Chickadee Maternity Collaborative Team Integration Project

A Team Optimization Project to expand the existing team of professionals at Chickadee Maternity Collaborative by integrating an Indigenous Support Worker, and Mental Health Clinician into the team to support delivering comprehensive person-centered team-based care throughout pregnancy, birth, and the postpartum period to the population of patients we serve.

Location: Dawson Creek, British Columbia

Lead Organization: Chickadee Maternity Collaborative
Focus: Collaboration between maternity providers and mental health professionals.

Project Team:

• Project Lead: Dr. Magda Du Plessis

• Charleigh Rudy, Project Manager

• Haley Hayner, Midwife

• Dr. Simon Eriki, Physician

• Dr. Colleen Hiscock, Physician

• Shawny Fraser, Registered Nurse

First Steps Early Pregnancy Triage Clinic

A Team Optimization Project to create an efficient and effective interdisciplinary team to establish a new first contact, “one-stop-shop” triage clinic for anyone newly pregnant and provide them with timely access and triage of prenatal investigations. The First Steps Early Pregnancy Care Triage Clinic accepts self-referrals, or referrals by primary care providers who do not provide focused maternity care.

Location: Kamloops, British Columbia

Lead Organization: Mighty Oak Midwifery
Focus: Supporting over 410 patients in the 25-week period with prenatal investigations and consultations.

Project Team:

• Joanna Norman, Registered Midwife, Clinic Lead

• Dr. Justyne Morrow, Family Physician

• Natalie Manhard, Nurse Practitioner, Family Practice

• Sage Thomas, Midwifery Student, Member of Tk’emlups to Secwepemc

• Shelley Breen, Project Coordinator

• Jael Roy, Registered Midwife

Community Outpatient Services

A Team Optimization Project to elevate primary care by implementing a thorough, interprofessional strategy. This involved enhancing hospital transitions for inpatients and sustaining a team-based dual walk-in and longitudinal care model, all supported by a team with expertise in change management and clinic operations.

Location: Penticton, British Columbia

Lead Organization: South Okanagan Division of Family
Focus: Supporting medically complex patients being transitioned from hospital care to primary care.

Project Team:

• Project Lead: Taunya Cossentine, Executive Lead, SOS Division of Family Practice

• Kelly Hawes, Primary Care Network and Clinic Support Manager, SOS Division of Family Practice

• Erin Millar, Clinic Support Lead, SOS Division of Family Practice

• Jessie MacBurney, Administrative Assistant, SOS Division of Family Practice

• Dr Tiffany Bursey, Physician Lead

• Dr Tom Oliver, Physician Lead

• Dr Glen Burgoyne, Physician Lead

• Dr Heidi Ingram, Physician Lead

• Dr Emily Kogel, Physician Lead

Equity in Practice: Integrating Cross Cultural Health Brokers to Implement Culturally Safer Equity-Oriented Primary Care for Immigrants and Refugees in British Columbia

A Team Optimization Project to advance the expansion and sustainability of Umbrella Multicultural Health Co-op's interdisciplinary primary care team with Cross Cultural Health Brokers, and establish infrastructure for ongoing evaluation.

Location: New Westminster, British Columbia

Lead Organization: Umbrella Multicultural Health Co-op
Focus: Expanding and sustaining interdisciplinary primary care with Cross-cultural Health Brokers (CCHB) and integrating new CCHB team members into the interprofessional primary care team.

Project Team:

• Project Lead: Mei-ling Wiedmeyer, MD, CCFP, Umbrella Multicultural Health Co-op

• Project Co-Lead: Jeanette Pedersen, MD, CCFP, Umbrella Multicultural Health Co-op

• Zarghoona Wakil, MPH, Umbrella Multicultural Health Co-op

• Lindsay Hedden, PhD, Simon Fraser University

Pilot Integration of Midwives into a Comprehensive Primary Care Setting

An IP Collaborative Project to integrate two salaried registered midwives as a pilot intervention to strengthen comprehensive primary care to youth clients aged 12-24 at the Victoria Youth Clinic Society (VYCS) and promote an alternate model of employment and practice to address workforce mental health challenges experienced by midwives working in a fee-for-service model.

Location: Victoria, British Columbia

Lead Organization: Victoria Youth Clinic Society (VYCS) 
Focus: Enhancing the integration of midwifery services into comprehensive primary care teams, building relationships, supporting Indigenous strategies, and providing collaborative sexual, reproductive, and perinatal care for youth clients.

Project Team:

• Project Lead: Cecilia Benoit, PhD, FRSC, FCAHS, Scientist, Canadian Institute for Substance Use Research, University of Victoria

• Andrea Mellor, PhD, Post-doctoral fellow, Canadian Institute for Substance Use Research, University of Victoria (Research Coordinator)

• Brett Koenig, MSc, Canadian Institute for Substance Use Research, University of Victoria (Research Assistant)

• Ricki Justice, Executive Director, Victoria Youth Clinic Society (Community Partner Lead)

• Nathalie Pambrun, Registered Métis Midwife, Victoria Youth Clinic Society (Indigenous Midwife)

• Melanie Mason, Registered Métis Midwife, Victoria Youth Clinic Society (Indigenous Midwife)

Primary Healthcare Expansion at The Alex Community Health Centre

A Team Optimization Project to integrate a Social Worker (SW) and Registered Nurse – Proactive Office Encounter Technician (RN-POET) into our clinical team and optimize their roles as well as clarifying roles across the team and act on opportunities for greater collaboration.

Location: Calgary, Alberta

Lead Organization: The Alex CHC 
Focus: The integration of RN and SW roles into the CHC team to improve cancer screening and manage social determinants of health.

Project Team:

• Project Lead: Dr Kerri Treherne, Physician

• Project Co-Lead: Dr Erik Singendonk, Medical Director & Physician

• Joe MacGillivray, Director of Care

• Jennifer Campbell, Manager of Community Health Clinic

• Cathy Deck, Manager of Social/Upfront Team

A Culturally Responsive Approach in Chronic Disease Management

A Team Optimization Project to enhance the care provided to clients living with a chronic disease in rural, First Nation communities by utilizing an interdisciplinary and culturally responsive approach.

Location: Regina, Saskatchewan

Lead Organization: Wellness Wheel Medical Clinic
Focus: Hiring an RN to lead the project and review charts/profiles, holding Chronic Disease Management (CDM) days in different Indigenous partner communities, and creating a more inclusive and culturally responsive approach to care.

Project Team:

• Project Co-Lead: Susanne Nicolay, RN, Clinical Coordinator, Wellness Wheel Supervisor, First Nations Métis Health Saskatchewan Health Authority

• Project Co-Lead: Nikki Williamson, RN, CDM Lead, Wellness Wheel, First Nations Métis Health Saskatchewan Health Authority

• Dr. Candina Beaurivage, MD, CCFP, Family Physician

• Dr. Megan Clark, MD, CCFP, Family Physician

• Dr. Kieran Conway, MD, CCFP, Family Physician

• Cynthia Kay, Health Director, Touchwood Agency Tribal Council

Responding to the Call: Centering Indigenous Knowledge Systems to Strengthen Comprehensive Primary Care

A Team Optimization Project to provide culturally safe primary health care that is rooted in ‘structural competency’ and embraces trauma-informed, strength based, non-judgement, and anti-racist pedology among an interprofessional team who operate from a place of knowing who they are and where they come from, to operationalize transformative care.

Location: Winnipeg, Manitoba

Lead Organization: University of Manitoba  
Focus: Hiring and incorporating an Elder, Mental Health Counselor, and Knowledge Keeper into the Primary Health Clinic.

Project Team:

• Project Lead: Mandy Buss

• Allen Katz, Project Evaluator

• Jacklyn Desharnais, Project Evaluator

• Martha Peet, Elder

• Kimberly Morrisseau, Knowledge Keeper/Elder Helper/Project Manager

• Linda Sundevic, Clinic Manager

• Ken Hahlweg, Clinical Director

Healthcare Connections: Connecting Diversity

A Team Optimization Project to expand IEHPs' contributions to comprehensive primary care workplaces and to help those workplaces better reflect the diversity, skills and experience of Canada’s population.

Location: Greater Toronto Area, Ontario

Lead Organization: ACCES Employment   
Focus: Interprofessional student learning and supporting families.

Project Team:

• Sue Sadler, Senior Vice President, Services and Program Innovation, ACCES Employment

• Cameron Moser, Senior Director, Services and Program Development, ACCES Employment

• Willa Tam, Program Manager, Healthcare Connections, ACCES Employment

On Track: Supporting Interprofessional Team-Based Primary Care and Collaborative Leadership Through Training in a Student-Led Environment

A Team Optimization Project for an innovative educational model that holds promise to transform interprofessional education (IPE) and healthcare practice in primary care. Integrating best practices from education science, clinical knowledge, and experiential knowledge, the SLE model provides learners with valuable, evidence-informed education to foster more compassionate, equitable, and collaborative care.

Location: Toronto, Ontario

Lead Organization: Holland Bloorview Kids Rehabilitation Hospital    
Focus: Interprofessional student learning and supporting families.

Project Team:

• Amanda Binns, PhD, SLP - CCC Reg. CASLPO Holland Bloorview Kids Rehabilitation Hospital; University of Toronto Department of Speech Language Pathology; The Institute for Education Research (TIER) at University Health Network

• Dara Abells, MD CCFP MScCH, University of Toronto

• Michelle Addison, B.Sc.PT. NOSM University

• Cooper Dupre, MSW RSW Holland Bloorview Kids Rehabilitation Hospital

• Farah Friesen, MI Centre for Advancing Collaborative Healthcare and Education (CACHE), Temerty Faculty of Medicine, University of Toronto; The Institute for Education Research (TIER), University Health Network

• Darlene Hubley, OT Reg. (Ont.), BScOT, MScCH Holland Bloorview Kids Rehabilitation Hospital

Healthcare Connect for Foreign-Trained Healthcare Professionals

A Team Optimization Project to enable, assist, and empower IEHPs to integrate into the Canadian labour force. We achieved that by facilitating employment opportunities in their respective field of practice, offering wage subsidies for 35 hours per week for 3- 6 months, and offering job readiness workshops, micro-credentials, IMG study groups, coaching and mentoring. We also established a huge network of healthcare employers who reduced hiring hesitation and provided opportunities for the IEHPs.

Location: Oakville, Ontario

Lead Organization: HMC Connections  
Focus: Assisting internationally educated healthcare professionals (IEHPs) to obtain employment in the healthcare field.  

Project Team:

• Kim Jenkinson, Executive Director

• Nilofar Yousof, Manager, Healthcare Connect Program

The TEMPEH Project: Team Care for Routine Emergencies Among People Experiencing Houselessness

A Team Optimization Project to engage peer and community health workers in ICHA’s team to enhance comprehensive primary care by responding to “routine emergencies” facing people experiencing houselessness, including encampment and shelter evictions, extreme weather events, and novel communicable disease threats.

Location: Toronto, Ontario

Lead Organization: The Inner-City Health Associates TEMPEH Committee
Focus: Serving Canada’s most diverse and marginalized populations and people experiencing homelessness (PEH) and responding to severe emergency threats to health in this population.  

Project Team:

• The Inner City Health Associates TEMPEH Committee

• Sara Maria Daou, MPH - Health Promotion Coordinator at Inner City Health Associates

• Bradshaw Byakuleka, Community Health Worker at Inner City Health Associates

Strengthening Interprofessional Collaboration for Effective Health Promotion and Education Initiatives at Toronto Western Family Health Team

An IP Collaborative Project to evaluate the extent to which a comprehensive training on interprofessional competencies changes overall collaborative practice among clinical staff working in a family health team setting.

Location: Toronto, Ontario

Lead Organization: Toronto Western Family Health Team  
Focus: Identifying health education needs, providing coaching and training to Interprofessional teams, and evaluating interprofessional competencies.  

Project Team:

• Project Lead: Catherine Ji, Physician, Toronto Western Family Health Team, Toronto, Ontario

• Navaldeep Kaur, Research Associate, Toronto Western Family Health Team

• Allison Mann, Nurse Practitioner, Toronto Western Family Health Team

• Lillian Ferreira, Health Promotion Specialist, Toronto Western Family Health Team

• Noah Crampton, Physician, Toronto Western Family Health Team

Memory Care in Primary Care - An Interagency Memory Care Service within a Community-Based Family Health Team

A Team Optimization Project to develop an Inter-Agency team-based Memory Care Service which provides all patients in a community-based FHO with memory concerns or dementia access to appropriate evidence-based assessment and management by their known Primary Care Providers.

Location: Peterborough, Ontario

Lead Organization: The Medical Centre Family Health Organization
Focus: Developing a partnership with the Alzheimer Society and providing training for an RN Embedded Assessor and for physicians/nurses in the FHT.

Project Team:

• Project Co-Lead: Dr. David Carr, Family Physician, The Medical Centre Family Health Organization

• Project Co-Lead: Dr. Jennifer Ingram, Founder and Consultant Geriatrician, The Kawartha Centre

• Jennifer Johnstone, Executive Director, Alzheimer Society of Peterborough

• Donna Hickey, Person with Lived Experience

• Geneviève Arsenault-Lapierre, Senior Research Associate at the Lady Davis Institute for Medical Research, Jewish General Hospital

• Don Bird, Information Technology Specialist, The Medical Centre Family Health Organization

• Jenna Butcher, Allied Health Receptionist, Peterborough Family Health Team

• Brenda Wigmore, RN, Peterborough Family Health

  Team

• Jennifer Gooderham, Client Support Coordinator,

  Alzheimer Society of Peterborough

• Sara Kennedy, RN, Peterborough Family Health

  Team

• Sara deRuiter, Client Support Coordinator,

  Alzheimer Society of Peterborough

Transforming Support for Isolated Older Adults Through Social Prescribing Within Team-Based Primary Care in Toronto, Ontario

A Team Optimization Project to improve loneliness, community connection and engagement, patient and holistic health outcomes among socially-isolated older adults living in downtown East Toronto through a link worker-based social prescribing program embedded in the St. Michael’s Hospital Academic Family Health Team.

Location: Toronto, Ontario

Lead Organization: St. Michael’s Hospital 
Focus: Assisting socially isolated older adults individually, addressing complex health issues and loneliness.

Project Team:

• Project Co-Lead: Dr. Braden O’Neill, Family Physician, SMHAFHT

• Project Co-Lead: Dr. Gary Bloch, Family Physician, SMHAFHT

• Nassim Vahidi-Williams, Manager of Patient and Community Engagement, St. Michael’s Hospital Department of Family and Community Medicine

• Dr. Karen Weyman, Chief of Family and Community Medicine, St. Michael’s Hospital

• Dr. Deborah Kopansky-Giles, Professional Practice Leader and Chiropractic Program Coordinator; IPE Committee Co-Chair, Department of Family and Community Medicine, St. Michael’s Hospital

• Linda Jackson, Senior Clinical Director, Primary and Community Care at Unity Health Toronto

• Mikhaila Bernales, Community Health Worker

• Orit Adose, Community Health Worker

• Sandesh Basnet, Link Worker

Scaling Up Labour Market Integration of International Trained Medical Graduates (IMGs) and Professionals in Clinical Assistant Roles

A Team Optimization Project training IMGs to be ready to fulfill the position of clinical assistant in primary care facilities to decrease waiting times while coaching family care facilities/employers to consider hiring IMGs as clinical assistants.

Location: London, Ontario

Lead Organization: WILL Employment Services
Focus: Training and integrating International Trained Medical Graduates (IMGs) into the healthcare field.

Project Team:

• Mohamed Awad, Team Leader, Alternative Career Options for Healthcare Professionals at WILL Employment Solutions

• Hussein Hassan, Employment Counsellor, Alternative Career Options for Healthcare Professionals at WILL Employment Solutions

Une Équipe Interprofessionnelle au Service de la Population Orpheline (EISPO)

A Team Optimization Project to demonstrate the great potential of a well-coordinated interprofessional team in expanding the capacity of family medicine teams to see new patients while enhancing the overall quality of care provided to unattached patients.

Location: Montreal, Quebec

Lead Organization: Clinique Indigo
Focus: Building, training, and sustaining an interprofessional team within a primary care clinic.

Project Team:

• Dr. Maxine Dumas-Pilon, médecin de famille, Clinique Indigo

• Dr. Elise Boulanger, médecin de famille, Clinique Indigo

• Mylaine Breton, chercheure, Université Sherbrooke

• Isabelle Gaboury, chercheure, Université Sherbrooke

• Mélanie-Ann Smithman, chercheure, Université Sherbrooke

• Phillippe Lachance, Directeur de l'accès et de l'organisation des services de première ligne chez Ministère de la Santé et des Services sociaux

• Dominique Perron, Conseiller en organisation de services de première ligne chez Ministère de la Santé et des Services sociaux du Québec (MSSS)

COACH COLLABO: A Quality Improvement Intervention to Increase Interprofessional Collaboration in Primary Healthcare Clinics)

A Team Optimization Project to optimize interprofessional collaboration of teams working in primary healthcare (PHC) clinics through a quality improvement approach.

Location: Sherbrooke, Quebec

Lead Organization: University of Sherbrooke
Focus: Providing active coaching to Family Medicine Groups (FMG) clinics, reviewing care management processes, and developing tools/strategies to improve IP within the FMG teams.

Project Team:

• Isabelle Gaboury, Université de Sherbrooke

• Mylaine Breton, Université de Sherbrooke

• Richard Fleet, Université Laval

• Ariane Girard, Université de Sherbrooke

• Nebojsa Kovacina, McGill University

• Elisabeth Martin, Université de Sherbrooke

• Melanie Ann Smithman, University of Toronto

Family Medicine In-Practice Certification Route for Certificates of Added Competence in Enhanced Surgical Skills, Obstetrical Surgical Skills, and Family Practice Anesthesia

A An IP Collaborative Project to create new certification pathways for family physicians with skills in ESS, OSS, and FPA, to maintain and strengthen rural surgery and enable care close to home.

Location: National

Lead Organization: College of Family Physicians of Canada
Focus: The development of an in-practice certification route (IPCR) process.

Project Team:

• Project Lead: Tatjana Lozanovska, Project Lead, College of Family Physicians of Canada

• Dr. Nancy Fowler, Executive Staff Lead, College of Family Physicians of Canada

• Dr. Roy Wyman, Senior Staff Lead, College of Family Physicians of Canada

• Danijela Stojanovska, Project Management Lead, College of Family Physicians of Canada

• Dr. Brian Geller, CCFP (EM), (ESS), Consultant

• Dr. Ryan Falk, CCFP (ESS), Consultant

Society of Rural Physicians of Canada’s National Advanced Skills and Training Program for Rural Practice

A Team Optimization Project to 1) support training and continuing professional development programs for practicing rural physicians to enhance their skills to meet identified rural community needs within local clinical teams, and 2) to conduct an evaluation and assessment of the project activities and deliverables, as proof of concept, with the goal to develop recommendations on indicators for system wide implementation for rural physician workforce strategies and for the sustainability of this project initiative to ensure continued support for rural physicians.

Location: National

Lead Organization: Society of Rural Physicians of Canada (SRPC)
Focus: Providing advanced skills and training for rural primary care physicians.

Project Team:

• Dr. Sarah Lesperance, President, SRPC

• Dr. Gavin Parker

• Dr. Brian Gellar

• Lisa Hetu

• Dr. Isabelle Cochrane

• Dr. Stuart Iglesias

• Dr. James Wiedrick

• Dr. Elaine Blau

• Dr. Sonja Poole

• Dr. Sivaruban (Ruban) Kanagaratnam

• Dr. Marcy Maracle

• Jen Barr, COO, SRPC

• Kristen Kluke, Coordinator, SRPC

• Daria Parsons, MSc, Project Manager