Team Up! Team-based primary and community care in action

Morgan and Sarah continue their discussion on Stage 2 of the Learning Pathway for Primary Care Teams. This episode is focused on Team Building, and specifically, seeing Patients as Team Members. The hosts make a point that patients are essential team members, and understanding the patient perspective when transitioning to team based care is important. If a practice is moving to team based care, patients likely won’t know what to expect, and may even be worried that their standard of care is lowering. Morgan and Sarah highlight the importance of exploring methods of communication to help explain this new care model. Furthermore, the discussion emphasizes how small communication changes in everyday practice can have a significant influence and help patients feel more supported. Finally, practical suggestions are made to help healthcare establishments in manifesting their teams via checklists, orientation activities for new patients, posters, and website representation.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

To get started check out the culture change toolbox and the “Questions to consider before getting started” on P 12 of the toolbox.

Read over the AHRQ White Paper discussed in this episode “Creating patient Centred Team Based Care” (2016). This includes a great list of strategies for providing patient centred team based care (p. 7-19)

Check out the activities laid out in the Patient Centred Teams “Setting the Stage” handout

Past Podcast Episodes that may be of interest:

• TeamUp podcast: S05 E02 Patients as team members
• Explore more of the resources in Stage 2 of the Team Based Care Learning Pathway.

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to info@teambasedcarebc.ca if you would like to learn more!

Stage 2 of the Learning Pathway for Primary Care Teams is focused on Team Building. In this episode of Team Up, Sarah and Morgan focus on a key element within this stage: the importance of building relationships within a team. We explore the value of returning to shared purpose and shared goals as a tool to support effective team building and collaboration. We also provide practical tips and discuss some of the great resources that are highlighted in the Team Building Stage of the Team Based Care Learning Pathway.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

• For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/
• For more information about shared purpose and some the resources we highlight in this episode check out the Shared Purpose Facilitation Guide
• Take a look at this template for Team Agreements and this collection of resources focused on Team Huddles, all resources that are connected to the Learning Pathway.

Past Podcast Episodes that may be of interest:

• TeamUp Webinar Feb 17 2022: Skill Building for Teams- Huddles
• TeamUp Podcast: S03 E03: Distributed Teams and Team Huddles
• TeamUp Podcast: S01 E07: Practical Tools for Virtual Team Based Care

Explore more of the resources in Stage 2 of the Team Based Care Learning Pathway.

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to info@teambasedcarebc.ca if you would like to learn more!

In this episode, Morgan and Sarah continue their discussion of the first stage of the learning pathway: Where to start with team based care. Our hosts focus on the importance of thinking about both service design and team readiness when transitioning to team-based care in primary care clinics. They emphasize the need to consider the existing services in the community when designing or redesigning a team. Sarah and Morgan also highlight a number of resources available for primary care teams in the first stage of the learning pathway, highlighting the Team Readiness Checklist as something for listeners to try out in practice.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

• For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/
• For more information about Team Mapping, a tool to support teams working together on how they want to work together, in a patient centred way take a look at the following resources:
• Team Mapping MIROVERSE toolkit
• Price M, Bellwood P, Hill TT, Fletcher S. Team Mapping: A Novel Method to Help Community Primary Healthcare Practices Transition to Team-Based Care. Healthc Q. 2020 Jan;22(4):33-39. doi: 10.12927/hcq.2020.26086. PMID: 32073389.

Past Podcast Episodes that may be of interest:

• S03 E07: A Quick intro to Team Mapping
• S03 E09: Clearer Roles in Distributed Primary Care Teams

For links to the job descriptions and role material described in this episode explore stage 1 of the team based care learning pathway

• Role Descriptions
• Sample RN posting

Find the Team Readiness checklist here to try it out in practice

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to info@teambasedcarebc.ca if you would like to learn more!

https://teambasedcarebc.ca/team-based-care-pathway/where-to-start-with-team-based-care/

In this episode, Morgan and Sarah introduce the first stage of the Team Based Care Learning Pathway and focus on the importance of getting to know your patients. Morgan and Sarah explore two ideas related to getting to know patients,

1. Utilizing EMR data for demographic insights and chronic condition trends and
2. Conducting patient surveys to uncover needs.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

Here are a few of the highlighted patient experience survey tools from a recent review by the ISU:

• Patient-Perceptions of Team Effectiveness (PTE) questionnaire (43 item survey- Canadian)
• Kilpatrick K, Tchouaket É, Paquette L, Guillemette C, Jabbour M, Desmeules F, Landry V, Fernandez N. Measuring patient and family perceptions of team processes and outcomes in healthcare teams: questionnaire development and psychometric evaluation. BMC Health Serv Res. 2019 Jan 6;19(1):9. doi: 10.1186/s12913-018-3808-0. PMID: 30612571; PMCID: PMC6322340.
• (Demonstrates strong reliability and validity in assessing healthcare team functioning, covers critical dimensions of integrated care such as role clarity, boundary work, perceptions of team effectiveness, and outcome of care. It is easy to administer and aligns well with the primary care context)
• **Patient Reported Indicators Survey (PaRIS) (121 item survey that can be broken up into sections- International)**
• Slawomirski, L., van den Berg, M., & Karmakar-Hore, S. (2018). Patient-Reported indicator survey (Paris): aligning practice and policy for better health outcomes. World Medical Journal, 64(3), 8-14.
• The Innovation Support Unit is currently working on a comprehensive review of patient surveys to recommend a survey for use as part of the TBC evaluation. Watch this space for updates!

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to info@teambasedcarebc.ca if you would like to learn more!

https://teambasedcarebc.ca/team-based-care-pathway/where-to-start-with-team-based-care/

In this episode, Morgan and Sarah introduce Season 6 of Team Up and discuss the new team-based care pathway. They highlight the motivation behind creating the pathway and how the pathway will structure the season. The episode also includes a tangible takeaway for listeners, as Morgan and Sarah suggest trying out the team effectiveness tool available on the teambasedcarebc.ca website as a place to start!

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources

For more information on the Team Based Care Learning Pathway check out https://teambasedcarebc.ca/team-based-care-pathway/

The Team Effectiveness Tool is a short, multiple-choice assessment that gathers information about your team’s values, communication, roles, and existing supports to help guide your learning on team-based care. https://teambasedcarebc.ca/team-effectiveness-tool/

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to info@teambasedcarebc.ca if you would like to learn more!

The transition to a post-pandemic world has drawn increased attention to the tensions, pressures and capacity challenges that are experienced by health care providers and patients in primary care systems around the world. In the face of these challenges, in British Columbia, policy makers, funders, providers, and patients are working through another transition- the transition to team based primary care. The Innovation Support Unit, in the Department of Family Practice at the University of British Columbia, has been working to develop a series of implementation supports for communities, teams, providers and patients engaged in this transformation of Primary Care. Designed to accelerate planning and implementation, the mapping methods support inclusive, patient-centred and equity focused discussion and decsion-making.

This podcast episode tells the story of the evolution and iteration of the mapping tools and supports that have been co-developed by the ISU and communities across BC engaged in the implementation of team based care in primary care.

Drawing on the experiences of the ISU team as well as community interviews, the episode highlights the challenges, opportunities and potential new directions in the transition spaces of primary care transformation. Please see the resources below for more information about the primary care supports highlighted in this story.

Thanks to our guests!

Megan Sloan is the manager of the Qathet Primary Care Network, the regional district that surrounds the city of Powell River. Over the last 13 years, Megan has very engaged with the local community of physicians and nurse practitioners in Qathet and has taken on a variety of roles supporting primary care practices and planning.

Leslie Keenan: is the Executive Director of the South Island Division of Family Practice. Leslie has a long history of supporting primary care in communities, prior to her time with South Island she was the ED of the Nanaimo Division of family practice.

Amanda Frazer is the Strategic Lead of Primary Care Implementation Supports with the Innovation Support Unit. We are so grateful she was able to join us from her maternity leave! Amanda is passionate about the intersection between community engagement and system change. Prior to joining the ISU Amanda worked with the Campbell River Division of Family Practice.

Aleah Ross is the Primary and Community Care Mapping Lead with the Innovation Support Unit and is currently a PhD student at the University of Victoria in clinical psychology.

Morgan Price is the director of the ISU. He is an Associate Professor at UBC and affiliate faculty at UVic Division of Medical Sciences, Computer Science, and Health Information Science. Morgan is a family physician and practices in a Community Health Centre where he provides team-based care to underserved populations in the inner-city in Victoria. His research is in health systems change and clinical information system design and adoption.

Resources

For more information about Team Mapping:

• Read Team Mapping: A Novel Method to Help Primary Care Teams in Transition
• visit teammapping.ca
• check out our MIROVERSE template at https://miro.com/miroverse/team-mapping/

For more information about PACC mapping:

• Read Primary and Community Care Mapping: Helping Communities Collaboratively Plan Health Services in a Patient-Centred Manner
• please check out our MIROVERSE template at https://miro.com/miroverse/isu-pacc-mapping/

You may also be interested in checking out some of the material related to TEAL organizations through the Re-Inventing Organizations WIKI based on the work of Fredrick LaLoux.

If you would like to learn more about the ISU or if you have any ideas for future podcasts please email isu@familymed.ubc.ca

It’s the end of Season five! In this wrap-up episode Morgan and Sarah reflect on the variety of roles that were showcased this season, share some season highlights and key recommendations for action and give a with a sneak peak at what’s to come- first a break, then SEASON 6!

Exciting plans are already in the works for Season 6, which will be focused on PRIMARY CARE CLINIC STORIES and (spoiler alert!) may include more in-person conversations and in-the-field reflections! Reach out to isu@familymed.ubc.caif you know of a clinic whose team story should be shared!

Thanks to our Guests and to the ISU Team

No guests this episode but a huge thank you to all the wonderful people who connected with us this season. Thanks to the over 30 providers who helped us create season five - we are so grateful to everyone who agreed to talk with our team!

Special thanks goes out our amazing ISU team who were behind the scenes making this season a reality! Thanks to Josephine Lam and Erza Mjekiqi who both jumped in to interviews, reviewing transcripts and coordinating and connecting with guests and special thanks to Tlell Elviss who did all that AND joined our script writing and production team!

Resources

If you are interested in learning about resources and supports available to primary care teams, try out the new Team Effectiveness Tool , part of www.teambasedcarebc.ca

As we take a break over the next few months take a listen to some our favourite episodes of Season 5 or spend some time listening to our earlier seasons!

In this episode Morgan and Sarah explore the Physician role in Primary Care. Physicians are the foundation of the primary care system and support cradle to grave care for a wide range of patient needs in a variety of care models. They provide care in rural and urban settings, in clinical settings that range from UPCCs to community health centres and FNPCIs. Team-based care is an opportunity for physicians to practice with the support of other healthcare professionals which can impact their wellbeing and adaptive capacity. We hear from physicians who practice in different settings about what they do, how TBC has impacted their wellbeing, and

The key takeaways from this episode include:

1. Family Physician roles can vary considerably depending on the model of care. This impacts how they connect, in person or virtually, with a team.
2. Second, teams can enhance the adaptive capacity of the overall primary care system which in turn can enhance the wellbeing of family doctors.
3. The best place to start is to just start! Take a small step towards team based care by hiring a single role, doing a few shifts with a primary care team in your area, or start working with the team already in your clinic slightly differently.

Guests:

A huge thank-you to our guests from this episode for sharing their knowledge and experience with us. In this episode you heard from:

• Terri Aldred: Dr. Aldred is Carrier from the Tl'azt'en territory located north of Fort St. James. She is a member of the Lysiloo (Frog) Clan. Dr Aldred is the medical director for primary care for BC’s First Nations Health Authority, the site director for the UBC Indigenous family medicine program, a clinical instructor with UBC and UNBC, a family physician for the Carrier Sekani Family Services primary care team, which serves 12 communities in north-central BC, and the Indigenous lead for the Rural Coordination Centre of BC.
• Daphne Green: Dr. Green is a family doctor who works with a team of professionals at the Kelowna Urgent and Primary Care Centre.
• Rahul Gupta: Dr. Gupta work as an integrative medical physician, professional coach, trauma-sensitive mindfulness instructor, and advocate for physician wellness. He is currently a coaching consultant for the Physician Health Program of BC, a clinical Assistant Professor for the Department of Family Medicine, UBC, and a facilitator for Quality Team Coaching for Rural BC.
• Dana Hubler: Dr. Hubler is a Family Physician with the FNHA, the UBC Rural CPD Medical Director and Physician Advisor with the Physician Quality Improvement Island Health program.
• Anne Nguyen: Dr. Nguyen is a Victoria Primary Care and Addiction Medicine physician who worked for a number of years with Victoria Cool Aid Society. She also works for Doctors of BC as the Physician Lead for the Physician Health Program.
• Christie Newton: Dr. Christie Newton as Associate Vice-President, Health, pro tem, an associate professor and the Associate Head, Education and Engagement in the Department of Family Practice in the Faculty of Medicine. In this role, she is working on a province-wide project funded by the Ministry of Health, aimed at supporting the design and evaluation of teaching within team-based models of care embedded in Primary Care Network communities. She is also the Medical Director of the UBC Health Clinic.
• Carolyn Canfield: Carolyn is the ISU’s in house patient-disruptor and adjunct faculty member in the Department of Family Practice at UBC. Carolyn is very involved in the Department of Family Practice and shares her expertise by teaching medical residents about patient experience and engagement. She also teaches in the undergraduate medical program, serves on the medical school admissions subcommittee and contributes on a number of provincial, national and international project teams on topics ranging from partnership evaluation to understanding systems resilience to advance patient safety.

Resources and Links :

• To learn more about the Centre for Resilience in Healthcare visit: https://www.uis.no/en/research/share-centre-for-resilience-in-healthcare. Some of their recent publications include:
  • Lyng, Hilda Bø, Carl Macrae, Veslemøy Guise, Cecilie Haraldseid-Driftland, Birte Fagerdal, Lene Schibevaag, Janne Gro Alsvik, and Siri Wiig. “Exploring the Nature of Adaptive Capacity for Resilience in Healthcare across Different Healthcare Contexts; a Metasynthesis of Narratives.” Applied Ergonomics 104 (October 2022): 103810. https://doi.org/10.1016/j.apergo.2022.103810.
  • Lyng, Hilda Bø, Carl Macrae, Veslemøy Guise, Cecilie Haraldseid-Driftland, Birte Fagerdal, Lene Schibevaag, and Siri Wiig. “Capacities for Resilience in Healthcare; a Qualitative Study across Different Healthcare Contexts.” BMC Health Services Research 22, no. 1 (December 2022): 474. https://doi.org/10.1186/s12913-022-07887-6.
  • Fagerdal, Birte, Hilda Bø Lyng, Veslemøy Guise, Janet E. Anderson, Petter Lave Thornam, and Siri Wiig. “Exploring the Role of Leaders in Enabling Adaptive Capacity in Hospital Teams – a Multiple Case Study.” BMC Health Services Research 22, no. 1 (December 2022): 908. https://doi.org/10.1186/s12913-022-08296-5.
• To learn more about the Quality Team Coaching for Rural BC program: https://rccbc.ca/initiatives/qtc4rbc/.
• To learn more about the Physician Wellbeing Program visit: https://www.physicianhealth.com/
• To assess the effectiveness of your team, try the new Team Effectiveness Tool on the Team-based Care BC website: https://teambasedcarebc.ca/team-effectiveness-tool/#gf_6
• To dig into a whole bunch of team-based care resources see: https://teambasedcarebc.ca/
• If you are interested in listening to Season 2, the episodes on resilience you can find that here: https://teamuppod.com/season-2/

Who doesn’t like Unicorns? Join Sarah and Morgan as they talk about primary care unicorns- or unique roles that are being tested in primary care- and the potential for extending the boundaries of how we think about primary care teams. In this episode we highlight the stories of BC’s one (and only) kinesiologist currently working in a primary care team as well as learning about the potential of adding genetic counselling to primary care teams to support patients with mental health concerns in primary care.

Thank you to our Guests!

• Carmela de Gracia Patten: Carmela is the first kinesiologist in the province hired to work in Primary Care. Based in northern BC, Carmela is a team member with the Change Program, a lifestyle intervention program focused on metabolic syndrome (people with type 2 or pre-diabetes)
• Jehaninne Austen: Jehaninne is a neuropsychiatric geneticist and a genetic counselor. They are a professor at the University of British Columbia.
• Prescilla Carrion: Prescilla is a senior research genetic counsellor and clinical associate professor in the UBC Department of Psychiatry and was the genetic counsellor for the Cool Aid Community Health Centre team as part of the GenCOUNSEL research project.

Resources

• If you would like to learn more about CHANGE BC and the engagement of kinesiologists in Primary Care in BC check out the Team UP webinar: CHANGE BC and Team Based Care: a rural experience and visit the Change BC website.
• To read more about the impact of embedding psychiatric genetic counselling in primary care visit: https://blog.invitae.com/real-stories-prescilla-c-2b8475b29e8f.
• To see the impact of psychiatric genetic counselling on a client, Prescilla recommends watching this video: https://youtu.be/gKX1MAggeX0?t=3321
• And coming soon: Carrion PB, Austin J, Elliott AM. A genetic counselor's reflections on lessons learned, challenges, and successes experienced during a one-year pilot integration in a primary care clinic. Public Health Genomics. 2023 Jun 12:1. doi: 10.1159/000530683. Epub ahead of print. PMID: 37307802.
• Slomp C, Morris E, GenCOUNSEL Study, Price M, Elliott, AM, and Austin JA. The stepwise process of integrating a genetic counselor into primary care. Eur J Hum Genet. 2022; DOI: 10.1038/s41431-022-01063-4.

In this episode Morgan and Sarah explore Indigenous Advocate and Indigenous liaison roles in Primary Care. Indigenous Liaisons and Advocates work across the primary care system to support Indigenous people in accessing care. This can also include supporting system transformation towards more culturally safe care, providing education to healthcare colleagues, and working alongside Indigenous Nations, elders, and community to design care for local needs. We will hear from two people who work in advocacy and liaison roles about what they do, how they work, and what they enjoy about working in primary care.

The key takeaways from this episode include:

1. Indigenous support roles might span the whole system of care and are responsive to the unique needs of each community and Nation they serve - they won’t ever look the same and that’s a good thing!
2. The approaches, decisions, and changes to care must be guided by community, elders and Indigenous people.
3. Care practice between Indigenous support roles and patients needs to: be grounded in relational care, have a deep understanding of history, take careful consideration of space, and allow the process to unfold with Indigenous patients setting the pace.

Guests:

A huge thank-you to our guests from this episode for sharing their knowledge and experience with us. In this episode you heard from:

• Reina Thurmer: Reina was born and raised in Whitehorse, Yukon, and she is a member of the Wikwemikong First Nation on her mother’s side and German on her father’s side. When interviewed for this episode, she held the role of Indigenous Wellness Advocate with the Comox Valley PCN, working on the K’ómoks First Nation supporting patients in receiving culturally appropriate care from family doctors, nurse practitioners and other healthcare team members. She has since left that role and started med school!
• Gracie Kelly: Gracie’s family roots are with the Soowahlie/Xaxlip First Nations and she is a Cultural Safety and Humility facilitator, an educator, enjoys sharing traditional teachings and is an advocate of supporting Indigenous communities. Gracie works with the Chilliwack Division of Family Practice, a non-profit society that represents Family Physicians in Chilliwack, Agassiz, Seabird Island and Hope. Their members provide primary care services from Chilliwack to Boothroyd and strive to improve health care services for patients by supporting an engaged and collegial medical community.

Resources and Links :

• To learn more about Gracie’s work with the Chilliwack Division of Family Practice have a look at the PDF they have created for Cultural Safety and Humility
• Cultural Safety and Humility Brochure.pdf
• and visit: https://divisionsbc.ca/chilliwack/sharing-cultural-safety-and-humility.
• To learn more about the breadth of work being done in the First Nations Health Authority see: https://www.fnha.ca/what-we-do. For more information about their work on cultural safety and humility across the healthcare system see: https://www.fnha.ca/wellness/wellness-and-the-first-nations-health-authority/cultural-safety-and-humility
• To learn more about pronunciation of First Nations in BC see the First Nations Pronunciation Guide: https://www.first-nations.info/pronunciation-guide-nations-british-columbia.html and https://www2.gov.bc.ca/assets/gov/british-columbians-our-governments/indigenous-people/aboriginal-peoples-documents/a_guide_to_pronunciation_of_bc_first_nations_-_oct_29_2018.pdf
• In Plain Sight Report on Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care: https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdf
• To read more about the Chilliwack & Fraser Health Rural Primary Care Centre: https://www.fraserhealth.ca/Service-Directory/Locations/Chilliwack/chilliwack-and-fraser-health-rural-primary-care-centre-momiyelhtelaxwt.

In this episode Morgan and Sarah learn more about the different kinds of roles that Family Nurse Practitioners (NPs) can take on in primary care teams in BC. NPs are uniquely positioned in BC and can act as Primary Care Providers and/or work with focused populations. In conversations with NPs who work in a range of models of care including NP clinics, Urgent and Primary Care Centres and Community Health centres Morgan and Sarah learn about NP scope of practice, and hear stories of how NPs work as part of these different kinds of teams.

Our calls to action this week are generalizable across all roles in primary care teams!

• First, create time to connect
• Second, build shared understanding of roles and standardize roles wherever possible - particularly when there is very real role overlap - like you would see with an NP and a Family Doctor (and include patients in building this shared understanding)
• Lastly Figure out communication pathways and build good communication cadence, to support coordination, and also relationships across the team.

Thanks to our guests this week!

• Eliza Henshaw: Eliza has practiced for 14 years as a primary care Nurse Practitioner across a populations ranging from refugees to complex populations in urban environments in Vancouver. She has been part of a number of interdisciplinary teams, and is currently joining a new clinic within the North Shore Primary Care Network, which is a partnership between Midwives and Nurse Practitioners.
• Sydney Richardson-Carrr: Sydney is a Family Nurse Practitioner who works at the Kelowna and Vernon Urgent and Primary Care Centres. She is also a council member with NNPBC.
• Erin Berukoff: Erin is an NP who has been providing primary health care services to her patients at Family Tree Health Clinic in Powell River for almost 5 years
• Kelvin Bai: Kelvin is an NP who works as part of the team at RISE Community Health Centre in Vancouver, which serves a diverse inner city patient population with a large number of immigrants and refugees, as well as folks with lower socio-economic status, and precarious status where the need for cultural safety and humanitarian concerns motivate the care that is provided.
• Spence Newell (RN): Spence Newell is a registered nurse who works at both the Kelowna and West Kelowna UPCCs. . He completed his BScN at McMaster University in 2017, and since that time he has worked as a nurse in primary care, public health and community health care settings

Resources:

If you would like to learn more about the scope of practice for nurse practitioners in BC check out :BC College of Nurses & Midwives: Scope of Practice for Nurse Practitioners (Standards, Limits, Conditions)

In our conversation Kelvin Bai referenced the integration guidebook as a great resource for clinics and providers. Check out : Nurse and Nurse Practitioners of British Columbia (NNPBC): Integration Guidebook

Take a listen to the TeamUp Webinar from Earlier this year focused on nursing scope of practice: TeamUP: Nursing Scope of Practice

In this episode Sarah and Morgan explore the role of Nurses in Primary Care. Nurses have an incredibly wide scope of practice and fill many roles in primary care - this presents a really unique opportunity to tailor Nurse in primary care roles to the needs of patients. We will hear from three primary care Nurses who work in UPCCs and PCN clinics about what they do, how they work, and what they enjoy about working in primary care.

The key takeaways of this episode are:

1. Nurses have a huge possible scope of practice. Focus in on specific care areas - chronic, preventative, urgent, specific patient populations to help narrow the scope to what is most needed in your clinic.
2. Give Nurses opportunity to identify care gaps they see and to generate innovative solutions to fill them.
3. Structure the work so nurses can build relationships - with patients and with the team.

Guests:

A huge thank-you to all of our wonderful guests for this season! In this episode you heard from:

• Spence Newell (RN): Spence Newell is a registered nurse who works at both the Kelowna and West Kelowna UPCCs. . He completed his BScN at McMaster University in 2017, and since that time he has worked as a nurse in primary care, public health and community health care settings.
• Janie Patrick (RN): Janie is a primary care Nurse working in two clinics as part of the North Shore PCN.
• Erin Williams (RN): Erin is a Certified STI Registered Nurse and Team Lead at the West Kelowna Urgent and Primary Care Centre. She has been working as a Team Lead since West Kelowna Urgent Care opened in October of 2020. Erin graduated with a BSN from UBC Vancouver in 2011 and spent her first ten years of nursing practice in the Acute Care setting before transitioning to Primary Care.

Resources and Links :

• To listen to the Team Up! Webinar on Nursing Scope of practice see: https://teambasedcarebc.ca/resources/resource/team-up-nursing-within-team-based-care-lessons-for-the-primary-care-sector-webinar/
• To learn more about the scope of practice for Nurses visit the BC College of Nurses and Midwives at: https://www.bccnm.ca/RN/ScopePractice/Pages/Default.aspx
• To learn more about RN & LPN roles in PCNs visit: https://www.pcnbc.ca/media/pcn/PCN_RN_LPN_RNC_Scope_of_Practice.pdf
• To learn more about differences between RN & LPN Roles check out some of the resources available on teambasedcarebc.ca
• To learn more about team-based care and the transformation of primary care in BC check out Teambasedcarebc.caand TeamUp community of practice (webinars and of course this podcast series).

In this episode Morgan and Sarah talk ‘bridges’ and ‘anchors’ (or Social Workers and Counsellors) in the context of primary care teams. Weaving together the stories and experiences of a number of primary care providers, social workers, counsellors and other team members, Morgan and Sarah discuss the scope and added value these roles can bring to primary care teams. Key take aways (that are of course generalizable to other roles in primary care as well) include:

• Figuring out how you are going to communicate and creating opportunities to get to know the counsellors and social workers on your team
• Thinking about small changes that can help to create therapeutic spaces in clinic settings and,
• Creating opportunities for providers to work together (in group appointments or case conferences)

Thanks to our Guests:

• Cayce LaViolette: Caycee is a Social Worker who supports patients across the Sunshine Coast Primary Care Network.
• Danielle Parent: Danielle is a social worker at two Urgent and Primary Care Centres in Interior Health.
• Kaila McGann: Kaila is a social worker with the STEPS Community Health Centre
• Tess Bantock: Tess is a registered clinical counsellor with the STEPS Community Health Centre.
• Amie Hough: Amie was a Primary Care Network Transformation Lead for Interior Health at the time this episode was recorded. She has a background in Social Work and has recently transition to Health Quality BC where she will be working closely with us on the next seasons of the Team Up webinar series!
• Eliza Henshaw: Eliza has practiced for 14 years as a primary care Nurse Practitioner across a populations ranging from refugees to complex populations in urban environments in Vancouver. She has been part of a number of interdisciplinary teams, and is currently joining a new clinic within the North Shore Primary Care Network, which is a partnership between Midwives and Nurse Practitioners.
• Shania Sholtz: Shania is a Medical Office Assistant in a maternity and pediatric-focussed primary care clinic in Victoria.
• Terri Aldred: Terri is Dakelh (Carrier) from the Tl'azt'en Nation. She is an outreach primary care physician with Carrier Sekani Family Services and a site director for UBC’s Indigenous Family Practice Program.
• Sydney Richardson-Carrr: Sydney is a Family Nurse Practitioner who works at the Kelowna and Vernon Urgent and Primary Care Centres. She is also a council member with NNPBC.
• Wendy Boyer: Wendy is a Team Based Care Coach with the Practice Support Program (Doctors of BC).

Resources

• To hear more about the work that Caycee does in the Sunshine coast take a listen to the Team Up Webinar episode from last season SW Team Up episode: Social Work and Team Based Care in the Community
• Kaila McGann was also a featured get on the Team Based Care in practice episode from last season: Reflections from the Field: STEPS CHC
• PCN Toolkit SW scope of practice: Social Worker Scope of Practice

In this episode Sarah and Morgan explore the role of Pharmacists in Primary Care. Pharmacists provide a unique lens to care through their detective skills, patient education focus, and deep expertise on medications. We will hear from two Pharmacists about the scope of practice for primary care Pharmacists and the ways in which PCNs and clinical teams can best utilize their skills to care for complex, frail and elderly, and patients on complex drug therapies.

The key takeaways of this episode are:

1. Pharmacists are impressive detectives who will be able to see opportunities for risk mitigation and enhanced patient care that you didn’t even realize were there!
2. Pharmacists are incredibly patient-centered and they look holistically at the patient to ensure that the prescribed treatment is effective, safe, and meets the unique values of the patient.
3. Co-locate your pharmacist! Those relationships are key and the more they can be part of the full clinical scope, the EMR, the team, the more opportunities there will be for them to use their full scope of practice on the team.

Guests:

A huge thank-you to all of our wonderful guests for this season! In this episode you heard from:

• Barbara Gobis (BSc(Pharm), RPh, ACPR, MScPhm, PCC): Barbara is the Program Lead, Pharmacists in Primary Care Network (PCN) Program and Director, Pharmacists Clinic, at UBC Faculty of Pharmaceutical Sciences. Barbara has practiced for the past 30 years as a licensed pharmacist and joined the UBC Faculty of Pharmacy in 2013 to develop, establish and oversee the on-going success of UBC Pharm Sci's Pharmacists Clinic. She has also been instrumental in facilitating the integration of pharmacists in PCNs across BC.
• Sadie Quintal (BSc (Pharm), RPh, BCPS): Sadie is a Pharmacist in the the Comox Valley PCN. Sadie graduated from the UBC Faculty of Pharmaceutical Sciences in 2010 and spent the next four years of her career as a Pharmacy Officer for the Canadian Forces. Working in Island Health since 2015, her varied roles have included ward-based clinical assignments, academic detailing, and temporary Pharmacy Site Coordinator.
• Carolyn Canfield: Carolyn is the ISU’s in house patient-disruptor and adjunct faculty member in the Department of Family Practice at UBC. Carolyn is very involved in the Department of Family Practice and shares her expertise by teaching medical residents about patient experience and engagement She is also engaged in a number of national and international research projects that range in focus from patient engagement in care, to system resilience, to patient safety.

Resources and Links :

• To learn more about the work being done to embed Pharmacists in PCNs across BC, visit https://pharmacistsinpcn.ubc.ca/health-care-providers and https://pharmacistsinpcn.ubc.ca/health-care-providers-and-pcn-administrators/tools-and-resources
• To learn more about the professional practice cope of practice and guidelines for Pharmacists in BC visit https://www.bcpharmacists.org/professional-practice-policies-and-guides.
• For an example of a role description for a pharmacist in primary care see: https://teambasedcarebc.ca/resources/resource/clinical-pharmacist-role-description/
• To learn more about team-based care and the transformation of primary care in BC check out Teambasedcarebc.caand TeamUp community of practice (webinars and of course this podcast series).

In this episode Morgan and Sarah dive into the role of the Medical Office Assistant in primary care teams. From team culture curator, to scheduling master, to on-boarder for new team members, and patient connector, MOAs are often the ‘glue’ that can hold teams together. In this episode we have the opportunity to hear from a number of MOAs, as well other other providers working in a range of clinic settings about how the MOA role is uniquely positioned to understand clinic and team capacity as well as the patient experience.

When you are thinking about how MOAs support team based care and what you can do in a team to really utilize the skills of the MOA team members here are three things to think about:

1. Engage MOAs in planning and decision making in the team
2. Create processes that really utilize the MOA’s unique position as a connector to patients and providers
3. And as always, create opportunities for teams to work together on how they want to work together

Guests:

A huge thank-you to all of our wonderful guests for this season! In this episode you heard from:

• Ava Mundy: Ava is a Medical Office Assistant and a coach with the Practice Support Program, where she has been very involved in supporting the Primary Care Network on the Sunshine Coast.
• Shania Sholtz: Shania is a Medical Office Assistant in a maternity and pediatric-focussed primary care clinic in Victoria.
• Carolyn Canfield: Carolyn is the ISU’s in house patient-disruptor and adjunct faculty member in the Department of Family Practice at UBC. Carolyn is very involved in the Department of Family Practice and shares her expertise by teaching medical residents about patient experience and engagement She is also engaged in a number of national and international research projects that range in focus from patient engagement in care, to system resilience, to patient safety.
• Caycee LaViolette: Caycee is a Social Worker who supports patients across the Sunshine Coast Primary Care Network.
• Eliza Henshaw: Eliza has practiced for 14 years as a primary care Nurse Practitioner across a populations ranging from refugees to complex populations in urban environments in Vancouver. She has been part of a number of interdisciplinary teams, and is currently joining a new clinic within the North Shore Primary Care Network, which is a partnership between Midwives and Nurse Practitioners.
• Erin Berukoff: Erin is a Nurse Practitioner in a Patient Medical Home clinic, where she works with a team of fee-for-service physicians and has her own panel of patients. Erin’s team includes an RN and a Social Worker, that they share with another clinic, as well as 3 MOAs.
• Spencer Newell: Spence is a Registered Nurse works at both the the Kelowna Urgent and Primary Care Center and the West Kelowna Urgent and Primary Care Center.
• Kelvin Bei: Kelvin is a Nurse Practitioner who works with a Community Health Centre in Vancouver, serving a diverse population that includes a large number of immigrants and refugees, as well as people who are at risk for homelessness, people struggling with mental health and substance use, and those with precarious status.

Resources and Links :

• For more information on the ‘Bread and Roses’ metaphor Sarah and Morgan reference throughout this season check out Heath, I., & Montori, V. M. (2023). Responding to the crisis of care. BMJ, 380.
• To learn more about team-based care and the transformation of primary care in BC check out Teambasedcarebc.caand TeamUp community of practice (webinars and of course this podcast series).

Patients are (of course) key members of primary care teams. In this episode Morgan and Sarah dive into the ‘patient role’ in primary care teams.

To prepare for this episode the ISU connected with a handful of patient advocates from across BC. Drawing on the stories and experiences from these interviews Morgan and Sarah weave together aspects of the patients role in teams to talk about 3 things:

1. Patients involved in direct care
2. Patients involved in supporting the system (Education Research and Advocacy)
3. How to best support patients in the shift of primary care to team based care

The episode wraps up with a call to action that includes some great suggestions of things to try out in your teams to support patient engagement in planning, care and feedback.

Guests:

Huge Thank Yous to all of our wonderful guests for this season! In this episode you heard from:

• Marilyn Parker: Marylin is a Patient Advocate who is very involved in research related to Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS) in BC. Marilyn is a member of the Patient Advisory for the BC Primary Health Care Research Network.
• Carolyn Canfield: Carolyn is the ISU’s in house patient-disruptor and adjunct faculty member in the Department of Family Practice at UBC. Carolyn is very involved in the Department of Family Practice and shares her expertise by teaching medical residents about patient experience and engagement She is also engaged in a number of national and international research projects that range in focus from patient engagement in care to system resilience, to patient safety.
• Layton Engwer: Layton is a patient advocate and member of the Patient Voices Network (administered by the BC Patient Safety and Quality Council) who is very involved in primary care transformation. Layton engages at the provincial, health authority and local levels assisting in the introduction of Primary Care Networks and Team based Care in BC.
• Darren Lauscher: Darren ****is a teacher, mentor and patient advocate who grew his activist and advocacy roles in the HIV sphere in the 1980s. He is an expert in patient engagement in research and system change. Darren sits at a number of tables as a patient partner, including the UBC health council, and systems and research tables.
• Barbara Gobis: Barbara is a pharmacist and the Director of the UBC Pharmacy Clinic and the Operational Program Lead for Pharmacists in Primary Care Networks
• Carmela Gracia-Patten : Carmela is one of the first kinesiologist working in Primary Care. Based in northern BC, Carmela is a team member with the Change Program, a lifestyle intervention program focused on metabolic syndrome (people with type 2 or pre-diabetes).

Resources and Links :

• A very recent article on the patient voice, co-authored with Carolyn Canfield and Darren Lauscher who are in this episode: https://onlinelibrary.wiley.com/doi/pdf/10.1111/medu.15121
• For more information on the ‘Bread and Roses’ metaphor Sarah and Morgan reference throughout this season check out Heath, I., & Montori, V. M. (2023). Responding to the crisis of care. BMJ, 380.
• If you are interested in thinking about system resilience take a listen to Season 2 of the Team Up podcast or read some of the latest work that Carolyn Canfield has been involved in with the resilient health care society : (Webinar) Patients and Families engaged in resilient health care systems
• To learn more about the work Darren in involved in around patient and community partnerships see: Towle, Angela & Godolphin, William & Kline, Cathy & Lauscher, Darren. (2020). Building and Sustaining Patient and Community Partnerships in Interprofessional Education. 10.1007/978-3-030-40281-5_15.
• To learn more about team based care and the transformation of primary care in BC check out Teambasedcarebc.caand TeamUp community of practice (webinars and of course this podcast series)
• You can learn more about the Change program [here](https://www.changebc.net/#:~:text=Because life is too short,improve your quality of life.) or listen to the TeamUP Webinar from earlier this season : Team Up! CHANGE BC and Team Based Care: a Rural Experience

In this Episode Morgan and Sarah reunite to kick of season 5 of Team Up: “Role-Call”, focused on -you guessed it- roles in primary care teams. In this introductory episode Morgan and Sarah discuss the plans for season 5, with ~10 role-focused episodes that are going to be released weekly! As they set up the season by re-iterating the value of high functioning teams in the context of the challenges currently facing primary care, the need to balance improved efficiency (with people working to scope), and relationships and trust in primary care teams is highlighted.

Guests:

Not this time! But get ready for longer lists here in the upcoming episodes for this season, as we connect with patients, MOA’s, Nurses, Social workers, Primary Care Providers and a host of other roles in primary care teams to hear their stories and learn from their experiences.

Resources and Links :

For more information on the ‘Bread and Roses’ metaphor Sarah and Morgan introduce in E01 (and may keep coming back to over the course of this season) check out Heath, I., & Montori, V. M. (2023). Responding to the crisis of care. BMJ, 380.

Sarah is back with a cameo to end off Season 4. 

And what better way to end our tech for primary care teams season than by putting Morgan in the hot seat

Sarah has questions you might also have about Electronic Medical Records (EMRs) and how primary care teams can use them better.

Morgan has his best professor elbow patches on and is ready to talk about:

• Care Planning and EMRs
• Team members using different EMRs
• Avoid Faxing in 2023
• EMR Templates and what to think about for EMR templates and different team members

If you also have questions, please send them to us - we’ll do another AMA episode:

isu@familymed.ubc.ca

A bonus episode for TeamUP Tech for Teams season - what about Dr AI?

Some useful links: 

2021 “Primer for artificial intelligence in primary care” by Jacqueline K. Kueper in Canadian Family Physician:

https://www.cfp.ca/content/67/12/889.long

HIPAA Compliance and ChatGPT

https://compliancy-group.com/hipaa-and-chatgpt/

2023, Foundation models for generalist medical artificial intelligence, by M Moor et al. in Nature:

https://www.nature.com/articles/s41586-023-05881-4

Position Paper on Indigenous Protocol and Artificial Intelligence: guidelines for Indigenous-Centred AI design, created from diverse communities in Aotearoa, Australia, North America, and the Pacific.

Please send us questions and topic ideas to isu@familymed.ubc.ca 

In this episode of TeamUP! Morgan talks about how your team can use a patient portal to engage patients and build capacity in your practice. 

Portals can be as simple as making your website more valuable by promoting your team or as complex as a way for patients to asynchronously engaged with their care team.

Based on request, we are continuing this theme of technology for primary care teams - please send questions to isu@familymed.ubc.ca and we will incorporate them into the podcast!