Integrating the community around the patient
Great Northern, Temagami, and Haileybury Family Health Teams

A far-reaching safety net for people who might fall

Primary care teams offer a broader scope of care than Ontarians have ever received in the past, but ideally they are just the hub of a network of care stretching and linking throughout the community. Effective primary care organizations count on partnerships to serve the broader needs of their patients and their areas.

There are several provincial and regional initiatives to improve coordination of care, but as health journeys become more complicated, smoothing the transitions through them and integrating the work of all providers takes on increased priority.

Still, effective partnerships are not easy to build, and may be particularly tough in rural parts of the province, where services can be scattered far across large regions. And that’s what makes the success of the winners in this category even more impressive.

The Association of Family Health Teams of Ontario’s Bright Lights Award for integrating the community around the patient goes to three family health teams — Great Northern, Temagami and Haileybury — in Ontario’s South Temiskaming, to recognize the outstanding work they did together to create their “Independent living through falls prevention strategies for those aged 65+.”

The impetus for the project came from data, which showed that in the area served by the three winning teams, close to 25 percent of patients in teams are 65 and over. Falling can take a heavy toll on older people; often, immobility caused by a fall is the beginning of a serious decline in health.

However, distance, lack of transportation and busy physicians appeared to be combining to keep people at high risk for falls from being identified and offered help.

In response, the three teams designed a pilot project to help people reduce their risk of falls. Now all patients who are 65 and older do a self-assessment of their risk of falling at least once a year.

If the results suggest someone’s at high risk for falls, a health provider has a standard algorithm of steps to follow to reduce that risk, which includes reviewing the patient’s medications and referring him or her to a community exercise program (exercise improves strength and balance, both of which help prevent falls).

The three health teams are sharing the results of their work with other family practices and healthcare organizations in their region.

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