Primary Care Research Update Tara Jeji Program Director Ontario Neurotrauma Foundation June 7, 2013

Mobility Clinic CFFM-Kitchener-Waterloo Clinical Activities Clinic continues to operate half day per week with support from CFFM another 4 days per week 2012: 103 new referrals; 146 patients seen including follow-ups 2013: 25 new referrals; 53 patients seen including follow-ups The Centre for Family Medicine has a roster of 30 spinal cord injured patients; there were 19 SCI clinic visits at the mobility clinic in 2012 (this does not include visits persons with SCI made to their family physician within the Centre for Family Medicine). 2013, in first quarter there have been 10 visits to the mobility clinic by persons with SCI other referrals to mobility clinic include: balance/falls, MS, Parkinson’s, TBI, arthritis

Primary Care Mobility Clinic at Kitchener Waterloo (KW) Expansion Plan Currently the Ministry of Health has 19 initial health links in Ontario, including one in Guelph Health links are regional clusters for healthcare sector organizations, such as CCAC, hospitals and FHTs CFFM only services 25,000 of 350,000 people in KW Concept is to give better care for less money for high users of the health care system and other social services This model would be more cost effective than the current system Getting buy in from family physicians

CFFM Proposal for funding as Health Links Concept to develop a Virtual Ward Would be an interdisciplinary team that work together with high system users The targeted patient population would be patients who have complex mental, including substance abuse and physical issues The program would be specifically for high users of the ER who frequently use the ambulance for transportation The patient would be contacted on a regular basis The team would be point of contact and discuss patient care plan Team would consist of a nurse from the hospital, CCAC personal, and primary care physician 6 proposed sites: Andrew St., Joseph St., New Vision, Freeport, Winston Park, and Williamsburg

Primary Care and Rehabilitation Integration with Self-Management (PRISM) Team Grant PI: Joe Lee MD Main accomplishments to date Establishment of Executive and Scientific committees, and learning collaborative which met in February, 2013 Executive Steering Committee (principle investigators and rehabilitation and consumers representative) responsible for oversight, strategic planning and coordination of day-to-day operations (budget, communications) Scientific Committee (membership to be established) to provide guidance and advice for the overall project and the specific research projects Learning Collaborative members are going to form Working groups to design and implement individual research projects Communication Platforms- Adobe Connect for videoconferencing, teleconference and Skype for group members to collaborate Main initiatives to conduct environmental scan of current post rehabilitation care models and self management resources and plan small research projects Team has 27 active members; 5 MDs (representing both primary care and rehab), 8 allied health professionals, 2 consumer representatives, 6 researchers, 2 students, 1 invited out-of-province member, and 3 project team supports

Access to Primary care for persons with SCI: A health service delivery study The purpose of this project is to evaluate the management of care for patients with SCI in a primary healthcare setting (Family Health Team or a independent primary care practice) Patients are supported by members of the Regional Spinal Cord team at Hamilton Health Sciences which is acute spine cord injury hospital and rehabilitation facility Patient participating in self-management program based on Stanford Self Management program to increase their self-efficacy to better manage their health and participate in planning their care

Community engagement  Presentations at Family Medicine Rounds, ER Rounds at HHS  Meetings with the FHTs  Collaboration with the SCI Navigators  Commitment from members of the Regional Spinal Cord Team to act as resources for the FHTs Product development  Development of a Resource Tool for Primary Care Practitioners  Adaptation of the Provider Flow Sheet (SCI Primary Care Toolkit) to align with current practice at HHS Collaboration with others involved in similar projects in Primary Care  The Ontario Spinal Cord Injury Research Network (OSCIRN) Primary Care Working Group  The Centre for Family Medicine Recruitment of participants Recruitment of patient participants from a variety of sources (primary care physicians, Inpatient/outpatient rehabilitation, CPA/SCI Navigators) Delivery of the intervention SCI Nurse Clinician engaging patients in the development of a self-management plan, collaborating with the patient and their GP, capacity building in the primary care setting Progress to Date

A Proposal to Design, Deliver and Evaluate and e- Learning Resource for Primary Care Providers on Care of Patients with Spinal Cord Injury The e-learning modules have been developed by a research team from Department of Family Medicine and Faculty of Education at University of Ottawa. e-learning modules contain information on each of the top five areas of concern for SCI population—Autonomic Dysreflexia, Neurogenic Bladder, Neurogenic Bowel, Respiratory Complications, and Pressure ulcers The e-learning resource is available on ONF website or The e-learning resource is being evaluated by the U of O research team Next steps is to implement e-Learning resource in primary care. Two sites selected are CFFM at KW and Hamilton FHT which are supported by ONF and involved in current primary care research

Other Initiatives: Applying for International Research Partnership Grant (Canadian- Australian Research Initiative) The proposed partnership would be between Ontario Neurotrauma Foundation, Centre for Family Medicine KW, University of Waterloo and University of Sydney in Australia This application is a cost splitting arrangement and is geared toward the purposes of establishing or further developing partnerships as a future platform for research project Partnership grant due Mid June