Thank you for joining us October 16 to 18 to participate in learning, knowledge sharing, connecting, and networking with colleagues in person!

Read through the post-event report for key learnings and take aways from the three-day Partners in Care event.

Event Agenda

Read through the agendas below to learn more about this three-day event.

October 16 – Shared Care Partners in Care | Project Lead and Project Manager Learning Day

October 17 & 18 – Shared Care Partners in Care | Full Event 

Note: Day 1 is for project leads/project managers only. Physicians and health care partners are invited to attend from Day 2 onwards.

Keynote Speaker: Dr Sarah Lea

Dr Lea is double-board-certified in Family Medicine and Addiction Medicine. In addition to her medical qualifications, she is a Certified Executive Coach through Royal Roads University, with further training in cultivating resilience through the Leadership Wellness Group. She is also a Certified Meditation Instructor. Her diverse training, clinical, and professional expertise allows her to effectively address a wide range of topics with her patients and clients. 

Dr Lea balances her time between the addiction medicine consult service at Victoria General and Royal Jubilee Hospitals in Victoria, BC. She has additional expertise in perinatal addictions and works as a locum GP obstetrics provider at Victoria General Hospital. She is the Medical Director for Medical Staff Onboarding, Education, and Leadership Development for Vancouver Island health authority, and has held several other leadership positions within the health authority. In addition, Dr Lea is a physician quality improvement coach for the Specialist Services Committee of BC and also offers 1:1 and group coaching programs through her company, She Thrives Coaching and Consulting. 

Dr Lea has been featured in several TV interviews, is an invited expert speaker, and has won several awards for her outstanding professional achievements and leadership skills.  Dr Lea is a sought-after speaker on subjects such as resilience, connection, burnout, and the dismantling of hustle culture. She has delivered a TEDx talk on the antidote to burnout, and has been a featured speaker at the BC Association of Pregnancy Outreach Professionals annual conference, Island Health’s Self-Care Cafe, and various academic half-days and faculty retreats. Her talks reflect her extensive medical training and coaching qualifications,  as well as her own expertise in personally and consciously stepping out of hustle culture. This unique blend of personal and professional insights offer a perspective that deeply resonates with her audiences.

Dr Lea lives into her values and practices what she preaches as a part-time physician, part-time coach, and full-time mama of three beautiful boys, two fur babies and 3 chickens. Sarah lives with her husband on lək̓ʷəŋən (Lekwungen) territory spending her free time hiking, biking, and generally enjoying the great outdoors.

Storyboards and Abstracts

Encompass Pregnancy Care Clinic Stabilization Project

Encompass Pregnancy Care Cranbrook is a team-based pregnancy care practice co-located in Cranbrook’s Urgent and Primary Care Centre (UPCC). The new model launched officially in May 2022 and is an innovative approach to sustaining maternity care in Cranbrook and the surrounding area.

Maternity care was in a precarious situation in Cranbrook and Kimberley. Family physicians struggled to maintain service to their own pregnant patients, the patients of colleagues, unattached patients, complex patients, and patients from surrounding communities. In 2021, several maternity physicians in Cranbrook stopped providing maternity services and others considered giving up their practice. Recruiting new FPs who wanted to practice maternity care was challenging. At the same time, two obstetricians left the community leaving one specialist to support the region. Sustaining and enhancing the community’s pregnancy care model before it collapsed was a priority.

The goal of the project was to improve patient access to consistent and equal prenatal and postnatal care including standardized screening, workups, and referrals to specialists and allied health providers. The project was successful in achieving that goal. Patients indicate they experience a positive pregnancy care journey, including easy access to a maternity physician. Encompass Pregnancy Care cannot be sustained by the dedication of Cranbrook’s FP-OBs alone. Maternity care in the community remains vulnerable because of retirements and shifting priorities amongst providers. There are many factors that will play a role in sustaining the team-based model developed through this project including funding, space, advocacy, support and financial viability. Some next steps are: Fully integrating Registered Midwives (RMs) into Encompass Pregnancy Care as part of a new shared Care Project. Continued support for relationship development among the FP-OBs-RMs and their efforts toward continual improvement and standardized care.

BC Child & Youth Eating Disorders Clinical Care Pathway

Since the onset of the COVID-19 pandemic, a shadow pandemic of new onset eating disorders in children and youth has emerged. Worldwide statistics are showing that eating disorders incidence in both children and adults have increased, and many individuals have experienced deterioration. This has resulted in significant pressure upon what was an already strained care provision system.

Within the context of children & youth in BC, Primary Care Providers (PCPs) and pediatricians are increasingly being called upon to co-manage this influx of patients. Yet, within both disciplines, there is significant variability in training experience and comfort in treating patients with eating disorders.

To address this gap, this project engaged PCPs, pediatricians/specialist physicians, allied health providers, community stakeholders, and patients/families with lived experience to co-design the Complex Care Clinical Pathway. This pathway was designed to function as a clinical decision-making tool with embedded, locally tailored resources, links, tools and referral information, empowering providers to more confidently navigate the care for children and youth with eating disorders. One of the places that this pathway will be hosted is on the Pathways BC platform, an online resource that provides physicians and their office staff/teams quick access to current and accurate referral information, as well as access to hundreds of patient and clinician resources, community service and allied health information that is categorized and searchable.

Through this project, the ultimate goal will be to improve the support to PCPs and specialists alike, leading to improved health provider coordination and communication, as well as improved patient flow and transitions between primary care providers and specialists in various clinical settings. Enhanced systems and easy access to up-to-date tools and resources will ultimately support providers in feeling more connected, knowledgeable, confident and skilled in navigating the maze that is pediatric eating disorders care.

Improving pain care in BC through a virtual community of practice

Approximately 25% of Canadians live with chronic pain, making pain a major public health issue. Unfortunately, health care providers in BC face challenges in the assessment and management of chronic pain, including inadequate training and limited access to specialists and interdisciplinary care teams. Furthermore, health care providers practicing in rural areas face challenges in receiving regular evidence-based training on chronic pain.

The Extension for Community Healthcare Outcomes (ECHO) model helps bridge this gap by providing an online platform to leverage specialist knowledge and support community providers to provide appropriate care to people living with chronic pain. Pain BC launched the BC ECHO for Chronic Pain in April 2019 and it is now in its ninth cycle.

Our ECHO cycles consist of four monthly one-hour sessions, each with a short didactic presentation followed by an anonymized patient case discussion. Recommendations for the case are shared with the case presenter. The program is led by a multidisciplinary team of specialist providers who act as role models and help to facilitate the community of practice. Since the program’s inception, more than 950 healthcare providers have attended 49 sessions featuring more than 40 patient cases.

The overall goal of our ECHO is to empower healthcare providers to provide appropriate pain care to people in their communities. Outcomes are measured using pre- and post-program surveys, as well as Zoom polls. In 2023, 87.5% of ECHO participants agreed that access to specialist expertise and health professionals from other specialties through ECHO was a benefit to their practice.

This program has faced challenges with healthcare provider attendance and evaluation. These challenges necessitated several program design and evaluation strategy changes in fall 2022. These changes have yielded positive results, including helping us to partner with Shared Care to deliver three additional years of the BC ECHO for Chronic Pain.

A Province-Wide Clinical Care Pathway for Youth Who Use Substances

Youth substance use has become increasingly hazardous in BC. Unregulated drug toxicity has surpassed suicide and motor vehicle accidents as the foremost unnatural cause of death in BC’s under-19 population, with 142 deaths between 2017-2022. Primary care providers may have limited training or experience in assessing and managing substance use in youth, which contributes to adverse outcomes for patients and moral distress for providers.

A clinical care pathway was developed via evidence-informed expert consensus. The aim was to aid primary care providers in building competency and comfort around substance use care for youth aged 10-25 years. The expert working group consisted of family physicians and specialists who provide substance use care for youth in a diversity of clinical settings in BC.

The pathway highlighted youth-specific communication strategies, navigating youth’s confidentiality while facilitating family involvement, and age-specific screening tools for substance use and mental health. Youth are a heterogenous population, so clinical recommendations were organized by stages of cognitive development (early adolescence to young adulthood) and psychosocial complexity (from low to high complexity across six domains).

Although the pathway’s hyperlinked resources were BC-oriented, the framework is applicable to other jurisdictions with parallel services. Furthermore, service gaps for youth may be more readily identifiable using the development-complexity grid. In partnership with the Pathways BC community service directory and UBC’s Division of Continuing Professional Development, this pathway is intended to be a living document with updates as resources change and user feedback is collected. An educational plan is underway to orient primary care providers to using the pathway, including delivery of a webinar and workshops in 2024, and plans for an online module and additional workshops in 2025/26. Additional results will be shared when available.

Enhancing Patient Access to Chronic Pain Services

Patients with untreated or poorly managed chronic pain struggle with activities of daily living and have an increased likelihood of developing complex conditions with associated comorbidities, such as anxiety, depression and substance use disorder. A more streamlined approach to chronic pain care and an increased awareness of resources was needed to reduce frustrations for patients and providers within the Fraser Northwest region. Recognizing the important role of the primary care providers, the aim of the project was to increase the confidence of primary care providers with managing chronic pain patients by providing them with adequate tools and resources.

A Chronic Pain Care Pathway resource was developed in the Pathways BC website as a tool to support primary care providers with information on evidence based guidelines while highlighting free to low cost resources. Feedback from primary care providers showed that 67% (n=18) thought the resource would be useful, highlighting its potential benefits for managing patients with chronic pain. Providers also emphasized the need for improvements, such as making the resource more concise to increase its overall usability. Sustainability and stewardship of the resource was handed over to Pain BC, who will continue to spread and maintain the resource. In addition, various communication channels such as electronic newsletters, workshops and email communication were used to spread awareness of chronic pain services in the community.

Another challenge and opportunity that arose during the project was the issue of opioid prescribing for patients on high doses of opioids for chronic non-cancer pain. A separate project on opioid prescribing was formed. The project highlighted the need for continued advocacy and awareness of the complexities of chronic pain management, requiring a multidisciplinary approach through systemic changes at both regional and provincial levels.

Creating a Gender-Affirming Care Project: Learning Through Humility

As a rapidly growing area of medicine, gender-affirming care raises many questions for the family physicians in Surrey-North Delta (SND) and beyond. What can seem like a simple question: “How can I identify my patient’s preferred pronoun in my EMR?” is not always easy to answer and often matters deeply to the patient.

To better understand what gender-affirming care looks like in SND, including gaps in the provision of that care, a working group was assembled in the Fall of 2023 including family physicians, endocrinologists, OB-GYNs, Fraser Health Authority partners, Indigenous Health partners, Foundry and Trans Care BC.

The working group explored community patient and provider needs, beginning with an open acknowledgment that many in the group were coming to the table with their own level of “unknowing”. A grace-based approach was chosen for tackling the various aspects of project work: questions were asked from a place of genuine curiosity and answers were shared under the premise that when we know better, we will do better.

To assess community needs, this same approach was employed in the creation of two surveys: one for providers and one for patients. Recognizing that language could cause further harm and/or division, several working group meetings were spent dissecting nuance and phrasing. The anonymous survey questions were grouped into themes that highlight educational opportunities, personal and clinical safety, personal bias, lived experience, and areas of need.

The surveys ran in October 2023 and received 95 provider responses and 17 patient responses. Survey results indicated both a high need and high interest among providers to learn more about gender-affirming care. These results form the foundation of a full Gender-affirming Care project, now underway. Patient lived experienced will continue to be sought and appropriately compensated throughout, using the framework of “nothing about us, without us”.

A regional approach to increasing care access for unattached patients

The primary care shortage in Kootenay Boundary (KB) has been detrimental for patients and providers. Patients with stable chronic conditions are decompensating, leading to challenging care pathways for specialists and an erosion of patient care coordination. Emergency department (ED) visits have increased and KB’s two walk-in clinics have closed as Primary Care Practitioners’ (PCPs) capacity was unable to keep up with demand. This project aims to establish new incremental services to ensure unattached patients have reasonable access to critical elements of primary care and reduce ED visits.

KB Screen was launched this spring, a preventive screening clinic for unattached patients. Patients can self-refer or are notified through the Health Connect Registry (HCR). Registered nurses (RNs) review patients’ needs and provide referrals for appropriate diagnostic care. Tests are ordered and results are reviewed by nurse practitioners (NPs). KB Screen provides coordination for regular screening until patients are attached. In the event of positive results, the NP follows up with patients to coordinate next steps, ensure specialist care and request attachment through the HCR. KB Screen has seen 91 unique patients with 215 screening tests ordered. To date, there have been three pertinent positive cases that may have gone undiagnosed.

KB Medical Clinic, set to open this fall, is an episodic care service for unattached patients, rostering longitudinal PCPs and sub-specialty physicians in collaboration with existing services. An NP working at the clinic will provide more longitudinal care and the team will work with the HCR to place patients in local clinics where possible. KB Medical Clinic is in the development stage with 27 KB family physicians and four NPs committed to working shifts monthly. Challenges include: identifying sustainable funding models, developing workflows to address variability in cases, and training new teams to work together virtually.

This project demonstrates the commitment of KB’s medical community stepping up with their time, expertise, and offering clinic space.

Value-Based Health Care Proof of Concept: The Carpal Tunnel Plus Integrated Practice Unit

Value-based health care (VBHC) prioritizes the organization of care around the patients over the full cycle of care and measuring outcomes that matter. Previously, care for patients with compression neuropathy such as carpal tunnel syndrome (CTS) was disjointed, often with long wait times between each step. The VBHC initiative, funded by Doctors of BC and the BC government through the Shared Care Committee, brought together family physicians and specialists to create an Integrated Practice Unit (IPU) for patients with compression neuropathies.

Twenty-seven multidisciplinary providers and staff attended a customized three-part VBHC workshop. A pathway was designed for patients with branches for mild, moderate and severe nerve compression. Working groups with family practice and specialist representation were tasked with patient journey mapping, development of the outcome measurement tool, referral process, and creation of community resources. New CTS+ Clinics were established at St. Paul’s and Vancouver Hospital. Examples of streamlined care in the pathway include in-clinic ultrasound guided steroid injection and automatic follow-up screening call at 3 months with follow-up arranged through the pathway as needed.

During the initial six-month start-up phase, 198 patients were seen (32% mild, 30% moderate, 11% severe CTS, and 27% with other conditions). 35 severe patients were referred to surgery, with an average time to consultation of 55 days. A PDSA cycle is underway to further reduce this to a target of < 1 month. 67 moderate patients received steroid injections, 1/3 on the same day as the EMG appointment. Outcome measures were completed on all patients; results regarding pain and function were communicated to the family physician. A patient satisfaction survey is currently underway. The CTS+ IPU acts as a proof of concept, and is a prototype for development of future IPUs, including Women’s Endocrine Clinic and Infective Endocarditis Pathway.

Child and Adolescent Psychiatrist/Raising Resilient Kids

The purpose of Raising Resilient Kids (RRK) is to provide participants with a reflective caregiver psychoeducation group, led by trained physician facilitators, designed to strengthen the caregiver-child relationship during the early childhood years. Primary care providers refer their patients to the RRK program through Mind Space, to learn essential parenting skills to navigate conflict, normalize distress, and support healthy emotional expression in children, utilizing attachment parenting approaches, self-regulation and co-regulation practices, and cognitive, behavioural, dialectical and interpersonal strategies for encounters with challenging behaviours in children.

From October 2020 to April 2024, 21 RRK groups were provided virtually to participants across BC. 247 participants attended one of these groups. 76% (n=188) of participants completed the group having attended at least 6 of the 8 sessions, while 24% of participants (n=59) attended 1-5 sessions. RRK content, including a comprehensive participant workbook, facilitator guide, and program powerpoint, were developed and revised throughout the four years of program implementation.

Evaluation summary findings are based on administrative data collated from these RRK groups, including a participant pre-and-post psychological survey, midway participant survey, and participant final evaluation survey. In addition, results include the RRK trainee final evaluation survey. Findings indicate that 88% (n=96) of survey respondents strongly agree or agree that the RRK group improved their overall satisfaction with care, 98% (n=107) indicated they were extremely satisfied (n=83) or somewhat satisfied (n=24) with how suitable the RRK skills/tools were to their everyday life, and 93% (n=101) strongly agree or agree that the RRK group improved their ability to self-manage their condition/parenting challenges. RRK facilitator training increased collaboration opportunities between family physicians and child and adolescent psychiatrists.

RRK groups provide a publicly-funded, accessible psychoeducational intervention, supporting caregiver capacity to strengthen the caregiver-child relationship during the early childhood years.

Integrated Palliative Care Transitions: Earlier Co-creation of Cancer Patient Palliative Pathway with Patient Medical Home

Patients in Fraser region on cancer treatment of non-curative intent often have uncertainties about how aspects of their care will be managed and who will manage them. Effective strategies to improve these care transitions and communications engaging the patient medical home have been successfully tested elsewhere. Our stakeholders explored rationale, defined content, and created actions for a fluid, documented and communicated management plan individualized, co-created and owned by the patient and family. The visions is for this plan to be discussed and populated by the cancer care team, the homecare team (where applicable) and the family physician for improved patient, care partner and provider experience.

Location

This year's event will be held in person at:

Fairmont Empress
721 Government St.
Victoria, BC V8W 1W5

This event is invite-only. If you are interested in attending, please contact Shared Care for more information. Fundholders have been allocated a specific number of seats and will receive a direct link to register.