What We Do

Welcome Victoria family physicians and thank you for your interest in the After Hours Coverage Program pilot. By registering below, you will indicate your interest in:

1. Using the service with your attached patients, and optionally
2. Staffing the service

For the pilot period (currently expected to launch mid- to late-September and run for six months), we seek family physicians from the pilot regions of Langley, Victoria, South Island, Thompson Region and South Okanagan-Similkameen Divisions of Family Practice.

After completing the form below, you will receive information from FPSC including an overview of the formal sign-up process.

How your information will be used
The information you provide on this form will only be used by FPSC, HealthLinkBC, and your division of family practice to help plan the after hours coverage service. Your information will not be shared with the College of Physicians and Surgeons of BC nor the BC Ministry of Health for any other purpose.

The GPSC Information Sharing Task Group is committed to providing you with updates on the ongoing development of a draft Integrated Activity Agreement (IAA) and the work underway to pilot the agreement within Primary Care Networks (PCNs). For the last several months we have been working on launching a pilot of the IAA with Kootenay Boundary.

The Information Activity Agreement (IAA) will be piloted in select PCNs and is not currently being rolled out broadly. Building on that experience, we will work towards finalizing and sharing an IAA that can be used by PCNs across the province. If your PCN is interested in being a pilot site for the IAA, please contact gpscinfosharing@doctorsofbc.ca..

Here are some common questions about the IAA:

What is the IAA?

Sharing identifiable patient information is integral to planning, implementing, evaluating, and delivering comprehensive care within PCNs. In addition to sharing information for direct patient care, PCNs may desire to share information amongst their PCN partners for quality improvement (QI), evaluation, and/or planning purposes. The IAA provides the legal framework for public providers (i.e., health authorities) and private providers (i.e., physician practices) to share identifiable information with each other and enable data-driven improvements to the PCN leading to improved patient outcomes.

What is the purpose of the IAA?

The IAA provides the legal framework that bridges the gap between the two privacy legislations, that exist for the public sector (FOIPPA) and the private sector (PIPA).

How would Information Sharing affect my practice?

For specific projects, an Information Sharing Plan (ISP) will be developed by the interested parties, which defines the scope, details, and accountabilities of each analytic project, including what information will be shared, how it will be used and kept secure, and what will happen to the collected data once the project is finished. The ISP must be signed by the parties who participate in the project and only information specified in the ISP can be shared and analysed. Projects can be local to a community or provincial in scope.

For example, a Health Authority and private practices could share linked identifiable information about patients with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), who present to the Emergency Department with a COPD exacerbation. This could provide the PCN with data to support creating an outreach program to patients with COPD in order to generate COPD Action Plans, conduct severity reassessments, and even offer weekly SMS check-ins about immunizations and current respiratory status during the fall/winter months.

What are the overall benefits of the IAA and Information Sharing?

• Improves patient care.
• Allows for more efficient use of resources.
• Identifies previously unknown gaps and care opportunities that may not be known until the patient’s complete journey through the healthcare system is understood.

What are the benefits of the IAA and Information Sharing for physicians?

There are four primary benefits the IAA aims to achieve for physicians:

1. Confidence that patient data is handled in a secure and respectful manner, consistent with privacy legislation, throughout its analysis journey;
2. Improved care for patients as all PCN stakeholders can use patients’ journeys through the health care system when planning services;
3. An ability to access data from other stakeholders in order to dive into data-driven research;
4. The ability to compare their own practices to others’ practices (anonymously), ask the question “Why am I different (than the average)?”, have the data necessary to answer the question, and improve care quality in their own practice, and even potentially throughout the system.

What are the next steps?

We are currently working with Kootenay Boundary PCN to initiate the first pilot of the draft IAA. Over the course of the year, we will support additional pilots with two other PCNs. Building on that experience, we will work towards finalizing and sharing an IAA that can be used by PCNs across the province. We are also developing new resources and supports that will help PCNs implement the IAA and engage in broader information sharing.

How can I learn more?

We will continue to provide updates on the progress of this work and hold engagement opportunities as required in the future. In the meantime, please direct any questions or feedback to gpscinfosharing@doctorsofbc.ca.

Additional information sharing documents:

• Team Charting Agreement FAQ (PDF).

Archived information: 2019 Community Longitudinal Family Physician Payment

Please note: The following is 2019 CLFP Payment information, please click here for 2020 CLFP Payment information. 

The Community Longitudinal Family Physician (CLFP) Payment recognizes community-based family physicians who work under fee-for-service and who care for a panel of patients for providing long-term, relationship-based care.

Longitudinal care includes providing patients with ongoing medical care, maintaining patients’ medical records, and coordinating referrals to other health care providers when needed. The CLFP Payment recognizes the additional, non-clinical responsibilities required to provide ongoing, coordinated care for which fee-for-service physicians are not compensated.

An eligible physician will receive a total payment amount of no less than $3,000 and up to $12,000, with exact payment amount per individual physician based on the number and complexity of Majority Source of Care (MSOC) patients associated with the physician in the MSP database.

The CLFP Payment may be subject to business arrangements pertaining to how MSP payments paid to particular payee numbers are split between physicians and clinic owners. In these cases, physicians and clinic owners are encouraged to come to a mutual agreement on how existing business arrangements apply to the CLFP Payment.

The CLFP Payment is an ongoing annual payment. Details for future CLFP Payments have not yet been determined. 

For more information, refer to the Community Longitudinal Family Physician Payment FAQs or contact gpsc.billing@doctorsofbc.ca.

The FPSC works with doctors, divisions, and partners to support the evaluation of projects and innovations within the integrated system of care being created through patient medical homes (PMH) and primary care networks (PCN). The evaluation process takes place at the local, regional, and provincial levels.

The goal of evaluation is to give divisions, doctors, and partners the opportunity to learn from experiences, adopt innovations, and make strategic decisions. The process supports knowledge sharing and health system improvement, and helps the FPSC to support the spread of success and identify and address needs in practices, communities, and the system.

Get involved

• Reflect on practice opportunities using PMH Assessment and Patient Experience Tool.
• Co-develop evaluations and case studies that highlight experiences and innovations.
• Share community voices through stories of most significant change.
• Contribute to the provincial understanding of PMH and PCN implementation and outcomes.

To learn more or to participate, contact evaluation@doctorsofbc.ca or a local division of family practice.

Work underway

Click on the following titles for more information on the work to date on key evaluation activities.

Join the FPSC Evaluation Roster - help us conduct health system evaluation across BC

The FPSC Evaluation team is looking for candidates with evaluation expertise to be part of a Consultant Evaluation Roster. Our team helps support the provincial evaluation of patient medical homes (PMHs) and primary care networks (PCNs) across British Columbia. These provincial, regional, and local-level evaluations are key to understanding the successes and challenges of PMH and PCN work.

Candidates in the roster will be available for consideration whenever relevant opportunities arise. Strong candidates will possess background and/or subject area expertise in the BC primary care system. We welcome candidates from a range of evaluation backgrounds and methodological approaches. Candidates will be contacted directly by the relevant team using the email address provided in their application.

Apply by filling out the intake form.

Participate in a supportive network of local primary care services to increase comprehensive care.

Across BC, divisions of family practice, the five regional health authorities, the First Nations Health Authority, First Nations, and community partners are working to establish primary care networks (PCNs).

Read about the refreshed primary care network (PCN) approach, announced August 22, 2023.

A PCN is a clinical network of local primary care service providers located in a geographical area, with patient medical homes (PMHs) as the foundation. A PCN is enabled by a partnership between a local division of family practice, their regional health authority, local First Nations, and other community partners.

In a PCN, physicians, nurse practitioners, nurses, allied health care providers, health authority service providers, local First Nations, and community organizations work together to provide all the primary care services a local population requires. Together, they:

• Enhance patient care using a team-based approach to care.
• Support each other and work to their own strengths.
• Ensure patients are linked to other parts of the system, including the health authority’s specialized community services programs for high risk and vulnerable population groups.
• Collectively work to increase access and attachment to primary care.

Participation in a primary care network helps patient medical homes operate at their full potential. A PCN aspires to provide patients with access to timely, comprehensive, and coordinated team-based care, guided by eight core attributes.

PCN Core Attributes:

• Access and attachment to quality primary care.
• Extended hours.
• Same day access to urgent care.
• Advice & information.
• Comprehensive primary care.
• Culturally safe care.
• Coordinated care.
• Clear communication.

When participating in a PCN, family physicians can:

• Provide optimal care for patients with the support of teams, and easily accessed health authority services.
• Access expanded services for vulnerable populations and those with complex health conditions.

Get involved

For more information about the primary care network in your community, please contact your local division of family practice. For all general inquiries please contact pcn@doctorsofbc.ca.  

Updated April 11, 2024

Support and get support from colleagues for continuous, comprehensive patient care

Physician networks are formal or informal relationships through which doctors support each other with clinical services to meet the comprehensive care needs of their patients, and a key element of a patient medical home.

Doctors can rely on each other to provide practice coverage and continuous care for patients when they are away from the office, as well as multidisciplinary care and peer support.

While some physicians in BC are already working together in groups, the creation of formal physician networks is an emerging area of focus for divisions of family practice, and foundational to the creation of primary care networks (PCNs) in local communities.

Physicians determine the makeup of their network(s) and the services they will collectively provide to best support their local needs. A network can be made up of a group of doctors and combination of relationships: family doctor-to-family doctor, family doctor-to-specialist, and/or patient medical home (PMH) to PMH, who collectively support each other to:

• Arrange for cross-coverage, locums, out-of-hours care, and on-call groups, including those for specific patient populations such as residential care, maternity, in-hospital, end of life, etc.
• Access shared team-based care resources.
• Provide peer support for clinical matters.

For patients

Physician networks can increase patient access to continuous, comprehensive primary care, including after-hours care and specialist care.

For doctors

In physician networks, family doctors can:

• Increase their capacity to support patients.
• Feel relief to know their patients are looked after, and they have someone to count on.
• Avoid burnout and increase work-life balance.

Get involved

Local networks are customized by physicians based on their needs.

This is an evolving area of work. In some communities and rural areas, physicians are already part of a network or on-call group, or are starting networks with colleagues to provide cross-coverage or after-hours care, and care for specific population groups, like maternity patients.

In some communities, divisions of family practice are taking on the job of planning for the development of formal physician networks with funding from the GPSC. More information will be available in spring 2019.

For more information about physician networks, please contact the FPSC or visit the Divisions of Family Practice website.

Access a team of health care providers to support quality care

BC is working to increase people’s access to primary care by introducing a team-based care approach to primary care. This is being done through patient medical homes (PMHs) in family practices, primary care networks (PCNs) in the community, Urgent and Primary Care Centres (UPCCs) across BC, and the Nurse in Practice Program.

Within a team-based model of care, multiple health care providers from different professional backgrounds work together and with patients/clients, families, caregivers, and communities to deliver comprehensive health services across care settings. Effective teamwork is a critical enabler of safe, high quality care and supports a patient's ongoing relationship with their primary care provider (a family physician or nurse practitioner). Teams broaden availability and accessibility of clinical supports for patients and for family doctors.

Teams are organized locally through various partnerships of doctors, PMHs, PCNs, divisions of family practice, health authorities, community partners, and the Ministry of Health, and are based on the needs of patients in a community or a practice.

By implementing team-based care, physicians and practice teams can:

• Provide preventive care, disease management and counselling, and arrange for follow-up services in the community.
• Increase support for patients with complex and/or chronic health conditions. 
• Work to their strengths, and support and rely on each other to give patients the best care. 
• Collectively increase a community’s capacity to attach patients to a primary care provider.

For patients

Patients get timely access to continuous, comprehensive care, and appropriate supports to support their health needs and prevent unnecessary ER visits.

For doctors

With the added support and expertise of a team, physicians can:

• Focus more of their time on difficult diagnoses, medical care, and strengthening patient relationships. 
• Reduce the burden of caring for patients alone, which can help prevent burnout. 
• Feel more at ease when they know their patients are well cared for and getting comprehensive support. 
• Increase the efficiency of a practice and streamline processes to maximize time and capacity.
• Improve the satisfaction of family doctors, staff and partners.

Team-based care models aim to attract new doctors to family practice to further reduce pressures on existing family physicians and communities.

Get involved

Opportunities for family doctors to work with teams are increasing as new models of care evolve in BC communities. Family doctors can:

• Use their EMR data (panel management) to understand their patients’ needs and arrange for appropriate team-based support to serve those needs.
• Work with other physicians and the local division of family practice to influence emerging, local team-based care models - including through PCNs. 
• Create an interdisciplinary team in practice or through the community as supports become available.

For more information about team-based care, please contact the FPSC.

Updated April 19, 2024

What is panel management?

Panel management is a process of proactively managing a defined population of patients, using EMR data to identify and respond to patients’ chronic and preventative care needs. The concept is simple: better information about patients leads to better care for patients.

Why do panel management?

The phases of panel management is a framework designed to support doctors as they work to provide longitudinal, proactive care to their patients. An accurate panel means doctors can easily track billings, improve their workflows, improve communications with patients, and maintain a better work-life balance.

The three-phase approach to panel management helps doctors:

1. Improve practice workflow efficiencies.
2. Identify others who can help family doctors care for their patients.
3. Inform and plan proactive care.

What is involved in panel management?

Panel management has three phases:

1. Empanelment assigns patients to individual primary care providers. Having an accurate list of active patients for each provider improves continuity of care and enables population-based care.
2. Building registries involves creating registries that accurately reflect all patients within the panel that have a specific diagnosis and are properly coded with the correct ICD-9 code.
3. Pro-active and preventative care involves using updated data to implement proactive care goals using decision support tools in the EMR. 

Compensation

Family practice teams can receive payment for up to 15 hours in total to participate in each phase of panel management. Once three phases have been completed, family doctors will receive a $3,000 bonus payment.

Certification

Family doctors can earn up to 45 certified Mainpro+ credits (three credits per hour), for up to 15 hours in total for the completion of each phase of panel management.

PSP team members can create and support manageable steps to help physicians optimize their EMR data as they work through the phases of panel management.

How do I get started?

Contact your practice support coach or email us at psp@doctorsofbc.ca to get started.

How long does panel management take?

Each phase could take up to 15 hours of physician or staff time to complete and the total time commitment may be up to 12 months. The process is certified for three Mainpro+ credits per hour and is compensated at sessional rates.

Do I qualify for panel management?

To be eligible for sessional compensation, you must:

• Be a Community Longitudinal Family Physician^[1] practicing in British Columbia.
• Intend to remain the Most Responsible Physician/Provider (MRP) for your patient panel for at least the next 12 months.
• Be using an EMR system to document and manage patient medical information (including medical history, tests, diagnosis, and treatments) in the clinic you are undertaking panel management.
• Commit to completing phase one, two, and three of panel management in the next 12 months.

Each eligible family doctor can claim payments only once.

For questions about eligibility or payments, contact panel.incentive@doctorsofbc.ca.

Panel management training for medical office staff

GPSC offers medical office staff the opportunity to take the Panel Management for Family Practice program through the University of Fraser Valley. The program consists of seven modules with a final capstone quality improvement project implemented in-practice. It offers practical, skills-based training designed to meet the competencies of a panel manager, including basics of the patient medical home and primary care network, empanelment, registry-based care, pro-active and preventative care.

Current course: Tuesday evenings from January 10 to April 18, 2023.

Deadline to submit applications was December 12, 2022.

^[1] A family physician is working as a “Community Longitudinal Family Physician” (CLFP) when they do all of the following:

• Assume the role of Most Responsible Physician/Provider (MRP) for a known panel of patients. The GPSC defines a MRP as a physician who takes responsibility for directing and coordinating the ongoing care and management of a patient. This includes coordinating clinical services delegated to other providers, ensuring cross coverage when MRP is unavailable, and coordinating referrals to specialty care when needed.
• Confirm patient-physician relationship with their patients through a standardized conversation or “compact”, as outlined in PG14070.
• Provide, or coordinate delivery of, longitudinal full scope family medicine primary care services to a patient panel that is inclusive of patients of diverse demographics and medical needs.
• Work in community settings such as physician offices or health care clinics where patients are seen in person. CLFP may also provide some virtual services to their patient panel via telephone, video or other virtual care modality. CLFP may also provide some services to patient panel in facility settings such as hospitals, long term care, hospices, assisted living, or group homes.
• Maintain the comprehensive longitudinal medical records of each patient on patient panel.

A family physician is not considered to be working as a CLFP while they are working solely in one or more of the following health care settings:

• Episodic care settings such as (but not limited to) walk-in clinics, urgent care centres, and hospitals, where physician does not assume the role of MRP for patients.
• Virtual care settings where patient care is delivered via telephone, video, or other virtual care modalities.
• Focused practices serving a specific patient population or providing sub-specialty services such as (but not limited to) maternity care, palliative care, sports medicine, chronic pain, and addiction care.
• Facility settings such as (but not limited to) hospitals, long term care, hospices, assisted living, or group homes.