Report to the community 2 0 1 3-14 CALG ARY FO OTHILLS P RIMARY CA RE NETWORK A NN UA L R E P ORT
www.cfpcn.ca
Working together to strengthen the health of our communities
myhealthhome
Calgary Foothills Primary Care Network
ABOUT US
OUR NETWORK, IN NUMBERS
who we are
Primary Care Networks are groups of family doctors who work with other health professionals and Alberta Health Services to deliver primary health care throughout the province. Calgary Foothills PCN, one of seven networks in the Calgary area, includes 385 doctors who serve more than 361,000 patients in north Calgary and Cochrane.
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what we do
Primary care is the care patients receive for most of their everyday health needs, typically at their family doctor’s clinic. Examples of this form of care include checkups, health promotion and wellness advice, counselling, maternity care and diagnosis and treatment for those suffering from chronic pain.
how it works Patients of doctors who are members of Primary Care Networks have access to physician-led health teams, as well as other clinics and services. Patients living in the Calgary area who do not have a family doctor can register online at www.needadoctorcalgaryandarea.ca.
my health home
our mission
A family doctor’s clinic is a patient’s Health Home, connecting them to the care they need, when they need it. Patients of doctors who are members of Primary Care Networks have access to physician-led health teams that may include health management nurses, clinical pharmacists, registered dietitians and behavioural health consultants. Patients also have access to other clinics and services. In the Calgary Foothills area, this includes after hours care, maternity care and comprehensive help with pain management, gastroenterology and medical musculoskeletal issues. For more information, patients can ask their family doctor or visit our website at www.cfpcn.ca.
To provide enhanced access, collaboration, continuity and comprehensiveness of primary care for patients, achieving positive health outcomes through physician-led multidisciplinary teams and coordination with the broader health care system.
361,464 patients
385
doctors
86
clinics
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Calgary Foothills Primary Care Network
CONTENTS
access
mission: provide coordinated 24-hour, seven-day-per-week management of access to appropriate primary care services
health promotion
mission: increase the emphasis on health promotion, disease and injury prevention, care of the complex patient and those with chronic disease
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mission: facilitate the use of multidisciplinary teams to provide comprehensive primary care
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mission: improve coordination and integration with other health care services including secondary, tertiary and long-term care
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my health team coordinated care
pages 6-9
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Calgary Foothills Primary Care Network
PCN BOARD REPORT
Primary Care Networks grow, evolve to serve communities AS we celebrate another year of growth and progress, there’s a sense of excitement about what the future holds for Primary Care Networks and all those involved in the delivery of primary care in Alberta. From a governance perspective, leadership of Calgary Foothills PCN has continued to evolve, and during the past year we added two more public members to our Board of Directors to bring the group to its full complement of nine members. The added diversity will be a strength to our organization as we move forward. As discussions intensify at the provincial level around PCN Evolution — the future of primary health care delivery in Alberta — and the publication of Alberta’s Primary Health Care Strategy, Calgary Foothills PCN is well positioned to continue to be
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a leader in primary health care. Our aim is to adapt and evolve to best serve the needs of patients in our communities. As part of this process we are developing a long-term strategic plan that will give us a road map on which we can build from year to year. The six-year plan will focus on ensuring patients have access to a Health Home, where they will receive comprehensive primary care from a physician-led team, are connected with other services and will have their health care journey coordinated and managed. Over the past 12 months Calgary Foothills PCN has continued to build on a strong and established group of core programs. That momentum will be carried forward into the next few years.
One of the most significant changes on the horizon involves moving to a new model of team-based health care delivery in which family doctors are supported with a series of programs and initiatives. Although we’ve accomplished a lot in recent years, the pace of change continues to intensify. Central to our success is the support the organization receives from our members and partners and I would like to take this opportunity to thank them for their efforts as we continue to work together to find innovative solutions that serve patients’ needs.
Calgary Foothills Primary Care Network Board of Directors David Wartman Board chair Dr. Heidi Fell Vice-chair Dr. Sarah Bates Board director Laurie Blahitka Board director David Farran Board director Dr. Peter Jamieson Board director Barbra Lemarquand-Unich Board director Dr. Jessica Orr Board director Barbara Pitts Board director
David Wartman Board chair
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Calgary Foothills Primary Care Network
PHYSICIAN BOARD REPORT
Supporting family doctors at heart of key programs PRIMARY care services delivered at the community level are the foundation upon which our health care system is built. Supporting family doctors and their teams to provide quality and comprehensive patientcentred care is at the heart of the work we do at Calgary Foothills Primary Care Network. One of our key priorities is to support our members in the development and evolution of the Health Home so that it can better respond to the needs of the local community. The Health Home is a physician-led team of health care professionals — centred in a physician’s clinic — where patients’ needs come first. It is each patient’s home within the health care system. At a time of great change within the health care landscape, it is essential that physicians are given the support and resources they need to continue to enhance
their practices at a pace and in a manner that suits their needs. The number of Calgary Foothills PCN members involved in quality improvement work in their practice almost doubled to 8o per cent last year. Panel identification — in which doctors identify the patient population they serve — has become a focus and priority. It has been a very busy time for physicians. One of the challenges in these times of great change is adapting and evolving as new ideas, strategies and policies are unveiled. In 2013, the Alberta Medical Association Primary Care Alliance Board produced two documents that propose a plan for implementing PCN Evolution in Alberta. In March 2014, the Physician Office System Program, the initiative which helped family doctors take up and use electronic medical records, came to an end. This has implications for the ongoing use of electronic
medical records in clinics. Practice enrichment and quality improvement will continue to be key PCN priorities moving forward and doctors will have the opportunity, if desired, to work with their PCN liaison to identify and plan their own enrichment projects at a scope and scale that works best for them. As we approach our ninth year of operations, I would like to thank our members, leadership and staff for their ongoing dedication to delivering quality care to over 361,000 patients in north Calgary and Cochrane. Together we will continue to build our capacity for care and ensure all patients have a home in the health system.
Dr. Heidi Fell Board chair
Calgary Foothills Primary Care Physician Corporation Board of Directors Dr. Heidi Fell Board chair Dr. Sarah Bates Vice-chair Dr. Habeeb Ali Board director Dr. Sanjeev Bhatla Board director Dr. Lisa Coffey Board director Dr. Dennis Fundytus Board director Dr. Richa Love Board director Dr. Jessica Orr Board director Dr. Wendy Stefanek Board director
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ACCESS
innovation & excellence mission: provide coordinated 24-hour, seven-day-per-week management of access to appropriate primary care services
TRANSFORMING CARE
Drug switch initiative a ‘life-changer’ for patients IMPROVING the life of just one patient is a true success story for any treating physician and team. Radically transforming the care of almost 20 is a major achievement. Over the past year, the lives of many of Dr. Ted Jablonski’s patients got a whole lot better, thanks to an innovative practice enrichment project. The drug-switching initiative took four months initially and involved at least six staff. But patients such as retiree Gillian Bottomley say it was time well spent. Diagnosed with atrial fibrillation six years ago, Gillian had endured almost weekly trips to a lab to check that her blood coagulation INR (international normalized ratio) was in the
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correct range. When it was not, she would go more often. “My husband used to drive me,” she says. “I’d have blood running down my arm because my blood didn’t clot very well. “If the count was too high, I’d go back four days later. I never really knew if my blood was too thin and if I was at risk of bleeding internally.” The drug Gillian had been taking was the gold standard treatment for atrial fibrillation for many years. For some patients, however, it was often ineffective. New oral anticoagulants were released several years ago, but were prohibitively expensive. So when Alberta Blue Cross announced last year that it would cover the cost of the
new drugs in certain cases, Dr. Jablonski realized a huge group of his patients could benefit from the change. Together with his Calgary Foothills PCN liaison, the proactive care coordinator, in-clinic nurses and clinical pharmacists, Dr. Jablonski reviewed his electronic medical record for patients who might qualify and benefit from the switch. Staff contacted patients and clinical pharmacists offered counselling sessions. “I knew this would be a life-changer for these patients and it would save us a lot of time in the long run,” Dr. Jablonski says. The drug patients previously used had been a day-to-day issue for the clinic. Staff were constantly playing phone tag with patients who needed
HEALTHY OUTCOME: Dr. Ted Jablonski helped improve the lives of almost 20 patients thanks to an innovative drug-switching project.
PRACTICE ENRICHMENT Calgary Foothills Primary Care Network family doctors are embracing practice enrichment projects in their clinics.
146
The number of Calgary Foothills PCN doctors who took part in liaison-facilitated quality improvement work last year
One area many doctors are focusing on is called panel management. This approach uses a doctor’s knowledge of his or her patients to improve care and clinical outcomes for groups of patients. It changes the focus from reacting to the needs of individual patients to proactive treatment of a group of patients.
74% to adjust their dosage. It was time consuming. “If you can take all of that away and have a medication that is foolproof, it is easy to get buy-in,” Dr. Jablonski says. “It was a very satisfying process.” Dr. Jablonski estimates the drug switch has saved him at
least a few hours a week, with about the same amount of time saved by health management nurses and clinical pharmacists at his clinic. “With even modest time savings from this initiative, our clinic is able to manage increased patient numbers,”
Dr. Jablonski says. “Our whole team has more time to deal more completely with other patients’ issues. Was it time well spent? Absolutely, yes.” For her part, Gillian says she has more peace of mind. Today she is less worried about the risk of blood clots causing a stroke because her
new drug controls her blood better. “I am very grateful Dr. Jablonski has done this, that he thinks about his patients and what is best for them,” she says. “It has been terrific for my husband and amazing for me. I’m much happier.”
Photos: Neil Zeller Photography TEAM EFFORT: Nurse Tina Ainsworth, left, proactive care coordinator Darlene Seguin, clinical pharmacist Amy Pham, Dr. Ted Jablonski, clinical pharmacist Esmond Wong, liaison/project manager Julia Mierau and patient Gillian Bottomley.
87
The percentage of doctors who have identified a group of patients within their practice — for example, those suffering from diabetes
The number of practice enrichment projects developed over the past year. Thirty-six per cent have been completed
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ACCESS
innovation & excellence mission: provide coordinated 24-hour, seven-day-per-week management of access to appropriate primary care services
A DOCTOR’S STORY
New graduates benefit from physician mentoring, support patients has proved to be a FOR new graduate Dr. Janice great learning tool. Lui, Calgary Foothills Primary “You get to see what a Care Network’s decision to start physician has done previously to the New Grad Program could treat a patient not have come at and how they a better time. have managed Launched things,” Dr. in July 2013, You get to see Lui says. the program The seven exposes new what a physician has new gradufamily medicine ates on the graduates to done previously to program different clinics, treat a patient were able to while focus more providing - Dr. Janice Lui on medicine, financial and because they mentoring weren’t out looking support. for their next locum job. It also expands access to Dr. Lui says she appreciated primary care services because the mentoring support of the new graduates see member Calgary Foothills PCN physicians’ patients, including family physicians, including Dr. those who call for same-day Ramninder Dhillon at Riley Park appointments. Primary Care Centre. The new graduates say Dr. Dhillon, for her part, says treating another doctor’s
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she also benefited from the sharing of ideas and the process of learning from each other. She says patients in participating clinics were able to book more timely appointments because of the program. “For patients, there is something to be said for having access to someone who is new from residency,” she says. “Medicine changes so quickly, with new research and new medications. “Having a new hungry physician looking into your problems can make all the difference in the world.” Dr. Lui says she feels more confident about her abilities after a year on the program. “It has been a learning curve, but I certainly feel ready to go out and practice in a clinic,” she says.
SHARING IDEAS: New graduate Dr. Janice Lui, right, was mentored by doctors including Riley Park Primary Care Centre physician Dr. Ramninder Dhillon, left, as part of the New Grad Program, which enables new family medicine graduates to work in different clinics.
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ACCESS
innovation & excellence mission: provide coordinated 24-hour, seven-day-per-week management of access to appropriate primary care services
A PATIENT’S STORY Health Home opens doors to streamlined approach to patient care WHEN she was expecting her first child, Jane Wickenheiser discovered she could access all the pre- and postnatal care she needed through her Health Home. After discovering her longtime family doctor had retired, the Calgary school teacher found a new physician via the city-wide Need a Doctor website. Because her new doctor was a member of Calgary Foothills PCN, Jane was able to access specialist care and treatment before and after her daughter, Bryn, was born. That included several trips to the Access 365 Clinic for after hours care, as well as a referral to Riley Park Maternity Clinic, where she saw several members of the multidisciplinary team including a lactation consultant. Throughout the whole process, Jane’s family doctor was kept
NEED A DOCTOR? Patients who don’t have a family doctor can visit www.needadoctorcalgaryandarea.ca to find a physician in their community.
4,370
The number of patients who found a Calgary Foothills PCN doctor through the Need a Doctor website within the past year
ACCESS 365 CLINIC Patients who can’t get in to see their doctor can ask to be referred to the Access 365 Clinic or call Health Link Alberta at 403-943-5465. The clinic offers year-round after hours care and is open weekdays, weekends and holidays.
9,832 informed and helped ensure she received all the support her young family needed. “When you are having a baby and especially when it’s your first one, it can feel overwhelming,” Jane says. “Instead of making 20 different appointments I was able to organize everything through my family doctor. “There’s no wait at the Access
365 Clinic — they call to give you an appointment time. “I was concerned about a tongue tie at one point and I thought it was incredible how quickly the referral to a lactation consultant at the maternity clinic went through. I didn‘t really have to do anything and I had the best care possible. I have nothing but good things to say about it.”
Photos: Linh Ly Photography SMOOTH PROCESS: Jane Wickenheiser and her husband Jason were impressed with the continuity of care they received before and after the birth of their daughter Bryn.
The number of patients seen at the Access 365 Clinic, up 14 per cent from the previous year
MATERNITY CLINIC 39,474
The number of appointments at Riley Park Maternity Clinic last year, a 14 per cent increase over the previous year. It provides maternity services to low-risk patients delivering at Foothills Medical Centre 9
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disease & injury prevention
HEALTH PROMOTION
mission: increase the emphasis on health promotion, disease and injury prevention, care of the complex patient and those with chronic disease
CRAVING CHANGETM
Healthy relationship with food on menu
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Photo: Neil Zeller Photography TOP TIPS: Patient Karla Mah, left, and health management nurse Shirley Sullivan discuss strategies to change the thoughts, emotions and behaviours that influence eating habits.
WHEN Frank and Karla Mah became concerned about the long-term effects of over-eating, they turned to family doctor Andrew Eddy for help. “We’ve both struggled with weight since we turned 40,” Karla says. “We were concerned about how it might affect our blood pressure and cholesterol levels.” As it turned out, Calgary Foothills Primary Care Network had just adopted Craving Change™, a free program designed to help people build a healthier relationship with food. The couple decided to attend. While most healthy eating programs teach patients what to eat and when, Craving Change™ focuses on thoughts, emotions and behaviours. It helps people understand why they make poor food choices and offers tools to develop new habits. “It was amazing,” says Karla, who attended a four-week workshop with Frank. “I’m just so grateful for the awareness.” Karla learned she was more
likely to eat when she was bored or tired and that night times were more challenging. Instead of watching television after dinner, she now goes for a walk, reads or works on her finances — taking herself away from food and out of her ordinary routine. Karla says Craving Change’s™ ‘change buffet’ of strategies continues to help when cravings hit. “I try different things,” she says. “I might stop and wait before I eat to see if the urge passes. Or I might choose a smaller plate at dinner (with the aim of eating a smaller portion). It’s a work in progress, but Craving Change™ has given me hope.” Facilitator Shirley Sullivan, a health management nurse, says offering Craving Change™ in a group setting offers unique support. “Sometimes people forget how challenging behaviour change is and blame themselves,” she says. “It is reassuring to be in an environment where you know you are not alone.”
TM CRAVINGHEALTHY CHANGE BITES Craving ChangeTM is a four-part how-to workshop that aims to change patients’ relationship with food.
98%
Thesfddsfdsfsdfsdf percentage of Craving ChangeTM workshop participants who found the information useful for daily life
HOW IT WORKS Craving ChangeTM is designed for adults who struggle with eating habits, such as eating for comfort in response to emotions. ashdg asjdgasj djgas To register, call 403-284-3726 ext 206. jdgjasgdjgasdjg jasgsdd asjsgdjag gh
TOBACCO CESSATION
50%
TheHOW percentage patients ITofWORKS who quit smoking three months after enrolling in Calgary Foothills PCN’s tobacco cessation program
WALKING PROGRAMS 226
The number of registrants in a peer-led walking program that seeks to promote healthy lifestyles and active living within a safe and social environment
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my health team
FAMILY DOCTOR
mission: facilitate the use of multidisciplinary teams to provide comprehensive primary care
Team approach offers patients ‘one-stop shop’ DR. Jaco Kruger’s first experience disorder really respond well to a few with multidisciplinary teams came sessions of cognitive therapy with a when he moved to Alberta. BHC,” Dr. Kruger says. “Most people Having worked in three countries don’t need medication for these without that in-clinic support, Dr. problems, but if you don’t have a Kruger says they vastly improve mental health professional to refer patient care. them to, there may be no other “It is such an asset choice.” to how we can Multidisciplinary practice,” he says. teams also promote “It really channels real-time care, he your treatment A patient It really channels your says. approach into an with diabetes treatment approach into who needs an evidence-based practice and insulin start can an evidence-based offers more often be seen by comprehensive a clinical pharpractice care.” macist or health Calgary Foothills management nurse - Dr. Jaco Kruger Primary Care Neton the same day. work has 54 multi“Being able to do disciplinary team members, these things in almost real including clinical pharmacists, time is amazing,” Dr. Kruger says. registered dietitians, health “It makes my life easier and it makes management nurses, behavioural the patient’s life easier.” health consultants and certified Patients also value talking to a respiratory educators. They operate clinical pharmacist about medicain 96.3 per cent of member clinics. tions, including the options available Dr. Kruger says having a BHC in and potential adverse reactions. the office helps limit the number of “Most patients feel they do learn patients who are prescribed a lot and it helps them make better medications to cope with mental decisions,” Dr. Kruger says. “They health problems. see it as an extension of our care, “Issues such as anxiety and panic like we are a one-stop shop.”
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Photo: Barb Briggs Photography PATIENT-CENTRED: Dr. Jaco Kruger, pictured with patient Olivia, believes multidisciplinary teams vastly improve patient care.
HEALTHY BITES
96.3% The percentage of Calgary Foothills PCN doctors with a family practice who have at least one multidisciplinary team member in their clinic
361,464 The number of people who were patients of Calgary Foothills PCN doctors last year, up by 2,077
HOW IT WORKS Doctors who are members of the Calgary Foothills PCN can offer their patients access to a team of health professionals and other resources to help improve patients’ overall health. That team is led by the family doctor and can include other health 11 professionals.
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my health team
PHARMACIST
clinical pharmacist / n. trained professionals who provide patient care that optimizes medication therapy and promotes health and disease prevention
Education plays key role in meeting health goals WHEN Kevan Austen received a after joining TrymGym, a diabetes diagnosis in early 2013, Calgary Foothills Primary Care he discovered a team of experts Network-sponsored program offered ready to help him at his Health by the University of Calgary, and Home — Dr. Patrick Lai’s clinic in strives to eat well. He feels positive Brentwood. about his health and his future. Among Kevan’s early supports was “With a patient like Kevan, a lot clinical pharmacist of our job is to motiAmy Yu, who is also vate and encourage,” a certified diabetes Amy says. educator. “We work as a A lot of our job is She helped team. We can Kevan understand advise and help to encourage the new set goals, but and motivate . . . medication he ultimately would need to what a patient We work as a team take and how to achieves is a build a healthier credit to the - Clinical pharmacist patient. lifestyle. “A diabetes “Kevan’s efforts Amy Yu diagnosis can be have been truly challenging for any amazing.” patient,” Amy says. Alongside other “When people understand what clinical pharmacists who work within is causing their condition, they are Calgary Foothills PCN clinics, Amy more likely to follow through with also reviews patient medications and a health plan. We can offer them helps with issues such as high blood detailed education about their pressure, high cholesterol, asthma condition.” and chronic obstructive pulmonary Kevan, who was overweight and disease. struggled to walk around the block Clinical pharmacists also assess at the time of his diagnosis, has issues such as poor sleep and high since lost over 100 pounds. stress and can refer patients to the Today he exercises with passion appropriate resources.
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Photo: Linh Ly Photography SUPPORT TEAM: Clinical pharmacist Amy Yu helped patient Kevan Austen, pictured, understand his body’s response to diabetes.
HEALTHY BITES
9,400 The number of interactions between Calgary Foothills PCN clinical pharmacists and patients last year (three months’ data extrapolated over a year)
14/16 The number of Calgary Foothills PCN clinical pharmacists who are certified diabetes educators
HOW IT WORKS Clinical pharmacists work in partnership with doctors to optimize patients’ medications and help them achieve their health goals through a personal action plan. Examples include education on diseases and management strategies, immunizations and information on home blood pressure monitoring.
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my health team
HEALTH MANAGEMENT NURSE
Photo: Neil Zeller Photography LIVING BETTER: Nurse Neelam Shah, left, helped patient Fred James to significantly reduce his cholesterol levels.
nurse / n. a licensed health care professional who is skilled in promoting and helping patients maintain health
Wellness role strives to educate, empower
HEALTHY BITES
FORMER Stampeder Fred James wanted to find out whether making lifestyle changes could help lower his cholesterol levels when they spiked last year. So Dr. Lindsay Jantzie referred him to health management nurse Neelam Shah to discuss strategies that could make a significant difference. “I wanted to see if I could get my cholesterol levels down by consciously doing the things I needed to do — eating better and exercising,” Fred says. “I wasn’t ready to start taking [prescription medication]. Talking with Neelam really heightened my awareness of what I needed to do.” Armed with advice about reading labels, shopping better and staying focused, Fred succeeded in almost halving his cholesterol levels within three months. He is not taking medication. “I really like the wellness approach,” says Fred. Last year, the 18 health management nurses at Calgary Foothills Primary Care Network had 9,728 patient interactions. In addition to helping patients
The number of interactions between Calgary Foothills PCN health management nurses and patients last year (three months’ data extrapolated over a year)
9,728
33% Photo: Scott Grant Photography FOOTBALL STAR: Patient Fred James was formerly a member of the Canadian Football League’s Calgary Stampeders.
make lifestyle changes, health management nurses provide detailed information about a range of diseases. They also take blood pressure readings and teach patients to do it at home. Neelam says the more patients learn, the more autonomy they develop and the greater responsibility they feel for their own health. “We play a role in reassuring and coaching the patients,” she says. “It empowers people to make changes and feel confident about them. The changes Fred made were impressive.”
The percentage of health management nurses who are certified diabetes educators
HOW IT WORKS Health management nurses help patients develop personal action plans to manage their health conditions. Examples include helping patients suffering from chronic pain, diabetes, obesity or high blood pressure to set nutrition and exercise goals.
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my health team
BEHAVIOURAL HEALTH CONSULTANT Mental health support focuses on solutions
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Photos: Neil Zeller Photography HELPING HAND: Behavioural health consultant Szymon Apanowicz offers support to patients referred by their family doctor.
SZYMON Apanowicz spends his day helping people regain their life balance. “For many patients, it is the first time they’ve really opened up to someone about the way they feel,” he says. One of 14 behavioural health consultants with the Calgary Foothills PCN, Szymon provides short-term mental health support for patients referred by their family doctor. Appointments typically take place in the physician’s clinic. Some patients may be coming to terms with a physical diagnosis, while others are dealing with social issues. Issues that behavioural health consultants help patients address include depression and anxiety, relationship issues, parenting problems, addiction and workplace stress. “We see a real range,” Szymon says. “People can be suffering because they are isolated and do not realize, for instance, how important maintaining friendships can be. “Parents may be struggling to cope with a child’s addiction to
behavioural health consultant / n. works in partnership with doctors to help patients with mental health concerns
HEALTHY BITES
4,428 The number of new patients seen by behavioural health consultants within Calgary Foothills PCN last year (four months’ data extrapolated over a year) OPENING UP: Patients turn to behavioural health consultants for help with issues such as depression, addiction and anxiety.
computer games. A child may be struggling to cope with a parent’s death.” Over the past year, behavioural health consultants in our network saw 11,954 patients — up 24.4 per cent from the previous year. The form of brief therapy that behavioural health consultants offer is solution-focused and aims to help people resolve their problems within a short period of time.
HOW IT WORKS Behavioural health consultants are available to discuss health concerns and provide short-term help for issues such as coping with loss, finding motivation for lifestyle changes and managing stress, anxiety or depression. They can also offer advice on care-giving, parenting and relationships.
myhealthhome
my health team
DIETITIAN
dietitian / n. an expert in dietetics, the study of diet and nutrition
Food choices fuel new outlook on life
HEALTHY BITES
AFTER learning he was overdiabetes and heart disease and, weight during a visit to his doctor, because salt increases the risk of John-David Malta embarked on a high blood pressure, it was good 10-month battle to trim down. to learn about it. Eight months later, after not “Being young, I want to make losing weight, John-David asked to this a habit so I avoid ending up be referred to a dietitian at his with either disease.” doctor’s clinic. While proud Together, they of John-David’s discussed a range achievement, Kari of food-related is quick to note We listen, educate health issues, that helping including how patients lose and help people John-David weight is a identify small goals could make very small healthier food part of a they can focus on choices and registered limit portion dietitian’s - Registered dietitian sizes. work. Kari Derbyshire Two months The four after speaking with registered dietiregistered dietitian tians within Calgary Kari Derbyshire, Foothills Primary Care John-David had lost almost 20 Network help patients with diabepounds. But in the space of one tes, hypertension, cholesterol issues, consultation, he had gained irritable bowel syndrome and celiac valuable information that he concerns. Over the past year, they believes will improve his health saw around 1,400 patients. for many years to come. “Each session is individualized,” “The thing that surprised me Kari says. “We listen, educate and most was the importance of help people identify small goals they checking salt content in food,” can focus on to achieve the lifestyle he says. “I have a family history of changes they want to make.”
The number of patient interactions last year with Calgary Foothills PCN dietitians (three months’ data extrapolated over a year)
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Photo: Neil Zeller Photography HEALTHY HABITS: Dietitian Kari Derbyshire, left, taught patient John-David Malta dietary tips he believes will benefit him for years to come.
1,404
92% The percentage of participants in the Ask a Dietitian program who felt able to make changes to their diet after taking the class
HOW IT WORKS Patients can meet with a registered dietitian for nutritional advice, dietary tips for diabetes or liver and kidney conditions, and information on stomach and bowel problems, celiac disease and food allergies. Women can also access dietary guidance during and after pregnancy. Patients should ask their doctor 15 about a referral.
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collaboration & team work
COORDINATED CARE
mission: improve coordination and integration with other health care services including secondary, tertiary and long-term care
PSYCHIATRIC ASSESSMENT
Specialist diagnosis, support available to family doctors WHEN Dr. Gabrielle Savard improved my patients’ quality needs a specialist’s opinion of life. about an older patient, she “They think he’s the best sends them to Dr. Robert thing since sliced bread.” Granger. Since its launch in June She’s grate2013, doctors ful to have have referred access to one 76 patients to of the few program. His consultations the geriatric Of those psychipatients have improved my atrists per patients’ quality of life 74 in the cent were country. female and - Dr. Gabrielle Savard 49 per cent “Sometimes I were aged on Dr. Robert need to 80 and above. Granger confirm a Most patients diagnosis or have have an overlap of a discussion with a dementia, depression specialist about how to best and anxiety. help a patient manage their Dr. Granger first assesses condition,” says Dr. Savard, a patient then consults with who refers patients to Dr. their family doctor to offer Granger through Calgary suggestions. Foothills Primary Care “If we feel it’s necessary, I’ll Network’s Geriatric see the patient for follow-up Psychiatric Assessment appointments, which program. are beneficial for the “His consultations have patient in most cases,” he
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Photo: Neil Zeller Photography WORKING TOGETHER: Dr. Gabrielle Savard, left, says her patients think geriatric psychiatrist Dr. Robert Granger is “the best thing since sliced bread.”
says. “I believe primary care should be barrier-free.” Dr. Granger has long understood the need for specialist psychiatric help at the primary care level — the entry point of the health care system. “I wanted to contribute to services that could help to keep older adults in their own home, rather than them ending up in acute care,” Dr. Granger says. Dr. Savard says she likes coordinated care programs, like this one for older adults, because they allow patients to see specialists while keeping them closely connected to the Health Home. “It keeps family physicians informed so a patient’s continuity of care is maintained,” she says. Dr. Granger also offers geriatric psychiatric tele-consult services to Calgary Foothills PCN member physicians.
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collaboration & team work
COORDINATED CARE
mission: improve coordination and integration with other health care services including secondary, tertiary and long-term care
NAVIGATION TEAM
Outreach program acts as ‘eyes, ears’ of Health Home
Photo: Neil Zeller Photography FINDING A WAY: Navigation Team community support worker Dayra Bello, left, helped patient Rosalyn Watson access crucial support services including transportation.
AS a personal care nurse, Rosalyn Watson built a long and successful career out of helping others. But when the Calgary senior developed health problems of her own and was forced to take a leave of absence from her job, she felt overwhelmed and turned to her family doctor for help. Dealing with chronic dizziness, a lack of mobility and financial and personal stress as she waited for head and neck surgery, she was referred to the Calgary Foothills Primary Care Network’s Navigation Team by her physician. Community support worker Dayra Bello, a member of the Navigation Team, visited Rosalyn at her home. After making a detailed assessment of her needs, Dayra spent the next month helping Rosalyn access the resources she needed to improve her quality of life. “There were so many things she was dealing with,” Dayra says of Rosalyn. “Due to her lack of mobility she was isolated and unable to access medication or the help and support she needed.” Dayra connected Rosalyn with the Calgary Seniors’ Resource Society and she was accepted into the Escorted Transportation program.
During follow-up appointments, Dayra also helped her to access income support. “The Navigation Team helps the patient to access the resources they need to deal with the challenges they face,” Dayra says. “This time it was social work but it could be mental health, geriatrics, health education and so on.” The Navigation Team focuses on providing comprehensive assessments and resources for patients with cognitive impairment and those who are at risk of falls, coping with a life transition or in need of a home safety assessment. In part because the team is mobile, it has a unique ability to act as the “eyes and ears” of the Health Home during home assessments. Rosalyn had successful head and neck surgery and is now awaiting knee surgery. “I was so happy to meet Dayra. I had been trying to cope by myself and I was having a lot of trouble just standing up,” she says. “She encouraged me to get help. If she hadn’t come to visit I don’t know what I would have done.”
FINDING A WAY The Navigation Team supports Calgary Foothills Primary Care Network doctors caring for patients with complex health needs.
376
The number of patients referred to the Navigation Team last year
HOW IT WORKS The Navigation Team provides assessments and resources for patients with cognitive impairment and those who are at risk of falls, coping with a life transition or in need of a home safety assessment. It consists of a social worker, two nurse clinicians, a clinical pharmacist and an occupational therapist. A geriatric psychiatrist and geriatrician provide specialist support. The team conducts home assessments and patients can also be seen at Crowfoot Primary Care Centre or in the patient’s Health Home.
EXTENDED TEAM The Navigation Team is one of four streams within the Extended Team, which consists of a group of health professionals that includes specialists, family doctors with a specialty interest and other multidisciplinary team members. The Extended Team is an extension of the doctor’s clinic. The other Extended Team streams are pain management, gastroenterology 17 and medical musculoskeletal.
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collaboration & team work
COORDINATED CARE
mission: improve coordination and integration with other health care services including secondary, tertiary and long-term care
FLOOD INITIATIVE
Emergency referral pilot hailed, set to continue
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Photo: Neil Zeller Photography SUCCESS STORY: Patient Michael Malone went to Foothills Medical Centre for a back problem and was referred to the Access 365 Clinic. He was delighted with the care he received. “It was amazing,” he says.
IF there is a silver lining to the dark cloud of the Alberta floods of 2013, it could be the new Calgary Foothills Primary Care Network and Foothills Medical Centre emergency department referral program. Initiated last June during the floods as patient numbers grew, emergency department staff were directed to refer suitable patients to PCN-managed after hours clinics. Some 27 patients were sent to Calgary Foothills PCN’s Access 365 Clinic. During a subsequent pilot program that ran from December to March, another 109 patients were referred to the clinic. Due to the success of the program, it will now continue indefinitely. Calgary Foothills PCN after hours program manager Marilyn Howlett says nothing like this has ever been done before. “It was too good to stop,” she says. Health care experts at all levels agree it is better to refer patients who do not need urgent care — and are more appropriately
treated in the primary care system — to a family doctor. “It helps take some pressure off the emergency department,” Marilyn says. Under the program, when patients are assessed by triage nurses in an emergency department, they are evaluated according to strict guidelines. These have been reviewed by the College of Alberta Registered Nurses Association and approved by Alberta Health Services and PCNs. If a patient meets certain guidelines, they are referred to the Access 365 Clinic. Patient Michael Malone, who presented at Foothills Medical Centre with a cyst on his back, was one of the patients referred to Calgary Foothills PCN’s Access 365 Clinic. “It was amazing,” he says. “They got rid of the cyst quickly and I had to come back a number of times for them to pack and bandage it. “They showed me such kindness and all knew me by name by the time I was done.”
REFERRAL PROJECT The goal of the emergency department referral program is to ensure that patients receive care from the right provider at the right time. A pilot held during a non-crisis period (December 2013 to March 2014) was found to be a success.
56%
The percentage increase of total referrals to Calgary Foothills PCN’s after hours clinic during the 2013 floods in Calgary
TELE-CONSULTS Calgary Foothills PCN has developed several telephone consultation partnerships with specialists. The service is growing, especially among family physicians starting a practice.
128
The number of tele-orthopedic consults last year. Of those, 98 per cent were managed in the Health Home
ACCESS TO PSYCHIATRY
394
The number of referrals made by doctors to a psychiatrist for an adult diagnostic assessment
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Calgary Foothills Primary Care Network
PROGRAMS & CLINICS
CONTACT US
clinics
programs & services
ACCESS 365 CLINIC Provides after hours care on weekdays, weekends and holidays, 365 days a year. Patients can ask their family doctor for a referral or call Health Link Alberta at 403-943-5465.
ASK A DIETITIAN Patients can meet with a registered dietitian to learn label reading and more. Group appointments are free to patients of Calgary Foothills PCN doctors. To register, call 403-284-3726 ext 206.
CROWFOOT PRIMARY CARE CENTRE Offers care to patients who do not have a doctor. It is also home to the Extended Team, which consists of a group of professionals that includes doctors with a specialty interest, other team members and partnerships with specialists. RILEY PARK MATERNITY CLINIC Provides care to pregnant women. Patients can ask their family doctor for a referral. Those without a family doctor can call the clinic at 403-284-3711.
TOBACCO CESSATION Patients can ask for a referral to this free group session if they are ready to quit or thinking about quitting.
CRAVING CHANGETM Free, four-session workshop for adults seeking to change their eating habits. To register, call 403-284-3726 ext 206.
TRYMGYM Patients can meet a personal trainer and dietitian as part of a structured exercise program. Patients of Calgary Foothills PCN doctors get a $200 discount when they join. To register, call 403-220-4374.
EXTENDED TEAM The Extended Team is an extension of each family doctor’s clinic. Doctors can refer patients for comprehensive help with pain management, gastroenterology and medical musculoskeletal issues, while the Navigation Team works with patients who have complex needs.
WALKING PROGRAMS Calgary: Join Walk with a Doc to exercise monthly with a group that includes a family doctor. A walking group also meets weekday mornings in North Hill Mall or Confederation Park in the summer. To register, call 403-284-3726 ext 206.
NEED A DOCTOR? Patients who need a doctor can register at www.needadoctorcalgaryandarea.ca or call Health Link at 403-943-5465.
Cochrane: Join men’s and women’s walking groups at Mitford Park, year round. Call 403-851-2534 for information.
Calgary Foothills Primary Care Network #500, 1716 - 16 Avenue NW, Calgary, Alberta T2M 0L7 communications@cfpcn.ca P 403-284-3726 F 403-284-9518
Our community Calgary Foothills Primary Care Network serves north Calgary and Cochrane
Other contacts
For questions about non-urgent health concerns, contact Health Link at 403-943-5465
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Thank you to all the doctors, patients and staff who shared their stories in this Report to the Community
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