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

Morgan and Sarah continue their discussion on Stage 2 of the Learning Pathway for Primary Care Teams. This episode is focused on Team Building, and specifically, seeing Patients as Team Members. The hosts make a point that patients are essential team members, and understanding the patient perspective when transitioning to team based care is important. If a practice is moving to team based care, patients likely won’t know what to expect, and may even be worried that their standard of care is lowering. Morgan and Sarah highlight the importance of exploring methods of communication to help explain this new care model. Furthermore, the discussion emphasizes how small communication changes in everyday practice can have a significant influence and help patients feel more supported. Finally, practical suggestions are made to help healthcare establishments in manifesting their teams via checklists, orientation activities for new patients, posters, and website representation.

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
To get started check out the culture change toolbox and the “Questions to consider before getting started” on P 12 of the toolbox.
Read over the AHRQ White Paper discussed in this episode “Creating patient Centred Team Based Care” (2016). This includes a great list of strategies for providing patient centred team based care (p. 7-19)
Check out the activities laid out in the Patient Centred Teams “Setting the Stage” handout

Past Podcast Episodes that may be of interest:
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-_3_01-25-2024_115307: Are you
looking for ways to engage your patients

as you change to team-based care?

Are you excited about the idea
of patients as team members?

Yeah, me too.

Sarah: So a really important
piece in the culture shift that is

team-based care is really thinking
about patients as part of the team.

morgan-_3_01-25-2024_115307: And
patient-centered care isn't new.


We've talked about it since I was a
student, and some disciplines, you know,

take this to heart more than others.

but still the, the system and the move
to team-based care isn't always as

patient-centered as we might hope it is.

Sarah: Right.

So when we think about, team
building, , the patient needs to be

included in our definition of team.

And the way we've talked about team
and define team is people who work

together on how they wanna work together.

The patient needs to be
included in that group.

morgan-_3_01-25-2024_115307: Sarah,
we looked last summer at what

patient's perspectives were on
the changing of the primary care

system to include team-based care.

Sarah: That's right.

So Elle from our team led this
work and she was joined by Leighton

Igu as a special patient advisor.

morgan-_3_01-25-2024_115307: Let's
go through some of the key takeaways

from what we learned last summer.

Sarah: So I think what we really
heard was that, even among patients

who are very engaged in primary care
transformation work, who kind of are,

are sitting at those tables, having
discussions about team-based care, there

wasn't a shared understanding of what.

Team-based care is, and we really heard
that patients wanna understand why

change is happening and what to expect.

I think a lot of the communication
that's gone out has been about how

team-based care is gonna kind of
alleviate burdens for providers.

And a lot less has, been framed
in the context of, you know, what

is this gonna mean for patients?

The other thing we really heard
is that patients want frequent

and irregular communication about
team-based care at the clinic level.

They really wanna understand how
things are working in their own clinic.

I think that's true.

I think patients probably less
interested in the whole system.

But they wanna know what's
happening in their clinic.

And, and that's particularly true
in the team building stage when

there's more change happening.

they'll want to know sort of
changes as things evolve over time.

But when the, quality of the care,
the style of the care changes,

they really need to know what's
happening and how it benefits them.

amie_1_12-20-2023_110634: patients need
to be involved in this and need to feel

like they understand what's going on.

So we actually added, quite a few
resources and suggestions around

communication, not only as a
team, so warm handoffs as a team.

Working together in that team-based way.

but including the
consideration of the patient.

So how is the patient
understanding our roles?

How are we building trust ? how
are we, explaining this team-based

care model to the patient?

Sarah: That was Amy Huff from Health
Quality BC describing a couple key

resources, from this stage that
are really designed to support the

inclusion of the patient in the team.

morgan-_3_01-25-2024_115307: And Sarah,
there's, there's several great resources,

but it doesn't have to take a lot of time.

It's probably gonna be a theme for
me as we talk about this all season.

it doesn't require a lot of effort.


It can be emails updating about what's
happening from the whole team to patients.

It can be, passive information that's out
in the waiting room or in the exam rooms.

and then it's also a bit of that act
of communication, so highlighting when

you've talked to another team member
or when you've reviewed their, notes.

To, um, describing why you might
be sharing care with somebody.

So I want you to see Kelly,
because she can do this with

you much better than I can.

And so you're gonna get the
benefit of working with her

as well as working with me.

And that starts to open up
the understanding for a person

about why they're, they're not
being sort of delegated away.

, they're getting more care.

So those, those don't take a lot of time
to just sort of embed those in your work.

Sarah: That's true and I think
those small changes in how you're

communicating with patients can make
such a big difference and really make

you feel like you've got, you know,
more than one person sort of behind

you looking after you part of the team.

We also have a great episode from
last season, specifically on the

role of patients in the team, and
we'll link to that in the show notes.

morgan-_3_01-25-2024_115307: So
Sarah, what do we wanna highlight

here in this episode as an interesting
activity for people to try?

Sarah: I think mostly our things
to try here beside thinking

really carefully about those small
communication changes things to

check out in the learning pathway.

there's a great resource called
Creating Team-based Primary

Care white paper from the A HRQ.

It's a short summary.

It has a lot of action suggestions
and ideas, things like.

Put posters up around, your office,
have sort of some patient targeted

communications, that you put together.

And Morgan, when we're thinking
about kind of how to make this really

tangible for people, you work in a team.

When patients walk into your clinic,
how is the team communicated to them?

morgan-_3_01-25-2024_115307: Yeah,
it's, that's interesting because I

mean, we've been a, community health
center for 25 years and so longer

than I've been there, and so it's,
very much embedded in, how we work.

And I mean, even if you
walk in, you'll see that I.

The front of the pharmacy group is
in our waiting room and you'll be

seeing nurses and counselors and
physicians and nps and all calling

in patients at different times.

So it's partly embedded in our process.

we do have a little bit of, of
intake for new patients 'cause

we do take new patients in.


We describe our team a little bit,
and then when they have their first

visit, we also talk about how we work.

So they get a bit of an orientation
that way, and then they see it in action.

Sarah: And maybe, you know, it's a little
bit different if, you know, as a patient

I'm moving from kind of a, I've always
seen my doctor and that's been pretty much

it to this new sort of model of team and
this idea of, you know, this is my team.

I no longer just have my primary
care provider, This really

needs to be explained to me.

I need to understand why things
are changing and how the change is

gonna benefit me and my provider.

people want their
providers to be supported.

I think there's an
awareness of the burnout.

And one thing of what we heard when we
were talking to patients was, you know,

people feel so lucky to have access to
care if they are attached to a provider.

But I think, communicating the
benefits to the patients is

just a really key piece here.

morgan-_3_01-25-2024_115307: You can
do that really quickly to spend five

minutes and make a quick checklist of
what are the things we wanna highlight

for patients, and then you can use
that to help communicate my own doctor.

Did that really well when a nurse joined
the practice and has just even through

email, kept people informed about the
changes in what's happening and why and,

and how that's an adaptation Sometimes
that it has been a benefit and sometimes

it's just been that there's been a
limitation of capacity, but then we're

aware of why there's a change there.

And I find that really helpful.

Track 1: I love this idea of thinking
through kind of a quick checklist

as sort of a communication reminder.

If you're changing your team, things
that a checklist might include.

You know, have I explained
team-based care to my patient?

Have I given them some background
on, what's gonna be happening?

Have I talked about how the team
is gonna connect and communicate

so people know that, there's.

If there is handoffs and handovers
happening, notes are being read.

has my patient met new team members?

Just a really simple checklist like that.

And I think if we spend sort of
five minutes thinking about what

that could include, that could
be a really good action for us

to get people to think about.

morgan-_3_01-25-2024_115307: I agree.

I think there's, that idea of how
do you connect and communicate,

it's often behind the scenes.

So for patients to understand how
that works, I think is really helpful.

but also, what if you don't gel
with one of the team members?


As a patient, what do you do?

and who can you talk to or
how can you give feedback?

'cause that happens too.

We're, we're all, we're all people.

And sometimes one person's style
doesn't mesh with a, a patient.

And so if there are opportunities
or ways of, of adapting, then they

should know that that's possible too.

Sarah: And I think an exciting kind
of spoiler for this space is we're,

we're actually currently working on
thinking through some of these knowledge

translation tools that might be helpful.

Posters, videos, checklists, when
we think about communication.

so there's gonna be more
resources in this space soon.

And, and just kind of watch over
the next, couple months and we'll,

we'll continue to update the show
notes as new things are developed.

So if I was gonna propose one.

Concrete, simple thing to do
that isn't too much effort.

Beyond the things that we've talked
about so far, it would be to put

up, small posters of each of the
team members in your waiting room.

if you do more virtual care, you
could even think about them on your

website, of course, but in the waiting
room, you could put up people's

photo, their name, their profession
position, and, and maybe a couple of

special interests or special skills.

. And that way when people, join the
team, you can add them and as patients

come to the, clinic and join the
practice, they'll be able to see

who the different team members are.

And it's , something that they'll be able
to look at while they're in the waiting

room, waiting for their appointment.

Sarah: That's a great idea, and
I think if you could see the team

right from the very beginning.

It sort of makes it a reality, right?

That brings us to the
end of, this episode.

just a reminder that we really
do, take feedback to heart.

Please reach out to

If you have any ideas of things
you'd like to hear on the podcast,

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.

Thanks for listening to Team Up.