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GP Update shares practical and useful information about programs of the GPSC
for BC family doctors.
Fall 2018
Clarifying patient medical homes and primary care networks
Doctors are telling the GPSC that the concepts of patient medical homes (PMHs) and primary care networks (PCNs) can be confusing.
In simple terms, the patient medical home refers to the doctor’s practice. It builds on what doctors are already doing and takes the practice to the next level where GPs can focus on diagnoses and longitudinal patient relationships. The physician is supported by teams and networks of care to provide the full spectrum of primary care needs that the patients within the practice need.
The primary care network refers to a clinical network of providers in a geographic area that responds to the primary care needs of the patients within the community, and provides clear linkages to more specialized care as needed. It includes GPs in PMHs along with allied health providers, health authority services and community health services.
Read more about differences between the two concepts.
This work involves change within physician practices and other parts of the system, most notably health authorities. Physicians have told us they can’t possibly meet all the primary care needs of the patients in their community by themselves: we agree. Productive partnerships with the health authority and other community partners - and meaningful input from patients - is essential to make this work. We need to keep improving the system for everyone: so physicians can avoid burnout, patients can get quality care for all of their primary care needs, and the system can work effectively and efficiently.
Use EMR data to inform and plan proactive patient
Family doctors can use EMR data to proactively manage their patient’s unique care needs so that they can understand what those groups of patients need. Known as panel management, doctors can make the most of their time by quickly accessing clear panel information, improving their approaches to preventative and proactive treatment, and organizing team members to best serve their different patients.
As a critical part of creating a patient medical home, successful panel management includes three steps: empanelment, panel clean-up, and panel optimization. Completing these steps will help doctors and their teams to smooth out their workflow and make data-informed improvements in practice. To help physicians and their staff, the GPSC offers several supports, including:
- Panel Management Manual and Workbook: a step-by step guide that is certified by the College of Family Physicians of Canada for up to 75 Mainpro+ credits.
- Panel Development Incentive: $6,000 to compensate eligible family doctors for documenting and completing the three phase of panel management.
Read more about panel management, how it benefits doctors and patients, and how the GPSC can support family doctors and their teams through this process.
The GPSC's story: 15 years
For more than fifteen years, family doctors have made their voices heard and therefore helped shape primary care in BC through the GPSC. With the support of the GPSC’s programs and initiatives, doctors have made significant progress to strengthen full-service family practice, increase professional satisfaction and experiences, and improve patient care.
Watch a short video that captures the journey thus far.
Maternity patients are in great hands in Burnaby
Regarded by people in the maternity care community to be the best-kept secret in Metro Vancouver, the Burnaby Maternity Clinic is a GP-to-GP network that supports family doctors to provide care to pregnant patients in their community.
GPs who do not provide maternity care can refer their pregnant patients to the clinic and be sure that they will be well looked after. Because of this clinic, low-risk pregnancies are rightfully kept in a primary care setting, enabling obstetricians to devote their expertise to high-risk pregnancies and obstetrical care. This model of maternity care has been linked to shorter wait times, fewer complications and interventions, and lower costs to the health care system over all. Read more.
Helping patients and families navigate dementia
A diagnosis of dementia, known as “the disease of a thousand goodbyes,” is a scary prospect for patients and their families. As the disease progresses, families increasingly turn to their GPs for information and resources on how to navigate this unfamiliar territory.
In response, the Kootenay Boundary Division of Family Practice has created two comprehensive resources called the Dementia Roadmap for Practitioners and the Dementia Roadmap for Families. Each roadmap outlines the events and milestones that can occur in the journey through dementia so that the patient’s GP and family are better equipped to understand the stages of the disease and the provide the best possible care, whether in the clinic or in the home. Read more.