Together, we are shaping the future of healthcare.

The Barrie & Community Family Health Team (BCFHT) has had another successful year, despite some of the challenges we continued to face through the pandemic.

As an organization, we continue to strive towards excellence in the provision of high-quality primary health care that meets the needs of our patients, is delivered by an empowered team, and supported by digital health technology. Our interprofessional team, together with the physicians of the Barrie Family Health Organization, provides care to more than 150, 000 patients in Barrie and the surrounding area. Our team continues to build on lessons learned during the pandemic and find innovative ways to deliver the many programs and services that are highlighted in this year’s Annual Report.

Our organization is also a proud partner of the Barrie Area Ontario Health Team. Through this work, we are committed to working together with our community partners, to enhance the health and well-being of all patients living in our community. Another aim of the Ontario Health Team is to improve the overall experience of our healthcare providers. We are deeply thankful for all our dedicated healthcare providers who continue to provide exceptional care to patients, families, and caregivers, on a daily basis.

We hope you enjoy reading this Report and look forward to sharing more of our accomplishments with you again in the future.

Kimberly Vickers,
Executive Director

Dr. Jaco Scheeres,
Medical Director
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Strategic Plan

Our Vision

Your Health, Our Community, One System: Leading the Way in Health Care

Our Mission

  • Develop a fully integrated Health Circle for health care delivery
  • Create timely access to quality health care for all
  • Maintain a securely stored and fully accessible health record
  • Enhance patient care through community partnerships
See full strategic plan
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Telemedicine

The Family Health Team (FHT) Telemedicine Program increases access to specialist for both FHT and non-FHT patients.  Providers can access 1639 active specialists in 105 different areas of specialty via e-consult, including mental health/psychiatry, dermatology/wound care, neurology, and respirology to assist in providing care to their patients. 

During the year, telemedicine has been a key support for FHT clinicians and physicians, providing 969 clinical visits FHT-wide. Many providers have moved to using telemedicine for patient care and have been supported in set-up and problem solving by the FHT OTN Telemedicine Coordinator.  The COVID-19 pandemic resulted in a significant increase in the number of providers using telemedicine for both eVisits and eConsults. The telemedicine program has worked with various specialists to set up successful video visits to the patients’ homes allowing continued and timely care during the pandemic and has reduced unnecessary travel and risk.

 The program implemented MEDEO secure patient email, which allows patients to complete necessary forms and send photographs for telederm appointments online instead of making a physical trip to the office.  Secure patient email improves timely access to specialist telemedicine care.  Patient feedback has been overwhelmingly positive.

Total Visits: 1169   |  Unique Patients: 404   |   eConsults: 821
Patient and Physician quotes
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Patient Story

A blind patient of the Diabetes team was taking medication by injection. She had been prescribed the medication by her physician in 0.5mg dose injection pens but had been increased to a 1mg dose so she was to take two injections. The patient stated that she was doing the first injection without issue, but the second injection was on the opposite side of her abdomen and it wet due to leakage. This was puzzling to her member of the Diabetes Team providing care. The patient could not come in to the FHT office for her appointments so she eagerly agreed to an OTN call when she was ready to do a medication dose so her provider could watch her do it. The healthcare provider could see that the patient did not remove the caps from the needles, so she had not been getting any medication. Without OTN this problem would not have been identified. The patient was very grateful for the help and support in using such an easy tool to improve her health.

Chiropody Program

The Chiropody Program provides foot care to patients at high risk of complications (patients with diabetes, those associated with the LINKS and Aging Well programs) who have no private health coverage.  When referral numbers and schedule allow, the program will also accept other types of patients who do not have private health coverage.

In-person chiropody care has continued through all waves of the COVID-19 pandemic.

 

Total Visits: 782  |  Unique Patients: 258
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Lung Health Program

The Lung Health team, consisting of four Certified Respiratory Educators (CREs), is clinically supported by a local Respirologist.

The CREs have completely reinstated in-person consultation for spirometry testing and health education for chronic lung conditions, such as COPD and Asthma. Additionally, the team assists with management for those seeking transplant in conjunction with the University Health Network Lung Transplant program.  Options for virtual care are available should a patient request this option for health education.  Respirologist consultations are in-person only and provide support for rostered and non-rostered patients in the community.

Lung Health team members were recently trained to provide mask fit testing, providing annual organizational testing for staff to ensure health and safety in the workplace.

The Lung Health Program continues to collaborate with RVH and SMDHU, providing ongoing support to patients who have visited the Emergency Department, had a recent hospitalization, or have been seen via the COVID, Cold & Flu Care Clinic, with a goal of minimizing future emergency room visits and hospitalizations.

 

Total Visits: 5017  |  Unique Patients: 1792
Patient Story
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Patient Story

Patient X has been treated for COPD in the Lung Health Clinic for many years. Despite optimizing his medication plan, making lifestyle changes, and regularly attending our pulmonary rehab program, his lung health continued to decline. For this reason, he was referred to the lung transplant team in Toronto for assessment and consideration. The transplant process requires the patient to complete a transplant-specific, supervised exercise program multiple days each week. To offload some of the stress related to transportation, and increase adherence to the program, the BCFHT Lung Health Team offered a one-on-one weekly supervised exercise program, meeting the requirements of the transplant team.

On July 8, 2022, the Lung Health Clinic received a call from the Transplant team advising that they were trying to contact Mr. X for transplant but were unable to reach him due to a nationwide cell phone outage. In quick response, the Lung Health Team deployed a BCFHT employee to the patient’s house. At the same time, the Lung Health Clinic’s Respirologist connected with the transplant physician to discuss the action taken to have the patient contacted, preventing the team from moving on to the next candidate. The BCFHT employee arrived at the patient’s home, advised of the possible transplant, and provided a cell phone to facilitate communication between the patient and transplant team.

Once connected, the patient was transported to Toronto and was a successful recipient of a lung transplant. With gratitude, Mr. X released a media statement on this process and has since had a follow-up assessment in the Lung Health Clinic further expressing his thanks to the team and his new lease on life.

STOP (Smoking Treatment for Ontario Patients) Program

The STOP Smoking Cessation Program continues to successfully support patients in their journey to quit smoking.  In the coming year, the program is working towards expanding inclusion criteria to individuals wishing support to quit vaping.

The STOP team, in collaboration with CAMH (Centre for Addiction and Mental Health), provides necessary support through smoking cessation counselling and the use of Nicotine Replacement Therapy. 

The team consists of six care providers, all certified in the Applied Cessation Counselling and Health TEACH program offered through the University of Toronto.

The program provides in person and virtual care via phone with positive feedback from patients.  The launch of a patient portal through CAMH was initiated over the last fiscal year, allowing patients to complete all intake forms independently online if able.  Patients requiring personal assistance or without internet access continue to receive team support to complete intake forms, ensuring all members within the community have program access.

 

Total Visits: 1033  |  Unique Patients: 317
Patient Story
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Patient Story

One individual recently enrolled in the STOP program made a special visit to thank a team member for helping her quit smoking. The individual stated her family could not believe that after 50 years she had been able to quit and that she could not have done it without our support.

Aging Well Clinic (AWC)

The Aging Well Clinic provides support to seniors in our community experiencing complicated medical conditions. The team provides assessment and treatment for cognitive concerns in patients over the age of 65 years of age. The clinic provides diagnoses and treatment of complex medical conditions for individuals over 70 years of age, and assessments for those with complex medical needs in preparation for complicated surgical procedures.

The team consists of a nurse practitioner, nurses, an occupational therapist, a pharmacist, and a consulting physician. They collaborate with community supports to assist patients and their care partners to connect with community resources. Patients are supported to remain in their homes for as long as possible. For those who cannot, assistance is provided with transition to long-term care.

The Aging Well Clinic is a supporting partner on the Barrie and Area Local Specialized Geriatric Services Team, assisting frail seniors and their care givers.  Care continues to be provided both in-person and virtually for this vulnerable population. 

 

Total Visits: 2356  |  Unique Patients: 422
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Diabetes Program

The Diabetes Program works one-on-one with patients, helping them manage their diabetes.  The program consists of nurses, dietitians, and a pharmacist, who are all Certified Diabetes Educators (CDE)s or are working towards the designation. 

This team works in partnership with other members of the Barrie and Area Diabetes Collaborative and the RVH Paediatric Diabetes Program for a variety of reasons, including providing patients education events.  The BCFHT has increased support for the population of patients with prediabetes to assist Collaborative team members.  One of the FHT’s Registered Dietitians currently sees each new patient with prediabetes in a virtual group setting to provide lifestyle counselling in an efficient manner.  If a patient with diabetes is trying to quit smoking, they may be assigned to a Diabetes Educator who is STOP certified.  These educators also act as a resource to other CDEs, ensuring the STOP Program is promoted within this chronic disease population.

 

Total Visits: 2903   |  Unique Patients: 1114
Patient Quotes
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Patient Story

Patient was a Pre-Diabetes patient and saw the BCFHT Dietitian expressing concerns regarding IBS, experiencing major constipation and bloating which was significantly impacting her quality of life and daily activities.

The dietitian worked on simply increasing the patient’s fibre and fluid intake and improving her overall quality of diet. The patient followed this advice for a month with significant positive results. Her constipation and bloating were completely resolved and she said she felt like a “completely new person.” She was able to go for longer duration of walks because she was no longer so uncomfortable. Her blood pressure came down into normal range without adding any more medication.

School Success Program (SSP)

The SSP consists of a multidisciplinary team of Paediatricians, nurses, a psychotherapist, a Social Worker, and an Administrative Assistant. The team provides valuable access to specialized support for elementary-level students having trouble in school.

The program connects students and their families/guardians to timely access to education, assessments, and resource recommendations. The team works in close partnership with school boards and the student’s primary care provider to ensure a cohesive approach. The SSP has been streamlined to provide better access to families. Allied support is offered in the interim of a wait for Paediatrician consultation. Families receive supportive social/emotional/behaviour counselling, providing the family, school, and student with an opportunity for school and home improvement, and mental wellness. This has also enabled physician access to clinical or appointment notes, where psychotherapists or social workers can identify trends or significant findings over longer timeframes.

 

Total Visits: 1812  |  Unique Patients: 315
Patient Quotes and Stories
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School Success Program Provider Stories

School Success therapist spoke to a patient’s mother for a follow-up call and this mother said that she watched a recommended webinar and found it helpful, and that she felt like the small changes are triumphs and she is quite happy with how things are going – “he is doing pretty well and I’m happy with all the things you’ve taught me”.

Therapist spoke to a mother and father in follow-up regarding their 7-year old son who had been a part of the School Success Program. The parents stated that the webinar they’d seen had been very helpful and outlined that their son had an incident the previous week at school where he had been having trouble getting comfortable in the library and was acting out. He was then sent to the hallway as a consequence and stated to staff that he wished to self-harm. The school then contacted the student’s mother. The boy’s father said he was very thankful to have had previous conversations with the SSP team and now had the webinar to use as a tool. He was able to see everything that happened from a brain-based perspective and recognized that his son went into shutdown phase. Dad was able to empathize and have a productive solution-focused conversation with his son and stated “I feel more empowered to deal with these situations” while noting ‘‘The School Success Program has changed the lives of many students by providing them the services and care needed to be successful! Thank you to the entire team for your help and dedication, especially during a crippling pandemic. I’m forever grateful for your knowledge and assistance!’’

 

Prenatal and Well Baby (PNWB)

The PNWB Program is staffed with Registered Nurses who support Physicians and Nurse Practitioners, as well as International Board-Certified Lactation Consultants (IBCLC) who provide breastfeeding support. The PNWB Program provides routine prenatal and well-baby care for local women and children (up to the age of 6 years) without a primary care provider (Family Physician or Nurse Practitioner) within the Barrie area. A Paediatrician provides consultations, including frenotomy procedures. 

A PNWB appointment may include: 

  • Routine prenatal care up to 28 weeks gestation
  • Routine well baby/childcare up to age 6 years – includes routine health assessments and recommended childhood immunizations
  • Seasonal influenza vaccinations (eligible clients of clinic only)
  • Episodic care (clients of clinic only)
  • Cervical cancer screening
  • 1:1 lactation support – pre & post natal
  • Frenotomy services
  • General pediatric consultation excluding behavioural concerns (pediatric clients of clinic only)

The PNWB program has slowly resumed all routine prenatal and well-baby care in-office, with the option to provide virtual care where appropriate and requested by clients. The team has increased their efforts to lessen the burden on the healthcare system by resuming assessment of episodic visits where able, except for acute respiratory and/or febrile illnesses.

The PNWB Program continues to work in collaboration with the Simcoe Muskoka District Health Unit (SMDHU) by offering COVID-19 mRNA vaccinations to pediatric populations.  

Total Visits: 3836 (RN and NP)  |  Unique Patients: 1272 (RN and NP)
*Lactation Services: Total Visits: 1021   |  Unique Patients: 646

* Lactation Services numbers represent visits provided by FHT and SMDHU staff at the PNWB clinic.

Provider Experience
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PWNB Provider Experience

Parents came into the Lactation Clinic with their 21-day old baby who had not been latching to the breast despite mom’s many attempts with and without a nipple shield. The dad had protectively reached out to Mom as she expressed her distress at not being able to achieve her breastfeeding goals. I worked with mom and baby to help them gently obtain a latch. As baby latched and started to feed you could feel the tension in the room just melt and the wave of relief wash over both parents. I feel privileged to be able to help parents on the path to achieve their breastfeeding goals.

Nurse Practitioners (NP)

The Nurse Practitioner team provides care and support across 62 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: 35,581  |  Unique Patients: 22,861
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Pharmacy and Registered Dietitian (RD) Services

Pharmacy and RD team members are involved on a consultation basis with Palliative Care Community Team Rounds at Hospice Simcoe. Pharmacy and RD team members participate in Bone Health and Fracture Prevention sessions, in partnership with Osteoporosis Canada and VON Canada. These sessions receive much positive feedback.

Our Pharmacy and RD teams co-facilitate to bring evidenced based information and recommendations to our ‘Successful Weight Management Using Medications’ patient group. This group has had a high referral rate since it started at the beginning of 2023 and has received overwhelmingly positive feedback from attendees.

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Pharmacy

The Family Health Team Pharmacists receive referrals to consult on a variety of aspects of patient care. These referrals include, but are not limited to, identifying, resolving, and preventing drug interactions, adverse effects, deprescribing, initiating and optimizing medication therapy, and drug dosing.

FHT Pharmacists have access to patients’ electronic medical records, and laboratory findings. While they do not have access to community pharmacy products (they work in offices rather than pharmacies), Pharmacists provide patient-centered care by using this information, their expertise in medication therapy, and by communicating directly with health care providers and patients.

Pharmacists support multiple FHT programs including: STOP, LINKS, and the Aging Well Clinic. FHT Pharmacists co-facilitate classes for both “Bone Health” and “Tools for Successful Weight Management”.

 

Total Visits: 1740   |  Unique Patients: 659
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Registered Dietician (RD) Services

Our Registered Dietitian services continue to be a highly valuable and well utilized service both to our primary care providers and our patient population, receiving approximately 150 referrals per month. To reduce wait times and provide more timely access for urgent referrals, a total of 1.2 FTE contract positions were added from December 2022 to March 2023.

Our Registered Dietitians continue to provide evidenced based Medical Nutrition Therapy to a broad spectrum of diagnoses across all age groups, offering both telephone and in-person assessments, follow-ups, and group classes based on patient preference (Zoom or in-person).

Newly updated for this past year was the obesity management section of the program. The ‘Successful Weight Management with Medications’ group class was added in response to the increase in referrals for this. We continue to run our Diet and Lifestyle class (formerly Quick Start to a Healthier You) and our Post Bariatric Surgery Management class.

The Registered Dietitians continue to consult with patients’ primary care providers and refer, when appropriate, to our Mental Health Wellness Counsellors and FHT Pharmacists, to optimize quality of care and patient outcomes.

 

Total Visits: 4728   |  Unique Patients: 1879
Patient Quotes
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Patient Quotes

“Patient is a 27-year-old male referred to the BCFHT Registered Dietitians for obesity. His starting weight was approximately 450 pounds with a weight gain of 120 lbs in the last 3 years. Patient had a previous diagnosis of ADHD but was not taking medication as well as anxiety and was on a BIPAP for sleep. Patient had a history of missing breakfast, skipping lunch or getting takeout, having a supper meal with family, then a takeout snack before bed. The RD assessed this patient and ordered bloodwork, finding his Vitamin D to be extremely low as well as an elevated ALT. This was discussed with the patient and doctor. The patient began taking ADHD medication, participated in the FHT Mindful Eating sessions, and began a dietary plan with protein, vegetables, fruit and healthy grains for 3 meals per day.”

“In time, the patient was on a weekly prescription vitamin D2 with his levels slowly improving after 6 months. He was having protein shake at breakfast and sometimes again at lunch or another protein/vegetable meal, as well as a family meal at dinner. His snack at night was something low calorie. Overall, this patient’s ADHD improved and he became better at his job and improved his relationships with family members. He lost 40 pounds and told his doctor he had “never felt so good or happy”.”

“I really enjoyed our conversation today. You are so knowledgeable and understanding of the challenges involved in getting on the right path back to health. Your advice was very helpful and I have updated my shopping list with some new foods to try. The recipes you have provided sound delicious! I’ll also add the vitamins you have recommended to my regime. Thanks so much for your assistance!”

“I just wanted to let you know whenever I get off the phone with you I feel so empowered, encouraged and confident. You always have an idea, suggestion or if you don’t you find out for me. I could not have asked for a better dietician. The struggles are real for me this past year, but with your guidance and knowledge I know I can get through this major hurdle. One day at a time. I am so grateful that you came into my life. You are truly the best. Thanks for all you do for me.”

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 – All initial patient contacts are conducted using a Single Session model. The Single Session model fits with the short-term focus of the program by increasing access, reducing wait times, and preventing the need for longer-term service.
  • 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, Better Sleep (CBT-I), 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 weekly Mental Health Clinic is provided to patients of Physician Residents of the Family Medicine Teaching Unit. Patients are identified by Residents as those who would benefit from mental health counselling. The Mental Health Therapist is onsite in the supervising room, listening to and watching as Residents interact with patients. They provide Residents with communication skill training for this sub-population of patients.

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: 5986 | Unique Patients: 1796 (*Therapist only)
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Information Technology (IT)

The IT Department continues to improve the security profile of our users. To provide better tools for that purpose, our EMR will be moved from an ASP (Application Service Provider) solution with QHR to their Accuro Cloud EMR platform. This will eliminate the need for the intermediate Citrix application and allow users to log directly into Accuro through the secured website. We will also be utilizing multi-factor authentication services, which will require the usual username/password credentials as well as a rolling code.

In addition, IT is working to clean up the SharePoint structure within the FHT/FHO to better isolate files and documents, to improve performance and better protect assets in the event of a cyber attack.

Last year a major rollout of EMR features such as Online Appointment Booking and we are looking to continue to expand our subscribers to those services through the year ahead. This work is part of a larger project being managed through the Barrie and Area Ontario Health Team. In addition, IT is working with vendors on the deployment of OceanMD’s eReferral platform as part of the province’s “axe the fax” initiative, which should improve communication between primary care providers and specialists/services within the region. As part of that same initiative, IT is working with QHR on their ePrescribe software solution, which should significantly reduce the need for fax services.

The QI Project team continues to work closely with external partners, such as REQIP (Research, Education, and Quality Improvement Program) at RVH and CPCSSN (Canadian Primary Care Sentinel Surveillance Network) to improve outcomes in primary care. New this year is an additional agreement with RVH and the NSQIP (National Surgery Quality Improvement Program) to help compute and report thirty-day risk-adjusted surgical outcomes.

 

Total Calls: 7542   |  Tickets Resolved: 5985
Accuro Users: 548  |  Locations: 20 sites and 51 offices
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Quality Improvement and Decision Support (QIDS)

The QIDS team works with clinical programs, physician offices and the IT department. Their goal is to ensure providers have the tools to effectively track performance measures, develop surveys for community feedback, and generate reports to facilitate quality initiatives.

The BCFHT QIDS team is responsible for compiling information and generating standard reports for the Board and Ministry of Health.

QIDS continues to work closely with providers and the large quality improvement community to share innovative ideas, enhance patient experience, improve overall clinical measures and processes, and develop the Quality Improvement Plan.

The team had an integral part in performing multiple FHT program reviews to ensure effective and efficient use of resources.

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Human Resources (HR)

Our annual Employee Satisfaction Survey was completed by over 80% of employees. Highlights include that over 95% of respondents were satisfied with the BCFHT as an employer, and 96% would recommend the BCFHT as an employer.

Professional development was at the forefront last year as all employees completed Emotional Intelligence training; this vital core competency will be added to our revised annual performance review. The development of emotional Intelligence skills will foster a positive working environment where employees communicate effectively, defuse conflict, and empathize with their peers.

The employee retention rate for 2022-2023 was 93.6%, up over 2% from the previous year; in addition, the IT Department hired two new employees.

 

Total Permanent BCFHT Employees: 78
New Permanent BCFHT Hires: 8