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Your Team. Making Health Happen. Report to the Community 2012


295,632 Patients

313

Physicians

104 Clinics

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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 over 300 primary care physicians, working in over 100 clinics to enhance patient care. Many of these physicians work closely with PCN allied health professionals including behavioural health consultants, dietitians, nurses, pharmacists 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-aweek 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 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.


With the ongoing support of our partners, the Calgary West Central Primary Care Network (CWC PCN) continues to make great strides toward strengthening the comprehensive, community-based primary care provided to patients through their family physicians in southwest Calgary. At the heart of our organization is a commitment to the patient and their health. Building on our six years of service in the community, the CWC PCN is continuing to improve the programs and support that we offer to our patients and their family physicians. We are guided by four key objectives - enhanced access, physician-led collaborative care, health promotion and sustainable family practice - that serve as our foundation and help direct us to meet the needs of patients under the care of our member physicians. The programs and services provided to patients and their member physicians have evolved to help ensure we achieve our key objectives and deliver the best results. Currently, the major thrust for the CWC PCN is to support our member physicians’ family practices with highly functioning teams of health care providers, or collaborative care teams, who directly contribute to the comprehensive health care received by patients. In this Report to the Community, you will be able to read more about our collaborative care teams, the dedicated and talented people who are on those teams and some of the ways they work together to deliver exceptional health care in the convenient and comfortable setting of the family physician’s office. You will also read a few of our success stories from the past year, highlighting some of the ways our team is working to improve the lives of patients and families every day. We look forward to building upon the successes of the past year as we also seek new opportunities to help make health happen.

Dan Doll, Executive Director Calgary West Central Primary Care Network

Jane Ballantine, Medical Director Calgary West Central Primary Care Network


PCNs in Alberta were established to enhance the delivery of primary health services. In meeting this objective, our goal at the CWC PCN is to ensure our family doctor clinics are the medical homes for patients in the Calgary area. However, we recognize our physicians cannot accomplish this huge task on their own. It takes a team to provide excellence in patient care. By working together, we celebrated many accomplishments over the past year. Collectively, our physicians care for 295,632 patients. We increased the number of physician members in our PCN by seven per cent. We have 49 allied health care professionals in 69 member physician clinics. We are proud these collaborative efforts have resulted in patients having improved access to primary care. We anticipate even more successes in the year to come as we continue to make a positive difference to our patients’ health, our physician members and the community we serve.

Thomas Tam, Family Physician, CWC P.G. Go. Board of Directors Chair Calgary West Central Primary Care Network

BOARD MEMBERS

GOVERNANCE MEMBERS

Dr. Thomas Tam CWC P.G. Co. Board Chair

Dr. Thomas Tam Co-Chair, CWC PCN P.G. Co.

Dr. Phillip van der Merwe CWC P.G. Co. Board Vice Chair

Lori Anderson Co-Chair, AHS

Dr. Ron Lim CWC P.G. Co. Board Secretary-Treasurer

Dr. Nicholas Myers AHS Representative

Dr. Margot McLean CWC P.G. Co. Board Director

Dr. James Silvius AHS Representative

Dr. Peter Thornton CWC P.G. Co. Board Director

Dr. Phillip van der Merwe CWC P.G. Co. Representative

Dr. Brendan Vaughan CWC P.G. Co. Board Director

Dr. Margot McLean CWC P.G. Co. Alternate

Dr. Waldemar (Waldi) Wilken CWC P.G. Co. Board Director

Dr. Brendan Vaughan CWC P.G. Co. Alternate

Dr. William Wu CWC P.G. Co. Board Director

Dr. William Wu CWC P.G. Co. Alternate


3,287

Patients seen in the after hours clinic

5,152

Referrals from HEALTHLink Alberta

SUCCESSES WITH OUR Primary Care Network

ACCESS Tracey De Almeida was getting increasingly worried about her five-year-old son Dominic, when his cold worsened to include a high fever and vomiting. Their family physician was unavailable and Tracey made a call to HEALTHLink Alberta. Since their physician is a member of the Calgary West Central Primary Care Network (CWC PCN), Tracey was told she could access a physician in the after hours clinic. With the referral from HEALTHLink, she soon received a call from the CWC PCN after hours clinic and was able to get Dominic in quickly. At the clinic, they waited only moments to see the physician. “Within five minutes, she said it’s either his appendix or pneumonia,” said Tracey. Tracey and Dominic were told to go to the emergency room at the Alberta Children’s Hospital. With a form from the attending physician at the CWC PCN after hours clinic, they were seen quickly and Dominic was X-rayed. The X-ray revealed that he did in fact have pneumonia, and antibiotics were prescribed to alleviate his painful symptoms. Within a short period of time, Dominic was back to normal.

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FROM THE PATIENT

In 2012, the Clinic at Westbrook opened, replacing the former clinics at Southland and 17th Avenue.

FAST FACTS

The Clinic at Westbrook offers an after hours program. The program is accessed through HEALTHLink Alberta, which in turn refers appropriate patients to the clinic that is open on weekends and in the evenings. This service is by appointment only and is available 365 days a year, potentially alleviating unnecessary visits to emergency rooms.

In partnership with other Calgary area PCNs, the CWC PCN offers a web registry where patients can sign up to be matched with a family physician in their geographic area. To get your name on the list, visit www.needadoctorcalgaryandarea.ca. The CWC PCN transition clinic 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.

DID YOU KNOW?

“The after hours clinic was fabulous. It was really nice inside and the people were friendly. I could tell the doctor was truly concerned and could understand I was frustrated.” ~ Tracey De Almeida

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. The Clinic at Westbrook facilitates a number of health programs that are available upon referral from a CWC PCN physician member. These programs include geriatric assessment and support, smoking cessation and nutritional awareness.

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FROM THE PATIENT “You have your doctor who can’t be everything to you anymore and that’s why these types of programs are so important. If there are teams out there we can believe in and receive good education from, who you respect, that’s the way to go.” ~ H.G. Newton

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C C SUCCESSES WITH OUR Primary Care Network

MD-LED TEAMS

“The selection of team members should be driven by patient population,” said Dr. van der Merwe who works closely with a pharmacist, registered nurse (RN) and behavioural health consultant (BHC) in the Mission-based clinic he shares with two other physicians. The inner-city clinic has a very diverse patient population with over 50 ethnicities and all ages represented. With the help of these professionals, Dr. van der Merwe said physicians are embracing a new culture where they don’t have to work alone and as a result, more patients are getting the care they need in a timely fashion. Measurement is key to ensuring the CWC PCN is meeting the needs of its patients, said Dr. van der Merwe and this is done through mechanisms like chronic disease and diabetic registries. “Our approach is evidence based, and our programs are objectively measured.”

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DID YOU KNOW?

Like many of his colleagues, Dr. Phillip van der Merwe believes that teamwork improves patient care and is a major proponent of collaborative care teams (CCTs) within the Calgary West Central PCN. The teams assist immensely in providing appropriate access at the right time resulting in improved experiences and health outcomes for patients.

Physician-led teams have various professionals working in team environments for the shared object i v e o f e nha nc e d patient care. The physician ensures continuity of care. Members of the CCTs keep records of all patient interactions that are then shared with the patient’s physician.

Collaborative care teams (CCTs) are physician-led multi-disciplinary teams that consist of professionals such as behavioural health consultants, dietitians, pharmacists, registered nurses and social workers.

FAST FACTS

Physicians in the CWC PCN can refer patients to any of these professionals to ensure the right care is provided at the right time. 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.


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69

The CWC PCN currently has CCT members assigned in CCT members also work in the Clinic at Westbrook

clinics

THE TEAM: Shawn Pharmacist Dr. Phillip van der Merwe Family Physician Carmen Behavioural Health Consultant Candice Registered Nurse

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7,220

Patients have been seen

FROM THE PATIENT

“Before I saw Kelli, I felt like when I opened a door, it was full of shoeboxes and they all fell on me. Now when I see her and can talk things out, I feel wonderful. It feels like I’ve lined the boxes up and put some order to them.” ~ Brian D.

SUCCESSES WITH OUR Collaborative Care Teams

FAST FACTS The BHCs work at physician clinics and see an average of eight to 10 patients per day. Appointments are 30 minutes in duration. In many cases patient concerns are addressed in one visit. Approximately 20 per cent of patients will receive longer-term assistance. BHCs see 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, chronic mental health issues, etc.

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BEHAVIOURAL HEALTH CONSULTANT When Kelli McMillan, behavioural health consultant (BHC), first met Brian, her role was to teach him coping and relaxation skills to help manage symptoms associated with depression. That quickly shifted when she recognized Brian had symptoms consistent with post-traumatic stress disorder.

Kelli said Brian, a senior, was originally skeptical about seeking treatment for mental health. The support Brian has received from not only Kelli, but from the entire collaborative care team, has resulted in his renewed appreciation for the CWC PCN and mental health.

“Once he was properly diagnosed, the treatment changed,” said Kelli. Brian was instead treated through trauma therapy. “Before, he didn’t know what was wrong and now he better understands himself and his symptoms. Depression was merely one part of a larger issue that had decreased his health and overall quality of life for many years. Now he has learned coping strategies and better communication skills.”

“I think it was the fact that he had a team of professionals all caring for him and supporting him that made the difference,” said Kelli. “Now his physician can target his medical problems and the rest of the collaborative care team can help alleviate lifestyle, mental health and pharmacological concerns. It’s been very rewarding to work as a team to improve Brian’s overall quality of life.”


FROM THE PATIENT “I know this is what works for me. This is the only program I’ve been to where I really feel they are trying hard for you to have a healthy mind and body. It’s a shared program between the behavioural health consultant and the dietitian. They really listen. You are there to learn and you don’t have to feel guilty about what you are not doing.” ~ H.G. Newton

821

Patients referred

SUCCESSES WITH OUR Collaborative Care Teams

DIETITIAN The top three topics that dietitians Renée Fagnou and Katie McCulloch address on a daily basis are chronic disease management, gastrointestinal issues and weight loss. Both are relatively new team members at the CWC PCN but they’ve already witnessed positive results from the weekly group classes they lead. One particularly inspirational patient attended the Gaining Lightness program, which the dietitians conduct with a behavioural health consultant to address the emotional components involved in healthy eating, lifestyle change and weight loss. “She has had quite a bit of success with continuing to lose weight with the program and found the support she received from the group to be very valuable,” said Renée. “This program is a wonderful option for people because it’s not just about food,” said Katie. “It’s run with a psychologist who delves into triggers as to why they might be eating and develops strategies to cope in a healthier way.” Dietitian clients range from infants to seniors. Patients must be referred by either a physician or a member of the collaborative care team.

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7,017

Patients have been seen

FROM THE PATIENT “We’ve had nothing but good experiences with the Westbrook Clinic. There are so many different things that could be wrong with John and we’re hoping for the best. Everyone seems to have a real concern to find out what it is.” ~ Judie Howard

SUCCESSES WITH OUR Collaborative Care Teams

PHARMACIST The CWC PCN currently has five pharmacists who work in various family physician offices and in our Clinic at Westbrook, which offers two main programs: a central pharmacy referral program and a Geriatric Assessment and Support clinic.

FAST FACTS 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.

The CWC PCN pharmacists facilitate programs focusing on smoking cessation and are currently participating in diabetes and respiratory management initiatives in conjunction with other health care professionals on physician-led collaborative care teams.

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Judie Howard was more than a little surprised to receive a follow-up call from one of the CWC PCN pharmacists, checking up on her husband John. She found it hard to believe in this busy day and age that a medical professional would be able to take the time. Shawn Lee made the call after meeting with John Howard, who suffers from Type 2 diabetes and was referred by his physician at the Strathcona Medical Centre. “My expertise is medication management,” said Shawn, who ensured the patient’s blood sugar levels were in line. The patient’s physician also had other concerns and referred John to the behavioural health consultant as well as the Geriatric Assessment & Support team at the Clinic at Westbrook. Shawn described how the members of the CWC PCN collaborative care team worked together to determine the best course of action. “We communicate and collaborate together for better patient outcomes, particularly with complex medical situations,” said Shawn.


16,130

Patients have been seen

43%

Increase from last year

FROM THE PATIENT “The help and support I got from Christine was just fantastic. One thing I really learned was not to be so hard on myself. She took the time to listen and respond in a very caring way. Any time I had any questions she was really able to clear it up and help me understand.” ~ Kathleen Minardi

SUCCESSES WITH OUR Collaborative Care Teams

REGISTERED NURSE When Christine Downey started working as a chronic disease management nurse for the CWC PCN, she felt fortunate to be able to take the time to get to know her patients. Patients like Kathleen, who had recently been diagnosed with diabetes and was struggling to adjust. Kathleen’s blood sugar was extremely high when her family physician referred her to see Christine. Christine explained how to keep the diabetes under control through diet and exercise. They met regularly until Kathleen gained the knowledge and confidence to succeed. Today Kathleen continues to see a nutritionist and has been successful in bringing her blood sugar to a normal level. “The patients we see are usually in a vulnerable state, as most people are when burdened with physical, mental or emotional stress,” said Christine. “A large number of my patients were successful making healthy, long-lasting lifestyle changes because I was given the opportunity and clinical time to encourage, advise and motivate them.”

FAST FACT Nurses work closely with patients, spending up to an hour at a time consulting with them on various topics such as chronic disease management, women’s health, breast cancer support, etc.

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FROM THE PATIENT “Byron is very dedicated to his clients. He helped me to get somebody in to help me when I was in a situation where I couldn’t handle the workload. He kept in touch to make sure everything was okay and came back to see us with a whole bunch of leads for us to look at for seniors’ homes.” ~ June Torok

SUCCESSES WITH OUR Collaborative Care Teams

SOCIAL WORKER Byron Renwick, social work consultant, scheduled an in-home consultation with June, a woman in her 80s who was the primary caregiver for her disabled husband. June had begun to feel overwhelmed with the combination of caring for her husband and maintaining their home in Canyon Meadows. Byron explained that June had no in-home supports and was single-handedly doing all the cooking, laundry, cleaning and yard maintenance while tending to her husband’s complex medical needs. He provided June with subsidized hours for in-home support and respite from an organization called Home Instead Senior Care. He also followed up with additional visits, providing information on caregiver support groups and assisted living options, should the couple choose to relocate. “The in-home supports have taken some of the pressures off of her as the primary caregiver,” said Byron.

FAST FACTS The CWC PCN social worker connects with patients as often as required to determine their needs and refer them to appropriate resources for ongoing assistance.

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The CWC PCN social worker, based out of the Clinic at Westbrook, assists patients and families with accessing support and navigating the health system. Sessions are conducted in the clinic or in-home.

Typically, patients are over 50 years of age. Issues that may be addressed include; psycho-social issues, family dynamics, depression, cognitive decline, financial, etc.


86

Patients completed the Tackling Tobacco Together program

FROM THE PATIENT “One of the main reasons why I’ve got to get this looked after is my son. I just think about his life and what it would be like for him growing up without a dad. I couldn’t imagine how hard that would be.” ~ Robert Banks

SUCCESSES WITH OUR Primary Care Network

HEALTH PROMOTION Robert Banks wondered why he could not find support groups for smokers. He had tried to quit smoking on his own many times and struggled. He thought it might be beneficial to share stories with others in the same situation. Robert suffered from a lung disease that limited his breathing capacity. Also contributing to his desire to quit smoking was the anticipated arrival of his first child. His family physician referred him to the CWC PCN Tackling Tobacco Together (3T) program where he received the support and guidance to help him quit. “She introduced me to the smoking cessation program in the PCN and it’s been really helpful and beneficial,” said Robert. “It was definitely something I needed to do and it’s worked out really well for me.” At one point, he suffered a three-month relapse, but is now taking Champix and says although it’s a constant battle he’s determined to succeed for the sake of his son.

Promoting health through education is a primary focus of the CWC PCN.

FAST FACTS

Upon referral from a family physician within the CWC PCN, patients have access to a number of health programs run by dietitians. These include Cholesterol & Blood Pressure Reduction, Nutrition for Diabetes and Elevated Blood Sugar, Gaining Lightness and Secrets to Weight Loss Success.

Seniors with complex medical issues can be referred by their family physician to the Geriatric Assessment & Support (GAS) program. Each diagnostic evaluation lasts about three hours and may involve consultations with professionals such as pharmacists, geriatric psychiatrists, gerontology nurses and dietitians.

CWC PCN offers a Tackling Tobacco Together (3T) program, available through referral from a member physician. The program involves an integrated behavioural and pharmacotherapy approach to support smokers to quit.

The CWC PCN provides informational health programming in over 30 of its member clinics through Health Unlimited TV (HUTV). The purpose is to deliver reliable and relevant health information to patients.

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DID YOU KNOW? FROM THE PATIENT

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. This unattached web registry is a partnership program with other Calgary-area PCNs.

“The unattached web registry is easy and effective. It gave me peace of mind by attaching me to a clinic quickly. I have learnt that the care available at the Primary Care Clinic is extensive – there’s lots of information about other services I can have access to.” ~ Eduardo Torres

CWC PCN offers a full program of Continuing Clinical Education (CCE) events for its member physicians and collaborative care teams to support up-to-date information on various health conditions.

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C C

296

Physicians attended educational events

44.7%

Of CWC PCN physicians were accepting new patients

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2,654

Patients without a family physician received care in CWC PCN clinics

7%

Increase in physician membership

FAST FACTS 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. A key initiative of the CWC PCN is a new physician incubator program. The purpose is to utilize the experience of existing physician members to mentor new physicians. This also helps match new physicians with patients who currently don’t have a family physician and are listed on the unattached web registry.


SUCCESSES WITH OUR Primary Care Network

SUSTAINABLE COMPREHENSIVE FAMILY PRACTICE To help ensure residents of southwest Calgary have access to family physicians, one of the goals of the CWC PCN is to ensure physicians receive the support they require. According to Dr. Jane Ballantine, medical director, it is vital to prevent burnout amongst family physicians that are sometimes overwhelmed keeping up with increasing patient care loads. “By offering our physicians additional support and services that are focused on the patient, we are enabling physicians to succeed in maintaining the good quality care they are trained to provide to patients,” said Dr. Ballantine. “As a primary care network, we can then flourish and draw even more physicians to further enhance access to health care in the community.” One of the ways the CWC PCN supports physicians is through continuing clinical education (CCE), for physicians and members of their collaborative care teams. Brad Lohman, director of clinical services for the CWC PCN, explained that approximately 30 events are offered annually with an average attendance of 50 participants at each session. “This format allows all team members to hear the same messages on the common issues they are dealing with in primary care,” said Brad. “In these sessions, we target specific areas that affect our patient population.” For example, diabetes is a common chronic illness within the CWC PCN and therefore specific CCE events are focused on diagnosis, managing the disease and evaluating outcomes. “Each team member affects patient care and will play a role to enhance the outcome.”

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2,413

Geriatric patients were seen

2,576

Patients were seen at the Tsuu T’ina Nation

1,236

Patients visited the Women’s Health Clinic at Tsuu T’ina Nation

655

Patients attended nutrition support groups

554

Patients attended the Geriatric Assessment Services Clinic

FAST FACTS & STATS

The CWC PCN has over 20 registered nurses who work collaboratively with family physicians and other members of collaborative care teams to create comprehensive, holistic care plans for patients.

The CWC PCN has dietitians who provide one-on-one nutrition counseling and group education classes out of the Clinic at Westbrook from Monday to Friday.

75.8%

Of physicians agreed that working as a team resulted in patient care being more integrated and coordinated

3,232

New patients were matched with a physician

Nurses provide
 education, resources, community and PCN referrals, as well as motivational interviewing to help increase the overall health and well-being of patients.

Individual sessions typically include topics like general healthy eating, gastro-intestinal concerns, diabetes, heart health, cholesterol management, hypertension, weight loss or gain, pre/post natal nutrition, disordered eating and meal planning support.

79%

Of member physicians work with a multi-disciplinary team

47%

Increase from last year

97%

Of patients surveyed say they received the right care, from the right health care provider, at the right time

Group classes include: Secrets to Weight Loss Success, Cholesterol & Blood Pressure Reduction, Nutrition for Diabetes and Elevated Blood Sugar, and Gaining Lightness. Each class is a one-time, two-hour session, with the exception of Gaining Lightness, which is a four-week program.


OUR GEOGRAPHICAL BOUNDARIES Calgary West Central 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.

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

P: 403.258.2745 F: 403.258.2746

P: 403.249.9907 F: 403.249.9976

VISIT US ONLINE AT www.makinghealthhappen.com

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Thank you to our physicians, patients and staff who shared their stories in this report to the community.

Report to the Community 2012  
Report to the Community 2012  
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