When David Chan walked into the Rocky Mountain Health Centre in Fernie B.C., he wasn’t expecting to uncover a team based care success story. As part of David’s role as a Clinical Services Manager for the Health Data Coalition (HDC), he often visits clinics in the East Kootenay region of British Columbia. The Rocky Mountain Health Centre has six Family Physicians (FPs) who enrolled with HDC Discover and began contributing data in July 2021. David has met with these six physicians on numerous visits, reviewing their practice aggregates and examining trends in their clinic, Division and province wide. On one of his recent visits, David met with Dr. Shelley Forrest and observed a notable change in the HDC Discover graphs for her patients with diabetes when it came to hemoglobin A1C (HbA1C) testing.

The HbA1C test is a common blood test, used to diagnose and monitor type 1 and type 2 diabetes. For patients living with diabetes, the HbA1C test indicates how well patients are managing their blood sugar levels. Canadian Medical Guidelines recommend it be measured every three months. David observed the percentage of diabetic patients who had a recent recording of HbA1C measurement in the past six months increased from ~25% to ~81% over an 18-month period.

Dr. Forrest HbA1C Graph

“I asked Dr. Forrest what she thought had contributed to this significant increase in the percentage of her patients getting an HbA1C test. When she looked at the dates on the graphs, her answer was immediate,” shares David.

“The significant improvement in diabetic care that occurred in 2021 is directly correlated to our clinic acquiring a Chronic Disease Team, particularly two Chronic Disease RN’s – Lynn Walker and Leah Folkmann. My patients are supported and followed so much more comprehensively than a GP can do alone,” explained Dr. Forrest.

One of the RNs, Leah, was in Dr. Forrest’s office that day and when David shared the statistics with her, she was ecstatic. Seeing her and Lynn’s efforts resulting in quantitative proof of care improvement for patients living with diabetes was incredibly rewarding. The data showed exactly what her efforts had netted in terms of improving patient adherence to regular blood sugar monitoring for their clinic and the community.

David chatted further with Leah, asking questions about her process and why she felt the team based care approach had improved diabetes care and HbA1C testing rates so remarkably.

“When we meet with a patient, it is usually in a combined appointment with their physician. We see the patient for the first 30-45 minutes to conduct an in-depth assessment, then the physician joins us for the end of the appointment. Once we are all together, often with the patient’s family or partners, we make a plan that includes diet, exercise, and medication recommendations, as well as safety information including recognition and treatment of hypoglycemia, renal considerations with sick day planning, and driving safely with diabetes,” explained Leah.

The numbers prove this 45-minute conversation between the RN and a patient is time well spent. Traditionally, the work of the Primary Care Networks has been evaluated anecdotally, through conversations and feedback at the community level. The value of team based care can now be represented through the quantitative numbers that prove the impact of these roles in the community. The opportunity for patients to spend extra time reviewing their lifestyle behaviours and understanding the importance of HbA1C testing allows Rocky Mountain Health Centre to better manage their health in addition, showing they care.

“Every individual patient comes with their history, personal goals and values around their chronic disease. Keeping an open, non-judgmental relationship with our patients is the most important thing,” explains Leah. She credits her colleague Lynn and the inclusive, welcoming and collaborative professional relationships she’s found in the primary care clinics in Fernie. Patients are no doubt the benefactors of this collaboration and improved quality of care being provided.

The East Kootenay Primary Care Network (EK PCN) is a partnership between the East Kootenay Division of Family Practice, Ktunaxa Nation, and Interior Health. Their goals are to improve the health of the population through timely access to comprehensive, person-centered, team based care that is equitable and culturally safe. Data is proving an important part of monitoring these goals.

“The EK PCN supports physician-led, multi-disciplinary coordinated health care that begins with the patient,” said Caitlyn Flint, EK PCN Support Coach. “This team-based approach to care means more patients have added support for their immediate and long-term health needs. It’s very rewarding to have captured hard local data that demonstrates team based care is leading to positive patient outcomes in our communities.”

Now that Leah and Lynn can rely on viewing regular HbA1C test results, they are able to monitor how patients living with diabetes are adjusting to new lifestyle behaviours and adhering to their care plans. “There is so much assessment, education and support that goes into excellent diabetes management,” shares Leah. She noted that reviewing measures in HDC Discover influences management of patient HbA1C ranges. Having the data and the ability to view the impact on patients within HDC Discover has reinforced that Leah’s time with patients and the conversations she has, are effective.

Quantitative evidence of the impact of team based care is exciting. Data is a powerful resource in quality improvement and in the case of the EK PCN, the data clearly shows the patient benefits of additional clinical capacity.

The HDC team is eager to support data driven success stories across the province. Learn more about how HDC Discover data can support your community planning and operations.

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