Team-based care revolutionizes health care in Langley

December 19, 2023

A revolutionary approach to health care is gaining recognition at the Murrayville Family Practice Group in Langley.

A collaborative team of eight family physicians, three nurse practitioners, three registered nurses, and a clinical pharmacist works cohesively to offer timely and comprehensive medical services for the group, which has offices in Murrayville and Willoughby.

Colin Fee, a clinical pharmacist with four years of experience at the practice, plays a crucial role on the team.

“Our aim is to ensure patients receive timely and effective care, matched with the right provider, at the right time and place, for the right reasons from the start,” says Colin.

Handling up to 20 patients daily, Fee primarily focuses on chronic disease management, covering conditions like hypertension, diabetes, asthma, COPD, and mood disorders. By accessing the practice’s electronic medical records (EMR), ordering labs and bloodwork, consulting with physicians, and prescribing medications, Fee’s approach guarantees patients receive necessary preventative care.

Dr Bruce Griffioen, a clinic physician, highlights the positive impact of the team-based approach. The collaborative model allows him to efficiently manage patients with complex medical issues. The clinic’s Population-Based Funding (PBF) model provides for flexible (15-30 minute) appointments, and Fee's thorough preparation before patient visits ensures a more productive consultation.

“Having the pharmacist and the nurse practitioners here helps me provide better care. They have a different skill set than I do," says Dr Griffioen. "For example, when I have a complex patient, the pharmacist can review the patient's medications before the visit, allowing me to concentrate on the patient in the room.”

Nurse practitioners (NPs), like Heather Jensen, further strengthen the shared care model. Trained and licensed to diagnose and treat medical conditions, NPs play a crucial role in direct patient care. Registered nurses also contribute significantly to the team, performing tasks such as child immunizations and PAP tests. This collaborative approach empowers practitioners like Jensen to efficiently manage a substantial patient load, providing care for needs such as long-term care, transgender care, and home-bound elderly patients.

Dr. Griffioen points out there are many benefits of this team-based model.

“While every patient has an identified Most Responsible Provider (MRP), we cover for one another during holiday coverage and same-day urgent care,” he says. “As a group, they can see 10 to 36 people in the first hour of the day. The interdisciplinary team provides invaluable support for doctors, allowing them to focus on patient care without being burdened by administrative tasks.”

The clinical team is supported by 17 medical office assistants (MOAs).

Jensen adds this approach broadens access to primary care, helping patients and providers alike. The NPs maintain an independent panel of patients in the range of 1,000 per FTE (full-time equivalent) compared to 2,000 per physician FTE at Murrayville Family Practice Group.

“Working together enables all of us to leverage our skills and abilities to care for a large population of patients spanning the continuum from birth to death,” says Jensen. “The group has a large presence in the local LTC initiative and feels well supported by the local division of family practice’s inclusive collaborative approach to care between physicians and NPs. Together, we ensure that more patients have access to comprehensive longitudinal primary care.”

The team is led by Dr Mitchell Fagan, a trailblazer in team-based care, who recently completed his term on the Family Practice Services Committee (FPSC). He attributes the team’s success to the support of the Ministry of Health and Doctors of BC for fostering its development and financial stability. Dr Fagan encourages each team member to practice at the top of their scope while maintaining a robust Quality Improvement (QI) focus.

Fee, on behalf of the clinicians, compiles QI analytics that demonstrate the success of their hard work. The team's achievements extend beyond clinical outcomes, with high rates of patient and provider satisfaction and an impressive patient attachment rate—96% plus of all primary care for their patient population comes directly from the team (excluding hospitalizations/deliveries).

The collaborative and inclusive nature of this primary care team stands as a testament to their commitment to enhancing patient outcomes and ensuring the delivery of the best possible care.