Mary Berglund Community Health Centre HUB – Quality …



Strategic priorityStrategic ObjectiveactivitiesProgress reportMBCHC Efficiency and EffectivenessEnhance communication within the health centre, the community of Ignace and with partner organizations.a.)Foster a cohesive and integrated team within the organizationb.) Develop improved lines of communication within the health centre team, the community of Ignace and with partner organizationsc. ) Provide regular QIP and staff reports- face book page updated regularly- back end of website experiencing glitches and unable to upload, update data. Working with site set up administrator to redo initial programming- QIP submitted. Team meetings have regular QIP discussion. First quarter shows significant increase in target numbers. New process in place for follow up on client indicators- Met with Metis First Nations to discuss partnership in community support programming. Presentation to team on services offeredMBCHC Efficiency and EffectivenessAttract, retain and develop skilled employeesa.)Use online advertising. b.)Partner with the Dryden Regional Health Centre`s recruitment initiativesc)Strengthen and ensure access for training and development through knowledge development strategies.d) Support staff members in personal development skill training- All positions posted are advertised in newspaper and online- Advertised for ft and pt with HFO for Physician recruitment- Discussions with 3 new Physicians.- Developed return to work plan for NP. Modification to onsite hours to include 2 days per week out of the Health Unit space in Vermillion Bay- 2 staff members attended Foot Care Course in Winnipeg- RN attended Stroke Summit in Thunder Bay- 3 staff members attended AOHC Conference in Toronto- Support Medical Records Clerk in ongoing education at Confederation College- 1 new Physician recruited and had a week Locum at Health Centre- Discussions with a Telemedicine Family Practitioner for potential services to Ignace- tuition support provided to Social Service Worker to enhance education - 2 internal staff persons promoted to advanced roles with departure of Admin Assistant. additional support and mentoring provided.-NP position will be vacant as of end of October. Recruitment strategies put in place. Ads placed on Indeed, Monster, Kijiji, Thunder Bay, Kenora and Dryden newspaper, HFO, Nurse Practioners Association of Ontario,-full day Skill Path Seminar arranged in September. All staff attended. -Alliance for Healthier Communities Privacy Lead presentation to staff onsite- 2 staff attended Dementia assessment training- Advance Care Planning Training for 2 RN’s- Memory Clinic Training 4 team members- DBT training for social worker- Nurse Practitioner hired with start date of April 8, 2019- Variety of recruitment efforts for NP position (kijiji, job monster, linkedin, indeed, facebook, ads in Dryden, Kenora, Sioux Lookout, Thunder Bay- Active offer training for all team members for FLSMBCHC Efficiency and EffectivenessContinue to improve access, safety and qualitya)Evaluate programs and analyze attendance at existing programs to ensure proactive approaches to new/refreshed program offersb)Provide holistic, proactive and reactive person centred care and support Community Garden expansions including the addition of chickens, bunnies and ducksProgramming with the school at Garden. Students planting2 classrooms at school partners in the introduction of the animals at the garden. Eggs and incubators kept in classroom. Baby bunnies in the other. Opportunity for students to learn and take babies home for weekends.Focus group held at Food BankLuncheon program offered at local church in partnership with MBCHC for food bank clientsFunding for expansion; chicken, rabbits, and aquaponics, additional raised garden bed: -Ignace community garden – Rotary ClubParticipated in Seniors FairSubmitted Health Canada Proposal for youth substance use programmingHealth Links process map, referral form, and workplan createdHealth links team meeting establishedFocus group held at Food Bank for transportation concernsSurvey of transportation access to Health Centre completedMBCHC Efficiency and EffectivenessMonitor trends and gaps in service, within the context of the model of health and wellbeing and health equity.a.) Participate in regional and provincial surveys to gather knowledge about health and wellbeing and health equity within the community/regionb.) Advocate for supportive housing for seniors to remain independent in the local community, and provide primary care services at home in their homes as appropriatec.) Assess health care transportation needs for our clients and work toward public transportation system with the municipality and the private sectord) Explore opportunity for meals on wheels program within community- Monthly ED meeting with Northern CHC’s- Met with Patricia Gardens, Metis Nation, Princess Court to discuss community support services programming expansion for Ignace- Proposal submitted to LHIN for Community Support Services which includes Meals on Wheels, Assisted Living Services, Transportation, Home Help etc.- Purchase taxi vouchers for Exceptional Circumstances Program- Partners in Care Program initiated to support clients experiencing complex or terminal diagnosisHome visits provided frequently by Physicians, NP, Nursing, Health Promoter, Social Service Worker- Travel grant facilitation and completion with multiple clients-Pilot Meals on Wheels program advertised. 1 client has expressed interest. Will continue to promote program-Discussion with Henry Wall, CEO of KDSB around models of Housing- transportation gap with local Taxi retirement. Survey and focus group held. - Meals on Wheels program planning continuesMBCHC Efficiency and EffectivenessChampion evidence based and innovative practices which consider diversity and health equity.a.)Strengthen competencies and capacity to ensure culturally relevant services and supportsb.)Include a focus on family health through family wellness programsc.)Implement best practices to improve patient careMultiple staff attendance at education events for leading best practicesFrench Language Services Plan submittedFLS committee establishedFLS Plan completedHealth Links Processes developedOTN use for Francophone Interpretation ServiceReview of FLS plan submitted for 2018. Updates completedActive Offer training for all team members for FLSMemory clinic program established. Client and family focused with involvement from caregiverHealth links case conferencingCertified Diabetes Educator MBCHC Efficiency and EffectivenessExpand the use of technology to reduce barriers and increase service accessa.)Develop use of social media to improve communications with clients and communityb.)Monitor and advance the use of e-health initiatives such as OTN home based carec) Implement PS Suites Software to replace existing Nightingale d) Develop and implement public websiteFacebook page updated regularly. Increased useExpansion of OTN appointments on Mondays and Fridays for NP working off site in Vermillion BaySigned agreement for HRIS implementation for payroll, HR functionsInitial discussions with Dr. Laith Mahdi to provide OTN locum Physician CoverageWebsite fully operational. Experienced many “back end” issues which would not allow for edits to the site. New materials have now been posted.MBCHC Efficiency and EffectivenessContinue to develop and promote service and program improvements and efficiencies through quality processes. a.)Complete regular community client satisfaction and client experience surveysb.) Gather knowledge acquired in client satisfaction surveys to identify ways to improve care and servicec.)Refresh and Use marketing materials at community events and screening clinicsd) Implement regular QIP team meetingse) Establish process to share satisfaction results more broadly- Feedback forms in waiting areas, on website- Signage updated to incorporate French Language- Annual Report created- Satisfaction survey revised. New process implemented to obtain feedback on an ongoing basis following client appointments. - all processes for MSAA and QIP indicator reporting has been refreshed. New process well established MBCHC Efficiency and EffectivenessContinue to provide resources to Board of Directors for development as a governance leader using a generative, strategic and fiduciary governance framework.a) Provide in depth board orientation to members.b) Provide clarity around structure and processes.c) Ensure best use of time through meeting structured) Seek resource to provide a one day retreat for all Board Members on generative insight and thinkingNew Board Member recruitedMeeting agendas include time allotments for topicBoard packages sent out minimum one week in advanceBoard materials presented on screen during meetingsAnnual board evaluation revisedBoard calendar edited and revisedBylaws reviewedProactively Manage Growth and Sustainability1.Work with partners to introduce and support system changes that strengthen services to be more client focused, better integrated and tailored to the needs of people in Northwestern Ontario.a.)Develop relationships by inviting existing and potential partners to dialogue at the Board level b.)Explore the most timely and cost effective method to relocate the current facility to a more centrally accessible location and with a rent that does not exceed NW LHIN approved funding locationc)Plan and monitor service growth and/or realignment within the NW LHIN Blueprintd) Engage in Health Links initiativee) Actively participate on Dryden Integrated Health Care Organization Modelf) Participate as a member in the Regional Seniors Steering CommitteeStaff and ED members of steering committee for Health Links. Co chair Kenora Sub Region Health Link Steering CommitteeMet with NWLHIN rep for Health Link to discuss process within our regionCreated process map, work plan and referral form for the regionActive participation from ED and Board Chair on DIHCO model. Second “alliance” model has been developed and proposed. ED a member of the Regional Seniors Steering CommitteeRepresentation on Policing and RFDA CommitteeIntroduction of MBCHC and discussions with new CEO of the LHINMeeting with township and ED of Regional Food Distribution Assoc. to discuss potential partnership for Food Bank expansion and possible food distribution plantDiscussions within DIHCO working group members to work on a joint proposal for high risk housing, similar to unit that was opened in Sioux Lookout this summer. Discussions with NWLHIN for potential to embed Care Coordinators in Primary Care. Expression of interest submittedED member of Sub Region Planning TableMembers of Healthy Communities Working GroupProactively Manage Growth and Sustainability2. Embed value for money into our program and service plana.)Define core services and align resources to respond to the changing needs of clients and our community(ies)b.)Engage clients and communities in system planning and designc.)Explore opportunities for "Community Capacity Building" (with KDSB- social housing, welfare, day care, etc...)d.)Develop and maintain programs and services that reflect actual community needsSubmitted proposal to Health Canada for a joint partnership with community agencies around substance misuse. Discussions held with agencies involved. KDSB, OPP, NWHU, SchoolsDiscussion with DSAAB to express interest in partnership for housingFocus group held with clients of Food BankExpansion of Pilot Project on Care Coordination/System Navigation to include involvement in Health Links Approach and Partners in Care For Cancer initiativeNew programming initiated at schoolDiscussions with Recreation Programmer for township. Partnership in programmingProactively Manage Growth and Sustainability3. Ensure services are accessible and equitablea.)Meet with NW LHIN for direction on a new facilityb.)Explore and act on opportunities for a new facilityc.)Design services in a location where people can access care and programsd.) Continue to provide community screening services and outreach services - Car seat clinic held at plaza- Blood pressure checks held at Senior Fair- Programming held at school with Kids Zone, Youth Zone, Teens in Motion- Continued outreach to clients in home, including foot careProactively Manage Growth and Sustainability4. Demonstrate strong fiscal management so that we may maximize the value we achieve for the tax dollars entrusted to us.a.)Optimize the use and management of our financial resources b.)Actively seek out new and more diversified funding sourcesc.)Proactive strategies which include community initiatives, grant applications and transitioning to a more integrated health care system d.)Monitor MSAA Targets and ensure staff and Board are continuously apprised of target achievement status.- Grant application submission to Health Canada, Rotary Club, Thunder Bay District Service Board, Kenora District Services Board, NWLHIN- MSAA targets monitored monthly and posted for staff - Cost analysis completed on houses-Participated in 3 sessions for Recruitment and Retention Funding through MOH-Reviewed Salary Grid -Regular monthly monitoring and assessment of financial statements-Regular huddles with team to discuss targets and strategize improvement initiatives-Client lists reviewed and updated-Call back process for RN client follow up on screening indicators- Funding grants provided by NWMO, Rotary Club, KDSBSupport Individual and Community Wellbeing1. Demonstrate the value and the impact of the Model of Health and Wellbeing on the improved health outcomes and experience of people and communities.a.)Use the CIW as an intake tool to help evaluate and develop strategic activitiesb.) Ensure all policies and procedures reflect Best Practice Guidelines and endeavor to be abreast of the development of new researchc.) Empower clients with knowledge so that they may make the best choices as per their intentions, and optimal functional competencies.d.) Evaluate care, services and programs, with clients and within and across teams, on an ongoing basis.e) Engage in Health Link Initiative to develop common care planning across the continuum - Regular policy review process in place and are updated -. Work continues on development of a policy and procedure manual with new template and table of contents- Met with HR Downloads consultant to discuss creation of a policy manual. - Hired consultant to develop one policy manual. All current policies being reviewed and revised- Draft policy manual created- staff development and training strongly supported within organization. Budget set for development and training- regular evaluation of care, services and programs completed throughout the year- discussions at monthly staff meetings on success and challenges- care conferencing initiated for Health LinksSupport Individual and Community Wellbeing2. Reduce the impact of povertya.)Actively work in partnership with other organizations and sectors to reduce the impact of poverty by advocacy, development of services in geographic regions where use of the health system is highb.) Share information with staff and Board about the provincial role of the Association of Ontario Community Health Centres and Aboriginal Health Access Centres( AOHC/ AHAC), and how knowledge acquired from our association supports our health centre in knowledge development and growth of our local health centre3 staff attended annual AOHC conferenceMet with Patricia Gardens, Princess Court, Metis Nation to discuss potential partnershipsMeeting with KDSB held to discuss district homelessness and povertyContinue to participate in AOHC webinars and info sessionsWork continues within DIHCO working groupCompetency training completed by Executive Director for Situational TableParticipate in Kenora Sub Region planning tableContinued work with Regional Food Distribution AssociationFood bank every second Thursday. Meal provided at each. Health teaching applied as a principle at the food bankContinued expansion of the Community Garden. Multiple learning activities at the school for garden, planting, animals Support Individual and Community Wellbeing3. Reduce the impact of obesity as an underlying cause of chronic disease.a.)Improve the quality of food available at the food bank by working with Regional Food Distribution Association(provide opportunities for a hand up as opposed to a handout)b.) Explore developing community kitchen opportunities and working with at risk populations- Partnership with school in planting at community garden- Provide local moose meat at Food Bank- Loonie lunch at school partners with Food bank to donate homemade soup which is made available to clients-Partnership with church, school to donate to the blessings in a knapsack program.- fresh veggies and fruits for Food bank, donate from RFDA-monthly essential vouchers for Food Bank clients to purchase, milk, eggs and bread.-clinical outreach clinics at Food bank-Increased work and partnership with RFDA on program improvements and expansion- Health Promoter member of board for RFDA. Attending regular meetings and conference- Applied for grant to sustain moose meat program. Received monetary grant from NWMO and Rotary Club to finance program for another fiscal year. Support Individual and Community Wellbeing4. Develop “place making” as a way to increase a sense of belonginga.)Seniors housing develop new partnership with KDSBb.)Host annual events at the local level as part of the AOHC’s provincial strategy, eg Community Health and Wellbeing week c.) Continue to enhance local initiatives for sports activities and cultural events- Community garden continues to grow and expand- Youth Zone, Kids in kitchen, Tween strong, Teen Strong- home visits to reduce isolation , and increase healthy activities social and physical- Community engagement session held for community garden expansion-Community Harvest Dinner held during Community Health and Wellbeing Week. 5. Provide support to new parents to establish healthy behaviours and relationships in developing families.(NEW added to strat plan Jan. 2018)***Provide supportive care through programmingCompletion of well baby exams at appropriate intervalsProvide and monitor vaccinationsEncourage breast feedingMonitor for maternal/parental bondingProvide support between well baby visits for any concernsProvide baby box and education for safe sleepingPositive relationships established with expectant mothersWork with suppliers to obtain samples of medications, vitamins and formulaGrant funding received to sustain Baby Box program for another yearVaccinations provided and monitoredComprehensive pre and post natal program establishedRN supported in expanding education around pre and post natal careSupport Individual and Community Wellbeing6.Embrace and support cultural diversitya.)Enhance service approaches that promote social inclusion and respect cultural needs, diverse traditions, heritage and experiencesb.)Contribute to the development of healthy policy through advocacy for First Nations peoplec.)Develop culturally and linguistically appropriate programs for Aboriginal and Francophone peopled) Develop FLS requirements into policies, Board bylaws and strategic plane) Implement suggested Francophone identification questions in registration process.f) Refresh Community Health Advisory Council to include Francophone and Aboriginal component.e) Explore opportunity for partnership with Dryden Native Friendship Centre- French language signage ordered- - Met with Dryden Native Friendship Centre/ Metis Nation to discuss future potential partnerships- French Language Service Plan has been created- Canada Day Celebration booth/ float/ presentation on summer activities- ED met with LHIN FLS representative- Participated in FLS Region Meeting- FLS requirements in policies, bylaws and strategic plan- Active offer training mandatory for all team members- initial discussions in creating an Indigenous Services Plan-RN attended training session at Dryden Native Friendship Centre for Maternal Care- Several attempts to refresh Community Advisory Council. No attendance from communityBuild Awareness and Ownership in the CHC Model of Health and Wellbeing and Health Equity 1. Raise awareness about the effectiveness of our centrea.)Continue ongoing media, news releases and advertisingb.)website and social media (Facebook), Newsletter, ongoing reports to the Driftwoodc) Develop community engagement strategyd) Explore additional opportunites to engage communitye)Health and Wellness Fair, Harvest Dinner- Facebook page updated regularly- Annual Report Booklet developed and circulated within community- Community Harvest Dinner well attended. Annual reports circulated at each table- focus group held at Food Bank- Orientation sessions initiated - Ignace Discussion Group used to provide informationBuild Awareness and Ownership in the CHC Model of Health and Wellbeing and Health Equity 2. Increase Membership Numbers.)Face to face presentations: screening clinics; b.)Ongoing membership drives;c.)Educate and inform the public about the importance of community engagement and capacity buildingScreening clinic in town plaza, grocery storeParticipation in Seniors Fair2 focus groups heldPartnership with school for expansion of community gardenBuild Awareness and Ownership in the CHC Model of Health and Wellbeing and Health Equity 3. Leverage data information and evidencea.)Use reports and information from AOHC/NWLHIN to better understand and improve our performanceb.)Share knowledge and information across the Dryden Local Health Hub and as appropriate with our partnersreports submitted to NWLHINRegular meeting with DRHCParticipation in sub region planning tablesED participant in Regional Dementia Capacity planningED participant in Regional Seniors Steering CommitteeBuild Awareness and Ownership in the CHC Model of Health and Wellbeing and Health Equity 4. Play our part to support the AOHC to advocate for the CHC Model of Care and Health Equitya.)Demonstrate our value by actively participating in advocacy group discussions to share knowledge about the CHC Model of Health and Well-being to other communitiesb.)Advocate strongly for priority populationsc.)Create local and regional awareness about the CHC Model of health and Well-being by sharing: - Our Vision for the future - The successes of CHC`s - The contributions of our dedicated Employees3 staff members attended AOHC Conference in June. Each person participating in various advocacy and group discussion on the model of Health and WellbeingUtilize social media to promote awareness of modelDiscussions with CEO of NWLHIN re model of care at MBCHCHDiscussions at Sub Region Planning Table on model of care of health centresMet with Bob Nault to discuss model of care and priorities for the centreLHIN MSAA IndicatorActivityTarget17/18 Actual Q4 18/19 Actual Q1 18/19 Actual Q218/19 Actual Q318/19Actual Q4Comments/Reason for VarianceGeneral ClinicService Provider Interactions10,000105232729523275789794Target met within the variance allowance (9500-10500)6 months with no NP position filledGeneral ClinicIndividuals Served1,3001371811105912121305Target metTherapyService Provider Interactions1,800154040673611151477Below target. Complexity of clients, longer appointments, physio absences, vacation, changeover of pt staff. Discussion with LHIN regarding this. Target was negotiated for next MSAA to reflect TherapyIndividuals Served300350136194251300Target metHealth PromotionGroup Participant Attendance2,000212749597818582936Above target. This was a significant increase this year in the numbers in group attendance.Health PromotionGroup Sessions1001103766113173Above target. Significant increase in number of sessions held. LHIN CHC SpecificCervical Cancer Screening Rate42%57%68%77%74%76%Exceeded target as well as the NWLHIN and the Provincial CHC Sector averagesColorectal Cancer Screening Rate33%46%57%65%63%61%Exceeded target.Interprofessional Diabetes Care Rate99%99%98%99%98%99%Exceeding target as well as the NWLHIN and Provincial CHC Sector averages.Influenza Vaccination Rate21%34%40%41%49%54%Exceeded targetBreast Cancer Screening Rate41%52%65%88%86%80%Exceeded target as well as the NWLHIN and Provincial CHC Sector averages.Panel SizeAccess to Primary Care66%75%75%75%74%74%Exceeded targetHealth Quality Ontario Quality Improvement PlanAIMMEASURECHANGE IDEAMETHODPROCESS MEASURETARGETCURRENT PERFORMANCECoordinating carePercentage of patients identified as meeting Health Link criteria who are offered access to Health Links approach1)Regularly review data that captures complexity for our clientsPull EMR reports quarterly to identify potential Health Link clients through identification of number of visits, number of chronic diseases and emergency or hospital discharge notifications we are aware of.Data collection and reviewCollecting baseline-List of clients who meet criteria pulled from EMR.--Process map, workplan, referral form finalized-focus at Sept. staff meeting to discuss Health Links-Brochure shared with providers- New process established and in place. - Calls placed to book appointments with clients who meet HL criteria- 12 clients completed health link care planning2)Increase the number of health link clients who are identified by MBCHC staffEducate staff on criteria for Health Links supporting them in identifying those who would benefit from the approachNumber of potential health links clients103)Have Providers identify clients as they see them for regular care who may benefit from Health Links Approach and additional care planningTo ensure appropriate amount of time is provided to Providers to review chart and determine complexity of clientNumber of clients identified by providers as potential Health Link clients5 clients identifiedEffective TransitionsPercentage of patients who have had a 7-day post hospital discharge follow up. (CHCs, AHACs,NPLCs)1)Collaborate with regional hospital to ensure discharge summary is available within 48 hours after discharge.1. Formalize process for discharge summary completion with hospital.Number of discharge summaries received and followed up on90% of patients who are discharged from hospital who notification was received will receive a follow up appointment or call-100% of summaries received have been followed up on 2)Educate clients/caregivers to notify Health Centre when discharged from hospital. Encourage client involvement and self management.1. Discuss importance of client involvement in care at orientation sessions and during appointments. 2. Use newsletter to educate clients 3. Have clients identify a provider that they most often see at the Health Centre to ensure the MRP is documented for return correspondence from hospital.1.Number of orientation/educations sessions held 2. Number of education articles included through newsletter, web or other means 3. Number of clients registered to a Most responsible Provider (MRP)100% of new clients will have orientation appointment. A minimum of 3 separate educational opportunities/information will be provided to encourage involvement in care 60 % of clients will be registered to an MRP-23 orientation sessions-3 CPP update appts.3)Collaborate with hospital to develop discharge summary that includes all necessary information to ensure a seamless transition in care.1. Review current discharge summary form. 2. Reach consensus with DRHC on process to receive form and the necessary information required. 3. Collaborate on a process to ensure discharge summaries are received.Number of discharge summaries received with all relevant data included.Discharge summary and notification form are revised.Discharge summary form has been revised. Wound CarePercentage of patients with diabetes, age 18 or over, who have had a diabetic foot ulcer risk assessment using a standard, validated tool within the past 12 months1)Identify a wound care champion within the primary care team and explore opportunities for educational/skill development1. Identify champion. 2. Explore educational opportunities available. 3. Support wound care champion to enhance knowledge and skills by attendance at conferences and learning opportunitiesWound care champion identified and at least 1 learning opportunity is supported.1 Wound care champion will be identified and minimum of 1 learning event will be supported-RPN identified as wound care champion. Attendance at conference in Winnipeg- Telederm being utilized by clinical team2)Analyze current data for Diabetes and Foot Care Diagnosis on foot care appointments to ensure assessments being completed are being coded under appropriate diagnosis to pull data.Foot care nurse will complete diabetic foot ulcer assessment and document under Diabetes and Foot careNumber of diabetic foot ulcer risk assessments completedAll clients with diagnosis of Diabetes and seeing Footcare nurse will have an assessment completeFoot care nurse completing risk assesmentsPopulation health - cervical cancer screeningPercentage of Ontario screen-eligible women, 21-69 years old, who completed at least one Pap test in 42-month period.1)Increase screening ratesRegular data pull and chart reviewsPercentage of clients screened20% increase-Regular data pulls completed-Follow up process established. Clients are called by RN- Process initiated with the screening van. All eligible clients were called by RN to book appointments- trending above set targets2)Identify clients through chart reviewCall clients to follow up once chart review is completedNumber of appointments attended for the screening20% increase over current. Mar 31 2018 was 53%(target this year is 73%)3)Explore accuracy of EMR dataRegular data pull and chart audits to ensure EMR report corresponds and documented appropriatelyNumber of discrepancies noted20 % increase4)Any client diagnosed with cancer will receive ongoing follow up and support.1. Cancer diary will be established 2. Support and system navigation will be providedNumber of cancer clients identified who have received cancer diary and system support and navigation100% diagnosed clients will be offered this supportCancer binder and bags in place. Population health - colorectal cancer screeningPercentage of Ontario screen-eligible individuals, 50-74 years old, who were overdue for colorectal screening in each calendar year1)Increase screening ratesRegular consistent data pull and chart reviews% clients screened20% increase Mar.31, 2018 was 43% (target this year is 63%)-Regular data pulls completed- Clear follow up process established- trending above the target sets 2)Identify clients through chart reviewCall client for follow upNumber of clients screened20% increase3)Explore accuracy of EMR report dataRegular data pull and chart auditsNumber of discrepancies noted20% overall increase in screening ratePopulation health - diabetesPercentage of patients with diabetes, aged 40 or over, with two or more glycated hemoglobin (HbA1C) tests within the past 12 months1)Increase screening rateRegular data pulls, chart reviews and clean up of active client listsOverall increase in percentage of screening rates Active client lists are maintained on a monthly basis5 % increaseMar.31, 2018 was at 74% (target is 79%)-Regular data pullsPopulation health- Well baby InitiativeAll expectant mothers will receive a structured comprehensive pre natal program.1)Equip parents with the vital education and resources needed to give babies a safe, healthy and equitable start in life.1. Assist expectant mothers to sign up for Baby Box University 2. Assist mothers to complete an online course created by experts 3. Supply Baby Box 4. Parent will have continued access to educational content including over videos on a wide range of topics.Number of baby boxes suppliedCollecting baseline-donation received from NWMO for purchase of supplies for baby boxes2)To ensure that all expectant mothers have the opportunity to have meaningful discussions and prenatal care that takes into account their individual circumstances and needs.1. All expectant mothers have the opportunity for a discussion about feeding their baby and recognizing and responding to their baby’s needs. Establish rapport and relationship to encourage continued follow up once baby is born. 2. All expectant mothers are encouraged to develop a positive relationship with their growing baby in utero. 3. Education provided on breastfeeding and skin to skin contact 4. Additional support with breastfeeding, with an appropriate referral pathway, is available for all mothers, and they know how to access this. 5. Follow up phone call and/or survey to determine effectiveness of baby box and prenatal experience. 6. Breast feeding assessment at one week well baby checkNumber of expectant mothers who received a positive prenatal experience.Collecting baselineComprehensive pre and post natal program in place. Client CenteredPercent of patients who stated that when they see the doctor or nurse practitioner, they or someone else in the office (always/often) involve them as much as they want to be in decisions about their care and treatment?1)Ensure all new clients understand and have the opportunity to ask questions and participate in their careNew clients will be booked an initial orientation appointment as part of the intake process.Data pull of all new clients to ensure that they have received an orientation appointment90% of all new clients will have been offered an orientation appointment100% of new clients have been offered and received an orientation appt2)All Practitioners providing services to clients will welcome and encourage clients to become involved in decisions regarding their care1. Clients will be provided information in the way of signage to encourage them to provide feedback using the satisfaction/ comment box tools 2. Month of October will be dedicated to community engagement, client satisfaction and feedbackInformation will be collated by Dec.31, 2018 to assess whether we are meeting the indicator95%Survey process has been redefined to include random surveying of clients3)Request additional information from clients on how we can better involve them in decisions about their care.During month of October we will add this question to our newsletter and facebook pageCollect feedback from this question to share with ProvidersAt least 5 additional responses will be received-New satisfaction survey has been developed-Process to obtain feedback through survey changed to be provided to clients throughout the yearMedication Safety% patients provided with an up to date medication list1)Aim to have a complete and accurate list of medication a patient is taking to optimize safe, effective and appropriate drug therapyPrint medication list from EMR for patients to review in waiting room before their appointment to self identify discrepanciesNumber of patients provided with an up to date med list70% of eligible patients will have been provided up to date med lists-medications being discussed at each appointment-providing med lists to patients was not successful2)Encourage/empower patients to become more involved in managing their medications by providing them with the necessary resources to do soOrientation appointments will include a discussion on medication safetyNumber of patients who attended an orientation session and have discussed current medications100% of patients who have an orientation will have a discussion on medications currently taking and safe practices-23/23 new patients attended orientation sessions in which meds were discussed-3 CPP updates were completed with clientTimely access to care/servicesAccess to care1)Home based appointments provided by any Provider or staff member.Home visits create access points for clients who have mobility issues or other barriers related to accessing the health centreNumber of home visits providedCollecting baselineTotal of 547 home visits provided Clinical: 254Therapy: 59Health Promotion: 2342)Explore opportunity for walk in clinic in downtown area1. Meet with local partners to discuss opportunity for space to allow for occasional "walk in" clinics in downtown area.Space is secured to provide the service.Clinic initiated-met with Township to discuss potential building opportunities-joint proposal submitted to Township with RFDA to encompass space within a shared site3)Ensure clients are able to attend Health Centre if there is no mode of transportation1. Explore funding opportunities to purchase taxi vouchers. 2. Create formalized approval process for vouchers.Number of taxi vouchers provided to clientsCollecting baseline-taxi vouchers purchased- 177 taxi vouchers provided to clients to access health centre ................
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