Team Based Care
The Timmins Academic Family Health Team (TAFHT) is a multidisciplinary team consisting of 32 independent physicians supported by 31 TAFHT staff including nurse practitioners, registered nurses and registered practical nurses, dietitian, social workers, health promoter and administration staff. The physicians employ an additional 21 support staff for a total of 75 people attached to the organization.

The goal of the Timmins FHT is to keep Ontarians healthy, provide access to primary care, and reduce wait times. The team draws upon the expertise and knowledge amongst its members, working collaboratively - and with clearly defined roles - in a supportive, respectful and effective way that is in tune with the needs of individual patients and the practice population.

Patient Engagement
The Timmins FHT has many individual and group sessions to teach patients and their families how to promote good health, prevent disease, and manage chronic illnesses. There is a strong focus for our team to support self-management of care, improving how care is delivered and evaluating patient satisfaction with programs and level of service. At present 23,000 patients are rostered and receive care from the team. We have a wait list of 600 patients waiting for care and have taken on 1700 new patients in the past year. Timmins FHT is leading an effort to have one wait list for primary care for the City of Timmins.

Program Development
To strive towards the goals set by the Timmins FHT a community assessment was completed and has helped to develop clinical program priorities. Each program being developed starts with a multidisciplinary committee that will research best practice guidelines, program algorithms and care maps, available resources and possible partnerships within the community. The program is piloted and takes shape through the Model for Improvement and a process known as Plan-Do-Study-Act. The teams can also plan and monitor changes once a program is in place. This includes identifying the needs of the population it serves, measuring the impact of staff and programs, assessing the satisfaction and ideas for improvements of those using the services, and using these data to further improve performance.

Quality Improvement and Research
Currently the TFHT is involved in a learning collaborative which is providing our team with the skills necessary for quality improvement. This has helped our team find ways to improve care, by supporting the continuing appraisal of programs and services delivered as well as office practice efficiency.
Our team is involved with many research projects that have been proposed to our team by the Ministry of Health and Long Term Care (MOHLTC), Ontario Telemedicine Network (OTN) and Universities. Projects include;

1. Women’s College Hospital – Increasing access to chronic disease self-management in rural and remote communities using Ontario Telemedicine Network.
2. University of Toronto, Nursing Secretariat, MOHLTC – Demonstrate the value and effectiveness of Personal Digital Assistants in improving access to information resources across various health care sectors.
3. OTN & Canada Health Infoway Telehomecare – Create and test a Telehomecare model that can be applied to chronic disease management and can be transferred to other health care settings and conditions.
4. Queen’s University, Ontario Rehabilitation Research Advisory Board – To study why there are no rehabilitation professionals in FHTs and possible roles that rehabilitation professionals might play in the future.
5. Dept of Medicine, McMaster University – To study how FHTs are developing and what factors are related to different levels of teamwork.
6. MOHLTC, Ontario Psychiatric Outreach Programs (OPOP) and Centre for Rural and Northern Health Research – Inform OPOP about different mental health service delivery models and inform MOHLTC about the range and types of mental health services provided in smaller northern Ontario communities.
7. Northern Ontario School of Medicine – Use of GPS mapping and special analysis of patient travel distances to primary care providers required by patients to manage their diabetes.

Community Partnerships
Community partnerships optimize many of the programs and services FHTs provide by ensuring they work closely with local health and community service partners who offer complementary services. This collaboration promotes integration of services across organizations.

These partnerships are made possible through the various community committees/coalitions our team works with. The TFHT has a community advisory committee which allows community partners to provide roundtable updates and the opportunity to discuss areas of partnership.

In addition our team is involved with the ALC/Seniors Task Force, Alzheimer’s Society, Bayshore, Canadian Mental Health Association, Canadian Red Cross, Centre for Addiction and Mental Health,  CDSAB, Child and Family Services for Timmins and District, East End FHT, Jubilee Centre, Misiway Milopemahtesewin Community Health Centre, North East LHIN, North East CCAC, Porcupine Health Unit, Spruce Hill Lodge, Timmins & District Hospital and Timmins Breastfeeding Coalition.