Abbotsford

2015 ANNUAL REPORT

Our Mission:Happy and healthy GPs providing

fun and innovative health care.

Our Purpose:Promoting sustainable primary

health care through programs which address the health care issues of our community and physicians.

GP Members: 122 UBC Residents: 15 Programs: 11

Abbotsford Division of Family Practice 2015 Annual Report2

Highlights + a view to the futureEach year, it is my pleasure to present this Annual Report on behalf of our board and members. It is an opportunity to not only review, but also celebrate, all the milestones the Abbotsford Division of Family Practice has achieved and continues to strive for. Our mission is for Abbotsford to be a community of happy and healthy GPs providing fun and innovative health care. Our achievements are only possible through the direct engagement of you—our members—so, THANK YOU for your continued passion and involvement.

PartnershipsThe Division is currently working on a total of 18 initiatives—initiatives that are strengthening our relationships with our community. Partnerships are now the cornerstone of everything we take on, and as a result, our division is enjoying greater awareness in the community and we are able to move our work forward effectively and efficiently because of these important collaborations.

Main Programs:• Abbotsford Youth Health Centre• Residential Care Program• Hospital Care Program• A GP for Me

Key Stakeholders & Partnerships:• Fraser Health Authority• Abbotsford Community Services• City of Abbotsford• Residential Care Facilities• University of the Fraser Valley• Abbotsford Chamber of Commerce• Healthy Abbotsford

Review. Rethink. Redesign.We all have a lot on our plates. It is critical to be always asking: Is this the best way? Is this the right way? Is there another way? Over the last year, the division consolidated the Abbotsford Youth Clinic so it is under the operational management of Abbotsford Community

Services, with guidance from the physicians who work there. This allows the work we do with Abbotsford’s youth to move from its previous innovation stage into a sustainable, permanent service in our community.

Our Residential Care and Hospital Care programs are also under review (see article below for full details). We are gaining many insights through this process—including learning how we must paddle together (especially when the water gets rough!) in order to steer our canoe towards our goal.

A GP for MeA GP for Me is the division’s biggest project to-date and will form a large portion of our focus into next year. Through a one-time funding opportunity, the division is actively working on four initiatives designed to address patient attachment, GP recruitment & retention, practice optimization and test the waters of team-based care. These initiatives are only successful in as much as our members are willing to participate and be involved. I invite and encourage you to join physician lead, Dr. Justin Boparai, and the A GP for Me Implementation Team as we leverage these opportunities together. Please read the A GP for Me Summary on page 3.

GratitudeA big THANK YOU to our board of directors: their contributions epitomize our mission of happy and healthy GPs providing fun and innovative health care. They show up, they step up, they represent our community well, and they make hard decisions for the betterment of primary care in Abbotsford. Please join me in thanking the following individuals for their leadership:

• Dr. John Chan: Treasurer & RCP representative

• Dr. Kara Aiton: Secretary & Child Youth Mental Health

• Dr. Virgil Danescu: Physician Lead, Hospital Care Program

• Dr. Justin Boparai: Physician Lead, A GP for Me

• Dr. Elizabeth Watt: Abbotsford Youth Health Clinic & NP4BC

• Dr. Glenn Collingridge: Incoming Treasurer & Healthy Abbotsford

• Dr. Reg Peters: Shared Care & Physician Wellness

• Dr. Richard Egolf: A GP for Me Governance

Special thanks to John and Reg for serving on our board for three years, and for their dedication, commitment and wisdom. We will miss them.

The coming year is sure to bring more new milestones for our division. We are looking forward to the outcomes of the GPSC (General Practice Services Committee) Visioning process which is expected to impact the future of primary care across the province. And at the local level, we will continue to chart a course that matches the work you, our members, need from us with the goals of community-based health care.

Sincerely,

Dan

Two of the Division’s founding initiatives have been under review and redesign over the last year. While the Hospital

Care Program (HCP) has had to react to the growing needs of Abbotsford Regional Hospital and Cancer Centre (ARHCC) and the shrinking capacity of our community of GPs, the Residential Care Program (RCP) has moved from a Ministry of Health pilot to a province-wide initiative through the GPSC.

The HCP Working Group met diligently over 10 months to collaboratively design a program that could meet the demands of the 19,000 annual inpatients of ARHCC. The community-based GP model of care has been one of a kind in regional hospitals. The determination of the GPs involved in the program has been a testament to the willingness of our GP community to stay involved in hospital care. Changes in the program are still being determined and should be resolved by the end of 2015.

With a new provincial scope, the Abbotsford RCP program has taken the opportunity to align with the new provincial clinical outcomes and best practices. Working with Fraser Health, residential care sites, and feedback from providers, the group has developed a new patient-centred system of care that includes ongoing education and team support. The transition for change will occur over 2015–2016 and includes ongoing evaluation and feedback from all involved. ■

Reviewed and Redesigned:

Message from the ChairMembership

15 UBC residents 79

Full Service Family Physicians

19ER Physicians

11Focused

Practitioners

7GP

Specialists

6Locums

Abbotsford Division of Family Practice 2015 Annual Report 3

A GP for Me is a provincial initiative being implemented across BC by 33 local divi-sions of family practice. The goals of

A GP for Me are to: 1) increase the capacity of the primary care system to improve patient ac-cess; 2) help more patients who want a family doctor to find one, while improving support for vulnerable patients; and 3) strengthen doctor-patient relationships to improve patient health.

Abbotsford began the Assessment & Planning phase in May 2014 and received approval (and funding) for its Implementation Plan on March 31, 2015. Through a series of consultations with physicians, medical office staff, allied health care professionals, patients, community organizations, and municipal, regional and provincial health care partners, we identified the following key challenges:

• 26% of family physicians plan to retire by 2023

• Chronic conditions, mental health, substance use, and weight/obesity

issues are among the main health concerns in our community

• Abbotsford has a number of distinct vulnerable populations with unique health care needs: new to Canada, seniors, youth, and the homeless

• Approximately 26,000 Abbotsford residents do not have a family doctor and an estimated 5,000 are currently looking for one

Our A GP for Me Implementation Team, led by Dr. Justin Boparai, Physician Lead, and the Steering Committee, is currently addressing these challenges through four main initiatives:

• Practice Optimization: Supporting doctors in their practices to enhance

GP capacity to accept new patients

• Recruitment & Retention: Making Abbotsford an attractive landing site for new and relocating family doctors

• Patient Attachment Mechanism: Creating a central registry of family doctors accepting new patients

• Team-based Care: Testing a promising model of care; placing registered dietitians within family practice clinics to serve patients with weight/diabetes issues

The Implementation phase began April 1, 2015 and runs through March 31, 2016. Ongoing updates and plans for continued primary care improvements are communicated via the Abbotsford Division of Family Practice monthly newsletter. ■

Dr. Justin Boparai, A GP for Me Lead

Four Shared Care projects have been initiated this year in Abbotsford, addressing mental health to cervi-

cal cancer screening. The partnerships between family physicians, specialists, and other allied health care providers, through these projects, are key to ad-dressing the barriers to care.

Abbotsford has the highest rate of child and youth mental health hospital intakes in Fraser Health, surpassing Surrey and Richmond. That statistic provided the impetus to launch our Local Action Team as part of the provincial Child and Youth Mental Health and Substance Use Collaborative in partnership with the Ministry of Children and Family Development (MCFD). A group of 20 CYMH community stakeholders have worked hard to develop projects to increase the number of children, youth, and their families receiving timely access to integrated mental health and

substance use services and supports in Abbotsford. Over the next year look for new supports to help you address this need.

In the spring we also launched our ”Circle of Care” through the Polypharmacy Risk Reduction Initiative. More than 40 GPs, specialists, pharmacists, and residential care nurses participated in a workshop to help address geriatric medication interactions. The workshop and tools are components of the medication review protocols available through our RCP program. A second session will be held October 13.

Over the summer a working group formed to address the need for cervical cancer screening for south Asian women. Members of this demographic are more likely to see a second biphasic spike in cervical cancer and are least likely to have been screened. Given 23% of

Abbotsford’s population is south Asian, it is an important health issue. Next steps include public education and a physician lead workshop to assess how this need can be addressed in our community.

Another upcoming project is the provincial heart failure strategy initiative, where Abbotsford has been selected as a pilot community. Through Pathways, some of the identified needs in orthopedic transitions and neurology have been remedied, but we will continue to evaluate the possibilities of further addressing these issues. ■

Shared Care: Grass Roots to Provincial Initiatives

A GP for Me

A GP for Me Strategies

Abbotsford Division of Family Practice 2015 Annual Report4

Board of Directors StaffDr. Dan Husband, ChairDr. John Chan, TreasurerDr. Kara Aiton, SecretaryDr. Virgil Danescu, HCP (Hospital Care Program) LeadDr. Justin Boparai, A GP for Me LeadDr. Elizabeth Watt, AYHC (Abbotsford Youth Health Centre) LeadDr. Glenn Collingridge (Incoming Treasurer)Dr. Reg PetersDr. Richard Egolf

Michelle Favero, Executive DirectorLeslie Gmur, A GP for Me Recruitment and Retention and Care CoordinatorRaymon Grewal, HCP/RCP (Residential Care Program) Project CoordinatorBohdan Zajcew, A GP for Me Strategic LeadLouise Smith, Child and Youth Mental Health Collaborative Project Lead

Abbotsford

Abbotsford Division of Family Practice202–2276 Clearbrook RoadAbbotsford BC V2T 2X5Phone: 604.746.3302Email: abbotsford@divisionsbc.ca

The Divisions of Family Practice Initiative is sponsored by the General Practice Services Committee, a joint committee of the BC Ministry of Health and Doctors of BC.

www.divisionsbc.ca/abbotsford

Photo Credits:Cover – City of AbbotsfordAll other photos – Abbotsford DFP

In partnership with Fraser Health, the Division has worked diligently to initiate three of the four accepted NP4BC (Nurse

Practitioners for British Columbia) proposals.

NPs Rona Loewen and Jamie Tourond began working through the Abbotsford Youth Health Centre to serve Youth at Risk. Since March they have provided care to underage parents and their children in the New Beginnings program, which operates at Mouat high school in a donated clinic space and provides outreach to youth shut-ins and those marginalized under the age of 25.

The Embrace Program, another NP partner-ship that includes Women’s Resource Society of the Fraser Valley, the Surrey North Delta Division, and Surrey Women’s Centre, is facilitated through the Forensic Nursing program of Fraser Health. The focus of the program is to provide follow-up care to victims of assault. In Abbotsford, NPs Anjie Gibson and Hanna Varto provide post-discharge care to patients of ARHCC’s forensic unit as well as providing care Mondays and Thursdays in clinic space located in the Warm Zone. To date they have helped 28 ARHCC forensic patients and see an average of 20 patients a week at the Warm Zone.

Positive Health is another NP program recently launched. As a partnership between primary care and public health, NP Monica Gregory will provide care to those without a GP who have contracted HIV/AIDS or Hep C or who maybe suffering from addictions. She will work in Abbotsford every Wednesday in locations close to marginalized populations. Monica joined this program after years of working in Vancouver’s Downtown Eastside and has a wealth of clinical knowledge around these issues that she is willing to share. ■

Nurse Practitioners Programs off the Ground

Happy Healthy GPs celebrate Walk with Your Doc.

in 13 working groups

28 physicians participating

7 committees

and 12 Community Tables