Ontario Health Teams

Ontario Health Teams are a new integrate health care delivery system.

Ontario Health Teams are a new integrated health care delivery system. At maturity, OHTs will be responsible for health planning, prioritizing and funding at a local level. Physician participation in building these teams is critical but voluntary. These teams can strengthen relationships among physicians and providers in a specific geographic area and have the potential to significantly ease the administrative burden on physicians. OHTs can lead to seamless coordination of care, improved work experience, stronger relationships and improved communication, unified physician voice, learning opportunities, and improved access to patient’s electronic health records.

The Connected Care Halton OHT was designated in December 2019 and encompasses the Halton Hills, Milton, and Oakville communities. CCHOHT partners are Halton Health Services, Acclaim Health, Halton Region, Home and Community Care (formerly the LHIN), the chair of the CCHOHT patient family advisory committee, one specialist, one primary care representative from each community for 9 members in total.

Our CCH-OHT Representatives

CCH-OHT is currently co-chaired by a primary care physician, Dr Kris Martiniuk (Oakville) and CEO of HHS, Denise Hardenne.

Dr. Kristianna Martiniuk

Dr Kristianna Martiniuk

Chair

Dr. Kiran Cherla

Dr Kiran Cherla

 

Dr. Carolyn Malec

Dr Carolyn Malec

 

Dr. Rosario Duncan

Dr Duncan Rozario

 

Connected Care Halton OHT

The physician representatives (Kris, Duncan, Carolyn and Kieran) who sit on the Connect Care Halton-Ontario Health Team (CCH-OHT) Collaborative Committee bring forward initiatives, give updates, and share discussion items regarding Halton physician’s concerns. This is a standing item on the Collaborative Committee agenda. Physician representatives are integral to the collaborative decision-making process at the CCH-OHT. 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 CCH-OHT work. The newly formed CCH-OHT 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 CCH-OHT is informed by our physician community.

Connected Care Halton OHT Collaborative Committee - Halton Physician Association is connected to Community Health Service Providers - CCH OHT - Hospital - Other Physician Groups

What is the HPA's relationship with the CCH-OHT?

97% of Halton physicians who responded to this question supported an informal collaborative relationship between the HPA and the CCH-OHT.

Therefore, the Halton Physician Association 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 Connect Care Halton-Ontario Health Team (CCH-OHT) Collaborative Committee; and having accountability at all levels.

As an HPA we, the physicians who work in the CCH-OHT 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 CCH-OHT physicians advisory group. Nor is the HPA agnostic of the CCH-OHT. 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:
  1. Unified Care Plan: The community agencies have developed a singular workplan 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.
  2. 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 October 2021.
  3. Branding of OneLink: Up to date communication with primary care regarding what Onelink is and isn’t, with a plan for rollout by October 2021
  4. Urgent Psychiatry Referral Pilot project for urgent psychiatry referrals in September 2021. Criteria have been developed and vetted with stakeholds through the workstream.
Dr. Kiran Cherla

Palliative Care

Physician Lead: Dr Tarek Kazem
Co-Lead: Kathy Davison

  1. Expanding Palliative Care 24/7 Support:
    Increased access and expanded service via 24/7 Community support line for 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)
  2. 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 now 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.
  3. Palliative Care Education: Building and improving palliative care capacity within our region by providing education and training including 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.
Dr. Tarek Kazem

Home and Community Care

Physician Lead: Dr Corine Breen
Co-Lead: Camille Carter

High Intensity Supports at Home Program (HISHP): HISH Program 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.

Dr. Corrine Breen

Scope

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.

CCH OHT’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. Nadia Alam

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. Antonia Seli

Dr. Gina Di Primio
Radiology Lead

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. Gina Di Primo

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. Deborah Marshall

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.

General Internal Medicine Lead

Carleen Shipley
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.

Carleen Shipley

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.

See an interview with Dr Rozario and MD Financial HERE
Read more about the vision of virtual care in the CanadianHealthcareNetwork.ca article HERE

Dr. Rosario Duncan
Dr. Kiran Cherla