2017 year in review mosaic refugee health clinicmosaicpcn.ca/mrhc chronicle/year in review...
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2017
Year in Review
Mosaic Refugee
Health Clinic
Last modified: 4/5/2018
Table of Contents
Numbers at a Glance ..................................................................................................................................... 4
Our Team .................................................................................................................................................. 4
New Patients and Current Panel Size ........................................................................................................ 6
Transition Program ................................................................................................................................... 6
Top Source Countries ................................................................................................................................ 7
Patient Demographics ............................................................................................................................... 7
Visit Volumes Trends by Day of Week ...................................................................................................... 8
MRHC Areas of Focus and Initiatives ............................................................................................................ 8
Billing ......................................................................................................................................................... 8
Booking Slip ............................................................................................................................................... 9
Calgary Health Trust Donation Account .................................................................................................... 9
Dental ...................................................................................................................................................... 10
External Specialists.................................................................................................................................. 11
Health Literacy ........................................................................................................................................ 11
Hepatitis B ............................................................................................................................................... 13
Influenza Campaign................................................................................................................................. 13
Intake Form Development ...................................................................................................................... 14
Internal Specialists .................................................................................................................................. 14
Immigration, Refugees and Citizenship Canada ..................................................................................... 15
LGBTQ2IA + ............................................................................................................................................. 16
Mental Health ......................................................................................................................................... 17
Mental Health - Youth ............................................................................................................................. 17
Optometry ............................................................................................................................................... 18
Panel Management ................................................................................................................................. 19
Patient’s Health Coverage ....................................................................................................................... 19
PSR Attachment Strategy ........................................................................................................................ 20
Prenatal ................................................................................................................................................... 21
Public Health Vaccinations ...................................................................................................................... 22
Quality Improvement Team .................................................................................................................... 24
Refugees with Disabilities ....................................................................................................................... 25
Refugee Youth Program .......................................................................................................................... 26
Research and QI Committee ................................................................................................................... 27
Transition Program ................................................................................................................................. 28
TB ............................................................................................................................................................ 29
Vicarious Traumatization and Vicarious Resilience ................................................................................ 30
Yazidis...................................................................................................................................................... 30
Multidisciplinary Team ................................................................................................................................ 31
Clinic Coordinator ................................................................................................................................... 31
Health Liaison .......................................................................................................................................... 32
Health Navigator ..................................................................................................................................... 32
Licensed Practical Nurses ........................................................................................................................ 33
Medical Office Assistants ........................................................................................................................ 33
Mental Health Therapist ......................................................................................................................... 34
Pharmacist .............................................................................................................................................. 34
Registered Dietitians ............................................................................................................................... 34
Registered Nurses ................................................................................................................................... 35
Social Workers ........................................................................................................................................ 35
Community Collaborations ......................................................................................................................... 35
Acknowledgements ..................................................................................................................................... 37
Numbers at a Glance
Our Team
The Mosaic Refugee Health Clinic team continues to grow each year. Our team in 2017 consisted of 17
family physicians, 11 specialists, 34 multidisciplinary, and administrative support staff and Mosaic PCN
leadership support.
17 Family Physicians Dr. Annalee Coakley Physician Lead, Mosaic Refugee Health Clinic
Dr. Michael Aucoin Physician Lead, Clinical Operations
Dr. Andrea Hull Physician Lead, Hep B Program
Dr. Giselle DeVetten Physician Lead, Prenatal Program
Dr. Rachel Talavlikar Physician Lead, MRHC Research & QI Committee
Dr. Jill Teschke Family Physician
Dr. Patricia Connick Family Physician
Dr. Jean Mateo Family Physician
Dr. Jazmin Marlinga Family Physician
Dr. Nureen Pirbhai Family Physician
Dr. Tania Lemay Family Physician
Dr. Liana Hwang Family Physician
Dr. Christine Gibson Member, Mosaic PCN Board of Directors
Dr. Sandra Allaire Family Physician
Dr. Mark Boyko Family Physician
Dr. Janelle Schneider Family Physician
Dr. Harshitha Gunawardena Family Physician
11 Specialists Dr. Pauline Ekwalanga Obstetrics-Gynecology
Dr. Alese Wagner Obstetrics-Gynecology
Dr. Stephen Vaughan Infectious Disease
Dr. Gabriel Fabreau General Internal Medicine Co-Chair, MRHC Research and QI Committee
Dr. Pin Li General Internal Medicine
Dr. Thiru Govender Pediatrics Member, Mosaic PCN Board of Directors
Dr. Natalie Forbes Pediatrics
Dr. Sangeeta Jain Pediatrics (maternity leave)
Dr. Tony Lo Psychiatry
Dr. Keith Courtney Psychiatry
Dr. Sam Lee Hepatology
34 Multidisciplinary and Administrative Support Staff Cheryl San Juan Primary Care Manager
Shayesta Noori Clinic Coordinator
Sarah Hamdan Medical Office Assistant
Ivonne Fajardo Medical Office Assistant Interim Transition & Community Coordinator
Rosi Grinan Medical Office Assistant Quality Improvement Specialist
Rabina Grewal Medical Office Assistant
Eric Norrie Medical Office Assistant Quality Improvement Specialist
Shazia Jat Medical Office Assistant
Katelyn Hewitt Medical Office Assistant (no longer with MRHC)
Tolue Isiekwenagbu Medical Office Assistant (no longer with MRHC)
Dashielle Gavin Medical Office Assistant (no longer with MRHC)
Nikki Tran Billing Clerk
Salimah Jetha Primary Care RN
Alda Garunia Primary Care RN
Mary Mather Primary Care RN (maternity leave)
Gagan Mattu Licensed Practical Nurse
Victor Liong Licensed Practical Nurse
Sarah Tessema Licensed Practical Nurse
Farah Aslamzada Licensed Practical Nurse
Ashley Amante Licensed Practical Nurse
Daren Bituin Licensed Practical Nurse
Princess Liong Licensed Practical Nurse
Nav Dhaliwal Licensed Practical Nurse
Atta Woldeselasie Health Liaison
Mia Baluyot Health Liaison (maternity leave)
Biniam Soquar Health Navigator
Christa Kahl Transition & Community Coordinator (leave)
Julia Condrea Social Worker
Jasprit Mangat Social Worker
Aida Haile Social Worker
Jassim Al-Mosawi Mental Health Therapist
Claire Izcovich Registered Dietitian
Karyn Tang Registered Dietitian, Pediatrics
Monica Veness Improvement Facilitator
Leadership Support Nicole Gleeson Executive Director, Mosaic Primary Care Network
Tannis Andersen Director of Clinical Operations
Peter Rymkiewicz Director of Evaluation and Measurement
Cindy Simpson Director of Operations
New Patients and Current Panel Size
In 2017, MRHC welcomed 1,016 new patients (see Figure 1). These new patients consisted mainly of
Government Assisted Refugees (GARs) and refugee claimants. In March of 2017, in an effort to improve
access in the clinic, the team implemented a strategy to connect all Privately Sponsored Refugees
(PSRs) with physician clinics in the community.
As of December 2017, the MRHC panel size, ie the number of active patient charts, was 4,337.
Figure 1. Number of new patients seen per month at MRHC, 2017.
Transition Program
The PSR Attachment Strategy began in March 2017. The low number of transitions in November was due
to staffing changes.
0
20
40
60
80
100
120
140
Jan Feb March April May June July Aug Sept Oct Nov Dec
Intakes vs. Transitions 2017
Intakes Transition
Top Source Countries MRHC continues to welcome refugees from around the globe. The top source countries in 2017 were:
Syria
Iraq
Eritrea
Ethiopia
Turkey
Congo
Sudan
Patient Demographics Figure 2 shows the age and gender distribution of patients seen at MRHC in 2017. We serve a very
young population.
Figure 2. Age and Gender Patient Distribution
Visit Volumes Trends by Day of Week
Figure 3. Visit Volume Trends by day of the week.
MRHC Areas of Focus and Initiatives
Billing Background Billing Clerk continues to pick up billing sheets from the clinic on a weekly
basis and processes billing sheets remotely
Completed billing sheets are reviewed by MOA to ensure that TM modifiers match the total number of hours that the physician/specialist has worked
Any billing sheet issues are dealt with primarily in-house and reconciled
Key Players Nikki Tran (Billing Clerk) Shayesta Noori (Clinic Coordinator) Ivonne Fajardo (MOA) Physicians and Specialists
Highlights in 2017 Health Liaison at Margaret Chisholm is set up with Medavie Blue Cross to bill for LPN appointments; restricted for patients who are living at MCRC
Challenges Setting up our psychologist, Jassim Al-Mosawi as a provider who can bill IFH
Next Steps Billing Clerk will develop resource sheet for new physicians on requirements for billing codes (diagnosis, fee code, modifier and time modifier)
Billing Clerk will develop resource sheet on WCB processes
Booking Slip Background Booking slip originally created in 2014 as an AIM initiative
In 2016, a working group was created to review and revise the booking slip
Goal: annual review of the booking slip
Key Players Sarah Hamdan (Lead) Rabina Grewal (MOA) Alda Garunia (MDT representative) Sarah Tessema (LPN) Dr. Mike Aucoin (Clinical Operations Lead)
Highlights in 2017 Booking slip working group met in December 2017
Additions and revisions discussed
Challenges Relevant sections of the booking slip were often left blank, including: Indication & Appointment type, Reason for MDT referral, Preferred Physician(s), Patient Coverage & Patient’s Preferred Appointment Days/Time
Verbal instructions given to check-out MOA instead of using the booking slip
Next Steps Recommendations LPNs
Will complete “Patient Coverage” and “Patient’s preferred appointment days/time” sections
Physicians
Indicate reason for referring to MDT
List 2 preferred physicians for follow up
Avoid verbal instructions during check-out
Use the slots at check-out rather than waiting for MOA to be done Specialists
Support visiting specialists to start using booking slip
Calgary Health Trust Donation Account Background In 2016, the Calgary Health Trust (CHT) conducted an audit and determined
that the process of transferring funds to Primary Care Networks (PCNs) was not CRA or AHS legally compliant.
A charitable organization can only gift or grant funds to another charitable organization. Both the CHT and Alberta Health Services (AHS) are charitable organizations and currently PCN’s are not. Mosaic PCN cannot have a direct relationship with the CHT until we become a charitable organization.
AHS and CHT closed the medication account originally set up and created three new accounts for refugee health. CHT contacted donors to ask how they wish to have their funds reallocated within the 3 new accounts.
AHS provides notification to MRHC of funds available one quarter in advance
Key Players Nicole Gleeson and Mosaic Board of Directors Dr. Annalee Coakley and MRHC physicians Cheryl San Juan (Primary Care Manager)
Jackie Liu (Pharmacist) Shayesta Noori (Clinic Coordinator) Atta Woldeselasie (Health Liaison) Wendy Yu (Finance Manager)
Highlights in 2017 June 2017: Mosaic PCN and AHS signed a Restricted Funding service agreement
CHT created 3 donation accounts for refugees served at MRHC: 1. Medications 2. Transportation 3. Greatest Needs
Through this agreement, AHS also included access to AHS Interpretation and Translation Services
Audit reports on how funds are used are maintained and submitted by the MRHC team to AHS on a quarterly basis (January, April, July, October)
Challenges Fundraising
Next Steps MRHC team to provide patient stories and examples of how refugees and their families benefitted from the funds in the CHT account, to assist the AHS grant writers as they prepare for fundraising activities.
Dental Background Vision: Educate and empower patients to become independent decision makers
to dental care decision making Goal: Make the dental referral process efficient, less resource-consuming, and provide clear communication to patients on how dental care works.
Key Players Rosi Grinan (MOA Lead)
Highlights in 2017 Patients are no longer automatically booked with a physician for dental concerns
Patients requesting dental treatment are given a handout with a list of dental clinics throughout the city who are set up to bill through the Interim Federal Health Program.
Patients are able to choose the dental clinic that best meets their needs (e.g. language line, location, specialty)
The MOA team has reduced the amount of patients scheduled with a physician for a dental referral
This has increased physician access
Beneficial change for patients who now see a dentist sooner, rather than going through a triangulation process that resulted in longer waiting times
Challenges Time-consuming for front desk staff to explain dental care to patients, team needs to define who will take over the orientation of oral health to patients.
Next Steps Short term goals: create a new handout for patients: how to book an appointment, types of coverage and what is/isn’t covered, and basic oral health care tips (e.g. teeth brushing, frequency of check-ups). Long-term goals: Define who will be providing orientation to patients about dental care. At MRHC (Health Navigator?) and at other agencies that send
patients to the MRHC for dental care (i.e. CCIS, Bow Valley College, Centre for Newcomers, etc.)
External Specialists Background Rabina Grewal continues to be the lead MOA overseeing the coordination of
care for all of our external specialist appointments. Patients are notified of external specialist appointments up to 4 months in advance and reminder calls are provided 1 week before the appointment. Goals:
Ensure patients are aware of appointment details (date/time/location)
Confirm patients have transportation and/or understand how to get to the external clinic
Ensure patient can bring an interpreter or will have access to interpretation services at external clinic
Ensure we have received the consult reports
Key Players Rabina Grewal (MOA) Sarah Hamdan (MOA)
Highlights in 2017 Created a standardized process to ensure all patients are aware of their appointments
Reduced amount of no shows
Completed over 3000 existing pending tests/consults. We no longer have a backlog of referrals with unknown status (ie was the appointment booked? Did the patient attend the appointment? Etc).
Created a secure, centralized system to monitor the status of referrals to prevent referrals from being lost to follow up
Mosaic Community Health Workers accompanied patients to their external specialist appointments from September to November 2017
Challenges Finding interpretation services for our patients with limited English proficiency
Next Steps Short-term goal: find resources we can access to assist our Kurmanji-speaking patients to their appointments
Long-term goals: Educate more staff members of external referrals process to ensure there will always be someone to follow up on pending referrals and to reduce chances of backlog in the future
Health Literacy Background Calgary Immigrant Women’s Association approached MRHC to collaborate on a
project to address the barriers faced by low educated second language (LESLLA) learners in accessing healthcare services and information. Vision:
1. Improve health literacy outcomes (knowledge, skills and confidence) of LESLLA learners and
2. Reduce barriers to accessing services in a refugee health clinic by low literate adult newcomers
Key Players Salimah Jetha (Lead) Cheryl San Juan (Primary Care Manager) CIWA (Monica Leung, Theresa Wall, Mara Hawkins, Eva Szasz-Redmond)
Highlights in 2017 Developed partnership with CIWA to develop a project to address health concerns in an ESL classroom
Dec 2017: Letter of intent submitted to and accepted by IRCC
Salimah met with AHS Diversity Liaisons to discuss their services/programs
Challenges Articulating clear objectives and deliverables
Finding a common communication platform to allow for CIWA and MRHC working group participants to communicate with each other when offsite
Finding a common lens and language both the Literacy Professionals and Health Care Professionals (HCP) can understand when discussing the project
Next Steps Feb 2018: CIWA to submit proposal to IRCC titled “Health Literacy Partnership: Improving Health Outcomes for Multi-barriered Immigrants and Refugees”
April 2018: Salimah to present project to MRHC Research and QI Committee
Develop Collaboration Agreement between MRHC and CIWA with the support of Mosaic’s Director of Operations and Privacy Officer
Activities of 2 year proposed project include:
Working with literacy learners and instructors to create tools and teaching aids that increase the knowledge, skills and confidence that learners have in relation to accessing health services
Working with the Refugee Health Clinic and health practitioners to increase their systems, tools, communication and approach to multi-barriered newcomers.
Conducting a Health Literacy audit of MRHC to ensure clinic is sensitive to needs of low literacy learners
Explore the possibility of having group classes at Refugee clinic that is tailored to patients with low health literacy
Patient Resources
Develop a database of patient-education resources that are: available in the patient’s first language and address low health literacy levels
Develop patient-resources that support Long-term goals:
Advocate to host a CME for healthcare providers on Health Literacy
Develop Resource Binder for healthcare providers
Hepatitis B Background Goals:
Ensure our Hepatitis B patients are aware of their diagnosis
Support patients to attend their routine Hepatitis B testing
Follow up with patients to ensure they have completed routine testing and results are reviewed by the physician
Key Players Dr. Andrea Hull Dr. Rachel Talavlikar Rabina Grewal (MOA lead) Dr. Sam Lee (Hepatologist)
Highlights in 2017 Improved the structured process to ensure Hep B patients are supported and not lost for follow up
All active and inactive Hepatitis B patients are added to an excel spreadsheet, which is updated daily by the MOA lead
Information monitored on the spreadsheet include: follow-up appointments, whether patients are due/overdue for follow-up testing, patients who are on treatment, their coverage type and the last time their chart has been reviewed by the hepatologist
Challenges Unable to contact patients for follow-up testing/treatment due to outdated demographic information
Patients who do not understand the importance of the routine follow up testing.
Next Steps Create a new internal process for newly diagnosed Hep B patients, which includes booking an appointment with an RN after patient has received new diagnosis from MRHC family physician. The RN will reinforce education about the diagnosis, treatment and follow-up testing schedule.
Influenza Campaign Background MRHC has participated and supported the Influenza Campaign annually
RNs are able to provide influenza shots to patients 6 months and older
LPNs are able to provide influenza shots to patients 5 years and older
Key Players Sara Evans (Mosaic PCN RN Lead) Salimah Jetha (MRHC Lead) Alda Garunia (RN) Gagan Mattu (LPN) Victor Liong (LPN) Sarah Tessema (LPN)
Highlights in 2017 All nurses completed the mandatory AHS influenza modules
MRHC once again supported the influenza campaign 2017-2018
Clinic able to provide onsite flu vaccinations to patients from 6mths and over
Challenges Limited ability to order large volumes of vaccines, during peak times when there are high numbers of new refugees staying at the resettlement house
Multiple cold chain breaks due to equipment failure and human error
Next Steps Document clear process for annual influenza campaign which includes appropriate documentation, reporting and ordering of vaccines/supplies
Limit number of cold chain breaks – MRHC nurses and MOA team will complete the AHS Cold Storage modules
Intake Form Development Background Identified need to create a standardized intake form
Intake form drafted by Dr. Fabreau and sent to the MRHC team for review and input
Key Players Dr. Gabriel Fabreau MRHC Family Physicians Rosi Grinan (QI Specialist) Eric Norrie (QI Specialist)
Highlights in 2017 Christa Kahl started beta testing the shorter version of the intake form during PSR attachment appointments
Rosi Grinan, in her temporary QI Specialist role, supported the beta testing of the long version of the intake form at MCRC with our Health Liaison
Rosi also solicited feedback about the intake form from the nurses, MOAs, Health Navigator and Transition & Community Coordinator
Challenges First trial of the intake form (long version) took place in December by our Health Liaison at MCRC. The process proved to be too time-consuming to complete.
Next Steps Quality Improvement Specialist will: observe current intake process by shadowing LPN team to understand how long it currently takes to complete the intake as well as the adherence to the current intake questions
Draft another iteration of the intake form, taking into consideration data that can already be extracted automatically and modifying the sequence of the questions
Internal Specialists Background The refugee clinic is able to truly provide wrap-around healthcare services
with visiting specialists coming to the clinic to support patients
Most specialists are at the clinic at least monthly
Clinic Coordinator liaises with specialists and their clinic staff regarding referrals and clinic dates
Clinic Coordinator works with the physicians, specialists and RN case managers to schedule new and follow up appointments for the internal specialists
Key Players Shayesta Noori (Clinic Coordinator) Salimah Jetha (RN case manager) Mary Mather (RN case manager, maternity leave) Alda Garunia (RN case manager) Dr. Thiru Govender (Pediatrics) Dr. Natalie Forbes (Pediatrics)
Dr. Sangeeta Jain (Pediatrics) Dr. Tony Lo (Psychiatry) Dr. Keith Courtney (Psychiatry) Dr. Gabriel Fabreau (General Internal Medicine) Dr. Pin Li (General Internal Medicine) Dr. Steve Vaughn (Infectious Disease) Dr. Pauline Ekwalanga (OB-Gyne) Dr. Alese Wagner (OB-Gyne) Dr. Sam Lee (Hepatology)
Highlights in 2017 Pediatrics: 226 appointments
OB/Gyne: 175 appointments
General Internal Medicine: 113 appointments
Psychiatry: 98 appointments
Infectious Disease: 21 appointments
Welcomed Dr. Pin Li back July 2017
Welcomed Dr. Keith Courtney to the team Nov 2017
Congratulations to Dr. Sangeeta Jain who had a baby boy in Dec 2017
Congratulations to Dr. Rita Watterson (Dr. Lo’s resident) who had a baby girl in Sept 2017
Salimah provided RN case management support to Dr. Fabreau and Dr. Li
Mary & Alda provided RN case management support to Dr. Ekwalanga
Developed a transition process for Dr Li’s patients who can now be seen at his Richmond Road clinic for ongoing support
Challenges Not having future clinic dates makes it challenging for staff to schedule follow up appointments
Finding an effective communication platform to use to relay confidential patient information from RN to Specialist when offsite
Next Steps Explore expanding the role of the RN case manager to support all specialists
Support specialists to start using booking slip so that team is aware of follow up care plan
Immigration, Refugees and Citizenship Canada Background Historically, Immigration, Refugees and Citizenship Canada (IRCC) has primarily
dealt with the resettlement and settlement sectors to coordinate the care of new refugee families arriving in Calgary
Key Players Nicole Gleeson (Executive Director) Laurie Blahitka (ED, AHS Community Health Services) Dr. Annalee Coakley (Physician Lead) Dr. Mike Aucoin (Clinical Operations Physician Lead) Dr. Gabriel Fabreau (General Internal Medicine) Tannis Andersen (Director of Clinical Operations) Cheryl San Juan (Primary Care Manager)
Highlights in 2017 IRCC and MRHC developed and strengthened a collaborative partnership
Both teams met multiple times throughout the year to better understand how best to support the Yazidi population
IRCC has expressed gratitude for the honest feedback and input the MRHC has provided regarding the existing challenges of caring for the Yazidis and other populations of refugees
March 2017: First meeting with John Biles (IRCC) and Nicole Gleeson, Dr. Coakley, Laurie Blahitka and Cheryl San Juan to discuss the background of the Yazidi refugees and discuss potential unique needs of this population
Aug 2017: Meeting with John Biles and Rhonda McIntosh (IRCC) and Nicole Gleeson, Laurie Blahitka (AHS) and Cheryl San Juan to discuss challenges of Yazidi population
Oct 2017: Meeting with John Biles (IRCC), Dr. Aucoin, Dr. Coakley, Dr. Fabreau and Cheryl San Juan to discuss Yazidi population
Dec 2017: IRCC team from Ontario visited MRHC and met with Dr. Coakley, Tannis Andersen and Cheryl San Juan to discuss Yazidi population
MRHC was invited by IRCC to attend the AAISA (Alberta Association of Immigrant Serving Agencies) Summit in month.
MRHC was invited to join the quarterly teleconference meetings with IRCC and Resettlement Assistance Programs providers
Challenges IRCC is not able to provide funds directly to MRHC as we are provincially funded
Next Steps MRHC team will continue to connect regularly with IRCC to advocate for increased social supports and interpretation services
LGBTQ2IA + Background Many refugees flee their home country due to persecution, violence and
discrimination based on their gender identity and/or sexual orientation. Being part of the LGBTQ+ community is still considered a crime in 73 countries and is punishable by death in 8 countries world-wide. Vision: MRHC to provide a safe, welcoming environment for all refugees who identify themselves as part of the LGBTQ+ community
Key Players All
Highlights in 2017 May 2017: MRHC staff received a half-day education with Calgary Sexual Health
Challenges Original plan to have a follow-up education day in fall 2017 for the staff and interested physicians. This plan has been delayed as staff support for vicarious trauma, compassion fatigue and burnout took higher priority this year.
Next Steps IRCC has invited Cheryl San Juan to be part of an LGBTQ2IA advisory committee for an upcoming national conference hosted by Centre for Newcomers.
Mental Health Background MRHC continues to offer mental health support in-house to all refugees
ready to access this resource.
Key Players Dr. Annalee Coakley (MRHC physician lead) Jassim Al-Mosawi (Mental Health Therapist) Alda Garunia (RN) Dr. Tony Lo (Psychiatrist) Dr. Keith Courtney (Psychiatrist) Cheryl San Juan (Primary Care Manager) Access Mental Health
Highlights in 2017 Mental Health Therapist (0.4 FTE): 278 direct patient appointments and 99 indirect appointments
Psychiatry: 98 patient appointments
Alda Garunia (RN) supported patients through intake process with Access Mental Health
Challenges Yazidi women expressed not wanting to see a male therapist, which is challenging for MRHC who has 1 male psychologist and 2 male psychiatrists
Having a clear understanding of the mental health resources that our patients are accessing outside of MRHC (for example, Centre for Refugee Resilience, through the school system etc.)
Next Steps Working group will start to meet in 2018: Alda Garunia (RN), Dr. Nureen Pirbhai, Julia Condrea (SW) and Jassim Al-Mosawi (MHT)
Trial of art therapy sessions with Mosaic mental health practicum student in March 2018
Mental Health - Youth Background Dr. Govender set up collaboration meetings with the AHS Alberta Children’s
Hospital psychiatry unit to start discussions on how best to care for the Yazidi refugee youth
Many of the Yazidi youth have presented with problems related to their trauma, including behavioural issues, such as aggressive and sometimes violent behaviour towards peers at school, sleeping difficulties, and enuresis.
MRHC consulted Dr. Wilkes, the Division Head of Child Psychiatry at AHS, regarding best practices for the management of children who have suffered significant trauma. Dr. Wilkes reports that the best mental health intervention for children is recreation and play. Therefore, these children would benefit greatly from engaging in recreational activities.
Key Players Dr. Thiru Govender (MRHC pediatrician) Dr. Annalee Coakley (MRHC physician lead) Cheryl San Juan (Primary Care Manager) Tannis Andersen (Director of Clinical Operations) Jassim Al-Mosawi (Mental Health Therapist) Alda Garunia (RN) Shayesta Noori (Clinic Coordinator) Dr. Chris Wilkes (Division Head of Child Psychiatry, AHS) Linda Anderson (Manager, AB Children’s Hospital)
Margaret Styczynska (CCIS) Fatima Mansouri (Health & Wellness Lead, CCIS) Jill Edgington (Centre for Refugee Resilience, formerly Survivors of Torture) Sarah Wong (Centre for Refugee Resilience, formerly Ethos)
Highlights in 2017 June 2017: first collaboration meeting with AHS AB Children’s Hospital, CCIS and MRHC (Dr. Govender, Jassim Al-Mosawi, Cheryl San Juan)
Quarterly mental health collaboration meetings in July & Oct 2017
Aug 2017: initial meeting with COPE (Community Outreach of Pediatrics and Psychiatry in Education) and MRHC (Dr. Govender, Dr. Coakley & Cheryl San Juan)
Oct 2017: Collaboration meeting with COPE, Calgary Board of Education, Calgary Catholic School District, Calgary Bridge Foundation for Youth and Ethos (now Centre for Refugee Resilience). MRHC team members: Dr. Coakley, Dr. Govender, Tannis Andersen and Cheryl San Juan
Proposal submitted by the Centre for Refugee Resilience to IRCC for funding for 3 case managers (with a social worker background) to support the care coordination of Yazidi youth. Tannis Andersen assisted with the development of the proposal as well as provided a letter of support.
Challenges Many mental health resources exist city-wide. The challenge lies in knowing which resources families are accessing. This requires clear communication between multiple organizations to reduce a duplication of services, reduce overwhelming families with too many appointments and ensure that families are seen by the right providers at the right time.
Next Steps Continue to have quarterly collaboration meetings with AHS, CCIS, Centre for Newcomers, CBFY.
Next collaboration meeting scheduled for May 2018. Will invited CBE & CCSD to join the meeting.
Optometry Background Health Navigator assists patients with optometry appointments.
Patients who have coverage (IFH, Alberta works, Alberta Health Benefit, employment benefit, etc.) are booked with an optometrist for a full eye exam
If patients have no coverage, they are booked for an “eye health checkup” which is covered if the patient has an Alberta health Card.
Physicians or LPNs initiate referral mainly during Intake or Post Intake appointments. Patients also approach Biniam directly for support.
Health Navigator processes the referrals and books appointments mainly at Marlborough Mall Optometry Centre and Dr. Bishop’s office
If it is more convenient for the patient, the appointment is booked with another optometrist closer to the patient’s home.
Key Players Biniam (Health Navigator) MRHC Family Physicians LPNs
Highlights in 2017 Approximately 500 clients were booked with optometrist (the list of clients booked in 2017 is incomplete)
Challenges Finding interpreters to accompany patients to optometry appointments continues to be a challenge
Biniam periodically provides interpretation support at the optometry appointment.
Many patients continue to have navigation challenges and are unable to find the optometry clinics, even after meeting with or speaking to our Health Navigator.
Next Steps Review the current internal referral and scheduling system for optometry and explore ways to improve the current processes
Panel Management Background MRHC last underwent a major panel clean up in 2015, supported at the time
by Eric Norrie (MOA) and Syed Mehdi (PS Specialist, Business Analyst).
Identified need to clean up the MRHC panel once again. Current panel as of December 2017, ie the number of active charts: 4337
Key Players Monica Veness (Improvement Facilitator) Syed Mehdi (Business Analyst) Christa Kahl (Transition & Community Coordinator) Nadia Gashar (PCC Educator) Cheryl San Juan (Primary Care Manager) Dr. Annalee Coakley (MRHC Physician Lead) Dr. Mike Aucoin (MRHC Clinical Operations Physician Lead)
Highlights in 2017 Monica, Syed and Nadia supported the development of a Paneling Project plan, including what to do with patient charts for patients who:
1. Have not been seen in clinic for more than 2 years (Inactive Patient List) 2. Had an intake more than 2 years ago and are still visiting MRHC
(Transition Patient List) 3. Had an intake within the last 2 years (Active Patient List)
Challenges Finding the MOA resources to support this project to move forward.
Next Steps Rabina (MOA) will lead the panel clean-up process and will attend the Towards Optimized Practice (TOP) Panel education day January 2018.
Patient’s Health Coverage Background In April 2016, the federal government reinstated full coverage for all refugees
via the Interim Federal Health (IFH) program.
Vision: To educate and empower our patients with the knowledge of existing
national and provincial healthcare coverage options
Goal: To support patients prior to the expiration of the one-year IFH support
Key Players Ivonne Fajardo (Lead, Interim Health Navigator)
SW
LPN
RN
Highlights in 2017 IFH Coverage Support initiative began in July of 2017
Goals of the initiative: To identify when new refugee patients reach the 9-
month mark since arrival and initiate supporting patient to explore other
health coverage options before IFH expires. Additionally, the MRHC team
can encourage GARs to meet with their CCIS counselor for the same
support.
IFH coverage process working well. LPNs identify which patients are at the
9-month mark during their morning huddle report and communicate this
information to the Health Navigator. Health Navigator then does a triage to
determine if patient should be booked in for an appointment.
Challenges This process works well for patients who are booked for an appointment at
the clinic as the LPNs are able to identify if they are at the 9-month mark.
The challenge lies in identifying patients who are not booked for an
appointment at the clinic
Next Steps IFH working group to meet again in 2018 to discuss successes and concerns and explore how to identify and support all new patients with their health coverage needs.
PSR Attachment Strategy Background From Dec 2015 to March 2016 (height of Syrian influx), all Privately
Sponsored Refugees (PSRs) were booked to meet with the Transition Coordinator for immediate attachment to a community physician. The clinic welcomed over 1,700 new patients in 2016.
In the first quarter of 2017, the clinic experienced challenges with access. A decision was made to re-implement the PSR attachment strategy, and modify the criteria for accepting PSRs into the patient panel.
A Triage system was created
PSRs still accepted into care at MRHC: Patients with complex medical concerns Prenatal patients Refugees with disabilities
Key Players Dr. Annalee Coakley (MRHC physician lead) Christa Kahl (Transition & Community Coordinator) Shayesta Noori (Clinic Coordinator) Rabina Grewal (MOA) Sarah Hamdan (MOA) Rosi Grinan (MOA) Ivonne Fajardo (interim Health Navigator; interim Transition Coordinator) Biniam Soquar (Health Navigator) Cheryl San Juan (Primary Care Manager)
Highlights in 2017 Since March 2017, PSRs have been booked with the Transition & Community Coordinator or Health Navigator for immediate attachment to community physician
Dr. Coakley drafted a letter to be sent to accepting family physicians with an open invitation to call our clinic or the physician hotline (Shayesta’s phone number) with questions about refugee health
A package is given to the accepting physician, including: Letter from MRHC physician lead Requisitions for recommended screening tests for new refugees
Creation of a new appointment type called “Attachment appointment” added to EMR in July 2017
Challenges Many internal challenges experienced by the team during the first couple of months of implementation related to workflow process and which PSRs to accept
PSRs no-show for Attachment appointment
PSRs already attached to MRHC: their newly arrived family members also want to be MRHC patients and is challenging to explain why they are instead being connected to a physician in the community
MRHC team concerned that PSRs in the community are not being supported to connect with public health, optometry, dental etc.
Next Steps Continue on with PSR attachment strategy
Try to support opportunistic PSR attachment appointments.
Cheryl San Juan to attend Calgary Zone Attachment and transition meeting (working group is comprised of PCN EDs, PCN medical directors etc) to discuss how best to support community physicians who are welcoming refugees into their practice.
Prenatal Background Vision: to standardize Prenatal Care at MRHC to promote continuity of care
and to provide the best support possible to refugee prenatal patients.
Since 2016, there has been a tangible improvement in prenatal care.Patients are seeing MD on a regular basis, and are getting the screening tests (imaging, blood work) done in a timely manner.
Dr. DeVetten has identified the resources available for refugee prenatal patients in the community, and developed relationships with different agencies.
Key Players Dr. Giselle DeVetten (Physician Lead) Dr. Andrea Hull Dr. Patricia Connick Dr. Rachel Talavlikar Rosi Grinan (MOA) Salimah Jetha (RN) Mary Alda Garunia (RN) Shayesta Noori (Clinic Coordinator) Aida Haile (SW) Lauren Wigham (Physician Assistant) Chelsea Cleary (Physician Assistant)
Highlights in 2017 Total # of prenatal appointments: 554
107 unique prenatal patients
74 newborns
New partnerships and collaborations with different agencies throughout Calgary (i.e., Children’s Cottage, Inn from the Cold, CIWA, Red Community Midwives, Best Beginning); and with other hospitals that historically did not accept Refugee Claimants.
All prenatal patients are receiving two perinatal education sessions with a Physician Assistant
All prenatal patients are being assessed by a Social Worker, and they also receive an orientation on resources available for them to help during pregnancy/postpartum.
Salimah (RN) continued to provide case management to low risk prenatal and complex prenatal patients
Mary (RN, now on maternity leave) and Alda (RN) provided case management to prenatal patients referred to OB/Gyne
Assist with Assist with transition and transfer of care of prenatals to ensure continuity of care
Challenges There are many challenges that have been identified for refugee prenatal patients, such as differences in language and sociocultural background, lack of transportation to health care centers, refusal of treatment or decision of leaving health problems unaddressed, lack of information about or awareness of the services, and difficulties navigating the health care system.
Mainstream care management of prenatal patients to minimize duplication of care/roles
Addressing ongoing barriers that prenatal patients face
Coverage issues
Next Steps Finalize protocol to refer patients’ children to Children’s Cottage
Finalize protocol to communicate with Inn from the Cold still on draft
Social Worker Aida to create a hand out for patients with the following elements: organization, contact (address, phone number, hours), supplies available, and others.
Prenatal Calendar (yellow hand out for patients) to be revamped
Handouts with information on perinatal care to be created (first draft presented by Dr. DeVetten and Physician Assistant, proposal to modify in accordance to patients’ literacy by RN Salimah). Handouts will be translated to 5 main languages spoken by MRHC’s patients.
Update Prenatal Binder for physicians
MOA Rosi working on Prenatal Standardized Operational Procedure, which will be part of the MRHC Clinical Operations Binder
Develop a Prenatal Record in the MRHC EMR that can capture data and extract it for research purposes
Define roles and responsibilities
Public Health Vaccinations Background In September 2015, Alberta Health Services (AHS) and the Mosaic Refugee
Health Clinic (MRHC) signed a Service Agreement with the initial term ending on August 31st, 2017
AHS offers vaccination appointments on Friday at MRHC and Thursday evening at their Village Square location. MRHC staff schedule appointments for Non-Syrian, Non-School Age children at both locations.
Syrian refugees are connected to the Community Health Centre (CHC) closest to their home.
MRHC Goals:
• Improve vaccination rates for newly arrived refugees attached to MRHC • Meet the demand of the increasing numbers of newly arrived refugees • Ensure equitable access to vaccination services for all • Provide patient education about the importance of getting vaccinations • Provide patient orientation to Community Health Centres (CHC) • Empower refugee patients to become independent navigators of the
Canadian health care system
Key Players Biniam Soquar (Health Navigator) Dr. Mike Aucoin (Clinical Operations Physician Lead) Cheryl San Juan (Primary Care Manager) Ivonne Fajardo (MOA, Interim Health Navigator) Gagan Mattu (LPN) Mary McIntyre (AHS Area Manager, Village Square & ECHC Public Health) Susan Chidoo (AHS Public Health RN, Vaccine Coordinator) Joanne Coldham (AHS Program Manager, Public Health, Calgary Zone)
Highlights in 2017 MRHC and AHS Public Health re-signed the collaboration agreement for a 2-year term.
Proposal submitted by MRHC to make amendments to current process:
- Adopt similar process as with Syrian refugees and connect all new refugees to the Community Health Center (CHC) closest to their home
- Proposed to have AHS RNs see refugee patients at CHCs rather than just at MRHC or Village Square
Public Health’s concerns with the proposal: - 75% no show rate for Syrian group - Current model is AHS “protected time” for outreach - RNs do half day prep for refugees, other AHS RNs do not have this
capacity
- Extensive wait times if we put refugees into the mainstream model - AHS RNs who work at MRHC & VS are familiar with refugee health,
other AHS RNs will not be
- Refugee appointments are booked for longer time
Oct 2017: Meeting with Public Health team and MOH Dr. Judy MacDonald
- AHS focused on no-show rates at MRHC & VS locations - Jan – Oct 2017: no-show rates improved from 30% to 16% - AHS expressed their challenges with refugees seen at CHCs, including:
patients unable to attend appointments due to work etc.; patients unsure of how to get to CHC; patients are unsure of why they are there
- AHS Public Health proposed the following: 1. MRHC physicians to complete referral form for each new patient 2. AHS created document: Recommended criteria for referring clients
- MRHC response: 1. Logistical challenge of completing referrals for each new patient 2. MRHC raised concern that current criteria proposed by AHS actually encompasses a large number of our patients (Clients of child-bearing age; Clients with no immunization history – most adults etc)
New internal process started Sept 2017
Goal: to connect all of our new patients with the AHS Public Health Vaccinations team (focus first on non-Syrian, non-school age patients) • LPN identifies on booking slip if patient should be booked with PH • Check-out MOA books appointment • Health Navigator started doing a weekly and monthly audit to ensure
that all new patients are booked with public health
Challenges Patient confusion (first vaccination appointment is booked at MRHC and subsequent appointments are booked at the CHC closest to the patient’s home)
Patient Accessibility
Limited Space at MRHC
No follow up process for no shows
Low vaccination rates
Next Steps AHS Vaccine Referral Letter • AHS RN to fax letter to MRHC requesting more patient information as
needed • 3 month trial: Jan to March 2018 • MOAs will track: volume & turnaround time • Dr. Aucoin will be main physician trialing new letter
Quality Improvement Team Background MRHC participated in the AIM collaborative in 2014
MRHC once again participated in the AIM collaborative that started in Nov 2016
When the official AIM collaborative ended, the MRHC team members decided to continue with the momentum of discussing QI initiatives and formally changed the name to the A-team (Access, Analysis, Awesome)
Key Players Monica Veness (Mosaic PCN Improvement Facilitator) Cheryl San Juan (Manager) Christa Kahl (Transition & Community Coordinator) Ivonne Fajardo (MOA, interim Transition & Community Coordinator) Biniam Soquar (Health Navigator) Salimah Jetha (RN) Rosi Grinan (MOA, Quality Improvement Specialist) Eric Norrie (MOA, Quality Improvement Specialist)
Highlights in 2017 November 2017 – March 2018: Temporary QI specialist positions (Rosi Grinan 0.6 FTE & Eric Norrie 0.4 FTE)
QI team meets every Thursday morning 830-930
Monica Veness supports the team with: creating agendas, chairing meetings, drafting minutes and sharing tools and best practices related to QI initiatives.
Started mapping Intake and Transition processes
Training on Quality Improvement
Challenges Having too many concurrent QI initiatives
MRHC team experiencing change fatigue
Next Steps Goals:
Establish a Continuous Quality Improvement System
To outline the Standard Operating Procedures (SOP) for MRHC’s clinical operations, and establish a Continuous Quality Improvement System
Develop a Clinical Operational Manual (COM)
Long term goal is to outline every single process at the MRHC, from registration of new patients to their transition to the community
Future QI initiatives include:
Focusing on no-shows and TNA for physician appointments
Decreasing TNA for RDs
Focusing on TNA and scheduling and referral process for specialists
Conducting a Workload Team Analysis
Addressing walk-ins
Focusing on work interruptions (which applies to everyone on the team)
Developing a system to control the distribution of documents to ensure that all staff has access to latest revised and authorized version of documents.
Finalize the development and implementation of a standardized Intake Form
Complete Prenatal Procedures (prenatal calendar, prenatal record, and other forms related to prenatal care)
Determine ideal MD panel size
Establish best way to provide patients with Educational/Orientation sessions on how to navigate the healthcare system, and determine who would be the best person to do it and when
Refugees with Disabilities Background MRHC has seen an increase in the number of refugees with disabilities arriving
in Calgary
Key Players Shayesta Noori (Clinic Coordinator) Dr. Annalee Coakley (MRHC physician lead) Christa Kahl (Transition & Community Coordinator) Julia Condrea (Social Worker) Jasprit Mangat (Social Worker) Claire Izcovich (Registered Dietitian) Kara Irwin (Psychologist at East Calgary Family Care Clinic) Cheryl San Juan (Primary Care Manager)
Highlights in 2017 Christa Kahl met with organizations supporting individuals with disabilities, including: Persons with Developmental Disabilities (PDD) and Family Support for Children with Disabilities (FSCD)
Christa developed a care pathway “Refugees with Disabilities” as well as an information sheet outlining available resources for refugees with disabilities
March 2017: Minister Kent Hehr had a meeting at MRHC with Dr. Coakley, Nicole Gleeson, Christa Kahl, Julia Condrea and Cheryl San Juan to learn more about the challenges faced by our patients with disabilities
June 2017: collaboration meeting with MRHC and AHS Neuromotor Clinic
Shayesta Noori liaises with CCIS team and AHS Neuromotor Clinic to coordinate the care for refugees with disabilities
Shayesta Noori and Claire Izcovich met with AHS dietitian team to discuss how to streamline the care provided for mutual patients
Shayesta worked with Jackie Liu to procure 2 loaner wheelchairs for MRHC. These loaner wheelchairs are given to patients until they are fitted and given their permanent wheelchairs.
Social Work team collaborated with FSCD team. FSCD worker and MRHC SW now do joint intake appointments with the patients at MRHC. MRHC SW serves as a patient advocate during these appointments.
Kara Irwin from the East Calgary Health Centre started performing IQ tests for our patients at a reduced cost, in order to support their eligibility for PDD funding
Dec 2017: Cheryl San Juan was asked to join Project IDEA steering committee – a collaboration between CIWA, Between Friends, Pace Kids and MRHC. Vision: to support parents and families of newcomers with disabilities through in-class and on-line modules.
Challenges Access Calgary unable to provide transportation to patients under 5
Refugees with disabilities and their families are overwhelmed with the number of medical appointments
Next Steps Continue our collaborative work with community partners to support refugees with disabilities
Refugee Youth Program Background Vision: Support refugee youth and adolescents to be more connected to
their peers in community, have the tools and skills to be more confident in their new home, empowering them to be more independent and to use their new found knowledge to support and educate older relatives alike
Goals:
To provide internal and external supports for our Refugee youth, with a large focus on the Yazidi population.
To connect with existing external youth-serving agencies to create collaboration opportunities
Key Players Alda Garunia (RN)
Ivonne Fajardo (interim Transition & Community Coordinator)
Highlights in 2017 Refugee Youth Program created in November 2017
Alda and Ivonne started to meet with youth-serving organizations such as: Calgary Bridge Foundation for Youth, Aspen Family Service, Boys & Girls, Centre for Refugee Resilience, Calgary Immigrant Women’s Association and Centre for Newcomers
Challenges New process and changes still needs to formalized and trialed
Next Steps Continue to meet with other youth-serving organizations
Create a resource list of available youth recreation programs
Create a process flowsheet regarding this program
Research and QI Committee Background Vision:
The Mosaic Refugee Health Clinic Research Governance Committee will assume responsibility for the stewardship and coordination of research projects involving the Mosaic Refugee Clinic patient population and patient data contained within the Mosaic PCN electronic medical records (EMR).
The committee will provide guidance, expertise, recommendations and approval of research projects specific to the MRHC patient population with accountability to the PCN Master Custodian. The committee will provide a platform to facilitate collaboration between research partners to identify researchers participating in projects with the same patient population. The committee will ensure that all projects undertaken will be in the best interest of and benefit to our patient population with the result of improving and advocating for the promotion of excellence in the care they receive.
Key Players Dr. Rachel Talavlikar (Committee Co-Chair) Dr. Gabriel Fabreau (Committee Co-Chair) Dr. Annalee Coakley Dr. Mike Aucoin Dr. Andrea Hull Dr. Giselle DeVetten Dr. Jazmin Marlinga Peter Rymkiewicz (Director of Measurement and Evaluation) Sonia Stortini (Privacy Officer) Dr. Helgi Eyford (Ethics Consultant) Cheryl San Juan (Primary Care Manager) Eric Norrie (QI Specialist) Rosi Grinan (QI Specialist) Garielle Brown (Research Associate, O’Brien Institute of Public Health)
Highlights in 2017 March 2017: First committee meeting with Dr. Talavlikar, Dr. Coakley, Dr. DeVetten, Dr. Aucoin, Dr. Fabreau, Dr. Turin Chowdry and Cheryl San Juan
June 2017: meeting with Dr. Talavlikar, Dr. Coakley, Dr. Aucoin, Dr. Marlinga, Peter Rymkiewicz & Cheryl San Juan. Discussed: updates from the North American Refugee Health Conference; Data extraction from EMR; Intake process for new projects; Data custodianship, TOR, MPCN Research Handbook; Cervical Cancer project led by Dr. Talavlikar and resident Molly Whalen Brown
Oct 2017: meeting with Dr. Talavlikar, Dr. Fabreau, Dr. Coakley, Dr. Hull, Dr. Aucoin, Dr. Marlinga, Peter Rymkiewicz, Cheryl San Juan, Eric Norrie, Garielle Brown & James Sakeah. Discussed: TOR, Custodianship/Data use, Application and Approval process, Information Management agreement, Data Sharing agreement, Management of learners, Project tracking system
Nov 2017: meeting with Dr. Talavlikar, Dr. Fabreau, Peter Rymkiewicz, Dr. Marlinga, Garielle Brown, Cheryl San Juan & Rosi Grinan. 2 projects reviewed: Dr. Aghajafari’s proposal to study refugee children and their integration to the education system; Dr. Fabreau presented the proposal for his work establishing a national collaborative data set.
Dec 2017: meeting with Dr. Talavlikar, Dr. Fabreau, Dr. Coakley, Dr. Hull, Dr. Aucoin, Dr. Marlinga, Cheryl San Juan, Garielle Brown, Rosi Grinan, Helgi Eyford. Reviewed 2 projects: TB Services QI initiative with Rachel Lim and the Cervical Cancer research project led by Dr. Talavlikar,
Development of the Terms of Reference
Development of the flowsheet outlining the committee’s role in approving research and QI projects, and the role of Mosaic PCN in this process
Creation of a spreadsheet to track all current research projects, which is updated and saved in the committee’s Drop Box
Challenges Role clarification
Governance structure
Defining which QI initiatives need to be reviewed by the committee (ie internal vs external projects)
Next Steps Development and trial of the decision matrix tool, which will be added in to the application forms so that individuals are aware of the grading system
Finalize Terms of Reference
Create an email for the committee, after developing parameters for its use
Increase the frequency of the meetings, with the goal to have one proposal presented and one discussion about the previous month’s proposal at each meeting
Invite a patient representative to join the committee
Transition Program Background Refugees often have complex health and social welfare needs and may struggle
to access coordinated primary health care services in the Canadian community. Currently, Canada does not have a consistent standardized approach to assist in the transition from a primary health care resettlement program to a community medical home for permanent resettled refugees. The Mosaic Refugee Health Clinic (MRHC) responded to this need by developing a process to address the gaps associated with transitioning to mainstream primary health care. The formal Transition Program at MRHC was developed in 2015.
Key Players Christa Kahl (Transition & Community Coordinator) Ivonne Fajardo (Interim Transition & Community Coordinator) Cheryl San Juan (Primary Care Manager) Dr. Mike Aucoin (Clinical Operations Physician Lead)
Highlights in 2017 June 2017: Presentation on the MRHC Transition Program at the North American Refugee Health Conference in Toronto by Christa Kahl & Cheryl San Juan
After consultation with Mosaic PCN’s Privacy Officer, it was determined that obtaining verbal consent is sufficient to send medical records to new family physician. This had a positive impact for our patients and the internal workflow process as patients no longer had to come to the clinic to sign consent forms. The Transition & Community Coordinator is now able to obtain verbal consent over the phone, reducing the barriers and travel time required for patients to come to the clinic.
Allied Health Transition (AHT) Document
• Created by working group: Transition Coordinator, SW, RNs, MDs • Trial started Sept 2017 • 3-month review: Dec 2017 – minor changes discussed
Goals of the AHT doc: • To provide a summary of care provided at MRHC for patients who are
transitioning out of MRHC • To have one document where multiple care providers can chart pertinent
information related to past and current care plans and any ongoing issues
• To ensure continuity of care as this document will serve as the cover letter of the medical record that our Transition Coordinator will forward to the new accepting family physician
Physician chart review
• Purpose of the MD chart review: to ensure safety and continuity of care, the physicians will review the patient’s chart for any current and outstanding issues
• Physicians will determine if the patient is medically safe to transition out of MRHC
• Any pending/ongoing medical issues that need follow up will be communicated to the new accepting physician
The Transition Chart Review (TCR) string has been created in PS – physicians have access to this string and may review charts when there is down-time due to no-shows, cancellations etc.
Challenges Implementation of AHT document and physician chart review process was initially challenging
Ivonne Fajardo took on the role of interim TCC with no formal training.
Next Steps Continue working on process to ensure that patients are transitioned at the appropriate time
Implement enhanced EMR functionalities to support the Transition Program. For example: a Reminder prompt that will show up at the 18 month mark and again at the 24 month mark. “Patient is ready for transition” (18 months) “Patient is due for transition” (24 months)
TB Background In 2016, due to a shortage of resources, the TB Clinic had to pull their
outreach RN support and they were no longer able to go to MCRC to do TSTs on all eligible GARs.
In 2016, the provincial TB program started to do a cost-benefit analysis of QFT vs TST.
Key Players Holly Gardiner (TB Clinic RN, Community Liaison ) Mica Shaw (Manager, TB Clinic) Atta Woldeselasie (Health Liaison) Gagan Mattu (LPN) Victor Liong (LPN) Sarah Tessema (LPN) Cheryl San Juan (Primary Care Manager)
Highlights in 2017 TB Clinic re-instated RN support to do outreach work at Margaret Chisholm
TB Clinic RN and Mosaic’s Health Liaison collaborated to provide mass TST screening for all GARs at MCRC.
June 2017: TB Clinic staff provided in-service for MRHC Health Liaison and manager
Dec 2017: Dr. Coakley and Cheryl San Juan met with Dr. Rachel Lim (Pulmonary Fellow) and Mica Shaw (TB Clinic Manager) to discuss trialing straight to QFT initiative. Currently, only 2 sites in Calgary draw QFTs. MRHC would be a pilot site. Plan is to have LPNs draw QFT during intake bloodwork.
Challenges Time consuming for Health Liaison to do TSTs at MCRC
Challenge at MRHC: having patients return 48 hours later for TST reading
Next Steps Straight to QFT initiative
Training of LPNs to draw QFT required
Vicarious Traumatization and Vicarious Resilience Background The MRHC team experienced challenges with vicarious traumatization,
compassion fatigue and burnout.
Identified need to support the MRHC team and teach self-care techniques.
Key Players Nicole Gleeson (Executive Director) Dr. Oliver David (Mosaic PCN Medical Director) Tannis Andersen (Director of Clinical Operations) Cheryl San Juan (Primary Care Manager) Amanda Berjian (Manager, Mental Health and Social Work Team) Rachel Clare (Supervisor, Community Health Worker Program and trained facilitator with Crisis and Trauma Resource Institute)
Highlights in 2017 Nov 2017: first session for MRHC staff facilitated by Rachel Clare
Nov 2017: first session for MRHC physicians facilitated Rachel Clare
Dec 2017: second session for MRHC staff and physicians facilitated by Rachel Clare and Kara Irwin
Challenges Applying learnings from the sessions and putting it into practicing
Next Steps Continue to support team wellness with follow up sessions with Rachel and Kara.
Build regular debrief sessions within the schedule.
Yazidis Background Yazidis are an ethnic and religious minority from Northern Iraq and Syria
In August 2014, Yazidi in Iraq’s Sinjar province were targeted, executed and captured by ISIS
~400,000 Yazidi displaced from Iraq and the UN has called ISIS actions a genocide
Canada committed to resettle 1200 Yazidi through a program called the Survivors of Da’esh
Key Players All
Highlights in 2017 Calgary is one of four Canadian centers to resettle Survivors of Da’esh (London, ON; Toronto, ON; Winnipeg, MB; Calgary, AB)
~150 Yazidis have arrived since Feb 2017
70 are children
Yazidis originally destined for Lethbridge, AB requested to transfer to Calgary upon arrival
MRHC team pre-books Kurmanji interpreters via Language Line
Most Yazidis are supported to attend external medical appointments by either the CCIS support worker or the CIWA settlement worker
Challenges Mental health support
Language support
Family reunification
Group is being primarily resettled in the SW and NW quadrants, making travel to the clinic challenging
Vicarious traumatization amongst healthcare team
Next Steps Continue to work with IRCC and community partners to best support the Yazidi refugees
Continue to support MRHC staff and physicians with education on self-care and opportunities to debrief to prevent burnout
Multidisciplinary Team
Clinic Coordinator Background The Clinic Coordinator supports daily operations in endless ways:
Coordinates with the Health Liaison and CCIS staff at MCRC about patient concerns and health appointments.
The Clinic Coordinator supports the physicians, MOAs, MDT and visiting specialists and students.
The Clinic Coordinator also triages all of the PS messages and delegates amongst the MOA team.
The Clinic Coordinator chairs MOA meetings and supports the daily work of the MOA team.
The Clinic Coordinator is the MRHC Fire Warden and OH&S representative.
Key Players Shayesta Noori – 1.0 FTE
Highlights in 2017 Working with Mosaic’s Finance team to understand existing gaps and streamline processes
Development of an auditing system to track Taxi Voucher use
Quarterly reports related to transportation funding used submitted to AHS on a quarterly basis
Next Steps Continue to document Clinic Coordinator processes for the Clinical Operations Manual
Health Liaison Background The position of Health Liaison began in March 2016, to address the need to
have a team member with a healthcare background that can triage acute and non-urgent concerns at the resettlement house.
The Health Liaison works full-time at the Margaret Chisholm Resettlement Centre meets with all new GAR families and provides introduction to the refugee clinic, coordinates with MRHC staff on medical appointments, transportation arrangements and acute concerns.
The Health Liaison also supports the needs of PSRs and refugee claimants who present to MCRC with social or health-related questions
Key Players Mia Baluyot (maternity leave) Atta Woldeselasie – 1.0 FTE
Highlights in 2017 332 direct patient appointments
Office space at Margaret Chisholm re-arranged to become more compliant with Mosaic safety regulations
Mia Baluyot welcomed her baby boy in June 2017
Atta Woldeselasie joined the team in April 2017 and took over the Health Navigator role
Challenges Vicarious traumatization
Increasing volume of patients
TST at MCRC
Next Steps Hire a full-time temporary 1.0 FTE Health Liaison
Health Navigator Background The Health Navigator role is diverse and oversees the following portfolios:
Optometry and Public Health Vaccinations
The Health Navigator also sees patients for 1:1 appointments for: IFH reporting, AAHB and ACHB applications, food bank referrals and PSR Attachment appointments
Key Players Biniam Soquar – 1.0 FTE Ivonne Fajardo (interim Health Navigator from June to September 2017)
Highlights in 2017 Biniam: 393 direct patient appointments; 175 indirect patient appointments Ivonne: 131 patient appointments
Challenges No consistent workspace
Next Steps Develop and implement Health Orientation classes
Role clarification for public health vaccinations process
Review optometry referral and scheduling process and identify areas for improvement
Licensed Practical Nurses Background The LPN team is vital to the daily operations of the clinic and support the
team to deliver high-quality patient care.
Key Players Gagan Mattu – 0.6 FTE; main contact with STI Clinic, CDC Victor Liong – 1.0 FTE; phlebotomist, does intake BW for all new GARs Sarah Tessema – 1.0 FTE; booking slip committee
Highlights in 2017 Victor developed clinic and medical supplies inventory lists and conducts a quarterly review
Monthly audits of anaphylaxis, STI and emergency procedures kit implemented. Audits stored in Mosaic’s shared internal drive.
Challenges Engerix – national shortage in 2017 caused a backlog of patients needing to complete their Hep B series.
Next Steps Hire LPN to take over Gagan’s position. Congratulations to Gagan who will be completing her RN degree in 2018.
Straight to QFT initiative
Medical Office Assistants Background The Medical Office Assistants are the first point of contact for all patients and
community partners entering or calling our clinic.
This role is vital to the daily operations of MRHC as this team triages and supports health concerns raised by our patients
The MOA team helps patients with the scheduling and coordination of appointments, external and internal referrals, reminder calls and system navigation.
Key Players Sarah Hamdan – 0.6 FTE; Scanning, Faxing; Booking slip committee Ivonne Fajardo – 1.0 FTE; Billing, GP & specialist reminder calls, Rosi Grinan – 1.0 FTE; prenatal, dental Rabina Grewal – 1.0 FTE; Hep B, external referrals Shazia Jat – casual; interim dental and prenatal
Highlights in 2017 Rabina Grewal led the MOA Practicum Student initiative and worked closely with the manager, Clinic Coordinator and Human Resources to develop a system to support MOA learners.
Ivonne supported two different interim roles: Health Navigator from June to September and Transition & Community Coordinator role starting in November
Rosi Grinan took on the interim Quality Improvement Specialist role in November
Sarah Hamdan led the Booking slip committee
Challenges Staff shortages
Next Steps Hire more casual MOAs
Mental Health Therapist Key Players Jassim Al-Mosawi – 0.4 FTE
Highlights in 2017 278 direct patient appointments; 99 indirect patient appointments
Challenges Supporting Yazidi female clients who are refusing to see a male therapist
Next Steps The mental health working group will meet to develop a mental health care pathway
Pharmacist Key Players Jackie Liu – 0.2 FTE
Highlights in 2017 Creation of multiple prescribing encounter forms for the physicians
Quarterly audits of the Medication Donation Account completed and submitted to AHS/CHT for review
Creation of a support system (providers submit pharmacy-related questions via email or can connect with pharmacist directly via phone for urgent questions).
Provided support to the physician and nursing team at MRHC as the lead of Mosaic’s Diabetes Optimization Team
Challenges Development of a medication inventory system at MRHC
Next Steps Transition MRHC pharmacy projects to new pharmacist
Finalize process for monitoring expired medications and medication disposal
Registered Dietitians Background MRHC has two registered dietitians, one with a primary focus on adults and
families, and the other whose primary focus is on the pediatric population.
Common referrals include: iron deficiency, G6PD deficiency, introduction to solids
Key Players Claire Izcovich – 0.2 FTE Karyn Tang – 0.1 FTE
Highlights in 2017 Pediatric dietitian joined the MRHC team in July 2017
Adults: 184 direct patient appointments; 2 indirect appointments
Pediatrics: 44 direct patient appointments; 2 indirect appointments
Challenges Time to third next appointment (TNA) remains consistently high, on average 100 days or longer
Next Steps Karyn is developing a group nutrition class (iron-deficiency; intro to solids) with an implementation date of summer 2018.
Registered Nurses Background Our RN team and the need for RN case management support continues to
grow.
The RN team continues to support many MRHC programs
Key Players Salimah Jetha – 1.0 FTE; Health Literacy initiative; Diabetes Optimization Team; Alda Garunia – 1.0 FTE; Refugee Youth Program; RN case manager for Dr. Ekwalanga (OB-Gyne) Mary Mather (maternity leave)
Highlights in 2017 1,013 direct patient appointments; 1,467 indirect patient appointments
Congratulations to Mary Mather who had a baby boy in Nov 2017
Alda Garunia joined the MRHC family in Sept 2017
Salimah completed her C-Endo advanced diabetes training Dec 2017
Challenges Role clarification
Next Steps Continue discussions of the creation of an RN care plan template for the EMR
Advocate for further RN resources to support complex case management at MRHC
Social Workers Background The Social Worker team supports the patients with the following: WCB
applications, AAHB and ACHB application, housing, food bank referrals, AISH applications, FSCD intake appointments.
The Social Worker team supports patients directly through 1:1 appointments and indirectly by advocating on the patients behalf to various organizations.
Key Players Julia Condrea – 0.6 FTE to 0.4 FTE Jasprit Mangat – 0.6 FTE Aida Haile – 0.4 FTE
Highlights in 2017 833 direct patient appointments; 755 indirect patient appointments
Social Worker coverage at the clinic Monday to Friday
FSCD initial appointments done with the MRHC social worker
SW prenatal support
Community Collaborations The work done at MRHC is supported by collaborative partnerships with community organizations. The
following list of community partnerships is not inclusive and continues to grow:
Calgary Catholic Immigraton Society (CCIS)
Calgary Immigrant Women’s Association (CIWA)
Alberta Association of Immigrant Serving Agencies (AAISA)
Immigration, Refugees and Citizenship Canada (IRCC)
Calgary Laboratory Services (CLS)
AHS Public Health
AHS Tuberculosis Clinic
Calgary Board of Education (CBE)
Calgary Catholic School District (CCSD)
East Calgary Family Care Clinic (FCC)
Sunridge Family Medical Teaching Centre (SFMTC)
The Alex
Centre for Newcomers
Boys and Girls Club
Aspen Families
AHS Alberta Children’s Hospital
Inn From the Cold
Children’s Cottage
AHS Neuromotor Clinic
Best Beginnings
Calgary Police Service – Diversity Resource Team
Marlborough Mall Optometry
Dr. Bishop’s Office
Pin Drop
Total Cardiology
Sheldon Chumir Dental Clinic
Checker Cabs
Red Community Midwives
Between Friends
Pace Kids
Acknowledgements
The creation of the MRHC 2017 Year in Review was a joint effort from many individual team members.
A special thank you to all those who provided feedback and contributed to this document!
Dr. Annalee Coakley
Ivonne Fajardo
Rosi Grinan
Alda Garunia
Rabina Grewal
Dr. Andrea Hull
Salimah Jetha
Victor Liong
Shayesta Noori
Eric Norrie
Gagan Mattu
Syed Medhi
Biniam Soquar
Dr. Rachel Talavlikar
Sarah Tessema
Cheryl San Juan, Mosaic Refugee Health Clinic
Primary Care Manager
Mobile: 1403.880.8243
www.mosaicpcn.ca