Access other health care providers to support quality patient care

When family doctors work in teams with other health professionals, they broaden the availability of clinical supports for their patients.

Team-based care is an essential component of a patient medical home.

Team members can include family doctors, nurse practitioners, nurses, social workers and other allied care providers; as well as therapists, pharmacists, and other clinical and non-clinical providers. They can be located in a family practice, or in the community and linked to the practice.

Teams are organized locally by doctors and partners based on the needs of patients in their practice and community. With the doctor leading care, team members can:

  • Provide preventive care, disease management and counselling, and arrange for follow-up services in the community.
  • Increase support for patients with complex and/or chronic health conditions. 
  • Work to their strengths, and support and rely on each other to give patients the best care. 
  • Collectively increase a community’s capacity to attach patients to a primary care provider.

For patients

Patients get timely access to continuous, comprehensive care and appropriate supports, which in turn can prevent unnecessary ER visits.

For doctors

With the added support and expertise of a team, physicians can:

  • Focus more of their time on difficult diagnoses and strengthening patient relationships. 
  • Reduce the burden of caring for patients alone, which can help prevent burnout. 
  • Feel more at ease when they know their patients are well cared for and getting comprehensive support. 
  • Increase the efficiency of a practice and streamline processes to maximize time and capacity.
  • Improve the satisfaction of GPs, staff and partners.

Team-based care models aim to attract new doctors to family practice to further reduce pressures on existing GPs and communities.

Get involved

Opportunities for GPs to work with teams are increasing as new models of care evolve in BC communities. Family doctors can:

  • Use their EMR data (panel management) to understand their patients’ needs and arrange for appropriate team-based support to serve those needs.
  • Work with other physicians and the local division of family practice to influence emerging, local team-based care models. 
  • Create an interdisciplinary team in practice or through the community as supports become available.

For more information about team-based care, please contact the GPSC.

Supports

GP Experiences

Gabriola Community Health Centre: If you build it, health care providers (and patients) will come

Working with nurses as part of a team

Team-based approach helps new physician settle in Keremeos

A sense of community benefits patients and providers

Engagement and collaboration set foundation for proof-of-concept journey

Life is better in team-based care

Resourcefulness supports teams and outreach to small communities

Doctors and community embrace alternative funding model

Strong leadership and engagement needed for real change

Collaboration starts with a conversation

Physician education and community collaboration build sustainability

Partners link services together to improve access to maternity care

Family physicians and dietitians collaborate to support patients in Abbotsford

Enhanced MOA role improves practice efficiency and patient care, supports team-based model of care

Team-based care attracts new physician to South Okanagan-Similkameen region

New model and networks support better care for patients, attract new physicians

North Vancouver clinic supports vulnerable patients, showcases effective primary care

Family doctors come together at Mission Attachment Clinic to support vulnerable patients

Family doctors work with teams at Martin Street Outreach Clinic to help patients at risk get their health and lives on track

Sunshiners Network provides “one-stop shop” services and resources for vulnerable and homebound seniors

School-based Wellness Centre in Nanaimo breaks down barriers and helps adolescents access primary care

Chilliwack Primary Care Clinic reduces excessive hospital admissions by connecting vulnerable patients to family doctors

Social workers team up with family doctors in East Kootenay to help patients address unmet needs and improve health

Expectant and new moms in Hope get more access to care, closer to home