Team Up! Team-based primary and community care in action

In this episode, Morgan and Sarah move into Stage 3 of the Learning Pathway for Primary Care Teams. The focus here is on — after we have built a team, how do we develop it further and showcase the continuity of care to patients? The hosts discuss how patients may perceive team-based care as a disruption to their healthcare continuity, and they provide ways to think about communicating this positive change to patients. Morgan then breaks down continuity into four types: information, management, relational, and inter-provider. Sarah highlights key resources and shares an anecdote where she realized that her MOA was integral for her continuity of care. Morgan and Sarah emphasize the importance of communication within the clinic, and including patients in conversations that demonstrate HOW you are communicating and connecting as a team in practice.

Special thanks to Amie Hough, a Leader in Health System Improvement for Primary and Community Care with Health Quality BC, and one of the creators of the learning pathway, who we will be hearing from throughout the season.

Links and Resources
For more information on the Team Based Care Learning Pathway check out

What Matters to You
These resources helps us use conversations to understand more about our patients
What matters to Patients with Virtual Care appointments

RN Virtual Virtual Primary Care Practice Guide

Relational Continuity Change Package

Through the TeamUp network we are working to advance supports for team based primary care. Please reach out to if you would like to learn more!

What is Team Up! Team-based primary and community care in action?

A podcast that brings together primary care providers, healthcare planners, patients, innovators and others to talk about the changes that are happening in primary care in British Columbia.

Morgan: Are you working with a team and
looking for new ways to work together?

Are you looking for innovative ways to
improve cognitive care across your team?

Yeah, me too.

Sarah, we're getting into stage three
of the pathway for team based care.

This is where the team is
really developing and starting

to gel as a team, isn't it?

Sarah: Right.

So in this stage, , team members
are already working together.

They're getting to know each other.

And they're kind of starting to
establish new ways of interacting.

Really, I think a key piece here is
thinking about, you know, not just who's

doing what, but also how are we sharing
leadership decision making and maybe

working a little bit differently to
really, draw in kind of team strengths.

Morgan: And Sarah, when you get into that
kind of shared leadership or distributed

authority that you need to have a lot
of trust in who you're working with.

So I think that's, that's
a part of this, isn't it?

It's that understanding about who
you're working with, knowing them

and, and having that trust for the
shared leadership to be effective.

Sarah: Exactly.

Morgan: Yeah.

And at this stage, I think also.

And this is my bias, but you're going to
start thinking about continuity as well.

It's not just here's a task
for somebody else to do and I'm

going to get the answer back.

But now thinking about if there is
that shared leadership, that shared

care that's really happening, how do
you ensure continuity across the team?

And that's particularly true if
you're growing up in a larger team.

Sarah: And Morgan, I know this
is a passion area for you.

You've done a lot of work

Morgan: It is.


Sarah: if we think about one of
the main concerns that we've heard

when we think about team based care
and how patients are understanding

what's happening in this space, both
patients and provider concern actually.

is really this idea that team based care
is going to decrease continuity of care

because all of a sudden as a provider You
might not have as close a relationship

with The patient that you're seeing
all the time the patient now has a team

rather than one person that they're
connecting with There's a lot of concern

here about you know, does this mean that
I'm gonna have less continuity of care?

Morgan: And it, doesn't
mean that if you do it well.

And I think understanding the
different kinds of continuity then

helps you understand how to do it.

but also for a patient who, who as part
of the relationship needs to feel part

of the team and connected, understanding
how relationship continuity happens

across a team is also really important.

So, if I can get a little academic, I
think of continuity myself in four ways.

And the first one is about information.

So, you know, the classic thing here
really is, do we all have access to the

same record if we're part of a team?

Are we able to see the same information
or is, are there barriers to that?

And if, if that continuity is broken, that
makes it hard to see what's happening.

Second one's a little different.

And, that's more about
management continuity.

And some people think of this as care
plans, so we all have, okay, this is our

protocol, we're going to run the protocol.

it's partly that, but it's
also, why are we here, and

what's our philosophy for work?

Sarah: Right.

Morgan: So that purpose of, like,
are we taking a harm reduction

approach, for example, in my practice?

If one of us is not taking a harm
reduction approach, it's very hard

to be consistent in our management.

one person, a patient sees one
member of the team and versus

another, that can be tricky.

So you have to have that sort of
general philosophical alignment,

Sarah: I'm guessing that, you know,
the management continuity could also

be really tricky when you think about
how a patient's needs might evolve

over time and how that, could change
over time and needing to really loop

back to that idea of, okay, do we all
have the same framing for our work?

Do we all have that same philosophy?

Does that management continuity continue
even when the team changes and adjusts,

Morgan: And sometimes the, the, goal
of different parts of care shift.

So having the informational
continuity helps with the management.

So it kind of builds on it.

So you can say, we're changing the plan
and there's a way to share that plan.

Sarah: and that's So

interesting because I think when I,
kind of think about continuity, all I

really think about is the relational
continuity side, which I think

Morgan: as a patient, that's,
yeah, and sometimes you think,

well, it's a given, isn't it?

That everyone has the information.

I think , that's a lot of it.

I remember my mom years ago
saying, well, the hospital

didn't have my doctor's records.

And I said, well, mom, where did
the doctor write the records?

So in the paper.

And then, and where does
the paper go afterwards?

On the shell.

Oh, right.

It goes on the shelf, so
obviously nobody has access to it.

Now, with electronic records, it's
a little bit different, but still.

relational continuity, though,
coming back to that, I think it's

about getting that connection so
people understand being, connected.

The patient knows who they're talking
to, so that small teams are actually

really good for this, because you build
a relationship, patient to team members.

I think with a team, too, You actually
can spend a bit more time as a, family

doctor or any team member, you can spend
more time getting to know the patient

Understanding what matters to them.

Sarah: And actually, there's
a tool for that, isn't there?

HQBC, Health Quality BC, has a great
resource, that's built out around asking

patients explicitly, what matters to you?

And I think we're going to
come back to that later today.

Morgan: Yeah, absolutely.

I think that's an important thing
to think about and it definitely

helps build relational continuity.

I'm almost done my academic piece.

Let me do one more type of continuity.

And this is my, my favorite one.

Cause this is part of what I learned
through my own work is this idea of,

what I call inter provider relationships.

So the, relationships between
team members across the team and

this inter provider connectedness
really is about how much we trust.

So coming back to that idea of trust.

How much we trust each other and how
closely we work together means we're

more likely to share all the other
pieces, and patients really feel that.

they just, they get that sense,
and, and also it's not so much,

you know, I want you to see one
of our nurses about such and such.

It's actually, you know what, I want
you to see Ann, and let's go down,

down the hallway and just double
check with Ann, or, you know, it,

it becomes so much more personal.

And then there is that personal attention
that is felt by the patient, so that

builds that relational continuity as well.

So that last part, I think, when you
think about how the team provides that

continuity, becomes really important.

And it happens across team members.

Sarah: And, you know, as you're
saying this, I'm thinking, Morgan,

you know, so many, so much of the
pathway that's been designed is

really to support this Interprovider
connectedness, build this trust and

then kind of extend that interprovider
connectedness to the relational

continuity and include the patient.


So really thinking about, all
of these stages of the pathway,

the getting started, the team
building, the team development.

And then as you move ahead, you know,
thinking about quality improvement

and what do you want to do better?

So much of that, I think, yeah.

It really needs that kind of
foundation of trust to work well.

Morgan: Yeah.


Sarah: And I think
patients feel this, right?

They see when a team works well together,
they, they, they can tell when, something

is, is, you know, well supported.

Morgan: Yeah.


Even if it's not directly with them,
one thing I've noticed is if, Sam, I'm

walking a patient out of, out of a visit
out to the waiting room and one of the

other team members is walking a patient
in the other direction, you know, just

even, acknowledging the, the nurse that's
going the other direction, patients see

that and they see how connected we are.

And that makes a big difference as
opposed to sort of cold and clinical,

don't know who that is, kind of.

walking the other
direction down the hallway.

So patients definitely pick it up.

Sarah: And it's, I mean, I know
I always come back to this, but

it's that culture piece, right?

That team culture.

How do you, how do you build that out?

Morgan: Yeah.

Sarah: Thinking about kind of this
team development stage that we're now.

And in the pathway, and you know, what
jumped out to me when we think about an

interesting activity, I really wanted
to come back to the what matters to

you, resources that have been included
here you can think that they're

really sort of not as team focused.

It really is more about how a provider is
connecting with a patient individually.

But I think it's one of those pieces.

If you can bring that back
into the philosophy of how

you're all working together.

and make it so that, you know, across the
team, everyone is really reflecting on

this question of, what matters to you to
keep care sort of patient centered and

to keep patients engaged in the team.

I just think there's a lot of, great
kind of team development that can

happen through the use of, of that tool.

Morgan: Yeah, I think so.

Now this, we're going to put some
links down to the, what matters to

you tool down below in the show notes.

And what I like about this
tool is I agree with you.

It, it comes back to that
question of how do we keep the

relational continuity going?

it's a very easy thing to also implement.

And I like that.

It makes you think in a patient centered
manner and it's something that all

the team members can do from the front
staff to nursing team members to nurse

practitioners family doctors Any team
member can take this approach and it

it really does help shift our thinking.

Sarah: And I mean, as far as an
example , of the kind of questions

and resources that are in this kind
of host of, tools, there's a series

of, checklists that you can work
through and we'll post the links below.

But one of the things is, before
an appointment and a checklist

of things to make sure, has
been communicated to a patient.

And when we were building out the,
the idea for this episode, I thought,

Oh, like I, that would be great
if I got a, before the appointment

sort of check in with my provider.

I don't, I don't get that at all.

But then I realized, no, actually,
if I think about how in the team that

I'm part of, my, the team works, it's
not the primary care provider who

reaches out to me, but it's the MOA.

and I absolutely do get all of those
things that are in that checklist.

But through, through the MOA, reaching out
to me and, and confirming, demonstrating

the flexibility and scheduling,
setting out what can be expected.

Am I connecting, over a phone
or is there a kind of virtual

platform that we're using?

and I realized, Oh, I do get everything
in this checklist, but I immediately

had jumped to, Oh, my provider doesn't
connect with me at all about this.

Morgan: Right.

Sarah: So I just think it's a
really, interesting reframe when

you think about the team and how
can the team fit into, these sort

of what matters to you questions.

Morgan: I think that's a really good
point and it might be helpful to share

that approach with the patients in your
practice so people understand, oh yeah,

we're all working together, as a team.

And so the things that the MOA might
be asking, I'm going to know about.

And, that extends the relationship
across team members for the person.

the simple idea of just asking somebody
in a visit what matters to you or what's

important for you right now or, you
know, what, what are you worried about?

Simple questions like that can change
the conversation so dramatically.

somebody comes in, you know, I
work in a shelter as, as people

have listened to this now.

it might be for a medication refill
is what I, what I'm initially

understood as the question, but then
as we start to talk, you know, , what

is it that's, , important for you
right now that I can help with?

And it might be something unsurprisingly
to do with housing or, finances.

And some of those things
are out of my scope.

but because I'm connected into a team,
I'll say, you know, what I'll do is I

will talk to one of the social workers
here or the client support worker here.

And and just help to advocate a little
bit, and even if it's a, a little bit

of advocate, you know, that, that could
be important for, for a patient to hear

that that's happening, and if I don't
ask the question what's important,

I don't, I don't know that that's
what they really want to know about.

a classic example is, something
that I think is completely benign.

It might be, a sprained ankle
or it might be a cough, but

somebody thinks it's cancer.

And if you don't ask and then all
of a sudden like, well, do you

think I'm going to die from this?

And you know, wait, wait, it's.

All you have is, you know,
it's just a sprained ankle.

There's nothing that, and, but for
some part of their history there's a

reason they think that, and then you
can unpack that and reassure them.

and so those things are important
little questions that really

suddenly change the conversation
and then change the relationship.

Sarah: And I think so, really learning
what matters to a patient I think

is just so important throughout
their sort of care journey.

And there's a lot of questions on
people's plates and that's when I

think these kind of checklist sort of
tools can at least be a good prompt

to, to review and, and think about.

One other thing that kind of comes to
mind here is if this kind of resource

is of interest to you, and if you
specifically have a nursing role on

your team, we actually did some work
at the beginning of the pandemic times,

about, uh, our end virtual visit tool,
very similar to the, what matters to

you tools, kind of checklists when
you think about how you're connecting

as a team and with your patients.

Morgan: Yeah, I think those are
excellent things to start looking at.

you know, the other thing in terms of the,
relational continuity and thinking about

how your team is structured, I think the
team let is, is something that I often

come back to is if you have a, if you have
a large clinic, and a potentially a large

team or a large group of members that are
potentially working together in different

ways, trying Shrink down into smaller
teams that work more consistently with

a panel of patients, obviously there's
going to be some shifts on certain days

or when people are available or certain
skills, but if you generally try to have

a smaller collaborative group, patients
are going to feel that continuity.

They're going to feel more listened to
across a smaller team than if it's just,

different people every single time.

And that goes for all the different roles.

So I think that that's one
thing to structure your team.

The other thing that I'll, I'll
highlight as a possible thing to try

to implement if you have a team is just
communicating with your patients about

how you're communicating across the team.

and it can be as simple as I'm
writing a note here so that,

that, your nurse will know, you
know, or Ann will know next week.

I've written something specially for
Roz here and the patient will realize

that you're communicating even if it's
asynchronously through the EMR note.

Sarah: And I think the,
the side benefit is.

Your patient is being reminded of
these other people that are on their

team and what their names are
and that you're working together

and all of those questions.

I think it can be really concerning
for folks when all of a sudden they

don't have maybe their one provider
that they're going to see all the time.

All of those concerns get mediated by the
fact that you're really open about how

you're connecting and communicating, which
is one of the biggest areas of feedback

that we heard when we reached out to
patients about, you know what they need

To be better supported in team based care,
I guess before we wrap up, I'm looking at

this kind of stage three of the pathway
and thinking about the other sort of

really interesting tools in this space.

there's a relational continuity
change package that has been

highlighted in the learning pathway.

This comes from Alberta and does some
really interesting sort of resource

linking, identifying actions and tools for
teams, to try out when they're thinking

about different aspects of continuity.

. Some of it is really Alberta, specific
and we are going to be working on

building out some more of these resources.

So this is another kind of check this
space, uh, note for, for our listeners,

come back to this and, and check
in and we'll continue to update it.

to wrap up, what do you think Morgan
is an action to try in practice?

Morgan: I'm going to keep it super
simple and very actionable, and

that is, as you're writing up your
care plan, just tell patients how

you're sharing them across your team.

I think any team can just start
to embed that into their practice

very simply, and it's a nice
way to wrap up a visit as well.

Sarah: Great.

Well, and while doing that, you're,
you're developing your team here.

You're moving forward kind
of through this journey.

So invite you also to check out some
of the other resources in stage three.

We've highlighted a couple here,
but there's so much more, and

thanks so much for listening.

If you've heard anything that's really
interesting today, if you have feedback

for us, we'd love to hear from you.

Reach out to info at teambasedcarebc.


The Innovation Support Unit is a
distributed multidisciplinary team.

We work mostly remotely from communities
across the Lower Mainland and

Vancouver Island in British Columbia.

Morgan: Sarah and I are both recording
from our offices in the territories

of the Lekwungen speaking peoples, the
Songhees and Esquimalt First Nations.

Sarah: And recognizing the colonial
history and the ongoing impacts of

colonization and healthcare systems
and in Indigenous communities in

Canada and around the world, as we
move through the season, we'll work

to bring an equity lens to this work.

And we really encourage you, our
listener, to reflect on your past,

present, and future participation.

On the indigenous lands
where you are situated.

Morgan: Thanks for listening.