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

Who doesn’t like Unicorns? Join Sarah and Morgan as they talk about primary care unicorns- or unique roles that are being tested in primary care- and the potential for extending the boundaries of how we think about primary care teams. In this episode we highlight the stories of BC’s one (and only) kinesiologist currently working in a primary care team as well as learning about the potential of adding genetic counselling to primary care teams to support patients with mental health concerns in primary care.

Thank you to our Guests!

  • Carmela de Gracia Patten: Carmela is the first kinesiologist in the province hired to work in Primary Care. Based in northern BC, Carmela is a team member with the Change Program, a lifestyle intervention program focused on metabolic syndrome (people with type 2 or pre-diabetes)
  • Jehaninne Austen: Jehaninne is a neuropsychiatric geneticist and a genetic counselor. They are a professor at the University of British Columbia.
  • Prescilla Carrion: Prescilla is a senior research genetic counsellor and clinical associate professor in the UBC Department of Psychiatry and was the genetic counsellor for the Cool Aid Community Health Centre team as part of the GenCOUNSEL research project.
  • If you would like to learn more about CHANGE BC and the engagement of kinesiologists in Primary Care in BC check out the Team UP webinar: CHANGE BC and Team Based Care: a rural experience and visit the Change BC website.
  • To read more about the impact of embedding psychiatric genetic counselling in primary care visit:
  • To see the impact of psychiatric genetic counselling on a client, Prescilla recommends watching this video:
  • And coming soon: Carrion PB, Austin J, Elliott AM. A genetic counselor's reflections on lessons learned, challenges, and successes experienced during a one-year pilot integration in a primary care clinic. Public Health Genomics. 2023 Jun 12:1. doi: 10.1159/000530683. Epub ahead of print. PMID: 37307802.
  • Slomp C, Morris E, GenCOUNSEL Study, Price M, Elliott, AM, and Austin JA. The stepwise process of integrating a genetic counselor into primary care. Eur J Hum Genet. 2022; DOI: 10.1038/s41431-022-01063-4.

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: do you like unicorns?

Are you excited by what new providers
might join your primary care team?

Are you wondering if there's some
more unusual and focused roles that

might work well in primary care?

Yeah, me too.

Sarah: With the increased focus
on team-based care and new funding

models that are emerging, we're
seeing the addition of some new

roles to primary care teams.

Morgan: So there's a number of
new professions that are starting

to work more in primary care, and
these aren't quite widespread.

Sarah: So Morgan, we always
joke that we look for unicorns

to join our team at the isu.

People with unique skillsets that are
able to fill gaps and address emerging

directions across the team in a number of
areas, As primary care teams expand and

the idea of team-based care becomes more
widely socialized, I think, this creates.

New opportunities for roles that have
maybe been, more focused or in acute

care, to really move into primary care.

Morgan: Yeah, we've been hearing
more about the inclusion of

new roles in primary care.

Now this has mostly been funded through,
pilot projects or even research projects.

And they do show promise.

when we think about the value of
expanding how people think about

primary care and what the scope is,
it's really important to think a

little more broadly and think of what
other roles can be part of the team.

Sarah: as we work our way toward the
end of this season, we wanted to do an

episode that's a bit different thinking
about these kind of unicorn rules in

primary care teams, and the potential to
expand the engagement of providers from

more professions into primary care teams.

Morgan: A lot often comes down
to funding models, Sarah, and I

think that with the role of the
PCNs and focus on team-based care.

We do have this ability to think of
those emerging edges of primary care

where we might be able to get some
additional capacity through some of

these new roles supporting our patients.

Sarah: Morgan, what kind of roles
are included in this bucket of

potentially in primary care team's
but maybe harder to find in practice?

Morgan: Well, I think
Sarah, there's a bunch.

We commonly think of the, core of
family doctor, m o a nurse, and

then there's others with a slightly
expanded team that could include

people like pharmacists, social
workers, dieticians, physio, and ot.

Those are some of the common
roles that , we're talking about.

And then we can sort of think beyond that.

There are other roles out there that
may be referred to in secondary care and

some of those can be very successfully
integrated into primary care teams.

it depends partially on your practice
into what your particular needs are

for the patients that you're serving.

And last episode we talked about
indigenous support workers.

As a new and emerging, really important
role, and I think they have a more general

value across all the PCNs, , but they do
have a higher need in certain populations.

Sarah: So there's a number of these
kind of roles I think that we're

starting to see more often and are
becoming more commonly considered

when you think about, what's
included in that primary care bubble.

We also have other roles that are really
unique in primary care contexts, and

we spoke to a couple people in our
interviews for this season who are the

only person in this role in the province.

so In particular we have two roles
that I wanted us to dip a toe into.

So the first is kinesiologist in primary
care and the second genetic counselors.

First, let's talk about the example
that we have of the inclusion of a

kinesiologist in a primary care team.

what can kinesiologist do?

Morgan: It's a good question because
I haven't worked with one , in a team.

Now, kinesiologists are really focused
on active components of rehabilitation,

so mobility, balance, exercise, movement.

my own family doctor was trained as
a kinesiologist and so I kind of have

that on my own personal team, but
they really help focus on healthy

movement and activity and can help
with different other kinds of injuries.

Sarah: you know, when I did a little
bit of background research here looking

into like what's the difference between
a kinesiologist and a physiotherapist?

Kinesiologist can also help with
musculoskeletal injuries, but there's a

little bit less of an acute injury focus
than you often see in physio and more of

that sort of longitudinal, getting people
to think about exercise differently.

That kind of focus in kinesiology,

Morgan: And Sarah, until recently, I
didn't think we really had any examples

of kinesiology in primary care in bc.

Carmela: The first time I meet someone,
it's really just getting to know them and

a lot of time in the beginning I think
is dispelling any myths they may have

about physical activity in their mind.

Figuring out what everyone's concept
of being fit or being active like,

I think there's a lot of saturation
in social media that being healthy

and being fit looks a certain way and
we spend a lot of time undoing that.

And, trying to bring it
back to the individual.

How do they wanna move?

Why is it important?

And grounding their rehab in that and
grounding their kinesiology care in, how

do you wanna move, that's not gonna stop
you from living the life you wanna live.

We do a functional test uh, I ask the
patient to move their body around.

I may manually move their body
around to see how their joints

and muscles move together.

And then we do a cardiovascular test

Sarah: As part of the change program.

Carmela Degrasia Patton Is the
only kinesiologist that we know

of working in primary care in bc.

Now, the change program was created
by Metabolic Syndrome Canada and n bc.

we have a number of clinics who are
currently engaged in this pilot, which

sees patients with metabolic syndrome, so
pre-diabetes or type two diabetes working,

with kinesiologist and their primary care
team, that also includes a dietician.

Morgan: When Carmella described to us
how she works with patients, what really

stood out to me was the value of the time
she sees being able to spend and work

with patients to build up their fitness.

Carmela: What's really unique is
the time, that I get to spend with

patients, and I'm hoping this is
something that, never changes.

That hour, if we use it all, is
the key I find for me to make

that bond and earn that trust.

People can adapt to movement
very slowly, but sometimes people

can also adapt very quickly.

And if you're not there as a practitioner
to see them progress in the moment, then

you may miss something and miss a moment
to advance their rehab a bit further.

Sarah: And having an hour , that
time with patience is so valuable

for building trust and also for
supporting the rehab and movement

and tracking fitness over time.

Morgan: Now with all the fitness,
Carmella talked about the importance

of accessible space for kinesiologists
to work with patients in primary care.

Carmela: I think what comes to the
forefront is a designated exercise

space and accessible to the patient.

I've, done some virtual care so
people can move in their homes.

However, I don't think there's
anything that replaces moving with

a person right in front of you
in a place where they feel safe.

So if you can have a safe movement
space for the patient to arrive

consistently every time, I think
that's the first place to start it.

Equipment doesn't have to be fancy.

Certainly sometimes having, different
types of equipment is a luxury.

You just need something to hold onto,
maybe something with a little bit of

weight and resistance and you can
make a lot of strides with people.

So yeah, a safe space to move and a
little bit of equipment to move around

and, and that's a good starting point.

Morgan: The change program presented
at the Team Up webinar and so

we'll make sure that if people are
interested they can see the webinar.

We'll put a a link in our show notes.

Sarah: So that's the kinesiology
kind of one-off role that

we have, in BC right now.

The next role as hoping to do a bit
of a quick case study exploration

of is the role of the genetic
counselor in primary care teams.

And I know that it's actually your
clinic Morgan, where some of the first

pilot work for the integration of this
role in primary care is happening.

Morgan: Sarah, this is, , as far as
we know, the first time that a genetic

counselor actually worked in primary
care and it was part of a research study

and, I got to be the sort of the local
investigator in that in our clinic.

So Koolaid was one of the first, that
we know of to have a genetic counselor.

And we were lucky to have
Priscilla work with us for a year.

Prescilla: Well, I think, part of
the interest in bringing a genetic

counselor to Cool-Aid was because of
the fact that genetic counselors, Can

and have specialized in mental health.

So, my training is in psychiatric
genetic counseling, and so

that was the initial draw.

and so essentially a large focus of my
work, especially at the beginning of

the integration, at Cool-Aid, was looking
at helping clients better understand the

role of genetics as well as environment.

When about, Causes of mental illness and
ways to promote recovery and management.

. As the integration went on, I was also
able to help clients who were at the time,

kind of trying to better understand, the
role of genetics as well in terms of other

illness, whether that a family history
of cancer, or, you know, a personal

history of complex medical concerns.

And a question, from their whether they
may have a genetic condition that could

explain what experiencing and where,
you know, a genetic counselor might

fit in helping them in this kind of
journey to get a better understanding.

Sarah: Morgan so what is it
that genetic counselors do?

I feel like there are a
lot of misconceptions here.

Morgan: So Sarah, I don't think
there's misconceptions, but there's

a, there's an understanding of
what they do at a genetic office.

So a geneticist clinic, what they can
do in primary care is unclear, and

that's part of what we were exploring.

it's not just, prenatal counseling
and, you know, making sure that

the right screening tests are
done , for women who are pregnant.

But there's a lot more.

Janine Austin, who's a genetic counselor
and researcher, has done a lot of

work in mental health, in specialty
clinics with genetic counselors.

And so we built off that at Kool-Aid to
see what genetic counselors could do.

And so there's a, a large focus
on helping patients understand

the genetic and environmental
components to mental health.

And we were looking to explore the other
aspects around supporting and counseling

patients around other chronic illnesses.

Jehannine: what we know from some of our
research is that when people hear the

term genetic counseling, there's a whole
bunch of things that pop into their head

as associations, most of which are wrong.

, so the first thing to know is that
genetic counseling is not the same

thing as genetic testing, right?

You can have and benefit from genetic
counseling even without any kind

of genetic testing being offered.

Whereas I would argue that probably
if you're gonna have genetic testing

of some kind, you might wanna think
about genetic counseling as well.

But, it's about more than just
testing is really the key..

Sarah: Both Janine and Priscilla,
really felt like that there is

this misconception about what
genetic counselors, actually do.

This idea of genetic counseling being
limited to something that was done

for pregnant people ,and, and if I'm
being honest, that's my experience

with genetic counselors, right?

That's when we got to go through
and kind of beat this new role

that I really didn't know anything
about was when I was pregnant.

That's really how I thought of the rule
until we started these conversations.

Morgan: Yeah.

I think it's a limitation of people's
understanding and absolutely when

Priscilla joined us, which was a few
weeks before the pandemic, That's what

we talked about as, the team was that,
well, what is Priscilla going to do?

We don't do a lot of prenatal care.

and then the second thing was, well,
what about rare diseases and can she

order all the rare disease tests?

So do we now not need to refer?

So it really was limited to those
two parts in the conversation.

And then over time, that started to
expand in terms of the knowledge and

the counseling part of the skillset.

Really became important.

And I think that that's something for us
to think about, in primary care, is we

do have a need for a significant amount
of that counseling support and genetic

counselors are very well trained in trauma
informed counseling and supporting people.

Sarah: So what can genetic counselors do,
they can support specific subpopulations.

So maternity, chronic
disease, cancer, mental health,

Morgan: yeah, so I think that idea
of helping people understand their

own health and what is it that
contributes to the development of

the conditions in the management,
using that idea of environment and

the genetic component or the nature
and nurture, I think that's , can be

a really powerful short intervention
that genetic counselors can do to help.

Sarah: The other thing that I
really learned in our conversation

is that they can take a different
kind of medical history that can

give people new perspectives,

Morgan: and Sarah, in our, pharmacy
episode we talked about how pharmacists

take a best possible medication history.

When I've seen Priscilla in action, she
takes the best possible family history.

Sarah: That's so interesting.

I mean, I think they can also
really help people understand this.

Combined effects of, genetics,
but also experiences and how

those can act together.

Jehannine does a way better job
of explaining this than I'm doing.

Jehannine: I specialize
in psychiatric conditions.

Psychiatric conditions are
not what I would refer to

as being genetic conditions.

They're not.

They arise as a result of the
combined effects of our genes and

our experiences acting together.

So there's a genetic contribution, but
that's not the be all and end all right.

but in, in that situation, we're
helping people understand how,

exactly how those things contribute
together to the development of these

conditions and how we can use that as
a framework to better understand how

we might be able to take better care
of our mental health for the future.

Morgan: Now, Priscilla also elaborated
on this idea of the value of

working with a genetic counselor.

Prescilla: I think for the clients who
were interested from the perspective

of mental health, they were really
keen to really talk to a healthcare

provider that could give them a different
perspective on their mental health.

I think they appreciated that part
of it would be taking that unique

perspective using the family tree
as a tool to discuss family history.

That that they didn't have that,
opportunity in other types of counseling

that they might have, , encountered
or, you know, , we know that the

time pressure is kind of within an
appointment with a physician are very

limited in terms of having to really
address all their complex needs.

Sarah: As an anthropologist in
this broader scope of what genetic

counselors can do, I think the
in-depth family tree tool that they

work with is really interesting.

, in our conversation, Priscilla also spoke
to the importance of, really bringing

a trauma informed lens to this work.

When you're looking at family trees
and family history, , and really

addressing concerns of team members.

In this space by giving them the chance
to really get to know how she works.

Prescilla: So I talked about the
example of how family history was

something that drew people and
clients to genetic counseling in

terms of that unique experience.

It was also perceived by the team
as potentially something that could,

trigger some past, traumas for
clients who are reflecting back, right?

And thinking generations and family
members impacted by mental illness.

And honestly, part of the process
throughout the integration was again

trying to ensure that the clinicians
were aware as well as my clients in

the trauma informed, culturally safe
approach that I was taking in my

genetic counseling practice, especially
with taking the family history.

Part of that was working with a team.

I had done initially a presentation
to the team to talk more about myself,

my training as a genetic counselor,
but also my clinical experience and

research experience, working in mental
health, to help reassure my team

members, with that particular challenge

Morgan: the onboarding that Priscilla did
was, really important, partly because of

those limited or misconceptions of what
the scope is, but also in understanding

how to introduce a genetic counselor.

To patients.

And in fact, we felt a little awkward.

Is there something genetically wrong with
me that I need to see a genetic counselor?

And that was something that we had
to figure out a way of, navigating so

that not only did our patients feel
comfortable, but we felt comfortable,

engaging Priscilla as a team member.

And once we did, the patients
found it valuable, but we

had to get over that hurdle.

The addition of these maybe less common
roles in primary care, what it does

is it really can enhance the access
to targeted supports for our patients.

And each practice is unique.

Each community is unique, and it's the
potential for breaking down some of those

silos and bringing more of the care.

That's needed for the practice into
primary care that I think is exciting.

This is something that both Priscilla and
Janine spoke about in our conversations.

Prescilla: my time at Cool Aid really
opened up my eyes in terms of the client

populations that I may not have been
able to really connect with, outside

of this primary care setting, right?

Because I think the current model of
genetic counseling being primarily

siloed in like specialty tertiary
clinics, it does prevent, clients

from really directly accessing it
in many cases when you think about

those barriers, just having a genetic
counselor located in a hospital barrier.

Jehannine: Historically, genetic
counselors have been siloed away, right?

It's a tertiary care service.

You you need a referral from somebody
to go and you go off to a specialist

center, usually in a big urban
teaching hospital kind of environment.

And that's where genetic counselors are
and that creates problems in terms of

things like access and equity patients.

So, this concept that we're talking about
today of integrating a genetic counselors

into primary care practice teams is
actually quite a novel concept, and it has

enormous potential, I think, in terms of,
I'm just gonna, I'm gonna be really bold,

realizing the quintuple aims of healthcare
in the primary care practice setting.

That is, we are looking for ways
to improve patient's experience

of care, to improve patient's
health, to improve equity, save

money, and improve the experience
of providing care all at the same.

I think that there are creative ways
that we can think about doing that, that

involve, for example, Genetic counselors.

Sarah: And, you know, having more novel
roles embedded in primary care teams

really does enhance the accessibility of
these services and supports for patients.

To wrap up this episode, and before
we move into our action ideas

here, I wanna loop back to where we
started with Carmella and her work.

In a primary care team as a
kinesiologist, and what motivated her

to move into this kind of uncharted
territory with her profession?

Carmela: I'd worked as a kinesiologist
in Nanaimo for five years and

kinesiology, I realized, was a service
that was only really accessible

to people with the right type of.

So those who might have been in motor
vehicle accidents or workplace injuries

or I also spent some time on the high
performance side working with athletes and

a lot of times I find money follows sport,
so, those individuals had the means to pay

for my services from a performance side.

But there's kind of this middle group
that , I found, got left behind.

it is empowering people
back into their bodies.

But what is really fulfilling is
being able to serve that population

that I wasn't able to in the past.

It's nice to be able to offer a service
that right now is, feels really equitable

and accessible, especially in northern bc.

Morgan: There are actually many more
of these less common roles that could

be incorporated into primary care
and so much potential here to think

about to improve access to care.

Sarah: There really is, and I think, you
know, we may revisit this idea in later

seasons of Team up or as one-offs if we
hear about, interesting or new to primary

care roles being integrated into teams.

So to wrap up today, what do we learn?

Morgan: I think the integration of
these less common roles in primary

care, one of the bigger barriers is
lack of knowledge that it's possible

and then potentially what the value is
for your, practice and your population.

Jehannine: I think the biggest obstacle is
that it's so new, like to do anything new

for the first time is always hard, right?

When it's not just standard of practice
and everybody's doing it, then you just

do it because everybody else is right.

So doing something novel is always scary.

So I genuinely think that's the biggest
barrier at the moment is that people

who are in primary care practice teams,
I think don't necessarily know, it's

hard to imagine how a genetic, I'm,
frantically using giant air quotes here,

listeners, um, how a genetic counselor
might be able to be useful in the

context of a primary care practice team.

I think that there's a bit of a leap
of faith required there in terms of

thinking about the bigger picture

Sarah: It is a bit of a leap of faith.

And it also requires, creating
intentional time and space to build

those relationships and let the team
get to know each other, to really

understand what some of these newer
roles do and how they can be useful.

Morgan: And if you are bringing on , a new
team member in one of these more unique

roles, just like any new team member, you
really want to think about onboarding.

Both for the team
members and for patients.

Priscilla gave us a great
description of how shadowing can be

a useful approach for onboarding,

Prescilla: we started off with
me shadowing for two weeks.

me spending time with first the
physicians in their client medical

appointments and then slowly kind of.

Introducing myself as genetic
counselor, the new team

member at Cool Aid to clients.

I had the nurse clinicians invite
me to appointments as well to

shadow them, as well as the
registered clinical counselors.

I think that all very much helped
because I think, one of the strengths

that Cool Aid is that they have
already established this safe and

supportive environment for their and
many of the clients have those strong

provider, , patient client relationships.

And so piggybacking off of that and
them introduce me really helped to

bridge I think, that sense of building
trust with and at the same time

increasing that comfort level with the
clinicians, with having me there and team

Morgan: And that kind of shadowing
idea I think is so useful when

you think about what it can do in
a team to get to know each other.

well as share the trust from one provider
to the new team member with patients

Sarah: It's like warm
handovers in action, right?

Morgan: in the same
room, it's even better.

So, Sarah, to wrap up today,
what are our calls to action?

Sarah: So as always, these are
pretty generalizable beyond the

kinesiology and genetic counselor roles.

But if you do have a new role that
you're bringing in, really creating

opportunities for the team to build
relationships and role understanding

and to include the patient in that
team, , I think is so important.

Morgan: And then make those
opportunities to have newer folks

in the team shadow other providers.

And this is a great way for team members
who are maybe even aren't new, but

haven't worked together very often.

Sarah: Thanks for listening.

Morgan: Sarah, I can't believe we're
almost at the end of season five.

Sarah: I know it's gone so fast, please
reach out if you have any questions

or ideas, , especially if you have
any ideas about what you might like

to see us focus on in future episodes.

Reach out to isu family

Morgan: Join us next week for the
final roll episode of Season five.