Strategic plan 2014-2018

The SAFHT offers primary health care in a diverse urban environment. In this community, there is an increasingly aged population who will live longer, in states of both health and illness. Seniors want to live in their homes for as long as possible and receive dependable community supports to meet their physical, social, emotional, nutritional, and caregiver needs. The SAFHT is likely to face significant challenges in providing quality and patient-centred care to this population — especially those 85 years of age or older. Their proportion of SAFHT’s patient mix will grow. SAFHT anticipates a greater demand for house calls and to more persons with multiple health and functional issues. This mode of delivery may decrease the number of patients that can be seen in a single day, and necessitate the development of innovative approaches.

As a result of both the aging population generally and hospitals discharging patients to the community earlier, there is an increasing role for primary care in the care of complex patients. External respondents noted that the SAFHT already has strengths in this area. Nonetheless, given the increase of these patients expected, the SAFHT will be challenged to take a comprehensive approach to their care and in an environment where there is a priority on integration with community partners in the health care system. New approaches to care may be required.

Ontario’s slow economic growth has prevented Ontario from balancing its provincial budget. Since health care costs are a huge part of the equation, the government continues to try to curb the annual growth in public health care spending, and transform the publicly-funded health care delivery system to extract more value for dollars spent. The SAFHT depends on public resources to deliver care to patients and any changes in government funding, along with the expected increase in the number of patients, may challenge the SAFHT’s ability to provide excellent patient care.

The government has signaled that family health care is a priority. Ontario’s Action Plan in 2012 identified faster access to primary care and the introduction of quality measures to family health care as key components of a fully integrated system. Given this priority, there will likely be a continued drive to assure the performance of primary care (and especially of family health teams) and to identify best practices and successes so as to disseminate them into wider practice. This drive for performance improvement is likely to translate to even more benchmarks and expectations for SAFHT and other FHTs from the Ministry and/or the LHINs. Access to primary care is a vital part of government’s efforts to improve coordination of care for high-needs patients such as seniors and people with complex conditions. Nineteen Health Links have been created across the province to encourage greater collaboration and coordination between a patient’s different health care providers as well as the development of personalized care plans. Each Health Link is expected to measure results and develop plans to:

• Improve access to family care for seniors and patients with complex conditions
• Reduce avoidable emergency room visits
• Reduce unnecessary readmission to hospitals shortly after discharge
• Reduce time for referral from primary care doctor to specialist appointment
• Improve the patient’s experience during their journey through the health care system

Related to the issues above, SAFHT maintains strong working partnerships with community organizations and the Community Care Access Centres in both the Toronto Central and Central LHINs. With the push to prevent and manage illness, thereby avoiding or reducing hospitalizations resulting from poor disease management, services such as home care, hospice care, mental health and addictions services, and supportive housing, must work alongside primary care in the home setting. At the time of this planning, the North East Toronto Health Link (NETHL) is identifying the top one per cent of health care users so that care around these patients in particular can be coordinated. The SAFHT is one of the partners in this initiative.

In the wider world of health care, technology is changing how things are done. There is development and greater use of medical technologies, and, in particular, the Electronic Medical Record (EMR). The next step in the system — beyond adoption — is the optimization and ‘meaningful use’ of the EMR at the individual practice, team, and inter-organizational level to take advantage of the full suite of benefits an EMR can provide. For example, at the practice level, the EMR needs to be deployed as a preventative care management tool for patient populations. In addition to EMRs, in some settings smart phones and tablets are enabling health care professionals to communicate more effectively and deliver treatment more quickly.

At the inter-organizational level, there must be inter-operability between systems so health care professionals from different institutions can see and input data. Clearly, new technologies can and will transform provider-patient and provider-provider interactions and redesign care pathways.

Respondents in the survey believe that the SAFHT provides exceptional patient-centred care. However, many worry that that the SAFHT will be over-stretched if it cannot prioritize or if it responds to too many external opportunities. For example, certain team members struggle to balance academic productivity with the goal of delivering excellent patient-centred care. Interestingly, SAFHT members believe that the SAFHT is inherently innovative and willing to try new things. Individuals point to past program innovations and speak to innovation as part of the culture. To resolve capacity issues as pressures increase, SAFHT’s innovation culture may help drive new models of the delivery of care and education.

The SAFHT has been a leader in IT innovation to enhance patient care. The organization implemented a comprehensive approach to the EMR, reviewing all work processes and converting them where possible. Within the academic environment, the SAFHT plays a leadership role regarding use of the EMR. From the survey done in this planning exercise, we learned that there is more to be done in this area. Areas for improvement include electronic communication with patients and advanced usage of the EMR.

We noted concerns to be managed in the sharing of patient information between care providers. We also noted that when it comes to information technology, the SAFHT relies on the IT infrastructure of the Sunnybrook Health Sciences Centre (“the Hospital”) and this has been, at times, problematic.

The SAFHT has strived to increase its profile within the Hospital so as to strengthen communication and understanding between the SAFHT and hospital departments.

With these and other issues and trends in mind, the Board has set direction. Our Strategic Plan for the next four years is as follows:

Statement of the SAFHT’s enduring role and why it exists, its mandate:
Providing quality interprofessional primary care for our community in an academic environment

What the SAFHT strives to be/accomplish:
Achieving Health Together

These values and principles are what we believe in and they guide all our decisions and actions:

• Person-centredness
• Innovation
• Respect
• Quality
• Prevention
• Teamwork

The following principles will help us decide where to focus our energies and resources when projects and opportunities come forward. We see the following dimensions as being key to both shape meaningful projects and make decisions regarding priorities:

We prioritize SAFHT opportunities and choose strategies within our Strategic Plan that best:

• Foster person-centredness
• Balance the needs of our various patient populations
• Demonstrate innovation
• Enhance quality
• Promote prevention
• Strengthen interprofessional teamwork
• Increase accessibility

We are person-centred and provide primary care throughout the lifespan of our patients. We offer our primary care services in a way that is sensitive and responsive to a patient’s needs, values and preferences. We have long recognized that patients and families should have an active role in making decisions about their own care. This goal is about realizing that vision of empowering and engaging patients to stay well, manage chronic conditions, and to enjoy the optimal quality of life possible for them. As a primary care provider with interprofessional resources, we know that we are best positioned to reinforce the patient’s and family’s goals to stay healthy by supporting the positive habits and lifestyle changes that promote illness prevention and better manage chronic conditions.

Improved access to primary care is a health system priority. This means coordinated 24-hour, 7-day-per-week management of access to appropriate primary care services offered by the SAFHT. This also means access according to need and irrespective of a person’s race, ethnicity, gender, sexual orientation, income, cognitive, and physical ability. We are also mindful of the transitions our patients may experience in their journey of care through the health system.

In an environment where care must be increasingly integrated, we will continue to work with the Hospital and all relevant community partners. Our goal is to strengthen our responsiveness and expertise in care complexity while supporting a broad-based continuum of patient care. Given the team’s ongoing relationship with our patients with complex care needs, we are well-positioned to anticipate their health risks and to recognize any decline. By being located within a large academic and research hospital with access to specialist and diagnostic services, the SAFHT can help prevent and/or minimize adverse outcomes.

The SAFHT is the setting for a model of primary care that is person-centred and interprofessional. Our approach is about exposing all learners to the various disciplines and demonstrating their value in primary care. We are preparing future physicians and other health care professionals to work in a collaborative interprofessional environment, which will be essential to meeting the increasing complexity of primary care.

The SAFHT will ensure the most appropriate and timely care is provided by the most appropriate provider. We will derive the greatest value for patients from our team through optimizing and coordinating our interprofessional care.

The SAFHT is already formally committed to and pursuing quality improvement successfully. In the next few years, we expect to increasingly improve quality and innovate in our delivery of health care. This goal involves pursuing evaluation to ensure our services are effective, integrating evidence-based best practices (including regarding interprofessional approaches), supporting change and innovation ideas and linking them with indicators, and setting and meeting appropriate quality improvement targets and measures for the team. People should receive care that is both informed by the best available scientific information and effective in its delivery.

The SAFHT will continue to strive to be a great place to work and practice so that we attract and retain high-quality team members. In this busy environment, strong ongoing internal and external communications are critical. Internally we will strive to enhance communication and information flows. Externally, in relationship to our community and our partners, through consistent messaging we will seek to present and demonstrate the brand of SAFHT as about professionalism, excellence and transparency. To support our strategic goals, information management and technology will continue to be utilized and improved.