SAFHT’s patient prevalence of Type 2 Diabetes as of March 2019 is an estimated 12% or 4,636 out of 38,513 patients. This number includes pre-diabetics. This disease of keynote concern to SAFHT’s 22 physicians, given that health complications from diabetes may result in heart and kidney disease, stroke, blindness and amputation; while accounting for a significant number of emergency room visits each year.

In 2012-2013, SAFHT began using a uniform stamp used by its clinicians for quarterly visits for diabetes management across its EMR servers. The stamp was used to grade patients into three categories: good, moderate and poor control of their blood sugar. Using extracted patient data, by August 31, 2019:

  • 22.3% (or 1,034) of SAFHT’s diabetic patients were considered to have good control [Hbg A1C: “6.4 – 7”];
  • 29.5% (or 1,366) had moderate control [Hbg A1C: “7.1 - 8.5”]; and
  • 8.7% (or 403) had poor control [Hbg A1C: > 8.6].

Footnote: Because of COVID-19 fewer patients have been willing to lab work; so for comparison 2019 year data is being used.

Focus on those who need it most

SAFHT is actively utilizing the government’s Stand Up to Diabetes program for enrolling patients, support and handouts. Other resources in use include: local DECs and access to the Central East Centre for Complex Diabetes Care. Because of the higher patient health risk associated with those with moderate to poor control, the three part categorization of diabetes patients enables SAFHT to focus and direct allied health resources to those patients most in need. For enrolled patients with poor control, 100% of patients are being sent for eye checks and 100% of those with poor control are being screened for renal function and depression. Patients with good control and pre-diabetics are being offered twice a year appointments to help them graduate to self-care.

Resource Utilization (Nurses)

A patient with diabetes requires considerable care, counselling, education and monitoring to assist them with their personal life change management . Following the physician’s initial assessment and diagnosis a Registered Nurse takes on a referred patient and begins a plan with them. Patients are requested to return every quarter for ongoing teaching, counseling and monitoring.

For those already in the program, normal family health team care requires that nurses call in patients for quarterly visits. During these 4 visits a registered nurse at one of SAFHT’s 11 sites follows up on blood-pressure, blood work, foot checks, medications, weight, BMI, waist circumference and on-site monitoring and counselling, this may be a scheduled IHP appointment, or directly following or preceding an appointment with a physician. In addition referrals are made internally to: Chiropody and Dietitian services and SAFHT’s Healthy You program.

Some physicians and patients also used the CMA website/portal to input insulin levels and enable patient self-management. Recent data roll-ups show that laboratory results do not exist for 87 patients. These patients tend to be in denial and SAFHT and its physicians continue to do follow-ups to bring them under care. With 4,636 diabetes patients and quarterly or twice yearly visits for all, this is a major utilization of treatment time.

It should be noted that a good number of diabetic patients stay with physicians instead of being enrolled in this program. In those instances it is DECs who are involved instead of the nurse led quarterly patient education, counseling and monitoring program. The Diabetes Program sub-committee promises to examine data by physician going forward to review best practices etc. and patient outcomes.

Resource Utilization (Nurses doing foot checks) + Internal Chiropody Referrals

Foot problems are a significant cause of both morbidity and mortality in patients living with diabetes. Approximately 20% of hospitalizations for diabetics in North America are related to foot complications. Once diagnosed with diabetes, patients with low risk of developing foot complications require at least one foot check each year. Clients with moderate risk require foot examinations every 4-6 months and those with high risk of developing foot problems need foot examinations every 1-4 months (Nova Scotia Foot Check). Clients with an existing ulcer or skin breakdown would be seen every 1-4 weeks. These clients are referred internally to the SAFHT Chiropodist as part of the program.

SAFHT nurses also provide comprehensive foot checks for diabetics. This examination includes the following assessments: skin, structural, vascular, sensation test using 10g Semmes-Weinstein 5.07 monofilament, mobility test including foot wear and foot care. Patient education is also a key component of the diabetic foot exam.

A detailed quarterly visit is next described.

Quarterly Visit Details


  • minimum unit of time 1 minute
  • RN charting during assessment
  • at least 2 BP in the same arm
  • Motivational interviewing used for lifestyle change counselling (3 mins for short intervention, 10 mins for more intensive counselling)

Task Minimum Time if no barriers* (minutes) Minimum Time if barriers* present (minutes)
Review blood sugar results (home log, take office blood sugar) 1 1
Check blood pressure 2 3
Measure weight 1 1
Measure waist circumference 1 1
Check feet/lower legs 2 3
Review nutrition 3 10
Discuss activity 3 10
Review medications 1 2
Discuss tobacco use 1 weighted average 3 weighted average
Discuss alcohol use 1 weighted average 3 weighted average
Psychosocial assessment (social supports, depression) 1 5
Review blood work including Hgb A1C, cholesterol 2 3
Review vaccination status, last eye exam 1 1
Make referrals 2 2

6 11

Adapted from Building Healthy Lifestyles Vascular Protection Diabetes Clinical Guide, Chinook Health Region; *barriers e.g. mobility, language, health literacy etc. Per the Atlanta Agency for Healthcare Research and Quality

  • Patients can achieve good diabetic control if providers recommend intensive therapies, use a team approach, furnish appropriate preventive care, and put into practice proven strategies that help patients better manage their care.
  • Intensive therapy using a team approach is an effective way to reach the major goals of diabetes therapy: lowering glucose (blood sugar) to appropriate levels and avoiding or postponing the onset of serious complications. From
  • Adapted from

Treatment Goal Required treatments and services including patient actions Member of CDM Team
Patient has a clear understanding of diabetes and the patient's role in managing the condition Patient education Registered Nurse
Medication management Ensure correct use of medications. Undertake Home Medicine Review Pharmacist/Registered Nurse/Nurse Practitioner
Maintain healthy diet and optimum weight range Maintain healthy nutrition and weight control Registered Nurses who have Diabetes Educator designation/Dietitian
Maintain physical activity Development of exercise program suitable to needs of patient Registered Nurse (on site)
Smoking cessation Smoking cessation program Referrals to Registered Nurse
Minimize complications Optimize medical management Nurse Practitioner/Registered Nurse
Foot wounds / bruising and foot care Chiropody Chiropodist
Co-morbidity, e.g. hypertension, dyslipidemia Optimize medical management Nurse Practitioner/Registered Nurse
Improve wellbeing Manage depression Referrals to mental health worker
Reduce social isolation Linkages to community services/involve in Diabetic Conversation Maps Case Manager/Registered Nurse


Physicians have identified depression/ anxiety as a high need and high demand area (in physician offices) that continues to rise. Most physicians see at least one patient a day who needs assistance in this aspect of their lives. They have noted that as anxiety, stress and depression are factors in chronic disease management, having the ability to internally refer patients to the team is a major benefit.

In 2020, the primary goal of SAFHT’s Mental Health Team is to provide patients with mental health services (including coping mechanisms and strategies), in order to enable them to take charge of their lives and be more effective in dealing with their day-to-day issues. The team consists of four MSWs (4.0 FTEs), a Psychiatrist (sessional = 130 sessions), and a Case Manager.

SAFHT has approximately 6,372 patients (16.5%) who were charted as having a mental health issue. This data it is recognized overstates the number of patients in need of current assistance.

The Board of SAFHT recognizes that continuous standardization in mental health charting will need to be done in 2020-2021:

  • Patients may have resolved issues with previous incidents being no longer manifest
  • Patient may be well controlled with either medication or self-management
  • Patient may be in need of counselling or assistance, but other than relating their issues to the physician, the patient is in denial because of stigma and declines a referral to the Mental Health team.

This is a very large group currently comprising 2,800 patients or 44% of all patients with an undefined or unresolved Mental Health issue/diagnosis.

Of the remaining patients approximately 660 are seen in a year by the SAFHT Clinical Social Workers/Counsellors. Patients being seen by counsellors are given between 8-12 individual counselling sessions in a year. Each session is approximately 45 minutes, leaving the MSW to chart for the last 15 minutes in the hour.

Patients experiencing issues of stress, anxiety and/or panic attacks are 28.9% of mental health patients. They take the bulk of the MSWs time and the team is expanding sessions, to provide patients with an understanding of their condition, and the tools and techniques that can be useful in managing their behaviour. Group evaluations were uniformly positive in meeting all or most of the client’s needs and in the words of a patient continue to resonate: “All of it was true to my disorder and now I must get out of my comfort zone and do the exercises so that I can have my life back”.

The next highest demand area is support for people with depression: There are approximately 1,714 patients currently charted with this condition. Here too the FHT has introduced a group learning and managing program entitled “Beyond Blue”. This group’s evaluation too met the needs of patients, and helped reduce the demand for individual counselling a well as the total hours needed per individual.

Besides these groups, teaching courses that are being planned for 2020-2021 include: Assertiveness Training for Women; Stress; and Positive Approaches to Trauma Healing (PATH).

SAFHT continues to work with a psychiatrist from Sunnybrook Health Sciences Centre to work with the Mental Health Team via OTN using anonymized cases. Physicians and the pharmacist have also found it useful in terms of working with the psychiatrist on the efficacy of appropriate medications.

Over the next year, within its existing resource base, SAFHT is proposing to:

  • Link with the out-patient psychiatry service at The Scarborough Health Network, Ontario Shores, Michael Garron and North York General.
  • Further improve efficiencies in the referral process.
  • Improve access through on-site counselling at various sites.
  • Provide assistance to outside specialized resources through resource navigation.
  • Develop protocols for identifying and tracking mental health services in more detail including patient follow through and satisfaction surveys.
  • Develop and distribute information packages to clients.
  • Post resources on the SAFHT website for patients.
  • Provide in-service training and tool kits/tip sheets for physicians in high-demand areas such as anxiety and coping mechanisms.
  • Encourage all physicians to enroll in the new mental health anti-stigma training program offered by the Mood Disorders Society of Canada (online and free to CMA members).
  • Implement screening tools for depression using computer tablets.
  • Leverage existing and develop new linkages to community groups/services to strengthen SAFHT’s community linkages and partnerships.
  • In 2019, SAFHT will note the total diagnosed and referred patients versus the patient population with mental health diagnosis in the EMR.

Hypertension Management

In 2020, approximately 6,373 (16.6%) of SAFHT’s patients were living with hypertension, and receiving care from the team of physicians, nurses, nurse practitioners and the pharmacist. Research indicates that hypertension is “the most prevalent chronic disease in Canada” and that it has a significant impact on the Quality of Life of those living with the condition. Also, hypertension is “the number 1 modifiable risk factor to address for strokes and among the top modifiable risk factors to address for heart attacks” (Heart and Stroke Foundation of Canada).

SAFHT has adjusted its hypertension tracking into two categories:

    1. patients with just hypertension
    2. patients with hypertension as a co-morbid condition.

Resource utilization in patient visits (Nurses)

Clients identified as having high normal blood pressure will receive annual follow-ups. Patients who have already been diagnosed with hypertension but whose blood pressure is at target will have follow-up appointments every 3-6 months. Patients whose blood pressure is above target will have follow-up appointments at least every 2 months. The hypertension visit with the SAFHT RN includes: measurement of blood pressure, waist circumference, weight and height, client education around hypertension, related complications, lifestyle counselling including weight management, dash diet, physical activity, medication review, blood work review, discussions around self-monitoring, smoking cessation and alcohol consumption and stress management. RNs also follow up on the last date of ECG and annual flu vaccine status. Referrals will be made to the Heart Healthy Program, Healthy You Program, Smoking Cessation, CAD/CHF Program, Dietitian and if appropriate other community resources.

Here too patients will be tracked based on both referrals to the EMR and SAFHT’s program.


In 2020, approximately 821 patients of SAFHT (2.1%) were living with Coronary Artery Disease (CAD) and approximately 0.7% (258) had Congestive Heart Failure (CHF). Another 5,957 or 15.5% had Dyslipidemia. Patients received care from physicians, nurses, nurse practitioners, and the pharmacist. A number of patients also attended the Healthy Heart pilot program which is now offered at three different community locations, four times a year.

SAFHT CAD/CHF program is intended to improve management of this chronic disease along with Dyslipidemia, to prevent a downward spiral, empower patients, and improve patient outcomes through intense monitoring, counselling and related programs such as Healthy Heart. In order to provide this program, SAFHT is redeploying its nurses to address this priority, based on physician referrals.

During Phase One (8 months), SAFHT would focus on those clients with the most complex illness experiences, and would consider multiple factors such as quality of life and frequency of hospitalizations. Patients would be grouped into two categories e.g. those who are good at self-management and only come in for routine checks, and those patients who have poor self-management, high lipids, frequent hospital visits etc. The new Program sub-committee will determine more accurate targets and initial measures.

During Phase Two, a nurse practitioner would establish an oversight committee to ensure effective internal coordination and use of resources. A “blitz” approach would then be planned for each site. Patient schedules and space booking would be planned for each site visit. Each site would begin to assess scheduling options for optimal access times. At each site, it is anticipated that each visit would take approximately 2 hours per patient (1/2 hour per NP, Pharmacist, and dietician time), plus 15 minutes to complete charts and follow up with the patient’s physician.

After a three-month evaluation and necessary adjustments to ensure operational feasibility, the roll-out would be scaled up in the latter half of the first year and in subsequent years.

On an ongoing basis, the Nurse Practitioner along with the Program Manager would facilitate external system navigation, identify gaps and trends, develop and update policies; procedures and protocols as required, revise/develop and monitor measures, and provide updates to the SAFHT team.

During Phase Three, the program will be evaluated.

COMPLEX VULNERABLE CARE/FoCuS (FoCuSed Complex Vulnerable Services)

Through SAFHTs interactions with the former East Toronto Health Link (ETHL) and the former North Toronto Health Link (NTHL), it has recognized the interventions possible in primary care that can reduce the number of ED visits, and dramatically modify the patient’s medical medium term outcome.

The individual SAFHT patients who participated in Health Link pilots and through a virtual ward type experience have experienced studied interventions. Others have had

home visits, and one SAFHT family member led the patient experience panel in NETHL. Through 2018-2019 SAFHT NPs undertook 1,348 home visits respectively and developed/managed updates to an equivalent number of

coordinated care plans. This does not include all patients who were handed over to hospital-based palliative care teams.

SAFHT has determined that it will do three things going forward:

  • Identify its complex vulnerable patients – especially through referrals from its physicians;
  • Utilize Coordinated Care Plans.
  • Connect the program with individual provider organizations (Home and Community Care, Community Specialists, Hospitals, etc.) and utilize or build on technology / advances (OTN/TIP nurses) where appropriate.

SAFHT recognizes that while the Ministry is seeking widespread consensus on defining complex vulnerable, SAFHT has refined its working definition based on the experience of its NPs running the program. The referrals to the program are now based on:

Selected patients having at least FOUR of the following Comorbid Chronic Disease Conditions:

  • Cardiovascular Disease (e.g. Arrhythmia, Atherosclerosis, CHF, HTN, PVD, CVA)
  • Respiratory Issues (e.g. Asthma, Chronic Obstructive Pulmonary Disease)
  • Diabetes
  • Renal Failure
  • Mental Health (e.g. Anxiety, Bipolar, Depression, Dementia, Schizophrenia)
  • Other (e.g. Cancer, Neurological diseases, developmental disabilities)

Footnote: Because of COVID-19, SAFHT NPs have ceased home visits and have resorted to virtual care since late February 2020.

Vulnerability and Socio-economic Factors

Selected patients should meet at least TWO of the following conditions

  • Vulnerable (frail senior 65+, palliative)
  • Economic (having difficulty making ends meet at the end of the month)
  • Social (inappropriate housing, communication barriers, education, inadequate social support, ineffective coping)

A dedicated SAFHT Team lead by the Nurse Practitioners looks to improve the outcomes for these patients based on a defined geographic program service area for each NP. The challenge for the NPs is in managing patients with care navigation and care coordination in the absence of these supports from the LHIN Home and Community Coordinator. Once stable, the patients may be visited by SAFHT nurses or other professionals to keep them in good health and home visits form part of the basic protocol where needed.

On the basis of current data SAFHT has the demographic poised to need this program. Approximately 2,600 patients or 6.9% of the patient population is over 80. Additionally for those with diseases, 9.9% or 3,800 have three or more co-morbid conditions. It is anticipated that demand for this program will spike. So SAFHT has added 2 NPs to this program in 2020-2021.


The chiropody service is an important element in SAFHT’s commitment to chronic disease management, and is delivered by two part-time chiropodist (1.7 FTE) situated at two sites. This program is in very high demand and is significantly under-resourced. Referrals are at saturation point with long waits (four months on average) for new patients, and the average wait time for a recurring appointment to the clinic for ongoing foot care is two months. Given that 21% (8,077) of SAFHT’s patients are over 65 this issue is expected to worsen.

Location has been identified as a fundamental barrier for many patients. During 2017-2018, approximately 2,200 patients were seen (10-12 clients per day) at one location. This was seriously overloading the chiropodist. This has now been reduced to 6-9 patients. Emergency appointment slots for new patients have been established by creating a daily urgent time slot. This is still an untenable situation. Over a third of the patients are diabetic with established risk status. Approximately 700 are seniors with disabilities that prevent self-management, and the remaining 600 patients have foot-related problems or require biomechanical assessment.

LEAP (Lower Extremity Assessment Project) program guidelines were implemented to identify the risk category of all diabetic patients seen, and risk categories were recorded in patient EMRs. In-service training was provided for nursing staff to aid in basic foot screening and better identification of risk status and potential foot complications. In addition, the EMR foot examination stamp was standardized to facilitate consistent data input on Practice Solutions software. The program has made referral connections with the Diabetes Regional Coordination Centre.

Forward Planning

SAFHT has also begun discharging low risk patients back to the community to reduce the number of active patients. SAFHT has begun to direct patients to outside foot clinics where they exist, and to specialists where insurance coverage permits (private insurance coverage is not available to most SAFHT patients). In-service training will continue to be provided to nurses and nurse practitioners as required. New nurses will be encouraged to take the online LEAP course.


The 2019 data from physician servers showed that over 5% of the FHT population has asthma and/or is afflicted with COPD. Physicians are best able to manage patients with their disease by prescribing puffers and reducing instances of lung scaring. The FHT is working with the physicians and Boehringer Ingelheim to route patients via the use of Ocean Tablets in some practices to referrals for spirometry and the FHT Smoking Cessation program.

Smoking Cessation: Disease Prevention

SAFHT has identified 2,470 patients who smoke, representing 6.4% of the patient population. This number is low when compared to the provincial average of 19%. Patients who have a diagnosis of COPD (1,005) and are smokers are prime candidates for this program.

SAFHT also has an ongoing agreement with CAMH, to deliver a program that offers NRT and counselling to patients wanting to quit. A SAFHT Medical Directive is in place and in use with this program.

SAFHT recognizes through studies like the STOP Study that the most helpful tool to assist patients in quitting smoking is counselling. Harvard’s School of Public Health Research further substantiates this claim. Therefore, in

the coming months, TEACH trained RNs will be holding training sessions for other staff, including nurses and mental health workers. This “train the trainer program” will utilize the Fundamentals of Tobacco Intervention: Trainer Toolkit program from CAMH. In 2020 SAFHT will expand the program by offering the Smoking Cessation program in a group setting to reach more of those patients who are interested. Follow-up counselling will be offered to group participants on a one on one basis. It is anticipated that these group sessions will initially be offered on a quarterly basis, and accommodate 8-10 patients per group.

In addition, brief interventions to identify and counsel smokers using the Tobacco Use Intervention methodology are planned to be conducted in individual practices. For all variations of SAFHT Smoking Cessation Programs, the focus will be on harm reduction and motivational interviews.


At the start of 2019, 35.3% of SAFHT clients were estimated as overweight, 40% had unhealthy eating habits and physicians reported over 50% were not physically active. As of

March 2019, 32% of SAFHT’s patients charts have shown then to have a BMI>25. In terms of chronic diseases, 16% of clients had hypertension, 12% had diabetes, 8.7% had asthma/ 2.6% COPD and 9% had osteoarthritis/arthritis. SAFHT recognizes the impact that healthy living can have on improving the quality of life of our clients. Lifestyle changes, including diet and physical activity, can reduce risk factors for developing chronic diseases and improve outcomes for those already living with chronic conditions.

In order to meet the needs of these clients, SAFHT will continue to make the Healthy You program a centerpiece in patient education. The program takes a dietary approach to help participants to improve healthy eating and make lifestyle changes. Referrals to the Healthy You program included clients living with chronic diseases as well as those with risk factors for developing chronic conditions. SAFHT is building on the continued success with 94% of the participants reporting increased confidence in their ability to make positive lifestyle changes and 90% better positioned to make healthy choices since completing the program.

To increase access and participation for the patient population, the program materials are being be adapted for different levels of health literacy. The aim is to make the Healthy You program client-centered. As a result, the material takes into consideration the multi-cultural composition of participants who are being referred, so that SAFHT can better meet their needs. To increase accessibility to the program, SAFHT will develop/acquire training materials so that RNs can deliver the program with the Dietician in an advisory role. The Healthy You program will also increase linkages with Eat Right Ontario services in the community and incorporate physical activity advice.

Approximately 13,600 of SAFHT’s clients could potentially benefit from the Healthy You program. In consideration of such factors as targeting the family care-giver, patient motivation, seasonal attendance, operational feasibility, etc., SAFHT converted its Health Promoter position to a dietitian role and hired an additional 0.5 FTE Dietitian to hold the program with a target group of 1,300. The goal is to offer the program to 300 more clients in year two, 300 clients in year three and 400 clients thereafter.

The target group will continue to include clients who have chronic disease as well as those with risk factors for developing chronic conditions.

In 2019 four 9 hour sessions (3 days for 3 hours) were held for 966 people, culminating in a grocery store tour to test and review learnings on nutrition labelling. Participants reported being 100% confident to choose appropriate foods, and motivated to make long term lifestyle choices focusing on healthy eating and physical activity.

A patient summarized as follows: “I am motivated to continue making small changes to build on making permanent changes to have a healthier life”.


At the beginning of 2019-2020, 35.3% of SAFHT clients were estimated as overweight, 40% had unhealthy eating habits and physicians reported that over 50% were not physically active. As of March 2019 – 5,957 patients had laboratory test results showing that they are dyslipedemic, which is 15.5% of the patient total. In terms of chronic diseases, 16.6% of clients had hypertension, 12% had diabetes and 2.1% had coronary artery disease. SAFHT recognizes the impact that healthy living can have on improving the quality of life of our clients. Lifestyle changes, including diet and physical activity, can reduce risk factors for developing heart disease and improve outcomes for those already living with chronic conditions. (

In order to meet the needs of clients with hypertension and dyslipidemia, SAFHT piloted the Healthy Heart education program in 2011 using materials offered by the Hamilton Family Health Team. The program takes a dietary approach to help participants improve their healthy eating and make lifestyle changes. Referrals to the program included clients who had been referred to the dietician for counselling about diet for hypertension and dyslipidemia as well as direct referrals to the program from other members of SAFHT. A total of 212 clients participated in the Healthy Heart program in 2019. 77% of program participants reported that they were confident about choosing the appropriate foods to eat when hungry. 80% reported that they were motivated to make lifestyle changes such as healthy eating and increased physical activity.

In order to increase access and participation for SAFHT’s patient population, the program materials will be adapted for those who have different levels of health literacy. The aim is to make the Healthy Heart program client-centered. As a result, the material will take into consideration the multi-cultural composition of participants who are being referred to better meet their needs. It is estimated that approximately 13,000 to14,000 of SAFHT clients could potentially benefit from the Healthy Heart program. However, in consideration of such factors as patient motivation, seasonal attendance, operational feasibility, etc., SAFHT will continue its 2020-2021 programs with a target group of 900. The goal is to offer the program to 250 clients this year and expand it based on additional resources in service hubs.


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