Report to the Community 2014
Natasha, PCN nurse.
Keith, patient and his wife Marilyn.
Message from the Calgary West Central Primary Care Network
As the city of Calgary continues to grow, so too does the Calgary West Central Primary Care Network (CWC PCN). Our physician membership has increased by over 10 per cent in the last two years and we currently support 360 member doctors representing 306,000 patients and 114 clinics. Now in our eighth year of service to the community, the CWC PCN remains committed to four key objectives that serve as pillars of our vision – enhanced access, physician-led collaborative care, health promotion and sustainable family practice. Through these objectives we aim to provide excellence in community based comprehensive primary health care. In coming years, we will continue to manage the growing demand for our programs and services while aligning with the future needs of primary care.
The CWC PCN is one of the largest of 42 Primary Care Networks in Alberta. As part of the continuing evolution of primary care, we are working closely with our partners in health care to develop our programs. PCNs across the province are rallying behind the concept of the medical home. The CWC PCN also embraces this concept where patients have a ‘home base’ from which their family physician and health team provide and coordinate their care. Over the next few years, we will further evolve our programs to support this model. In this Report to the Community you will read about the many ways our PCN is already supporting the medical home. This includes surrounding our member physicians and their patients with talented groups of health care professionals called Collaborative Care Teams. There are currently over 76 team members enhancing patient care in some 72 clinics, including behavioural health consultants, dietitians, nurses, pharmacists, physiotherapists, and social workers. These teams are helping to make health happen in your community today. At the CWC PCN, we are proud of our successes and look forward to building on them as we grow and develop through patient centred care.
Governance Committee Members Dr. Brendan Vaughan CWC PCN P.G. Co. Co-Chair Nancy Guebert CWC PCN P.G. Co. Co-Chair Dr. Brian Boyd CWC P.G. Co. Alternate Dr. Scott Forsyth CWC P.G. Co. Alternate Dr. Margot McLean CWC PCN P.G. Co. Representative Dr. James (Jim) Silvius CWC P.G. Co. Representative
Dan Doll, Executive Director Calgary West Central Primary Care Network
Jane Ballantine, Medical Director Calgary West Central Primary Care Network
Dr. Nicholas (Nick) Myers CWC P.G. Co. Representative
Message from the Board of Directors
At the Calgary West Central Primary Care Network we are committed to continuous improvement. This means measuring our work and the Report to the Community contains many program and service measurements from the past year. As always, physician satisfaction is one of the key operating metrics.
this program to ensure these teams work effectively together in community practices. To date, 124 physicians and 54 CCTs have participated in team and practice effectiveness training sessions to help facilitate enhanced patient-focused teamwork. In addition, 91 per cent of our members have attended a continuing clinical education event on a range of health topics.
In the past year, 160 member physicians completed an annual survey that helped benchmark satisfaction with their CWC PCN membership and our programs and services. Approximately 96 per cent were satisfied with their membership - a three per cent increase from the previous year. This number can be attributed in part to the hard working allied health professionals and doctors who came together to form partnerships in enhanced patient care.
To further enhance access to medical care, the CWC Primary Care Centre (CWC PCC) located in Westbrook recently began providing seven-day-aweek, same-day appointment referral service for patients of member physicians. This service builds upon the after-hours or evening and weekend service previously offered. In addition, many referral-based lifestyle programs and nutritional programs, as well as geriatric assessment and support, remain available and are heavily subscribed. We continue to grow and build on our successes.
Other benchmarks show that over 82 per cent of physician members reported that the PCN provides useful support for running a community practice, 77 per cent said that their work life balance has improved since joining the PCN, and 75 per cent indicate they have opportunities to advocate for their patients because of their membership with the CWC PCN. Collaborative care teams (CCT) remain a pillar of our PCN and a key component to building a medical home. We continue to place significant resources behind
At the CWC PCN we have much to be proud of. We continue to gather input from member physicians and our partners at Alberta Health, and remain focused on improving today while building for the future.
Board Members Dr. Brendan Vaughan CWC PCN P.G. Co. Board Chair Dr. Margot McLean CWC PCN P.G. Co. Board Vice-Chair Dr. Ronald Lim CWC PCN P.G. Co. Secretary-Treasurer Dr. Thomas Tam 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
Brendan Vaughan, Family Physician, CWC P.G. Go. Board of Directors Chair Calgary West Central Primary Care Network
Dr. Elisabeth Woolner CWC P.G. Co. Board Director Dr. Brian Boyd CWC P.G. Co. Board Director Dr. Scott Forsyth CWC P.G. Co. Board Director
306,000 Patients
360 Physicians
114 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 42 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 360 primary care physicians, working in 114 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 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.
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.
Building better health: Your medical home
Having a medical home ensures that you have greater access to primary health care.
Dorothy was right when she said, “There’s no place like home.” After all, in an often busy and stressful world, it’s the one place we always feel comfortable, safe and secure. At Primary Care Networks (PCNs), we believe patients can feel a similar sense of home under the care of their family doctors. In fact, your medical home is your family doctor’s office.
MEDICAL HOME
R
PCNs support your family doctor to help him or her 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 nurses, behavioural health consultants, physiotherapists, kinesiologists and pharmacists (availability varies by PCN and clinic), who enhance your doctor’s ability to care for you. Having a medical home ensures that you have greater access to primary health care. And 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 medical services outside of your doctor’s office. By having a family doctor that you see regularly, you are building a lifelong relationship of appropriate, consistent and coordinated primary care. And research has shown that this continuity of care leads to better health outcomes for patients!
Calgary West Central Primary Care Centre
Seven-day-a-week, same-day appointment service The CWC Primary Care Centre offers enhanced access with a seven-day-a-week, same-day appointment service for patients in immediate need who are referred by their PCN 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 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 Alberta 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.
Tackling Tobacco Together (3T) The CWC PCN offers a Tackling Tobacco Together (3T) program, available through referral from your family physician. The program involves an integrated behavioural and pharmacotherapy approach to support smokers to quit.
5,483
patients seen in the Primary Care Centre after hours service
4,660
patient referrals from Health Link Alberta
Additional services Geriatric Assessment & Support (GAS) The CWC Primary Care Centre offers a Geriatric Assessment & Support clinic that conducts comprehensive assessments for medically complex elderly patients. The team meets with elderly patients who typically have multiple health problems and may have limited access to resources and help.
Clinic Statistics
Nutritional programs The CWC PCN has a number of nutritional programs 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 clinic does not see patients on a long-term basis. Need a doctor To help match you to a family doctor in your geographic area, provide your information through an online registry at www.needadoctorcalgaryandarea.ca.
1,281
3,502
1,771
2,398
patients were seen as part of the Women’s Health Clinic at Tsuu T’ina Nation
patient were matched with a family physician
patients were seen at the Tsuu T’ina Nation Clinic
patients without a family physician received care in the Primary Care Centre
Collaborative Care Teams (CCTs)
What is a CCT?
CCTs are physician-led, multi-disciplinary teams that consist of behavioural health consultants, dietitians, pharmacists, physiotherapists, registered nurses and social workers. The common objective is enhanced patient care and access to the right professional, at the right time. As a member of the CWC PCN, your physician can refer patients to these professionals. Availability may vary by clinic.
11,503
2,592
patients seen by a Behavioural Health Consultant
patients seen by a Physiotherapist
1,299
12,194
patients seen by a Dietitian
5,554
patients seen by a Pharmacist
patients seen by a Primary Care Nurse
Meet the TEAM
Dr. Gorrie
Family Physician
Iordanka
Behavioural Health Consultant (BHC)
Kristen Dietitian
Natasha
Registered Nurse
Lauren
Physiotherapist
Shawn
Pharmacist
Jeanne
Primary Care Nurse
Syndrome X: Keith’s Story
“I thought I was fit and healthy,” says Keith Shaw, a 71-yearold retired school teacher and competitive swimmer. “I was surprised to learn that I wasn’t.” Keith had learned from his physician that he had a deadly mix of health issues that when combined forms Syndrome X. Keith did not seem to fit the model of a patient with this type of diagnosis, so how did he get here? Upon seeing his physician, Dr. Phillip van der Merwe, in April 2013, Keith learned that he had a combination of increased blood pressure, problematic blood sugar levels and, potentially, pre-diabetes (a condition in which blood sugar levels are higher than normal, but not high enough to be full-blown diabetes). In addition, Keith had an increased waist circumference. “Patients with this syndrome are five times more likely to develop diabetes and twice as likely to have heart attacks and strokes,” says Dr. van der Merwe, who has been Keith’s doctor for more than 15 years. When Keith sustained an injury to his arm and shoulder, it prevented him from enjoying his regular swim at maximum effort and distance. As a result, his waist circumference increased and his energy levels were lower. Until that point, Keith had been Photo: Dr. Phillip van der Merwe and patient, Keith Shaw
Health team helps patient swim around disease risks
swimming up to 15 kilometers regularly each week and sometimes enjoying bread or fast food as a reward afterwards. “This was like a crystal ball, because the path to avoid major problems was now clear,” says Dr. van der Merwe, who immediately provided Keith with some resources to start him on the path to wellness. One of those resources was Natasha Veric, a chronic disease management nurse with the Primary Care Network (PCN). Natasha is a member of the allied health teams integral to PCNs. These teams include registered nurses, licensed practical nurses, pharmacists, behavioural health consultants, social workers, dietitians, kinesiologists and physiotherapists who work alongside family physicians in PCNs (availability varies by clinic and PCN).
following advice on healthy versus unhealthy fats,” says Natasha. In particular, Keith reduced the amount of bread and starchy carbohydrates he consumed and cut out the occasional fast food. He also started eating more protein from nuts and included different forms of carbohydrates, such as those from fruits and milk. “I actually had more energy when I returned to the pool, so I could work out even harder,” Keith adds.
Natasha began meeting with Keith monthly. “I learned a lot from Natasha right away, and she was always very positive,” says Keith.
Within weeks, Keith had started to lose weight and his LDL cholesterol (bad cholesterol) level dropped remarkably in just a few months. “My keys to success were returning to exercise, the education and nutritional support from Natasha and also from my wife, Marilyn, who not only did a lot of research on diet but also helped prepare the right foods and gave me encouragement, too,” says Keith.
“Keith immediately started to use the Live Well – Daily Diet Tracker provided by the PCN, in addition to
Recently Keith participated in the 70–74 age group Alberta swim meet and earned a new provincial record
– beating his previous time by 7.5 seconds. Keith also participated in a swimming competition in Victoria on March 1, where he set four more records. “Treatment is about better quality of life and healthier outcomes,” says Dr. van der Merwe. “Imagine if we knew where the iceberg was and could arrange to adjust the Titanic’s course ahead of time?” Syndrome X affects almost one-quarter of all patients. “Physicians are advocating the team approach to care, and patients like Keith are proof of the outcomes,” adds Dr. van der Merwe.
Letters from Patients Success in our Primary Care Network
Being able to see a Behavioural Health Consultant (BHC) at my doctor’s office, at a time I may not have sought someone on my own
made access to the help
convenient and easy.
~ BHC patient
Recently, I had a lot of pain while
Through family health struggles,
my physician was on holidays. I was
we were pleased to see the
referred to the at Westbrook where I was
appropriate use of the medical
greeted by a welcoming atmosphere,
system. The CWC PCN thrives
quick service
and supports my mum in the
and thorough care.
very best
~ Primary Care Centre patient
~ Nursing patient
way I can imagine.
306,000 Patients
360 Physicians
114 Clinics
1
Network
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
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
Primary Care Centre
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@cwcpcn.com
e: info@cwcpcn.com
Services available to residents of Tsuu T’ina Nation.
Calgary West Central Primary Care Network MEMBER CLINIC & PRACTICE LISTING 12West Medical Clinic
Deerfoot Meadows Medical Clinic
Dr. Scott Beach’s Office
Associate Clinic #330
Dr. A. Pandya’s Medical Clinic
Dr. Shahebina Walji’s Office
Associate Clinic #362
Dr. Catherine McKenna Nutrition & Weight
Dr. Stajen Warness’ Office
Associate Clinic #363
Management
Dr. Stinton’s Office
Associate Clinic #364
Dr. Christopher J. Gorrie’s Office
Dr. Brandon, Loehr, Lovo & Wilkinson’s Office
Associate Clinic #370
Dr. David Falk’s Office
Dr. Bryden, Scurfield & Young’s Office
Braeside Medical Centre
Dr. David Gill’s Office
Dr. Lambert & Campbell’s Office
Braeside on 24th Medical Clinic
Dr. Diana Turner’s Office
Dr. Louie & Tse’s Office
Breast Cancer Supportive Care
Dr. Dina Radinskaia
Dr. MacQueen & McMurren’s Office
Bruce W. Jespersen Professional Corporation
Dr. Herget’s Office
Dr. McLean, Harvey & van der Merwe’s Office
Calgary West Medical Centre
Dr. Keith Laatsch’s Office
Dr. Wilmot’s Office
Calgary West Central Primary Care Centre
Dr. Lesley Coulter Professional Corp
Dr. Woolner, Chan & Yuen’s Office
Canyon Meadows Clinic
Dr. Lyne Audet’s Office
Elbow River Healing Lodge
CareWest Dr. Vernon Fanning Centre
Dr. Mish and Dr. Noiles Professional Corp
Fairmount Medical Clinic
CareWest Sarcee Hospice
Dr. P.A. Mitha’s Office
Family Health Clinic
Chinook Medical Centre
Dr. Paul James Tkalych’s Office
Glenbrook Medical Clinic
Chiron Medical Clinic
Dr. R. Dargie’s Office
Glenmore Family Physicians
Copeman Healthcare Centre
Dr. Richard P. Lam’s Office
Glenmore Landing Vein Clinic
Cornerstone Medical Centre
Dr. Robert Cole’s Office
Glenwood Medical Centre
CUPS Community Health Centre
Good Health Medical Centre
New Brighton Medical
Southwood Medical Centre
Heritage Family Medical Centre
Nichol Pereles Professional Corp
Springview Medical Clinic
Heritage Hill Medicentre
Oak Bay Medical Centre
Strathcona Family Medicine Centre
Humana Medical Clinic
Prime Care Medical
Sunnyhill Pediatric Clinic
Intramed Medical Centre
Provital Health & Wellness
Susan Poon Professional Corp
Killarney Medical Clinic
Rhythm Health
The Alex Community Health Centre
Lakeview Medical Clinic
Richmond Square Medical Centre
The Alex Community Health Centre - Seniors Care
LifeMark Health
Rockyview General Hospital
The Alex Community Health Centre - Youth Centre
Lynne Murfin Professional Corp
Rockyview Health Centre
Tom Baker Cancer Centre
Mayfair Medical Clinic
Rockyview Maternity & Family Practice Group
Total Skin Care
MCI The Doctors Office at 130th Ave
Rockyview Medical Clinic
Tsuu T’ina Health Centre
MCI The Doctors Office at Kingsland
Salveo Family Medicine Clinic
University Health Services Clinic
MCI The Doctors Office at Sarcee
Signal Hill Medical Centre
Valley Ridge Medical Clinic
Meadows Maternity and Family Practice
SMC Family Medicine Clinic
V-Medi Spa
Medical Express
South Health Campus
Wentworth Medical
Mission Medical Clinic
South Trail Medicentre
Westbrook Medical Clinic
Mount Royal MediCentre
Southland Medical Clinic
Westglen Medical Centre
Mount Royal University - Health Services
Southland Sport Medicine
Westside Medical Clinic
My Calgary Doctor
Southport Family Practice
WestSide Sports Physiotherapy
Making Health Happen. Thank you to our physicians, patients and staff who shared their stories in this report to the community. Visit us online at www.cwcpcn.com. Please share this copy with a friend.