Report to the Community 2013
Dion, Alyson and Maevey, patients
302,000 Patients
330 Physicians
107 Clinics
1
Network
OUR VISION Providing excellence in community based comprehensive primary health care.
WHO WE ARE Primary Care Networks were established to improve access to family physicians and other frontline health care providers in Alberta. There are currently 40 Primary Care Networks in Alberta, and the Calgary West Central Primary Care Network (CWC PCN) is one of the largest. The CWC PCN is made up of 330 primary care physicians, working in 107 clinics to enhance patient care. Many of these physicians work closely with PCN allied health professionals including behavioural health consultants, dietitians, nurses, pharmacists, physiotherapists and social workers to collaborate on patient care. The CWC PCN addresses the unique health needs of our population and implements innovative programs; many of which are prevention and wellness focused.
Our Goals
Our goals have been established as the strategic framework that guides our PCN and its members.
ACCESS
MD-LED COLLABORATIVE 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 appropriate primary care services.
To facilitate the right service at the right time for patient needs through physician-led collaborative care teams that consist of health professionals like behavioural health consultants, dietitians, nurses, pharmacists, physiotherapists and social workers.
HEALTH PROMOTION
SUSTAINABLE COMPREHENSIVE FAMILY PRACTICE
To offer patients access to referral-based programs that reduce risk and promote healthy lifestyles. These programs range from weight loss and nutrition to smoking cessation as well as cholesterol and blood pressure management.
To support family physicians by providing programs that target the unique needs of community-based comprehensive primary care, such as continuing clinical education.
Message from the Calgary West Central Primary Care Network
Our Calgary West Central Primary Care Network (CWC PCN) provides a unique sense of community for its hundreds of member physicians and their teams, who deliver excellence in care for hundreds of thousands of Calgarians. The strong connections created through this community allow family physicians in our PCN to know that their patients are supported, even in challenging times. This all became apparent in June, 2013, when Calgary was faced with flooding that impacted 22 CWC PCN member physician clinics - representing 78 family doctors - due to power loss, flood damage and issues with access. Along with other local PCNs and AHS, CWC PCN member physicians and staff rallied to ensure patients could get the help that they
needed. CWC PCN physicians opened their doors to their colleagues who were directly affected, offering available space to those physicians needing a place to see their patients. CWC and other local PCNs directed patients unable to contact or access their family doctors to central PCN clinics and worked with local health care facilities, like the Rockyview General Hospital, to provide another avenue for non-urgent patients to be seen. As the city came together in response, CWC PCN staff and physician members quickly found new ways to ensure that their patients were supported. The response to the flooding crisis reflects what the CWC PCN works for year-round. We aim to connect family physicians with their colleagues and other health professionals. We seek to strengthen our members’ practices, to help ensure that patients receive convenient access to the care they need and seek opportunities to improve their wellness, right in their “medical home.” We look forward to building on the sense of community that was demonstrated this year, as we continue to work on new ways for our physician members and their teams to make health happen for their patients.
Dan Doll, Executive Director Calgary West Central Primary Care Network
Jane Ballantine, Medical Director Calgary West Central Primary Care Network
Governance Committee Members Dr. Thomas Tam CWC PCN P.G. Co. Co-Chair Nancy Guebert AHS Representative Co-Chair Dr. Nicholas Myers AHS Representative Dr. James Silvius AHS Representative Dr. Brendan Vaughan CWC P.G. Co. Representative Dr. Margot McLean CWC P.G. Co. Alternate Dr. Waldemar (Waldi) Wilken CWC P.G. Co. Alternate Dr. William Wu CWC P.G. Co. Alternate
Message from the Board of Directors
Expansion of care team services in clinics as well as increased membership and program satisfaction contributed to a theme of sustained growth in the past year and to our mission of making health happen. In a recent survey sent to member physicians, over 90 per cent of our members who responded were satisfied or very satisfied with their membership and the associated programs and services designed to enhance patient care. We are pleased to have increased physician satisfaction alongside that program growth, in addition to a 10 per cent increase in membership last year. We now have 70 health care team members consisting of behavioural health consultants, dietitians, pharmacists, registered nurses, social workers and most recently, physiotherapists, working within member clinics. There are 69 clinics hosting teams, an increase of 20 clinics from the previous year. Members overwhelmingly agreed that collaborating with these teams improved patient care.
The level of attendance at Continuing Clinical Education (CCE) sessions held by the CWC PCN for our members more than doubled with 185 physicians attending different events. Topics focused on chronic disease management and ranged from diabetes and respiratory issues to geriatric patient care. The referral services at our Clinic at Westbrook continued to be well utilized by member doctors. The clinic’s transition service for patients without a family physician saw 2,545 people cared for, with another 3,455 people seen after hours. In addition, PCN members referred hundreds of patients to the clinic’s many health promotion and education programs that are focused on seniors’ services, nutrition and lifestyle changes. While we have much to be proud of, we also continue to evaluate and measure our work and strive for continuous improvement. By reviewing health and activity indicators, gathering input from member physicians and working closely with our partners at Alberta Health, we maintain our focus on excellence in community based comprehensive primary health care.
Thomas Tam, Family Physician, CWC P.G. Go. Board of Directors Chair Calgary West Central Primary Care Network
Board Members Dr. Thomas Tam CWC P.G. Co. Board Chair Dr. Brendan Vaughan CWC P.G. Co. Board Vice Chair Dr. Ron Lim CWC P.G. Co. Board Secretary-Treasurer Dr. Margot McLean CWC P.G. Co. Board Director Dr. Phillip van der Merwe CWC P.G. Co. Board Director Dr. Waldemar (Waldi) Wilken CWC P.G. Co. Board Director Dr. Elisabeth (Betsy) Woolner CWC P.G. Co. Board Director Dr. William Wu CWC P.G. Co. Board Director
What is ACCESS?
Increasing the proportion of residents with access to a family physician and helping to support continuous care through coordinated 24-hour, seven-day-a-week access to appropriate primary care services.
SUCCESSES WITH OUR Primary Care Network
AFTER HOURS: Patient Story
As first time parents, we were worried. It gave us comfort knowing it was nothing serious and that we could go back if needed. We feel so much more confident knowing this is there for us. ~ Alyson
When Maevey was nine-months-old, her parents became worried about her health as she’d been unwell for about 10 days. At the point where Maevey developed diarrhea and started to vomit, her parents Alyson and Dion feared she would become dehydrated. Both their pediatrician and their family physician, a member of the CWC PCN, were unavailable so Alyson and Dion weren’t sure what to do. It didn’t seem serious enough to go to the emergency department, yet they didn’t want to wait until one of their physicians returned to the office. Alyson recalled their family physician telling them that they could access care through Health Link Alberta for non-urgent, yet immediate health needs. “We called Health Link and they asked a number of questions about Maevey’s situation,” said Alyson, noting that they called at about 4 p.m. on a weekday afternoon. Since their family physician was a member of the CWC PCN, Health Link Alberta was able to contact the Clinic at Westbrook, and staff there scheduled an appointment early that evening for Maevey as part of the clinic’s after hours service. “We were in and out within half an hour,” said Alyson. Maevey had a virus and, as her parents had suspected, it didn’t require a trip to the hospital. The physician at the clinic told them to make sure Maevey kept drinking to keep hydrated, and that they could return to the clinic if they didn’t notice an improvement. Alyson and Maevey, patient
FAST FACTS
How to access after hours service. The CWC PCN Clinic at Westbrook after hours service is accessed through Health Link Alberta (403.943.5465). Patients are then referred to the Clinic at Westbrook, which is open on weekends from 1 – 4 p.m. and on weekday evenings from 5:30 – 8:30 p.m. This service is by appointment only and is available seven days a week, 365 days a year, addressing immediate patient needs while ensuring continuity of care by keeping patient records updated with member physicians. Need a family physician? Patients who do not have a family physician can visit the Clinic at Westbrook and join a web registry to match them with physicians accepting new patients. Alternately, to get your name on the list, visit www.needadoctorcalgaryandarea.ca.This unattached web registry is offered in partnership with other Calgary area PCNs. What is the transition service? The CWC PCN transition service at the Clinic at Westbrook is a place where patients can receive care while they are waiting to be connected with a family doctor. It is an appointment based clinic that does not see patients on a long-term basis. Patients without a family physician can call the clinic at 403.249.9907 for an appointment. Tsuu T’ina Nation services. 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.
Access Statistics
3,455
patients seen in the Clinic at Westbrook after hours service
2,799
patients were matched with a family physician
912
patients were seen as part of the Women’s Health Clinic at Tsuu T’ina Nation
3,011
patients were seen at the Tsuu T’ina Nation Clinic
4,879 2,545 patient referrals from Health Link Alberta
patients without a family physician received care in the CWC PCN Clinic at Westbrook
What is MD-LED COLLABORATIVE CARE?
Facilitating the right service at the right time for patient needs through physician-led collaborative care teams that consist of health professionals like behavioural health consultants, dietitians, pharmacists, physiotherapists, registered nurses and social workers.
SUCCESSES WITH OUR Primary Care Network
COLLABORATIVE CARE TEAMS The concept of having a medical home for every patient is strengthened by physicianled collaborative care teams (CCTs). The CCTs consist of health care professionals like behavioural health consultants (BHCs), dietitians, pharmacists, physiotherapists, registered nurses and social workers. They are currently working in 69 member clinics as well as in the CWC PCN Clinic at Westbrook. In an effort to introduce these professionals into smaller physician practises, the CWC PCN developed the concept of virtual clinics this past year. Laura Schipper, a registered nurse who works in both typical and virtual clinics, says nothing differs in terms of patient care. “We are able to increase access to an entire collaborative care team for patients in smaller clinics,” said Laura. Dr. Keith Laatsch, one of the member physicians utilizing a virtual clinic, said the concept is working exceptionally well. As the sole physician in his own clinic, Dr. Laatsch did not have enough referrals for any one member of a CCT. “Finally, I have access to all the things I need to give my patients the most comprehensive care I’ve been able to give in over 15 years,” said Dr. Laatsch, who now regularly refers patients to the BHC, pharmacist, registered nurse and geriatric nurse. “Patients are almost always virtually ecstatic with the services they receive.” Whether it’s a virtual model that refers patients to a centralized clinic or the typical model, Dr. Laatsch said the CCT program is invaluable to the PCN, offering physicians team-based support and empowering them to spend more time focused on immediate patient needs.
Dr. Keith Laatsch, family physician
Collaborative Care Team Statistics
SUCCESSES WITH OUR Primary Care Network
COLLABORATIVE CARE TEAMS: Patient Story By the time Marabella Lee (name changed to protect identity) escaped an abusive relationship in 2012, she was facing a multitude of health challenges. With the support of her family physician, she soon became acquainted with several members of the CWC PCN collaborative care team (CCT) who would assist with her medical and emotional issues. Marabella was never overweight as a teenager, but she turned to food as a coping mechanism during the relationship, and her physician referred her to a CWC PCN dietitian. With the help of a dietitian, Marabella lost almost 40 pounds over the following eight months. “She empowered me with the knowledge and skills I needed,” said Marabella, who had many other health factors to take into consideration with her diet. Her challenges include a heart condition, severe allergies to nuts and legumes, an iron deficiency, lactose intolerance and abnormal cholesterol. “I was trying to do it on my own and realized I really do need a team,” said Marabella. Her team included her family physician, a physician specializing in weight management and the dietitian, who introduced her to a supplementary resource called Living Well. Marabella also utilized the services of a CWC PCN physiotherapist for treatment of chronic pain and a behavioural health consultant (BHC) for her emotional issues. “People don’t realize how domestic violence affects your health, but there are resources in the PCN to help.” Marabella wanted to share her story to inspire others in similar circumstances. “I was walking home one day recently and saw my reflection in the window and thought, I look so much healthier and happier than I did a year ago,” concluded Marabella. “That is with much thanks to my physicians, the PCN team and the many others who have supported me in my journey.”
c c
70
TEAM members working in
69 clinics
The objective of CCTs is to increase the emphasis on health promotion, disease and injury prevention, and improved care of medically complex and chronically ill patients. Physicians work directly with CCT members to ensure continuity of care.
BHCs address a wide range of issues with the most common reasons for consultations being depression, anxiety, stress, relationship issues and sleep concerns. They also assist patients struggling with addictions, eating disorders, chronic pain and illness, anger management, lifestyle concerns, ADHD and chronic mental health issues. BHCs are part of the Alberta Health Services Shared Mental Health team and work in CWC PCN physician clinics.
SUCCESSES WITH OUR Primary Care Network
BEHAVIOURAL HEALTH CONSULTANT
I was not really aware of the Primary Care Network structure before this. I can only hope this service will be expanding in our city and province. ~ Betty
Many patients are reluctant to ask for help when they suffer from anxiety or depression, but when there’s a resource readily available within their family physician’s clinic, it becomes easier. Kelli McMillan is one of the behavioural health consultants (BHCs) who works in various CWC PCN member physician clinics every week and says access to the service is a key contributor to the effectiveness of addressing the needs of patients like Betty Parr. Betty found herself sinking into a depression after the death of her mother in 2011, which was compounded by the loss of her husband a few years prior. At the encouragement of her children, Betty decided to see her family physician about her depression and was offered the services of a BHC. “Kelli was the right person for me at the right time. She aimed me in the right direction,” said Betty. Kelli attributes the CWC PCN team approach to care for Betty’s rapid improvement. “It was really helpful that we were in her doctor’s office as it was comfortable for her to come in,” said Kelli. “With something as difficult as grief, we were able to be responsive in terms of getting relief for her very quickly.”
Betty Parr, patient and Kelli McMillan, behavioural health consultant
CTAs provide support for 111 CCT shifts per week.
SUCCESSES WITH OUR Primary Care Network
COLLABORATIVE TEAM ASSISTANT With the successful implementation of collaborative care teams (CCTs) in physician member clinics, the next phase was to provide additional support to ensure patients had the best possible access for appointments. The PCN hired a practice support manager to facilitate the recruitment of a team of collaborative team assistants (CTAs) to ensure the CCT health care professionals had the support required to focus on patient care. After joining the CWC PCN, Diane Klatzel placed 15 CTAs in 34 clinics, supporting 135 physicians and enhancing patient access to CCT members. This helps with the administrative burden of the office staff as well as the CCT members themselves, enabling them to have as many face-to-face encounters with patients as possible. Gladifel Santos is one of the CTAs and is proud of the contribution she has made towards patient care. “I value the opportunity to work for an outstanding company with a collaborative care team that works together with a team of physicians to provide patients with access to a variety of resources. I see the positive changes our PCN team accomplishes with our patients.�
Collaborative Care Team Statistics
10,830
patients were seen by a Behavioural Health Consultant
15
CTAs working in
34 clinics supporting
135
physicians
Gladifel Santos, collaborative team assistant
Dietitians are trusted food and nutrition experts whose primary goal is to offer practical advice to help patients make the right food choices and form healthy eating habits. The CWC PCN dietitians provide one-on-one nutrition counselling and group education classes out of the Clinic at Westbrook from Monday to Friday.
SUCCESSES WITH OUR Primary Care Network
DIETITIAN
The sessions definitely had a positive impact. They flagged a lot of things for me and my weight is down. ~ Jurij
When Jurij Storoshchuk made up his mind to lose weight, his physician referred him to the nutritional program at the CWC PCN Clinic at Westbrook, where he took full advantage of the diverse range of programs offered. “I’m starting to get on the bandwagon,” said Jurij, who attended three of the four CWC PCN nutritional programs while also meeting one-on-one with Katie Zimmerman, one of the dietitians. Jurij signed up for Secrets to Weight Loss Success, Gaining Lightness, as well as Cholesterol and Blood Pressure Reduction. After a total of seven group sessions along with individual one-on-one sessions, Jurij made a few simple changes that resulted in a loss of 11 lbs over 11 weeks. Jurij began reading food labels to determine calories and sodium content, along with drinking more water and increasing the amount of vegetables on his dinner plate. With helpful tools from his dietitian including a portion plate magnet and a Live Well fitness tracker, Jurij is confident that he will continue to see success in achieving his goals and has become an advocate of the CWC PCN’s nutritional programs. The CWC PCN nutritional programs consist of: Gaining Lightness, Secrets to Weight Loss Success, Cholesterol and Blood Pressure Reduction, and Nutrition for Diabetes & Elevated Blood Sugar.
Katie Zimmerman, dietitian and Jurij Storoshchuk, patient
The CWC PCN pharmacists support physicians by collaborating on the care of patients with complex issues requiring management through the use of prescriptions. The pharmacists’ primary focus is medication management for conditions such as diabetes, COPD, asthma, osteoporosis, chronic pain, mental health and cardiovascular issues. Patient education in chronic disease, medication reviews and therapeutic drug monitoring are other areas of focus.
Collaborative Care Team Statistics
SUCCESSES WITH OUR Primary Care Network
PHARMACIST During her ongoing treatment for diabetes, Marlene Bird found her blood sugar levels began consistently acting up. Despite the thorough care she was receiving from her physician, the prescribed treatments were not working optimally, and Marlene became concerned.
Elska explained that because her diabetes had changed, Marlene was in need of better blood sugar control to prevent complications and most likely needed insulin therapy. Elska spent a couple of sessions talking about options and easing Marlene’s mind on the concept of injecting insulin. “Initially we struggled to find an insulin that Marlene could tolerate. Eventually we were able to find a good option that Marlene was comfortable with. About a week later Marlene called to express her excitement,” said Elska. “She was over-the-moon that it worked so well and that it was a lot less scary than she initially had thought.” Since Marlene is also on other medications, Elska has helped her better understand how her medications work as well as reviewing proper dosing. In addition, Elska has liaised with Marlene’s community pharmacy to ensure all care-providers are on the same page. Marlene continues to follow-up with Elska around insulin adjustments and whenever she has any questions or concerns. Elska Balliant, pharmacist
patients were seen by a Dietitian
}
When her physician referred Marlene to Elska Balliant, a CWC PCN pharmacist, her outlook changed. “Elska put my mind at ease and explained how the diabetes was progressing,” said Marlene. “She takes the time to listen to me and makes sure I understand what she is trying to communicate.”
1,641
387
individual sessions
1,254
attended group programs
6,709
patients were seen by a Pharmacist
If your family physician is unavailable, call Health Link Alberta.
Patient
Health Link Alberta 403.943.5465
Health Link nurses answer calls 24 hours a day. Patients of CWC PCN physicians are referred to the Clinic at Westbrook for non-urgent care or to emergency units for urgent care.
R
Walking through your care options. For non-urgent care, book an appointment with your family physician.
Updates are communicated back to your family physician for continuity of care. Your CWC PCN physician’s clinic is YOUR MEDICAL HOME for primary health care.
MY FAMILY
PHYSICIAN
Referral services available to you vary by clinic and are by appointment only.
The Clinic at Westbrook offers an after hours service to patients of CWC PCN physicians and acts as a temporary medical home for patients without a family physician.
Referral Services making health happen
Clinic at WESTBROOK
Appointment Based
Behavioural Health Consultant
Physiotherapist
Dietitian
Registered Nurse
Pharmacist
Social Worker
Physicians may refer patients to the Clinic at Westbrook for programs including: Tackling Tobacco Together (3T) Nutritional Support Geriatric Assessment & Support (GAS)
The physiotherapist’s role on CWC PCN collaborative care teams is to maintain and restore a client’s functional abilities. Physiotherapists often assess basic functions like walking, sit to stand, balance, squatting, reaching and other activities of daily living. They give exercises specific to the issues that are identified.
SUCCESSES WITH OUR Primary Care Network
PHYSIOTHERAPIST
After only a couple of sessions with Yaara, I was walking normally again. I am very grateful. ~ Mike
When Mike Maurette first walked in to see a CWC PCN physiotherapist, he was using a cane for his spinal injury. He had fallen twice in the past few months and suffered from a slipped disc. Physiotherapist Yaara Eilon-Avigdor met with Mike and was quickly able to assess his situation and provide education and exercise to help improve his condition, primarily through self-management. Yaara used a combination of treatments, and Mike was committed to doing four daily exercises that would maintain his health. Soon he was enjoying improved sleep and increased agility. Physiotherapy is the newest healthcare profession to be added to the CWC PCN’s collaborative care teams, and since the program was initiated in January of 2013, it has been overwhelmingly well received. Yaara currently sees up to 60 patients a week in seven different clinics. The physiotherapists offer individual consultations as well as group sessions with the most popular being those for osteoporosis, osteoarthritis and fall prevention. One of the most recent sessions focuses on collaboration in treating chronic pain and also involves other professionals such as physicians, pharmacists and behavioural health consultants. Yaara said these sessions have been so well received that many are booked well in advance. “This is a well needed service for a population that can’t always afford it,” explained Yaara.
Mike Maurette, patient and Yaara Eilon-Avigdor, physiotherapist
The CWC PCN social workers assist patients and their families with accessing support and navigating the health system. They connect with patients as often as required to determine their needs and refer them to appropriate resources for ongoing assistance.
Collaborative Care Team Statistics
SUCCESSES WITH OUR Primary Care Network
SOCIAL WORKER Dr. Jaclyn Safran encountered a patient dealing with a social situation and wanted to help but wasn’t certain which resources would be beneficial. Upon the advice of one of the CWC PCN collaborative care team members in her clinic, she called the social worker at the Clinic at Westbrook. “I had a long standing patient who had become homeless with short notice and was unable to find accommodation,” explained Dr. Safran. “It was really as simple as contacting the social worker who did everything they could for this patient.” The social worker directed the patient to the appropriate resources for temporary accommodation and a suitable solution was found. “This patient was very grateful for the service that was provided,” said Dr. Safran. Social workers assist with a variety of psycho-social issues primarily with a geriatric focus including: Cognitive decline Family dynamics Depression Obesity Grief support
Transportation Mobility equipment needs Alternative living environments Requirement for in-home supports Need for respite
The social workers also play a key role in the Geriatric Assessment & Support (GAS) program.
Rochelle Roach, social worker
352
patients were seen by a Physiotherapist Since January 2013
387
patients were seen by a Social Worker
13,261
patients were seen by a Registered Nurse
The CWC PCN has a team of registered nurses who work collaboratively with family physicians and other members of collaborative care teams to create comprehensive, holistic care plans for patients. Nurses provide education, resources, community and PCN referrals, as well as motivational interviewing to help increase the overall health and well-being of patients.
SUCCESSES WITH OUR Primary Care Network
REGISTERED NURSE
She’s taught me a lot and I learn something new every time I go to see her. In my opinion, she is a lifesaver, and the whole concept of the (CCT) program is great for me. I couldn’t be any happier. ~ Tim
The biggest obstacles for Tim Roberts in managing his diabetes have been keeping track of what and how much to eat, along with what medications work best. Tim was reluctant to use insulin and had been using oral medications to treat his diabetes. In addition, his diabetes in combination with COPD made it hard for him to keep up a dedicated exercise regime, making nutritional choices even more important. His family physician referred him to Laura Schipper, a CWC PCN registered nurse, to help him with a care plan. Laura discussed the benefits of insulin as a medication option and Tim agreed to give it a try. “The next thing I know, she has me on insulin and is showing me how to do it,” said Tim, adding that the medication has since worked well. Next, Laura helped Tim tackle meal planning, focussing on specifics like carbohydrate counting. Within a few months, Laura was successful in working with Tim to bring his blood sugar levels down.
Laura Schipper, registered nurse and Tim Roberts, patient
What is HEALTH PROMOTION?
Offering patients access to referral-based programs that reduce risk and promote healthy lifestyles. These programs range from weight loss and nutrition to smoking cessation as well as cholesterol and blood pressure management.
SUCCESSES WITH OUR Primary Care Network
SMOKING CESSATION: Patient Story After being a smoker off and on, but mostly on, for over 20 years, Deanna Wylie had come to the conclusion that the only way to successfully quit was to do it on her own and only by enduring tremendous suffering. “Like all smokers, I wanted to quit but without going through the quitting part,” said Deanna. “I repeatedly expressed this to my doctor; however, when she suggested more than once that I join a smoking cessation program, I declined. I pictured a depressing dark room where a bunch of people sat around chain-smoking and talking about how miserable they were.” Ultimately, she came to the realization that she couldn’t do it on her own and accepted her physician’s referral to the CWC PCN Tackling Tobacco Together (3T) program. “Though skeptical of what I was walking into, five minutes into the first meeting I felt like I was finally in an environment where my battle with smoking was entirely understood. Contrary to my predictions, the feeling in that room was positive and, even more to my delight, the other people were just like me; just a group of people who had gotten stuck in this addiction trap and who had realized they needed help to get out.” With the help of CWC PCN health care professionals, her perspective shifted and her confidence increased. “The language used within the group focused on the positive efforts each of us had made, rather than the shame of being dependent, and recognized that every smoker needs their own plan and method of quitting. This program guided me in designing the quitting plan that would work just for me.” Over the course of the four-week program, Deanna’s confidence continued to grow as she knew she had support and tools to help her cope with potential triggers. “I am now three months smoke-free, and have never at any point felt that I was suffering through something. Instead I have felt pride and satisfaction with each passing day that I go without smoking.”
Deanna Wylie, patient
Seniors with complex medical issues can be referred by their family physician to the Geriatric Assessment & Support (GAS) program. The initial evaluation typically lasts about three hours and may involve consultations with professionals such as pharmacists, geriatric psychiatrists, gerontology nurses and dietitians. Direct referrals and follow-ups with these professionals, and others, is also possible.
SUCCESSES WITH OUR Primary Care Network
SENIOR SERVICES: Patient Story When Ronnie Wilderman’s family physician referred him to the Clinic at Westbrook’s Geriatric Assessment & Support (GAS) program, his family wasn’t sure what to expect. Ronnie had been diagnosed with Alzheimer’s Disease, with his wife Jackie and daughter Christine assuming the full-time responsibilities of caregiving as the disease progressed. The GAS program offered a three-hour comprehensive visit with a team of geriatric professionals who could provide specific assistance to Ronnie’s needs. “They were on time and so pleasant,” said Jackie. “They were very good with Ronnie. I felt at that time that there was help out there for us. We have nothing but good things to say about the clinic.” Ronnie’s daughter Christine said prior to their referral to the Clinic at Westbrook, the situation had all been very stressful. “After my parents went to Westbrook, I felt there was light at the end of the tunnel,” said Christine. CWC PCN pharmacist Brian Abernethy was among the health professionals who met with Ronnie, and explained that each individual assessment varies based on the specific needs of each patient. “The combination of a nursing assessment, medication review, social worker assessment and physician management were matched to his needs,” said Brian. “One of our objectives is connecting all of the pieces together,” said Brian, noting that they work closely with the referring family physician as well as other community healthcare practitioners. After a patient receives an initial assessment at the GAS program, they continue to be monitored by the team, with updates communicated to the patient’s family physician, who manages their care going forward. Jackie and Ronnie Wilderman, patient
Promoting health through education is a primary focus of the CWC PCN.
Health Promotion Statistics
SUCCESSES WITH OUR Primary Care Network
COMMUNICATIONS Informing patients about services and programs available to them through their family physician clinic, or “medical home,” has been a key focus for the CWC PCN. To promote health referral programs, several projects were launched in 2013 including a new website. The www.cwcpcn.com website contains useful information for patients with a CWC PCN member physician or for those seeking a physician. The site also offers information on the various programs available such as smoking cessation or nutrition, along with descriptions of the collaborative care team (CCT) members who work with member physicians to provide excellence in patient care. The CWC PCN also launched a patient magazine in 2013 called Health Matters, which is available both in print and online, offering program information, health tips and patient stories. Other ongoing initiatives include the distribution of brochures and wallet sized referral cards for CCT members as well as the creation of new content for the Health Unlimited Television (HUTV) in member clinics. “PCNs have been around for a relatively short period of time,” said Bart Goemans, communications & member services manager. “With programs and services evolving over time, the message of what a PCN does had become somewhat fractured. We have developed a communications approach that we hope creates better awareness for patients and increased program usage of programs and services by physicians.”
237
Patients completed the Tackling Tobacco Together (3T) program
2,348
Geriatric patients were seen at the Clinic at Westbrook
853
Patients attended a GAS consultation
What is SUSTAINABLE FAMILY PRACTICE?
Supporting family physicians by providing programs that target the unique needs of community-based comprehensive primary care, such as continuing clinical education.
SUCCESSES WITH OUR Primary Care Network
SUSTAINABILITY The CWC PCN helps support strong community-based family practices for its member physicians through various programs and services. Doctors are faced with challenges related to the costs of facilities, staff and overhead. They need to carefully manage their time and clinic resources to ensure the best possible patient access to care. Of the 330 physicians who are members of the CWC PCN, many run solo practices where ensuring access to the clinic can be particularly challenging against the need for ongoing education, time-off and other commitments. “Our objective is to enhance patient access to care by supporting the needs of community practices,” said Dan Doll, executive director. “These tailored initiatives focus on educational opportunities, colleague coverage for patient care, clinic office supports and communication tools.” For example, many people may not realize the dilemma family physicians face when they choose to take vacation or attend educational events. “The CWC PCN assists with a program that helps physicians to arrange for a colleague to provide coverage for their patients during their absence,” said Dan. “We also help keep physicians up-to-date with required clinical tools to ensure they and their team are properly equipped,” concluded Dan. “Based on feedback received from physician members, we believe that we are making a difference in supporting sustainable comprehensive family practices.”
Dr. John Coppola and Dr. Natalie Ward, family physicians
Sustainable Family Practice Statistics
SUCCESSES WITH OUR Primary Care Network
CONTINUING CLINICAL EDUCATION One of the benefits for physicians in the CWC PCN is the opportunity to attend Continuing Clinical Education (CCE) sessions on core areas of chronic disease management, and according to the numbers from this past year, physicians overwhelmingly supported this initiative. Dr. Jane Ballantine, medical director, reported that 39 CCE events were held over the past fiscal year with 185 physicians attending various sessions along with members of the CWC PCN collaborative care teams (CCTs). Almost all of the sessions were booked up within a few days. “This speaks volumes that physicians feel it’s a valuable use of their time and that we’re providing a significant, high calibre program,” said Dr. Ballantine, adding that the hope is to provide the necessary tools and education for teams to be successful. The CCE events focus on medical issues that physicians and CCTs address every day including mental health, geriatrics, diabetes, respiratory and women’s health. New topics for this coming year include cardiology and men’s health. “We align with the areas where we believe our teams can improve care and access for patients,” said Dr. Ballantine. “There’s no end to the opportunity for education.” Ongoing education is also essential to communicating changes in medical practice guidelines. Over the past year, CCEs have helped by outlining new diabetes, hypertension and cholesterol guidelines. “CCEs give us an opportunity to have credible specialist speakers in new and evolving areas,” concluded Dr. Ballantine.
39
Continuing Clinical Education (CCE) events were held
185
Physicians attended Continuing Clinical Education events
The objective of the CWC PCN is to create an environment where its physician members are supported in their efforts to provide quality primary care.
SUCCESSES WITH OUR Primary Care Network
Evaluation & Measurement
There’s nothing like demonstrating positive outcomes through objective inquiry to build confidence that we are improving the lives of our patients. ~ Garth
The CWC PCN strives for continuous improvement in patient care, and an essential component to achieving this objective is the ongoing evaluation of programs and services. To enable better evaluation, in the past year the CWC PCN created and rolled out a data collection tool called CREDIT that has since been deployed in 61 physician clinics. CREDIT stands for Capturing Results, Enhancing Delivery and Improving Tomorrow, and according to Garth Mihalcheon, evaluation manager, over 10,000 patient visits were logged into the system by collaborative care team (CCT) members during the first six months of use. Currently, that number has doubled to over 20,000 patient visits recorded in CREDIT. “The purpose of CREDIT is to collect key health and activity indicators for in-depth analysis” said Garth, including the top reasons for referral and key patient interventions. Through the CREDIT statistics, for example, the PCN is well aware that the top three reasons for referral are diabetes, weight issues and anxiety/depression. “Based on this knowledge, we can ensure our care team programs are aligned with the patient population.” Other evaluation projects within the CWC PCN include measuring the time it takes for patients to book an appointment with their family doctor, analyzing how our CCT professionals (behavioural health consultants, dietitians, pharmacists, physiotherapists, registered nurses and social workers) are meeting patient needs and getting family physician feedback via our annual physician survey.
Our Geographical Boundaries
The CWC PCN is bounded on the north and east sides by the Bow River, on the south side by Anderson Road and to the west by the city limits.
VISIT US ONLINE AT www.cwcpcn.com or www.makinghealthhappen.com
CONTACT US If you have any questions or if you would like more information regarding our services, please feel free to contact us with your questions.
Main Office
Clinic at Westbrook
Tsuu T’ina Clinic
P: 403.258.2745 F: 403.258.2746
P: 403.249.9907 F: 403.249.9976
P: 403.251.7575 F: 403.251.1627
E: info@makinghealthhappen.com
E: info@makinghealthhappen.com
Services available to residents of Tsuu T’ina Nation.
Calgary West Central Primary Care Network MEMBER CLINIC & PRACTICE LISTING 12West Medical Clinic
Dr. Elumir’s Office
Associate Clinic #330
Dr. Faith Nixdorff’s Office
Associate Clinic #362
Dr. Herget’s Office
Associate Clinic #363
Dr. Keith Laatsch’s Office
Associate Clinic #364
Dr. Lesley Coulter Professional Corp
Associate Clinic #370
Dr. Lyne Audet’s Office
Braeside Medical Centre
Dr. Marni Brydon’s Office
Breast Cancer Supportive Care
Dr. Michael Davison’s Office
Bridge Docs
Dr. Mish and Dr. Noiles Professional Corp
Bruce W. Jespersen Professional Corporation
Dr. P.A. Mitha’s Office
Calgary West Medical Centre
Dr. Paul James Tkalych’s Office
Canyon Meadows Clinic
Dr. R. Dargie’s Office
CareWest Dr. Vernon Fanning Centre
Dr. Richard P. Lam’s Office
CareWest Sarcee Hospice
Dr. Robert Cole’s Office
Copeman Healthcare Centre
Dr. Scott Beach’s Office
Cornerstone Medical Centre
Dr. Shahebina Walji’s Office
CUPS Community Health Centre
Dr. Stajen Warness’ Office
Day Hospital South Glenmore Park
Dr. Stinton’s Office
Deerfoot Meadows Medical Clinic
Dr. Brandon, Loehr, Lovo & Wilkinson’s Office
Dr. A. Pandya’s Medical Clinic
Dr. Bryden, Scurfield & Young’s Office
Dr. Alexander Morrison’s Office
Dr. Harper & Wilmot’s Office
Dr. Catherine McKenna Nutrition & Weight Management
Dr. Lambert & Campbell’s Office
Dr. Christopher J. Gorrie’s Office
Dr. Louie & Tse’s Office
Dr. David Falk’s Office
Dr. MacQueen & McMurren’s Office
Dr. David Gill’s Office
Dr. McLean, Harvey & van der Merwe’s Office
Dr. Diana Turner’s Office
Dr. Woolner, Chan & Yuen’s Office
Dr. Dina Radinskaia’s Office
Elbow River Healing Lodge
The listed clinics had member physicians in the 2012/2013 fiscal year.
Fairmount Medical Clinic Glenbrook Medical Clinic Glenmore Family Physicians Glenwood Medical Centre Good Health Medical Centre Heritage Family Medical Centre Heritage Hill Medicentre Humana Medical Clinic Intramed Medical Centre Killarney Medical Clinic Lakeview Medical Clinic LifeMark Health Mayfair Medical Clinic MCI The Doctors Office at 130th Ave MCI The Doctors Office at Beacon Hill MCI The Doctors Office at Kingsland MCI The Doctors Office at Sarcee McKenzie Towne Medical Meadows Maternity and Family Practice Medical Express Mission Medical Clinic Mount Royal MediCentre Mount Royal University - Health Services My Calgary Doctor Nichol Pereles Professional Corp Oak Bay Medical Centre Prime Care Medical
Provital Health & Wellness Rhythm Health Richmond Road Family Medical Clinic Richmond Square Medical Centre Rideau Medical Clinic Rockyview Health Centre Rockyview Maternity & Family Practice Group Rockyview Medical Clinic Salveo Family Medicine Clinic Signal Hill Medical Centre Southland Medical Clinic Southland Sport Medicine Southport Family Practice Southwood Medical Centre Strathcona Family Medicine Centre Susan Poon Professional Corp The Alex Community Health Centre The Alex Community Health Centre - Seniors Care Tom Baker Cancer Centre University Health Services Clinic Valley Ridge Medical Clinic V-Medi Spa Wentworth Medical Westbrook Medical Clinic Westglen Medical Centre Westside Medical Clinic Westside Sports Physiotherapy
Making Health Happen.
TM
Thank you to our physicians, patients and staff who shared their stories in this report to the community. Please share this copy with a friend.