Located in Vancouver, the UBC Family Practice Team-based Practice Profile: UBC Family Practice CentreCentre supports the education of UBC’s family medicine residents as well as providing full-service primary care to patients.

Approach

• This is one of 10 BC practices receiving populated-based funding as part of the BC Ministry of Health’s Primary Health Care Organization (PHCO).
• The Centre receives an annual funding payment for each patient based on the patient’s need for care, and this payment is reduced if patient seeks primary care services elsewhere, e.g., walk in clinics.
• The practices take turns at being “doctor of the day”  in addition to staffing a urgent clinic on Saturday and taking call along with residents. Most of the physicians also provide home visits. In general, physicians who do not provide maternity care refer their patients to a colleague within the practice. However, some patients opt for external midwifery care.

Population

• The focus is on serving people who are unattached, particularly mothers and newborns who are unattached after maternity care, unattached cancer survivors who have been treated by the BC Cancer Agency, and the frail elderly.
• Population-based funding limits recruitment to patients who are prepared to attend the Centre for all of their primary care needs.

Team Members

• Ten family physicians (operating as eight separate practices) and three nurse practitioner practices (two of them focusing on cancer survivors under the cancer survivorship program).
• The team also includes a dietician. Although there is no pharmacist on the team, the practice provides collaborative care with local pharmacies.

EMR /Communications

• The team communicates about patient care via the EMR, and it’s possible for physicians to access patient records remotely when they are on call.

Insights

• The population-based funding model/team approach provides improved continuity of care, and more flexibility in care provision – including the ability for practitioners to handle some patient questions by phone, and the ability for patients to see other team members as needed, e.g., well woman or urgent appointments.
• Patients benefit from comprehensive care, timely access to their own family doctor (or someone within the practice that has access to their information). Centre has a low outflow rate (few patients de-register) and high patient satisfaction.
• Advantages of population-based funding for physicians and multi-disciplinary team include: increased job satisfaction; more time for teaching; funding for the care you provide (rather than the services that can be billed on fee-for-service); and the reassurance that patients are well-looked after in the absence of their own personal primary care provider.
• In an ideal world, there would be: additional disciplines represented on the team, e.g., pharmacists and counsellors, and more team-based chronic disease management.

Advice for family physicians contemplating team-based care

• For successful team-based care, there has to be good trust and collegiality among the members, and physicians need to be comfortable with delegating.
• If the team is in different locations, communication via the EMR is necessary, and you need to look at how the EMR can support the true Patient’s Medical Home model.

 

Our thanks to Dr. Kuljit Sajjan, UBC Family Practice Centre, for providing this information (June, 2016).