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Collaboration Across Interprofessional Teams to Foster Improvement 

Espanola & Area Family Health Team; Powassan & Area Family Health Team; City of Lakes Family Health Team; Great Northern Family Health Team; East End Family Health Team

Not every primary care team is created equal. Some are blessed with greater financial resources, some can access additional expertise or support through their academic or hospital affiliations, some are located in densely populated areas and can draw on the services of many other kinds of professionals as needed. Last – but not least – there are teams like the honorees for our eighth award, who know how to make the most of scarce resources and employ innovative thinking to improve patientcaregiver involvement.

These six teams in northeastern Ontario worked in partnership with the Public Health Department, the LHIN and the Stay on Your Feet Initiative to create an innovative approach to falls prevention. This was in response to an identified need -- data show that one in three seniors have a fall within one year. Their evidence-based, sustainable program can be easily adapted elsewhere; the teams are already busy recruiting new participants. It is a boon to their northeastern communities, where 22 per cent of the patient population is 65 and older.

This falls prevention program integrates a falls risk screen and assessment tool into the EMR and embeds links to community prevention and education resources, such as exercise classes. Providers can direct at-risk seniors to these programs, proactively working to keep them on their feet.

The screening effort continues to grow and develop. Patients use tablet-based technology to complete the falls prevention screening themselves, and their feedback, along with input from providers, has led to improvements to the process. An added bonus is that the program allowed the teams to incorporate falls prevention and screening without significantly affecting workload. They have already implemented this program in one EMR platform. The next phase of this project incorporates the functionality developed for falls prevention screening and intervention into other EMRs.

The program is an excellent example of collaboration and partnership, and it demonstrates the importance of looking beyond silos and communicating with other providers in order to provide comprehensive care to a rural, far-flung patient population.

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