Acting on your concerns:
Primary Care/Specialist Collaborative
In line with your requests to improve interaction and coordination between primary care and specialists, 12 participants have come together after the "Transforming the Way We Work Together" event that was hosted on October 26, 2022. The goal of this collaborative is to explore and identify potential improvements to communication, coordination and shared care between primary and secondary care that was highlighted in that event.
The collaborative comprises six family physicians representing a range of practice models and six specialists from various medical disciplines. On the first meeting held on March 7,2023, members came together to identify and highlight the following goals:
To work on the recommendations from the "Transforming the Way We Work Together" forum, identifying quick wins, priority improvements, current barriers, and enablers to potentiate implementation.
To continue a co-creation, co-design framework with a broader group of specialists and primary care practitioners
To champion elements of the quality improvement initiative within respective institutions, practice settings, university departments, and professional associations
The collaborative will add 3-4 patients representing different patient populations and age groups and hospital partners in the Midwest to the membership to bring lived experiences and add patient voices to this collaboration.
This is a movement whose time has come; bringing Family Practitioners and Specialists together to address pain points has the potential to improve practice life for all of us. Stay tuned for more information on this unique initiative.
Primary Care/Specialist Collaborative Members
Chair
Pauline Pariser: Chair, Mid-West Toronto Ontario Health Team, Co-Chair of Mid-West Toronto Family Practice Network, SCOPE Provincial Clinical Lead
Primary Care
Michelle Naimer: Family Physician, Mount Sinai Academic Family Health Team and Co-Chair of the MidWest Toronto Family Practice Network
Sonika Kainth: Family Physician, Parkdale Queen West Community Health Centre
Hedi Erenrich: Family physician, Primary Care Lead for Mid-West Toronto SCOPE
Peter Sakuls: Family Physician, Wychwood Family Health Centre
Faye Goldman: Family Physician, MyFamilyMD
Specialists
Reza Maleki -Yazdi: Respirologist, Women's College Hospital
David Tang-Wai: Neurologist, Head of Neurology at the University of Toronto
David Urbach: General surgeon, Chief of Surgery, WCH
Amanda Steiman: Rheumatologist, Sinai Health System
Richard Ward: Hematologist, co-chair Outpatient Care Program, UHN
Daniel Blumberger: Co-Chief, Outpatient Psychiatry, CAMH
What is the SPIN Program at Access Alliance Multicultural Health and Community Services?
Solo Practitioners in Need (SPiN) is a direct referral program that allows family physicians to connect medically complex and socially vulnerable patients to services available within a network of Health Service Providers (HSPs) as an extension of their ongoing primary health care.
Solo Practitioners in Need (SPiN)
Referral to SPIN Program
Solo Doctors, unaffiliated with teams, can refer to SPiN by faxing the referral form to Access Alliance SPiN Central Intake.
Available services include:
Dietician
Diabetes education
Physiotherapy
General counseling
Sexual Health
Housing services
Chiropody
Legal aid
Settlement services
LGBTQI (French only)
Employment services (French only).
Services are covered by OHIP and are not considered primary care, so referring practices are not penalized with outside-use designations.
SPiN Central Intake staff (a nurse) at Access Alliance coordinates all referrals to allied health services. The nurse accepts and reviews each form for eligibility and determines community agencies to refer clients to. Average wait times for these services are 2-3 weeks, based on the priority and availability of service providers in each CHC agency.
Data: There are 105 Solo physicians registered with the SPiN Program, and the total number of referrals made to SPIN from July 2022 to December 2022 was 119. 18 CHCs accept referrals from the SPiN Program.
The SPiN program allows solo doctors to refer their patients to other healthcare services in the community, which have many benefits for both family practioners and their patients. By working together, healthcare providers can improve patient outcomes, increase collaboration, reduce workload, provide access to specialized care, and increase patient satisfaction.
Independence at Home Community Outreach: Expanding home-visiting team for older adults at risk
Philanthropic funding and in-kind support have enabled the expansion of the UNH/Sinai Health System Independence at Home Team, to support family practices, especially those unaffiliated with teams, to access a geriatric home-visiting team for their older adults at risk.
The Independence at Home Community Outreach Team is a short-term (average 30-90 day), home based interdisciplinary team appropriate for medically and socially complex, community dwelling older adults (65+) who have experienced recent functional decline and have potential to regain function, or may be struggling for other reasons to remain in the community – e.g. poor connections to community services, cognitive impairment and caregiver stress. Ideal for more home-bound older adults.
This program can include interprofessional assessment, care plan development and coordination by the team. Team members can include RN, pharmacist, social worker, care coordinator from Home and Community Care Support Services (HCCSS), geriatrician and geriatric psychiatry based on patient’s needs. Our time to first contact is variable but we aim to make our first assessment in under a month, often it is sooner. The team communicates assessments with the patient’s GP to optimize assessments and plans.
Catchment area: South of St. Clair Avenue, North of Lake Ontario, West of the Don River, and East of Parkside Drive/Keele Street.
More information can be found on the website:
www.uhn.ca/TorontoRehab/Clinics/Home_Community_Outreach_Team
Referrals to this and all UHN/Sinai Health outpatient geriatric programs can be made on the Geri Hub common referral form: