Annual Report 2019 Membership & Stakeholders

PCN Provincial Objectives

Primary Care Networks across the province provide services that best meet the needs of their patient populations. With this being said, provincial objectives are set for all PCNs.

Accountable & Effective GovernanceEstablish clear and effective governance roles, structures and processes that support shared accountability and the evolution of primary healthcare delivery.

Strong Partnerships & Transitions of CareCoordinate, integrate and partner with health services and other social services across the continuum of care.

Health Needs of the Community and PopulationPlan service delivery on high quality assessments of the community’s needs through community engagement and assessment of appropriate evidence.

Patient’s Medical HomeImplement patient’s medical home to ensure Albertans have access to the right services through the establishment of interdisciplinary teams that provide comprehensive primary care.

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About UsThe Leduc Beaumont Devon Primary Care Network provides services for patients in the City of Leduc, towns of Beaumont and Devon and all communities in Leduc County. A group of 56 family physicians in 13 clinics along with additional health care professionals work together to improve primary care for our patients.

Primary Care Networks (PCNs) use a collaborative team approach to provide care for patients and to coordinate primary health care services provided by family physicians, Alberta Health Services and other health care professionals.

PCNs are a way to provide team support for family doctors by bringing teams of health professionals together – doctors, nurses, dietitians, social workers, mental health professionals, pharmacists, occupational and respiratory therapists and others. PCNs also manage 24-hour patient access to appropriate primary care services.

A PCN is a network of family physicians and health care providers working together to provide primary care to patients. A PCN may be composed of one clinic with many physicians and support staff, or several physicians in several clinics across a geographic region.

Each network is unique and has the flexibility to develop programs and provide services that meet the specific needs of its patients. This grassroots approach allows – and encourages – the PCN to focus on the needs of the local patient population.

Alberta has 41 PCNs operating in communities and areas across the province with over 85 per cent (3800+) of all family doctors in the province practicing within those PCNs.

The Leduc Beaumont Devon Primary Care Network began operating on March 1, 2006.

Core Values

We will maintain the highest standards of INTEGRITY in our behaviour and ethics, by being transparent, honest and honourable in all our interactions.

We will be ACCOUNTABLE to the public and our members and take responsibility of our own actions and decisions.

We will strive for QUALITY in our organization by following best practices and challenging ourselves for continuous improvement in our work.

We will demonstrate RESPECT in all of our interactions with others.

Message from the President of the Board of Directors

The Leduc Beaumont Devon Primary Care Network is an integral piece of the excellent health delivery system we offer our community. Over the years we have grown to become an immeasurable value add for patients and care providers alike. For our patients, we offer enhanced support and care for numerous complex and chronic health conditions. We provide support and counselling for those struggling with mental health issues and we have become a provincial and national leader in the development of preventive health measures. Further to this, collectively we have formed deep ties to the community we serve, through the commitment and efforts put forth by all of our staff and member physicians.

We have become many things to many people. The PCN provides support and services to member physicians to allow them to provide a level of care and support that many would deem impossible. It provides a network and venue for health care professionals to interact and work in teams. Most importantly, the LBD PCN has created a place where patients and their families can expect to receive world class community care. Our community’s belief in our ability to deliver care is the result of the skill, dedication and perseverance of the entire team at the Leduc Beaumont Devon Primary Care Network.

Over the years, I recall myself acknowledging the challenges we have had to face and overcome in order to maintain the level of care our community has come to appreciate. Year after year I am overwhelmed and honoured to be part of this organization. The level of skill, knowledge and concern for patients that is exuded is truly humbling. Yet again our organization has risen the bar to address challenges we have faced. The PCN went through a significant transition in the past 12 months, including substantial changes to our team, a marked shift in our chronic disease management program and a transition from centralized allied care providers to a model that includes centralized and decentralized care.

The LBD PCN managed these widespread changes without any losses in quality of care and without any noticeable impacts to workflow within member clinics; this is solely attributable to the LBD PCN team. We faced the transitions and adapted to the changes in stride and have simply evolved to become an even stronger organization.

A sincere thank you to all of the staff and member physicians of the Leduc Beaumont Devon PCN. Your dedication to patient care, active participation and engagement is the reason why we can continue to celebrate success. John F. Kennedy once said “Change is the law of life. And those who only look to the past or present are certain to miss the future.” The dedication, skill and concern for patient care within this organization has ensured our readiness for the future.

Thanks again to you all.

Justin Balko, MSc, MD, CCFPPresident Leduc Beaumont Devon Primary Care Network

LBD PCN Board of Directors

PCNs are board-run and directed organizations. Under the guidance of the Board of Directors, there are a number of committees that directly support the work of the board.

Board of DirectorsDr. Justin Balko (Chair)

Dr. Gurpreet Dinsa (Vice)

Dr. Lily Chen (Treasurer)

Dr. Rebecca Saunders

Dr. Gerard Amanna

Dr. Donna Klay

Dr. Alida van Heerden

AHS Governance Representatives

Aleem Rajani - Primary Care & Chronic Disease Management

Heather Durstling - Executive Director, Community Hospitals, Edmonton Zone

Korynna Wolfe - Director, Leduc Community Hospital, Devon General Hospital

PCN Staff:Len Frank/Cliff Richard - Executive DirectorShelley MacEachern - Office & HR Manager

LBD PCN Committee Structure

Team-Based Care CommitteeDr. Jana Holden

Dr. Gurpreet Dinsa

Dr. Rebecca Saunders

Len Frank/Cliff Richard - Executive Director

Dawn Estey - Program Manager, Primary Care and Chronic Disease Management, AHS

Lori Briggs - Team-Based Care Manager

Mental Health Sub-committeeDr. Alida van Heerden

Lori Briggs - Team-Based Care Manager

Rasheal Charles - MHC, Practice Lead

Alrene Rose - Manager, Mental Health, AHS

Len Frank/Cliff Richard - Executive Director

Evaluation CommitteeDr. Justin Balko

Dr. Sheila Gothjelpsen - Evaluations

Aleem Rajani - Program Manager, Primary Care & Chronic Disease Management, AHS

Len Frank/Cliff Richard - Executive Director

Panel Management and Quality Improvement CommitteeDr. Rebecca Saunders

Sandee Foss - Quality Improvement Lead

Christine Ridden - LA Medical Office Manager

Candace Chamzuk - Beaumont Medical Office Manager

Megan Sawyer - Leduc Medical Arts, Office Manager

Len Frank/Cliff Richard - Executive Director

Vision Integrated and comprehensive primary health care for a healthier Leduc County and its communities.

Message from the Executive Director

The Leduc Beaumont Devon Primary Care Network has been proudly operating for over 13 years now, though it has only been my pleasure to serve as Executive Director since May 2019. While it has been a whirlwind of meeting people, learning the ropes and coming up to speed with myriad local and zone committees and initiatives, I can state emphatically that this PCN is in great shape, thanks in no small part to our outstanding team of employees, solid leadership from our dedicated Board of Directors, and ongoing engagement from our governance partners in Alberta Health and Alberta Health Services. I am indebted to my predecessor, Len Frank, and the PCN Leadership Team for building this PCN into what it is and for keeping it running smoothly – it made for an easy transition and it is idyllic that the corporate knowledge embedded in these talented people remains within such easy reach.

Our PCN is emerging from a period of transition away from a historical centralized service delivery model to our new hybrid centralized/de-centralized model, coupled with the recent change of Executive Directors and modifications made to some services and positions. I am proud to be serving with the exceptional team that will continue to move our organization forward while providing first-rate patient care in support of our physician members’ practices and our communities. It will be important to provide some measure of stability while we institutionalize these recent major changes, and to that end, I hope to keep significant change at bay for the next while focusing on teambuilding and the optimization of our new service delivery model.

There is considerable work ongoing in the Edmonton Zone and efforts to move it forward will be anchored by the newly published Zone Service Plan – developed collaboratively between Edmonton Zone PCNs and Alberta Health Services – which highlights addictions and mental health, transitions in care, and specialty linkages as zonal priorities. With our business plan due for renewal in 2021, our business planning cycle will

soon commence and it will be important to focus on these areas while further reaching out to our members and stakeholders for input and suggestions that will guide and inform our programs and services into the future. Stand by for a survey and/or focus group invitation at some point over the coming year!

Our PCN continues to lead the way in terms of panel management, screening and appointment availability reporting; you will find the statistics in this report and it is certainly something that we are all proud of. We are also involved in Alberta’s opioid crises response by providing workshops and training support to our member physicians; our coordinated efforts with other stakeholders are resulting in positive outcomes through defining new health care approaches in our region and across Alberta. We continue to advocate for the Patient’s Medical Home and Team-Based Care and we remain proud that so many clinics in our network have embraced these philosophies. Indeed, Primary Care Networks continue to be the cornerstone of primary healthcare, which continues to be the foundation of the healthcare system.

I wish to thank the Board of Directors for welcoming me onto the team, and I offer my sincere thanks to the physicians, clinic staff and PCN staff who contribute to the health of so many in our part of the province. What we do in healthcare is noble and it matters. I hope you are as proud to be associated with the Leduc Beaumont Devon Primary Care Network as I am!

Cliff Richard, CD, P.Eng., MDSExecutive DirectorLeduc Beaumont Devon Primary Care Network

Mission To sustain and enhance health care provision in Leduc and area through coordinated health care delivery and to improve quality of life for the community of patients and physicians.

After-Hours Clinics and Extended Hours

The Leduc Beaumont Devon Primary Care Network supports our communities through funding of the Leduc After-Hours Clinic, Beaumont After-Hours Clinic and the Devon and Calmar Extended Clinic Hours programs.

The Leduc After-Hours Clinic is staffed by LBD PCN physicians; the Beaumont After-Hours Clinic is staffed by Beaumont Medical physicians, who are all members of the LBD PCN.

Both after-hours clinics offer online booking for that evening’s clinic through the LBD PCN website www.lbdpcn.com.

Team-Based Care Program

Our Team-Based Care program includes a team of healthcare professionals that help people living with various chronic conditions such as diabetes, pre-diabetes, high blood pressure, high cholesterol, obesity and other nutritional concerns. A tobacco cessation program is also offered. Our team, which includes registered nurses, registered dietitians, an exercise specialist, mental health clinicians and behavioural health consultants works with patients to help them learn strategies to improve their ability to manage their health.

PCN physician members requested that allied health providers work directly in clinic to enhance services provided as part of the Patients Medical Home. With restructuring of services in 2018, allied providers were placed in seven of our PCN clinics. Staff working in clinic teams include: Nurse Practitioners, Registered Nurses, Licensed Practical Nurses, Behavioural Health Consultants and Registered Dietitians.

PCN allied providers have expanded services to see patients across their lifespan. For example, BHC’s and

RD’s will work with children and youth with common primary care behavioural or nutrition concerns.

The Mental Health supports available to patients expanded with the addition of three Behavioural Health Consultants in addition to two Mental Health Clinicians. The BHC’s provide more services directly in clinic. Wait times to access Mental Health services have improved in the past year with the addition of these supports both in clinics and the central office.

Seeing both these professionals (registered nurse, registered dietitian) on a monthly basis has really helped me in my fight against diabetes. The follow up from my doctors’ visits are great and really help.

~ Team-Based Care patient

It really helps to meet with the above professionals (registered nurse, registered dietitian). It keeps me trying to stay with my progress. Very Good.

~ Team-Based Care patient

Health Education Classes

The Team-Based Care healthcare professionals offer a variety of classes and workshops to our patients and the public. All classes are free and do not require a referral from your family physician; registration is required.

Regarding the anxiety workshop - I’m so happy it’s free and full of information.

~ class participant

Great to talk to about the Grief & Loss class. Nice just to clarify some things.

~ class participant

Specialty Linkages

Access to specialists for patients living in suburban and rural communities has always been a challenge. Our PCN aims to partner with various specialty groups to provide patients with local access to specialist consultation services. These clinics are offered at the Leduc Beaumont Devon PCN office.

Access to these specialty clinics are by referral from a PCN physician.

Geriatrics

The Leduc Beaumont Devon Primary Care Network provides a specialized geriatric assessment service for seniors who have chronic, complex health issues through the Leduc Eldercare Consultation Team. This team, made up of Care of the Elderly physician, Dr. Trevor Byers, and geriatric nurse, Carla Moore, runs a weekly clinic out of the Leduc Community Hospital.

The goal of this program is to ensure seniors living in Leduc, Beaumont and Devon enjoy optimal health and quality of life while remaining in the community for as long as possible.

The Leduc Eldercare Consultation Team accepts referrals for the following conditions:

- cognitive/behavioural concerns

- functional decline (falls, mobility issues)

- review of medications

- capacity assessment

This program is by referral from a PCN physician.

Referral Coordination

The delivery of primary care services to patients has become increasingly complex over the last 20 years. Alberta’s growing and aging population has created numerous pressure points in many areas of service delivery. Family physicians and their staff identified referral coordination between family physicians and specialists and other community health organizations to be an area of concern.

Family physician offices find it more and more difficult to, among other issues, access appropriate services and expedite treatment through the health care system. They report a lack of access to information as well as long waiting periods for health assessments with specialists.

In order to help family physicians and their staff deal with these issues, the PCN developed the Referral

Coordination program. The purpose of this initiative is to assist physician clinics in scheduling and tracking appointments with specialists, outpatient clinics and other community agencies. The Referral Coordination program launched in 2010 and is supported by five referral coordinators and a team manager.

The Referral Coordinators advocate for the patient and assist the physicians in making sure patients move through the system as seamlessly as possible, with good quality care, from both within and outside the PCN. They develop linkages with various community health resources to deal with patients requiring treatment and referral. The Referral Coordinators develop and manage patient referral programs, confirm appointment details with referring offices as well as initiate, maintain and update the referral database and confidential medical files and records, as indicated.

"The work she (referral coordinator) does is very much appreciated. It is like being the cinematographer. The actors and directors get all the credit and the awards but it is the cinematographer that puts it all together. They are very important and don’t get the credit that they deserve. Please let her know that all of us here appreciate and value the work that her and her coworkers do.”

~ Dr. Karpman, Dermatology

Panel Management and Quality Improvement

This program is available to LBD PCN member physicians to engage in the work of the Patient’s Medical Home (PMH). Our focus is to offer practice facilitation for teams to build the best medial homes for their patients and themselves.

Each clinic’s journey to PMH will be different; our QI team can support meaningful, sustainable changes at the clinic level to create a culture of continuous quality improvement and build the PMH that best serves

physicians and their panel. The foundation of the Patient’s Medical Home is the relationship between a patient and physician and the team that provides care.

Establishing processes to identify, maintain and manage each physician panel, thus enabling continuity of care remains a priority for LBD PCN.

Panel Management and Quality Improvement

Access, Panel Verifiation and Continutity of care

The Edmonton Zone Metrics report shows where the Leduc Beaumont Devon PCN sits across the areas of Access, Panel Verification and Continuity of care.

PCNs working together

Edmonton Zone Committee

Leadership representatives from all Edmonton and area PCNs, as well as Alberta Health Services have been working together on ways that PCNs and AHS can integrate better. The areas of focus are:

• Addictions and Mental Health

• Transitions of Care

• Access to Specialists

The recently developed Zone Service Plan will guide the work to be done in these realms.

Pan-PCN

The Pan-PCN Steering Committee in the Edmonton Zone formed five working groups last year in areas identified for increased collaboration. They include Medical Home, Clinical, Administration, Evaluation and Communications, with representatives from all nine PCNs in the Edmonton Zone participating. The group meet regularly and are progressing in creating greater efficiencies between PCN programs and services improving collaboration and program consistency between PCNs.

In 2017, all PCN members voted on changes to the governance structure of PCNs. This created five zones in the province that resulted in increased collaboration between PCNs in close geographic area to one another. Two groups that were created from this change were the Edmonton Zone Committee and the Pan-PCN.

Find A Doctor

Having a family doctor improves the health and well-being of a person. Edmontonareadocs.ca was created to help make finding a family doctor easier. There are currently over 300 doctors in the Edmonton and surrounding communities that are accepting new patients.

In April 2019, Albertafindadoctor.ca was launched as a provincial initiative to help attach patients to a family doctor, no matter where in the province they are looking for a family doctor. You can search for a doctor by specific criteria (languages spoken, female/male) and find their contact information easily.

Prescription To Get Active

This program encourages physicians to write a prescription for activity, similar to what they would do for any type of medication the patient may need. The patient then follows the “prescription” for activity, or they can take it to a participating recreation centre and redeem it for free services.

PrescriptionToGetActive.com has 25 PCN members, over 150 recreation partners and has spread across the country.

Leduc Beaumont Devon Primary Care Network

#301, 4710 - 50 Street Leduc, AB T9E 6W2

780-986-6624 www.lbdpcn.com

your health. your team.