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HRFHT Program and Service AGM Prezi

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Rose-Ann Bailey

on 26 September 2013

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Transcript of HRFHT Program and Service AGM Prezi

1) Patient demographic, contact information and health card #
2) Language spoken if not English
3) Indicate if patient is hearing impaired
3) Reasons for referral clearly state; Urgency of referral
4) Referring practitioner's information
5) Diagnosis.
6) Relevant Medical/family History
7) Relevant lab results, current medications, vitamins and minerals supplements
8) State home visit (home visits guidelines will be coming shortly)
9) Educate patients on reason(s) for referral

Humber River FHT Programs & Services
FHT Programs & Services
Each of the six program areas proposed in the original Business Plan has been reviewed, with the goal of streamlining programs, services, and workloads to make the most effective use of our resources. .
To help diabetes patients to manage the disease, to prevent rapid deterioration affecting their quality of life, and those with pre-diabetes to delay the development of diabetes.
To deliver obesity prevention and management programs, with a focus on nutrition, exercise and lifestyle choices and to partner with existing agencies to standardize diabetes care

prevent deterioration of health by enhancing or restoring capacity,
to reduce ER visits, hospitalization and institutionalization to LTC facilities.
to improve the quality of life and health of seniors (keeping seniors in their home if possible) and minimizing the premature decline in health, and functional capability
to identify seniors at risk and in need of service

As Interdisciplinary Health Professionals we support you to provide the optimal health services to your Patients
All appointments are made through our referral system and are based on HRFHT triaging guidelines
Referrals should include:
Patient demographics, contact information, language, need for interpretation, Urgent / non-urgent, a copy of the most recent blood work incorporating, HBA1C, FBG, LIPIDS, CREATININE, eGFR
and other relevant measures, (active) medications, co-morbidities/ medical history and, mobility concerns.

How is (interdisciplinary) care provided?
Once a referral is received by the diabetes team, they will refer to other disciplines as required.

Intra IHP Referral will occur to Social Worker or Chiropodist based on assessment throughout the initial or follow up visit with the IHP.

Monthly diabetes education session are occurring which provide general diabetes education to patients

Planned activities:
What happens when a referral is made?
delivered a wellness workshop for patients called
Love your

Heart. Love your Mind
. The goal of this session was to offer patients coping strategies to help manage stress and promote mental health/wellbeing.

The team have developed an Assertiveness Empowerment Workshop directed at patients who have self-identified as having poor communication skills (passive or aggressive).

Mental Health and Addiction
to provide mental health and addiction counselling and intervention for adults and young adults.
to provide referrals to other mental health and addiction services in the hospital and in the community (if needed).

develops and delivers a shared care approach to mental health and addictions for patients. The team provides counselling (and case mangement) for patients experiencing:

a) Depression / Post-partum
b) Anxiety
c) Stress
c) Bi polar disorder
e) Grief
f) Family Conflict
g) Schizophrenia
h) Substance abuse (or misuse)
Reasons for referrals should be clear and include whether the client should be seeing a:

1. Dietitian
2. Nurse Educator or a
3. Chiropodist or
4. All of the above

Planned Activities
What happens when a referral is made?
Planned Activities
Seniors Wellness ( including information on:
nutrition, fall prevention, foot care and exercise)
Flu Clinic
Mobility clinic
Advance Care planning workshop
How is (interdisciplinary) care provided?
Individualized care
Case management
Home visits (when/where necessary)
Group activities

What happens when a referral is made?
Step 1:
Triaging by the Reception staff.
Step 2:
Reception staff contacts patients to schedule initial appointment
Step 3:
IHP meets with patient at the scheduled date for assessment, care plan or service plan and interventions
Step 4:
Reports and documentations are done in Oscar and physician notified through Oscar. For physicians not in Oscar, reports are faxed to them
Step 5:
Follow up appointment made by IHP.
patient may be referred from one IHP to another based on identified issues.
patient may also be referred to other agencies or community resources based on need
Step 6:
IHP works with patient until goal(s) are met

For all programs, a complete referral has:

As Physicians you provide Patients with
General Primary Health Care

- to provide assessment, counselling, education, and intervention in the following areas:
- mental health, finance, isolation, etc
- cognitive impairment, incontinence, heart disease and other chronic diseases
- nutrition-related chronic disease, malnutrition, obesity
mobility, home safety and chiropody care

Target Populations:
targets seniors (65+)
at risk (e.g. frail seniors,
co-morbidities, and dementia, decline in health and functional capability), seniors experiencing difficulty with nutrition, sudden or unexplained weight loss, chiropody needs and wound care management

When and how to refer
Refer via OSCAR consult and include the following:
• Presenting problem
• Precipitating event
(what happened that caused
the referral to be made)
• Present Risk/harm

• Consent
to leave a Voice mail for SW appointment (If not given, reception will assume consent)
• Updated contact information/demographics.

Once the referral is received
Reception will assign it to a social worker(s). The Pt. will be seen within
2 weeks
. If a sooner appointment needs to be made, please select
in the OSCAR consult form.

What to expect for treatment

The Pt. can expect to be seen between
times for approx.
45 in-1 hr
. During this time, the Pt. and worker will work towards a measurable goal. After
12 sessions
, they will be discharged and this will be documented in their chart. If they would like more counselling, they will be advised to get another referral from their doctor.

At the first visit an Initial assessment and appropriate counseling is provided.
This will take
60-90 minutes
depending if interpretation is needed. Patients are provided with a
free glucometer, 10 strips and lancets
if they so desire.

A follow up session for
30-45 minutes
is booked within: ·
4-6 weeks
if diabetes and associated conditions need to be stabilized.·
3 months
if improvement in blood glucose and A1C indicator occurs ·
6 months
if diabetes and associated conditions are stabilized to correspond with A1C blood works completed with the MD.

What is expected at the visit.
A client will need a new referral if they are not seen for over
6-12 months
and no bookings have been made.· Client does not show up for
2 appointments
and have no further booked appointment with the IHP, a new referral may be required

Dietitian and Nurse will determine if more frequent visits are needed or consult with the family physician if complex Diabetes care is needed.
Initial and follow up appointments may be separate or Joint appointments with nurse and Dietitian together based on the degree of diabetes management needed.

Documentation will be charted in OSCAR. A physician report is made through OSCAR or faxed to the referring physician.
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