Ontario Health Teams
Ontario Health Teams are a new integrated health care delivery system.
Ontario Health Teams (OHT) are a new integrated health care delivery system. At maturity, OHTs will be responsible for planning, prioritizing, and funding healthcare initiatives at a local level. Physician participation in supporting the OHTs is critical but voluntary. Working together can strengthen relationships among physicians and providers in the community and have the potential to significantly ease the administrative burden on physicians. OHTs are working towards the seamless coordination of care, improved work experience, stronger relationships, and improved communication, as well as a unified physician voice, learning opportunities, and improved access to patient’s electronic health records.
The Connected Care Halton Ontario Health Team (CCHOHT) was designated in December 2019 and supports the communities of Halton Hills, Milton, and Oakville. CCHOHT partners are Halton Healthcare, Acclaim Health, Halton Region, Home and Community Care Support Services (formerly the LHIN), the Chair of the CCHOHT Patient, Family, and Caregiver Advisory Committee, one specialist representative, and one primary care representative from each community, for a total of 9 members.
Our CCHOHT Representatives
CCHOHT is currently Co-Chaired by Dr. Kris Martiniuk, an Oakville primary care physician, and Denise Hardenne, CEO and President of Halton Healthcare.
Dr. Kristianna Martiniuk
Dr. Kiran Cherla
Dr. Carolyn Malec
Dr. Duncan Rozario
Connected Care Halton OHT
The physician representatives (Kris, Duncan, Carolyn, and Kiran) who sit on the CCHOHT Collaborative Committee bring forward initiatives, give updates, and share discussion items regarding Halton physicians’ concerns. This is a standing item on the Collaborative Committee agenda. Physician representatives are integral to the collaborative decision-making process at the CCHOHT. Currently, the OHT is focused on strategic planning, virtual care proposals for physicians and patients, mental health care, palliative care, and home and community care priorities.
The HPA is emerging as a new and critical partner in CCHOHT work. The newly formed CCHOHT administrative team is supporting organizational and communications priorities of the HPA for this current fiscal year. Regular communications between OHT and HPA executive team ensure the work undertaken by the CCHOHT is informed by our physician community.
What is the HPA's relationship with the CCHOHT?
97% of Halton physicians who responded to this question supported an informal collaborative relationship between the HPA and the CCHOHT.
Therefore, the HPA has:
- our own separate rules and regulations
- our own separate agenda
- our own separate projects and initiatives
The HPA provides an organized, cogent, legitimate way of providing physician input at local, regional and provincial levels; of electing our representatives at the CCHOHT Collaborative Committee; and having accountability at all levels.
As an HPA we, the physicians who work in the CCHOHT area (Oakville, Milton, and Halton Hills) can speak with a unified voice. Together we can impact the prioritization of healthcare resources and programs to suit our needs and those of our patients and communities.
NOTE: The HPA is not the CCHOHT physicians’ advisory group. Nor is the HPA agnostic of the CCHOHT. We speak on behalf of, and advocate for, you—the physicians who work in Oakville, Milton, and Halton Hills—and your patients.
SEE WHAT OUR PHYSICIAN COLLEAGUES AND LEADERS ARE WORKING ON
MENTAL HEALTH AND ADDICTIONS
Physician Lead: Dr. Kiran Cherla
Co-Lead: Monica Bettazzoni
4 Main Pieces of Work:
- Unified Care Plan:
The community agencies have developed a singular work plan and pathway for clients with corresponding primary care communication. This will simplify communication, reduce redundancy, and hopefully improve efficiency. This is currently being piloted and evaluated.
- Primary Care Communication:
Currently, there is inadequate communications between specialists/health care workers and primary care physicians regarding referred clients. Communication touchpoints for referrals with relevant information is being developed, with a plan for roll out in 2022.
- Branding of one-Link: Developing a digital and print marketing campaign to promote one-Link will raise awareness in the community. The plan was developed in the fall of 2021 and began execution in winter 2021. Review of the campaign and adjustments for future execution continue on in 2022.
- Urgent Psychiatry Referral
Pilot: The project will address the need for urgent psychiatry referrals in September 2021. Criteria have been developed and vetted with stakeholders through the work stream.
Physician Lead: Dr. Tarek Kazem
Co-Lead: Kathy Davison
- Expanding Palliative Care 24/7 Support:
Increased access and expanded service via the 24/7 Community Support Line assists front-line palliative care workers, patients, and family members. This includes access to a Palliative Care Nurse Practitioner on-call during regular working hours and after-hours to better support patients, families, and providers.
Tel: 905-667-1865 Mississauga Halton Palliative Care Network | (mhhpc.ca)
- Expanding Community Palliative Care Programs to Oakville & Halton Hills: Building on the successes of the establishment of a Community Palliative Care Program in Milton, we have integrated and launched a Community Palliative Program in Oakville within Halton Healthcare to ensure seamless transitions across locations of care including home and hospital. We are also in the process of planning and organizing the launch of Community Palliative Care Program in Halton Hills.
These programs are teams of Physicians available and willing to provide palliative and end of life care to patients who have no Family Physician, or those whom have a Family Physician unable to provide this type of care. Integrating community care within Halton Healthcare across the region allows for one electronic patient chart that can be accessed across care settings, easier access to community PC physicians on call via hospital switchboard in each district, and ensures no patient is without palliative and end of life care.
- Palliative Care Education: One way to build and improve palliative care capacity within our region is to provide education and training, such as the Learning Essential Approaches to Palliative Care (LEAP) course. To date, this course and other means of education have been provided to LTC front line staff, Halton Paramedics, and a wide array of community care providers including Family Physicians. This work continues as we also look to build a more comprehensive paramedic approach and response for community palliative patients to help keep and support patients in their homes when this is their wish.
Home and Community Care
Physician Lead: Dr. Corrine Breen
Co-Lead: Camille Carter
- High Intensity Supports at Home Program (HISHP): HISHP was initiated in partnership with the Mississauga Halton LHIN as well as CANES Community Care. The program promotes increased linkages between Halton Primary Care physicians and CANES Community Care in order to prevent hospital admissions, provide primary care support as well as community-level support at home. The model for this program enables patients to be discharged from hospital to their homes with the supports that they need while they wait for a Long Term Care placement.
- Primary Care Communication with Service Providers: This initiative is aimed at improving communication between primary care physicians and community service providers by giving physicians feedback on the progress of their patients. This initiative also allows for physicians to reach out to care coordinators if the physician is requiring any information.
- Issue Resolution/Escalation Process (HEART): HEART process is an escalation process created by the Mississauga Halton LHIN. The model brings together partners in real time to mitigate risk to patients in the community and to eradicate avoidable ED admissions/hospitalizations.
Over the years, we’ve all seen patients, young and old, become more and more complex. The complexity extends beyond medical care to many aspects of social care, including navigation and supports for income, housing, job and food security. Without adequate resources from the acute care and the community-based care sectors, family physicians have struggled to meet the needs of these complex patients. The system as we know it is fragmented and stretched thin. This means we need to find opportunities to work together with all health sector partners to achieve the quadruple aim: better patient and caregiver care, better population health outcomes, improving the work life of all providers, and getting more bang out of each health care dollar.
CCHOHT’s newest program, Seamless Care Optimizing the Patient Experience, SCOPE for short, is one such opportunity. SCOPE program provides a virtual interprofessional health care team to family physicians and promotes collaboration between family physicians, hospital services and community health partners to serve patients.
Family physicians, regardless of funding model, will be able to receive support for complex and urgent patients through a single point of access to reach a nurse navigator, specialist support, community services and patient navigation all in real time. This will allow family physicians rapid access to diagnostic imaging, general internal medicine advice, palliative care advice, home care, and system navigation, and in a phased approach, mental health and addictions specialist advice.
The SCOPE program has been rolled out in other cities and is linked to reduction in avoidable ED visits and more appropriate use of health care resources. Feedback from SCOPE program users has demonstrated high satisfaction with the patient experience, physician experience, system navigation, health literacy and physician burnout. This is exactly what we need in Halton. Stay tuned for the official roll-out later this fall.
Under this scope umbrella, a Remote Monitoring Proposal has also been initiated, with the involvement of Dr Kiran Cherla, Dr Nadia Alam and Heather McAlpine.
Dr. Nadia Alam
Co-Primary Care Lead
Dr. Nadia Alam is a recognized physician leader and policy analyst. She has worked as a family doctor and anesthetist for over a decade. She graduated from Dalhousie University’s undergraduate medicine program, after which she completed Family Medicine and a 3rd year in GP-Anesthesia at Queen’s University. She has also completed a Masters at the London School of Economics in Health Economics, Policy and Management.
She is active in policy and strategy with a special focus on primary care at the provincial, regional and local level. She has co-chaired bilateral tables with the Ministry of Health, as well as representing family medicine in Ontario Health’s Central Region Mental Health and Addictions table as well as other tables for the Central Region. Locally, she has worked on the COVID@Home program and the business case for the Halton SCOPE program for Connected Care Halton OHT. She is cross-appointed as faculty at U of T’s Department of Family and Community Medicine and the Institute of Health Policy, Management and Evaluation. She is a sought-after speaker and writer for traditional and social media. She is Past – President and Past – Board Director of the Ontario Medical Association and has won a number of awards over the past five years for her leadership.
Dr. Tonia Seli
Mental Health Lead
Dr. Antonia Seli is an Adult Outpatient Psychiatrist who has worked at Halton Healthcare since 2003. She completed her BSc (Combined Honours Biology & Psychology ’95) and MD (’98) at McMaster University, then went on to complete her Psychiatry Residency at the University of Toronto (2003). She currently works in the areas of Consultation Clinic, Medication Review Clinic, Urgent Care Clinic and Mental Health Day Treatment Program.
She is also an Assistant Clinical Professor at McMaster University providing clinical supervision of residents and medical students. She has participated in Shared Care with a local family health team and was previously Co-Mentor for the Collaborative Mental Health Network. She is also an examiner for the Royal College of Canada, Medical Council of Canada and an Assessor for the Inquiries, Complaints and Reports Committee at the College of Physicians and Surgeons of Ontario.
Dr. Gina Di Primio
Dr. Di Primio has worked at Oakville Trafalgar Memorial Hospital since 2015 and a Professor adjunct at McMaster University. She completed her undergraduate education, medical school and diagnostic radiology residency at the University of Ottawa. She completed sub-specialty, a musculoskeletal fellowship at the Mayo Clinic (Jacksonville and Rochester) in 1999 and went on to complete a mini-fellowship in Body MRI in Montreal, Quebec in 2000. In 2014, after 16 years of Academic practice in Ottawa, new family commitments led to move to the Toronto area and is currently in community practice at the Oakville Hospital. In November 2020, she took on the role of Medical Director for radiology at the Oakville Trafalgar Memorial Hospital and focused on improving radiology services to the community using evidence-based best practice guidelines.
She is committed to providing radiology insight into the SCOPE program in order to improve services to community physicians and help avoid Emergency room referrals.
Dr. Deborah Marshall
Palliative Care Lead
Dr. Deb Marshall is a Hospitalist at Milton District Hospital and Physician Co-Lead of the Milton Community Palliative Care Physician Group, which she helped develop from its infancy.
Dr. Marshall is passionate about improving palliative care access and quality in the Halton Region. She will apply this enthusiasm to her role as the Palliative Care Lead for SCOPE.
Dr. David Skogstad-Stubbs
General Internal Medicine Lead
Dr. Skogstad-Stubbs is a specialist in General Internal Medicine. He attended medical school at Queen’s University and then completed internal medicine residency as well as a two-year fellowship in General Internal Medicine at the University of Toronto.
His areas of interest include diagnostic reasoning, perioperative medicine, and point of care ultrasound.
SCOPE Nurse Navigator
Carleen is the SCOPE Nurse Navigator at Halton Healthcare.
Carleen graduated from Conestoga College with a diploma in Practical Nursing in 2011, a Bachelor of Nursing Science in 2015 from McMaster University, and a Master of Nursing in 2017 from the University of Toronto.
Carleen has experience working in both hospital and community settings. She has worked in ER, PACU, and complex continuing care. Prior to beginning the SCOPE nurse navigator role, Carleen worked as a Rapid Response Nurse with HCCSS Mississauga Halton (formerly Mississauga LHIN).
In the role of SCOPE nurse navigator Carleen will provide primary care providers with assistance navigating hospital and community resources to improve patient care needs.
Virtual Primary Care Proposal
Dr. Duncan Rozario and Dr. Kiran Cherla
Over the course of COVID19, virtual care has been demonstrated to be another effective way to deliver care. When appropriately remunerated and integrated at a systems level, virtual care combined with in-person care has the potential to transform how we interact with our patients by allowing us to use the right care modality for the right patient at the right time. Ontario Health has released one-time funding for OHTs to implement Integrated Virtual Care and Primary Virtual Care (26 million dollars for the province) and we are in the process of applying for a share of that funding to transform the way care providers provide integrated team-based care. Dr. Cherla is leading a team to evaluate approved solutions, and we hope to have news about a suggested plan of action shortly.