Patient attachment: Identifying methods for improvement in the Cowichan Valley

The Attachment initiative—also known as A GP for Me—aims to provide access to primary care for all British Columbians who want a family doctor. We know that strong patient attachment to a primary care provider improves care quality and satisfaction and can decrease overall health care costs. 

On 1 April 2013 the BCMA and the provincial government announced A GP for Me to improve primary care in BC. Its goals are to confirm and strengthen the relationship between family physicians and to increase capacity so that physicians can take on new patients. The initiative will provide $40 million to Divisions of Family Practice over the next 3 years to conduct research evaluating the needs of the divisions’ communities and develop plans to improve local primary care capacity.

The Cowichan Valley Division of Family Practice was one of three divisions to prototype the attachment work at the local level. In 2011–2012, this Division worked with representatives from the regional health authority and other partners comprising the health authority, the local Collaborative Services Committee, the Learn, Evaluate, Act, Design (LEAD) lab (part of the UBC Faculty of Medicine Department of Family Practice), and the University of Victoria’s eHealth Observatory to explore the issue of attachment in the region and ways to improve it. Collaboration among a wide range of partners is key to finding local solutions to local challenges.

A number of BC communities are now actively exploring ways to meet the complex challenge of patient attachment, and many others will follow. Following are our experiences and the methods by which we undertook the work, with the goal of supporting other regions as they navigate their own journeys in this area. 

Process for finding community-based solutions
The Cowichan Valley Division held a series of four debates, facilitated by the LEAD lab, to explore how various attachment and integration initiatives might improve care in the region. Over 30 attendees participated in each debate. Attendees included family doctors, specialists, nurses, patients, and representatives from First Nations, health authorities, and the community.

The debates were structured using a set of evidence-based personas or patient cases that were developed using local community data, ensuring that the discussion was patient-focused and addressed the needs of the community. The data used for the personas were collected through surveys of both patients and physicians. The personas helped the group explore how various initiatives would or would not improve patient care for specific populations. 

The debates first explored the attachment issues for each persona, then focused on how each potential community initiative might support enhanced attachment for each persona. The discussions then moved to summarizing and reflecting the findings back to the participants, sharing evidence from other communities and jurisdictions to help inform choices, facilitate the discussion of priorities, and assess the feasibility of the proposed initiatives.

The discussions made clear that a multipronged approach was needed, as unattached and poorly attached patients have differing needs. Four improvement options were considered for the Cowichan Valley—one for unattached patients and three for poorly attached patients.

Unattached patients 
A small cohort of patients had no attachment to primary care and only limited access. Improving attachment for unattached patients first requires getting them access. The first initiative, a multidisciplinary community health centre in the Cowichan Valley, was considered an effective approach to helping difficult-to-treat, unattached patients.

Poorly attached patients 
A larger cohort of patients was poorly attached, meaning that they had a family doctor but did not consistently seek care from that physician or location. Three initiatives were considered to enhance existing services:

•    Inreach specialized services supporting GPs with specific patient populations (e.g., patients with mental health issues) by bringing trained professionals (e.g., psychiatrists/psychiatric nurses) into the GP office to see patients. 
•    Office redesign coaching to examine care services and optimize care delivery to improve access and thus improve attachment.
•    Enhanced home and community care to better support chronic dis-ease management in the community and be connected with the primary care home and family physician rather than being geographically based.

In the Cowichan Valley, attachment was explored through a patient-centric lens, and several improvement options were supported by the division and its partners. The prototype work has seen early positive results, connecting about 2000 Cowichan residents with family doctors. However, the issue of patient attachment is complex. The next step is to implement additional changes and to continually evaluate their impact in order to share the outcomes.

For more details on the Cow-ichan Valley Attachment initiative prototype, visit www.leadlab.ca/wp-content/uploads/2013/09/CowichanAttachment.pdf.

For more information on the GPSC’s Attachment initiative, visit www.gpscbc.ca/attachment-initiative.
—Morgan Price, MD, PhD, CCFP
Assistant Professor, UBC Family Medicine Residency Program
—Nicole A. Kitson, PhD
Social Science Researcher, eHealth Observatory, University of Victoria
—Grey Showler, RN, BA, BSN
Nurse, Cool Aid Community Health Centre
—Valerie Nicol, MA, CCC
Executive Director, Cowichan Valley Division of Family Practice

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This article is the opinion of the GPSC and has not been peer reviewed by the BCMJ Editorial Board.