Health care staff and physicians laid out plans at a two-day workshop that wrapped up today for new models of primary and community care in 14 communities.

The models will shape improvements to how frail seniors access and are supported by the health care system throughout the province.

“We have been working with health authorities, physicians, patients and other stakeholders to develop strategies for real change in a number of challenging areas, with a key focus on more proactively responding to the needs of frail seniors,” said Health Minister Terry Lake, who attended the forum on the opening day. “We are starting to see a more patient-centered approach come to fruition. I was inspired by the local teams’ levels of enthusiasm, commitment and dedication to seniors in providing greater access to supports close to home.”

Northern Health has already seen good progress, partnering with local doctors at primary care clinics in Vanderhoof and Prince George to work more closely and collaboratively with health authority staff in the community. A key to success in Vanderhoof has been linking the electronic medical records between the family doctors and community clinicians who work for the health authority.

“We were serving the same patients and sharing the same information already,” said Vanderhoof family physician Dr. Sean Ebert. “This just means we are doing it more seamlessly and quickly, to create a real interprofessional team between the GPs and care providers in the home and community care, rehab, mental health, and public health programs.”

Supports for frail seniors in other communities may include:

• putting in place care co-ordinators, who can proactively identify seniors at risk of decline and help them to access more appropriate services;
• after-hours phone services where frail seniors in distress can talk to a nurse to determine whether they should go to the hospital or can wait to get services in the community;
• establishing primary care pharmacists to help seniors proactively manage their medications; and
• communities partnering with long-term care homes to establish more responsive resources for seniors in the community through day programs and quick access to respite programs.

More than 200 people from across the health system, including representatives from health authorities, physicians, patients, the ministry, unions, regulatory colleges and Seniors Advocate Isobel Mackenzie, participated in the workshop. Attendees shared innovative approaches set to get underway in the next three to six months. This work is part of a longer-term two-year plan being rolled out across the health system to improve care in the community for frail seniors.

“Every community has consistent elements that are important from the point of view of the patient, for instance they want to know the plan of care, know their health care team and find their way easily through the system,” said Cathy Ulrich, Northern Health CEO. “But how it happens in each community will look a little different, because of the unique services and needs of the population they each have.”

The 14 communities will serve as prototypes for implementing change to seniors’ services and supports across the health system. New models will be rolled out in Prince George, Vanderhoof, Kamloops, Kelowna, Lake Country, Langley, Abbotsford, Mission, Vancouver, North Shore, Richmond, Comox Valley, Cowichan Valley and Saanich.

“We have to think creatively and take an innovative approach that looks at everything we do from the patient’s and resident’s perspectives,” said Howard Johnson, president of Baptist Housing, which provides housing and care for more than 2,000 seniors throughout the province. “Our long-term care residences are positioned to provide supports not just for our residents, but seniors living independently in the community as well.”

A key principle of the work is to ensure changes make sense from the perspective of patients.

“I really like that several of the communities are looking at creating one central place where patients can access care,” said Chris Saunders, a patient representative. “It simplifies the whole process for patients and their families.”