Team-based care in Northern BC: North Peace Division’s journey to an integrated model of care

Issue: BCMJ, vol. 59, No. 4, May 2017, Pages 228-229 Family Practice Services Committee

Team-based care is a core attribute of the patient medical home model, and a key foundational piece in building an integrated system of primary and community care.

Team-based care is a core attribute of the patient medical home model,[1] and a key foundational piece in building an integrated system of primary and community care. A comprehensive team-based care approach enables providers to work together more effectively to create a clear path to care and provide efficient services to vulnerable and high-needs patients. This approach also benefits physicians by helping them achieve a better work-life balance and by ensuring that responsibility for supporting patients with complex needs does not rest solely on the physician’s shoulders.[1]

Much of the work toward developing a team-based care approach that can be broadly implemented by practices around the province is based on projects and initiatives currently being led by divisions of family practice. One example is North Peace Division’s team-based care model, which is being implemented in three clinics in Fort St. John to resolve a critical situation created when 16 of the community’s physicians left practice in 2013 and 2014, leaving 23 344 patients without a family doctor.[2]

Building on an existing team-based care model
The challenge in Fort St. John inspired the division to brainstorm innovative ways to provide services to vulnerable and high-needs patients, take some of the patient care burden off the shoulders of the community’s remaining doctors (many of whom had extended their hours into the early morning and evening to accommodate more patients), and provide integrated and holistic care to the community. To address the community’s needs, the division turned to the model they’d used to develop a local prenatal clinic (a collaboration between North Peace Division and Northern Health, using funding from A GP for Me).

The prenatal clinic uses a team-based care model that provides the services of a public health nurse to all pregnant patients, with positive results: between January 2014 and March 2016, the clinic delivered babies for 1315 patients, attached 1040 mothers and babies to a GP, and decreased the cesarean rate from 31% to 21%.[2] As the division considered options for addressing the patient attachment crisis in Fort St. John, they focused on the team-based care learnings from the prenatal clinic—specifically, the importance of enabling patient-centred care and creating a seamless experience for patients. Taking those factors into account, the division and Northern Health used the prenatal clinic model to co-design team structures and processes for three clinics in the community: the North Peace Primary Care Clinic, Fort St. John Family Practice Associates, and ABC Medical Clinic.

Community and stakeholder engagement
As the division moved forward with plans to embed health care teams within three local clinics, community engagement was paramount. The division used their Collaborative Services Committee as a forum to discuss shared responsibility for common areas of development between the health authority, the community, and the division. The engagement process also involved dialogue with all local GPs, the local Citizen Health Group, and Deputy Health Minister Stephen Brown. As this broader engagement process took place, Northern Health was realigning their nursing staff to work in a generalist model, giving the division the opportunity to connect with the health authority to discuss embedding nursing staff (and other staff) into doctors’ offices to support primary care.

New funding models
Physicians in two of the clinics are compensated through an innovative population-based funding model, while the third clinic operates on a traditional fee-for-service model. The following allied health team members (shared among all three clinics) are provided and funded by Northern Health:
•    Mental health and addiction clinician
•    Social worker
•    Dietitian
•    Primary care nurse

Embedding a team-based care model within three community clinics has helped the North Peace Division ease the physician shortage in Fort St. John. The division’s team-based care work, recruitment efforts, and successful locum housing initiative have resulted in a decrease in patient wait times for access to primary care from 2 months to 3 weeks. One clinic, initially designated as an “unattached patient clinic,” was immediately able to attach 5574 patients, including 602 patients with complex care needs. One new GP was able to attach 1525 patients; another took on 2468 patients from an existing practice, preventing them from becoming unattached; and there are currently seven physicians in the community who continue to accept new patients. Additionally, the clinics have attracted a number of new physicians to the community—12 new GPs and 11 specialists began practising in Fort St. John between 2014 and 2017.[2]

The collaborative journey toward the patient medical home
Transformation of policy and systems takes time, patience, and a strong commitment to listening to physicians’ voices and engaging with local, regional, and provincial partners. The work of the North Peace Division toward developing their local team-based care model has greatly strengthened their collaborative partnership with Northern Health—a positive relationship that continues as the division and health authority work together to design the patient medical home.
—Susan Papadionissiou
Director, Community Partnerships and Integration, Doctors of BC


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


1.    Hefford B. The patient medical home: Working together to create an integrated system of care. BCMJ 2017;59:15-17.
2.    North Peace Division of Family Practice. A GP for Me final evaluation and project implementation close-out report. Released 30 June 2016.

Susan Papadionissiou. Team-based care in Northern BC: North Peace Division’s journey to an integrated model of care. BCMJ, Vol. 59, No. 4, May, 2017, Page(s) 228-229 - Family Practice Services Committee.

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