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PHCTF Operational Grant Funding

2003-2004 Funded Projects (November 2003 Round)


Inter-disciplinary Project in Mental Health

The Gizhewaadiziwin Health Access Centre wishes to develop a mental health program that will address the mental health issues of our First Nation and Aboriginal clients. Their team of doctors and NPs have identified a need for a mental health worker who would provide counselling, education and prevention programming for the Aboriginal clients that they serve.

Gizhewaadiziwin Health Access Centre

Fetal Alcohol Spectrum Disorder (FASD) : A Rural Strategy for Diagnosis and Case Management

This project will develop and implement an inter-disciplinary demonstration project that will provide fetal alcohol spectrum disorder diagnostic and case management services in the districts of Kenora and Rainy River for children aged 0-12. Each site in Kenora and Rainy River will employ an inter-disciplinary team including representation from primary health care services, speech language pathology, occupational therapy, psychology and social work.

Lake of the Woods District Hospital

Early Intervention in Psychosis and Withdrawal Management

This project will develop and deliver educational materials focused on two topics identified as difficult to address in primary care settings: Early intervention in psychosis (mental health) and withdrawal management (addictions). Primary care will be defined broadly, as also including nurse practitioners and Community Health Centers (CHCs). The approach will be appropriate to an inter-disciplinary environment so that patients' holistic needs are taken into account. Health promotion and illness prevention will be integral components. The materials will be multi-media and based on an effective education model that has already been developed by the Ontario College of Family Physicians. The approach will acknowledge the present paper-based and face-to-face learning needs of primary care providers while, at the same time, ensuring that the project's products are made available through the latest e-learning technology. They will also be ready for embedding in Family Health Team technology, as well as other available networks, where appropriate.

Canadian Mental Health Association, Ontario

Primary Health Care in Ontario : A Practice Atlas

The Atlas of Primary Health Care in Ontario will provide descriptive information about patterns of primary health care utilization in Ontario. It will describe the type of ambulatory/office-based primary care services received by the population of Ontario overall and by age group (children, adults, the elderly), gender and geographic area as well as by patients with specific chronic diseases such as cardiovascular disease, asthma, cancer and mental illness. The project will assess whether these patterns have changed over time and whether they vary by socioeconomic status. It will estimate the population with no access to office-based primary care. The Atlas will include an analysis of the level of continuity of care provided to patients. It will describe the type of primary care services provided by practitioners according to the type of practitioner, the timing of care (e.g. after hours, emergency, daytime) and funding method (fee-for-service, health service organization or health centre).

Institute for Clinical Evaluative Sciences

Ontario Centre for Support of Collaborative Projects in Primary Care

This proposal will establish a provincial centre for consultation and support to communities, agencies and primary care practices developing collaborative projects or who wish to integrate specialists from any discipline into primary care settings. It will prepare and support providers as they move into new multidisciplinary primary health care models and partnerships, assist them in managing change and analyze their outcomes.

St. Joseph's Healthcare, Hamilton

Using Personal Digital Assistants and Patient Care Algorithms to Improve Access to Cardiac Care Best Practices

The University of Ottawa Heart Institute and the University of Waterloo have formed a team to develop and test cardiac care algorithms on personal digital assistants to deliver standardized care to cardiac patients. The project aims to identify the issues facing patients when they return to the community, communicate these issues to primary care practitioners, and provide them with a tool to deliver best-practice cardiac information and care.

Ottawa Heart Institute Research Corporation

Best Practices in the Evaluation of Primary Health Care Interdisciplinary Teams

Community Health Centres have been providing team-based primary care for 30 years in Ontario. However, our knowledge and expertise has not been systematically collected and analyzed.
The Association of Ontario Health has been funded to develop best practice guidelines for the implementation and evaluation of effective primary health care teams in community-based primary health care organizations in Ontario. Our research project will build on the knowledge and expertise in the sector and build mechanisms to share this knowledge with primary health care teams across the province and nation.

Association of Ontario Health Centres

Integrated Maternity Care for Rural & Remote Communities

This project addresses the current crisis in maternity care services in rural and remote communities by facilitating the development of inter-disciplinary models which meet local needs. This process will engage physicians, nurses, midwives, consumers, hospital and community managers in identifying existing concerns and community-led solutions. Participating communities include Alliston & South Simcoe County, Hearst, Kenora, Moose Factory, Winchester, and Cornwall. Recommendations and an action plan will be developed, in collaboration with the "Babies Can't Wait: Primary Care Obstetrics in Crisis" project, to present to government and professional organizations to support the implementation of the proposed models and sustain maternity care in local communities.

Ryerson University

A Demonstration Project to Improve the Primary Health Care Systems Delivery of Effective Palliative Care in York Region

York Regional Palliative Care Physician Network and PalCare Network for York Region are undertaking a project to develop, implement and evaluate an interdisciplinary Palliative Care Consultation Program intended to improve access, reduce suffering and increase the quality of living and dying experienced by patients and their families.The project will encompass key aspects of palliative care including :

  • Providing expert consultations to physicians and healthcare providers 24-hours a day, seven days a week.
  • Providing education and mentorship to physicians and healthcare providers, including volunteers.
  • Improving access for patients by formalizing a network of physicians skilled in palliative care and by developing an integrated network of primary care providers and specialists.

A key outcome of the project is to improve access to coordinated, interdisciplinary palliative care in the home, reducing the need for acute care resources such as emergency department visits, hospital stays and deaths in the hospital.

Palliative Care Network for York Region

A Rehabilitation Network

The goal of this project is to ensure access to and coordination of regional rehabilitation services available at St. Joseph's Care Group through convergence of technology and clinical practice.

St. Joseph's Care Group, Thunder Bay

"A Good & Healthy Life" : An Aboriginal Approach to Health Promotion

The purpose of this project is to enhance the delivery of culture-based, effective and sustainable health promotion programs for urban Inuit, Métis and First Nations people in the City of Ottawa through the Wabano Centre for Aboriginal Health. Through the development of projects and working in partnership with Elders, traditional people and other health services and groups, the Cultural Health Educator/Promoter :

  • supports the Aboriginal community by developing strategies that address significant factors affecting the health of urban Aboriginal people.
  • builds the capacity and infrastructure of the health system to deliver better, effective and sustainable health services to Aboriginal people and communities.

Wabano Centre for Aboriginal Health

An Interdisciplinary Medication Management Program for Seniors in the Community

This project will add a clinical pharmacist to a supportive housing program that serves 1000 tenants of 12 seniors' apartment buildings in Peel. The pharmacist will lead and coordinate a medication management program that aims to enhance or maintain seniors' independence and quality of life by optimizing their drug therapy. The core of the service is a pharmacist home visit to review medications and obtain information about the senior's medication taking behaviours and medication problems. The pharmacist then develops a medication care plan that is shared with the family physician, and the pharmacist, physician, supportive housing staff, and community pharmacist jointly participate in carrying out the care plan. After 4 months, the service will be evaluated by comparing medication costs, complexity, compliance; and unplanned hospital usage between the client group and a group of seniors who did not get the service. Also, client, physician, and supportive housing staff satisfaction with the service will be assessed.

University of Toronto

THE PAC Project - Integrating a Physical Activity Counsellor in the Primary Health Care Team : A Randomized Controlled Trial

This project will establish a collaborative interdisciplinary primary care team to encourage physical activity. The main intervention is to integrate a physical activity counsellor to the primary care team so that the most appropriate care is given by the most appropriate provider. A randomized controlled trial will be conducted and will involve using an objective measure to track changes in physical activity, determining why the intervention is effective or ineffective by measuring key mediating variables and assessing fitness and metabolic outcomes. This project represents an innovative multi-level multi-intervention approach to promoting physical activity in primary care and is of great public health importance.

University of Ottawa

A Shared Care Program in Primary Care and Addictions for an Urban-Core Population : Proposal for Demonstration and Evaluation

Research has shown that physicians, nurses and other primary care providers (PCPs) can help addicted patients reduce their substance use and improve their health. Shared care programs have great potential to improve PCPs' interest and skills in managing addicted patients. A shared care program is proposed for PCPs in the region served by St. Joseph's Health Centre (SJHC) in Toronto. The program will be provided by the Substance Use Medical Service (SUMS), a division of the Department of Family Medicine at SJHC. The SUMS service will be transformed from its current structure as a traditional consult service into a shared care model, in which the service works closely with the patient's PCP. The program will have three components: education, office systems, and clinical shared care.

St. Joseph's Health Centre, Toronto

The Timmins Palliative Centre

The Timmins Palliative Centre (TPC) will provide primary health care services 24/7 through the services of a palliative care nurse case manager, a palliative physician consultant and a core of palliative care family physicians. The center will collaborate with existing family physicians and interdisciplinary health teams of professionals and volunteers (community and hospitals).

This demonstration project brings together the local health care system to provide a single point of entry for health services for palliative clients in the City of Timmins.

These coordinated palliative services are anticipated to reduce visits to emergency rooms and hospital admissions while supporting shorter hospital stays and increasing the length of time at home for palliative clients.

Cochrane District Community Care Access Centre

Diabetes Screening, Risk Management and Disease Management in a High-Risk Mental Health Population - An Evaluation Project

Family physicians are the primary health care providers for complex patients such as persons with serious mental illness. For example, Schizophrenia is associated with a higher than normal incidence of diabetes, and first line treatments of Schizophrenia have also been found to increase risk for diabetes. As such, this high-risk group requires targeted diabetes strategies. In London Ontario, services are provided to this group by The Western Ontario Therapeutic Community Hostel and the Canadian Mental Health Association. Accordingly, the goal of this project is to assess how these patients are currently being managed by their family physicians and to pilot a community-based, multidisciplinary diabetes clinic model within this population. If this delivery model proves feasible and effective, family physicians could be assisted by existing community agencies in the management of their patients' diabetes and patients will receive improved access to this vital multidisciplinary team.

Lawson Health Research Institute

Integrating Substance Abuse Treatment with the Rehabilitation of Persons with Acquired Brain Injury

This project will facilitate the interdisciplinary management of substance abuse in persons living with acquired brain injury by supporting collaboration between Community Head Injury Resource Services, The Toronto Acquired Brain Injury Network and the Centre for Addictions and Mental Health.

Community Head Injury Resource Services of Toronto (CHIRS)

The Essex County Community Asthma Care Strategy (ECCACS) Demonstration Project

Canadian research indicates that approximately 6 out of 10 patients who have asthma are not in good symptom control. Essex County Community Asthma Care Strategy (ECCACS) is a proactive program of preventative medicine with the goal of improving the health of people with asthma. The program is founded on the high care standards published in national and international asthma treatment guidelines and provides practical solutions for their implementation in the community. ECCACS employs an inter-disciplinary care model in care delivery, which facilitates active participation of the patient, the patient's primary care physician and a certified asthma educator. Patients are provided with the skills and necessary medication to support their asthma control. This includes a written asthma self-management action plan that the patient activates immediately and independently when there is a change in asthma symptoms. Asthma patients become active participants in their own asthma care.

Asthma Research Group - Windsor Essex County Inc.

Developing and Evaluating an Eating Disorder Curriculum for Primary Care Providers

This project will provide support and education aimed at improving primary care provider confidence and comfort in screening for the presence of an eating disorder, improving knowledge of when and where to refer patients for more specialized care and improving awareness around those aspects of patient care that can be managed in their primary practice settings. It will strengthen primary care providers' knowledge about how the medical care they provide supports and compliments the treatment provided through specialized eating disorder treatment programs. More collaborative relationships between primary care providers and a Network of interdisciplinary community based outpatient eating disorder programs will be established.

Halton Healthcare Services

Turning Points for Teens: Ontario Community-Based Intervention for Disordered Eating Attitudes and Behaviours

Disordered eating attitudes and behaviours are rather common among female teens. Such behaviours as binge eating, purging and attitudes that glorify thinness can all serve as risk factors for developing a variety of physical and emotional problems. Unfortunately, few teens come to the attention of health care professionals where barriers to care range from personal readiness to change through to unavailability of appropriate community-based services. This project will develop a targeted intervention program designed to stimulate healthy lifestyle choices with regard to eating attitudes and behaviours, exercise, body image, emotional and interpersonal well-being. A video program will be developed along with companion manuals for use by female teens and health care providers. These materials will be pilot tested by offering group based programming in teens' academic settings in an effort to minimize barriers to timely and age-appropriate care. The project will conclude by making these new resources available to health care and related professionals throughout Ontario.

Lakehead University

Enhancing Provision of Palliative Care by Physicians: A Demonstration Project Integrating Primary Care and Interdisciplinary Specialist Palliative Care

This study will look at how expert palliative care teams can work with family doctors and their patients. For example the study will look at how many patients and what kind of patients the team see in their homes, what kinds of care and support are given, what kinds of problems they find, and if patients and their families feel the care is better. It will also look at the best way to help family doctors manage patients' needs at the end of life. Many people with terminal illness wish to be cared for and die at home. Some people may not get the best care possible because their problems are very complicated or serious. This can lead to people going to hospital to die when they prefer to be at home. Most family doctors would like more training and knowledge to help the patient and family during this time. If doctors and nurses who are experts in end-of-life care could work with patients' family doctors, this could improve quality of life for patients and their families.

McMaster University

Building Knowledge and Skills for Effective Leadership for Change in Primary Care

Investigators in this project will create a leadership development project based on an action-learning model. Project participants will learn and apply best practices in four areas critical to the advancement of primary care: information management, work redesign, collaboration and integration, and performance improvement. Participants will be teams of primary care practitioners from Ontario practices. They will participate in three learning sessions with faculty and experts, test and evaluate local changes to improve their practices, and share their learning with other participants. To validate the four areas of critical knowledge an assessment of practitioner's needs, identification of existing best practices and review of the scholarly literature will be conducted The project will be evaluated in terms of individual learning and changes in practice. Materials developed through this project will be disseminated electronically and through conference presentations.

University of Toronto

Babies Can't Wait : Primary Care Obstetrics in Crisis

This project includes a literature review to inform us about interdisciplinary primary care obstetrics including some of the obstacles and how to over-come those challenges, as well as data collection on the number and type of providers in the province. A Models Development Panel will develop a model or models of interdisciplinary obstetrical care. The proposed model(s) will be tested with current and future providers of obstetrical services. The findings will be brought forward to a consensus building workshop and an implementation plan will be developed. The project will help inform and will be undertaken in support of the Ministry of Health and Long-Term Care's Maternity Services Strategy.

Ontario College of Family Physicians

Quality in Family Practice - Phase 2 : A Demonstration Pilot Project

The goal of the proposed Quality in Family Practice project - Phase 2, A Demonstration Pilot - is to explore the feasibility and affordability of the voluntary accreditation program developed in Phase 1(G03-04052). A multidisciplinary steering committee of health care providers in family practices meets regularly to guide the project. In Phase 1 recommendations were made for a quality program in Ontario. An assessment tool will be developed and a multidisciplinary master assessors workshop will be convened. In Phase 2, the trained master assessors will pilot test the assessment tool in three family practice settings and advise and guide the practices through a pre-assessment, mid-assessment and a final assessment process. Evaluation of the demonstration pilot, the assessment tool, the assessment process and the cost of the program will be included in the final report.

Ontario College of Family Physicians

Measuring Quality Improvements in Preventive Care Services in the First Two Family Health Networks in the Greater Toronto Area

This project uses observational research methodologies to measure changes in preventive services provided by the nineteen family physicians who have joined the first two Family Health Networks (FHN) in Toronto. Using a before and after approach, we will assess the impacts of the FHN template's incentive approach to improving preventive practices. We will provide feedback to the physicians and assess the impact of the feedback loop on practice. In the third phase of the study, all physicians will participate in the implementation of a computer-based program to support preventative services. In addition, fifty (50%) percent of the physicians will be randomly assigned to also participate in the P-PROMPT demonstration project and will receive provider and patient reminders. The two projects are different but complementary.

Ontario College of Family Physicians (OCFP)

Community Based Developmental Team Rehabilitation Project for the Child Health Network

This proposal focuses on a two-year pilot project in the Toronto West and South quadrants, where there is a demonstrated lack of service for the targeted client population i.e. children with developmental disabilities. This initiative represents a key missing component in linking developmental programs, community based interventions, and mental health, to provide efficient, timely assessment and integrated services for clients and their families, within their own communities. This pilot will provide the system with a more in-depth understanding of the role of health assessment services in integrating with community developmental and mental health services which are rehabilitative components of a more broadly, defined primary health care system.

Bloorview Macmillan Children's Centre

Improving Access, Continuity and Quality of Primary Health Care for a Community of Patients with Complex Continuing Care Needs: A Demonstration Project

In this demonstration project, investigator teams from the Toronto Rehabilitation Institute and University of Toronto will collaborate to evaluate the impact of a Nurse Practitioner (NP) on the access, continuity, and quality of Primary Health Care (PHC) for a community of patients who reside in one Complex Continuing Care (CCC) setting. Residents of CCC communities are admitted for a variety of complex conditions, have multiple health care needs which demand constant nursing and medical care, and have limited potential of returning to their homes. CCC units become a community of living (home) for these individuals, and a first point of access to PHC services. In the GTA alone, there are 20 organizations that provide complex continuing care services to over 3000 patients (Toronto District Health Council, 2002). The lessons learned through this project will be useful in guiding the introduction of NP in other CCC units or facilities.

Toronto Rehabilitation Institute

Interdisciplinary Collaboration in the Delivery of Primary Health Care Services : Inclusion of Psychologists in Family Medicine Teams (IPFMT)

The aim of the project is to develop a real interdisciplinary collaboration between psychologists and physicians in a family medicine practice; collaboration based on principles such as proximity, direct access, integration, continuity, coordination and collaboration. This collaboration will lead to improved access to service, quality of patients' lives, quality of physician's practice and quality of collaboration process. Furthermore, the project assumes that the presence and support of psychologists in family medicine clinics will assist in earlier identification of psychological disorders and in diagnosis, support the therapeutic approach, improve the quality of the care provided to the patient and free up time for family physicians, who could then offer more efficient primary health care.

Elisabeth Bruyere Research Institute

Shared Mental Heath Care : A Three Year Demonstration Project

The North Simcoe Community Mental Health System (NSCMHS) is a collaborative venture that includes Wendat Community Psychiatric Support Programs, the North Simcoe Catholic Family Life Centre, Outpatient Services of the Mental Health Centre Penetanguishene, and Vocational and Educational Services of the Mental Health Centre of Penetanguishene. The Shared Mental Health Care is a conceptual model that will partner primary care physicians or family doctors, mental health clinicians and consulting psychiatrists. The addition of Shared Mental Health Care to North Simcoe County will improve access to the most appropriate service for clients of primary care physicians. Clients will be managed collaboratively within the Primary Care setting and family physicians will gain knowledge and experience in the management of mental health issues for their patients.

Wendat Community Psychiatric Support Programs

Interdisciplinary Approach to Fall Prevention and Risk Reduction in Older Adults

This project will evaluate the impact of an interdisciplinary (physician, nurse and physiotherapist) fall prevention program on the incidence of falls and fall injury in seniors. Patients of family physicians in a Family Health Network (FHN) in Kingston, who are 65 years of age or over, and have identified risk factors for falls, will receive a fall prevention program targeted at reducing modifiable risk factors identified through comprehensive team assessment. The effectiveness of the program will be determined by comparing the number of falls and fall injuries sustained by participants in the 12 months after enrolment in the program with numbers from the previous 12 months. The model developed in this demonstration project could form the basis of fall prevention programs within primary care across the province.

Queen's University

Promoting An Interdisciplinary Substance Use Focus in Primary Health Care / A Demonstration Project of The Vitanova Foundation

Health care professionals working collaboratively in York Region will improve services for people coping with alcohol and drug problems. Beginning in the fall of 2004, The Vitanova Foundation of Woodbridge will work with doctors, nurses, nurse practitioners and allied health professionals to build inter-disciplinary substance abuse teams. This approach ensures that the appropriate medical, social services, and addiction treatment skills are delivered in a coordinated, community-based program. Individuals and families facing alcohol and drug-related problems will benefit from increased access to alcohol and drug treatment services and a comprehensive approach to their needs. York Region will benefit from more appropriate use of scarce medical resources and back up for doctors and nurses. This coordinated approach will contribute to a reduction in the use of health and hospital resources to deal with the social and non-medical aspects of drug and alcohol problems.

The Vitanova Foundation

Development of Accord on the Nurse Practitioner Role in Ontario: Developing Models of Interdisciplinary Practice that Enhance Patient Care

Nurse Practitioners are a recent addition to the health care providers available to Ontarians. They perform some of the same functions as physicians (ordering some medications and diagnostic tests). They work throughout the health care system in communities and hospitals adding to the health care services to improve timeliness and access to treatment and care. Since introduction of the role the Nurse Practitioner Association of Ontario has been working with other stakeholders to determine how to use the NP role to the best advantage for patients and families. This project brings together physicians, nurses, nurse practitioners, regulators, leaders and other practitioners to develop ways in which the role can be best used to promote heath care services in Ontario. Through a series of meetings we will create broad communication around some key issues to help nurse practitioners be better able to perform the role they are educated to do.

Nurse Practitioner Association of Ontario (NPAO)

Primary Care Partnerships for Blood Pressure Reduction Strategy

This project seeks to improve the management of high blood pressure (HBP) by primary care providers, including doctors, nurses and pharmacists. Working with the relevant key partners, including the Ontario College of Family Physicians, the Ontario Pharmacists' Association, and the Registered Nurses Association of Ontario, the project creates new educational opportunities, combined with related tools and supports that are designed to enhance physician, pharmacist, and nursing approaches to HBP detection, intervention, and follow up measures. In addition, it will address communication challenges between these providers, as well as trying to improve provider-patient interactions. Working within organized groups of providers (e.g. Family Health Networks), the intent is to improve quality of care via developing/augmenting interdisciplinary relationships and collaborations that will ensure the utility and replicability of developed approaches and tools across various settings. The improved primary care responses and new nursing guidelines can then be disseminated more broadly through the networks of the key partners.

Heart and Stroke Foundation of Ontario

Transition into Primary-Care Psychiatry (TIPP)

The objective of the TIPP project is to determine how feasible it is to conduct a study to evaluate a new primary care focused program of mental health care delivery for people with chronic mental illness. We ask, 'Do clinically stable patients discharged from an outpatient psychiatric service do better with their family doctor or with their family doctor supported by a TIPP team? This will be done by comparing a primary care based, collaborative, interdisciplinary (visiting psychiatric nurse and psychiatrist), model to the current state of care-as-usual on health related quality of life, client symptomatology, client's perceived need of care, participant satisfaction and cost effectiveness.

Lawson Health Research Institute

Enhancing the Use of interRAI Instruments in Primary Health Care: The Next Step toward an Integrated Health Information System/"IDEAS" (Innovations in Data, Evidence and Applications) for Primary Care Project

The University of Waterloo and Homewood Research Institute are collaborating to lead a province-wide initiative to improve the effectiveness of communication between community based organizations providing health care to the frail elderly. The IDEAS (innovations in data, evidence and applications) for Primary Care project includes three main sub-studies: 1) pilot testing a new assessment system for nurse practitioners and community support agencies; 2) evaluation of screening systems to be used by home care agencies, primary care clinicians and acute hospitals; and 3) demonstrating the use of personalized summaries of health information to improve continuity of care between home care and primary care service providers.

University of Waterloo

Enhancing the Use of interRAI Instruments in Mental Health: Making an Integrated Mental Health Information System Happen/"IDEAS" (Innovations in Data, Evidence and Applications) for Mental Health Project

The University of Waterloo and Homewood Research Institute are collaborating to lead a province-wide initiative to evaluate new clinical assessment systems for mental health in order to improve the evidence base for psychiatric services in Ontario and beyond. The IDEAS (Innovations in Data, Evidence and Applications) for Mental Health project includes three main sub-studies : 1) refining clinical and quality applications of assessments done in in-patient psychiatry; 2) evaluation of new screening and assessment systems for emergency and community mental health services; and 3) development of a system to identify older persons in need of geriatric psychiatry services.

University of Waterloo

Interdisciplinary Continuing Professional Development in the Primary Health Care of the Elderly

Family physicians, nurse practitioners, clinical nurse specialists, and pharmacists who care for people in long-term care in Ottawa, Huntsville, Hamilton and London will: select collaborative clinical practice topics; create three e-learning modules for use with facilitators, and, field test the modules to improve care.

Elisabeth Bruyere Research Institute

Improving the Quality and Cost-Effectiveness of Decision Support Provided by Primary Health Care Practitioners in Family Health Networks

Patients face many challenging health care decisions including choosing the level of care for common complaints (self care, family doctor care, urgent care), managing chronic conditions (diabetes, asthma), and choosing among two or more options recommended for the same condition (options for menopause or enlarged prostates). We aim to design and evaluate the quality and value for money of a new approach to supporting patients' decisions provided by the primary health care team (doctors and nurses). The program is designed to improve : patient and practitioner access to decision support tools, training in using these tools, team models for delivering decision support as part of the process of care. We will pilot test this program in 2 family health networks with a view to disseminating successful elements to other networks.

Ottawa Health Research Institute

A Care Navigator Program for Family Medicine Practices

The Care Navigator Program attaches a social worker to family medicine practices to assist patients with complex chronic illness who have multiple physical needs and/or are at distressing or difficult stages in their chronic illness. People with serious chronic illness may have periods when they are overwhelmed by their illness. At these times there are considerable medical and psychosocial needs requiring a wide range of support and rehabilitation in physical, emotional and social domains. This program will help people in such situations by working with the patient's Family Physician and the family practice team. It will provide: individual assessments; information and support; referrals to social and support services for both the patient and the family; translation services; emotional support; and advice on information sources about treatment options and about the patient's condition.

Ottawa Health Research Institute

A New Organizational Structure for Family Medicine Association of Hamilton: Needs Assessment and Feasibility Study

This project is designed to propose a more effective organizational governance structure for family physicians in Hamilton. A steering committee of representative family physicians and an interdisciplinary group of primary care providers and community organizations will guide the process. We will review what family medicine and interdisciplinary organizational structures are in existence in Canada and internationally. We are planning to seek input and advice from family physicians in the community through a needs assessment process, strategic consultations with other primary care disciplines and agencies, and a site visit to Australia to examine their 'divisional' structure. The feasibility of reducing redundancies of the various family medicine organizations in Hamilton will be explored. In our final report we will propose a new structure that will promote innovative initiatives with participation and linkages to other primary care disciplines, community agencies and institutions in Hamilton.

McMaster University

A Case Managed Approach to Improve the Care of the Most Severely Afflicted Mentally Ill Patients Through their Family Physicians' Office

This project will use a case-management, collaborative interdisciplinary team approach to patient care focusing on improving the overall health of patients experiencing severe and persistent mental illness. This project harnesses the combined expertise of a primary care nurse practitioner, the patient's family physician, and a consultant psychiatrist to deliver comprehensive primary care within the family practice setting. Outcome measures include; health status, diagnosis specific symptomatology, family burden, patient/family/provider satisfaction, quality of life, and health service utilization. The intended end results are that patients will experience improved access to needed care, increased satisfaction with care, improved compliance with treatment, improved continuity of care, reduced admissions to hospital, improved quality of life, and improved overall health.

Niagara Medical Group

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