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PHCTF Operational Grant Funding

2003-2004 Funded Projects (June 2003 Round)


Rehabilitation in Primary Care: A Project to Maximize the Health Status of Adults with Chronic Illness

To assess the effectiveness and cost of a demonstration project that introduces rehabilitation for chronically ill adults into primary care.

McMaster University

The East End Health Network

This is a multidisciplinary delivery project located in the East End of Timmins that will provide coordinated multi-disciplinary access to primary health care. This project will have a focus by all primary health care providers on patient education leading to improved self-care. The team will include a nurse practitioner, pharmacist, dietitian and consulting physician. The project provides primary care services by these interdisciplinary providers to patients in the East End of Timmins with a focus on health promotion and illness prevention through patient education programs.

Northern College of Applied Arts and Technology

Integrated Post-Fracture Care for Osteoporosis in Ontario: A Demonstration Project

This local resource-based interdisciplinary model facilitates continuity of care from the hospital where the fracture is first treated, to the primary care physician for investigation and follow-up for osteoporosis and then to the community for rehabilitation and fall prevention and involves various disciplines working collaboratively. Primary care physicians will work more as coordinators of care with support from other health care professionals. In our model, the health care providers include: physicians, nurses, orthopaedic technicians, physical and occupational therapists working in emergency departments, fracture clinics and outpatient rehabilitation who then link patients to primary care physicians, pharmacists, public health, community-based rehabilitation and fall prevention in the community. The benefit to patients is access to a full range of services including counselling for appropriate dietary levels of calcium and vitamin D, exercise programs, bone-sparing medications and fall prevention programs to manage their osteoporosis and prevent future fractures.

Sunnybrook and Women's College Health Sciences Centre

Shared Mental Health Care Linking General Hospital Acute Care Mental Health Services with Two Comprehensive Family Medicine Groups

This project will involve a multidisciplinary mental health team linking with psychiatric emergency services, mental health urgent consultation clinics and two comprehensive family medicine practices. This will result in improved access to and quality of both psychiatric and physical care for patients with mental health problems who are seen either by a primary health care system or acute care mental health system.

The Ottawa Health Research Institute

Promoting Inter-Disciplinary Identification and Improved Service Delivery for Children with Developmental Coordination Disorder and their Families

To develop, implement and evaluate a new educational package and program of health care delivery that will facilitate earlier identification of children with developmental coordination disorder (DCD).

Children's Hospital of Eastern Ontario

Coordination of Care: Factors that Influence Horizontal and Vertical Information Transfer between Primary Care Practices and Medical Specialists

This project focuses on examining factors and developing interventions (specifically related to information content, format, mode, context, etc.) to facilitate information transfer horizontally and vertically between primary care physicians, nurse practitioners and medical specialists involved in the care of asthma patients.

University of Toronto

Using Performance Indicators and Benchmarks in Primary Health Care

This research project will apply primary health care (PHC) performance indicators in 48 family practices to assess performance and identify benchmarks and best practices that can be used by family physicians and nurse practitioners to improve the quality of care.

University of Toronto

A Randomized Controlled Trial of the Effects and Expense of a Primary and Secondary Cardiovascular Risk Reduction Clinic in Primary Care

This project will demonstrate how an innovative proactive clinic in primary care can reduce cardiovascular risk. The project will study the effects on risk reduction and the expense of three approaches to the care of people with cardiovascular risk factors in a naturalistic primary care environment.

Caroline Medical Group

Interdisciplinary Nutrition Services in Family Health Networks

This project will place registered dietitians in three Family Health Networks to develop and test an integrated model for nutrition services. Nutrition is a major lifestyle factor in health promotion, and important in the prevention and management of some common chronic conditions such as diabetes, heart disease and obesity. Comprehensive nutrition services are placed in the primary health care setting where initial identification, accessible intervention and long-term relationships can be established between the client and provider. Such comprehensive services would include a range of health promotion and treatment services that require the skills of several providers, including the services of dietitians. Dietitians apply the science of nutrition to support positive dietary behaviour to achieve optimal health, illness prevention and chronic disease management.

Dietitians of Canada

Community Health Early Assessment, Resource and Treatment (CHEART) Demonstration Project in Under-serviced, High Risk Areas in London, Ontario

This project will provide timely, accessible primary health care to young family-caregivers in underserviced areas using an interdisciplinary and holistic approach at several existing sites where young families come together. The team of practitioners will include a public health nurse, dietitian, nurse practitioner, early years resource specialist and administrative support. This team will provide health services with an emphasis on promotion, prevention and early interventions. This will include individual assessment and treatment, counselling, parenting groups, health education sessions and referral to community supports. There will also be capacity for home visits to appropriate families. Together with resources from the service locations, ongoing support and continuity will be available to families. Partners in this project include three Ontario Early Years centres, the Middlesex London Health Unit and the Community Nursing Resources Centre (University of Western Ontario).

Middlesex-London Health Unit

Integrating Chiropractic Health Care in a Primary Care Hospital-Based Setting

This project will integrate chiropractic health care with conventional primary care by bringing chiropractors on staff in a major urban hospital. The project will develop and assess a model of integrated service delivery within the inner city hospital's primary care family practice unit.

Canadian Memorial Chiropractic College

Optimizing Drug Therapy in Primary Care: Integrating Pharmacists with Ontario Family Physician Group Practices

The project is investigating the effects/impact of improving drug therapy through the integration of pharmacists into family practice. The integrated pharmacist will conduct patient assessments for medication problems, optimize office system medication management and provide education focused on key therapeutic areas. The intervention is aimed at optimizing drug therapy to improve patient outcomes (blood pressure, cholesterol, diabetes, pain control, constipation, etc.) The goal of the project is to develop an effective, practical and transferable primary care practice model.

McMaster University

Integrated Collaboration in Existing Community Health Centres : Demonstrating Collaboration between Chiropractors and Interdisciplinary Health Care Provider Teams

The goal of this demonstration project is to improve the delivery of community health care services at two Community Health Centres in Ottawa through the integration of chiropractors with interdisciplinary health care provider teams.

Carlington Community and Health Services Corp.

Sharing and Caring: Building a Shared Care Approach in Cochrane and Timiskaming Districts

This project will provide direct primary care to people with mental illness through implementation of a nurse practitioner in the underserviced district of Timiskaming. As well, a recovery-oriented, shared care education program will be delivered to local general practitioners by an interdisciplinary team of mental health experts including consumers. A sustainable model for shared care service in rural districts will be developed. The evaluation protocol for this project has been designed with the intent to both generate new knowledge related to shared care models (particularly in rural locations), and evaluate the effectiveness of the nurse practitioner and education components.

Canadian Mental Health Association - Cochrane Timiskaming Branch

Prevention of Avoidable Acute Care Use by Retirement and Long Term Care Residents: Management of Chronic Heart Failure through the Use of an Innovative, Interdisciplinary Education Program for Care Providers

This project aims to develop and implement an innovative education program for community-based facilities to address knowledge gain, attitude and behaviour change on management of chronic heart failure (CHF). The first target round for CHF education is on care providers of retirement homes and Long-Term Care (LTC) facilities in the Waterloo Region. It is the goal of this project that the residents with CHF will be managed in their own residences according to guidelines, and inappropriate acute care usage will be reduced. Secondary gains such as better quality of life, improved functional and mental abilities, may also occur. This project will involve a multidisciplinary team of nurses, cardiologist, social worker, physiotherapist, spiritual care provider, occupational therapist, and pharmacist in developing and delivering the education program. Nurses, physicians and personal care workers in the retirement homes and LTC facilities will be trained to implement the CHF management strategies in their workplace.

St. Mary's General Hospital

The Development of an Interdisciplinary and Teaching Medical and Dental Clinic for Inner City Youth as a Satellite Clinic of the Bruyere Family Health Network

This is an interdisciplinary project which focuses on developing a model of service delivery to street youth that could be reproduced and sustained in larger cities and will increase the youths' access to primary health care. The project involves collaboration of the University of Ottawa's Department of Family Medicine, Algonquin College's Dental Hygiene Program, the Youth Services Bureau of Ottawa, the Sexual Health Clinic of the City of Ottawa and the Sandyhill Community Health Centre. A medical and dental clinic will be constructed at a drop-in center for the street youth and staffed by family medicine residents, dental hygiene students, public health nurses, a nurse practitioner and a chiropodist. The clinic will provide a full range of primary health care services as well as preventative dental care. It is expected that the youth will be able to receive the care they need as well as the students and residents having an opportunity to improve their knowledge and skills in dealing with this age group.

Institute on Health of the Elderly (Elisabeth Bruyere Research Institute)

Integrating Shared Mental Health Care in Primary Health Care Practice

This project will focus on expanding service provision at Hamilton Urban Core Community Health Centre (CHC) to integrate mental health services with primary health care services to make our service system responsive to the health and well being of the identified populations.

Hamilton Urban Core Community Health Centre

A Collaborative Process for Integrating the Allied Health Professional into a Primary Care Practice as Applied to the Pharmacist

This project will study how to integrate a clinical pharmacist into a primary care group of family physicians and nurses for purposes of providing drug therapy information and advice to both the health practitioners in the group and their patients. The study will be conducted with 2 primary care groups in Ontario: A Health Services Organization of 15 family physicians housed in a Medical Centre in Cambridge and a Primary Care Network of 6 family physicians in separate offices in Paris, St. George, and Ayr. At each site the family physicians, nurses, and the pharmacist will work together to decide on the pharmacist services that are most needed in that practice to ensure that patients get the best results from their medications. The pharmacist will then provide these services for a 6-month period of time. In the end, the researchers will learn what new services family doctors and nurses want from a pharmacist for their practice, how provision of those services affects their practice, and how satisfied they and their patients are with the services.

University of Toronto

The Community-Based Materno-Fetal Health Care Network

This project will establish a community-based primary materno-fetal health care network to provide better care to pregnant mothers whose babies are diagnosed with birth defects.

The Hospital for Sick Children

Improving Access to Primary Health Care Services Through an Electronic Registry of Nurse Practitioners in Ontario

This project aims to develop an electronic database of nurse practitioners for the purpose of matching individuals with other health care professionals and to develop a communication plan to educate the public and others about the role of the nurse practitioner.

Nurse Practitioners' Association of Ontario

The Research Connect : A Five-Weekend Capacity Building Project in Primary Health Care Research

Five weekend education program to train community-based family physicians/nurse practitioners/other health care professionals to conduct interdisciplinary primary health care research and link these practitioners with university-based Interdisciplinary Primary Health Care Research Units.

Ontario College of Family Physicians

Actively Building Capacity in Primary Health Care Research

This project encompasses : a review of primary health care (PHC) provider surveys regarding service delivery, a review of PHC population surveys regarding access, an inventory of 'Centres of Excellence in PHC', a review of seminal PHC papers, the exploration of barriers and supports to interdisciplinary PHC teambuilding and team work, an inventory of interdisciplinary PHC educational programs, the development of a framework for Primary Health Care Transition Fund (PHCTF) project evaluation and knowledge exchange.

Ontario College of Family Physicians

Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools : P-PROMPT

This project will develop and evaluate a scalable and adaptable intervention to significantly increase the proportion of eligible patients who receive appropriate recommended preventive care services in the primary care network-family health network setting in Ontario.

McMaster University

Primary Care Management/Action Plans for Advanced Chronic Diseases (The Road MAP Project)

This project will examine whether chronic disease management, through best practice guidelines as well as multidisciplinary and inter-sectoral coordination, will result in better outcomes and lower tertiary care utilization for patients with congestive heart failure and chronic obstructive pulmonary disease.

Queen's University

Mental Health Reform Demonstration Project

This project focuses on the addition of social, rehabilitation and education resources to a small medical team working with the homeless, many of whom have been diagnosed with one or more significant psychiatric illnesses. This fragile population is growing and their needs are increasing. The goal is to get this population off the streets, give them the help and health care they need and the respect and dignity they deserve. Further, this project will provide increased educational experiences for students from Fanshawe College and the University of Western Ontario. By teaching nursing, medical, social work and journalism students about critical issues experienced by this population, we hope to not only recruit health care workers to the community but also create an educated public.

Victorian Order of Nurses Middlesex-Elgin Branch

Primary Health Care Clinic for Pregnant Substance Users : An Evaluation and Dissemination Project

This project aims to evaluate the effectiveness of a primary care multidisciplinary centre in the management of substance use during pregnancy. Short and long-term maternal and neonatal outcomes of pregnant substance-using women will be determined and compared to a general Family Medicine obstetrical population. Health care providers will also be surveyed to assess their knowledge, attitudes and beliefs about substance use in pregnancy.

St. Joseph's Health Centre

Utilization of Emergency Services and Walk-in Clinics among Patients from FHN versus non-FHN Family Practices

This project focuses primarily on comparing Family Health Network (FHN) and non-FHN patients in terms of frequency and type of emergency and walk-in clinic visits. It also examines physician and patient satisfaction in FHN and non-FHN practices.

McMaster University

Implementation of the Rehabilitation Integrated Transition Tracking System (RITTS)

This project will establish a web-based rehabilitation referral tracking and database system which spans acute care through to community care in the Ottawa area. This will enable providers and clients to seek appropriate referrals and manage information without individual case managers.

The Rehabilitation Centre and the Ottawa Hospital

Assessing the Usability of Neighbourhood Level Variations in Illness Burden to Estimate the Primary Care Needs of Local Communities : Phase 2

Phase 2 of this project (Phase 1: G03-03854) focuses on comparing the variation in need for primary health care services at the neighbourhood and community level using different indicators (i.e. illness burden profiles versus other indicators such as poverty, low education, high unemployment). The aim is to develop methodologies to assist with planning and funding community health centres.

McMaster University

Preventive Primary Care Outreach for High Risk Older Persons

This project aims to evaluate the impact of a Preventive Primary Care Outreach (PPCO) intervention compared to usual care for seniors aged 75 years and over who are at risk of functional decline. This intervention will be provided to clients of family physicians who are members of Primary Care Networks (PCNs).

McMaster University

Tele-homecare In Palliation Study (T.I.P.S.) : A Randomized Controlled Trial Comparing the Efficacy of Tele-Homecare vs. 'Standard' Homecare for Palliative Oncology Patients and their Caregivers

This project aims to assess the effectiveness of tele-homecare vs. standard care in decreasing the utilization of acute health care services and improving quality of life. It also assesses whether tele-homecare is at least as effective or more effective in improving access to, and satisfaction with, health services.

Temmy Latner Centre for Palliative Care, Mount Sinai Hospital

Developing and Testing a Comprehensive Telemanagement System to Improve Chronic Disease Treatment in Primary Health Care : A Demonstration Project in Diabetic Patients with Uncontrolled Hypertension

The investigators will develop a blood pressure telemanagement system that amalgamates the separate functions of telemonitoring, clinical decision support and telecommunication. Its effectiveness will be tested in a pilot study involving type II diabetic patients with uncontrolled hypertension, and appropriate modifications and adjustments will be made based upon the results.

Mount Sinai Hospital

Evaluation Project of Primary Health Care Payment and Delivery Models on the Screening, Detection and Control of Hypertension

This project will compare three health care payment and delivery models (Fee-for-Service, Family Health Network, Community Health Centre) with respect to the screening, detection and control of hypertension in order to determine the factors that contribute to the best quality of care provided to patients.

Institute for Clinical Evaluative Sciences

Compete III : Integration, Implementation and Innovation for Better Vascular Outcomes

The Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE) III project will connect family physicians, medical specialists, clinical care coordinators and patients through an electronic network to monitor, inform and support patients with vascular risk factors. A randomized trial will examine the effectiveness and cost-effectiveness of this intervention, which is primarily aimed at improving prescribing practices, compared to usual care.

St. Joseph's Healthcare Hamilton

Development and Evaluation of Interdisciplinary Practice-Based Research and Education Networks : Facilitating the Movement of Health Professionals into Group Practice with Enhanced Primary Care Learning and Research Opportunities

This project will establish a network of physicians, pharmacists and nurse practitioners in community-based group practices in order to implement clinical practice guidelines and other peer-reviewed educational materials. A community-based primary care education network will be fostered by providing material resources to interdisciplinary teams within existing group practices and by encouraging new relationships among community providers.

Medication Use Management Services (MUMS) Inc.

A New Community Primary Care Model for Persons with Lower Extremity Ulcers

This project will create inter-disciplinary teams to facilitate efficient assessment and the delivery of a new evidence based model for the community care of lower limb ulcers. The project will link Community Care Access Centre (CCAC) coordinators with community nurses, who have wound care expertise, family doctors, key leaders, other health care professionals and patients.

University of Toronto

A Collaborative Process to Achieve Access to Primary Health Care for Black Women and Women of Colour

This project will use a collaborative process to address a pressing need within the community to achieve access to primary health care for black women and women of colour.

Women's Health in Women's Hands Community Health Centre

Teleprimary Care : Demonstrating the Role of Telehealth in Enhancing Primary Health Care

This project will utilize telehealth technology incorporating two-way videoconferencing and electronic medical devices over a virtual private network, for the purposes of nurse practitioner initiated interdisciplinary consultation; participation of patients from rural and remote communities in primary care group classes; and supporting continuing professional development for nurse practitioners in rural and remote locations.

Sunnybrook and Women's College Health Sciences Centre - NORTH Network

"Just-in-time Information" Librarian Support at the Point of Service Delivery for Family Health Networks (FHNs)

This project will demonstrate a librarian consultation service to Family Health Networks (FHNs) to answer short reference questions. The primary health care team will be taught how to use this service.

University of Ottawa

Comparison of Models of Primary Health Care in Ontario

This research project will study four models of primary health care (PHC) in Ontario: Community Health Centres (CHC), Family Health Networks (FHN)/Primary Care Networks (PCN), Health Service Organizations (HSO), and Fee-for-Service (FFS). Specifically, it will describe the four different models of PHC; study and compare the quality of care in the different models; and, explore opportunities to link with administrative databases to study quality of care.

Institute on Health of the Elderly (Élisabeth Bruyère Research Institute)

The Vascular Intervention Program

This project will decrease the modifiable risk factors for primary care patients at risk for vascular disease in the Algoma District and increase collaboration between family physicians, pharmacists, physiotherapists, dietitians and nurses in the community.

Sault Ste. Marie District Group Health Association

Primary Health Care Measures on Quality, Prevention, Comprehensiveness, and Continuity - Estimation, Validation and Generalization

This project will develop and compare measures for Primary Health Care (PHC) practice/delivery and quality of care from health administrative data (HA-data) and from researchable electronic medical records (EMR-data). It will also describe PHC practice in various PHC models (including family doctors, family practice nurses and nurse practitioners), validate the measures, and assess their generalizability.

The University of Western Ontario

Financial and Work Satisfaction: Impacts of Becoming a Family Health Network

This project will compare general practitioner (GP) income and work satisfaction (among GPs and other providers) pre and post adoption of recent primary health care models such as the Family Health Network (FHN). It will also explore whether work satisfaction affects quality of care.

The University of Ottawa

Anticipatory and Preventative Team Care (APTCare): At Risk Patients of Family Health Networks

This project will test a new model of integrated service delivery for at risk elderly patients integrating primary care reforms with new policies for the renewal of the home care sector. It will also conduct a randomized controlled trial (RCT) to determine whether a nurse practitioner (NP) and pharmacist home-based model of preventive care that is supported by telemonitoring and that complements family practice will reduce service utilization (ED visits) and improve patient outcomes compared to usual care.

Institute on Health of the Elderly (Élisabeth Bruyère Research Institute)

The Sioux Lookout Anishinabe District Health Plan - Development of a Reinvestment Plan to Enhance Community Based Primary Health Care Services for the Sioux Lookout District

This project will identify health priorities and health status, determinants of health, community strengths, existing Primary Health Care (PHC) services, a vision for future PHC, and develop an evaluation framework for aboriginal people, in the Sioux Lookout First Nations Health Authority.

Sioux Lookout First Nations Health Authority

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