Written by Jessica Young, Registered Dietitian, Clinical Nutrition

One of the first team-based care pilot projects in Abbotsford hosted Registered Dietitians in GP's offices and results show successful health outcomes.

The health care system is changing. People want health care that is accessible, coordinated and understandable – no matter where or by whom they are cared for. In our Transforming the Health Care System series, we share the stories of how we are changing the system and achieving positive outcomes for people and health care providers in our communities.

In September 2015, the implementation of a Team-Based Care pilot project in Abbotsford was born out of an innovative partnership involving the Abbotsford Division of Family Practice, Fraser Health and the Ministry of Health.

I was one of the registered dietitians working in ten physician clinics across Abbotsford, educating individuals on diet and lifestyle and supporting them to make changes to improve their health over the long term. Patients valued being able to see the dietitian in the familiar environment of their GP’s office. Assisting motivated patients to set realistic goals resulted in improved nutrition knowledge and understanding of chronic disease management, weight loss, reduced Hgb A1C (average blood sugar) levels, as well as other benefits. Collaborative patient care amongst cohesive teams resulted in improved health outcomes, improved patient and provider experience, and reduced cost to the health care system.

We were thrilled with the success we saw in a short period of time! To keep our community healthy and at home, it seems that nutrition knowledge is key. Equipping people with appropriate and reliable nutrition information enables them to better care for themselves and their family.

Some of my inspiring interactions have been:

  • Teaching an adult man how to cook for himself and go from eating out for all meals to cooking and packing meals to work, and seeing how it has turned his health around;
  • Encouraging a senior, who has cooked meat for dinner for her entire adult life, to try lentils and then find out she loves them as an alternative source of protein;
  • Supporting weight loss in more than one-third of patients seen, who otherwise found it difficult to lose weight on their own; 
  • Assisting a young patient with Irritable Bowel Syndrome (IBS), who was scared to leave home because of frequent and urgent diarrhea, re-establish regular bowel function so that she can now get out and get on with her life;
  • Assisting a family to expand the food choices of a picky eater and see them progress from feeding the child on his own and; going from rarely seeing his parents eat, to regular family meal time and enjoying a variety of foods together.

Funding for this pilot has completed and we are looking at the next steps for creating a permanent position. We have seen the success of team-based care in action with a dietitian and look forward to more collaboration across other disciplines in the future to provide the best care to our community.

How are you transforming the health care system? Tell us in the comments. Read more stories about how we’re changing the health care system.


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