Hamilton Family Health Team

Family Health Teams are a key piece of the Ontario provincial government's plan to build a health care system that promotes good health, reduces wait times and improves access to care. In Family Health Teams, family doctors work with other health care professionals such as nurse practitioners, nurses, mental health counsellors, dietitians and pharmacists to see more patients and to keep them healthy.

InfoClin is helping the Hamilton Family Health Team meet its goals by helping physicians use electronic medical record technology more effectively. InfoClin is helping spread best practices amongst physicians and helping physicians use their technology to track patients and improve the care of patients with chronic diseases.

Family Health Teams are an important part of changing both the health care system and the way people think about health care. Family Health Teams will focus more on preventing illness and promoting health. They will look at the best ways to manage chronic illnesses such as diabetes and depression. Family Health Teams will provide care that is more accessible and comprehensive. They will give patients the opportunity to be more involved in making decisions about their own health.

Since April, 2005, the Ontario government has approved 150 Family Health Teams across the province. The Hamilton Family Health Team is the largest, serving approximately 250,000 people and was built on the “platform” of the H-W HSO Mental Health and Nutrition Programme.

The Hamilton Family Health Team includes:

113 family doctors
76 nurses and nurse practitioners
16 dietitians
56 mental health counsellors
17 psychiatrists
6 pharmacists joining soon

The Hamilton Family Health Team serves approximately 250,000 people. It is the largest of the 150 approved Family Health Teams in Ontario. The services provided by the Hamilton Family Health Team are free of charge to patients.

How can the Hamilton Family Health Team help patients get healthy and stay healthy?

by sharing accurate, up-to-date information about the best ways to prevent disease and promote health

by looking at risk factors and offering appropriate screening and follow-up
by detecting and addressing health (including mental health) problems earlier, when care is more effective and less costly
by increasing the range of health conditions that can be assessed and treated in the family doctor’s office, the place where most patients first seek care
by offering support and strategies to better manage chronic illnesses like diabetes, depression and asthma
by working with patients and their families to “navigate” the health care system so that care is better co-ordinated

How can this improve the health care system?

by helping doctors and other members of the team use their time more effectively, so practices can provide high-quality care to more patients
by increasing access to care through extended hours and Telephone Health Advisory Services to improve continuity of care and help ease the strain on emergency services
by providing the supports family doctors need in order to be able to accept new patients, so more people will have a family doctor
by building partnerships between different parts of the health care system, for example, between family doctors and community organizations such as hospitals and CCACs, so services are better co-ordinated across the system
by making the system more flexible, so each community can tailor services to meet their specific needs
by using health care dollars as efficiently as possible

The Hamilton Family Health Team currently includes four programs: Mental Health, Nutrition, Nursing and Pharmacy. A number of other programs are in the planning stages.

In each program, health care professionals with special training, skills and experience work with family doctors to provide care to patients and their families.

For example, registered dietitians are experts in the area of diet and nutrition. Working with the family doctor, they can play an important role in preventing, assessing and treating conditions where diet is a factor such as heart disease, diabetes and obesity.

Pharmacists are experts in the area of prescription and non-prescription drugs. In collaboration with the family doctor, they can help patients to better monitor and prevent side effects and adverse drug reactions and interactions.

The Hamilton Family Health Team also has several pilot projects underway. These include a child & youth mental health pilot, a substance abuse/addictions pilot and a peer support pilot.

Peer support looks at how people living with an illness (in this case, diabetes or depression) might benefit from being matched with a peer support worker who has the same illness. The peer support workers receive special training from the Hamilton Family Health Team. They can share experiences and provide support and advice. Other pilot projects are currently being developed.