Report to the Community 2015
Shawna, PCN Nurse
Ray, patient and his wife Darleen
Scott, Family Physician
Message from the Directors The Calgary West Central Primary Care Network (CWC PCN) is about community - your community. We help ensure a healthy community for more than 320,000 people by supporting a network of over 410 family physicians in 118 clinics, with health teams, programs and services. Everyone works alongside your family doctor to provide the best possible care for you. This Report to the Community is our opportunity to share some of our success stories and to tell you more about your PCN. Now in our ninth year, the CWC PCN remains committed to improving the health of the community through the patient’s medical home, which is the family practice where you feel most comfortable and connected. Medical homes are a central hub for the essential health and medical services that you need. CWC PCN support for your medical home includes access to care 365 days of the year, enhanced health teams and help with sustaining and improving the comprehensive health care available to you. The CWC PCN addresses the unique health needs of the people living in the central and southwest areas of Calgary with innovative programs, many of which are prevention and wellness focused. Primary Care Network programming, developed and delivered in partnership with your family
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doctor, is designed to help meet your everyday health needs. Research shows that people who are connected to a family doctor and visit them regularly remain healthier over the years. In addition, they receive better chronic disease care, make fewer visits to the emergency room and are hospitalized less often. Please take some time to learn about how we support your medical home as well as your family doctor and find out about the programs, services and health team members that are there for you. The health teams include behavioural health consultants, dietitians, nurses, pharmacists, physiotherapists and social workers. Last year they worked with over 37,000 patients! They are making health happen. We are proud to share our patient success stories and invite you to learn more about your CWC PCN.
Dan Doll, Executive Director Calgary West Central Primary Care Network
Dr. Jane Ballantine, Medical Director Calgary West Central Primary Care Network
Message from the Board of Directors
Board Members, CWC P.G. Co. Dr. Brendan Vaughan President & Board Chair Dr. Margot McLean Vice Chair Dr. Waldemar (Waldi) Wilken Secretary-Treasurer
An annual physician member survey is conducted as part of our ongoing evaluation activities. This year, approximately 97 per cent of our doctors reported that they are satisfied with their involvement with the CWC PCN and an equal number reported that CCTs improved their ability to provide quality care to their patients. The Primary Care Centre (PCC) continues to serve as a valuable hub for patient access to care. Over 9,105 patients were seen by appointment in the PCC’s seven-day-a-week, same-day service for all types of medical needs, including blood pressure monitoring. There were also 4,274 patients referred to the PCC from their call to Health Link. Ninety one per cent of patients surveyed rated their care at the PCC as the best. In addition, over 5,000 patients accessed primary care through our partnership with the Tsuu T’ina Nation. Top left to right: Dr. Phillip van der Merwe, Dr. Scott Forsyth, Dr. Waldemar Wilken, Dr. Elisabeth Woolner. Bottom left to right: Dr. Scott Beach, Dr. Brendan Vaughan, Dr. Margot McLean. Dr. Jacqueline Swirsky – not pictured.
Overall, the physicians in our network are saying that the CWC PCN helps improve patient flow, access to their practice and the health of patients with chronic disease. They also report how we helped them through the addition of complementary skills to their practice, while improving patient satisfaction.
On behalf of the Board of Directors, I am pleased to share some key program highlights from the 2014 fiscal year. This Report to the Community provides a snapshot of our work, ranging from the number of patients we have cared for to a measure of physician satisfaction. In addition, beyond the numbers there are stories from our collaborative care teams (CCT) and patients that provide a deeper sense of how we impact lives.
We are proud of what we are accomplishing for our patients and excited about being leaders in the evolution and improvement of primary care.
The CWC PCN services and programs are designed for this network of family doctors and their patients, enabling excellence in community-based comprehensive primary care.
Dr. Brendan Vaughan, Family Physician CWC P.G. Co. Board of Directors Chair Calgary West Central Primary Care Network
Dr. Scott Beach Board Director Dr. Scott Forsyth Board Director Dr. Jacqueline Swirsky Board Director Dr. Phillip van der Merwe Board Director Dr. Elisabeth (Betsy) Woolner Board Director
Governance Committee Members Dr. Brendan Vaughan CWC P.G. Co., Co-Chair Dr. Karen Fruetel AHS Representative Nancy Guebert AHS Co-Chair Julie Kerr AHS Representative Dr. Margot McLean CWC P.G. Co. Dr. Scott Beach CWC P.G. Co., Alternate Dr. Elisabeth (Betsy) Woolner CWC P.G. Co., Alternate
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About Our Organization What is a Primary Care Network? Primary Care Networks were established to improve access to family physicians and other frontline health care providers. There are currently 42 Primary Care Networks in Alberta, and the Calgary West Central Primary Care Network (CWC PCN) is one of the largest.
320,000 patients
410 physicians 118 clinics
PCNs support your family doctor to help build a medical home for you – the place where you can feel most comfortable talking about your health and medical concerns and where you’ll receive streamlined and coordinated primary health care. In your medical home, you may have access to an extended team of health professionals, such as behavioural health consultants, dietitians, nurses, pharmacists, physiotherapists and social workers (availability varies by clinic), who enhance your doctor’s ability to care for you. A strong medical home ensures that you have greater access to primary health care. Because your medical home is part of a larger health community or neighbourhood, you not only have timely access to appointments at your doctor’s office, but also to health and other medical services both at and outside of your doctor’s office.
1 network Dr. Vaughan, Family Physician
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Our Vision
Providing excellence in community based comprehensive primary health care.
To increase the proportion of residents with access to a family physician and to help support continuous care through coordinated 24-hour, seven-day-a-week access to affiliated and appropriate primary care services.
Enhanced Team-Based Care
To facilitate the right service at the right time for patient needs through collaborative care teams that consist of inter-disciplinary health professionals.
Access
Access
Sustainable Comprensive Family Practice
A patient’s Medical Home is a family practice regarded by a patient as the place they feel most comfortable or at home to discuss their personal, family health or medical concerns. It is a hub for the timely provision of comprehensive health and medical services.
Enhanced Team-Based Care
Medical Home
Medical Home
Sustainable Comprehensive Family Practice
To support family physicians by providing programs that target the unique needs of community based comprehensive primary care, such as continuing clinical education, evaluation and quality improvement initiatives, panel management facilitation, and continuity of care enhancement and integration with external health system supports.
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Recovering from a Heart Attack hen you meet Calgarian Ray Morton, you are greeted by the strong, friendly handshake of a former professional hockey player, and the confident demeanor that comes from a long and successful media sales career. But on June 11, 2014, all that strength and confidence weren’t enough to prevent a heart attack. Ray had just completed his final business appointment of the day and felt unusually tired, sweaty and short of breath. During the drive home, he lost consciousness and awoke in an ambulance as paramedics were defibrillating his heart. “The pain was tremendous,” says Ray. “I was asking the paramedics to stop shocking my heart, because it hurt so much.” Good thing they didn’t. After undergoing heart surgery to insert a stent, followed by time in recovery, Ray was back home under the watchful care of his cardiologist as well as his family physician, Dr. Scott Forsyth. “Ray’s diagnosis included anemia, high cholesterol and blood pressure and he was on blood thinners following his heart attack,” says Dr. Forsyth. “In addition, he had an increased body mass index.” Assisting with his care was registered nurse Shawna Curry from the Calgary West Central Primary Care Network, part of the care team at Dr. Forsyth’s practice. Shawna spent time with Ray carefully reviewing his diet. Because of his high blood pressure, some changes had to be made, including recommendations about sodium intake and changes to his eating habits.
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A story of how health professionals work with your family doctor as part of your care team.
With a busy, stressful schedule packed with numerous client meetings around the city, Ray’s lunches were typically fast food that may also have contributed to his difficulty sleeping through a full night. “His dietary intake included a lot of carbohydrates and fatty foods including ice cream, hamburgers and chicken wings or convenience food when you are on the go,” says Shawna. “We had a lengthy discussion around food quality focusing on unprocessed, unrefined foods. It is difficult to dramatically change your diet and part of my role is help manage the resistance through understanding and by setting goals.” “Ray and I talked about the difference between deserving a treat and wanting a treat and that food should not be a reward,” says Shawna. Family are critically important in the circle of care that surrounds a patient and Ray’s wife Darleen attended the initial meeting with Shawna. As part of his health team, Darleen helps Ray stay on track by sorting his medication and monitoring his dietary choices.
“If anything ever happened to her, I’d be lost,” Ray adds. So far, all this support has helped. Over the last few months Ray has lost nearly 15 pounds and maintains notes on his blood pressure for his follow-up appointments. Dr. Forsyth and Shawna also support him with information on managing coronary artery disease, low sodium diets as well as general nutrition information. Ray loves to walk his dogs and enjoys a good game of golf, but the heart attack has left him in a period of recovery. He is looking forward to easing back into more activity and has already returned to meeting with his many friends and clients.
Ray and I talked about the difference between deserving a treat and wanting a treat and that food should not be a reward. ~ Shawna, Nurse
“The road to recovery can be a long one,” says Dr. Forsyth. “Patients need support to cope with immediate changes in their lifestyle whether dietary or activity based – it can add additional stress. The chain of patient care includes many people to help Ray back to his full potential. Through his cardiologist, our nurse Shawna and myself, his wife Darleen and family and friends, it takes a team effort.”
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Our Clinical Services CWC Primary Care Centre
3,083
Patients seen at the Primary Care Centre (during the day)
4,961
Patients seen at the Primary Care Centre (evenings/weekends)
4,274
Patients referred to the Primary Care Centre by Health Link
The CWC Primary Care Centre (PCC) offers enhanced access with a seven-day-a-week, same-day appointment service for patients in immediate need who are referred by their family physician. Available from 9 a.m. to 9 p.m. weekdays and from 1 to 4 p.m. on weekends, this referral service provides an alternative to the walk-in system or a visit to the emergency room (ER). Instead, patients unable to see their PCN member physician receive an appointment at our comfortable centrally located clinic. On evenings and weekends patients can also call Health Link if their physician’s practice is closed. This service is by appointment only and is available 365 days a year to patients whose family physician is a member of the CWC PCN. Through a partnership with the Rockyview General Hospital, patients requiring non-urgent care may also be re-directed directly to the PCC from the ER for an immediate appointment.
Tsuu T’ina Clinic
The CWC PCN provides primary care services to the Tsuu T’ina Nation, which borders Calgary’s southwestern city limits. The clinic is located in the federal health building and serves to enhance access to a substantial population that otherwise might be challenged to find primary care. Page | 7
The PCN clinic (PCC) has been an amazing service providing a second medical home when my colleagues or I have not been able to see our patients within 24 hours. This has prevented many visits to the ER, urgent care and walk-in clinics. I find there is a very high quality of care given there. ~ Family Physician
Primary Care Centre Additional Services 496
262
1,061
Patients seen in the Geriatric Assessment & Support program
Patients referred to the Tobacco Cessation program
Patients seen at the Primary Care Centre (Blood pressure monitoring)
Geriatric Assessment & Support (GAS) The Geriatric Assessment & Support service conducts comprehensive assessments for medically complex elderly patients. The team meets with geriatric patients who typically have multiple health problems and may have limited access to resources and help. Tackling Tobacco Together (3T) This tobacco cessation program involves an integrated behavioural and pharmacotherapy approach to support smokers attempting to quit. It is available through referral from a member physician.
327
5,013
2,690
Patients attended nutritional programs
Patients seen at the Tsuu T’ina Clinic
Patients attached to a family physican
Nutritional programs A number of nutritional programs are available upon referral from a physician member. Transition service The Primary Care Centre acts as a temporary medical home or transition service for patients within our boundary seeking a permanent family physician. The PCC does not see patients on a long-term basis. Need a doctor To help match you to a family doctor in your geographic area, visit an online service at www.calgaryareadocs.com that will direct you to physicians that are accepting new patients.
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We need to know our patient. As an advocate for them and as their primary care physician, it is absolutely vital to the foundation of a medical home, for they as stakeholders create it. By learning more about who is accessing your service, we can build on the services patients require.
We are not cookie-cutting primary care. We are looking to create an architecture for a medical home that allows individuals to receive the care that’s most appropriate to them. My ideal future for primary care would be working closely with the patient and in direct partnership on their wellness needs. We have been given a great gift of knowledge, compassion, empathy and certainly some insights into the human condition that allows us to play a strong role in the wellness of patients.
Perspectives on the
future of Primary Care
One of the main benefits I have seen to collaborative care teams is improved patient access to health care services. Through the work of CCTs patients are provided with multiple opportunities to effectively address their health concerns. For example, a patient recently diagnosed with Type 2 Diabetes can meet with their family doctor as needed, attend a dietitian led nutrition education class and meet with a pharmacist for further medication management. Combining medical services allows patients and their families to build a toolbox they can use to improve their health and well-being.
Erin, Dietitian
I feel that I can offer patients much more effective care by being part of a collaborative care team, because if questions or problems arise that are out of my scope of practice, I know I have a great team of resources I can refer to that keep the patient close to their home clinic and connected with their physician. It’s also nice to know that in many clinics, patients have access to support nearly every day of the week and since all CCTs can access the patient chart, patient care can be a lot more seamless and consistent between providers.
I can tell you that ever since early university days when I imagined my future within healthcare, what came to my mind was the goal to be involved in a team of experts from various patient care fields (pharmacy, medicine, nursing, mental health, etc.) that work together with the patient in the centre. From this perspective, the patient can learn about their own health from various perspectives and get assistance from a preventative point of view while treating any issues that come up. The PCN seems to fit that model and has evolved over the past several years into a comprehensive organization that houses many of these teams in various locations.
Jill, Nurse
Our practice should feel like a home for a patient’s medical needs - a medical home. This is a place where a patient feels that they belong and can access the majority of their health care needs supported by PCN programs and services. Unfortunately, society can be more of a fast food mentality and some patients don’t care who delivers their care. We are trying to build the concept of a lot of services under one umbrella - kind of like a one stop shop. It is also going to have to be more of a team effort. Overall, the physician will be doing more of a directing role for teams. We have to get more into leadership roles and use our people for all their talents. ~ Dr. Swirsky, Family Physician
Working for the PCN provides an opportunity to network and to see how different health care professionals practice. From these observations I have discovered new perspectives on familiar problems and new ways to describe medically complex ideas.
By being in different clinics, I have become more dynamic as a practitioner and more perceptive as a person. It has challenged me and fostered my professional growth, which in turn has translated into better patient care.
Darren, Dietitian
I think that’s the most unique thing about this - when you work at hospital or clinic you see the same faces every day, potentially in the same department every day, so you’re kind of seeing the same issues. But here, as soon as I enter a clinic, the referral doors open to anything that’s within the scope of what physiotherapy can treat, ranging from chronic disease management to preventative care and everything in between. It’s nice to treat someone when they actually don’t have the problem facing them right now. In other words, this is what could happen if you don’t make changes, whereas working in hospitals a problem has usually already happened and you are trying to fix it.
Meet the TEAM c
c
Collaborative Care Team
What is a CCT?
CCTs are physician-led, multi-disciplinary teams that consist of behavioural health consultants, dietitians, nurses, pharmacists, physiotherapists and social workers. The common objective is enhanced patient care and access to the right professional, at the right time. Collaborative care teams are a pillar of our PCN and a key component of your medical home.
Family Physicians
x 410 As a member of the CWC PCN, your physician can provide a medical home for you. By referring patients to the skilled members of our CCTs, they can conveniently connect you to an extended team of health care professionals in your community and further enhance their ability to care for you.
In 2014, there were approximately 77 team members helping to make health happen in 77 clinics.
All of the health team members have made a difference to at least one patient, either to help with their anxiety and depression, motivate them to make lifestyle changes, help keep my diabetic patients controlled, or find resources in the community for my geriatric and home care patients. My practice would drastically change for the worse if the resources and services provided by the PCN was taken away. ~ Family Physician
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Dr. McLean, Family Physician
Behavoural Health Consultants (BHC)
Dietitians
x3
x 18 Behavioural health consultants (BHCs) are part of the Alberta Health Services Shared Mental Health team and work in CWC PCN physician clinics. BHCs see individuals, couples and families and can address a wide range of mental and behavioural health concerns, often in a single visit. In collaboration with physicians and supporting the work of other team members, BHCs identify and help treat depression, address motivational issues and improve coping strategies.
Dietitians are trusted food and nutrition experts whose primary goal is to offer practical advice to help patients make the right food choices and develop healthy eating habits. Dietitians offer individual and group counselling at the PCC or support in your physician’s practice. Group classes include: Secrets to Weight Loss Success, Cholesterol & Blood Pressure Reduction, Nutrition for Diabetes and Elevated Blood Sugar, and Gaining Lightness. All classes are one-time, two-hour sessions, except Gaining Lightness, which is a four-week program.
11,438
2,403
Patients seen
Patients seen
Iordanka, Behavioural Health Consultant
RenĂŠe, Dietitian Page | 14
Pharmacists
Physiotherapists
x6
x8
The physiotherapist’s role is to maintain and restore a patient’s functional abilities. Physiotherapists often assess basic functions like walking, sit to stand, balance, squatting, reaching and other daily activities. They give exercises specific to a patient’s issues and provide appropriate hands-on therapy for injuries, accompanied by a home program to facilitate the healing process. They also educate patients about active lifestyle, injury prevention, stages of healing and restoring and maintaining function with aging and injury.
CWC PCN pharmacists support physicians in caring for patients with complex issues requiring management by prescription medications. They work in various family physician offices and in the Primary Care Centre, which offers a central pharmacy referral program and a Geriatric Assessment and Support clinic. Pharmacists also facilitate smoking cessation programs and participate in diabetes and respiratory management initiatives with other collaborative care team members.
5,281
4,456
Patients seen
Patients seen
Farah, Pharmacist Page | 15 Laatsch, family physician Dr. Keith
Yaara, Physiotherapist
Nurses
Social Workers
x 41
x3 Our social workers help patients and their families’ access support and navigate the health system. They accept referrals for issues relating to environmental and personal circumstances, and strive to enhance living situations and improve quality of life. Social workers connect with patients at the PCC or in the patient’s home as often as required to determine their needs and refer them to appropriate resources for ongoing assistance.
Our nurses work with physicians and other CCT members to create comprehensive care plans for patients. They provide education, resources and motivational interviewing to help improve overall patient health. Nurses monitor, evaluate and adjust patient health plans and offer counselling about lab results, diagnostic tests, specialist reports, drug therapies and possible side effects. Nursing focuses include chronic disease management, maternity care and geriatric care. Nurses include Registered Nurses, Licensed Practical Nurses and Nurse Practitioners.
10,410
974
Patients seen
Patients seen
April, Registered Nurse
Catharine, Social Worker Page | 16
Clinic Listing 12West Medical Clinic
Coach Hill Medical Clinic
Dr. Susan Poon’s Office
AHS - Addiction Medicine Sheldon Chumier
Copeman Healthcare Centre
Dr. Wilmot’s Office
Associate Clinic #330
Cornerstone Medical Centre
Drs. Brandon, Loehr, Lovo & Wilkinson’s Office
Associate Clinic #340
CUPS Community Health Centre
Drs. Bryden, Scurfield & Young’s Office
Associate Clinic #362
Deerfoot Meadows Medical Clinic
Drs. Louie & Tse’s Office
Associate Clinic #363
Dr. A. Pandya’s Medical Clinic
Drs. MacQueen & McMurren’s Office
Associate Clinic #364
Dr. Bruce Jespersen’s Office
Drs. McLean, Harvey & van der Merwe’s Office
Associate Clinic #370
Dr. Catherine McKenna Nutrition & Weight Management
Drs. Nichol, Pereles and Searles Office
Braeside Medical Centre
Dr. Diana Turner’s Office
Drs. Woolner, Chan & Yuen’s Office
Braeside on 24th Medical Clinic
Dr. Keith Laatsch’s Office
Eaton Centre Medical Clinic
Breast Cancer Supportive Care
Dr. Lesley Coulter’s Office
Elbow River Healing Lodge
Bridgeland Medical Clinic
Dr. Lynne Murfin’s Office
Fairmount Medical Clinic
Calgary Foot & Ulcer Care Clinic
Dr. Mish and Dr. Noiles’ Office
Glamorgan Medical Clinic
Calgary Weight Management Centre
Dr. Paul James Tkalych’s Office
Glenbrook Medical Clinic
Calgary West Medical Centre
Dr. Pyarali Mitha’s Office
Glenmore Family Physicians
Canyon Meadows Clinic
Dr. Richard Lam’s Office
Glenmore Landing Vein Clinic
CareWest Dr. Vernon Fanning Centre
Dr. Robert Cole’s Office
Glenwood Medical Centre
CareWest Sarcee Hospice
Dr. Robert Herget’s Office (Associate Clinic #366)
Good Health Medical Centre
Chinook Mall Medical Clinic
Dr. Scott Beach’s Office
Grasslands Medical Clinic
Chinook Medical Centre
Dr. Stajen Warness’ Office
Heritage Family Medical Centre
Chiron Medical Clinic
Dr. Stinton’s Office
Heritage Hill Medicentre
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Humana Medical Clinic
My Calgary Doctor
Southwood Medical Centre
Hygieia Medical Clinic
Oak Bay Medical Centre
Springview Medical Clinic
Infinity Pediatrics
Primary Care Centre
Strathcona Family Medicine Centre
Innovations Health Clinic
Prime Care Medical
Sunnyhill Pediatric Clinic
Intramed Medical Centre
Rhythm Health
The Alex Community Health Centre
Kaleidoscope Pediatrics
Richmond Road Family Medical
The Alex Seniors’ Health
Killarney Medical Clinic
Richmond Square Medical Centre
The Alex Youth Health
Kingswood Medical Centre
Rocky Ridge Retirement
Tom Baker Cancer Centre
Lakeview Family Doctors
Rockyview Heritage Clinic
Total Skin Care
Lakeview Medical Clinic
Rockyview Maternity & Family Practice Group
Tsuu T’ina Health Centre
LifeMark Physiotherapy
Rockyview Medical Centre
University Health Services Clinic
Matrix MSK
Signal Hill Medical Centre
Valley Ridge Medical Clinic
Mayfair Medical Clinic
SMC Family Medicine
Vesia - Alberta Bladder Centre
MCI The Doctors Office at 130th Ave
SMC Sexual and Reproductive Health
V-Medi Spa
MCI The Doctors Office at Sarcee
South Health Campus
Wentworth Medical
Meadows Maternity and Family Practice
South Trail Medicentre
Westbrook Medical Clinic
Medical Express
Southland Medical Clinic
Westglen Medical Centre
Mission Medical Clinic
Southland Sport Medicine
Westside Medical Clinic
Mount Royal Medicentre
Southport Family Practice
Woodlands Medical Centre
Mount Royal University - Health Services
Southwood Care Centre
Zamin Medical Centre
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Thank you to our physicians, patients and staff who shared their stories in this report to the community. Please share a copy with a friend.
403.258.2745
info@cwcpcn.com
www.cwcpcn.com