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

The transition to a post-pandemic world has drawn increased attention to the tensions, pressures and capacity challenges that are experienced by health care providers and patients in primary care systems around the world. In the face of these challenges, in British Columbia, policy makers, funders, providers, and patients are working through another transition- the transition to team based primary care. The Innovation Support Unit, in the Department of Family Practice at the University of British Columbia, has been working to develop a series of implementation supports for communities, teams, providers and patients engaged in this transformation of Primary Care. Designed to accelerate planning and implementation, the mapping methods support inclusive, patient-centred and equity focused discussion and decsion-making.
This podcast episode tells the story of the evolution and iteration of the mapping tools and supports that have been co-developed by the ISU and communities across BC engaged in the implementation of team based care in primary care.
Drawing on the experiences of the ISU team as well as community interviews, the episode highlights the challenges, opportunities and potential new directions in the transition spaces of primary care transformation. Please see the resources below for more information about the primary care supports highlighted in this story.

Thanks to our guests!
Megan Sloan is the manager of the Qathet Primary Care Network, the regional district that surrounds the city of Powell River. Over the last 13 years, Megan has very engaged with the local community of physicians and nurse practitioners in Qathet and has taken on a variety of roles supporting primary care practices and planning.

Leslie Keenan: is the Executive Director of the South Island Division of Family Practice. Leslie has a long history of supporting primary care in communities, prior to her time with South Island she was the ED of the Nanaimo Division of family practice.

Amanda Frazer is the Strategic Lead of Primary Care Implementation Supports with the Innovation Support Unit. We are so grateful she was able to join us from her maternity leave! Amanda is passionate about the intersection between community engagement and system change. Prior to joining the ISU Amanda worked with the Campbell River Division of Family Practice.

Aleah Ross is the Primary and Community Care Mapping Lead with the Innovation Support Unit and is currently a PhD student at the University of Victoria in clinical psychology.

Morgan Price is the director of the ISU. He is an Associate Professor at UBC and affiliate faculty at UVic Division of Medical Sciences, Computer Science, and Health Information Science. Morgan is a family physician and practices in a Community Health Centre where he provides team-based care to underserved populations in the inner-city in Victoria. His research is in health systems change and clinical information system design and adoption.

For more information about Team Mapping:
For more information about PACC mapping:
You may also be interested in checking out some of the material related to TEAL organizations through the Re-Inventing Organizations WIKI based on the work of Fredrick LaLoux.
If you would like to learn more about the ISU or if you have any ideas for future podcasts please email

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.

Sarah: Hey, Morgan.

It's been a while, and I know
we're busy working on season

six of the Team Up podcast.

Morgan: That's right.

We're working on a different season.

We've heard from people that, we
wanted to focus more on nursing

roles in primary care teams.

So that's what we're going
to do for season six.

Sarah: And I'm going to be heading off
virtually to the American Anthropological

Association conference in Toronto..

The theme of this year's
conference is transformations.

Um, so thinking about this, we put
together a special podcast episode.

Focus on the implementation supports
that the ISU has developed over the

last couple years to really support the
transformation of primary care and primary

care teams in clinics and in communities.

Morgan: I think this would be really
interesting for our team up audience.

So why don't we share it today?

Sarah: Great.

Here it is.

Megan: I think we're not unique
in the pressures that we've

been facing aging, populations.

Complexity , growing mental health
issues, and shrinking supply not

only of providers, but also of,
available in-person appointment time

, ,

Leslie: and with the tremendous
workload, the administrative

burdens they have, and then, of
course, you throw COVID in there.

it actually, led to.

A number of physicians either
retiring earlier or leaving

family practice altogether.

It was just too much stress.

Megan: So just haven't had a whole lot of
luck recruiting, into the open positions.

we've also had a social worker
position posted for over a year and

so far haven't had a single applicant.

Amanda: I'd really like to see high
functioning teams within the clinic.

Because not only does that benefit
our providers and take some of the

load off of their shoulders, but also
it benefits the patients downstream.

We needed something to help
clinics start thinking about

how they would work as a team.

Megan: I think we are gonna
face a inequity in supply and

demand in our current structure
and system for years to come.

Sarah: Primary care in BC is
facing a number of challenges

and is currently at the start.

We're in the middle of a huge
transformation effort, with policy and

funding moving to support the shift
to team based care in primary care.

The Innovation Support Unit, a
small team based in the Department

of Family Practice at UBC, was
initially set up about five years ago.

to focus on innovation in primary care.

I'm Sarah and I'm a medical anthropologist
and a member of the ISU team.

We've really worked to create these
very adaptable, flexible tools that

can be easily used in communities
to accelerate engagement and support

planning for team based care.

I had the opportunity to connect with
some ISU team members and a few of

our community partners to reflect on
how our tools are working in practice.

The really interesting thing that has
emerged from these conversations is

that even though these tools have been
designed to be adaptive and are definitely

useful, they aren't adaptive enough.

More needs to change.

And we need to kind of figure
out what the next thing is.

And as you listen to these stories
of supports that we've created for

the team level, for the community
level, it'll kind of become evident

that there's something else we
need to be thinking about next.

hey Morgan, it's good to see you.

It's been about like, what,
10 minutes since our last

Morgan: been, it's been about 10 minutes.


Sarah: Uh, but can I get you to
introduce yourself and tell me a little

bit about the Innovation Support Unit?

Morgan: Yeah.

I'm, I'm Morgan Price and I'm a
family doctor and the director

of the innovation support unit.

I'm faculty at UBC.

And over the last five years,
we've really been focusing the

ISU on supporting team based care.

in primary care, mostly
in British Columbia.

That's a lot longer than
what we first thought.

We thought we would start helping with
some team based care stuff and then move

on to other aspects of primary care.

And this was all pre
pandemic when we started.

But as the changes in BC got more
extensive Sarah, we stayed focused

on team based care and, and helped
with the more strategic changes

that are happening in the system.

Sarah: So I'm wondering if I can get you
to tell us a little bit about kind of team

mapping as one of our first areas of focus

Morgan: so yeah, so when we started
the ISU, we really tried to, and we

still do, partner with folks in the
community that have real world questions.

And one of our, friends and colleagues
approached us with a question that

was, we were about to start one of
the first Interdisciplinary teams

in primary care in our community.

We know who we're going to hire, we've
got funding, we've got a building,

but we don't know how to be a team.

Can you help?

So we looked around and we said,
there's got to be something about that.

Of course there was.

There's lots of material about,
you know, high functioning teams

and features and there was.

Materials to read and things to watch.

But there wasn't a lot, Sarah, on
getting the team members to work together

on how they wanted to work together.

And so that idea is what
became team mapping.

We started to think about what was a co
design process that we could facilitate.

There was patient centered,
and we put the patient in the

center of a circle, literally.

And, and how do we get people to talk
about that persona of a patient, to figure

out how they wanted to work together.

And we flew out to Kamloops
and we ran a session.

And we worked with a lot
of teams along the way.

Morgan: Well, and lots of
different types of teams.

So big teams and small teams, virtual
teams, co located teams, teams

that don't exist yet, teams that
just got formed last week and teams

that have been around for 20 years.

And it's worked differently in each
of those areas and it, and it's worked

pretty well when you get the right
people around the table talking about.

What a patient needs, we
all tend to start to help.

And that's kind of, I think, the
secret sauce for team mapping.

I also had the chance to connect with
someone who's now really close to the ISU,

a great friend of ours who was involved
in some of our early team mapping.

Sarah: Hey, Amanda!

I'm so excited to see you!

Amanda: And my baby's waking up,

which is of course going to happen.

sarah_3_09-08-2023_092850-1: buddy.

He's smiling.

You guys can't see, but right now we're
getting smiles from the cutest baby ever.

Amanda: I suppose we should probably chat

about the things we need to chat about.

I'm Amanda Fraser.

I am currently on maternity leave, and
when I'm not on leave, I'm the strategic

lead for primary care transformation,
which includes implementation supports

with the innovation support unit.

And I've had the luxury of
working with the team for the

last three and a half years.

But before that, I actually was working
in community with The Campbell River and

District Division of Family Practice,

Sarah: Now, it's probably
worth noting that in B.


There's a number of divisions in
different regions of the province.

Uh, each division is a non profit.

The Campbell River Division of Family
Practice is a small community organization

that represents family doctors in a
rural community of about 35, 000 people.

Amanda: So in that position, I
was leading the early development

of primary care networks.

So I was scouring, what was available
for supports came across , team mapping.

Sarah: And this is when we used to do team
mapping in person on actual maps, large,

laminated, kind of bullseye looking maps.

And so we headed up to Campbell
River, about a four hour drive

from Victoria, with what was
then our very small ISU team.

. Amanda: And we brought together three
clinics from across the community to

start exploring team based care and
how they would work together, which

was super effective in starting the
dialogue of what team based care

could look like, particularly within
these private fee for service clinics.

Sarah: And team mapping is a great
example of exactly how, as an

innovation unit, we want to work.

The community identifies a problem,
we review evidence, design a thing,

pilot it, refine it, and scale it.

And really, we've been able to
scale team mapping quite well.

We developed facilitator training,
it's all open source, And over the

past couple of years, we've delivered
training to over 375 facilitators

across the province, and across Canada.

It's worth mentioning that the rapid
scaling of this was really made possible

by some amazing collaborations with
both Health Quality BC and Doctors of

BC with their practice support program.

and now, it's the practice
support coaches that are really

the people out in communities on
the ground supporting clinics who

are primarily using this, tool.

There's a lot of value to team
mapping, and we're still doing it.

It helps people work together on how they
want to work together or become a team.

But team mapping just
doesn't work for everything.

It became pretty obvious fairly
quickly that we needed to think

about the next level of supports.

I asked Morgan about the
time team mapping broke.

So Morgan, can you tell me what happened
when we tried to kind of stretch

team mapping a little bit too far?

Morgan: Yeah, this one,
came really clearly.

we kind of hit a sweet
spot with team mapping.

But what was happening at the same time
is that communities were starting to plan

what they wanted for their primary care
networks, which were larger than teams.

There were multiple teams
in a geographic area.


We started to do larger team mapping
sessions with multiple tables

and so multiple teams at multiple
tables and that, that worked okay.

That worked really well actually.

It was kind of exciting to do

Sarah: Like a

big event with dinner.

Morgan: Yeah, we'd have dinner and we
would run a three hour session and it

was a big deal and people got to compare
different teams and it was, it was fun.

And then we got asked if we could
do that but for three networks

simultaneously, and that's when team
mapping broke, because team mapping

is for clinical teams, figuring
out how they want to work together.

And what we had were stakeholders
coming together . And the people

that were there were representatives
they were different teams.

talking about what they did.

the funny thing with that was we, we
knew we needed something different

before we went into the session,

Sarah: Right?

We were telling them it
wasn't going to work.

Morgan: but, but it was funny because
they were promised team mapping.

And they had heard about it, and
they really wanted that, even

though it wasn't the right fit.

It was the wrong level of tool
for the people that were there.

And that's where we came up with, The
primary and community care mapping,

we call it PACC mapping, and PACC
mapping starts to talk about those

service needs and how different
organizations can coordinate together

Sarah: and one of the first communities
that we had the chance to sort of pilot

our PACC mapping with was in Nanaimo.

Leslie: I'm Leslie Keenan, Executive
Director of the South Island Division

of Family Practice, and I've been
here for two years and then prior to

that, I was with the Nanaimo Division.

of family practice up island and
previous to that two years with the

North Shore division of family practice.

I've been, I've been around the block

Sarah: Although Nanaimo and South
Island are really very different

communities, the primary care issues
in those communities are so similar.

You know, on the backdrop of COVID and
the opioid crisis, we have challenges with

health human resources and training and
recruitment, provider burnout, patients

without family doctors and kind of system
challenges with capacity and access.

In Nanaimo, we learned that there was
a significant wait list for patients

waiting to see psychiatrists and the
coordination of mental health and

substance use services for patients
with mild to moderate symptoms was

identified by the community as a gap.

Leslie: And then of course, you know, you
came along with, the opportunity to host

a PAC mapping session, with psychiatrists,
family physicians, and MHSU staff.

And it was an interesting process
because Well, at first glance,

it seemed kind of complicated.

It's very simple.

And it's, beautifully so, and at
that time, , we weren't doing the

digital work that you're doing now.

large piece of paper.

Sarah: Right we had like a paper map On

Leslie: the table.

And what we did is we plotted
out the various MHSU services in

Nanaimo, and we simply ran patient
personas through the services

that , were available at that time,

and it identified gaps for us, but more
importantly, it actually expanded our

collective awareness of how we could use
the system in a much more efficient way

Sarah: And so much of what we see in
the value of PACC mapping is really

in this awareness raising across
communities that come together.

And we've seen this process facilitate
some real changes on the ground.

Leslie: and following that work.

We developed a family physician
psychiatrist model where a specially

oriented, trained, physicians would
work with a psychiatrist on that long

wait list with the family physician doing
consults with the patients and connecting

with the psychiatrist as needed . And if
memory serves me correctly, that wait list

went down from a thousand people to 30.

And I a period of a year.

Sarah: you know, that's
an amazing outcome.

And they were already doing this work
in the community, so PACC mapping, of

course, can't take all the credit here.

But this pilot was a great
proof of concept for the method.

We refined and adapted it as we went.

And keep in mind that, you know,
the first pilot of this was

in person in January of 2020.

So very quickly, everything changed and
we moved this to a virtual platform.

And we've been working
in this way ever since.

I had the chance to connect with
Aleah from the ISU to talk a

little bit more about pack mapping.

Aleah: So my name is Aleah ISU team
member with the team for the past couple

of years most recently Really coming in
full into our primary care transformation

work to lead our primary and community
care mapping strategy across the province

Sarah: So tell me about your
favorite PACC mapping session.

Aleah: Oh, that's a good question.

We did one that was kind of looking
at, how service providers were kind

of allocated across the community.

That was all centered around
pharmacy and pharmacy services.

I think everyone got to get together
and really think collaboratively

in terms of like how they were
delivering services together and what

it actually looked like on the ground

Sarah: So that's kind of
like an adaptation, right?

we knew it wasn't quite team mapping,
because they really were talking

about pharmacists in different parts
of the community, but it really was

how they were going to be working
together as a team a little bit more

than our typical, PACC mapping session,

Aleah: yeah, and I think that's the
magic of all of our kind of ISU mapping

tools is just that they're so adaptable
and flexible and we really like people

to kind of take them and run with them

So I thought it was a really creative
use of some of our tools, but that was

really well adapted to the community
and really worked well for them to

kind of connect and collaborate.

Sarah: what's the most exciting
thing about PACC mapping?

Aleah: The exciting thing about
PACC mapping for me is Just

the amount of connection that
happens across the community.

I think it's often surprising for
participants how much they didn't

really know about the people that
are working around them and the

services that are working around them.

From the equity side, I think, So, um,
I pack mapping does a really good job

of allowing facilitators and communities
to think about, , how they want to

bring equity, diversity, inclusion into
the sessions up front in that we work,

through persona , these case examples
that we'll bring into the session, to

allow us to talk through some of the,
care priorities and care challenges

and I think you really get this unique
opportunity to think about diverse needs.

Sarah: So we know that these
tools are really useful, and

communities get a lot of value here.

And they're super flexible.

We also know that there are
definitely challenges that can

hinder the effectiveness of
pack mapping and team mapping.

And sometimes things can come out of
sessions that we're not expecting.

Megan: My name is Megan Sloan
and I am the manager for the

Qathet Primary Care Network.

I see my role as.

Guiding both the future and
current state of implementation

of, teams into primary care.

So supporting family physicians and
nurse practitioners to increase their

capacity and comprehensiveness of care.

Sarah: Qathet is the regional district
that surrounds the city of Powell River.

It's a rural, geographically
dispersed community.

And we've had the opportunity to
work with Cathet in a number of

different ways, including pack mapping.

Megan: we, again, not unlike many
communities have had, a shortage of

providers emerge for maternity care,
including nursing staff as well.

Um, so there's been a lot of
work behind the scenes to look

at our model and think about how

to manage the demand with
the supply that we had.

Sarah: And Qathet used PACC
mapping as a tool to explore the

coordination of maternity services.

Megan had some interesting reflections
on what worked and what didn't

work in their pack mapping session.

Megan: I think it's interesting
because bringing a group together to

do team mapping or community mapping,
I feel like, everybody needs to

be fairly comfortable to speak up.

and I think we had some people on
our call that weren't comfortable

speaking up and didn't actually
say what they were thinking.

So then when we got feedback on
the report, it, came to light

that some of what was brought
forward was not like people weren't

actually in agreement with that.

But that's still a good starting
point because you can reflect

back, the disagreement and
start to unpack it a bit more

so, I think it, it's still valuable
because you, you start to see one

side of the, a vision emerging and
then it gives people the opportunity

to gut check that and, and understand
what would or wouldn't work.

Sarah: What's interesting here is that
although the outcomes of the mapping

itself didn't end up aligning with what
the community wanted, the process of

the mapping did uncover some of these
challenges and got everyone together

to the table in a different way.

And these kind of moments are, I think,
a key part of transformation efforts and

the supports that are needed behind them.

Primary care is a complex system and
there's a lot of change happening

right now in communities as they work
toward more team based care models.

But so much of the challenges
and the context is really

coming from the systems level.

We realized, you know, we have great
tools now to support teams thinking

about working together differently.

And then we have PACC mapping To get
communities together, but, additional

support is needed at the systems
level and particularly when we think

about how governance is working.

Megan: what needs to change for
governance to be successful?

And in a small community like ours
as well, it's all the same players.

So we, we talk to each other a lot.

Health authority director,
health authority manager,

division manager, physician,
there are so many intersections.

But we had a, you know, sort
of a high level philosophical

conversation this morning.

and it's something that we hear often
from our family physicians who really

know their patients quite well here.

what we often hear is, by
the time the person is in my

office, it's almost too late.

There's so much work I think that we can
do around, collective ownership of health.

Sarah: Social

Megan: connectivity, good sleep, good
food to eat a roof over your head.

Oftentimes people are going into their
family physician door because it's the

only publicly funded door open looking
for like psychological or social supports.

Sarah: Really, when we think about primary
care transformation, there are so many

systems at play, and so many overlapping
roles and areas of responsibility.

Morgan, you and I talk about this a lot.

How do we encourage system change,
work upstream to really kind of

engage and improve primary care?

What do you think is needed next?

Morgan: So I think you're, you're right.

it's complex.

we're hoping to have groups work together
that are independent and yet they coexist.

And so there's some, hopefully,
symbiosis across different organizations,

and there's some reciprocal
accountabilities and other big words

that need to be thought about that,

it's often multiple organizations trying
to figure out how to work together.

And, well, PACC mapping and team
mapping are very clinically focused.

I think there's definitely some, some
need for something to actively support

people better understanding how to work
together on governance and planning.

But people don't have that conversation.

And so I think what we need next is that,
that level of governance mapping that

helps people understand the different
roles, the accountabilities in those roles

and, and the people that might hold them.

Sarah: And you know, we've done some
interesting things in our own little

team, kind of very small scale.

When we think about, we've drawn from
reinventing organizations and the idea

of TEAL organizational structures.

How do you work in a non hierarchical
way and, have really clear roles

and accountabilities built into
our processes , but then it gets

really challenging when you think
about how do you translate that to.

the health system, which is probably
one of the most hierarchical

systems that exists, right?

Morgan: It is and it isn't because you
don't have a hierarchy in primary care

the same way as you do in a hospital

Sarah: Right.

Morgan: because it's different orgs.

And so the different organizations
, are not necessarily hierarchical,

they're just different.

And they might have overlapping
areas of responsibility or not.

And so defining those.

In terms of the planning
and the governance.

I think that that is, really
the space to think about.

It's tricky though.

But I do think that that kind of
ecological model of different groups

having clear purpose and roles,
is a better fit than your more

traditional org chart kind of structure.

Sarah: So maybe that's , the kind
of next space we have to move into

when we think about how are we going
to support this transformation.

Morgan: think so.

Amanda got really excited when I asked
her about her thoughts on kind of the

next thing that might be needed to
support primary care transformation.

Amanda: We need to think about
what are these organizations

that come to the table.

What are they each responsible for?

What's their unique domains and where
are they overlapping and collaborating?

And I think that can be a little
bit vague It's new to communities.

it's new to these governing
bodies to work in this way.

So creating a tool or support to
help accelerate some of that work,

and bring clarity to the domains,

does help to break down those power
dynamics and traditional silos.

That's where we see the strongest
benefit and potential outcome

of these tools and resources.

Sarah: And I think really that's where
we're at now, if there's one thing

that we've learned as we've been working
through supporting the transformation

to team based care, it really is that,
you know, there are a whole range of

needs at different levels of the system

I asked Megan and Leslie what they
thought needed to change to make these

kind of primary care transformation
efforts work for communities.

Megan: I think acknowledging that we
don't necessarily need a collective

steering committee, um, that we will
work together as partners, , but that it

really is the, , primary care teams and
the network of clinics that are driving.

This change forward.

Leslie: You know, what am I hoping
for I've worked in, the B.


healthcare system now for over
40 years, so I've seen it all.

I think now we tend to
overcomplicate things.

So my hope is for a supportive
healthcare system that's responsive to

physician and patient needs within an
overriding principle of self government

where local physicians, patients,
and community lead what they need.

Sarah: Thanks for listening.

If you're interested in learning more
about the Innovation Support Unit

and what we're doing to support team
based care in British Columbia, please

see the show notes for this episode.

Or you can visit isu.




We love feedback and we'd
love to hear from you.

Recording, all good.

Morgan: I think so.

Sarah: Hey Morgan, so I know
we're busy working on season

six of the Team Up podcast

Morgan: That's right.

We're editing away right now
and, uh, we've changed gears.

We've heard from
providers and communities.

And so we're putting together the
next season, which is going to be

focused on nurses in primary care.

Sarah: and I'm going to be heading off
virtually to the American Anthropological

Association conference in Toronto in
a couple weeks and the theme of this

year's conference was transformations.

Um, we put together a special podcast
episode for this conference focused

on implementation supports that the
ISU has developed, uh, to support

the transformation of primary care.

Morgan: So the stuff that
we've been doing in the ISU.

And I think that'd be great to share
with, uh, the audience on team up.

Sarah: So, here it is.

Morgan: We've got to do that again.

Sarah: Boop!

Morgan: I feel like we
want to go back and forth.



Sarah: Hey, Morgan.

It's been a while, and I know
we're busy working on season

six of the Team Up podcast.

Morgan: That's right.

We're working on a different season.

We've heard from people that, uh,
we wanted to focus more on nursing

roles in primary care teams.

So that's what we're going
to do for season six.

Sarah: And I'm going to be heading
off virtually really soon to

the American Anthropological
Association conference in Toronto.

The theme of this year's
conference is transformations.

Um, so thinking about this, we put
together a special podcast episode.

Focus on the implementation supports
that the ISU has developed over the

last couple years to really support the
transformation of primary care and primary

care teams in clinics and in communities.

Morgan: I think this would be really
interesting for our team up audience.

So why don't we share it today?

Sarah: Great.

Here it is.

Morgan: That sounded better.

Sarah: Much better.


A couple times.

Now we're good.

Now we're good to go.

Morgan: Now, do you, do you want an outro?

I don't think it

Sarah: I don't think so.


Morgan: Let's press stop.