Older adults and seniors receiving home-based care can lack the connected, primary care support networks that others take for granted. From June 2020 to March 2023, the Surrey-North Delta Division of Family Practice led the Coordinating Complex Care for Older Adults (CCCOA) project, to help older adults with complex health needs remain healthy and safe at home. At its core was a simple but powerful focus: strengthening connections between family physicians (FPs) and community health nurses (CHNs).
When providing care, FPs and CHNs aren’t always easily connected—whether due to limited awareness of each other’s roles, caregiver turnover, or uncertainty about how to reach one another. This adds further complexity to medical, communication, and psychosocial challenges.
The project delivered eleven cohorts of Home Health Meet and Greet sessions between 2021 and 2025. According to Project Lead and Manager of PCN Special Projects & System Integration, April Bonise, the sessions were an opportunity to foster trust, discussion, and build relationships. During the sessions, FPs and CHNs explored real-world frustrations such as referral delays, while learning how to navigate systems more effectively together.
“We started with a Shared Care project, but it was the creation of intentional space for authentic conversation that built trust and teamwork,” April explains.
After the sessions, physicians’ knowledge of their CHN improved by 62%, and 98% of participants knew how to contact their CHN. Six months later, 89% of those connections were sustained. Beyond the numbers, both groups reported feeling empowered, supported, and better equipped to care for their patients.
“The meet-and-greet sessions with the Home Health nurses were extremely valuable, and our team is grateful for the opportunity to connect with them. We continue to greatly appreciate the important work they do,” says family physician Dr Maria Anderson.
The initiative improved communication, care coordination, and patient outcomes by prioritizing relationships. For communities seeking to replicate this model, April emphasizes intentional design, leadership buy-in, and thoughtful engagement as keys to success.
About the project:
This work was developed and operationalized by the Surrey-North Delta Division of Family Practice, which is funded by the Family Practice Services Committee.
Project-specific funding was provided by the Shared Care Committee, one of four joint collaborative committees of Doctors of BC and the Ministry of Health, with sustainment funding provided by a Fraser Health HSR (Health System Redesign) grant.
The Surrey-North Delta Division of Family Practice is funded by the Family Practice Services Committee.
Partners in this work included the Surrey division of Home Health (Newton / Gateway), the CCCOA working group, and participating family physicians in the Surrey-North Delta community.
To learn more about this work or get involved, contact Project Lead and Manager of PCN Special Projects & System Integration, April Bonise at april.bonise@snddivision.ca.