The Victoria Primary Care Network’s combined team-based care and data-informed approach benefits patients, physicians and communities. The experience and results of working collaboratively are becoming more common and with the utilization of primary care data, communities are understanding which resources are needed for impactful patient support. The Victoria Primary Care Network (PCN) leverages a variety of data sources to plan community primary care with an evidence-based and data-informed approach. The Victoria PCN uses the Health Data Coalition’s (HDC) Discover application and other data sources, such as billing and panel data, surveys, appointments and referral numbers to identify trends to manage their resources and supports accordingly. This data-informed approach helps identify change, sustainment or areas that may benefit from additional support.
The Victoria PCN has embedded Allied Health Providers (AHP) to work alongside the clinic’s physicians and staff within each of the cohort group practices. These supports can range from social workers, Mental Health and Substance Use Services (MHSU) consultants, clinical pharmacists, Indigenous Wellness Providers and RNs. The Victoria PCN meets with the cohort members, providing updates and feedback while evaluating the benefits of these clinic supports.
“It has been an incredible experience to work with the Victoria PCN Allied Health Providers. Having access to a pharmacist has been absolutely practice changing,” explains Dr. Sarah Chritchley, University Plaza Family Practice, Clinical Assistant Professor UBC and HDC user. “It has been particularly effective with patients that have concerns about medication side effects and drug interactions. These medication reviews take time and having a pharmacist available to go into depth with the patients is great to help them understand the benefits and answer any questions.”
With the guiding support of Dr. Melissa Duff, Victoria PCN Physician Lead and HDC Board Director, the Victoria PCN service plan identified mental health concerns as one of the primary focuses for their cohort groups. Cohort physicians can trust that AHPs will help support their patients within the scope of their expertise. By adding AHPs to the patient’s care team, patients receive the care they need, and physicians are kept up to date as AHPs chart directly into the clinic’s Electronic Medical Records (EMRs). This allows the patients to receive consistent longitudinal care and the Family Physician to remain aware of their patient’s progress while freeing up their capacity.
“Patients feel significantly more supported with this team-based approach. They trust their doctor and by extension, trust the team that is helping to support them,” continues Chritchley. “I was impressed by the scope of the pharmacists and also with the benefits of access to a social worker and mental health consultant. They have helped patients navigate the health care system, connect them with local supports and much more. As a result, we’ve been able to keep more patients independent and at home.”
The data analysis process has provided valuable guidance in offering targeted support to local medical clinics, that ensures the resources are allocated where they are needed most, resulting in effective healthcare delivery. Dr. Chritchley agrees, “I can’t imagine going backwards after the PCN support. All our patients are attended to, reducing the number of patients going to emergency.”
The benefits of working with a PCN are evident in the improved patient outcomes and the enhanced capacity of clinics to address a wide range of health issues. This combined team-based care and data-informed approach increases access to primary care. By continuing to leverage data assets, like HDC Discover and to inform how to integrate Allied Health Professionals, the Victoria PCN sets a strong example of how evidence-based planning can transform community healthcare.
Learn more about how HDC Discover data is used by physicians around BC.
Additional articles on PCN: (Understanding the demand, supply, and gap in care: How analyzing data can help)