Yearbook 2016 – 2017

A year in review of the CEP’s journey in health care

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Executive Messages

Tupper Bean

Executive Director

When I look back at the last decade at the Centre for Effective Practice, I am struck by how much we have grown and evolved. We’ve evolved from a two staff shop with a $60,000 budget within the University of Toronto’s Department of Family and Community Medicine, to an independent not- for-profit organization raising over $15 million in project work. Our work has expanded to include academic detailing, tool and support development and implementation, EMR optimization, and program evaluation. Our team now includes staff with skills ranging from evaluation to information and knowledge management to user-centred design. Our formal partnerships – a demonstration of our commitment to share, align and collaborate on work – include the College of Family Physicians of Canada (CFPC), Ontario College of Family Physicians (OCFP), the Nurse Practitioners’ Association of Ontario (NPAO), Canadian Agency for Drugs and Technologies in Health (CADTH) and CognisantMD. These organizations share our values and vision to contribute meaningful health system solutions.

Yet over the years, what has not changed is our steadfast commitment to developing tools and delivering services to support primary care providers in care delivery. We translate provincial priorities and policies to make them real on the ground, in the offices of providers. We bring to the frontlines what they tell us they need. We listen and work with providers because context matters. Through engagement and the experience and expertise of our clinical leaders, we are able to curate, create and implement change interventions that reflect both the evidence and realities of primary care providers.

As you leaf through our first official yearbook, bear in mind that this is a reflection of our journey and how far we have come. Our journey has been one of a nimble organization, unobscured by regulation and policies, that has innovated, pivoted and rebuilt itself to meet the needs of providers and implement health system priorities. The numbers and narratives tell a story of hard work and dedication that has amounted to many wins and I thank everyone who has contributed to our success – our board, our staff, our partners, our clinical leaders, all the countless collaborators, and most of all, the providers who use our resources, give us their feedback and hold us accountable as they continue providing patient care.

We recognize there is still a long road ahead. We see the growing list of demands placed on providers. We look forward to continuing to walk alongside providers and our partners at the crossroads where policy meets practice.

Bernita Drenth

Board Chair

As Board Chair, I am pleased to share CEP’s first official yearbook and contribute to a small piece of our story. As I reflect upon my message here, I want to share what was missing from the narrative – the value of the CEP approach. Similar to other organizations, we measure value in a number of ways including value to providers, value to patients and economic value. These are all very important metrics of impact and success. Yet, this is not enough nor is it the full picture because it does not capture the value of the CEP approach.

As I immersed myself in CEP’s work, as board members often do with small organizations, I quickly realized the significant investment—in time and people—the organization makes to engage with providers and stakeholders. Engagement and communication is not something the team takes lightly. It is not a checkbox on a list or a basic requirement for a project. It is much more. The commitment to engage and communicate permeates throughout the organization with each staff member, and across every client, clinical lead and stakeholder. It translates into bringing people in from the onset, active listening, iterative learning, innovating, and sharing information and ideas openly. This culture and approach of engagement and communication is what makes CEP’s tools and resources for providers practical and useable. This skillset lies at the heart of their academic detailing program. It is what brings clinical leaders and providers back to the CEP to lead work, participate in focus groups and sign up to receive their tools and resources.

But more importantly, even at times when there are stark differences, all perspectives and experiences are welcome, in pursuit of common ground and mutual interest. It is the difficult job of bringing various parties to the table to focus on the collective good that is immeasurable. It is the continuous dialogue and discussions that open the lines of communications, facilitate relationships, create trust, build partnerships and catalyze change. Amidst the formal presentations and informal conversations, the false starts and strong finishes, and the public successes and internal setbacks, herein lies the hidden value of the CEP approach.

Hugh MacLeod

Board Member

Today, through the looking glass of a former health care executive, parent and patient, I see a dynamic primary care landscape with juxtaposing realities. At 50,000 feet, the policy environment continues to navigate unprecedented complexities to work towards better patient care and outcomes. At 5,000 feet, the organizations and structures that will be overseeing change and measuring results seek to find the balance between provincial and local priorities. At five feet, the day-to-day realities of providers are often far removed from the aggregated data upon which we measure the collective success of our health care system.

Between these three layers—provincial policy, regional management and local implementation — there exists enormous opportunity for leadership. It is in these spaces, these gaps — the intersections of evidence and practice, policy and implementation, knowledge and behaviour change—where any organization such as the CEP bring a unique skillset and quietly demonstrate remarkable results. Based on a decade of learning, both through successes and failures, the CEP has deep knowledge of primary care and understands how to work with providers to help develop practical solutions. Solutions which help move the policy agenda forward whether it is related to poverty, mental health and addictions, MSK or any other provincial priority.

As a board member, I understand that the CEP alone cannot fill the vast space or solely address current gaps. Through their many partnerships and collaborations, the CEP supports frontline providers with practical tools and resources to help them deliver quality care to patients and improve health outcomes. By working together, and sharing ideas and lessons learned, the CEP works hard to fill the spaces in a meaningful way that bring policy and priorities to the frontlines and ultimately to patients. We are privileged to work in this space. We are proud of how we address the gaps in the health system. We are pleased to share our successes with our partners.

David Price

Board Member

The success of our health care system relies heavily on effective primary care services to deliver quality patient care. Today, the primary care context is more dynamic than ever and in a constant state of flux. We know that patients are living longer, have multiple co-morbidities and more complex illnesses, and have access to new medications and technologies. In addition, providers must stay on top of the evolving legislative and regulatory landscape as most health care policy decisions impact or can be affected by primary care.

For these, and a host of other reasons, it is important to have tools and resources available to support primary care providers, and there is no shortage of tools, supports and information available. There are countless clinical guidelines. The body of evidence on behaviour change in primary care is plentiful. The list of interventions and implementation science literature continues to grow. In reality, many change interventions frequently fall by the wayside for one simple reason – context. Studies have shown that guidelines are not always followed in primary care because they are typically created with a focus on one disease and do not reflect the complexity of patients. Moreover, they are often written for settings other than primary care. As a policy advisor, academic and practicing clinician, it is this opportunity and challenge – translating knowledge in the primary care context – that brought me to the CEP.

This is where the CEP excels and supports provincial priorities by bringing academic rigour to clinical tools and resources created specifically for primary care. Based on their experience and through their evidence reviews, clinical engagement and user-centred design testing the CEP has unearthed the science and art of developing meaningful resources and interventions to support primary care providers in their practices. Building on international evidence of effectiveness, the CEP’s provincial academic detailing program is one such example. The CEP’s Poverty Tool is another example of a resource that brings a provincial priority to the frontlines and makes it real in primary care. The tool has been embraced by primary care providers: it’s been included in teaching curriculums, reprinted in textbooks, integrated into EMRs, and has been adopted
in provinces across Canada. In the pages that follow, you will find numerous examples of CEP-led initiatives that bring policy and practice together for providers.

By the Numbers

70
Tools, resources and programs developed
220
Stakeholder organizations directly engaged
17200
Tool downloads since November 2016
18867
Print Tools, resources and guides distributed

Really excellent that [the tools] are centrally developed from a reputable source.

Primary Care Provider
  • ~2,000 direct provider engagements/inputs
  • 50+ stakeholders organizations engaged
  • 10 clinical tools developed
  • 30+ clinical leads and experts directly engaged

I would love to see the academic detailing service continue in long-term care homes. It provides an excellent educational resource which can be flexible to meet the needs and practices of particular facilities.

Dr. Lyla GrahamMEDICAL DIRECTOR, ST. PATRICK’S HOME OF OTTAWA
  • 41 long-term care homes serviced

  • 5,000 residents services across 9 LHINs

  • 788 individuals directly engaged

  • 548 visits

  • 181 educational presentations

  • 7,220 discussion guides disseminated

Who We Work With & Our Partners

"Our strong partnership with the CEP supports primary care providers and contributes to provincial priorities by leveraging evidence-based knowledge products across the country and across a range of clinical topics."- Dr. Jamie Meuser Executive Director, Professional Development and Practice Support, College of Family Physicians of Canada
"We’ve been so proud to partner with the CEP on the KT in PC initiative, which meets the clinical needs of providers through engaging health information and clinical tools to help close the gap between evidence and practice."- Jessica Hill Chief Executive Officer, Ontario College of Family Physicians
"There has been great uptake from our nurse practitioner members on this initiative both in the development and utilization of the clinical practice tools that have been developed. The Knowledge Translation in Primary Care Initiative has enabled primary care providers to be better equipped to provide the best possible care to their patients.<br /> These clinical tools and resources have been pivotal in improving NP practice in Ontario."- Vanessa Mooney Continuing Education Manager, Nurse Practitioners’ Association of Ontario
The health care landscape is far too big to address issues on our own.
Collaboration and partnership is at the heart of what we do. This is why we partner with other organizations to help address health care challenges together. We have partnership agreements with the Ontario College of Family Physicians (OCFP), the Nurse Practitioners’ Association of Ontario (NPAO), Canadian Agency for Drugs and Technologies in Health (CADTH), CognisantMD and the College of Family Physicians of Canada (CFPC). We also partner and collaborate with many organizations such as the Ontario Medical Association (OMA), the College of Physicians and Surgeons of Ontario (CPSO), Health Quality Ontario (HQO) and the Registered Nurses’ Association of Ontario (RNAO), to help identify linkages within the health system and innovate primary care further without sacrificing quality or provider satisfaction.

Our partnerships have given us opportunities to meet, share views and perspectives, and participate in collaborations—all of which have helped us make strides towards a more coordinated, streamlined approach to support quality evidence-based resources for providers in a timely and efficient manner. Our partners and collaborators have enabled us to establish and validate our:

Topic prioritization and selection processes

Provincial stakeholder engagement framework

Clinical tool/resource development (with LHIN specific resource mapping)

Provincial communications/dissemination model

Cutting Across the Continuum of Care

Click on the boxes below to see each of the sections.

eHealth

From integrating tools to collaborating on implementing eReferral solutions, the CEP has worked on multiple projects that help providers maximize their EMR use. We have integrated our Preconception Health Care Tool and our Chronic Non-Cancer Pain Tool into Telus Practice Solutions Suite EMR. We are also currently working on integrating our Poverty Tool into EMRs to support providers in the identification and care of patients affected by poverty. Finally, we are supporting the implementing of an EMR-integrated eReferral solution to improve coordinated access of services and transitions for the Waterloo Wellington LHIN.
Waterloo Wellington Local Health Integration Network eReferral solution

The CEP is working with the Waterloo Wellington Local Health Integration Network (WW LHIN), Think Research and CognisantMD to support the implementation of an EMR-integrated eReferral solution to improve access and coordination of services in the region. Our core role is to engage target end users of the system in the design and development of eReferral forms and training material, as well as training target end users and central intake teams on future state eReferral workflows. Once live, the eReferral solution will support a system-wide eReferral process where standardized information can flow and be distributed across the continuum of care. It is our hope that this project will be used to develop a scalable change model to support eReferrals across Ontario.

Screening: Poverty

We launched a poverty screening tool—Poverty: A Clinical Tool for Primary Care Providers. The tool uses key questions to help providers assess patients’ living situations and current benefits, and help link them to key government and community services.

This year, we’ve expanded and customized the tool for participating provinces across the country. The poverty tool has been in presentations and courses throughout Canada and internationally, and continues to be covered by the media.

Successes of the poverty tool include:

  • McMaster University recently embedded the tool into its undergraduate medical school curriculum.
  • The tool has also been integrated into RNAO’s e-learning module: Nursing towards equity: Applying the social determinants of health in practice
  • It was also incorporated within American Medical Association medical textbooks.
  • The College of Family Physicians of Canada (CFPC) collaborated with the CEP to expand the Poverty screening tool across the country by customizing the tool for participating provinces and territories.
  • The CEP has recently received funding to partner with 211Ontario and CognisantMD,  to pilot an EMR-integrated strategy for screening for poverty within primary care practices. The pilot project will develop and implement a patient-focused screening tool and an EMR-integrated intervention process in 4-5 primary care practices across Ontario.

Acute Care

To support high-quality care in small and rural hospitals in the North West Local Health Integration Network (NW LHIN), the CEP partnered with the ten hospital corporations in the region to develop a set of quality indicators that take into account the local context, volumes and resources.

Presentations

Improving the Quality of Measurement in Ontario Small and Rural Hospitals
11th Annual Showcase of Health Research 2016,
Ontario Hospital Association Rural and Northern Health Care Leadership Conference 2016

North West Local Health Integration Network

The CEP worked with the ten small and rural hospital corporations from the NWLHIN to spearhead the development of quality indicators that reflect the unique environment and challenges of delivering care in small and rural care settings. These indicators have been incorporated into a quality scorecard that focuses on accessible, effective, integrated, safe and patient-centered indicators, to align with the attributes of a high-quality health system, as identified by Health Quality Ontario. This scorecard is being used across participating hospitals to appropriately measure the quality of care being delivered at the site, regional and LHIN levels. In the last year, expansion indicators have been added to the scorecard that reflect the integrated nature of care delivery roles within the small and rural care context, and the CEP has partnered with the North West Health Alliance to integrate the scorecard into their electronic business intelligence tool to ensure sustainability of the scorecard.

Ontario’s long-term care academic detailing service

As part of the Appropriate Prescribing Demonstration Project, the CEP designed and lead the largest long-term care (LTC) focused academic detailing service in Ontario. Our service delivered LTC providers and staff, through one-on-one and small groups visits with our academic detailers, objective, balanced, evidence-informed drug information on best prescribing practices related to two topics:

  1. The appropriate prescribing of antipsychotic medications for residents living with the behavioural and psychological symptoms of dementia; and
  2. The role of appropriate prescribing in falls prevention.

Overall 97 per cent of LTC providers and staff who received an academic detailing visit and completed a post-visit evaluation (across both topics) said they would be interested in receiving another visit. Participating LTC providers and staff found academic detailing valuable and favorably compared to other educational experiences.

In the News

Possible help for the opioid crisis: academic detailing
Canadian Healthcare Network

Symposium on Academic Detailing

On February 14, 2017, the CEP team held a Symposium on academic detailing where over 50 provincial healthcare leaders met to discuss academic detailing’s potential role in provincial health system improvement. Throughout the event, participants acknowledged that academic detailing should be part of the broader quality improvement agenda. These comments were echoed in the evaluation survey where 87.5 per cent of respondents noted that academic detailing could make a significant contribution to health system improvement in Ontario. Learn more.

Policy to Practice

Click on the boxes below to see each of the sections.

Over the past few years, we collaborated on a wide range of clinical topics to meet providers’ needs and support the Ontario Ministry of Health and Long-Term Care’s provincial priorities. A major challenge in the provincial health care system is the movement from policy to practice. Below are three provincial priorities that showcase how we’ve worked to target priorities at the provider level.

The work we do is also flexible to the changing health care landscape. For example, we are starting to work on potential solutions by focusing on priorities, not only at the provider level, but at the LHIN/sub-regional level as well. MSK and Chronic Non-Cancer Pain are the first topics in which we’ve begun to implement work tailored to LHINs/sub-regions, in addition to the general work we do for providers.

MSK and Chronic Non-Cancer Pain

For several years, we’ve worked on multiple projects related to musculoskeletal management and chronic non-cancer pain management to support primary care providers. This year, we introduced an updated CORE Back Tool along with a CORE Neck Tool and Headache Navigator, and the Management of Chronic Non-Cancer Pain Tool. These tools are part of our suite of pain tools, which include the updated Primary Care Focus on Low Back Pain online course and our soon to be updated Opioid Manager, which will reflect the new guidelines.  These resources were created to help address appropriate prescribing approaches by Ontario providers and develop and implement a management plan for those living with chronic non-cancer pain.

Read our academic detailing clinical leads’ Op-Ed on opioids in the Medical Post.

Low Back Pain

The CEP worked collaboratively to engage primary care providers and over 50 relevant stakeholder organizations to develop and test an evidence platform, patient self-management education material and provider curriculum designed to improve the treatment and management of low back. Due to ongoing interest and feedback from primary care providers about the tools and program the CEP has continued to update the tool and online program to reflect current evidence with the latest launch in March 2017. To date, 4,500 primary care providers have participated in the on-line education program.

Mental Health and Addictions

As part of the Knowledge Translation in Primary Care Initiative, we worked with providers, partners and collaborators  to develop a series of mental health and addictions-related tools including the Keeping Your Patients Safe Tool, Management of Chronic Insomnia Tool and the Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) Discussion Guide. These tools help support the province’s aim to enhance delivery of mental health and addictions care for patients at the primary provider level.

Presentations

Improving the Quality of Measurement in Ontario Small and Rural Hospitals
11th Annual Showcase of Health Research 2016,
Ontario Hospital Association Rural and Northern Health Care Leadership Conference 2016

Keeping Ontarians Healthy

We collaborate with other health care organizations to develop and disseminate
tools and resources that can help guide providers on how to keep Ontarians healthy. Through this work, we have developed a Preconception Health Care Tool and a Childhood Obesity Tool.

Childhood Obesity Tool

Under the clinical leadership of Dr. Yoni Freedhoff and a clinical working group, the CEP developed the Preventing Childhood Obesity Tool, which is designed to help guide conversations with paediatric patients and their families over a series of visits that focus on goal setting and healthy lifestyle choices. The tool has been used for Healthy Kids Community Challenge seminars throughout the province and presented at several primary care conferences and workshops. The tool is also available in French.

Preconception Health Care Tool

Identified through the Healthy Kids Strategy and the strong evidence that shows good health begins before conception, our Preconception Tool helps assess health and risk factors for pregnancy of all patients of reproductive age. The tool was circulated to more than 400 providers including public health nurses, registered dietitians, community nutritionists and physicians. It was listed as a resource on Toronto Public Health’s intranet, Best Start Manuals and in the integrative course handbook for primary care nurse practitioners. The tool is available also in French and in Telus PS Suite EMR.

A research grant has been awarded by Women’s College to implement and test the tool with public health nurses and postnatal patients and a Praxis article about the development and use of the Preconception Health Care
tool was recently accepted for publication in Canadian
Family Physician
Journal.

Clinical Practice Guidelines

Clinical practice guidelines (CPGs) are a core component of evidence-based medicine.

The CEP is one of the leading organizations in Canada that actively and consistently appraises CPGs on its methodological quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

Through CEP’s CPG training and assessment services, we help guideline developers implement best practices in their methods to improve the quality of national guidelines. We also actively undertake CPG quality reviews to ensure that the best available evidence informs both policy-making and clinical decision-making processes.

Over the past several years we have worked with the Canadian Partnership Against Cancer (CPAC) to assist in the redevelopment and update of its Standards and Guidelines Evidence (SAGE) repository, a publically available directory of English language cancer control clinical practice guidelines and important knowledge resource for the cancer control community. Part of this update has entailed the identification, review, and evaluation of all guidelines addressing the cancer care continuum published since mid-2012.

Additionally, CEP has been engaged by several other organizations including the University of Alberta to execute, compile and apply literature searches and reviews for many clinical topic areas including chronic disease prevention and screening.  We are considered among the number one reviewer of CPGs in the province.

Presentations

Training a diverse team on critical appraisal using AGREE II Instrument
Joint Canadian Health Library Association / Medical Library Association Conference 2016

Improving how we update guidelines
G-I-N Philadelphia 2016