A new mindfulness group for youth led by family doctors is making a tremendous difference for adolescents in the Comox Valley by equipping them with techniques for managing stress, pain, and anxiety as well as preventing depression relapse.
People living in long term care (LTC) facilities are more likely to enjoy better health outcomes and avoid emergency room visits when they have access to a dedicated physician who can observe, manage and coordinate their medical needs in a consistent and timely fashion.
The stories below are real-world examples of how family doctors and local divisions improve patient care in BC through innovation and collaboration.
With so much innovative work underway to improve primary care in BC, it’s no surprise that the Practice Support Program’s Adult Mental Health (AMH) module has the medical community in other areas taking notice. While designed for practising family physicians in BC, the module’s positive impact on patient care and physician experience have gained recognition elsewhere—the module is now being used for training in other provinces and incorporated into training for the next generation of BC family physicians.
“We’ve taken the module on the road and presented at major conferences, trained front-line workers in Manitoba and front-line workers and physicians in PEI, and taught it at McGill University in Quebec,” says Rivian Weinerman, a physician in Victoria who was part of the team that created the AMH several years ago. “We’ve presented it in Hong Kong, Grenada, Tennessee, and other places. And now we’re embedding the module into the University of BC’s family practice residents’ program and the University of Victoria’s nursing program.”
A joint initiative of Doctors of BC and the BC Ministry of Health, the Practice Support Program (PSP) is a training and support program for physicians and their MOAs that is designed to improve clinical and practice management and to support enhanced delivery of patient care.
The AMH module includes screening and assessment tools and three supported self-management approaches: the Bounce Back program, the Antidepressant Skills Workbook, and the Cognitive Behavioural Interpersonal Skills (CBIS) Manual, which form the core of the AMH. CBIS provides an organized, guideline-based system for physicians to assess patients and to develop treatment strategies that incorporate self-management processes to empower patients to be active partners in their mental health treatment. The manual is also featured in the Canadian Medical Association national e-learning anti-stigma course for physicians, in partnership with the Mental Health Commission of Canada.
“We’ve trained front-line workers such as case managers, pain clinicians, diabetic clinicians, substance use clinicians, nurses, and family practice residents in the use of CBIS,” says Weinerman. “Both patients and clinicians enjoy it.”
PSP learning modules typically involve three half-day group-learning sessions, offered locally in communities throughout the province. Each group session is followed by an action period of approximately eight to12 weeks during which PSP participants try out what they’ve learned in their own practice. During action periods, participants receive in-practice support to ensure they get as much benefit as possible from the learning sessions, and have the guidance they need to incorporate newly acquired tools and processes into their everyday practice workflow.
For UBC’s family practice residents, the exposure to the module is more limited. During their residency, new medical school graduates have a one-day session on CBIS as part of their academic training that supplements their clinical work.
“Residents consider CBIS to be important, and they can be a hard bunch to please at times,” says Dr Karen Shklanka, faculty member for behavioural medicine in the University of BC’s Department of Family Medicine Residency Program.
Dr Helen Campbell, who was also part of the team that developed CBIS, teaches residents on Vancouver Island and in the Lower Mainland and says she’s had great feedback.
“Residents are very receptive to it,” she says. “Through their training, they are comfortable with the medication side of managing mental health in the office but are not quite as confident with non-medication options for their patients. Learning about CBIS increases their satisfaction. It feels good to be offering more than just reaching for a prescription pad.”
“I feel like I have some tools to use for mental health conditions that I didn’t have before,” said one resident after Campbell’s lecture. “I look forward to testing out the different strategies with my patients.”
Dr Annemarie Falk teaches the AMH module both as a mentor to doctors receiving training through the PSP, and to residents at St. Paul Hospital in Vancouver. “The AMH module has given physicians a much bigger toolbox of treatments to offer patients, and more information about treatments other than medication,” says Falk.
Falk teaches St. Paul’s residents about the online resources the PSP provides. “They get everything on a flash drive, and I show them the CBIS manual and go through some basic screening tools,” she says. “Then we spend time listening to residents describe their real-life office experiences with patients. Having this training earlier in their practice benefits everyone. As family physicians, we have to know so much about a wide range of medical and health-related conditions. Treating mental health conditions can be daunting if you don’t have adequate skills.”
Weinerman says that teaching these skills to physicians and other front-line workers can also decrease the stigma sometimes associated with patients presenting with mental health issues. “I think that physicians sometimes avoid patients when they feel they don’t have the tools to treat them,” she says. “The module enhances the idea of patients being heard and understood by their doctors, which makes them feel respected. Doctors begin to feel more comfortable and confident, and when a patient senses that and feels heard and respected, it helps decrease self-stigma.”
Weinerman is currently working with the Mental Health Commission of Canada on a randomized controlled trial of the AMH module with family doctors in Nova Scotia that will run from January 2014 to the end of 2015. Doctors will partake in module group training, and the module’s efficacy and the participating physicians’ attitudes toward patients with mental health conditions will be evaluated. Weinerman’s hypothesis is that there is a relationship between training and skills-building and health care provider stigma reduction, but, she says, “This is the first time we’ll have a formal study with a control group to see if this reduction is really happening.”
The PSP began as an initiative of the General Practice Services Committee (GPSC) – a joint committee of Doctors of BC and the BC Ministry of Health (the ministry) – and now receives additional direction, support, and funding from the Shared Care Committee and the Specialist Services Committee (also partnerships between Doctors of BC and the ministry).
When a woman goes through menopause, her body is changing rapidly, and many women have a lot of questions about how to cope with the changes.
Dr Liz Zubek wants to answer all her patients’ questions, but sometimes an office appointment is just not long enough to impart all the information her patients need, especially when a long chat might be needed. That’s why Zubek’s group medical visits for menopause are so popular.
“I like to have my patients fully informed, so I love the group visits as a doctor,” says Zubek, a family physician in Maple Ridge. “I can sit back and talk without a time limit, without worrying also how many people are waiting for me in the waiting room. It’s very invigorating to have these group visits.”
Group medical visits are one of the practice innovations popularized by the Practice Support Program (PSP), a joint initiative of Doctors of BC and the BC Ministry of Health that provides training and support for physicians and their MOAs designed to improve clinical and practice management and to support enhanced delivery of patient care.
Zubek attended PSP sessions on practice efficiency methods, such as group medical visits, and working with patients on mental health issues.
She has been holding group medical visits for different groups of patients for a few years now, including groups for heart health, nutrition, aging, chronic pain, and diabetes. But Zubek says her menopause groups bring a different tone to the notion of a group visit.
“Some groups are more medical, some more of a teaching session, but my menopause group is really a cluster of women gathering together,” she says. “We have up to a dozen women after office hours gather in my waiting room, and we can cover everything. It’s really a lot of back and forth, with chatter all the way through.”
Zubek holds the menopause group session a few times a year. Her patients can sign up online if they want to attend the next session, as they can for all her group visits. Patients of other doctors in her clinic often ask to attend, and if she has room, they can.
Each group visit begins with a discussion about privacy and confidentiality, and every patient signs a confidentiality agreement. Some women start out at the group as the shy ones, nervous about asking questions on some topics. “ Some of the more outspoken women usually ask the questions at first, like about sex during menopause, or hormone replacement therapy, and I can see that the shyer ones are really benefitting from my answers,” notes Zubek.
For Rosie Keating, 57, the menopause group visit was an important experience.
Keating said the age range of the patients also helped her, allowing her to hear from older women who could share their journeys through these big changes.
“I went in with my own questions, but having others in the visit with me made me listen to their questions and the answers, and it made me reconsider decisions I’d made about how to treat my symptoms,” she says.
While Zubek plans the menopause groups to last an hour, she says they always go a bit longer. “And there’s always a lot of laughter,” she says.
“I believe in medicine that information is power,” adds Zubek. “I’m trying to let patients make the best choices for treating the symptoms of menopause. In the group visit we get to spend a lot more time discussing the options.”
The PSP began as an initiative of the General Practice Services Committee (GPSC) – a joint committee of Doctors of BC and the BC Ministry of Health (the ministry) – and now receives additional direction, support, and funding from the Shared Care Committee and the Specialist Services Committee (also partnerships between Doctors of BC and the ministry).
Like most family doctors, Herman Keyter of Valemount saw many patients dealing with mild to moderate depression, but his ability to help these patients relied more on referrals and medication than he’d have liked. But now Dr Keyter is armed with new tools that help him to manage the care of patients with mental health conditions, allowing both him and his patients more control over their treatment.
Keyter now follows the protocols set out in the Practice Support Program (PSP) Adult Mental Health learning module.
A joint initiative of Doctors of BC and the BC Ministry of Health, the PSP provides training and support for physicians and their MOAs designed to improve clinical and practice management and to support enhanced delivery of patient care.
The PSP Adult Mental Health module helps family doctors like Keyter to screen their patients more thoroughly for mental illness and diagnose conditions that were previously more difficult to detect. The module tools and resources include common screening scales, a diagnostic assessment interview tool, a tool for organizing patient issues, a cognitive-behavioural skills program, and a patient self-management workbook.
“The module provides a structure to my work with patients who have mental health issues and adds an extra dimension to the treatment,” says Keyter. “With a process in place, including worksheets for me and the patient, there is much less frustration for both of us.”
Led by other family doctors, known as “physician practice leaders,” the Adult Mental Health module helps physicians develop a care plan that incorporates cognitive-behavioural, interpersonal, and problem-solving skills in real office time.
Jeanette (who asked that her last name not be used) has been through several programs to deal with her depression but is very happy with her current treatment from Dr Keyter.
“It’s easier for me to do appointments with him,” she says. “It’s much more personal, and I prefer the one-on-one. He’s my doctor, and he knows a lot of my situation and how to work with me. And he is so compassionate. He could be a counselor. ”
Jeanette also likes getting new worksheets at each appointment that have something for her to work on or a list of resources. “Being able to write things down and go through it with Dr Keyter face-to-face is wonderful,” she adds.
For Keyter, the Adult Mental Health module has resulted in not only more patient satisfaction but also more professional satisfaction.
“As my patients become empowered, I feel much less frustration with my practice,” he says. “I’ve always tried to help patients with mental health problems, but now I feel I have the tools to deal with the whole patient in a more patient-centred way.”
The PSP began as an initiative of the General Practice Services Committee (GPSC) – a joint committee of Doctors of BC and the BC Ministry of Health (the ministry) – and now receives additional direction, support, and funding from the Shared Care Committee and the Specialist Services Committee (also partnerships between Doctors of BC and the ministry).
Many family doctors in British Columbia are holding group medical visits to see patients with similar conditions in a larger setting, but for Dr Karin Blouw of Smithers, group visits are a chance to expand her work in geriatric psychiatry. She is the first BC doctor to hold group visits for patients with dementia and their caregivers.
“We’re holding these group visits monthly for 6 months, and while we’ve only had three so far, to date it’s been very successful,” says Blouw. “The group dynamic is working better than I expected.”
Group medical visits are one of the practice innovations popularized by the Practice Support Program (PSP), a joint initiative of Doctors of BC and the BC Ministry of Health that provides training and support for physicians and their MOAs designed to improve clinical and practice management and to support enhanced delivery of patient care.
Blouw attended PSP learning sessions on practice efficiency methods such as group medical visits.
Blouw is a family doctor and she consults in geriatric psychiatry. She has many patients with dementia, so she decided to start holding group sessions for them. Her first sessions had six to eight patients per visit, along with one or two caregivers per patient. Each monthly session features a speaker, such as a dietician, occupational therapist, mental health expert, or pharmacist.
The group visits are held in a large, central space at the community healthy living centre, and snacks are served. First, confidentiality agreements are signed; then there is a presentation from the speaker. Blouw then holds a round-table discussion to find out how things are going for each patient, and there is time for questions, medical checks, and prescription renewals.
“At first, it was tough to adjust to the group setting with patients,” says Blouw. “I’m used to doing things one-on-one in a closed office. But after doing a couple, I see that the group dynamic is working better than I expected, and I’m getting used to it. The participants are very comfortable discussing their issues together.”
The patients in Blouw’s group have mild to moderate dementia. “They are all very respectful of each other, and there is good interaction, lots of interest, and positive feedback,” she says.
Kim De Sensi has been bringing her father to Blouw’s group visits and finds they offer a different level of interaction.
“At first, I wasn’t sure what the group visit was about, but by the second one, we were sharing medical information and feeling completely comfortable about that,” says De Sensi. “The speakers offer great information, and this is definitely more medical than my usual caregiver support group. I’m glad to see new stuff like this.”
While Blouw admits she is in the early stages of incorporating the group format into treatment, she believes it is valuable for the patients and for her so far. “I’ve already had requests from others wanting to join the next group,” she says.
The PSP began as an initiative of the General Practice Services Committee (GPSC) – a joint committee of Doctors of BC and the BC Ministry of Health (the ministry) – and now receives additional direction, support, and funding from the Shared Care Committee and the Specialist Services Committee (also partnerships between Doctors of BC and the ministry).