Insights (Essays)

Insights (Essays) March 2020

Early Lessons: Tackling a Global Crisis with a Community Response

Thuy-Nga (Tia) Pham, Jeff Powis, Mark Fam, Ian Fraser and Anne Wojtak

East General 

In the 17 years since the SARS crisis, Ontario has invested in our public health system and improved connections across the healthcare system to better respond ‘as one.’ Although we are still a long way from having a fully integrated healthcare system, we at least understand the imperative to think and act like one system, and every day there are leaders and clinicians stepping-up to lead positive change. 

As the COVID-19 crisis escalates, we see similar critical success factors for developing integrated systems of care such as Ontario Health Teams, and the response to large-scale healthcare emergencies - both scenarios are complex and dynamic, requiring a shared sense of purpose, trusted personal and organizational relationships across different sectors, distributed leadership, and a strong role for organized primary care networks. However, large-scale emergencies further demand the system make changes quickly, within a precarious context, and with significantly higher stakes.

For the East Toronto Health Partners (ETHP), the investment in building our core partnership over more than two decades helped accelerate our initial response to the novel coronavirus. The ETHP are a network of healthcare and social services organizations, recently named as one of the first Ontario Health Teams, that have partnered to better integrated care in our East Toronto community of more than 300,000 residents. The core leadership for the ETHP includes patients and caregivers, the East Toronto Family Practice Network, Michael Garron Hospital, Providence HealthCare (Unity Health Toronto), South Riverdale Community Health Centre, VHA Home HealthCare and WoodGreen Community Services. Our broader partnership includes more than 50 other health and social services organizations. The story of our planning for COVID-19 is not just about preparing our hospital to provide acute care for pandemic patients but about mobilizing our community and primary care providers as a whole. This includes management of pandemic patients outside of the hospital and provision of services which are essential to support a local pandemic response. 

Started planning early

As in the rest of Ontario, our local infection control specialists have been monitoring the coronavirus situation in China since it started. As broad community transmission began in China in early January, and the first presumptive case of COVID-19 in Canada occurred, it had the effect of a shot from a starter pistol. Leaders from our East Toronto Family Practice Network-EasT-FPN (established in September 2019 as the voice of our 270 local family physicians at our Ontario Health Team leadership table), connected immediately with our infection control specialists at Michael Garron Hospital (MGH). Our historical fabric of solid partnerships meant a tacit agreement to take care of our community together.

Our family physician leaders from EasT-FPN represent all family practice models that exist in East Toronto. This level of organized physician leadership and diversity of voices has proved invaluable in the current crisis. When the medical department chiefs and hospital leaders from MGH first came together for emergency pandemic planning, community family medicine and our Community Health Centre partners were at the table. This partnership between the hospital and our local family physicians enabled rapid, shared decisions on Personal Protective Equipment (PPE) stocks, supply distribution and mask-fit testing for all community clinicians in East Toronto. Through the EasT-FPN connections, and with winter flu surge funds made available by the hospital, arrangements for mask-fit testing and PPE distribution for local family practices happened quickly, starting with the family physician practices in Chinatown East given the initial higher risk for their population.

As early as January, our emergency pandemic planning team started investigating best practice solutions to divert potentially infected, lower needs patients from the hospital, including opening a community-based testing and assessment centre properly equipped with PPE. The team at the South East Family Health Team (SETFHT) initially volunteered to host the assessment centre in their location - a building owned by MGH across the street from the main hospital, but after broad community consultation the assessment centre was eventually housed within the hospital itself. EasT-FPN sent out a call to all family physician practices to participate in rotational staffing for the centre. 

Dr. Jeff Powis, MGH’s infection control lead, set up weekly calls for all family physicians starting in February. Knowing the need for broader engagement across our Ontario Health Team (OHT) organizational partners, we subsequently established weekly calls for all leaders across ETHP, including home care, community services, mental health and addictions services, independent living, housing, homeless support services and others. These calls enable local problem-solving, sharing up-to-date best evidence, decision-making, common messaging, sharing human resources practices, and greater consistency in response across in our community, keeping us a few steps ahead of official provincial communications.

Lessons Learned

The COVID-19 efforts are pushing us well beyond our capacity - the overloading of our hospital phone system and long waits to access our assessment centre, one of the first to have opened in Toronto, are just the tip of the iceberg. However, we are still taking precious moments to flag the lessons we are learning.

  1. This is not the time to ‘pause’ our OHT work with community partners; in fact, it is becoming more critical. The speed at which a system can innovate and change is dependent on the strength of its relationships. Advancing our partnerships and our integrated leadership models allows us to respond at every level, from ensuring our community health and social care partners are ready, to prioritizing PPE and COVID-19 assessments for the health care workers who need them the most.
     
  2. Organized primary care leadership is essential. Our ability to quickly connect, communicate, and coordinate with local family physicians would be nearly impossible without our new Family Practice Network. Due to this network, the hospital was able to grant temporary hospital privileges within a 24-hour period to all members of EasT-FPN who did not already have them. This rapid credentialing, with information facilitated by EasT-FPN, enables all our community physicians to access IT systems and other resources to help stem the tide of COVID-19. Additionally, as the pandemic progresses, this will allow the hospital to plan physician human resource cross-training.
     
  3. In a crisis situation, ‘fires’ can quickly spread without quick acts of containment. Concerns from other tenants in SETFHT’s location forced a swift relocation of the assessment centre to an isolated ambulatory care clinic space at the main hospital, but the cooperation across multiple partners enabled the centre to still open within a week of its announcement. Within two hours of asking for physicians to staff the assessment centre, the East FPN filled 3-weeks of shifts, enabling 12-hour coverage, 7 days/week. This amazing contribution from primary care colleagues meant the community of East Toronto could get rapid access to COVID-19 assessments while enabling emergency physicians to focus on other critical volumes coming to the hospital.
     
  4. We have been struggling with digital health advancements and clinical updates, use of virtual care, and communication tools for a long time. Email and teleconferences are last century’s technology, so now our digital health strategy must shift in real-time. From collaborating with other hospital partners to establish online assessment screening and test results reporting, to exploring rapid deployment of virtual ICU capacity, we will build new models to deliver care to our community. With the onset of COVID-19, patients have been scared to visit their regular physicians’ offices, and rapid introduction and expansion of video consults has enabled clinicians to continue providing safe care to patients.
     
  5. Funding and access to PPE is an issue for the hospital, for primary care and our community partners. All of us across ETHP contribute to the fight, and all of us need the resources to do that. For example, when our partners at South Riverdale Community Health Centre needed urgent supplies of PPE to maintain critical Consumption and Treatment Services in the community, the hospital stepped-up.  The commitment and ability to share what limited resources we have is an important principle for how we work as partners.
     
  6. Although obvious, it deserves restating, we need ongoing recognition and support for our frontline healthcare workers. The viral video from Spain of community members cheering from their balconies for health care workers is an example of how a small gesture can go a long way to supporting the resilience of our teams.  We try to replicate that now at the hospital, perhaps not with songs sung across balconies, but with an amazing positive energy at our staff screening entrance that welcomes our teams every day.
     
  7. We need to think about how we will engage our patients and caregivers in our emergency plan to the same degree we have in other aspects of our integrated care work. Given that it will take months to deal with the pandemic, we will need patients, caregivers and our community involved in co-designing solutions to help all of us manage through this crisis.

Knowing the pandemic one day will abate, we must capitalize on the platform COVID-19 provided to leapfrog our efforts in healthcare transformation. The months ahead will be arduous for all of us – patients, families and healthcare providers alike. While no one wants an emergency like this one, we can already see how challenges provide a spark for innovations when relationships and systems such as the OHT exist to facilitate them. The work we do together now will go a long way in determining our path to becoming ‘one’ coordinated system. 

About the Author(s)

Thuy-Nga (Tia) Pham MD, MSc, CCFP, FCFP is the Physician Lead for the South East Toronto Family Health Team and Associate Professor, Department of Family and Community Medicine, University of Toronto.

Jeff Powis MD, FRCPC, MSc is the Medical Director, Infection Prevention and Control at Michael Garron Hospital, Toronto East Health Network and Assistant Professor, Department of Medicine, University of Toronto. 

Mark Fam, MHA is Vice-President Programs at Michael Garron Hospital, Toronto East Health Network and Adjunct Faculty, Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto. 

Ian Fraser MD, FRCPC is the Chief of Staff at Michael Garron Hospital, Toronto East Health Network and Director of the Provincial Weaning Centre of Excellence for prolonged ventilation and a lecturer in the Division of Respirology, Faculty of Medicine, University of Toronto.

Anne Wojtak DrPH, MHSc is the Lead for Integrated Care for the East Toronto Health Partners and Adjunct Faculty, Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto.

Acknowledgment

The authors would like to express our sincere thanks to the team at Longwoods for providing a communications platform that enables health leaders and providers across Canada to share information and ideas to help us learn from each other. This matters now more than ever. We would like to encourage other organizations to share their stories through Longwoods to facilitate dialogue across the country on the leadership and policy implications of the current crisis as we start to think about the long-term implications for our healthcare systems. 

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