Leduc Beaumont Devon Primary Care Network 2019 2020 Annual Report

ANNUAL REPORT FISCAL YEAR 2019-2020 IN REVIEW We are a network of primary care providers supported by a team of healthcare professionals.

We work together, and with our patients, to treat and manage their health conditions.

PCN PRIMARY PROVIDERS 62 DOCTORS 1 NURSE PRACTITIONER WORKING IN 18 CLINICS AND SUPPORTED BY 18 ALLIED HEALTHCARE PROVIDERS

PCN TEAM 37 PROVIDERS AND STAFF *Registered Nurses *Registered Dietitians *Exercise Specialist *Behavioural Health Consultants *Mental Health Therapists *Nurse Practitioners *Licences Practical Nurses *Referral Coordinators *Clinical Administrators *Administrative Support Staff

WHO WE SERVE 68,000 CATCHMENT AREA 59,000 PANELED PATIENTS Leduc * Beaumont * Devon Calmar * Thorsby * Warburg * Leduc County

Our Vision Integrated and comprehensive primary health care for a healthier Leduc County and its communities.

Our Mission To sustain and enhance health care provision in Leduc and area through coordinated health care delivery and to improve quality of life for the community of patients and physicians.

Our Core Values We will maintain the highest standards of INTEGRITY in our behaviour and ethics, by being transparent, honest and honourable in all our interactions.

We will be ACCOUNTABLE to the public and our members and take responsibility of our own actions and decisions.

We will strive for QUALITY in our organization by following best practices and challenging ourselves for continuous improvement in our work.

We will demonstrate RESPECT in all of our interactions with others.

PCN Provincial Objectives Primary Care Networks across the province provide services that best meet the needs of their patient populations. With this being said, provincial objectives are set for all PCNs. Accountable & Effective Governance Establish clear and effective governance roles, structures and processes that support shared accountability and the evolution of primary healthcare delivery.

Strong Partnerships & Transitions of Care Coordinate, integrate and partner with health services and other social services across the continuum of care.

Health Needs of the Community and Population Plan service delivery on high quality assessments of the community’s needs through community engagement and assessment of appropriate evidence.

Patient’s Medical Home Implement patient’s medical home to ensure Albertans have access to the right services through the establishment of interdisciplinary teams that provide comprehensive primary care.

About Us The Leduc Beaumont Devon Primary Care Network provides services for patients in the Cities of Leduc and Beaumont, Town of Devon and all communities in Leduc County. A group of 62 family physicians and 1 Nurse Practitioner working in 18 clinics, along with additional health care professionals (registered nurses and dietitians, an exercise specialist, mental health therapists and behavioural health consultants) work together to improve primary care for our patients.

Primary Care Networks (PCNs) use a collaborative team approach to provide care for patients and to coordinate primary health care services provided by family physicians, Alberta Health Services and other health care professionals.

PCNs are a way to provide team support for family doctors by bringing teams of health professionals together. PCNs also manage 24-hour patient access to appropriate primary care services.

A PCN is a network of family physicians and health care providers working together to provide primary care to patients. A PCN may be composed of one clinic with many physicians and support staff, or several physicians in several clinics across a geographic region.

Each network is unique and has the flexibility to develop programs and provide services that meet the specific needs of its patients. This grassroots approach allows – and encourages – the PCN to focus on the needs of the local patient population.

Alberta has 40 PCNs operating in communities and areas across the province with over 85 per cent (3800+) of all family doctors in the province practicing within those PCNs. The Leduc Beaumont Devon Primary Care Network began operating on March 1, 2006.

PATIENT'S MEDICAL HOME The Patient’s Medical Home, as defined by patients, is the place they feel most comfortable to discuss their personal and family health concerns.

The patient’s family physician or nurse practitioner, the most responsible provider of their medical care, works together with a team of health professionals, to coordinate comprehensive healthcare services and ensure continuity of patient care. These professionals can be located in the same physical site as the family physician or linked through different practice sites such as a PCN. The Patient's Medical Home enables the best possible outcomes for each person, the practice population and the community being served.

TEAM-BASED CARE CENTRALIZED ENCOUNTERS - 4662 DECENTRALIZED ENCOUNTERS - 1897 Our team of Registered Nurses, Registered Dietitians, an Exercise Specialist, Behavioural Health Consultants and Mental Health Therapists also offered 18 health-related classes and workshops to 212 participants.

LEDUC ELDERCARE CONSULTATION TEAM 139 NEW REFERRALS 946 TOTAL ENCOUNTERS Our geriatric team saw 296 unique patients in 45 clinic days.

This clinic has historically operated out of the Leduc Community Hospital and has been temporarily moved to the PCN office.

SPECIALITY CLINICS VISITING PSYCHIATRIST MSK CLINIC The PCN provides local access to specialists to improve continuity of care between primary and secondary care. Our visiting psychiatrist saw a total of 169 discrete patients throughout the fiscal year. In February 2020, we opened the MSK clinic; the specialist received 18 unique patient referrals to the first 2 clinics.

REFERRAL COORDINATION REFERRALS PROCESSED - 19,129 Our Referral Coordination team of six coordinators coordinates referrals, appointments and closes the loop between primary care providers and specialists.

LEDUC AFTER-HOURS CLINIC PATIENT ENCOUNTERS - 3501 UNIQUE PATIENTS SEEN - 2549 Providing after-hours care to the community Monday - Friday, 6:00 p.m. - 9:30 p.m.

Book an appointment online.

BEAUMONT AFTER-HOURS CLINIC PATIENT ENCOUNTERS - 2796 UNIQUE PATIENTS SEEN - 2666 Providing after-hours care to the community Monday - Thursday, 5:00 p.m. - 8:00 p.m.

Book an appointment online.

EXTENDED HOURS SUPPORT DEVON AND CALMAR CLINICS All 4 clinics in these towns offered extended hours to patients, providing 567 hours after typical office hours for patient care.

NURSE PRACTITIONER-LED CLINICS THORSBY NURSE PRACTITIONER-LED CLINIC WARBURG NURSE PRACTITIONER-LED CLINIC Two new nurse practitioner-led clinics offers care to unattached patients in the previously underserved communities of Thorsby and Warburg.

PANEL MANAGEMENT AND QUALITY IMPROVEMENT 100% OF PHYSICIANS REPORTING ON PANEL AND THIRD NEXT AVAILABLE APPOINTMENT This program supports member physicians to validate patient panels and to pursue optimal screening for the purpose of the Patient's Medical Home and continuity of care.

PRESCRIPTION TO GET ACTIVE WWW.PRESCRIPTIONTOGETACTIVE.COM A primary prevention program to promote physical activity for at-risk patients. Created at our PCN, this program now has 25 PCNs, more than 600 health care members and 160 recreation activity members participating in Alberta.

ALBERTAFINDADOCTOR.CA CONNECTING ALBERTANS TO A PCN FAMILY DOCTOR WHO IS ACCEPTING NEW PATIENTS Expanding on the success of the EdmontoAreaDocs.ca and CalgaryAreaDocs.ca websites, PCNs in all 5 zones created the award-winning AlbertaFindADoctor.ca website to a list of physicians accepting new patients.

WALK WITH A DOC LEDUC WORLDWIDE Walk With A Doc is an initiative whose mission is to encourage healthy physical activity in people of all ages and reverse the consequences of a sedentary lifestyle in order to improve the health and well-being of the community.

Find out more about our programs and services: www.lbdpcn.com Click each icon to follow us:

President's Address Dear Colleagues, Never before have two words rung so true to me‌ pride and gratitude. The unprecedented events of this past year have created a crisis and challenges that none of us ever expected. Despite this, everyone has risen to the challenge and faced it head on for the benefit of the Albertans we serve. In witnessing this, I cannot begin to express the level of pride I have in our organization and all of you individually. Despite the uncertainty and fear, we have all adapted to ensure that the care we provide has never faltered. In fact, it has improved. Our patients rely on us, and we have continued to provide the service they need. There has been boundless teamwork, adaptability, and dedication from every corner of this organization.

And on to gratitude... personally, my gratitude is on more levels than I could express in one letter. I am thankful for everyone's professionalism and commitment to our organization during the numerous crises we have navigated through this year. I am grateful in the knowledge that, if needed, my family's primary health care needs would be addressed by the best of the best. Finally, I am grateful to be part of the Leduc Beaumont Devon PCN team as we find our way through the mess that 2020 has presented.

Despite the uncertainty in world in the world around us, our patients remain confident in the care they receive. Our unity, advocacy in the community, and consistent quality of care that all levels proves this day after day.

Collectively, we have committed to providing our patients with the best Medical Home possible. As a care community, we provide patient-centred care whereby our patients are connected to their own family physician and have access to a team of highly skilled and dedicated allied professionals. Regardless of health needs, complexity, or socioeconomic factors, patients receive the care they need when they need it. This is a massive responsibility and it happens because all of you make it happen.

In 2020, success meant there was never time to hesitate. Challenges presented in many ways, punctuated by an unprecedented infectious disease and an economic collapse. In the face of this, we have succeeded. We did not hesitate.

Our professional organizations stood up to the challenge immediately and adapted to ensure we supported our patients and each other. In doing so, patient care never faltered. The medical home stayed strong, the services our patients needed never went away, and the support and respect we expressed to one another seems to have strengthened. Â Pride and gratitude. Through our efforts, care for others, and teamwork, you have all reminded me of what it means to be proud, and to be thankful for the dedicated professionals that surround me. I hope you all feel the same.

Your friend and colleague, Justin Balko, MSc, MD CCFP President Leduc Beaumont Devon Primary Care Network

Message from the Executive Director It has been an interesting year indeed for the Leduc Beaumont Devon Primary Care Network! While most of our PCN programming remained consistent for most of the year, the materialization of the COVID-19 pandemic in earnest in March 2020 led to the significant and lightning-fast transition into a remote-work paradigm, a concept quite new to the PCN. Fortunately, our PCN had been tracking and anticipating the arrival of COVID-19 and the team was ready to respond immediately when its impacts were first imposed upon the PCN. As a result, our PCN continues to operate very successfully with many staff working remotely from home and many clinician appointments and other meetings being conducted virtually.

Prior to the introduction of the COVID pandemic, however, the PCN was busy setting up its new Nurse Practitioner-led clinic covering the remote and underserviced regions of Warburg and Thorsby – geographically located within our PCN’s catchment area but unfortunately lacking any practicing physicians.

Thanks to grant funding obtained through Alberta Health’s Nurse Practitioner Support Program, our PCN was able to hire a full-time nurse practitioner and, in partnership with the County of Leduc, Town of Thorsby, Village of Warburg, and Alberta Health Services, secure space and additional limited funding in order to establish clinics in both communities. This program was highly anticipated by area residents and our PCN is proud to be able to deliver primary care provider services where none have been available in recent memory (since the 1960s in Warburg and 1971 in Thorsby).

The PCN’s hybrid centralized/decentralized Team-Based Care Program continues to operate quite successfully with the no-longer-so-new hybrid model having proven its utility such that additional clinics have expressed interest in obtaining decentralized PCN staff support. The high staff turnover rate experienced during fiscal year 2018/2019 has largely subsided and staff morale was gauged to be quite high on a recent staff engagement survey. The addition of a dedicated Evaluation Advisor to the PCN has paid off in terms of the number of staff, physician and patient surveys conducted over the year, the results of which will inform forthcoming business planning efforts as the PCN enters the business plan renewal cycle this year. Thank you to all of you who have provided your input.

The uptake on the PCN’s other priority initiatives (24/7, Geriatrics, Panel Management and Quality Improvement, Referral Coordination, Specialty Linkages, etc.) continues to be high and recent strategic planning efforts by the Board of Directors revealed that the PCN is on the right track with program offerings and no substantial changes are forecast for the near future. The introduction of the Edmonton Zone Service Plan and its priorities of addictions and mental health, transitions in care and specialty access has guided our PCN’s involvement in zone-level initiatives, and the PCN leadership team continues to contribute to the Edmonton Zone PCN Committee and Pan-PCN Steering Committees and their numerous derivative subcommittees, supporting the culture of collaboration that pervades Edmonton Zone.

In addition to being proud of our PCN staff for their many contributions, we are especially proud of our member physicians and the frontline clinic staff who have so selflessly served our communities through this pandemic. Your dedication to your patients is remarkable – indeed not one Leduc Beaumont Devon PCN member clinic closed its doors to its patients during COVID. In addition, we are proud to be leading the way in the province in terms of reporting time to third next available appointment and in adopting the Community Information Integration (CII) and Central Patient Attachment Registry (CPAR) software initiative in support of enhanced patient care.

As our PCN continues to operate and persevere through these unprecedented times, I wish to offer a hearty thanks to all of you, our numerous stakeholders, who help us to bring our vision and mission to life every day in support of our communities.

Stay safe everyone!

Cliff Richard Executive Director Leduc Beaumont Devon Primary Care Network

Board of Directors Dr. Justin Balko - President Dr. Gurpreet Dinsa - Vice President Dr. Gerard Amanna - Secretary Dr. Lily Chen - Treasurer Dr. Rebecca Saunders Dr. Charlene Dinakaran Dr. Caroline Spiers Dr. David Tran Len Frank - Public Director

Committees Joint Governance Committee Dr. Justin Balko - PCN President Dr. Gurpreet Dinsa - PCN Vice President Aleem Rajani - AHS Program Manager, Primary Care and SCOPE Heather Durstling - Executive Director, Suburban Hospitals, EZ Korynna Wolfe - Director, Leduc Community Hospital, Devon General Hospital Pearl Lavigne - PCN Executive Assistant Evaluations Committee Dorothy Pinto – Chair, Evaluator, PCN Dr. Justin Balko – Evaluations Physician Lead Aleem Rajani – Program Manager, Alberta Health Services Cliff Richard – PCN Executive Director Carla Moore, PCN Registered Nurse, Geriatrics Lori Briggs, PCN Manager, Clinical Operations Sandee Foss, PCN Manager, Quality Improvement Shelley MacEachern - PCN Manager, Finance & Administration Pearl Lavigne - PCN Executive Assistant Finance Committee Dr. Lily Chen - Chair, Board Treasurer, Finance Physician Lead Cliff Richard - PCN Executive Director Shelley MacEachern – Manager, Administration & Finance Len Frank – Public Director (NPC Board) Pearl Lavigne - PCN Executive Assistant Mental Health Committee Rasheal Charles - Chair, PCN Mental Health Clinician, Practice Lead Dr. Alida van Heerden - MH Physician Lead Dr. Caroline Spiers - MH Member Physician Arlene Rose - AHS Manager for MH Leduc, Sherwood Park, Fort Saskatchewan Karin Solberg Wells - AHS Manager Josie Rinella - AHS Clinical Supervisor Addictions and Mental Health, Edmonton Zone Bryan Meetsma - AHS Clinical Supervisor for East Clinics Adults Lori - Thompson - AHS Care Manager, Additions & Mental Health, Edmonton Zone Lori Briggs - PCN Manager, Clinical Operations Cliff Richard - PCN Executive Director Monika Delannoy - Clinical Administrator Panel Management and Quality Improvement Committee Sandee Foss - Chair, PCN Manager, Quality Improvement Dr. Rebecca Saunders - PMQI Physician Lead Christine Ridden - LA Medical Office Manager Candace Chamzuk - Beaumont Medical Office Manager Cliff Richard - PCN Executive Director Pearl Lavigne - PCN Executive Assistant Transitions in Care Committee Carla Moore - Chair, PCN Geriatrics Nurse, Leduc Eldercare Team Manager Dr. Gurpreet Dinsa - TIC Physician Lead Dr. Anna Detorakis - TIC Member Physician Dr. Grant Davies – TIC Member Physician Cliff Richard - PCN Executive Director Lauren Stone - PCN Manager, Referral Coordination Sandee Foss - PCN, Manager, Quality Improvement Pearl Lavigne - PCN Executive Assistant Team-Based Care Committee Lori Briggs - Chair, TBC Manager Dr. Gurpreet Dinsa - TBC Physician Lead Dr. Jana Holden - TBC Member Physician Dr. Rebecca Saunders - TBC Member Physician Dawn Estey - AHS, Manager, Primary Care/Chronic Disease Management Shauna Frig - PCN Registered Nurse, Practice Lead Rasheal Charles - PCN Mental Health Clinician, Practice Lead Cliff Richard, PCN Executive Director Penny Garton - PCN Team Lead, Clinical Administrator

COVID-19 responce The first Canadian case of the novel coronavirus was reported by Health Canada on Jan. 25, 2020, in a Toronto man who had recently travelled to Wuhan, China. On March 11, the World Health Organization declared COVID-19 a global pandemic and on March 17, a state of public health emergency was declared in Alberta by Chief Medical Officer of Health, Dr. Deena Hinshaw. On February 21, a Calgary-area woman returned from a Grande Princess cruise ship but did not self-isolate until February 28th. On March 5th, Dr. Hinshaw reported this person to be Alberta's first case of COVID-19.

On March 17, the Leduc Eldercare Consultation Team moved its weekly clinic from the Leduc Community Hospital to the Leduc Beaumont Devon Primary Care Network's main floor office.

Also on March 17th, The Leduc After-Hours Clinic temporarily closed; the Beaumont After-Hours Clinic temporarily closed on March 18th.

On March 20th, the Leduc Beaumont Devon Primary Care Network closed its office to patients and staff and moved all appointments to telephone services; soon, video conferencing through our EMR was made an option to patients.

Both patients and providers reported the transition was smooth and multidisciplinary care continued uninterrupted.

On April 29th and with strict screening measures and protocols in place, the Leduc Eldercare Consultation Team resumed its clinic at the PCN office while our Team-Based Care providers continued to provide virtual support.

During the first several months of the pandemic, the PCN supported our membership clinics with the ordering and distribution of personal protective equipment (PPE); we continue to order PPE for member clinics through the Government of Alberta.

The PCN also supported our clinics through our Quality Improvement team and patient outreach and through a joint provincial campaign with Alberta Medical Association and through daily, then twice weekly, weekly, then biweekly COVID-19 physician and provider newsletters. COVID-19 specific information continues to be shared with our membership in the monthly physician, clinic and PCN staff newsletter.

The PCN Leadership team immediately began work on a back-to-office, phased strategy. As public health measures allowed and with strict protocols established, including screening of patients, enhanced infection control, continuous masking for patients and providers during appointments, masking for all staff when moving around the office or in shared spaces and a mandatory fit for work online questionnaire for staff, the PCN rolled out the first phase on June 22.

Our current state includes a rotation of staff in the office and a return of our visiting specialists to the office and our providers now offer the choice of inperson, telephone or video appointments to all patients; virtual classes and workshops are being developed at a zone level and are expected to launch soon. Board of Directors meetings, sub-committee meetings, staff meetings and Pan-PCN committee meetings all continue via virtual platforms.

Future phases include a return of all staff to the office, in-person classes and workshops and reopening the Leduc and Beaumont After-Hours Clinics; a timeline for these will be determined on the Government of Alberta implementing phase 3 of Alberta's Relaunch Strategy.