Written by Rhonda Veldhoen, Interim Vice President, Community Hospitals and Programs

A redesign of our primary and community care model includes using team-based care to wrap services around patients.

Rhonda Veldhoen, Interim Vice President, Community Hospitals and Programs.

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.

When my 92-year-old father has a health concern, he goes to his family doctor. Like many of us, his doctor is his point of contact with the health care system as a whole and my dad doesn’t know, nor does he need to know, how the system works. Is a service provided by his GP, by a community organization or by Fraser Health? Who in Fraser Health is the right person to talk to? He depends on his doctor to figure that out.

The truth is, most of us who work in the health care system rely on a network of our colleagues to know the intricacies of our services across primary care, home health, mental health and substance use, surgery, residential care, and more. No one person can do it alone, and that includes the family practitioners who are so many of our patients’ first point of contact.

Fraser Health is redesigning our primary and community care services to create community-based teams that may include allied health, mental health and other disciplines to work more closely with patients, their GPs and other care providers. We’re building relationships so the team can work as a network, rather than relying on sending referrals and reports back and forth.

This work is part of the overall shift to more primary and community care that we’ve been pursuing for the past few years, to help people, like my dad and his doctor, have supports wrapped around them where they need them, when they need them.

In partnership with the Divisions of Family Practice, we’re working within a provincial vision to create a primary care network with these attributes:

  • Teams of various disciplines (allied health, mental health, substance use, etc.) working in partnership with primary care practices
  • Single contact point
  • Rapid access for urgent needs
  • Extended hours, with increased access to evening and weekend services
  • Shared care plan between primary care providers and Fraser Health
  • Case finding and screening so we can identify vulnerable patients earlier, to prevent or delay frailty and progression of their disease
  • Standard intake and assessment

We started with what we called seniors prototype communities in Langley, Abbotsford and Mission, and now all our communities are working toward a future where more care is provided in the patient’s home and community, where the most vulnerable and complex patients are identified and supported, where health care providers follow the patient as they move through community and acute care.

There’s no one size fits all approach, because the needs of our communities are different. We’re sharing our efforts and spreading good ideas, and working toward a model that we can spread across the health authority while allowing for customization depending on the needs of our patient populations.

We’re working on standardized job descriptions to realign community-based staff so they can partner with GP offices and build teams based on patient needs. You may have heard about the primary care nurse (“Nurse Debbie”) model, and that role -- a registered nurse who makes house calls and connects patients to appropriate services -- is one way some communities are implementing the principles.

Other communities are implementing the CARES project – Community Actions and Resources Empowering Seniors – to assess and support seniors to prevent frailty. Langley has implemented Seniors LINC (Langley Integrated Network of Care) to embed allied health into GP offices to focus on age-related changes, common diagnoses and missed diagnoses found in older adults. Chilliwack is moving to team-based care in partnership with a group of local physicians, enabling coverage seven days a week from 7 a.m. to 11:30 p.m. and simplifying the referral process.

Variability across communities, guided by the provincial and Fraser Health vision, is part of the plan, but all our communities are working to move us toward a future where patients and doctors don’t need to struggle to navigate the health care system, but where the system is designed to navigate around the patient.

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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