Together, we are shaping the future of healthcare.
As an organization, we continue to strive towards excellence in the provision of primary health care, the foundation of our health care system. Despite the current challenges faced by the system, we were able to meet the needs of many patients in our community who are attached to primary care and the needs of some who are unattached. Our interprofessional team, together with the physicians of the Barrie Family Health Organization, provides primary care to more than 150,000 attached patients in Barrie and the surrounding area. Our School Success, Prenatal and Well Baby, and Telemedicine programs also provide care to unattached patients from these specialized population groups within our community.
The BCFHT is a committed partner of the Barrie Area Ontario Health Team. In conjunction with our community partners, we are working together to enhance the health and well being of all patients living in our community, including marginalized and unattached patients. As an example, this year we participated in the development of a new pilot program, the Good Foot Forward program, which aims to decrease the number of lower limb amputations by patients in our community. We are measuring the outcomes of the work within this program and are hopeful that the positive impacts we are seeing so far will ensure that this program can be continued.
Our BCFHT team continues to build on lessons learned and find innovative ways to deliver its many programs and services to serve the needs of our community. We continue to advocate to our Ontario Health and Ministry of Health partners to assist us with the struggles of limited health human resources as well as issues of pay inequity faced by providers in the primary health care sector, compared to other sectors in the system. This year, we plan to update our strategic plan with valuable input from our patients and other key stakeholders. We look forward to sharing that with you in next year’s annual report.
In closing, we are deeply thankful for all our dedicated healthcare providers who continue to provide exceptional primary care to patients, families, and caregivers in our community, supported by digital health technology. We hope you enjoy reading this report.
Respectfully,
Kimberly Vickers,
Executive Director
Medical Director
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
Telemedicine
The Family Health Team (FHT) Telemedicine Program increases access to specialists 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.
Telemedicine is a key support for FHT clinicians and physicians. Many providers use telemedicine for patient care and have been supported in set-up and problem solving by the FHT OTN Telemedicine Coordinator. The telemedicine program has worked with various specialists and patients to set up successful video visits to the patients’ homes allowing ongoing and timely care.
The program utilizes 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.
Total Visits: 1256 | Unique Patients: 563 | eConsults: 992
Chiropody Program
The Chiropody Program provides foot care to patients at high risk of complications (patients with diabetes, those associated with the LINKS program, or those associated with the Aging Well program) 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.
Due to staffing issues, the Chiropody program was on hold for a portion of the year. During this time, foot care was supported by the Good Foot Forward Program through the Barrie and Area Ontario Health Team.
Total Visits: 653 | Unique Patients: 336
LINKS Navigation Clinic
The goal of the LINKS (Linking Individuals Needing Key Services) Navigation Clinic is to support patients who have multiple chronic diseases and who require support with a variety of social determinants of health.
The LINKS team, consisting of an RN Patient Navigator, a Social Worker, an Occupational Therapist, and Pharmacist support, links patients with community partners and provides them with a healthcare plan. The individualized plan empowers patients to take responsibility for their own health and provides them with a reference to access the care that is appropriate for their concerns. This, in turn, works toward achieving the program goal of reducing EMS and ER usage.
LINKS team members sit at the Barrie and Area Navigators Collaborative (BANC) table with Home and Community Care Support Services and Royal Victoria Regional Health Centre (RVH) are also represented. Resources are shared and communication is improved between community programs involved in navigating high-use, high-risk patients.
Total Visits: 1879 | Unique Patients: 186
Lung Health Program
The Lung Health team, consisting of four Certified Respiratory Educators (CREs), is clinically supported by a local Respirologist.
The CREs provide 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 lung transplants 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 and can now provide 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: 3828 | Unique Patients: 1991
STOP (Smoking Treatment for Ontario Patients) Program
The STOP Smoking Cessation Program successfully supports patients in their journey to quit smoking cigarettes. Criteria has not yet been expanded to support individuals who wish 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 based on patient choice. CAMH offers a patient portal which allows 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: 1287 | Unique Patients: 325
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, as well as the diagnosis and treatment of complex medical conditions for individuals over 70 years of age.
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 available resources. Patients are supported to remain in their homes for as long and 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: 2466 | Unique Patients: 435
Diabetes Program
The Diabetes Program works 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. Our FHT Registered Dietitians see patients with newly diagnosed pre-diabetes in a 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: 3632 | Unique Patients: 1114
School Success Program (SSP)
The School Success Program (SSP) comprises a multidisciplinary team consisting of Paediatricians, Nurses, a Psychotherapist/Social Worker, an Occupational Therapist, an Administrative Assistant, and a Clinical Manager. Together, they offer specialized support for elementary-level school students in Barrie who are experiencing school-related concerns. The SSP aims to empower students and families by providing holistic support and fostering their success in school and beyond.
The SSP facilitates timely access to assessments and resource recommendations for students and their families/guardians. Working closely with teachers and primary care providers (Family Physicians or Nurse Practitioners), the team ensures a cohesive approach to addressing students’ needs.
This streamlined process delivers comprehensive care, including specialist consultations and access to services provided by the Psychotherapist/Social Worker and Occupational Therapist while families await Paediatrician consultations. Families receive social, emotional, behavioural, and developmental support throughout their participation in the program and are directed to community resources for ongoing care.
Total Visits: 1837 | Unique Patients: 478
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 (IBCLCs) who provide breastfeeding support. The PNWB Program offers 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 pediatrician provides consultations, including frenotomy procedures.
A PNWB appointment may include:
- Routine prenatal care (initial and follow-up appointments up to 28 weeks gestation)
- Routine well-baby/childcare up to age six years, including routine health assessments and recommended childhood immunizations
- Seasonal influenza vaccinations (eligible clients of the clinic only)
- Episodic care (clients of the clinic only)
- Cervical cancer screening
- One-on-one lactation support, pre- and postnatally
- Frenotomy services
- General pediatric consultations excluding behavioral concerns (pediatric clients of the clinic only)
- Links to community supports
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 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: 3848 (RN and NP) | Unique Patients: 1451 (RN and NP)
*Lactation Services: Total Visits: 1000 | Unique Patients: 628
*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 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: 38,578 | Unique Patients: 24,302
Pharmacy and Registered Dietitian (RD) Services
Our pharmacists and dietitians co-facilitate the Tools for Successful Weight Management (SWM) program for patients taking medications for obesity. This program has improved patient access to these services and has been shared with Family Health Teams (FHTs) across Ontario, helping to establish obesity management programs in other FHTs. Since its inception in early 2023, this group has seen a high referral rate and received overwhelmingly positive feedback from attendees.
Dietitians and pharmacists also update and lead the Bone Health and Fracture Prevention sessions for Ontario in partnership with Osteoporosis Canada and VON Canada. These sessions are available to both rostered and non-rostered patients and consistently receive positive feedback.
Additionally, dietitians and pharmacists collaborate with Hospice Simcoe on a consultant basis with the Palliative Care Community Team Rounds.
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”.
In February 2024, we launched a Minor Ailment Prescribing (MAP) six-month pilot program in four clinics. Our pharmacists offer same-day appointment availability and prescribe for 19 minor ailments. MAP improves access to timely care, decreases non-scheduled workload for primary care providers, and diverts care from walk-in clinics and emergency services. We have received very positive feedback from patients and providers about this program.
Total Visits: 1738 | Unique Patients: 535
Registered Dietician (RD) Services
Our Registered Dietitian services continue to be highly valuable and well-utilized by both our primary care providers and our patient population, receiving approximately 150 referrals per month.
Our Registered Dietitians provide evidence-based Medical Nutrition Therapy to patients with a broad spectrum of diagnoses across all age groups, offering both virtual and in-person group and individual sessions. They work closely with pharmacists, mental health providers, nurse practitioners, and physicians to ensure patients receive comprehensive healthcare that meets their needs.
This year, we released an updated and streamlined referral form to optimize triage and the efficiency of patient booking.
To improve access to group classes and accommodate a wider range of patients with variable schedules, the RDs have pre-recorded webinar options for Managing High Blood Pressure, Heart-Healthy Eating, Emotional Eating and Food Craving Management, and the Quickstart session to help patients get started with diet and lifestyle changes.
Total Visits: 4060 | Unique Patients: 1742
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. 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. Residents identify patients 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: 6354 | Unique Patients: 1662 (*Therapist only)
Information Technology (IT)
The IT Team continues to work with our Electronic Medical Record (EMR) vendor on the implementation of electronic prescription writing. They have also worked with Ocean on their eReferral platform and are now awaiting Ministry process before implementation, hopefully by the end of 2024. Both digital solutions are critical to modernizing healthcare communication and realizing the Ministry’s “axe-the-fax” initiative.
IT has been working to improve our security footprint, implementing a fully monitored endpoint detection and response solution to ensure robust protection of all systems within our environment, as well as new remote monitoring and management software to help the support team respond to hardware issues and automate patch management throughout our organization. We have also increased our existing multi-factor authentication requirements across more services to add an extra layer of security to service access.
In addition to these security measures, IT has also taken steps to isolate all satellite office networks both from each other and the hub, to limit the scope of any possible cyber events. Within the Family Health Team, they will be taking measures to isolate the networks of individual clinical program areas so devices are limited from having access to one another.
Over the past year, our primary care providers have continued leveraging digital tools such as Online Appointment Booking, as part of the province’s Digital First for Health strategy. OAB provides convenient, 24/7 access to booking options and automated appointment confirmation and reminders, which in turn can provide increased efficiency and improved administration capacity.
Total Calls: 7866 | Tickets Resolved: 6137
Accuro Users: 558 | Locations: 21 sites and 56 offices
Quality Improvement and Decision Support (QIDS)
The Quality Improvement (QIDS) team works closely with clinical programs, physician offices and the IT department. The team’s 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 clinical programs, Board, and Ministry of Health.
The team is an integral part of performing program reviews to ensure that the most up-to-date, evidence-based care is provided, enhancing patient and provider experience, improving overall clinical measures and processes, and developing the Quality Improvement Plan.
Human Resources (HR)
In the 2023/2024 fiscal year, many more employees reached milestone employment anniversaries with the BCFHT. We now have 12 employees with 15 or more years of employment, and a further 24 employees who have been with the BCFHT for 10 years or more. These milestone anniversaries highlight our employees’ continued satisfaction with the BCFHT as an employer.
Employee wellness was a top priority last year. We provided opportunities for all employees to participate in My Health Space Training, with a focus on Psychological Health and Safety, Burnout and Mindfulness in the workplace. These initiatives were designed to ensure employee well-being and mental health are prioritized. In addition, all employees participated in Safer Spaces Training offered by the Gilbert Center, a training program that focuses on strengthening 2S-LGTBQ+ diversity in the workplace through opportunity and change. Our leadership team also completed a program on fostering well-being through leadership, demonstrating our commitment to leading by example.
A fall walk, spring lunch, and Taco Tuesday were ways that our employees connected and collaborated, with a focus on team building.
Our retention rate stayed steady at 93.7 percent, remaining essentially the same as last year.
Total Permanent BCFHT Employees: 79
New Permanent BCFHT Hires: 5
