Together, we are shaping the future of healthcare.
Our team of health care professionals remain at the heart of our organization and go above and beyond every day to provide patients with excellent care. This year’s annual report will highlight the many programs and services that patients have accessed in our FHT over this past year, to support their health and well-being.
Kimberly Vickers,
Executive Director
Medical Director
Telemedicine
TThe Family Health Team (FHT) Telemedicine Program enhances access to specialists for both FHT and non-FHT patients. Providers can consult with 1,639 active specialists across 105 different specialties through eConsult, helping them deliver comprehensive care. Over 1,000 eConsults are processed annually.
A recent addition to the program is the Movement Disorder Clinic, which allows patients to receive a neurological assessment within one month—significantly faster than the provincial average wait time of 12-18 months for in-person consultations with a neurologist.
Telemedicine plays a vital role in supporting FHT clinicians and physicians. Many providers rely on telemedicine for patient care, with assistance from the FHT OTN Telemedicine Coordinator for setup and troubleshooting.
The program also uses MEDEO, a secure patient email platform, enabling patients to complete forms and send photographs for telederm appointments online, eliminating the need for in-person visits.
Total Visits: 1321 | Unique Patients: 503 | eConsults: 1052
Foot Care Program
The Foot Care Program provides essential foot care for patients at high risk of complications who do not have private health coverage. This includes individuals with diabetes, frail seniors aged 65 and older, and those connected with the LINKS program.
Without proper professional foot care, patients are at risk of complications such as diabetic foot ulcers, which can lead to digit or limb amputation; decreased mobility in the senior population; and infections from trauma to soft tissue.
The program offers ongoing care to monitor for early signs of potential complications related to foot health. Education is provided at every appointment, along with strategies for safe self-care at home.
Total Visits: 676 | Unique Patients: 325
LINKS Navigation Clinic
The LINKS (Linking Individuals Needing Key Services) Team supports patients who are managing multiple chronic conditions, as well as the economic and social factors that impact their health.
The LINKS team includes an RN Patient Navigator, who has access to the expertise of an Occupational Therapist and Pharmacist. After intake, patients are connected to appropriate resources with the goal of reducing EMS and ER visits. A key focus of LINKS navigation is advocacy, ensuring patients receive the care and support they need.
Total Visits: 1234 | Unique Patients: 198
Lung Health Program
The Lung Health Team is comprised of three registered nurses and one registered respiratory therapist, all of whom are Certified Respiratory Educators (CRE). The team is supported clinically by a local respirologist.
The clinic offers comprehensive services for individuals living with chronic lung diseases such as asthma, COPD, and interstitial pulmonary fibrosis. Services include consultations with a respirologist, spirometry testing, and patient education. A key component of the program is initiating specialized medications tailored to each patient’s condition.
Respirologist consultations are available in person, supporting both rostered and non-rostered patients in the community. The Lung Health Team is also trained to conduct mask fit testing and can provide annual organizational testing to ensure workplace health and safety.
The primary goal of the Lung Health Program is to support patients who have recently visited the emergency department or been hospitalized, aiming to reduce future ER visits and hospitalizations.
Total Visits: 4410 | Unique Patients: 2161
STOP (Smoking Treatment for Ontario Patients) Program
The STOP (Smoking Treatment for Ontario Patients) Smoking Cessation Program provides effective support to help patients quit smoking cigarettes, cigars, and vaping nicotine. In collaboration with CAMH (Centre for Addiction and Mental Health), the STOP team offers smoking cessation counseling and Nicotine Replacement Therapy.
The team consists of seven care providers, all certified in the Applied Cessation Counselling and Health TEACH program through the University of Toronto.
The program offers both in-person and virtual care via phone, depending on the patient’s preference. CAMH also provides a patient portal, allowing patients to complete intake forms independently online. For those who need personal assistance or lack internet access, team support is available to help complete the intake process, ensuring all members of the community can access the program.
Total Visits: 1286 | Unique Patients: 298
Aging Well Clinic (AWC)
The Aging Well Clinic supports community-dwelling older adults experiencing memory concerns and/or complex health challenges. The team includes a nurse practitioner, nurses, an occupational therapist, pharmacists, and a consulting physician.
The clinic provides comprehensive geriatric assessments for individuals over 65 with memory concerns (not attributed to normal aging) and/or those over 70 with complex health challenges. Working closely with the family physician and nurse practitioner, the team develops patient-centered care plans to address these issues and provides ongoing support.
Additionally, the clinic connects patients and caregivers to community resources and helps them navigate the local healthcare system.
The clinic’s goals are to optimize health, maintain function, and assist with future planning.
Total Visits: 2302 | Unique Patients: 446
Diabetes Program
The Barrie and Community Family Health Team’s Diabetes Program offers a multidisciplinary approach to help individuals aged 18 and older, diagnosed with diabetes or prediabetes, improve their health. Through education and support, we empower patients to manage their conditions and make informed decisions about their care.
In addition to one-on-one appointments, our Registered Dietitians provide group sessions specifically for individuals newly diagnosed with prediabetes. These sessions focus on lifestyle counseling and equip patients with practical tools to manage their health effectively.
Our Registered Nurses collaborate with patients to review lab results (including pathology, A1C, and blood glucose levels), assess medications, and evaluate the patient’s medical history. Recommendations are then sent to the patient’s primary care provider for further review and follow-up.
Total Visits: 3111 | Unique Patients: 1113
School Success Program (SSP)
The School Success Program (SSP) is a multidisciplinary team that includes Paediatricians, Nurses, Social Workers, an Occupational Therapist, and an Administrative Assistant. Together, they provide specialized support to elementary school students attending schools in Barrie and Shanty Bay who are facing school-related challenges.
The program empowers students and their families through holistic, student-centered care that promotes success both in and outside the classroom. SSP offers timely access to assessments and personalized recommendations for resources and support.
Through close collaboration with teachers and primary care providers (Family Physicians and Nurse Practitioners), the SSP team delivers a unified and well-coordinated approach to care. This integrated model streamlines access to services, including specialist consultations and interventions from Social Workers and the Occupational Therapist.
In 2024, the SSP team launched several key initiatives to enhance family engagement and support. This included the introduction of a monthly newsletter designed to keep families informed about program updates, parentings strategies, and relevant mental health topics. Additionally, a parent/guardian drop-in group was established with a focus on ADHD education, providing a supportive space for caregivers to learn, share experiences, and access expert guidance.
Total Visits: 2230 | Unique Patients: 599
Prenatal and Well Baby (PNWB)
The Prenatal and Well Baby (PNWB) Program provides routine prenatal and well-baby/childcare for local women and children (up to age 6) in the Barrie area who do not have a primary care provider (Family Physician or Nurse Practitioner). The program is delivered by a dedicated team comprised of Registered Nurses who support Physicians and Nurse Practitioners, as well as International Board-Certified Lactation Consultants (IBCLCs) who provide expert breastfeeding support.
A PNWB appointment may include:
- Prenatal Care: Initial and follow-up visits for expectant parents up to 28 weeks of gestation.
- Well-Baby and Well-Child Care: Routine check-ups, developmental assessments, and recommended immunizations for children up to age 6.
- Seasonal Vaccinations: Influenza and RSV vaccines (for eligible clinic clients).
- Episodic care: Available to clinic clients, excluding acute respiratory or febrile illnesses.
- Cervical Cancer Screening
- Lactation Support: One-on-one breastfeeding support, both prenatal and postnatal. Prenatal group sessions.
- Community Connections: Referrals and links to local health and social services.
The PNWB program provides all routine prenatal and well-baby care in-office, with the option to provide virtual care where appropriate and requested by clients. The team continues to offer episodic visits where able, except for acute respiratory and/or febrile illnesses, to help clients access timely healthcare and lessen the burden on local tertiary care centers.
The PNWB team provides in-person care at the clinic, with virtual visits available when appropriate and requested. By offering timely episodic care (excluding acute respiratory/febrile illnesses), the program helps reduce pressure on local hospitals and urgent care centers.
The PNWB program continues to work in collaboration with the Simcoe Muskoka District Health Unit (SMDHU). Lactation service numbers represent visits provided by FHT and SMDHU staff at the PNWB clinic.
Total Visits: 4493 (RN and NP) | Unique Patients: 1459 (RN and NP)
*Lactation Services: Total Visits: 1059 | Unique Patients: 698
*Lactation Services numbers represent visits provided by FHT and SMDHU staff at the PNWB clinic.
Nurse Practitioners (NP)
The Nurse Practitioner team provides care and support across 64 family practices offices, including the Family Medical Teaching unit (FMTU) at the Royal Victoria Hospital. As well, the NP team supports the Aging Well and Prenatal Well Baby Programs.
NPs provide valuable in-person and virtual care to ensure ongoing access to a primary healthcare provider in the community. NPs work to their full scope of practice, providing preventative and chronic disease management care. Additionally, the NP team provides same day access for acute/episodic care appointments.
Nurse Practitioners provide and encourage mentorship through preceptorship programs for NP students and have received positive feedback from past students for their participation in this role.
Total Visits: 34,456 | Unique Patients: 22,812
Pharmacy and Registered Dietitian (RD) Services
Our Pharmacists and Registered Dietitians co-facilitate the Tools for Successful Weight Management (SWM) program, designed for patients interested in, or already taking medications for obesity. Since its launch in early 2023, the program has improved access to these services and has been shared with Family Health Teams (FHTs) across Ontario to support the development of similar obesity management programs. The SWM group has seen high referral volumes and consistently receives overwhelmingly positive feedback from participants.
In partnership with Osteoporosis Canada and VON Canada, Pharmacists and Dietitians also lead the Bone Health and Fracture Prevention sessions. These sessions are open to both rostered and non-rostered patients and are regularly praised for their quality and impact.
Additionally, Pharmacists and Dietitians collaborate with Hospice Simcoe on a consultant basis, participating in the Palliative Care Community Team Rounds to support end-of-life care planning.
Pharmacy
Pharmacists in the Family Health Team play a key role in supporting patient care through collaborative consultation. They receive referrals for a wide range of services, including identifying, resolving, and preventing drug interactions and adverse effects, deprescribing, initiating and optimizing medication therapy, and managing drug dosing.
FHT pharmacists have access to patients’ electronic medical records (EMRs) and laboratory results, allowing them to make informed, patient-centered recommendations. While they do not dispense medications or access community pharmacy inventories (as they work in office settings), they contribute significantly to care planning by leveraging clinical expertise, EMR data, and close communication with healthcare providers and patients.
In addition to direct patient care, FHT pharmacists develop and deliver educational content for prescribers and interprofessional teams. They have presented at various conferences, including the Association of Family Health Teams of Ontario (AFHTO), the North Simcoe Muskoka SGS Special Event: A Focus on Geriatric Pharmacotherapy, and the Family Medicine Teaching Unit (FMTU) Faculty Retreat.
Pharmacists also contribute to several FHT programs, such as STOP, LINKS, Diabetes, the School Success Program, and the Aging Well Clinic. They co-facilitate group sessions for programs including “Bone Health”, “Tools for Successful Weight Management” (SWM), and “ADHD, Now What?”.
Total Visits: 1852 | Unique Patients: 569
Registered Dietician (RD) Services
Our Registered Dietitian (RD) services continue to be highly valued and well-utilized by both primary care providers and patients, with 140–180 referrals received each month. To reduce wait times and ensure more timely access for urgent referrals, 1.0 and 1.8 FTE contract positions were added from August 2024 to March 2025.
RDs provide evidence-based medical nutrition therapy for patients across all age groups, supporting a wide range of diagnoses. Services are offered in both individual and group formats, through virtual and in-person sessions. Our RDs work closely with pharmacists, mental health providers, nurse practitioners, and physicians to ensure coordinated, comprehensive care.
RDs are currently piloting the delivery of shared educational sessions with another provincial FHT to expand access for patients. We continue to support nutrition services for all patients, including unattached individuals in our community.
Collaboration with Ontario Health Team (OHT) partners remains a priority. Notable successes include partnerships with:
- Osteoporosis Canada – delivering Bone Health and Fracture Prevention sessions
- RVRHC – offering our Food and Mood session to support their Mental Health Outpatient Program
Total Visits: 4090 | Unique Patients: 1779
Mental Health
A team of Mental Health Therapists provides FHT patients with short-term, focused, and confidential counselling. Typical referrals include depression, anxiety, relationship issues, and grief and loss.
Services include:
- Counselling – A team of Mental Health Therapists provides FHT patients with short-term, focused, and confidential counselling. Typical referrals include depression, anxiety, relationship issues, and grief and loss.
- Psychiatric consultation – Two local Psychiatrists offer a combination of in-person and virtual appointments. Telemedicine consultation is provided by The Centre for Addiction and Mental Health (CAMH), Ontario Shores Centre for Mental Health Sciences – Prompt Care Clinic and The Hospital for Sick Children’s Virtual Emergency Room (VER).
- Psycho Educational Groups – Anxiety, Depression 101, Mindful Yoga, Dialectical Behaviour Therapy Skills, Mindful Eating, Healthy Communications, Freedom from Your Inner Critic, Healthy Communications, and Understanding Stress and Self.
- System Navigation and Advocacy – Connecting individuals to other community resources where appropriate.
A monthly Mental Health Clinic is provided to patients of Physician Residents of the Family Medicine Teaching Unit. Residents identify patients who would benefit from mental health counselling. The Mental Health Therapist observes the session and provides support and guidance to the Physician Resident.
CMHA Simcoe County Branch’s Peer Support Program actively provides valuable service and support to many FHT clients. This program connects individuals with lived experience who are struggling with a health challenge, illness or addiction with others who may also be struggling.
Total Visits: 6854 | Unique Patients: 1522 (*Therapist only)
Information Technology (IT)
Our IT Department is focused on improving the client experience with Accuro, our electronic medical record software. They are working closely with the vendor on improving enterprise deployment functionality, which can open up features to end users, as well as integration with third party digital tools, such as AI Scribes, Clinic Automation software, ePresciption services, and eReferral platforms. IT has also been supporting the FHT and FHO in rolling out Online Appointment Booking services, such as Medeo and Ocean, to provide greater flexibility for patients in accessing physician schedules and to improve office productivity.
IT continue to work through the upgrading process throughout both organizations to ensure that all endpoints are running Windows 11 systems, as well as continuing to upgrade critical infrastructure such as core servers and firewalls. They have worked diligently to harden the security footprint and protect critical data and services.
IT is also implementing an improved email security platform that leverages AI to detect and block phishing, malware, and social engineering attacks before they reach users’ inboxes. With real-time threat detection, automated quarantining, and user-friendly alerts, it will enhance security while adding a proactive layer of defense that will safeguard communication.
Total Calls: 7437 | Tickets Resolved: 5290
Accuro Users: 519 | Locations: 22 sites and 55 offices
Quality Improvement and Decision Support (QIDS)
The Quality Improvement (QIDS) team collaborates closely with clinical programs, physician offices, and the IT department to support continuous improvement efforts. The team’s primary goal is to equip providers with the tools needed to track performance measures, gather community feedback through surveys, and generate reports that drive quality initiatives.
At the BCFHT, the QIDS team is responsible for compiling data and producing standardized reports for clinical programs, the Board, and the Ministry of Health.
As a key contributor to program reviews, the team ensures that care remains up-to-date and evidence based. Their work supports improved patient and provider experiences, enhanced clinical outcomes, streamlined processes, and developing the Quality Improvement Plan.
Human Resources (HR)
Our 2024 annual employee satisfaction survey achieved the highest response rate ever, with 90% of employees participating. Key highlights included ongoing satisfaction with professional development opportunities, mental health support, and internal communication. Employees expressed a desire for continued advocacy for increased funding for wages and employee benefits.
During the 2024/2025 fiscal year, the Human Resources department focused on recruiting new talent for our workforce. Unfortunately, for the first time since we began tracking these numbers several years ago, our employee retention rate fell below 90%. We attribute this decline to our ongoing challenge to provide competitive wages due to insufficient funding for compensation.
Corporate professional development offerings included:
- Emotional Intelligence
- Mindful Growth
- Self-Compassion for Healthcare Professionals
- Introduction to Psychological Health and Safety
- Burnout: From Exhaustion to Efficacy
- Mindfulness in the Workplace
- Moral Distress in the Workplace
Total Permanent BCFHT Employees: 79
New Permanent BCFHT Hires: 11
Retention Rate: 87.34%
