Champlain Primary Care Digest

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New Program Supports Quality Improvement Through Practice Facilitation

A new program for physicians and nurse practitioners* in the Champlain region offers support to those who want to improve their primary care practice’s systems and patients’ experience and outcomes.

Through the Champlain Quality Practice Facilitation Program, experienced facilitators with expertise in improvement science meet with the practice on a regular basis – anywhere from 6-24 months – to guide the process of improving an aspect of the practice’s system of care. The improvement project is identified by the practice through a practice assessment and there is a menu of options to consider including: access and efficiency, chronic disease prevention and management, and preventive screening. Practice Facilitators provide the tools needed to make meaningful and sustainable change and focus on building skills to adapt clinical evidence to the specific circumstance of the practice environment.

The program is funded by the Champlain LHIN and there is no cost to join. There is, however, an expectation that primary care providers will devote at least three hours per month over the course of the relationship to attend facilitated team meetings and test improvement ideas. The program is offered in English and French.

Practice Facilitation is internationally recognized. The research shows it is an effective intervention for sustained improvement of chronic disease management and the adoption of clinical preventive care guidelines in primary care (Hogg, Baskerville, & Lemelin, 2005; Parchman 2014).

* to be eligible, nurse practitioners must be functioning in a role where they are responsible for the care of their own panel of patients.

MainPro Accreditation

This program meets the accreditation criteria of the College of Family Physicians of Canada and has been accredited for 20 Mainpro-C credits.

More Information

If you have questions about the program, visit or contact a practice facilitator directly:

Article written by: Ruth Dimopoulos, Quality Practice Facilitator

Geriatric Emergency Management in the Champlain Region

Adults over the age of 65 represent as many as 25% of the patients seen in the Emergency Department (ED). Older adults have unique physiological, medical and social requirements that make their care in the ED more challenging. These patients frequently have multiple co-morbidities and may present to the ED with atypical symptoms when compared to younger patients.

When combined with the high-paced, high-stress ED environment, this complexity may lead to an approach focused on treatment of the presenting complaint in isolation of other existing concerns such as falls, cognitive impairment, medication and declining function.

The Geriatric Emergency Management (GEM) was developed to meet the needs of high-risk older adults who present to the ED. Within the Champlain Local Health Integration Network, there are currently 9 ED’s with GEM programs: Pembroke, Renfrew, Arnprior, Ottawa (The Ottawa Hospital [2], Queensway Carleton and Montfort), Cornwall and Hawkesbury.

The GEM nurse provides a structured geriatric assessment focused on geriatric concerns and facilitates direct referral to Specialized Geriatric Services (SGS) such as Geriatric Assessment Outreach Teams, Geriatric Day Hospitals, Community Geriatric Psychiatry Services, as well as community support services such as the Going Home Program and Community Care Access Centre.

This approach ensures that high-risk seniors obtain age appropriate care that meets their needs, while supporting their safe, sustainable discharge home. The ability of GEM nurses to access SGS and community services in a timely manner reduces the likelihood of unnecessary repeat ED visits and hospital admissions.

The GEM program represents a consistent, evidence-based approach to screening, management and follow-up of high risk seniors being discharged home from the ED and integrates individualized and coordinated strategies to optimize and support the capacity of seniors to remain safe and independent in the community.

Article written by: AnnMarie DiMillo, Regional Program Manager – Geriatric and Community Intervention Program, Regional Geriatric Program of Eastern Ontario

To Call or Not to Call? CCAC Support for Primary Care

Over the past year, the Champlain CCAC has been exploring new opportunities for improving communication with primary care practices. For example, we recently launched a Physician Priority Phone Line to assist physicians and their office staff more quickly. You can now call 613-310-2222 and press ‘2’ to receive priority service from an Information and Referral Specialist.

A physician and a Care Coordinator reading a patient fileCare Coordinators at the Champlain CCAC are also amazing resources for primary care practitioners. Let me illustrate this with a story. Jennifer, one of our Care Coordinators, received a phone call from a physician looking for assistance regarding a patient of hers. The patient fell seriously ill while on vacation overseas. While in hospital, she was diagnosed with metastatic cancer and given a very poor prognosis.

Her daughter, in Ottawa, was very anxious to have mom return home as soon as possible to be with family. She was relying on her family physician for support and guidance.

The physician contacted Jennifer to find out about care options for her patient once she got back to Ottawa. Within the hour, the physician had received information about potential CCAC services, palliative care and transportation options from the airport. The physician expressed gratitude for the prompt assistance, stating that she felt better prepared to support her patient and family in returning to Canada.

The moral of the story – call us! We are here to support primary care and to help you navigate the system more efficiently for patients in the Champlain region.