How team-based care is supporting patients & family physicians

April 24, 2023

Adding allied health professionals to the family practice team is improving patient care and easing physician burdens at medical clinics in Mission, BC.

The Mission Primary Care Network (PCN) provides access to a clinical pharmacist, counsellor, and social workers who support medical clinics in the community along with Dr Parin Patel’s practice.

“I can access their support really quickly,” says Dr Patel, family physician with The Medical Group. “I pick up the phone and text and they’ve over in my office, sometimes even within a few minutes. That’s been very helpful.”

About half of Dr Patel’s panel of 1200 patients are older than 65 with multiple medical problems and various social needs.

Clinical pharmacist Caitlin Lang joined the Mission Primary Care Network in October 2022. She works with Dr Patel’s team to pull a list of patients with chronic obstructive pulmonary disease (COPD) from the clinic’s electronic medical record (EMR). She meets with each of these patients to review and document their medications, providing a record to both the patient and doctor. They review symptoms and side effects, consider alternate medications, and talk about reducing medications and dosages where appropriate.

“Some people have multiple inhaled medications to help control COPD symptoms and prevent flare ups,” says Caitlin. “I provide education about which inhaler to use, review their inhalation technique, and go over their action plans if they have a flare up. We’ve had good outcomes with patients as we’ve been able to optimize their inhaler techniques and sometimes change their inhalers.”

“Caitlin advises me if there’s a better device patients could be using according to their ability—such as arthritis in their hands—and what other devices are covered through PharmaCare,” says Dr Patel. “She reviews their medications and recommends patients in whom we could de-prescribe medications if it’s appropriate.”

Patients have told Caitlin that reducing their daily pill burden reduces their stress and greatly improves their quality of life.

As cost can be a huge barrier for patients, Caitlin provides information on PharmaCare coverage and reviews medications to ensure they are optimized.

The PCN social workers who work with Dr Patel’s team help patients find ways of covering the costs of medications and medical supplies like diabetes test strips. They direct patients to community resources for financial support and housing and in some cases, they’ve even found accommodation for patients. They fill out lengthy patient forms, recommending the most appropriate forms for each patient according to their disability, which removes a burden from Dr Patel’s workload as he can review and sign the extensive forms instead of completing them.

“It’s really awesome, especially the help with financial support and housing,” says Dr Patel. “I’m very appreciative of that. Over the years, I would feel frustrated myself because I didn’t know what was out there for patients, and now I have help with that.”

“Patients don’t exist in isolation,” says Rebecca Suchodolski, Mission PCN social worker. “Social issues impact their health and health can impact their social situations. The Mission primary care network acknowledges the intersectionality of patient’s lives and supports them in ensuring they don’t fall through the cracks.”

The social workers provide interim counselling to patients on the wait list for the counsellor, funded by the Mission PCN, who provides one-to-one therapy at no cost to the adult and pediatric patients in Dr Patel’s practice. Dr Patel says patients appreciate the counsellor’s services because they trust the team and they feel comfortable in the clinic.

Ruthann Robinson is a team-based care coach with Doctors of BC’s Practice Support Program (PSP) who’s worked with Dr Patel for many years on practice improvement initiatives. She recalls how team-based care began in his practice.

“Team-based care started organically in February 2022 with conversations with the primary care network team talking about what did they want to do differently and what did collaboration look like,” says Ruthann.

These early meetings involved family physicians from four different clinics, PCN allied health professionals, and the Mission PCN managers from Fraser Health Authority and the Mission Division of Family Practice.

“We had nine months of organic conversations about patient-centred care, collaborative leadership, good communication in team-based care, and we’d done some workflow processes – all of those things with support from FPSC’s (Family Practice Services Committee) practice support program,” recalls Ruthann, “and this brought everyone to say enhanced team collaboration and case conferencing is the next step.”

Ruthann facilitated the team working through the patient journey, communication, and workflow, as well as overcoming a few challenges while implementing team-based care in the practice.

For one, the team needed to find space in a clinic with ten physicians, five medical office assistants, and a registered nurse. They also had to figure out how best to schedule appointments with multiple providers. Then they had to set up EMR access so the allied health professionals could document directly onto the patient charts and share notes through the EMR’s instant message function.

“Many family physicians don’t know how to utilize team-based care because we’re not used to that in primary care,” says Dr Patel. “That’s why this [team-based care] pilot project was introduced. It’s been very effective. I have lots of elderly patients with multiple medical problems and various social needs. I conference with the health professionals, similar to what we do in the hospital care setting, and I ask them what they think the needs are in their areas for the patients. It’s a team approach.”