Black Creek Community Health Centre’s Primary Care in Interpersonal Health Teams and Digital Equity

Power In Community

Primary Care in Interpersonal Health Teams & Digital Equity

Presenters: Doris Forlemu-Kamwa, Julie Fung, Maniola Sejrani

Acknowledging Dorothy Ayela, NP for her contribution to this project and presentation

Black Creek Community Health Centre • Non –profit community based organization • Provides health care services and programs geared to vulnerable population living in Toronto North West and Toronto North Central communities • We are a part of North Western Toronto-Ontario Health Team (NWT-OHT) • Neighbourhood within Black Creek CHC service area are the hardest hit regions of the city for COVID cases • Identified as being a “Hotspot”, with higher than average COVID-19 rates

Primary Care in Interprofessional Health Teams •

COVID-19 Pop Up Testing & Vaccine Clinics

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Portable Blood Pressure Machines Program

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Food security services / support

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Best Practice Guidelines for Person & Family Centered Care

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Online Client experience survey

COVID 19 Pop Up testing Clinics • Provide accessible COVID testing for community members.

• Connect clients with resources and supports available at Black Creek CHC. • No appointments are necessary.

• OHIP is not mandatory to get tested.

• Inter-professional health team staff involved: • Primary Health Care • Medical Admin and • Health Promotion teams

COVID 19 Pop Up testing Clinics Cont.

• Collaboration with key stakeholder, partners and community to implement COVID pop up testing clinics.

• COVID Pop up testing provided in community spaces:  Toronto Paramedics  Toronto Public Health  Sheridan Mall  Yorkgate Mall  MPP, Councillor ward 7  Ontario Health –Central Region

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Health Promotion Team – Community Health Workers Inter-professional health teams support the registration, outreach and testing process at these events.

Medical Administrative Team – Receptionist, Screener Ccollaboration between Black Creek and organizations/partners who provide support with coordinating logistics, and resources for these events Primary Care Team – Nurse Practitioner, Registered Nurses, Registered Practical Nurses Organizational Partners:          

Councillor Anthony Perruzza – Ward 7 Humber River-Black Creek MPP Tom Rakocevic – MPP Humber River Black Creek Toronto Public Health Ontario Health Central Region Switch Health Team Rubicon Global Medic Toronto Community Housing Jane Finch Mall Sheridan Plaza

COVID 19 Vaccine Clinics • Provide COVID vaccines to BCCHC Clients • Appointments are necessary and OHIP is not mandatory to get vaccinated • Humber River Hospital is custodian of vaccines and provides BCCHC with vaccines • Inter-professional health team staff consist of:  1 Nurse practitioner  3 RN/ RPN  4 Medical Admin staff and Screener  2 Managers

Portable Blood Pressure Machines Program • Available to clients to help monitor their blood pressure at home with the support and close monitoring of their primary care provider.

• Providers monitor the @ Home use of Monitors by their Clients thereby reducing clients’ visits to BCCHC. • Approximately 80 portable blood pressure machines have been distributed to clients.

Portable Blood Pressure Machines Program • Interprofessional staff consist of Primary Health Care and Health Navigator team.

• Health care Navigators have been trained to train Clients how to use BP Monitors prior to dispensing to Clients as per Providers instructions.

Food Security During COVID Emergency Food Cupboard Fresh Food Bag & Food Hampers • 20 Fresh produce bags monthly • 25 cultural specific food hampers weekly • Providers referral clients to receive food bag & hampers • Selected clients receive food bags & hampers

• Non perishable food cupboard • Clients can access EFC for food emergency

Prepared Meals • Donated food utilized to prepare cultural appropriate meals • Prepared meals were picked up by clients

Interprofessional Health Care

Grocery Gift Cards • Good Food Access Fund provided grocery food cards • Providers referred clients to receive gift cards

Hot meal delivery • Hot meals delivered to clients with decreased mobilization 1 x week

Daily Drop In • Monday – Thursday 2:30-4:30 drop in for snacks & hot beverages • Friday 2:30-4:30 drop in for hot meal

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Partnered with number of food donation agencies (i.e. 2nd harvest, ANIDA, food rescue).

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Some of the donated food are used to make culturally appropriate meals with the help of our local cater and African food basket.

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Donated food & hot / prepared meals are either delivered to clients and families or picked up at a designated location.

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Have applied for grants and received funds to purchase grocery gift cards and culturally specific food hampers to disseminate to our community.

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Collaborating with our local agencies / organizations (i.e.

Asante, JFFC, Falstaff, Tobermory, Shoreham).

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Collaborating agencies help distribute food and grocery gift cards to families within community that we could not reach.

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These food program / services enable staff to connect with their clients and families and check on their well being.

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Interpersonal health care providers refers clients and families to variety of food programs and help disseminate meals, food bags, food hampers and food vouchers to client and community.

Best Practice Guidelines (BPG) for Person & Family Centered Care (PFCC) • Black Creek CHC is part of North Western Toronto Ontario Health Team (NWT-OHT).

• Ministry of health & Long term care has mandated all organizations within same OHT to implement BPG’s and become Best Practise Spotlight Organization (BPSO).

• PFCC approach is to ensure that the person and their family are at centre of their health care and services.

• Respects and empowers individuals and caregivers to be genuine partners with health care providers for their health.

Black Creek CHC BPSO Team Champions Role • Inter-professional health care team  Primary Care Team – Nurse Practitioners, Registered Nurses  Therapy Clinic Team – Dietitian, Social Workers.  Health Promotion Team – Health Promoter, Health Navigators,  Admin. Team – Senior leadership, Medical secretary,

Black Creek CHC BPSO Team Champions Role • As part of the NWT-OHT: support the roll out the PFCCBPG developed by the Registered Nurses Association of Ontario (RNAO) leading to:         

Strong client health outcome Reduce variation in care Consistent Standard care Transfer research evidence into practice Promote nursing knowledge base Identify gaps in research Stop intervention that have little or no effect Reduce cost Improve efficiency

Online Client experience survey • The survey focuses on in-depth:  Client’s perceptions of being involved in decisions about their own care and the care of their family  Client’s ability to manage their family and their own health conditions  Sources of information / support that they utilize • Client feedback information:  Gives insight on how well interprofessional care teams work together around person and family centred care  Plan and develop programs and services with a person and family centered care focus

Stories “Ever since I have been going to BCCHC it helped me a lot. They speak to me, and advise me. I would be more down because they help me to do more things. I feel better with this help. Everybody helped me a lot. You can speak to anyone and everyone can help you get help. I have been joining Social groups and Support groups in person and online now due to CoVID-19” (From phone interview of a 3rd client)

https://youtu.be/FYmYSko-78w

https://youtu.be/MOeNgSfQx00

Digital Equity • Virtual health care services and programs • Laptop and Tablet accessibility program • Digital Client

Virtual health care services and program  Telehealth appointments available to clients and Jane / Finch community.  Deliver primary and allied health care through phone or video calls.  Have created videos with health tips to share on our social channels.  Engaging groups virtually (e.g. use of OTN, ZOOM for variety of programs)

Virtual health care services and program  Development of new resources to share with clients electronically, by phone, on our website and on social media (e.g. COVID clinics, COVID support line, client experience survey).  Developed new policies, protocols and training for staff to ensure safe and effective use of electronic communication with clients.  Confidentiality policies and procedures reinforced.

Laptop Accessibility Program • Laptops provided by Siemens company • Helps our community increase equal access to digital services • Laptops was distributed to seniors and families in need of a computer.

• Presently, 50 laptops have been distributed.

Tablet Accessibility Program • 100 Tablets and internet service are provided

by Black Creek CHC • Staff will meet seniors in small groups in outdoor space on a rotation • Teach seniors how to use tablet, create emails, download apps and cyber security • Will be available to seniors involved in internal Senior programs this summer 2021

Digital Client Feedback • All clients have access to Client Experience Survey electronically through Black Creek CHC weblink, QR Code and text message.

• This give clients equitable digital access to provide feedback