy, primary care providers and Public program or service. Health. Improve coordination regarding Provincial Action Plan- services, programs and resources with other agencies or organizations Build in user-friendly reporting such as Public Health Units. features or capabilities with new Increase access to local vascular EMRs. health related programs involving: activity, smoking and nutrition.

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Collaborate with others when as the Heart and Stroke Management planning these programs. Initiative. Improve access to vascular disease

prevention programs and facilitate the removal of barriers. Involve the patient or client and include them in plans for vascular health-related programs or services. Planners should ask the patient or client what they think is needed (e.g., “what will help you to change your lifestyle to improve your vascular health”).

Clinical Tools (EMR)

Seek input from primary providers and involve primary care in the development of clinical tools. Invest in time and training of all staff. Training could include ensuring the inputting of relevant health data. Build into the system relevant health indicators that can be abstracted

easily (e.g., blood pressure, weight and waist circumference). Embed validated cardiovascular disease risk assessment tools within the EMR such as the Framingham tool. Need to have consensus on an appropriate and validated tool and use the tool consistently.

Provide support for establishing blood pressure management clinics or services including screening. Integrate the management of blood pressure (e.g., program) within primary care organizations and utilize other resources if needed such

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Table 6 Common Themes in the Action Plans across all Three Locations o EMR improvements such as integration within different EMRs. Lack of integration was seen as a barrier and facilitating the integration of the EMR between organizations was identified as an action plan item for the region. o Sharing of information or knowledge transfer across organizations. Many felt that the sharing of templates, flow sheets, tools and documentation records would be useful and helpful. The sharing of information could be facilitated by a shared website or the creation of a vascular health portal where providers can enter and identify what’s working well in their practices. This website link or portal perhaps could be used to facilitate communication with specialists, other primary care providers and vascular health related networks. o An integrated vascular health strategy and increase efforts to enhance collaboration between organizations. Strategies to enhance collaboration: sharing of resources, programs and services; promoting established resources that are working well; and collaborating with other partners when planning vascular health related initiatives including the patient. One possible doable action plan identified that might be helpful for primary care providers is to develop an inventory of prevention resources, tools, programs and services in reference to vascular health for local communities. Note: Related themes from action plans obtained from detailed participants’ actions plans (Appendix G) Conclusion

As a result of performing an environmental scan involving primary care teams and hosting three well- attended Think Tanks (n=73 participants) much detailed information has been gathered and reviewed. Prioritizing needs locally will assist with future planning for improving vascular health. Valuable

information was collected from many different health care professionals, administrators and support staff from different rural and urban locations. There was some overlap in the prioritized needs

identified among the local areas and this will facilitate future regional planning.

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Table 7 Common Needs & Opportunities Identified in the Environmental Scan and Think Tanks Communication & Collaboration Integration

o Increase sharing of information o Develop one user-friendly integrated between primary care organizations system that incorporates improved such as lessons learned and tips for access (e.g., EMR) and has one valid success to initiate, sustain and expand vascular health-related guideline; one vascular disease prevention services or vascular disease risk assessment tool that programs; and how others effectively everyone can agree to use; one clinical utilize their EMR (e.g., generate reports flow sheet that captures all relevant and referrals). health indicators. Determine what o Facilitate consistency such as vascular health indicators should be documentation practices within the EMR. tracked consistently. Regular training o Examine innovative ways for sharing for all staff to increase comfort with the up-to-date vascular health-related functions within the EMR system. information, tools, and resources such Increase access to other clinical tools as a common web site. such as point-of-care blood testing. o Continue to improve connections with o Develop a person or patient-centred groups interested in vascular health such integrated vascular health service or as the SEO Health Collaborative, Public program within each primary care Health Units and specialty clinics. organization encouraging self- o Increase awareness and promotion of management, physical activity, a healthy established vascular disease diet and smoking cessation. A vascular prevention community services or health program, service or system should programs to reduce duplication of efforts. be flexible in order to be applicable to a Further development of partnerships and local setting. Components of a vascular plans to increase physical activity and health program, service or system could safe exercise programs. be modelled after established programs such as the Global Risk Reduction program in the Upper Canada Family Health Team.

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Recommended Next Steps ongoing activity for the coming year. The intent would be to carry on the 1. This report will be shared with: momentum for improving vascular a. Primary care providers across health by translating the identified the region – including all who prioritized needs into actionable participated in the environmental plans. This will be initiated in scan and the Primary Care Think partnership with the Primary Care Tanks; Lead for the SE LHIN, the SE Primary b. The Southeastern Ontario (SEO) Health Care Council and associated Health Collaborative including local primary care leads. The Primary the Primary Care Lead for the SE Health Care Council will validate LHIN and each of the Regional actionable plans and collaborate on Steering Committees of its implementation through its primary represented chronic disease care hub network. networks;

c. The SE Primary Health Care 4. Consideration may need to be given Council; to the development of community d. The SE LHIN; vascular health tables to support e. The leads for the Cardiovascular primary care locally in relation to Clinical Services Roadmap of the proposed actions in vascular health. SE LHIN and This consideration would need to be f. The Project Manager for the made in alignment with the ongoing Ontario Integrated Vascular work of the SE Primary Health Care Health Strategy. Council.

2. Local Action Plans will be followed 5. The SEO Health Collaborative is well up by those engaged and self- positioned to become the Regional identified in developing the Vascular Collaborative as described preliminary action plans made at the in the August 2012 release of the Primary Care Think Tanks. Integrated Vascular Health Blueprint

for Ontario. This will be discussed 3. The SEO Health Collaborative will with the SE LHIN. review this report to guide the focus

for a collaborative and supportive 6. The SEO Health Collaborative will partnership with primary care in build communication with the addressing regional concerns and Ontario Integrated Vascular Strategy proposed actions. The SEO Health Project Manager to ensure that areas Collaborative will lead a process to outlined in this report that align well identify a consolidated regional with the provincial strategy be action plan that will guide its referred on.

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Walker, C., Swerissen, H., & Belfrage, J. (2003). Self-management: Its place in the management of chronic illnesses. Australian Health Review, 26(2), 34-42.

Weeks, A., McAvoy, B., Peterson, C., Furler, J., et al. (2003). Negotiating ownership of chronic illness: An appropriate role for health professionals in chronic illness self- management programs. Australian Journal of Primary Health, 9(2-3), 25-33.

White, S., Feely, J., & O’Neill, D. (2004). Community-based study of atrial fibrillation and stroke prevention. Irish Medical Journal, 97, 10-12.

Whitford, D. L., Hickey, A., Horgan, F., O’Sullivan, B., McGee, H., & O’Neill, D. (2009). Is primary care a neglected piece of the jigsaw in ensuring optimal stroke care? Results of a national study. BMC Family Practice, 10 (27). Retrieved from http://www.biomedcentral.com/1471-2296/10/27/

WHO. (2005). Preventing chronic disease: A vital investment. Geneva, Switzerland: World Health Organization.

WHO. (2010). Global strategy on diet, physical activity and health. Geneva, Switzerland: World Health Organization.

Wolbeck Minke, S., Smith, C., Plotnikoff, R. C., Khalema, E., & Raine, K. (2006). The evolution of integrated chronic disease prevention in Alberta, Canada: A community case study. Preventing Chronic Disease, 3. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1637790/

Vascular Health in Southeastern Ontario 2012

Appendix A

Family Health Teams (FHT) in Southeastern Ontario Athens District FHT Athens 613-924-2623 Bancroft FHT Bancroft 613-332-6300 Brighton Quinte West FHT Brighton 613-475-1555 Central Hastings FHT Madoc 613-473-4134 CPHC Brockville Community FHT Brockville 613-342-3693 & CPHC Gananoque Community FHT Gananoque 613-382-7383 Kingston FHT Kingston 613-531-4234 Lakelands FHT Northbrook 613-336-8888 Loyalist FHT Amherstview 613-507-0213 Maple FHT Kingston 613-531-5888 North Hastings FHT Bancroft 613-332-5692 Prescott FHT Prescott 613-925-5977 Prince Edward FHT Picton 613-476-2181 Queen’s FHT Kingston 613-533-9300 Sharbot Lake FHT Sharbot Lake 613-279-2100 Upper Canada FHT Brockville 613-423-3333

Community Health Centres (CHC) in Southeastern Ontario Belleville & Quinte West CHC Belleville 613-962-0000 Country Roads CHC Portland 613-272-3302 Gateway CHC Tweed 613-478-1211 Kingston CHC Kingston 613-542-2949 Rideau CHS Smiths Falls 613-283-1952 Merrickville 613-269-3400

Nurse Practitioner (NP)-Led Clinics in Southeastern Ontario Belleville NP-Led Clinic Belleville 613-779-7304 Smiths Falls NP-Led Clinic Smiths Falls 613-205-1025

Vascular Health in Southeastern Ontario 2012

Appendix B

Primary Care Questionnaire

1. Is there more than one location? 2. Who will be the main contact to send updates and information about vascular health prevention? 3. Who are the members of your team? 4. What are the functions of the primary care delivery group? 5. What services and programs are in place related to vascular health? (e.g., diabetes education, hypertension management and smoking cessation) 6. What cardiovascular risk assessment tool is used? 7. Is there an anticoagulation service or clinic on-site? 8. What computer system stores your patient information? 9. What links does your organization have with the community in relation to community agencies and rehabilitation? 10. Do you refer patients to the Stroke Prevention Clinic? 11. Are motivational interviewing techniques incorporated into your practices in relation to self-management? 12. Discuss one issue in relation to vascular health? 13. What educational opportunities would your organization be interested in?

Vascular Health in Southeastern Ontario 2012

Appendix C Environmental Scan of Southeastern Ontario: FHTs, CHCs and NP-Led Clinics

General Functions/ Vascular Health CVD Risk Anticoagulation Depression Electronic Community Motivational Services Related Programs Assess For Atrial Fibrillation Screen Record Rehab Links Interviewing

1 Primary Health Care Diabetes program Anticoagulation Program Oscar YMCA Yes Educating medical led by pharmacist Clerks have Cardiac Rehab students & physicians SW coordinates in collaboration with Directives Foot Care program smoking cessation other members of team to update Ottawa model program Point of Care Testing blood work Medical Directives Patients have access to part of electronic record Ability to abstract, trend, run reports 2 Primary Health Care Hypertension program Framingham Anticoagulation program xwave YMCA Yes Chronic Disease Prevention managed by 2 RNs coordinated by RNs Refer to cardiac rehab Would like to Health Promotion Would like to maintain Point of Care Testing Refer to day Rehab expand and expand program. More Well Woman Program resources needed. INR result obtained Stanford Self- Management Foot Care program Diabetes program Dose adjusted Model Smoking Cessation- Teaching provided coordinated by 2 RNs Plans to attend TEACH program

3 Primary Health Global Risk Reduction Program Framingham Anticoagulation program Nightingale Primary Health and Care coordinated by 2 RNs Wellness Clinic After hours telephone Diabetes program Would like to advice coordinated by RN develop a Cardiac Rehab General Family Practice Cardiovascular RNs global Point of Care Testing Foot Care program vascular Medical Directives . Hypertension program coordinated assess by 2 RNs. Smoking cessation led tool and by 1 RN would share this . tool

4 Primary Health Care Starting a blood pressure Framingham No program Utilize Use paper No community services Need to follow- Services a very rural area program coordinated by a RN depression up High substance abuse Provided info from CHEP, Purchased the Point of screening tool. xwave coming in Lower socio-economic Heart & Stroke Hypertension Care Not sure what July 2011 status Management Program tool Provided info about equipment recently Diner club for seniors BP program at CHCs

NP is undergoing Local school has a CDE training and will assist both sites with a gym for the community to diabetes education exercise Napanee Diabetes Ed No walking due to visit 1/mos for teaching highway through the All NPs are going to town Smoking cessation course in Ottawa in fall 2011 Tennis Court & Lions Would like more C-CHANGE info Hall Low participation in rec and physical activities

5 Primary Health Care Diabetes program run by Framingham Had piloted an Starting a QI xwave Aquatic Centre Yes Chronic Disease RN anticoagulation project for Prevention CHF Clinic program. Ran out of chronic pain funding & depression use PHQ-9 as Healthy heart rehab Foot Care Cardiac Rehab-PEACH Still have machine screening tool course Asthma Clinic Blood Pressure Monitoring RNs go and present

Wound Management Seemed interested in re healthy lifestyle Clinic vascular prevention Would like to find out more about a Blood Pressure program RN & NP coordinate smoking

cessation

Vascular Health in Southeastern Ontario 2012

6 Primary Health Care No programs No program Practice Quick note that they don't Short Webinar Mental Health HMI presentation took place Solutions really have community rec Nutrition counseling Interested in starting services Foot Care program Family Dr. will be lead COPD program starting soon

RN considered CD prevention lead NP coordinates Diabetes services Refer out for most services No one trained for smoking cessation Refer to Public Health 7 Services very rural + large CDPM program: Blood pressure, Framingham No on-site program Use PHQ-9 Wenoka Link with 1 Fitness Gym- Yes through smoking cessation coordinated by smoking Geographical territory RN. Physicians fill out Rx cessation Would like to Nutrition counselling Health Unit has a walking learn program in local school more and how Women’s Health 2 RNs coordinate Diabetes Clinic Swimming program at to hotel change Diabetes Education run by RN behaviour Obesity Education Physician request for fitness program at an "under- Smoking Cessation- used" site Thinking about sending others and will contact us

8 "Interim" Clinic with part-time Heart Healthy Class RN coordinates Interested in Planning on having Would like to physicians run by dietitian program 3-question Cardiac Rehab soon develop more transitioned to FHT Blood pressure, smoking depression Resident training program cessation, Diabetes ed screen coordinated by RN Choose to Loose 9 Primary Health Care RN involved with RN Screen for Have community exercise Yes CVD interests runs program depression A senior exercise Services a very rural Diabetes Education run by no identified program with 63 people community RN and Dietitian tool in the local gym involving Have people trained their health promoter in smoking cessation

10 Primary Health Care All staff participate in Framingham No Anticoagulation clinic PHQ-9 Practice Walking program Services a very rural CVD prevention. No programs Good relationship with Solutions Refer to CPCHC for day area or specific lead for a on site lab program and exercise particular area No CVD programs/service Have NP trained in smoking cessation Diabetes education

11 Primary Health Care Would like to start a Blood No anticoagulation clinic Unsure Oscar Have partnered with Would like Urban setting Pressure program Have a lab on site local recreation training Have 3 staff in training for Would like Medical Directives centre and offer a walking Chronic Disease Manage Diabetes education and to start an anti- program run by OT Memory Clinic partnered coagulation program Find there are too many with the Alzheimer’s Society RN trained through Ottawa services and don't know Falls prevention clinic in smoking cessation where to turn run by the OT Would like to send more Partner with PHU for smoking cessation of high risk pregnancies Enrolling in the STOP study 12 Family Medicine Operate a "Living Well" program Framingham Lab on site PHQ-9 xwave Cardiac Rehab Have an coordinated by Able to abstract interest Internist sees patients 1am/wk Dietitian-& RN provide nutrition No program and run reports counseling and exercise on site RN coordinates Hypertension Social Worker program and the Diabetes has excellent Populate education program. Smoking electronic referrals Linked with physiotherapy cessation by RN partnered with program with Referral Centre CMAH and participates in STOP built-in alerts templates Community Rec Centre study

Vascular Health in Southeastern Ontario 2012

General Functions/ Vascular Health CVD Risk Anticoagulation for Depression Electronic Community Motivational Services Related Programs Assess Atrial Fibrillation Screen Record Rehab Links Interviewing

13 Primary Health Care in an Healthy Living Clinic led by Framingham Point of Care testing BECK inventory Practice Cardiac Rehab Have an urban setting RNs-primary prevention Medical Directives for HADS Solutions YMCA-have partnered re interest Chronic disease prevention starting INR difficult to control chronic pain program & management services at age 40 then every 5 years: Stable INRs: monthly Sleep therapy Patients are screened, goals blood work Loving Food & Feeling Fine discussed Stress Management 101 On track-Diabetes Intensive Foot Care Carec led by NP and dietitian Getting the Fats Straight (cholesterol) Feeling Calmer: Managing Anxiety Feeling Better: Managing Depression Arthritis Clinic Chronic Pain Clinic 14 Primary Health Care Just starting None No program Would like to Purkinje--all Yes Urban Setting CHCs Lower socio-economic status Plans in place to target Interested in info about Point Changing Health promotion high risk people of Care testing for INR and vendor Many programs: such as someone who equip costs Living Well with Health Conditions hasn’t had BP taken Feeding your family via EMR with help from Cooking for One Data Coordinator Craving Change Diabetes Education REACH-Exercise for CD Living Well with Diabetes TAP Dental Health program Aboriginal Health Smoking Cessation led by Fear of Falling RN who covers Diabetes Managing Fatigue Managing Depression Managing Powerful Emotions Managing Pain before it Manages You Foot care 15 Grass roots organization Heart Healthy Group Framingham No Program but have Not sure if they Purkinje--not System Navigator assists Yes started in 1991 to provide Now individual counseling A Coaguchek point of care have a happy with referrals Most of the staff Worried about sustaining Machine. Worried about depression tool with Purkinje have been Primary Health Care Program covering the costs of the Use Communicare and trained and link with community strips CCAC partners Diabetes Education Aware of day rehab Services a very rural area. Lower Smoking Cessation program socio-economic status Extended hrs/on-call Not many recreation Programs: activities Stretching Your Food Dollars Pole walking coming soon Early Years Program Community Resource Prgm Nutrition Counseling Crisis/Emotional Support Aging @ Home Assessments run by RN System Navigator-run by RN Dental Health Unit located in basement Community Gardening Pole Walking 16 Primary Health Care RN coordinates CDPM Framingham Point of Care Researching Purkinge-Hasn't Refer to tertiary centre for Yes Community Programs & Services RN-coordinates heart healthy INR testing tool-(e.g., PHQ- switched to rehab referrals but Health promotion and CDPM program 9) Nightingale yet distance Most trained in Many programs: CD prevention counseling Staff have can be a barrier self- Senior's Wrap Around-keep Medical Directives Would like 3- management seniors in home longer Diabetes Support monthly question tool Limited community techniques Provide transportation for clients group meetings recreation Partners with Arthritis Society- RN is diabetes educator Not everyone OT comes on-site Partners with Public Health embraced MI Day Away Program-Caregiver Staff utilize CHEP Support Info including the action plans Get with It-Ottawa program- for BP manage at local high school facilitated by RN/dietitian manage Community Health Worker lifestyle counseling In the winter Living Well with CD NP on-site at local high school- Choices & Changes-NP 2 days/week-health promotion, - trains others sexual health Mindfulness Program & Oral Hygiene-have Meditation Dental hygienist on-site Stay Fit Groups Healthy Wt Programs 2x mos Seniors Fit exercise program Community Kitchen Good Food Box Depression Support group

Vascular Health in Southeastern Ontario 2012

General Functions / Vascular Health CVD Risk Anticoagulation for Depression Electronic Community Motivational Services Related Programs Assess Atrial Fibrillation Screen Record Rehab Links Interviewing

17 Provide increase access to CDPM RN Framingham Point of Care INR testing Mainly PHQ-9 Purkinge-Hasn't Provided directories Yes most RN coordinates diabetes Staff have BECK inventory switched to YMCA trained would education Medical Directives Nightingale yet HPs know about like to learn Coaguchek resources more about MI lower socio-economic status No blood pressure clinic Refer to Day Rehab RN is interest in vascular dse prevention services Let’s Get Healthy not operating Urban pole walking led by HP Living well with CD Condition Anxiety, Anger & Depression Low attendance to get program led by SW healthy program involving Living well with pain program exercise. RN would like program led by SW to spend time with Kinesiologist re exercise program training Would like to have more CDPM programs Most trained in Choices & Changes

18 Primary Health Care, Planning for a Cardiovascular Point of Care PHQ-9 Purkinge- Free Walking Trails Yes Health Group INR testing Change in 2 illness prevention, Health Community Arena Living Well with Chronic Staff have years Promotion, health education, Disease and Not many community community development Living Well with Diabetes Medical Directives recreation services Service a large area with low socio- modified to meet needs of local

. economic status and high mental community

health illness Diabetes Services

Diabetes Education Good Food Box Guys Get Cooking 2 Sessions last year Diner's Club on blood pressure Good Food for Healthy Babies management open Craving Change to general public “Mind Your Blood Pressure” Better Health Project Part of the Healthy Community Nutrition Counselling Staying Well Get With It walking program Would like to expand the scope Community Gardening of nursing

practice

Dental Health

19 Family Health Care services Hypertension program INR clinic starting PHQ-9 Practice Aware of Yes Difficulty accessing Solutions Community services Primary care provider starting soon with RN Coaguchek Equipment leading this initiative Pharmacist is the lead Take walk-ins Trying to establish links Extended hours 5days/week RN attended the with hospital to know No on-call Hypertension Collaborative more about their patient’s Diabetes program led by hospital experience RN and pharmacist RN attended Ottawa and TEACH sessions and is the lead

Note: Environmental Scan conducted June 2010-September 2012. More details can be obtained from [email protected]. Information collected may have changed since initiating the Environmental Scan.

Vascular Health in Southeastern Ontario 2012

Appendix D

Planning Committee for Primary Care Think Tanks Marg Alden Executive Director, Maple FHT Mike Bell Director Primary Health Care, Rideau CHS Sherri Fournier-Hudson Executive Director, Upper Canada FHT Dr. Jonathan Kerr MD, Primary Care Lead SE LHIN Dr. Hugh Langley MD, Primary Care Lead South East Diabetes Coordination Centre & Regional Cancer Program Christanne Lewis Coordinator, District Stroke Centre Cally Martin Regional Director, Stroke Network SEO Colleen McMahon RN, CDE Colleen Murphy Regional Stroke Best Practice Coordinator, Stroke Network SEO Stafford Murphy Manager, Napanee CHC Lynne Poff Executive Director, North Hastings FHT Sue Saulnier Regional Education Coordinator, Stroke Network SEO Dr. Adam Steacie MD, Upper Canada FHT Ron Shore Director, Kingston CHC Mary Woodman NP, Prince Edward FHT

Note: In addition Maureen McIntyre, Regional Director of the Regional Diabetes Centre for SE LHIN and Julie Gordon, Regional Director of the Ontario Renal Network provided helpful feedback and support during the Primary Care Think Tanks

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Appendix E

Invitation and Agenda Template for Think Tanks

Dear Colleagues,

We would like to invite you to participate in the “Southeastern Ontario Primary Care Think Tank on Vascular Health: Making it Easier to Put into Practice”

This 3-hour evening “Think Tank” has been designed to give primary care physicians, nurse practitioners, administrative leads and health professionals the opportunity to begin discussions about enabling the prevention of vascular disease: “making it easier to put into practice”.

By the end of the “Think Tank”, participants will have had the opportunity to: Discover what tools, resources and programs are currently in place and how can they be shared: determine what is most important Identify other tools and resources that are needed Determine collaboratively what is required to support vascular health in primary care organizations Define the next 3 steps for action

Primary care providers/organizations/ teams from across Southeastern Ontario will come together to begin facilitated discussions to collaboratively meet the objectives above.

In preparation for this meeting, a list of vascular-related programs, services or systems in Southeastern Ontario has been developed. This list including local environmental scan results and the “blueprint” for an integrated vascular strategy in Ontario will be shared with participants.

The “Think Tank” agenda is attached. The planning committee looks forward to what is expected to be the start of enhanced collaboration for vascular health in our region.

Thank-you,

Planning Committee: Dr. Adam Steacie Dr. Hugh Langley Mike Bell Cally Martin Dr. Jonathan Kerr Ron Shore Christanne Lewis Lynne Poff Sue Saulnier Colleen McMahon Marg Alden Sherri Fournier-Hudson Colleen Murphy Mary Woodman Stafford Murphy

Vascular Health in Southeastern Ontario 2012

Primary Care Think Tank on Vascular Health Dinner Provided Date: June 5, 2012 from 5:00pm- 8:00pm

Time Topic Presenters 5:00pm-5:25pm Dinner and Introduction 5:25pm-5:35pm Setting the Stage: Environmental Scan Results 5:35pm-5:45pm Ontario Integrated Vascular Strategy “Blueprint” 5:45pm-7:00pm Focus Group Discussion

Questions: 1. What does a robust vascular health program look like? 2. What’s needed to make it happen? a. What tools, resources or programs are already in place and working? b. What tools, resources or programs are needed?

Focus groups report back on what’s needed Organize input into common needs

7:00pm-7:10pm What matters the most? Rank top 3 needs

7:10pm-7:50pm Action Plan for top 3 needs 1. What are feasible next steps/actions? 2. How will we tell if the action plans are successful?

Focus groups report back on action plan

7:50pm-8:00pm Wrap Up

8:00pm Adjournment

Vascular Health in Southeastern Ontario 2012

Appendix F

Needed Tools, Resources or Programs HPE Primary Care Think Tank CHC FHT SOLO/FHO Other & NP

1. EMR (22 votes)

EMR tools (e.g., flow sheets that Access to chart by all Chart access Direct feed populate the record) EMR– need to access accessible to all from hospital, Integrated EMR – flow between reports Common shared lab, provincial different partners (e.g., hospitals) EMR more user friendly patient medical programs – Electronic record – access to for identification record patient portal information Communication access of Integrated Common EMR search capability relevant aspects of the health Shared tools chart for outside information o Flow sheets providers system o Screening tools Communication and sharing of information Reliable, effective, user- friendly EMR Specific templates in EMR with prompts of test dates, risk factors, etc. Opening up EMR to all “circle of care” Guidelines embedded in EMR 2. Primary Care Engagement (Tied with System Navigation) (13 Votes)

Process to engage primary care providers not in CHC/FHT

3. System Navigation (Tied with Primary Care Engagement) (13 Votes)

System navigation One referral System navigator The process for the to help utilize vascular network should programs and be a lot quicker than foster sending a referral collaboration Easier access to many other health professionals (e.g., through groups, geography, video/telephone chats) Dedicated resources (person) to coordinate vascular programs o Avoid duplication of programs o Tract outcomes Subject matter “Champions” “Experts” Ease of access Streamline referral process

Vascular Health in Southeastern Ontario 2012

HPE: Primary Care Think (Needs) CHC FHT SOLO/FHO Other & NP

4. Common Evidence-based Guidelines and Standardized Screening (12 Votes)

Integrated guidelines Collaboration of Using evidence-based o What is needed? guidelines…confusing for guidelines o Common guidelines practitioners and clients (C-CHANGE) Increased screening for clients at risk- early identification, early intervention 5. Data Mining (12 Votes) EMR should be able to pre- EMR-Pulling populate with hypertension data and guidelines for diabetes and statistics from non-diabetes ER for Should be easier to pull programs (time information out of the EMR and staff) through searches, so if history show high risk-should be easy to follow To ensure patients have milestone weights, blood pressure readings, cholesterol levels (evidence-based) Patient history placed in EMR should pre-populate exactly what the patient needs 6. Collaboration and Community Partnerships (11 votes)

Coordination of cardiac Elimination of silos of care – Community level Collaborative services including rehab better feedback from collaboration on CHC models Sharing of programs within community agencies programs (FHO, CHC, sharing other CHC/FHT/etc. Cooperation between FHTs, NPLC, etc.) services and Tools to facilitate easier inter- etc. to offer variety of Centralized: resources agency cooperation programs o Smoking Partnerships Access to programs Involve Public Health cessation with Collaboration between clinic community organizations and agencies based programs Integrating with Public Health Linking with and other community community resources resources / partnerships Prevent duplication 7. Measurement, Quality, Evidence-based Indicators (11 votes)

Common indicators to Data/quality funded person to Ability to extract data Standardized measure success for current evaluate measures from EMR’s quickly to metrics and strategies monitor lead and lag indicators (to Common approach to data measures to reach measure impact) collection and indicators specific goals (i.e., number of patients with BP on target)

Vascular Health in Southeastern Ontario 2012

HPE Primary Care Think Tank (Needs) CHC FHT SOLO/FHO Other & NP

8. Patient Centred (10 votes)

Combining Group sessions Self-management Patient based/focused programs to meet Internet – Twitter approach (for long programs needs, (e.g., Patients should be made aware term sustainability diabetes and that they are ultimately results) hypertension) responsible for their health care Patient engagement People have diseases; diseases don’t have people 9. Leadership Resources (9 votes)

Resources needed -TIME: o To learn about vascular health o To collaborate on project o To develop tools o To do the surveillance on patients o To do the analysis Resources needed: o people with awareness, knowledge & interest o people with positive attitude for change o Motivation 10. Public Education (6 votes)

Posters on risk Education to further knowledge Focus on healthy factors/prevention in prevention, promotion lifestyles for Some patients have basic health individuals, families literacy (e.g., what “vascular” and communities means) Increase use of social media for education 11. Interprofessional Collaboration within Team (6 votes)

Multi-professional Interdisciplinary Shared involvement team multidisciplinary (team) Centralized group resources (to reduce Dietitian counseling redundancy) 12. Public Policy (4 votes)

Coordinated Remove the financial penalty if a Social policy to help approach to patient misdiagnosis myocardial health vascular disease infarction/stroke and calls 911 Long term plan to prevention with Healthy public policy – foods, address next emphasis on youth active living, etc. generation, it is too late and involving Evidence-based health for us – related to: schools, primary promotion strategies (e.g., o Obesity care and public Ottawa Heart Institute smoking o Inactivity health cessation model) o Lousy food More resources for o Smoking health promotion o Alcohol

Vascular Health in Southeastern Ontario 2012

LLG Primary Care Think Tank (Needs) CHC FHT

1. Public Policy (Public Policy, Advocacy); Funding & Resources (33 Votes)

Access to collaborative primary care for everyone More resources (people) to meet increased needs once (transportation) identified Transportation – rural areas – FOR ALL Drug coverage for all cardiovascular and diabetes Policies that address the Social Determinants of medications Health – safe place to live for example o How to know which ones cost the least Nursing and primary care for frail seniors in their Worker-friendly programs homes – monitor nutrition, blood pressure, blood o Hours work o Schedules Ambulatory primary care for seniors Working poor Seniors – get together o Medications o Local – community centre o Where to go for help with costs o Walking together Resources for mental health – a barrier to care o Volunteer work Physiotherapy and coverage Gardening with local schools Community-based (accessible) recreation FUNDED – gardening Funding for exercise Comprehensive basic dental care 2. Healthy Lifestyle (e.g., Nutrition & Activity) Community/Primary Care/Specialty Clinics (18 votes)

After school programs Exercise/trainer availability Children/Youth School-based programs o Physical Activity Family-centred initiatives o Nutrition Nurse Educator who coordinates Policies that limit portion sizes – (e.g., bottled drinks) o Physical activity Teenagers – exercise programs o Lifestyle change o In each small community o Goals of treatment o Funding for equipment or snacks Community—based program (e.g., kinesiologist and staff) o Health topics, ie, smoking, drugs o Not just for people who have had events – primary o Volunteer work – clean up, community prevention care focus Nutrition and activity programs in all schools o Health care-based monitoring As “usual care” – activity/exercise Motivation and Education o Primary Care Providers provide Weight management clinic prescriptions and follow-up – parents/children Coordinated Community Vascular Health Centres: o Exercise o Healthy food/nutrition o Smoking cessation o Preventive medications for diabetes, CHF , Atrial Fib, renal risk, acute coronary syndrome Accessible activity and organized sport for youth o Activity/sport/nutrition for youth o Food/nutrition o Activity best practice primary care provider prescription for families and youth Coordinated Primary Care & Community Leaders/Business – “Health Programs for our Kids”

Vascular Health in Southeastern Ontario 2012

LLG Primary Care Think Tank (Needs) CHC FHT

3. EMR / EHR (14 Votes)

EMR that is intuitive and alerts based on Consistent assessment and documentation harmonized guidelines Integrated EMR (gather data, reports, consistent way to Universal screening tools (integrated into EMR) communicate) One medical chart accessible across the system EMR-Good flow Communication between providers (EMR) EMR o Reports o Evaluate Progress o EMR guideline integration EMR photo capability Ability to extract information from EMR Unified EMR o Hospital/lab/x-ray/primary care team/speciality care/CCAC o Discharge, diagnostic imaging o Proven tools o Electronic record goes with patient EMR-patient tools o Link to social media (e.g., APPs) EMR to identify individuals for screening/monitoring EMR reports Time Flow Sheets 4. Communication and Coordinator/ System Navigator (12 Votes)

Better communication System navigation for patients o Electronic and otherwise between various Case Managers providers – Primary Care /CCAC/Long o Navigators with links to community resources to assist term care /hospital/specialist patient with system/resources follow-up Coordination between community health resources Awareness of who does what o No duplication across system When something works – how to spread it OTN use more 5. Tools for Providers (8 votes)

More standardized Guidelines geared towards multidisciplinary teams o Patient education Consistency: o Patient identification (screening) o Assessment Timely access to diagnostic tools (imaging) o Process for identification and intervention of at risk Way of assessing impact/evaluation patients Simplified guidelines incorporated into unified single EMR for: o Cardiovascular disease /vascular health o Diabetes o Chronic diseases o Cancer screening Medical Directives: o Diabetes o Lab requisitions More Medical Directives Tools for outcome measures Implementation tools that have been validated and we know work Ongoing education support for programs Buy-in by all members of the FHT

Vascular Health in Southeastern Ontario 2012

KFL&A Primary Care Think Tank (Needs) CHC FHT Other 1. Quality Improvement/Data & EMR (EHR)/Infrastructure & Methodology (25 votes)

1 or 2 measures to assess process Working knowledge of EMR EMR and associated training and quality One EMR only support Expert/ patient/client working EMR data and feedback Universal Health record with quality improvement All agencies linked electronically accessible by any provider and Reminders for providers to Data mining patient screen, ask and help Common interfaces Infrastructure for quality Easy to use EMR improvement related to vascular health Plan/Study/Do/Act 2. Integrated Vascular Health Programming & Community Partnerships (21 votes)

Access to healthy food Designated team members who work Skills coordination resources to Transportation with clients on health behaviour support joint planning and program Nicotine Replacement changes and self- management evaluation Therapy/medications to assist programs Family-based programs with smoking cessation Adequate staffing to accommodate all o Nutrition Services from “cradle to grave” Staff to run adolescent health program o Activity at FHT Virtual team approaches where no Better partnerships for food security primary care team is in place-share – Partnership with community partner organizations for life skills training Collaborative entities (e.g., cooking classes) Programs close to peoples’ homes Partnerships with exercise facilities Sustained partnership/joint and/or kinesiologists to help patients initiatives for vascular health: develop exercise programs Primary care organizations, schools, Free community activities to promote public health, chronic disease exercise and health for all ages networks Adequate resources-health promotion Knowledge of the system by health materials care provider and primary care Partnership with schools – health organization promotion Integration with Public Health programs Ottawa Heart Institute-like validated tool for health living (e.g., exercise) 3. Clinical Tools/EMR (Risk Factor Screening, Integrated Clinical Guidelines, Assessment tools (18 Votes)

Access to point-of-care testing Blood pressure checked and recorded EMR: Health Information Network Reminders for providers to: in EMR every 3 years (Personal Health Medical Record) screen, ask, help o Screening for hypertension o Measuring whether we are doing this Ways to collect data from EMR to identify those with risk factors Registry of patients with risk factors System identification of patients at risk Tools integrated in EMR o Framingham (consensus-do we use Framingham or Reynolds Risk Score o Whether patient should be on ASA

Vascular Health in Southeastern Ontario 2012

KFL&A Primary Care Think Tanks (Needs) CHC FHT Other 4. Family/Patient Ownership & Self-Management/Motivational Interviewing (13 Votes)

Engage families Every patient has at every visit-ask Personal Health Record Exercise, healthy living what they are doing to improve their EHR that is OWNED by the person programs health and what they would be Motivational interviewing willing to try Patient buy-in compliance Ways to keep patients interested & motivated More video programs for office and waiting rooms Patient education- program/identified target group/goals More self-management courses Model-embraced by all involve including patients Parent education on childhood eating, exercise, obesity Family exercise activities The exercise component-trained resource facility Patient education program: identify target group and set goals Consistent communication with patients at risk 5. Provincial Incentives/Social & Public Policy/Education (13 Votes)

How to combat cigarettes Consistent guidelines Provincial initiative to really deal bought on the reserve Public school programs to teach with: Grassroots, in the community, cooking and activity o Obesity on the street: blood pressure Consistent messages-provincial, o Smoking monitoring regional, local and team-wide o Inactivity Robust programs (e.g., integrated o Bad diet with community resources) o Alcohol Tax incentives of relief for access to Not only run by Health Unit but gyms, YMCA, etc. with Social services, etc. Need a Ongoing free smoking cessation generational change, longer than 1 nicotine replacement election cycle Integration with local gyms tied to Appropriate polices personalized training programs Make McDonald’s, etc. pay Sell the vision additional taxes to account for Connections/partnership disease caused by their “food” Less duplication Unified message/strategy for our region 6. Interprofessional Care & Education/Work to Full Scope of Practice (7 Votes)

Working at top of scope of Interdisciplinary teams Equal access and provision to practice-education to support Pharmacist (medication services across our region Lead education programs reconciliation) o Physicians, NP, RN,SW, Integrated interprofessional Dietitian approach for “specialty” clinic Providers working to full scope (hypertension, diabetes) Trained multidisciplinary health professionals

Vascular Health in Southeastern Ontario 2012

KFL&A Primary Care Think Tanks (Needs) CHC FHT Other 7. Resources Used Differently (6 votes)

Sharing of resources More administration support to contact target populations initially Expand focus of data entry people 8. Access to Primary Care (6 Votes)

Every person in Ontario has a primary care provider who asks if they smoke, checks their blood pressure and manages their diabetes 9. Resources and Funding Models (5 Votes)

Funding source for transportation Money Money to programs Different funding models or more Funding Subsidized funding for access to money YMCA programs Resources More funding for those out of work Transportation resources on Ontario Disability Support especially in rural areas Program for diet support for all More RNs/RPNs participants and not just those More nursing staff to do the with disease education 10. Local Control for Decision-Making (5 votes)

Indigenous health programs Give FHT and CHC more authority Local control-Facilitative process Community-based health care on how to spend Ministry money (e.g., which staff to hire, programs to run) 11. System Navigation (1 vote)

Case managers for hard to serve System navigation Note: HPE: Hastings & Prince Edward Counties LLG: Lanark, Leeds & Grenville Counties KFL&A: Kingston, Frontenac, Lennox & Addington

Note: CHC: Community Health Centre FHT: Family Health Team NP: Nurse Practitioner-Led Clinic FHO: Family Health Organization

Note: Information taken directly from participants’ written statements

Vascular Health in Southeastern Ontario 2012

Appendix G

3 Action Plans for 3 Local Areas

HPE Action Plan: EMR How Enablers, Barriers & Sustainability Who / Timeline How To Measure Success Needs Local hospital(s) identify ‘primary care provider’ for hospital Barriers: Different EMR Access visits/tests, etc. Hospital, primary care, IT coming together Electronic data transfer to and from: Radiology/diagnostics, “Billing system of MOH” not Reduce duplication hospitals, specialists up-to-date with scope of Local Plan practice Patient satisfaction Shared health information between organizations Shared patient profile between organizations Enabler: System integration Time to receive reports Shared standard flow sheets/forms/tools

Regional As above Plan Put it into action

Provincial Implement and fund Plan Reduce barriers for NP, Midwives to request referrals, diagnostics, etc.

HPE Action Plan: Primary Care Engagement How Enablers, Barriers & Sustainability Who / Timeline How To Measure Success Needs Health Care Integration Committee – move meeting time to 3- Barriers: Time (to attend) 5pm or 4-6pm to facilitate MDs attending Dr. Jonathan Kerr Silos of care

Surveys to primary care providers – obtain feedback/ideas Threatened Local Plan Find ways to collaborate between groups (after hours, etc.) New / change Primary care lead visiting/contacting primary care providers Re-brand CHCs as community program provider

Primary Health Care Council of Southeastern Ontario

Primary Care Lead collaborating/communicating with:

Regional o Vascular / Stroke Plan o Southeastern Ontario Health Collaborative o Diabetes o CCO Primary Care Lead Committee (Provincial) Provincial

Plan LHIN/Ministry priorities - access

HPE Action Plan: System Navigation How Enablers, Barriers & Sustainability Who / Timeline How To Measure Success Needs Internal referrals – streamline internal referral process

External referrals – right person Mental Health – need for Health Promoter / Vascular Enabler: Navigation in health Local Plan Prevention in this high need group and Vascular Health promotion and in acute Programs/Strategies – accommodate mental health episodes Match need of patients to resources given

Integrate Stroke Prevention Clinics with Diabetes programs, Vascular Health Regional Plan Health Providers in hospital – facilitate discharge (local hospitals) Resources – e.g., who is doing what? (like KGH specialist list) Wait time – for referrals

Provincial Funding for “Navigators” – hospitals/FHTs/CHCs/Clinics Plan

Vascular Health in Southeastern Ontario 2012

LLG Action Plan: Public Policy How Enablers, Barriers & Sustainability Needs Who / Timeline How To Measure Success

Promote better utilization of existing resources (public health) “Big policy changes too difficult” through communication and collaboration – both ways: Primary Care <-> Public Health <-> Primary Care. Examples: “We can do smaller things locally” o Primary Care doesn’t always know what’s out there Local Plan and Public Health often has a lot going on already o Students Breaking down silos

Inventory of services and programs for professionals – link to EMR Regional Plan Provincial Plan

LLG Action Plan: Healthy Lifestyle How Enablers, Barriers & Sustainability Needs Who/ Timeline How To Measure Success

Lifestyle change programs with defined goals and measureable outcomes Self-management groups/plans Problem with sustainability with only volunteers, therefore need funding Local Plan Recognizing barriers created by rural settings – it’s different for rural areas and requires different types of programming Coordination of different types of programming within a community (e.g., nutrition, activity, etc.), “Not in a vacuum but between groups” Regional “Chronic Disease Prevention” – implementation of Provincial Enabler: Buy-in by local school boards Plan Plan Focus on programming at all levels throughout the province in order to plan for funding and sustainability Moving away from physician-centred model to patient-centred Measure costs in MD model visits/imaging versus allied health (e.g., PT) Provincial Plan Measure waiting lists for specialist

Look at vital sign results (blood pressure)

LLG Action Plan: EMR How Enablers, Barriers & Sustainability Needs Who/ Timeline How To Measure Success

Policies for consistent documentation (input of information) Barrier: Different practice patterns All health # extraction errors providers when pulling data Local Plan reports Universal screening tools accessible through EMR Enablers: Agreeing to guidelines Increased ability to gather meaningful data Software and qualified human resources Regional Integrate EMR with other agencies and hospitals Barrier: Privacy issues EHR Plan Provincial Sharing/knowledge transfer between providers, agencies Barrier: Software licensing 2015 (EHR) Plan

Vascular Health in Southeastern Ontario 2012

KFL&A Action Plan: Quality Improvement /Data/Infrastructure Methodology How Enablers, Barriers & Sustainability Needs Who / How To Time Measure Success Develop infrastructure for local reporting –including education/training Barriers:

Local Plan Good data in; in the right place Multiple EMRs Multiple providers

Lack of standardized orientation How Enablers,to Barriers uses of & EMR Sustainability Who Time Line How To Measure EMR Needsinitiation Success Enabler: Enforcing input Regional LHIN collectsIntegrated and shares Vascular Q1 data Health wit Programmingh Primary Careand Community FHT/CHC Partnershipss, Public Health Barrier: Plan Sharing of existing EMR templates/flow sheets, etc. (may be a local plan) Multiple EMRs o Identify local resources then use, eg, CHC Diabetes Education Centre – increase exposure, Built in reporting tools in new releasesreferrals of EMR from all clinics E-Health Ontario

Common Qualityo ImprovementGroup clients methodology with similar (vascular) (this should health problems be a regional seek advice plan too) Interoperability of EMR

Common indicators/benchmarks Risk of EMR not provincially o Clarify roles of providers regarding vascular management, eg, self management done by one funded – no control over specs Provincial provider Plan Barrier: Province not funding data

Define roles of team members in a vascular strategy input/analysis

Local Plan o Coordinate services – Public Health, Primary Care, etc KFL&A Action Plan: Integrated Vascular Health Programming & Community Partnership o Prevention programs –How increase local access; meet with partners Enablers, Barriers & Sustainability Needs Who / How To o Activity Time Measure o Smoking Success o Nutrition Identify local resources then useo ( e.g.,Reduce , CHC barriers Diabetes to programs Education Centre) – increase exposure, referrals from all clinics Group clients with similar (vascular)o Ask health patients problems what is needed? then seek advice o What will help you to change your lifestyle to improve vascular health Clarify roles of providers regarding vascular management (e.g., self -management done by one provider) Define roles of team members in a vascular strategy Local Plan Coordinate services – Public Health, Primary Care, etc. Prevention programs – increase local access; meet with partners Regional Plan o Activity o Smoking o Nutrition Reduce barriers to programs Ask patients what is needed? o “What will help you to change your lifestyle to improve vascular health” Regional Plan

Provincial Plan

KFL&A Action Plan: Clinical Tools/EMR/Integrated Guidelines

How Enablers, Barriers & Sustainability Needs Who / How To Provincial Plan Time Measure Success Educate all staff as to how to capture relevant information so it can be mined, e.g., me weight, BP Local Plan EMR should include tools to evaluate cardiovascular risk (e.g., Framingham; ?others) – need to have consensus Consider how to set up a hypertension screening program for our FHT – evidence that it is worthwhile Regional Consider for patients identified with hypertension to have such patients handled within Plan our health team re: education/management and then liaison with Heart and Stroke if this is of use LocalProvincial Plan Plan Note: Information taken directly from participants’ written statements