2018 2019 FHT Annual Operating Plan FINAL1

Family Health Team
Annual Operating Plan Submission: 2018-2019
FHT Name: Barrie and Community Family Health Team

Date of Submission: May 31, 2018
Primary Health Care Branch

Ministry of Health and Long-Term Care
FHT Annual Operating Plan Submission: 2018-2019
TABLE OF CONTENTS
BOARD APPROVAL OF SUBMISSION
INTRODUCTION
PART A: 2017-2018 ANNUAL REPORT

1.0 Access
2.0 Integration and Collaboration
3.0 Other
PART B: 2018-2019 SERVICE PLAN

1.0 Strategic Priorities and Vision
2.0 Operations, Programs and Services (Schedule A, Appendix 3)
PART C: 2018-2019 GOVERNANCE AND COMPLIANCE ATTESTATION
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Board Approval of Submission
By providing the signature of the Board Chair, the Board of the FHT certifies the
following:
 The Board has formally approved the following Annual Operating Plan
Submission
 All mandatory parts of the submission have been completed:
o 2017-2018 Annual Report
o 2018-2019 Service Plan
o 2018-2019 Governance and Compliance Attestation
 The completed submission has been returned to the ministry on or before May
31, 2018.
Signature of FHT Board Chair or alternate Date: 05/31/2018

Board authority:
Print FHT Name:

Nancy Roxborough, Board Chair
Barrie and Community Family Health Team
I have the authority to bind the corporation
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Introduction
The Family Health Team (FHT) Annual Operating Plan Submission is part of each
FHT’s accountability requirements to the Ministry of Health and Long-Term Care. The
submission is comprised of three sections:
PART A: 2017-2018 Annual Report – mandatory

PART B: 2018-2019 Service Plan – mandatory
PART C: 2018-2019 Governance and Compliance Attestation – mandatory
The healthcare sector has undergone significant transformation and improvement in key
areas of accessibility, integration, quality and accountability. FHTs play an integral role
in enhancing primary care by organizing services around the following principles:
 Enhancing patient access through reducing the number of unattached

patients, increasing house calls and community outreach, offering timely
appointments, etc.
 Local integration and collaboration with health care providers,

community partners and Local Health Integration Networks (LHINs) in
person-centred planning, care coordination and program/service
delivery.
 Improved quality through the implementation of improvement

activities identified in Quality Improvement Plans and through the
design and delivery of person-centred primary care services and
programs.
The Annual Operating Plan Submission must be submitted electronically to the FHT’s
Senior Program Consultant no later than May 31, 2018.
Note:
Opportunities for increases to FHT operating budgets in 2018-2019 are limited. FHTs
are encouraged to base their 2018-2019 budgets on their existing allocation and to work
closely with their ministry representative to address any unforeseen operational
pressures using the in-year reallocation process. If a FHT is seeking funding for any
additional resources in 2018-2019, the request must be justified by the submission of a
detailed business case.
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Part A: 2017-2018 Annual Report
1.0 Access
Increasing access to comprehensive primary care has been a key priority of Ontario’s
interprofessional programs. Considerable progress has been made in attaching patients
to a family health care provider. Access is about providing the right care, at the right
time, in the right place and by the right provider, through activities such as offering
timely appointments, providing services close to home, after-hours availability, and a
compassionate approach to bringing on new patients.
1.1 Patient Enrolment
State your patient enrolment target for 2017-18, as indicated in Schedule A, Appendix 3
of your current agreement. Please also state the number of patients you have enrolled
by March 31, 2018.
Patient enrolment Target March 31, 2018 Actual March 31, 2018
Number of enrolled patients 141,000 144,215 (by MOH roster lists)

141,157 (as designated in EMR)
Are physicians enrolling new patients? Yes No
☒ ☐
Please explain:
Over the past fiscal year several physicians have retired and new physicians that
have been added have generally taken over existing practices. A few of the
physicians are enrolling new patients.
There is an ongoing Roster Management project, which identifies discrepancies

between the MOH and the EMR patient roster lists. This enables participating
physicians to maintain accurate rosters and to ensure that their patients become
rostered. About 40 physicians are participating in that project at this time. The
discrepancy between the MOH number and the EMR number points to the need to
expand that project.
In addition to the enrolled patients, there are13,000 – 16,000 patients who are
attached to a physician of the BFHO but not rostered. The EMR lists 157,212
attached patients in total (rostered and fee for service).
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If the target was not met, please explain why and outline your plan to meet this target:
N/A
It is important to note that the BCFHT’s physician group as of March 31, 2018 had
157,212 attached patients. While the BCFHT’s physicians have 141,157 enrolled
(rostered) patients, they also have 16,055 fee-for-service patients that are under the
direct care of BCFHT physicians.
1.2 Patient Enrolment – Access for New Patients in 2017-2018
Please explain how new patients were referred to FHT services.
Yes No
Were patients who contacted the FHT directly (self-referrals) enrolled? ☒ ☐
Were any new patients referred by Health Care Connect (HCC)? ☒ ☐
Were patients from other sources enrolled? (e.g., hospital, home care, ☒ ☐
other physicians/specialists)
Were any new patients referred by Health Links? ☒ ☐
1.3 Non-Enrolled Patients
Where resources are available, FHTs are encouraged to offer interprofessional

programs and services to both enrolled and non-enrolled patients. If the FHT serves a
specific non-enrolled patient population, describe the target population, services
required, method used to estimate the number of patients served by the organization,
and why the patients are not enrolled. Please provide an estimate of the number of non-
enrolled patients served.
The Prenatal and Well Baby (PNWB) Program
Prenatal and Well Baby: 2714 patient visits (884 patients)

Breastfeeding: 668 patient visits (510 Patients)
The PNWB Program provides routine prenatal and well-baby care for women and
children (up to the age of 6 years), without a family doctor in the Barrie area, along with
lactation consultant services. Our goal is to improve health outcomes for individuals in
the maternal child population by providing access to health care, lactation support,
education as well as referrals and links to community supports, as appropriate. Care is
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provided by a team of 4 physicians, one RN, one part-time NP and 2 part-time Lactation
Consultants. Breastfeeding services are provided by a Lactation Consultant (RN) within
the PNWB program, for all women (FHT and non-FHT) in the Barrie area. We have
been able to successfully roster some of our Prenatal and Well baby program patients
to a family doctor within our FHT. Some patients continue to remain non-enrolled
because physicians are at maximum capacity or these patients have recently moved
into the community.
A specialist (pediatrician) is now available in the PNWB program to provide increased,
timely access to care for frenulotomy procedures and other pediatric consults, as
needed.
The PNWB program delivers the following:
Routine Prenatal Care (initial and follow up appointments)

Routine Newborn care
Well Baby Checkups, including Immunizations
Lactation Consultant appointments
Breastfeeding information and support
Links to Community Supports, as needed
Smoking cessation support, including access to free Nicotine Replacement Therapy
through the STOP program
Breastfeeding Education (group) sessions – available during the day or evening
Breastfeeding services at the BCFHT are available to ALL childbearing families in our
community, including non-rostered patients.
Breastfeeding support is provided by an International Board Certified Lactation

Consultant (IBCLC), who is also a Registered Nurse, 4 days per week (this includes RN
support from the SMDHU 0.5 day per week). The BCFHT strives to promote, protect
and support breastfeeding in our community in the following ways:
• Offer Breastfeeding support (1:1 Appointments) to ALL childbearing families in our
community.
• Collaboration of our Lactation Consultant with other BCFHT Team Members, including
BCFHT Family Practice Office Staff, as needed.
• Group Classes are offered monthly to promote and support successful breastfeeding
for childbearing families.
• Link with Community Partners, as appropriate, around breastfeeding issues.
We are actively involved in system integration and coordination to increase access to
breastfeeding services. We have an agreement with our local Public Health Unit, which
provides the services of a Public Health Nurse, one half day every week, in our
breastfeeding clinic. This will ensure that women requiring this service will have
improved access to care. The BCFHT provides the space and additional support
necessary for this service provision. The clinical manager of the PNWB program is
actively involved in a community breastfeeding collaborative, which strives to promote,
protect, and support breastfeeding in our community.
The LINKS Team (formerly The MVP Clinic)

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719 unique patients serviced - Apr. 1, 2016-Mar. 31, 2018

2380 total patient interactions – Apr. 1, 2016 – Mar. 31, 2018
The LINKS Team sees unattached patients over the age of 18 with more than 2
medically complex health concerns who are frequent users of the healthcare system.
These patients require a great deal of medical and socio-economic support. Our goal is
to stabilize their health and wellness and attach them to primary care (physicians within
the Family Medicine Teaching Unit and the BCFHT and the Barrie Community Health
Centre). The clinic uses a multidisciplinary approach with NP, RN, Social Worker,
Pharmacist, Occupational Therapist, Registered Dietitian, and Barrie Community Health
Centre, Community Health Worker on the team working with Family doctors and
specialists. Linkages have been made with other health sectors such as Royal Victoria
Hospital, CMHA, local CCAC, and Crisis Services and OTN.
These patients are incredibly complex, often transient, and require a great deal of
support both medically and socio-economically, which makes it difficult to become
attached to primary care and to stay attached to a particular care provider.
Barrie Family Medicine Clinics

The BCFHT’s affiliated FHO supports four after hours clinics (Barrie Family Medicine
Clinics). In these clinics, patients who are non-enrolled or unattached can receive care.
The majority of patients receive acute episodic care. A few, particularly the transient or
homeless receive some degree of chronic disease management such as medication
renewal and monitoring of clinical status.
From April 1, 2017-March 31, 2018 – 86772 patients were seen in the Walk In clinics.
Over 69% of patient visits are for non-enrolled patients. Many of these patients have
chosen not to enrol with family physicians of the BCFHT for personal reasons related to
the fact that they have a physician in another community or that they prefer not to have
a family physician.
Mental Health
The program offers an Eating Disorders group and a Dialectical Behaviour Therapy
skills based group in collaboration with the Canadian Mental Health Association
(CMHA).
An After Baby group is available to new parents experiencing depression and difficulties
coping. It is a collaboration between the BCFHT Mental Health Program, the Georgian
Nurse Practitioner-led Clinic and the Barrie Public Library.
Are FHT programs available to members of the broader community? Please explain.
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Our FHT Telemedicine Program has been very successfully integrated into our FHT
and has grown to increase local access to specialists by patients in our community
(for both FHT and non-FHT patients). 447 patients have been seen in the program
from April 2015 to Feb 2016, for a total of 791 clinical telemedicine encounters. The
following specialists were accessed during those visits: mental health/ psychiatry,
dermatology/wound care, neurology, respirology and others. **Other includes visits
such as allergy, gastro-enterology, hematology, orthopaedic surgery, genetics,
paediatrics and a few others.
Our Telemedicine Program has also been used for educational and administrative
purposes to support the needs of our large interdisciplinary team.
Non-rostered patients accepted to The LINKS Team are referred to and can be seen
in all FHT programs such as the Lung Health Program, Diabetes Program, and Aging
Well Clinic.
Breastfeeding services at the BCFHT are available to ALL childbearing families in our
community, including non-rostered patients. The BCFHT Breastfeeding Services
began in October 2010 in response to a community need for additional breastfeeding
services to support childbearing families in our community. Breastfeeding support is
provided by an International Board Certified Lactation Consultant (IBCLC), who is
also a Registered Nurse, 2.5 days per week. The BCFHT strives to promote, protect
and support breastfeeding in our community in the following ways:
• Offer Breastfeeding support (1:1 Appointments) to ALL childbearing families in our

community.
• Collaboration of our Lactation Consultant with other BCFHT Team Members,

including BCFHT Family Practice Office Staff, as needed.
• Group Classes were offered monthly to promote and support successful

breastfeeding with childbearing families.
• Link with Community Partners, as appropriate, around breastfeeding issues.
Barrie & Community Family Medicine Clinics (BCFMC) are open for extended hours
well beyond the contractual obligations of the Barrie FHO (BFHO). In addition they
provide regular daytime hours for patients who are unable to be seen in their primary
Family MD’s office on any given day. The service is also available to unattached
patients in the community.
The Clinics operate using a shared EMR with the BFHO and BCFHT providing
remarkable continuity of care. As clinic patients are seen their visits are recorded in
their family practice chart with immediate notification going to the Family Physician.
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The EMR also provides some continuity of care for the unattached patients utilizing
any of our clinics because their health records are available at any of the 4 locations
they choose.
The clinics divert enrolled and unenrolled patients from the Emergency
Department. They are situated in four different areas of the community for easy
access. The clinics are staffed by 92 BCFHT/BFHO physicians and 32 BFHO
contract physicians. These clinics provide access during the daytime, evenings,
weekends and holidays 364 days per year. Patients can find the clinic hours of
operation as well as up to date wait time and registration status on our website
barriewalkinclinics.ca
Clinic hours:
Wellington - 121 Wellington St. W. Ste 112
Monday to Thursday
8 am to 10 pm
Friday
8 am to 9 pm
Saturday, Sunday
and Holidays
10 am to 4 pm
Prince William - 829 Big Bay Point Rd. Unit D12

Monday to Thursday
8 am to 10 pm
Friday
8 am to 9 pm
Saturday, Sunday
and Holidays
10 am to 4 pm
Bell Farm - 125 Bell Farm Rd. Ste 101

Monday & Wednesday 2 pm to 10 pm
Tuesday, Thursday
6 pm to 10 pm
Friday
6 pm to 9 pm
Saturday, Sunday & Holidays
10 am to 4 pm
Innisfil - 2101 Innisfil Beach Road

Monday, Tuesday, Thursday
6 pm to 10 pm
Wednesday
2 pm to 10 pm
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Friday
6 pm to 9 pm
Saturday & Sunday
9 am to 3 pm
From April 1, 2017 to March 31, 2018 - 86772 patients were seen in the Barrie &
Community Family Medicine Clinics. 69% of the patients seen are un-attached to a
BFHO family doctor. We estimate the BCFMC sees as many patients as the Royal
Victoria Regional Health Center Emergency Department on an annual basis.
1.4 French Language Services
Does the FHT provide programs and/or services in French Yes No

for patients whose mother tongue is French, or patients who ☒ ☐
are more comfortable speaking French?
If yes, provide an estimate of how many patients Small Minority – less

than 2%
1.5 Accessibility to Cultural and Language Services
Does the FHT address the linguistic and cultural needs of the population being served,
where possible? Please explain.
The BCFHT has several staff fluent in many languages. These include Italian, German,
French, Cantonese, Mandarin, Romanian, Russian, Afrikaans and Polish.
Many of the FHT staff have received Aboriginal Cultural Awareness Training.
19% of doctors surveyed offered appointments in other languages. The following

languages are provided in some of our FHT Physician offices.
Afrikaans, Polish, Hindi/Urdu, Gujarati, Swahili, French, Konkani, Urdu & Hindi,
German, Cantonese, Spanish, Russia, Hungarian, Portuguese.
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Patient education materials are available in different languages.
1.6 Regular and Extended Hours
What are your regular hours of operation Hours of operation:

when patients can access IHP services?
Ex.: Mon: 9-5, Tues: 8-4, etc. Mon: 8–4
Tues: 8-4
Wed: 8-4
Thurs: 8-4
Fri: 8-4
Sat: Closed
Sun: Closed
Mental Health Services are Monday to
Friday 9-5
When are FHT services available after Extended hours:
hours?
Mon: 4-6
Tues: 4-6
Wed: 4-6
Thurs: 4-6
Fri: 4-5
Sat: Closed
Sun: Closed
Mental Health Services work extended
hours of 5-7 pm.
Identify which programs are offered after RDs 730am on Fridays
hours: Breast feeding, smoking cessation OTN until 5 daily as needed
Pharmacists until 5
Diabetes 730 Mon-Thurs, until 430 M,W,F
Aging Well until 430
Links until 430 daily as needed
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Additional information:
Registered Dietitians run programs in the evening – Healthy You is Tuesday 530-730,
Cooking Class is Wednesday 530-630 and Craving Change is Thursday 530-730.
PNWB runs a Breastfeeding program once every other month and is 6-8pm – the day
varies.
1.7 Timely Access to Care
Please provide information on how appointments were scheduled in 2017-2018.
Timely Access to Care
Does the FHT currently schedule appointments on the same Yes No

day or next day (within 24 to 48 hours)?
☒ ☐
If yes, what percentage of total enrolled patients is able to see 100%

a practitioner on the same day or next day, when needed?
(Please indicate with an asterisk “*” if the value entered is an
estimate)
1.8 Other Access Measures
Please provide information on other types of access measures provided in 2017-2018.
Other Access Measures
Percentage of FHT practitioners who currently provide home 35%

visits?
Which types of IHPs perform home visits? OT, Pharmacist, NP,

Nurses, Social Worker,
Navigators
Number of home visits performed by IHPs in 2017-2018 1102
Emergency Department (ED) Diversion
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Does the FHT have a strategy to divert enrolled patients from Yes No
the ED (aside from physician contractual requirements for
after hours)? X ☐
Please describe the strategy: (Examples: NP after-hour clinics, ED Reports (CTAS 4, 5),
triaging, patient awareness procedures (phone calls, posters, website, reminders),
hospital discharge follow-up, outside use reports follow up)
The BCFHT, through a partnership with the Barrie and Community Family Medicine
Clinics, is initiating a public awareness campaign to help patients make educated
decisions as to where and when they need to access care. One of the intended outcomes
of this is to divert CTAS 4 and 5 to our walk-in clinics if that is the most approperate place
of care.
The BFHO after-hour clinics see enrolled (and unenrolled) patients and are open for hours
that far exceed the MOH contractual requirements. This clearly diverts significant
numbers of patients (both enrolled and unenrolled) from the ED. Opening hours are as
follows
Wellington - 121 Wellington St. W. Ste 112

Monday to Thursday
8 am to 10 pm
Friday
8 am to 9 pm
Saturday, Sunday
and Holidays
10 am to 4 pm
Prince William - 829 Big Bay Point Rd. Unit D12

Monday to Thursday
8 am to 10 pm
Friday
8 am to 9 pm
Saturday, Sunday
and Holidays
10 am to 4 pm
Bell Farm - 125 Bell Farm Rd. Ste 101

Monday & Wednesday 2 pm to 10 pm
Tuesday, Thursday
6 pm to 10 pm
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Friday
6 pm to 9 pm
Saturday, Sunday & Holidays
10 am to 4 pm
Innisfil - 2101 Innisfil Beach Road

Monday, Tuesday, Thursday
6 pm to 10 pm
Wednesday
2 pm to 10 pm
Friday
6 pm to 9 pm
Saturday & Sunday
9 am to 3 pm
Outside use reports do not report on ED visits and are therefore not helpful with respect to
reducing ED visits or following up with patients about those. They are also provided
individually to the physicians of the BFHO, not to employees or administration of the
BCFHT.
The LINKS clinic, in cooperation with RVH, compiles a list of enrolled patients who are
frequent users of the ED and works to advise each physician of any patients they have on
that list. The LINKS Team accepts patients who are high users of the emergency
department (as well as high users of the healthcare system in general). This clinic works
closely with our local hospital (RVH) to divert emergency visits as possible using the
following strategies:
-direct referrals of patients meeting LINKS Clinic criteria from RVH ED to The LINKS
Team
-The LINKS Team participates in RVH team meetings aimed at discussing the ‘ED high
users’ and creating care plans to ‘manage’ these users
The FHT looks after a large population of women and children in our community who do
not have a primary care provider. By providing routine prenatal and well-baby care, as
well as breastfeeding support, and some acute care to more than 1316 patients last year,
we likely have prevented these patients from accessing care through walk in clinics and/or
emergency rooms.
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How are patients made aware of hours of operation? (Examples: visible clinic signage,
voicemail, patient pamphlets, FHT website or other means)
Our hours are posted on our Website, are on a screen in the lobby of our main building
and are posted in the Waiting Rooms. This is also on our Facebook and Twitter accounts.
2.0 Integration and Collaboration
Collaboration with community partners is a key priority for FHTs. As the entry point to
the health care system for many Ontarians, primary health care providers need to
partner with other health and social service organizations in the communities they
serve.
These partnerships can improve patient navigation, expand the suite of supports
available to patients, and facilitate seamless transitions in all steps of the patient’s
journey. Meanwhile, care providers benefit from more efficient and coordinated service
delivery.
2.1 Service Integration and Collaboration with Other Agencies
For those agencies that you are either collaborating or integrated with, please check the
appropriate box if you have coordinated care plans, memorandums of understanding,
shared programs and services, or shared governance.
Shared Programs
Memorandums of
Understanding
and Services
Coordinated
Governance
Comments:
Care Plan
Shared
Other
Children’s ☒ ☒ ☒ ☐ ☐ OTN/Mental Health- The Virtual

Services Emergency Room is an urgent service
available through Ontario Shores to
provide children and youth with quick
access to psychiatry via telemedicine.
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Mental Health-informal referral

protocols with New Path Youth and
Family Services. Collaboration and
care coordination with Family
Connexions.
Access to Youth Services including

Crisis Response, Early Psychosis
Intervention, Youth Case Management
and Youth Addiction Counselling
through the Canadian Mental Health
Association.
LHIN - Home ☐ ☐ ☐ ☐ ☒ Embedding of Home and Community
and Community Care coordinators in FHO physician
Care offices
Community ☐ ☐ ☐ ☐ ☒ We are partnering with BCHC to
Health Centre support physiotherapy services within
our current FHT programming.
BCHC provides physician support to

the BCFHT Aging Well Clinic. The
BCHC physician (who holds an
advanced competency in care of the
elderly) works collaboratively with clinic
IHPs to diagnose, treat and manage
patients referred with concerns re
cognitive impairment &/or multiple
complex medical conditions.
Barrie Area Diabetes Collaborative -

The Barrie & Area Diabetes
Collaborative is a community
partnership of key stakeholders
involved in diabetes care, that work
together to ensure that all diabetes
patients in our community are seen in
the ‘right place, by the right provider, at
the right time’. Coordination of
diabetes services, improved access of
diabetes care and improved efficiency
of health care delivery involving
diabetes are some of the collaborative
main goals.
Mental Health-
referral/recommendations including the
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Chronic Pain Management Program of

the BCHC.
Community ☐ ☐ X ☐ X The FHT Pulmonary Rehab
Support Maintenance Program is offered at our
Services local YMCA.
We host our dietitian run Healthy You

patient education group sessions at the
Barrie YMCA and work in partnership
to support patients’ needs for physical
activity.
Mental Health - Collaboration and care

coordination with the Women and
Children’s Shelter of Barrie, Athena’s
Sexual Assault Counselling and
Advocacy Centre, Family Mental
Health Initiative, Triple P Parenting
programs, Gilda’s Club etc. Through
consultation and collaboration with
other service providers, the program
provides for the effective management
of shared patient care.
Developmental ☐ ☐ ☐ ☐ ☒ Mental Health-Collaboration with
Services Catulpa Community Support Services
and Developmental Services Ontario to
coordinate the care of patients with
developmental disabilities.
Diabetes ☐ ☐ ☒ ☐ ☒ The Barrie & Area Diabetes
Education Collaborative is a community
Centre partnership of key stakeholders and
programs involved in the provision of
diabetes care, that work together to
ensure that all diabetes patients in our
community are seen in the ‘right place,
by the right provider, at the right time’.
Coordination of diabetes services,
improved access of diabetes care and
improved efficiency of health care
delivery involving diabetes are some of
the collaborative main goals. The
primary agencies involved include:
BCFHT, BCHC, RVH and LMC
Diabetes and Endocrinology.
Local Hospital ☐ ☒ ☒ ☐ ☒ The BCFHT Diabetes and Lung Health
programs are integrated with RVH.
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BCFHT Lung Health Program now

accepts direct referrals from Royal
Victoria Regional Health Centre for
COPD patients being discharged from
the hospital to ensure prompt follow up
and seamless transition of care.
 IT integration: Physicians
receive most RVH reports
through the Hospital Report
Manager. There is access to
RVH Meditech in LINKS Clinic.
 The Family Medicine Teaching
Unit for the University of Toronto
Medical School Department of
Family and Community Medicine
is part of the BCFHT but located
at RVH and fully integrated
 The DFCM Quality Improvement
Program representative from
Barrie is a BCFHT Family
Doctor
 The BCFHT physicians are
members of the Quality and
Operational Committee at RVH
 The Research arm of the
BCFHT, REQIP,(Research,
Education and Quality
Improvement Program)
collaborates with the Research
Program at RVH. REQIP
utilizes the RVH Ethics
Committee
The BCFHT Aging Well Clinic has

partnered with the Simcoe Muskoka
Regional Arthroplasty Intake Clinic at
the Royal Victoria Health Centre to
offer a preoperative optimization
program to medically complex & frail
seniors booked for elective joint
arthroplasty.
BCFHT is represented at the hospital’s
Senior’s Strategy Working Group
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BCFHT Registered Dietitians accept

pediatric feeding referrals from RVH’s
SLP in order to decrease patient wait
times. Our RD’s also have partnerned
with the RVH RD’s to develop a
protocol for malnutrition screening and
follow up to help improve outcomes
and reduce hospital re-admissions.
The BCFHT Aging Well Clinic accepts

direct referrals from RVH for inpatients
being discharged back to the
community and for at risk seniors
assessed in the ER Department. RVH’s
Outpatient Geriatric Clinic diverts
referrals for FHT patients to the Aging
Well Clinic
Mental Health- Collaboration and care

coordination including admission and
discharge planning. Facilitate referrals
to the Partial Hospitalization Program,
Eating Disorders Services and
Addiction Services.
RVH staff is on the Steering Committee

of the Health Link.
BCFHT and RVH have a data sharing

agreement to share information.
Many physicians of the BCFHT are on

staff at RVH.
Mental Health ☐ ☐ ☒ ☒ ☐ CMHA is on the Steering Committee of

and Addiction the Barrie Health Link. CMHA provides
Services case consultation for the LINKS Team
Clinicians in order to better support
LINKS patients with addiction issues
Formal agreement with the Canadian

Mental Health Association-Simcoe to
provide the Mental Health Program of
the BCFHT. This partnership ensures
access to an array of Mental Health
and Addiction Services including Crisis
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Services, Early Psychosis Intervention,

Youth Services, Case Management,
Addiction Services, Assertive
Community Treatment teams, Justice
Services, and Family Support. It also
allows for the effective managmenet of
shared care.
The Health Link Navigators participate

in ALC Rounds to identify potential
Health Link Clients
The Health Link Navigators work very

closely with Various departments and
discharge planners at the hospital to
promote smooth transitions in and out
of hospital.
For the past 3 years there has been a

MOU in place placing a dedicated RVH
Data Analyst on secondment to the
Health Link
Public Health ☐ ☐ X ☐ X The Simcoe Muskoka District Health

Unit Unit and our FHT have a formal written
agreement supporting one Public
Health Nurse to work out of our PNWB
Clinic supporting Lactation services
one half day per week. This is a
donation in kind offered to the FHT by
the Simcoe Muskoka District Health
Unit, which helps improve access
issues for women in our community
requiring support with breastfeeding.
The BCFHT and the SMDHU are also

founding partners on the Healthy Barrie
initiative. The Executive Director of the
BCFHT and the Chief Medical Officer
of Health collaborated closely over the
past year to see this initiative move
forward with the other founding
partners.
Senior ☐ ☐ ☐ ☐ ☐ Many of the FHO Physicians provide
Centre/Service service to Retirement Homes.
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The BCFHT medical director and the

Aging Well Clinic Team Lead sit on the
RVH Seniors Strategy committee. The
Aging Well Clinic is aligned with the
North Simcoe Muskoka Specialized
Geriatric Services.
FHT: ☐ ☐ X ☐ ☐X Mental Health- Collaboration and care
(Integration coordination with BCFHT Pharmacists
within FHT and Dietitians-counselling and co-
programs and facilitation of groups (Healthy You,
services)
Craving Change, Depression Group
and the Anxiety Series).Collaboration
and care coordination with the Aging
Well Clinic.
RD working in our PNWB program to

provide care for that specific population
and implement the Nutristep screening
program. Enables collaboration with
NPs, MDs and RNs working within that
program as the location is offsite.
Our RD and Pharmacy program have

developed a class for Saxenda starts
and co-facilitate it.
OT works with our lung health program

in their pulmonary rehab program.
Diabetes Educators work within some

MD offices, including our FMTU, to
provide DM education to patients and
collaboration with MDs.
Pharmacist support is available within

in the FMTU and other MD offices for
collaboration and care coordination.
Long-Term ☐ ☐ ☐ ☐ X☐ The Barrie FHO has many doctors who

Care Homes work in Long Term Care homes.
Long Term Care has a representative

that is a voting member of the Barrie
and Community Health Link.
Hospice X Pharmacy and RD participate in Hospie
Simcoe Simcoe weekly rounds
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Family ☒ ☒ The BCFHT is a strong partner of the

Medicine FTMU through the providing of QIDS
Teaching Unit and IT support, and EMR access to
(FMTU) Quality the physicians and residents at the
Improvement FMTU. One of the areas of largest
Projects and
contribution by the BCFHT is thorugh
Academic
Reseach the its QIDS team. QIDS provides
support to the FMTU for the residents
annual quality improvement and
research projects. The Manager of
QIDS is a sitting member of the
Research, Enducation and Quality
Improvmeentr Program (REQIP),
wihich is a committee of the shared
Board of Directors between the BCFHT
and the Barrie FHO. The QIDS assists
resident physicians in the drafting of
their QI and research projects,
accessing and cleaning data, and
providing analytical assistance.
Mental Health-
Provides an academic session to 1st
year residents- Introduction to
Counselling Skills.
Offers a biweekly mental health clinic
to supervise residents working with
patients experiencing mental health
issues.
School Success X X X X The BCFHT has formed a strong
partnership with the Simcoe County
District School Board in an effort to roll
out the School Success Program for
our community. This program is an
attempt to provide seamless transitions
and coordinated care between the
education system and healthcare
system for children who are struggling
in school with behavioral issues, likely
due to a medical condition. Timely
access to: system navigation,
counselling, occupational therapy and
pediatrician support are key
components that will support students
and families in Barrie. This integration
and collaboration will improve the
22
students’ chance for success in school

along with improved quality of life and
well-being for children and their
families.
BBAT X The BCFHT is a key partner in the
Barrie Breastfeeding Action Team, a
community collaborative involving key
stakeholders interested in promoting,
protecting and advocating for
breastfeeding in our community.
OTN X X X X Our FHT uses the Ontario
Telemedicine Network (OTN) in our
Telemedicine Program to ensure that
patients receive the right care at the
right time and the right place. The
OTN system is used to ensure that
patients get more out of the health care
system by bridging the distance of time
and geography to bring more patients
the care they need, where and when
they need it. Using innovative
technology, OTN streamlines the
health care process, while also
expanding the way knowledge is
shared and how members of the
medical community interact with each
other and with patients. Referrals are
accepted from all physicians and NPs
in our FHT and from providers outside
of our FHT. Using the Telemedicine
program, patients are now able to
access timely health care in their local
area instead of travelling long
distances and incurring long wait times.
The LINKS Team partners with CAMH

(Toronto) to case conference with and
for clients
Barrie Smoking X The BCFHT is represented and actively
Cessation Task involved in the Barrie Smoking
Force Cessation Task Force.
Healthy Barrie X X X Healthy Barrie

The goal of the Healthy Barrie Initiative
is to position Barrie at the forefront of
health system and population health
23
improvement. The founding partners of

Healthy Barrie are:
• The City of Barrie
• The Barrie Community Family
Health Team (BCFHT)
• The Barrie Community Family
Health Organization (FHO)
• The Simcoe Muskoka District
Health Unit (SMDHU)
• The University of Toronto: Dalla
Lana School of Public Health
• The Family Medicine Teaching
Unit (FMTU)
One of the key objectives of Healthy
Barrie is to create a more integrated
and collaborative platform for improved
population health and health system
sustainability. One way that this can
be achieved is through projects that
have mutual accountabilities for their
overall success.
Navigation X X As part of the Health Links, we have
created a network of system navigators
chaired by the Health Link navigator
who meet regularly to provide
assistance to community wide patients.
The following organization participate
in the Navigation Committee.
• Home and Community Care

(HCC) formerly CCAC
• Barrie Area Native Advisory
Circle
• Barrie Native Friendship
Centre
• Independent Living Services
• Barrie Fire Department
• County of Simcoe Housing
• Spinal Cord Injury of Ontario
• Jarlette (long term care and
Retirement Representative)
• CMHA
• County of Simcoe Paramedics
• RVH
• Gilbert Centre
• Barrie Community Health Centre
24
• Red Cross
• David Busby
• 211
• Health Quality Ontario
• Helping Hands
• County of Simcoe Ontario
Works
• City of Barrie Accessibility
 Acquired Brain Injury
Please describe any involvement in LHIN-led initiatives (e.g. sub-region work)
Our interim Executive Director is involved with the LHIN CDPM Steering
Committee, the LHIN lung health planning committee and the Perinatal Mood
Disorder (PMD) Steering Committee.
The NSM QI Network meets quarterly to discuss provincial and region wide
issues surrounding quality improvement. This network is comprised of
representatives from the NSM LHIN, HQO and various healthcare provides in
NSM. The Network works closely with health providers to provide
understanding of Quality Improvement Plans and to provide knowledge
translation of any major projects that have been undertaken by network
members.
Barrie and Community Health Link
As the lead organization for the Barrie and Community Health Link (BCHL),
the BCFHT continues to support the provincial goals of the initiative.
Over the past year the BCHL identified the need to expand our navigation
support in order to build capacity within the system. Our two Navigators put
out an expression of interest to our community partners to bring together
those that do navigational work for clients in our community regardless of
whether they are called ‘Navigators’. The response was overwhelmingly
positive and our Navigator Collaborative is active and growing. We trialled a
partnership with 211 Ontario which proved very successful and is now being
spread to other regions as a way of connecting those that fall shy of the
Health Link criteria (by definition) but require light navigation and support.
We received and responded to the most referrals in our LHIN from the
Community Paramedicine Program and our Health Link exceeded their HQO
targets and are projected to exceed this years (increased) targets. Our
community is working through their Transition Planning between April 1st
2018 and March 31, 2020. We are working closely with our LHIN and HCC
25
to onboard our Health Link partners onto the CHRIS HPG system by Fall
2018 so as to have a central repository and site for our care plans. The
Health Link looks to play an active role in sub-regional planning and will work
collaboratively with the Community Safety and Wellbeing Planning that will
The BCFHT and BFHO are participating in the NSM LHIN project to
connect Home and Community Care (HCC) Care Coordinators into
Primary Care Practices. This is a major strategic direction under
Patients First. 19 physicians were involved in a pilot project in 2017-
2018 and this is continuing. An additional 9 physicians are planning to
participate in the next phase. A Care Coordination Summit was held
on January 10, and was attended by the MD and ED of the BCFHT.
The Primary Care Network of NSM is a group of physician leaders

from the region who meet about every 2 months. Meetings are
organized by the LHIN VP Clinical, Dr. Becky Van Iersel. At these
meetings Primary Care providers share new developments, local
initiatives, information about resources, and other items of interest.
The MD and IT Clinical Lead of the BCFHT participate in these
meetings.
The IT Clinical Lead participates in the LHIN eHealth Advisory Council.

This Council is working on an e-prescribing project for the region and
improvement of integration of primary care medical records.
On April 11th the North Simcoe Muskoka LHIN hosted their annual
networking and planning meeting in Orillia. This was a meeting of
regional telemedicine coordinators, managers and LHIN staff, hosted
by Marsha Moland director ehealth NSM LHIN.
During this one day event we had presentations on :
• Telemedicine utilization and reporting in NSM – strategic

measures and outcomes from data collected over the last year.
• Discussion around what was working and the program

strengths were at each telemedicine site.
• Presentation on opiod, addiction and Mental Health in relation to

telemedicine
• Spotlight presentation from a surgical pre-op program from

sault area hospital.
• We had clinical brainstorming and telemedicine program design

with small groups to facilitate uptake and utilization of the telemedicine
programs at each location. Each group presented their brainstorming
ideas to the room.
26
2.2 System Navigation and Care Coordination
Is the FHT involved in Health Links? Indicate if Lead (i.e. Yes No Partner/Lead
funding recipient) or Partner
☒ ☐ Lead
How does the FHT help navigate patients through the health care system? Please
provide up to three examples, i.e. referral protocols to link patients with other
appropriate providers or organizations; coordination with hospital for post-discharge
primary care; LHIN collaboration for home care supports, other follow-up care, etc.
LINKS Team – The LINKS Team Clinicians work closely with all community agencies to
ensure these complex patients have access to a variety of services within the
community that will support all aspects of the patients physical, mental, and socio-
economical wellness. This includes direct referrals to all community services. We also
regularly contact government agencies (ODB, ODSP, OW) and local centres such as
David Busby Centre to assist with issues regarding housing, transportation, finances,
and medication coverage.
This clinic also connects with patients and hospital staffs while patients are admitted to
the local hospital (RVH) to ensure appropriate plans of care (home services, follow-up
appointments and testing) are in place for patient discharge in order to support a
smoother transition back to the community.
LINKS Team patients are also linked with Healthcare Connect to support efforts to
attach these patients to primary care once their chronic conditions are stabilized.
Aging Well Clinic - The Aging Well Clinic works closely with the local hospital and
community agencies. This ensures dementia patients and medically complex/frail
seniors receive specialised community based geriatric care and are connected with
appropriate community services. Patient referrals are accepted from RVH hospitalists,
Arthroplasty Intake Clinic, ER Dept & local vascular surgeons. RVH’s Geriatric Clinic
diverts FHT patients to the Aging Well Clinic. The sharing of personal health information
between the Aging Well Clinic and RVH inpatient units/RVH Geriatric Clinic facilitates
appropriate medical interventions & medication reconciliation as patients transition
between the community and acute care. The Aging Well Clinic provides system
navigation to ensure patients have access to a variety of services within the community.
This includes direct referrals to services such as CCAC, Alzheimer’s Society, Simcoe
Community Services, Simcoe Muskoka Brain Injury Services, CMHA, Waypoint,
Wendat, Accessible Transportation Services & Simcoe Independent Living Services.
Patients/families are linked to Lifeline, Safely Home Service, Adult Day Programs,
27
Respite Care, CHC chronic disease & fitness programs, foot care services, private pay
community support programs and community centres
Barrie Area Diabetes Collaborative - The Barrie & Area Diabetes Collaborative is a
community partnership of key stakeholders involved in diabetes care, that work together
to ensure that all diabetes patients in our community are seen in the ‘right place, by the
right provider, at the right time’. Coordination of diabetes services, improved access of
diabetes care and improved efficiency of health care delivery involving diabetes are
some of the collaborative main goals.
Mental Health- The Mental Health Program engages in system navigation and care
coordination through the facilitation of referrals to other appropriate services including:
the Canadian Mental Health Association, New Path Youth and Family Services, Royal
Victoria Regional Health Centre, Developmental Services Ontario, Kinark Child and
Family Services, Athena’s Sexual Assault Counselling and Advocacy Centre, Barrie
Community Health Centre, Family Mental Health Initiative, Women and Children’s
Shelter of Barrie,Triple P Parenting programs, Hospice Simcoe and Gilda’s Club.
Through consultation and collaboration with other service providers, the program
provides for the effective management of shared patient care.
2.3 Digital Health Resources
Clinical Management System/Electronic Medical Records
Please provide information on your EMR
Which EMR vendor/version is being used?

Accuro Version 2017.01.447
Vendor is QHR
Level of integration If no EMR integration, are

other data-sharing
1) None arrangements in place (e.g.,
2) Read-only case conferencing)?
3) Full integration Please provide any other
comments
LHIN – Home and Choose an item. Pilot project HCC
Community Care
28
Emergency Read-only The BCFHT has a data-

Department sharing agreement with the
Royal Victoria Regional
Health Centre (RVH). This
data sharing agreement was
created as part of Health
Links and allows for the
BCFHT to identify chronic and
complex patients and
provision of hospital clinical
data to physicians. This
agreement is a first step
towards more broad data
integration between the
BCFHT and RVH.
Hospital Read-only The BCFHT has a data-
sharing agreement with the
RVH. This data sharing
agreement was created as
part of Health Links and
allows for the BCFHT to
identify chronic and complex
patients and provision of
hospital clinical data to
physicians. This agreement is
a first step towards more
broad data integration
between the BCFHT and
RVH.
Currently the Health Link,

BCFHT is working with the
Royal Victoria Regional
Health Centre (RVH) to
establish a data sharing
program to improve referrals
and reporting for the Health
Link.
The BCFHT is connected to
RVH through Hospital
Remote Manager, which is
integrated with the BCFHT’s
EMR.
Doctors with Full privileges

have full Integration.
29
Laboratory Service Full integration
FMTU: Full integration
Links Clinic: Full integration to EMR

Read-Only to RVH Meditech
Specialists – Full integration to EMR
Atrium Cardiology
Barrie Sports
Medicine
Dr. McClelland
Barrie and Full integration to EMR
Community Family
Medicine Clinics
Are you able to electronically exchange patient Yes No

clinical summaries and/or laboratory and diagnostic ☒ ☐
test results with other doctors outside of the practice?
Are you able to generate the following patient information with the Yes No
current medical records system:
Lists of patients by diagnosis (e.g., diabetes, cancer) ☒ ☐
Lists of patients by laboratory results (e.g., HbA1C<9.0) ☒ ☐
Lists of patients who are due or overdue for tests or preventative ☒ ☐

care (e.g., flu vaccine, colonoscopy)
Lists of all medications taken by an individual patient (including ☒ ☐
those ordered by other doctors)
Lists of all patients taking a particular medication ☒ ☐
Lists of all laboratory results for an individual patient (including ☒ ☐

those ordered by other doctors)
Provide patients with clinical summaries for each visits ☒ ☐
Do FHT patients have access to the following patient-facing online Yes No

services?
Direct email communication with the FHT ☒ ☐
View patient test results ☒ ☐
30
Request prescription refills/renewals ☐ ☒

Book appointments with Family Health Team providers ☒ ☐
Does the FHT have a data sharing agreement with the affiliated Yes No
physician group(s)? ☒ ☐
Please explain how the EMR is used for tabulating patient statistics, identifying and
anticipating patient needs, planning programs and services, etc.
The BCFHT considers itself as an advance user of the EMRs. The BCFHT is one of
the few FHTs in the province that has a fully fleshed out EMR Joint Management
Agreement that allows for the accessing and usage of all patient information in the
EMR for purposes of information management, quality improvement and decision
support.
The BCFHT’s QIDS team uses the EMR for a verity of iniatives and projects including,
but not limited to:
 A bi-annual roster management process of approx. 60 physicians that
improves the accuracy of the physician rosters, both in the EMR and MOH
roster lists, by and average of 15%.
 The QIDS team works on any research based projects that require access to
EMR data. This includes the annual resuident quality improvement and
research projects, and other research initiatives that are either initated by the
local physicians or through research partnership like the BCFHT’s partnership
with the Dalla Lana School of Public Health at the University of Toronto.
 The QIDS team has been leading annual, scientific program evaluations that
rely heavily on data from the EMR. Data from the EMR that is used include
workload, statistical and clinical information of patient that are both in the
BCFHT’s program and those that are not, but would quality to be in.
 The creation of an alpha version of a physician sorcecard that provides
comparative statsitcal and clinical infomraiton of a physicians partice. This also
includes the provision of patient lists that allow for improves monitoring of care
for those that are the most in need.
 The BCFHT, along with the City of Barrie, Simcoe Muskoka District Health Unit
and the University of Toronto, are in the midst of developing a Health Atlas for
the City of Barrie that will allow community partners to identify georgraphic
areas of need while allowing for the evaluation of current efforts in improving
care.
31
The BCFHT accomplishes the about both through the use of the forward EMR
interface query tool and access to the back end of the EMR through a SQL server
system.
Lastly, the BCFHT is one of the pilot FHTs using QHR’s Accuro New Analytics Tool.
This tool is similar to provide back end access to the EMR with regards to the amount
of data that is accessible. In addition, it provides a user friendly interface that also
allows so the publishing of finalised reports and dashboards that can be access by
users of the publishers choosing.
2.4 Data Management Support
Please provide information on any data-management support activities in 2017-2018.
Does your organization use the services of a QIDS Specialist or any Yes No
other data management specialist?
☒ ☐
If yes, how has this role helped your organization with quality improvement, program
planning, and performance measurement? Please describe any challenges and
successes.
The BCFHT has two members of its QIDS team that provide services to six BCFHT
clinics and 92 member physicians. The QIDS team has been involved in a wide variety
of initiatives and projects in 2017-18, which include, but are not limited to:
 Standardizing and Modernizing Lung Health assessment forms in the EMR.

 Providing research support to the FMTU and University of Toronto.
 Conducting BCFHT program evaluations.
 Designing implementation plans and charters for the School Success Program
an the LINKS program.
 Improving EMR data quality.
 Providing support to the Barrie and Community Health Link.
 Overseeing the BCFHT’s project approval process.
 Development of Quality Improvemt Plan
32
The QIDS Team has achieve many success in 2017-18 including the evaluation of the
BCFHT Diabetes Program. The biggest challenge faced by the QIDS team is current
resources not meeting current demand for quality improvement assistance.
3.0 Other
3.1 Other Information and Comments
Public Engagement Strategy: Does the FHT have a formal mechanism to include
patient and community input into FHT planning and priorities?
Mental Health- The program uses the Ontario Perception of Care Tool for Mental
Health and Addictions. This survey is completed by patients and identifies both areas
of strength and improvement for the program.
The BCFHT has historically surveyed patients in an ad hoc manner that produced
results that were not truly reflective of the patient population that it serves. In 2017-18,
working with Georgian Colleges Research Analytics Program, the BCFHT implemented
a bi-annualy patient survey that draws on BCFHT patients from all available sources
(BCFHT clinics, walk-in clinics and physician offices). The survey has been designed to
not only meet provincial standards, but to meet the specific needs of the those withing
the BCFHT community. The survey process is uniquely focused on achieving the
highest level of representation, to ensure that the feedback we receive is statistically
representative of our patient population.
We have four Community members on our Board of Directors. They are involved in
the Strategic planning process for the BCFHT.
Healthy Barrie
Healthy Barrie is a collaborative that brings together leaders from the community
(including the City, public health, primary care, and researchers) to explore how they
can align their work to better address complex health issues in the community.
Healthy Barrie is co-led by the BCFHT and the Dalla Lana School of Public Health.
Over the past year the Healthy Barrie collaborative has been active in pursuing three
initiatives:
33
1. Piloting an initiative called Park RX
2. Developing a Health Atlas Indicator Tool
3. Championing the ‘Active People for a Healthy Barrie’ initiative which is funded by
the Ontario Trillium Foundation through their Collective Impact funding stream.
Park Rx
Park Rx was a small pilot involving a small co-hort of Physicians within the BCFHT to
offer a prescription for ‘Park Time’ to select patients that met the criteria of stable
depression and or anxiety. This initiative was based on the hypothesis of biophilia
which looked at patients overall sense of wellbeing after being present in green space
a minimum of 30 minutes per week.
Health Atlas Indicator Tool
The Health Atlas Indicator Tool will be used by partner organizations (the City of Barrie,
BCFHT, SMDHU, Uof T) to inform program planning, service delivery, support the
health system, population health and healthy community design improvements.
This tool could be used by Healthy Barrie to design Collective Impact community and
individual level prevention and intervention strategies.
‘Active People for a Healthy Barrie’
As part of the Stage 1: Define the Impact Trillium grant, the working group under
Healthy Barrie is working with a broad range of community partners to tackle the
complex system challenge of increasing the overall activity levels and opportunities for
engaging in physical activity for the citizens of Barrie.
An active lifestyle is good for health, however, getting people to be physically active is
a challenging issue. Physical activity is not just a personal or lifestyle choice, but also a
function of the built environment, quality programming, socio-economic status, and a
host of other factors that either promote or discourage engagement in physical activity.
Our aim is to optimize the community’s ability to engage in physical activity through
built environment and neighbourhood characteristics while ensuring inclusivity based
on age and ability, from youth to seniors, in order to improve individual and community
health.
34
Does the FHT have a formal process to include input from the Local Health Integration
Network (LHIN) and other system and community partners?
No
The Ministry of Health and Long-Term Care likes to promote the work done by FHTs.
Please describe any awards, acknowledgements or achievements from 2017-2018.
Our Diabetes Program presented a poster at AFHTO 2017 titled “Sharing is Caring: Our
model for dividing FHT patients among diabetes services in Barrie”. At the same
conference an NP and pharmacist from our Aging Well Clinic did a joint presentation
with Leeds Grenville CFHT titled “Aging Well & At Home: Two Approaches for Primary
Care Teams”. The Barrie FHT portion was titled “Aging Well, a Team Based Approach
to Complex Elder Care” and highlighted how our Aging Well Clinic uses an
interdisciplinary team to provide comprehensive geriatric services to a specific
population, partnering with the patient-caregiver dyad and focusing on capacity building
with a patient first philosophy. Also at AFHTO 2017 and RD and Pharmacist from our
FHT did a presentation titled “Community Palliative Care Rounds – strengthening our
Expertise” where they highlighted our Palliative Care Rounds, how it has evolved and its
benefits.
Our Barrie FHT RDs collaborated with RDs from Orillia, Midland and Georgian College
to organize, plan and host the 12th Annual Dietitians of Canada Ontario Family Health
Team Registered Dietitian Conference in Barrie ON last year. This conference was
attended by 100 IHPs with the majority of them being RDs and was quite successful.
The BCFHT QIDS Team presented a poster at the 2017-18 AFHTO Conference
highlighting its work at improving the data quality of the one of the largest EMRs in the
province. The QIDS team has worked closely with 53 out of its 92 physicians to improve
the accuracy of their rosters. The QIDS team has been able to reduce the error rate
between EMR rosters and MOH rosters from an average of 25.1% to 9.6%. 89% of all
35
participating physicians and staff believe that their rosters are more accurate due to the
initative.
Mental Health- The Program Lead completed quality improvement training through the
IDEAS (Improving & Driving Excellence Across Sectors) Advanced Learning Program
through Health Quality Ontario. The program equips healthcare professionals with the
knowledge, practical skills and tools to lead quality improvement initiatives that aim to
improve patient care, experience and outcomes. The new Quality Standards for
Depression were the focus of this project.
The 6th Annual Mental Health FHT’ness Conference was held in April 2017. This is a
Continuing Medical Education event that is offered to physicians, residents, nurse
practitioners and other IHP’s.
We are proud to announce that we are now members of HOOPP! This is something
that was very important to our employees and we made the commitment to use
available funding to ensure it would become a reality. This year we also made the
decision to terminate the long standing contract of our benefit provider to move in the
direction of a cost neutral/option based benefit plan. Our employees now have the
ability to choose the benefit package that best suits the needs of them and their
families, while allowing our FHT to save money to ensure the viability of HOOPP for
years to come. These changes have been welcomed by staff and have increased moral
and engagement.
REQIP
In association with the Family Medicine Teaching Unit (FMTU), the BCFHT supports
REQIP (Research, Education, and Quality Improvement Program). This innovative
program supports primary care research and QI projects by guiding providers through
the process and providing relevant assistance. Family Practice residents are required
to do QI and Research projects as part of their training. The BCFHT, BFHO, and FMTU
share a single EMR. This creates potential for significant research and QI projects.
Examples of QI projects include: “Advance Care Planning in Primary Care” and
“Smoking Status and Cessation in the CPP”. Examples of Research projects include
“Acute Otitis Media in Children and Antibiotic Use” and “FP Follow-up after Admission
for COPD and Effect on Readmission”
36
Is there anything else that the organization would like to communicate to the ministry
regarding its activities in 2017-2018? Any challenges, opportunities and
recommendations for the ministry can also be detailed in this space.
REQUEST FOR RESOURCES - SCHOOL SUCCESS PROGRAM
Program Description
The School Success Program (SSP) is a coordinated, multidisciplinary approach to

assist school-aged children, along with their parents and care givers, address health-
related issues that are affecting their ability to be successful in school. This strategy has
recently been initiated at the BCFHT as a pilot program during the last quarter of 2017-
18.
The Barrie & Community Family Health Team (BCFHT) has created strong partnerships
over the past year with the Simcoe County District School Board and local pediatricians
in our community to better understand the needs and existing gaps impacting the
inability of school aged children in Barrie to be successful in school. From there, they
have worked together to implement a strategy that will provide timely and coordinated
clinical services and connection community resources and supports, to school-aged
children and their families in need.
The main program goal is to create a more positive educational experience for children
through collaboration between the education and health care systems to better address
the challenges students are facing. The program aims to improve communication
between the education system and primary care providers for purposes of identifying
students that are struggling or at risk in the school system. Another goal of the program
is to provide families and their children with a coordinated, wrap around approach to
addressing challenges, by eliminating some of the barriers that currently exist and by
creating more seamless approaches to care.
In order for the program to continue, however, we need commitment from the Ministry of
Health and Long Term Care to provide permanent human resources to sustain and
enhance the program. The BCFHT would like to continue the program on an ongoing
basis, and expand to service all eligible school aged children in our community. The risk
of this program not continuing due to insufficient resources is enormous for the
impacted children, families and the community.
Program Planning-Pilot Phase
37
In response to a huge community need, the BCFHT partnered with the Simcoe County
District School Board and local pediatricians to explore the issues and create a solution
to the identified problem. We are continuing to gather information regarding the existing
gaps in our community that are required to adequately service the needs of children
who are struggling in school. We have been working closely with the Couchiching
Family Health Team, which is in close proximity to us. The Couchiching FHT already
has a School Success Program which has been up and running for several years now
and demonstrating great success and value in their community. Our community has
similar populations and need, in terms of support for children and families at risk of not
being successful at school, and other areas of their lives.
There are a large number of young families living in Barrie and many children are
struggling with behavioral and development issues. These issues are especially
problematic for them in school. The struggles are often due to undiagnosed medical
conditions such as: anxiety, depression, and attention deficit hyperactivity disorder,
amongst others, and learning disabilities. Unmanaged, these conditions will prevent
children from being successful in school and ultimately have a negative short-term and
long-term impact on their health, well-being and quality of life.
The SSP program has started as a very modified and small scale program, servicing
only select schools in the community, to start and with a very select and small team.
Funds from the BCFHT unused ‘human resources salaries’ 2017-18 budget were used
to hire the team which included: a part time RN, SW and OT. As such, the team has not
been able to grow to include the health care professionals required on the team and can
only service limited numbers of the students needing support. This approach is
unsustainable long-term, since these funds will be allotted to the positions they were
intended for in 2018-19 (there were temporary gaps in some positions in 2017-18 for
various reasons including: unfilled maternity leaves, difficulty recruiting some positions,
etc.). To continue with this extremely valuable program, and expand its reach beyond
select public elementary schools, the BCFHT is requesting additional resources, which
will be outlined in this proposal. We hope that the program value will be recognized with
sufficient support from the MOHLTC to expand the team to what is needed for the
population of Barrie.
Statistics
According to Statistics Canada, in 2016, children ages 0 to 14 years accounted for 16%
of the population in Simcoe Muskoka, for a total of 86,720 children. In Simcoe County
alone there were a total of 79,100 children. The largest populations of children in
Simcoe Muskoka live in the southern municipalities of Simcoe Muskoka, one of which is
38
Barrie. The Simcoe County District School Board, which is only one of three major
school boards in Barrie, services nearly 13,000 elementary school students.
Nearly one in five of these children live in low-income families. Simcoe County also has
one of the largest indigenous child and youth populations in Canada. Furthermore,
according to the 2015 Ontario Student Drug Use and Health Survey (OSDUHS), 20% of
Simcoe Muskoka students (Grades 7-12) experienced severe psychological distress in
the four-weeks prior to the survey, which was significantly higher than the provincial
average of 14%. Statistically, there are a large percentage of children living in our
community, many of whom are experiencing high risk factors and require support, such
as that available through the School Success Program, in order to obtain equitable
access to healthcare resources and services. Many of the resources that would be
available to these children and families in the SSP are either not available to these
children due to financial barriers (not publicly funded) or lengthy wait times.
Current Situation
39
School boards have limited resources and supports to help children and families in
need, and often require a validated need from the health care system to provide
additional supports. Wait times for supports in schools, including psychological
assessments, are lengthy and only available to those with the greatest need. Services
including: Occupational Therapy, Psychology or Speech Language Pathology are not
available to those who are unable to pay for it out of pocket or through private
insurance. The current wait time to see a pediatrician for these types of reasons in
Barrie is also lengthy (upwards of 18 months). Parents need a timelier and coordinated
approach to break down barriers and reduce the time it takes to get the support needed
for their child. Delayed intervention is critical for young, developing children in need of
support. There is a tremendous, urgent need for dedicated resources to support the
School Success Program in Barrie.
Proposed Solutio
Every attempt is made to identify children who are struggling in school early, and to
make the referral process to the SSP seamless and reasonably quick. The referral
process should be easy, regardless of where the need is identified (school system or
heath care system). Communication and information sharing processes have been
initiated in both systems in order to allow for ease of program entry by families in need.
Efforts towards success in this area are shared jointly amongst the school personnel as
well as the FHT health care team.
The SSP team will work with each child and their family to develop individualized
solutions to the identified need, using a multidisciplinary team approach. A
multidisciplinary team consisting of: a social worker, occupational therapist, registered
nurse, and pediatricians use standardized assessments and best practice clinical
decision making to confirm or rule out a diagnosis, which is likely resulting in the
behavioral issues presenting at school. Based on this comprehensive assessment,
together with the family, they create an individualized care plan necessary to support
the children and families.
Specialized supports are provided by the team and/or connections to the most
appropriate community supports to effectively manage the identified problem behaviour.
There is a need for a clinical psychologist and Speech Language Pathologist to join the
team, as these are identified gaps in services, which are not publicly funded by OHIP
and currently has a very lengthy wait time to access in our community. Many children in
need are going without the support of these services in our community.
The transition between the education and healthcare system is seamless and
coordinated. Recommendations from the team are also shared with the school, with
appropriate consent, in order to coordinate care and create the greatest chance of
40
success for the child. If there is a need for school visits, involving the healthcare team,
school staff and the family, this will be accommodated.
Wait times are significantly less in the program. Care is taken to not duplicate any
services or resources accessed in the community. To date, there are currently 50
children enrolled in the program, with an increase in referrals expected, due to the
communications within the school board and the Family Health Team. Meetings are
taking place between the SSP team and schools in Barrie to communicate and market
the program and further explore how we can continue our mutual efforts for the benefit
of this vulnerable population. Vulnerable populations are identified and targeted.
Information exchange sessions are offered to the school board employees as well as
the Family Health Team and affiliated FHO.
Rationale to continue with our program, beyond the pilot phase, and expand it to
meet the needs of the community:
As the program is still in its infancy, we have little program specific data to share to date
to support our rationale to continue with this program. However, we have incorporated
a strong evaluation component in the program planning phase, which will allow us to
pull data in the near future. There is evidence however, of a high need and interest in
the program from key stakeholders in our community, as previously highlighted in this
proposal. Other supporting evidence for the program is listed below:
1. Outcomes/metrics/data from the existing program, including patient

satisfaction surveys or patient stories
• Improved coordination of care, improved access to care, collaboration between

multidisciplinary team (RN, OT, SW, SLP. Psychologist and Pediatrician) as well as with
external community partners where appropriate using system navigation.
• The program has just gotten off the ground and no meaningful performance
information is available at this time. 50 children and their families enrolled in the
program after only six weeks of operation.
• While there is not enough program specific data to present meaningful results at
this time, the BCFHT is collecting data on the following indicators to evaluate the
performance of the program:
o Number of referrals made to other organizations, programs or services
Including a breakdown of the organizations, programs and services
Also look at current services being offered before attending the program
41
o Satisfaction/Perception of the value added from the services
SERT/Schools will be provided a survey
Patients
Parents/Caregivers
o Number of providers referring into the clinic
o Wait times for the program
o Referrals for the clinic
o Total unique patients seen
o Average visits per patient
o Total number of encounters
o # of new diagnoses (and diagnoses ruled out)
o Screening tools, including pre and post scores for:
SNAP Child ADHD checklist
SCARED (screen for child anxiety related disorders)
o Primary reasons for referral (such as behaviour, family, school concerns,

sensory, etc.)
2. Waiting List/Number of Referrals
• 50 referrals received at start-up of program (first 6 weeks). This has been with a
limited number of schools being eligible to refer patients. The BCFHT and the Simcoe
County School Board have limited the number of referring schools to allow time for the
program to mature, with the limited resources available to commit to the program.
3. Early intervention can have an astounding impact on young children
• Research has overwhelmingly shown that a child who is successful in school has
better outcomes in terms of health and overall quality of life. This is strongly supported
in the literature, including the infamous research published by Fraser Mustard. Early
investments in children have the greatest value and long-term impact on the overall
health, well-being and quality of life for children, families and societies, at large.
4. Have you tried to partner with others?

42
a. We have collaborated with and developed very positive relationships with

key community stakeholders who have a keen interest in the program. Three
pediatricians will provide team based support and the School Board has committed to
being involved, to ensure there is a seamless approach to students and families
needing the coordination of support and resources offered by the program. The school
board has communicated and marketed the program in the community, starting with
schools of the highest need in terms of families and students who are struggling in
school and would benefit from a coordinated approach from both parties (the education
system and the health care system).
b. We are connecting patients/families to community supports and

resources, where appropriate including: New Path, Kinark, CMHA, and Family
Connexions. Careful efforts are being made to not duplicate services or resources in
the community.
5. Is there anything else in the community currently that supports this type of
work?
No. Not in our community of Barrie. The Couchiching FHT in Orillia has implemented
this program several years ago and is experiencing great results/success in meeting the
needs of students and families in that community. We feel that our community needs
are very similar…and the program has the potential to make a remarkable impact on
our community.
6. Any other solutions have been tried?
Traditional approaches have been for school staff/families to think about a referral for
the student to the family doctor if a student is struggling in school with
behavioral/developmental/social/ emotional issues. The family doctor may then ask for
information to be submitted from the school to gain a better understanding of the issues.
Then, a pediatrician referral is likely to be made, of which there is currently an 18 month
wait time. From there, there may be school meetings, and referrals for other types of
supports (OT, counselling, parenting, etc.) which the families have arrange and get
placed on yet another wait list. This uncoordinated and lengthy process (which can
sometimes last for several years) does not efficiently meet the needs of students and
families who are struggling. As a result, critical and unnecessary time is wasted without
appropriate interventions and supports that can help the child be successful and
achieve better outcomes in school. This also negatively impacts the overall quality of
life for both the child and the family, as they are going through this process.
This program is a prime example of upstream population-based approach to health and

wellness in our community, resulting from strong partnerships and shared resources.
43
This exceptional collaborative approach to care is not available anywhere else in our
community. Without the commitment from the Ministry of Health and Long Term Care
to provide permanent resources to this program, children and families will continue to
struggle.
Resources Requested
Based on anticipated demand for program/team services, the BCFHT is requesting the
following human resources to support the continuation of the SSP:
RN-1.0 FTE
Social Worker-3.0 FTE
Occupational Therapist-1.0 FTE
Clinical Psychologist-1.0 FTE
Speech and Language Pathologist-1.0 FTE
Administrative Support-1.0 FTE
Please see below an excerpt from an email communication received from one of our
pediatricians who feels that a Speech and Language Pathologist is an essential request
and need for the SSP:
“In conversation with the team today in SSP, I thought I'd send you a note about
requesting funding for a SLP for the Barrie SSP.
The primary purpose would be for supporting children with reading based LDs. SLPs
are skilled at using multi-sensory, phonetic-based programs with children with reading
based LDs that are approaches supported by multiple LD societies (including LDAO)
and clinical psychologists.
These approaches are aimed at remediation or attempting to "correct" the underlying

issue. This is most effective when implemented prior to grade 4 as there is evidence
that a child's brain is still very malleable at these ages. Remediation should be the
primary goal when working with primary school children with flags for LDs. If the
problem can be remediated, this will save the child from great frustration/negative self-
esteem, potential academic failure with all the associated consequences (including
unemployment), and use much less school resources over the long term (including
accommodations such as technology or special classes/SERT resources, and
behavioural supports).
44
Currently, the schools primarily focus on accommodations (IEP for SEA equipment or
added time, etc). Although these accommodations may play an important role they
should be considered secondary to remediation.
Our goal should be to address the underlying issue (LD) and not just "work around it"
when children are younger. This is akin to screening for cancer so that it can be treated
in early stages rather than waiting until it's metastasized -- treatment is more effective
when implemented early.
LDs affect more than 15% of children and in the referred population of the SSP the
percentage would be much higher. It's very difficult for me to properly address the
"school success" of a child if we cannot address a LD properly. Remediation of LDs is
not within my scope of practice, nor would it be in that of a SW, OT, or RN (our current
team). These other team members bring other expertise which is invaluable to school
success but we are still missing an important "piece".
Of course, a SLP would also be useful for children with articulation issues, fluency
issues, etc. However, there is some access to SLPs for these indications via the school
board (albeit limited). There is no access to SLPs for reading remediation.
Thanks for your consideration.
Miriam Hansen, Pediatrician”
Please also see the letter of support from Chris Samis, SCDSB School Board
Superintendent, attached.
Thank you for your consideration of our request for resources for the School Success
Program. We will patiently await your response.
Respectfully submitted,
Kimberly Vickers,
Interim Executive Director
Barrie & Community Family Health Team
45
Mental Health
Patients experiencing mental health issues require timely access to appropriate care
and as such would benefit from additional mental health resources. The program
receives on average 350 new referrals per month. The current Therapist complement
of 11.6 cannot effectively meet this demand. Efforts to reduce wait times have included
a stepped care approach to service including increased self management, revised
intake process, reduced child and youth services and increased group development.
IT/EMR
We are piloting add-on modules for our Accuro EMR in order to comply with our
contract requirements re: Electronic Communication with patients. These include the
following:
1) Patient Messaging: allows physicians to communicate with patients directly from

within the EMR. Patients receive a “no reply” email telling them they have a secure
message – they then login to a secure platform to view the message. Physicians can
share lab results, provide treatment instructions, and even perform post-op and remote
patient consults. Physicians fully control when communications are initiated and
terminated through this module. Patient Messaging cost is $24.95 per provider per
month. For our ask, we’re considering each program to essentially be a provider and
have broken the FHT down into twelve programs. Total cost: $24.95 x 12 programs x
12 months = $3,592.80 plus tax annually.
2) Online Booking: allows physicians to create blocks of time for certain types of
appointments and make them available via a secure web interface. Patients sign on
and are prompted to select their physician, type of appointment, time slot, and reason
for appointment – the request is then reviewed by the physician staff and a confirmation
email is sent to the patient when the request has been approved.
3) Appointment Reminder: provides automated appointment reminders to patients

and is fully integrated into the EMR. Patients can choose to be reminded via automated
phone call, text message, or email, and the reminder status is displayed on the EMR
scheduler, including whether the patient confirmed, cancelled, or was unreachable for a
response.
Appointment Reminders cost $0.35 per reminder. FHT saw 29,690 patients last fiscal
(includes estimated School Success projection). Total cost: $0.35 x 29,690 =
$10,391.50 plus tax annually.
4) ePrescribe: provides the option for a physician to send a prescription directly to a

participating pharmacy (while still permitting them to fax if they so choose). A fully
integrated and secure messaging system is available directly within the EMR so the
46
pharmacist may request clarification or correction to a prescription and includes drawing

tools to permit the pharmacist to mark up the prescription for the physician to see. This
module will eventually interface directly with the pharmaceutical management software
so the prescriptions may be entered directly (though always with human review for final
approval), which will help eliminate transcription errors.
We are requesting funding to allow us to move forward with this contract obligation of
electronic communication with patients. We are requeting a total of $13,984.30 plus
HST for a total of $15,802.26 to support our needs, as outlined above.
47
Part B: 2018-2019 Service Plan

The objective of Part B is to capture your organization’s vision and strategic priorities as
well as program and service commitments in 2018-2019. The five-year longitudinal
evaluation of FHTs showed that organizational factors such as articulating a clear vision
and establishing clear priorities were often associated with higher performance. Part B
therefore provides you with the opportunity to describe the results of visioning and
priority-setting exercises for your organization, and how these translate into program
and service commitments and associated measures. Part B is comprised of two
components:
1. Section 1.0: Strategic Priorities and Vision: in this section, FHTs are provided
with the opportunity to identify their strategic priorities and broader vision for
2018-2019, with an emphasis on the activities planned in the areas of access
and integration, collaboration and quality improvement.
2. Section 2.0: Operations, Programs and Services are to be detailed in the

attached Schedule A, Appendix 3 template. FHTs are strongly encouraged to
reflect their vision and strategic priorities in the programs and services offered.
Performance measures for programs and services should be detailed in
Schedule A, Appendix 3 which will be incorporated into your budget, forming the
basis for performance monitoring and evaluation throughout the fiscal year.
1.0: Strategic Priorities and Vision
1. If available, please describe the vision of the Family Health Team. Please
indicate if this has been clearly articulated to staff, patients and partners.
Your Health, Our Community, One System: Leading the Way in Health Care.
48
2. Identify the strategic priorities for the FHT that will apply to the 2018-2019
fiscal year.
 Improve timely appropriate access

 Continue to improve quality of care
 Promote primary care research
 Integrate care delivery among all health care and community service
providers in our region
 Improve collaboration of care delivery among the FHT, FHO and BCFMC
 Encourage patient ownership of their personal health care plan
 Promote physician engagement and wellbeing
3. Please explain how the strategic priorities identified in Question 2 support the
objectives of advancing access, integration/collaboration and quality
improvement, as applicable.
Improve timely appropriate access

1) Advocate for improved access to Seniors Care and Mental Health
2) Improve access to specialist care
3) Advance use of the EMR in the clinics
4) Optimize use of staff in the clinics
5) Modernize office workflow
6) Support physicians in determining roster size
Continue to improve quality of care
1) Improve data quality in the EMR
2) Evaluation of FHT programs
3) Implement patient experience survey across all FHT programs and family
practices
Promote primary care research
1) Continue to support community based research in family practices
2) Continue to collaborate on community research project
3) Identify areas of interest for research
Integrate care delivery among all health care and community service providers
in our region
1) Integrate patient care with RVH
2) Explore integrated patient care with specialists
3) Improve communication with Health Care Connect
4) Improve communication Home and Community Care
5) Collaboration with the LHIN and its health service providers and fully
participate in sub-region planning
Improve collaboration of care delivery among the FHT, FHO and BCFMC
49
1) Improve collaboration between FHO and FHT programs.

2) Improve collaboration with IT Department
3) Improved collaboration between the BFMC and physicians and their offices
Encourage patient ownership of their personal health care plan
1) Increase patient understanding of the Health Circle ( relationship between the
FHT, FHO and BFMC)
2) Empower patients to take responsibility for their own health
3) Educate patients about utilization of the health care system
Promote physician engagement and wellbeing
1) Ensure that the Vision and Mission of the organizations are well understood
2) Ensure a comprehensive orientation for all new physicians
3) Promote ongoing physician engagement to maintain a strong organization
4) Promote engagement in QI and optimize use of EMR
5) Promote physician health and wellness
4. Does the FHT plan on undertaking a capital project (major

renovation/construction/lease-hold improvement/re-location to a new or
existing space) within the next two to three years? If yes, please provide us
with a brief project description, including anticipated timelines and budget (if
known).
Currently we have two clinical programs (Pre-Natal Well Baby and Aging Well) that
are located at other locations, both of which have leases that will expire in fall 2020.
It is our hope that we can complete our vision of having all programs in one location,
our Primary Care Campus at 370 Bayview Drive. Our current location houses all
programs and administrative staff, including the two out layers will be an additional
benefit to patients that require combined care. 370 Bayview is located in a growing
part of Barrie with many businesses choosing to make this area their home. We have
a senior’s facility opening beside our office that will certainly bring more patients to
our Aging Well clinic if we could relocate it in our building. In order to move PNWB
and Aging Well to our main campus after their leases expire we would require
additional new office space within our existing building and would require additional
capital funding to support this. We are currently in the process of working with our
landlord to complete the costing of a new space to home approximately 15-20
employees.
2.0: Operations, Programs and Services
50
Using the attached template for Schedule A, Appendix 3, please describe how the
organization’s IHP resources are being applied across each of the programs and
services offered to patients. The template should be completed for new and existing
programs and services and should capture the involvement of all ministry-funded IHP
FTEs.
Please populate the template, using one row per FHT program and one row for Acute &
Episodic Services.
The attached Appendix A “Programs and Services Details” provides further

direction on how to complete Schedule A, Appendix 3.
To assist with Schedule A, Appendix 3 completion, FHTs are encouraged to access a

wide range of resources on program planning and reporting available through the
Association of Family Health Teams of Ontario (AFHTO).
Part C: 2018-2019 Governance and Compliance

Attestation
Strengthening accountability in Family Health Teams is a key component of
enhancing the quality and performance of the primary care sector. Sound governance
practices play an important role in enhancing accountability, performance and the
overall functioning of an organization. As part of the efforts to enhance access, quality
and accountability, beginning in the 2015-2016 fiscal year, all Family Health Teams
are required to complete and submit the Governance and Compliance attestation
annually.
Please complete the Governance and Compliance Attestation (separate document)

with accurate information on current board and governance structures and practices.
APPENDIX A – PROGRAMS AND SERVICES

DETAILS
When deciding whether an activity should be classified as a program on Schedule A
Appendix 3, consider the following:
51
 Was the program planning process followed to establish specific goals,

objectives and admission criteria to the program?
 Are there admission or referral criteria to access the program?
 Will a targeted intervention be delivered?
 Is it a planned patient visit?
 Has the Family Health Team (FHT) assigned specific FHT staff (Full Time
Equivalents = FTEs) to deliver the activities of the program?
Program categories can include:
 Disease specific programs, e.g. heart health or lung health. Often these
programs involve multiple provider disciplines in the delivery of care
 Population group focused programs, e.g. seniors’ health
 Discipline specific programs, e.g. this could be a program of services delivered
by a practitioner, such as chiropody services or occupational therapy services
 Health promotion/prevention programs, e.g. immunization program or cancer
screening
The attached Decision Flowchart provides a schematic that outlines the patient’s
journey through Acute/Episodic Services and/or Programs:
Step 1:
Often, the patient’s initial encounter for a health concern is through an

acute/episodic service encounter. Exceptions are when the patient can self-refer
directly to a program or is triaged through reception directly to a program, based
on admission/referral criteria for that program.
Step 2:
After assessment by a Physician/Nurse Practitioner/Physician

Assistant/Registered Nurse/Registered Practical Nurse for an acute/episodic
service, a determination is made to:
i. Refer to a program that will address the patient’s needs. Referral is based
on established referral/program admission criteria; or
ii. Follow-up with the patient through another acute/episodic service
appointment; or
iii. Refer to external providers or programs/services; or
iv. Issue is resolved and no further follow-up is required.
Performance Measures for Programs and Services:
Programs should include clinical outcome measures as performance measures:

52
 e.g. Number of patients with Chronic Obstructive Pulmonary Disease (COPD)

who have diagnosis confirmed with pulmonary function test/post-bronchodilator
spirometry and have an advanced care plan completed or in progress
Acute/episodic services may include performance measures such as:
 access (e.g. availability of same day/next day appointments)

 system level indicators such as impact on patients seen within 7 days post
hospital discharge, Emergency Room diversion, etc.
Summary:
Overall, Schedule A, Appendix 3 should “tell the story” of the FHT – how are the FHT
interdisciplinary provider resources used to meet the needs of the patient population?
What are the outcomes of the services and programs that are delivered?
For additional information on developing, implementing and evaluating programs

and services please visit the AFHTO website.
53

2018 2019 FHT Annual Operating Plan FINAL1

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Family Health Team

Annual Operating Plan Submission: 2018-2019

FHT Name: Barrie and Community Family Health Team

Primary Health Care Branch

BOARD APPROVAL OF SUBMISSION

PART A: 2017-2018 ANNUAL REPORT

PART B: 2018-2019 SERVICE PLAN

PART C: 2018-2019 GOVERNANCE AND COMPLIANCE ATTESTATION

Board Approval of Submission

Signature of FHT Board Chair or alternate Date: 05/31/2018

Print FHT Name:

I have the authority to bind the corporation

PART A: 2017-2018 Annual Report – mandatory

 Enhancing patient access through reducing the number of unattached

 Local integration and collaboration with health care providers,

 Improved quality through the implementation of improvement

Part A: 2017-2018 Annual Report

1.1 Patient Enrolment

Number of enrolled patients 141,000 144,215 (by MOH roster lists)

There is an ongoing Roster Management project, which identifies discrepancies

1.2 Patient Enrolment – Access for New Patients in 2017-2018

Please explain how new patients were referred to FHT services.

Were patients who contacted the FHT directly (self-referrals) enrolled? ☒ ☐

Were any new patients referred by Health Care Connect (HCC)? ☒ ☐

Were any new patients referred by Health Links? ☒ ☐

1.3 Non-Enrolled Patients

Where resources are available, FHTs are encouraged to offer interprofessional

Prenatal and Well Baby: 2714 patient visits (884 patients)

Routine Prenatal Care (initial and follow up appointments)

Breastfeeding support is provided by an International Board Certified Lactation

The LINKS Team (formerly The MVP Clinic)

719 unique patients serviced - Apr. 1, 2016-Mar. 31, 2018

Barrie Family Medicine Clinics

• Offer Breastfeeding support (1:1 Appointments) to ALL childbearing families in our

• Collaboration of our Lactation Consultant with other BCFHT Team Members,

• Group Classes were offered monthly to promote and support successful

• Link with Community Partners, as appropriate, around breastfeeding issues.

Prince William - 829 Big Bay Point Rd. Unit D12

Bell Farm - 125 Bell Farm Rd. Ste 101

Innisfil - 2101 Innisfil Beach Road

1.4 French Language Services

Does the FHT provide programs and/or services in French Yes No

If yes, provide an estimate of how many patients Small Minority – less

1.5 Accessibility to Cultural and Language Services

19% of doctors surveyed offered appointments in other languages. The following

Patient education materials are available in different languages.

1.6 Regular and Extended Hours

What are your regular hours of operation Hours of operation:

Please provide information on how appointments were scheduled in 2017-2018.

Timely Access to Care

Does the FHT currently schedule appointments on the same Yes No

If yes, what percentage of total enrolled patients is able to see 100%

1.8 Other Access Measures

Please provide information on other types of access measures provided in 2017-2018.

Other Access Measures

Percentage of FHT practitioners who currently provide home 35%

Which types of IHPs perform home visits? OT, Pharmacist, NP,

Number of home visits performed by IHPs in 2017-2018 1102

Emergency Department (ED) Diversion

Wellington - 121 Wellington St. W. Ste 112