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

In this episode, Morgan and Sarah introduce the first stage of the Team Based Care Learning Pathway and focus on the importance of getting to know your patients. Morgan and Sarah explore two ideas related to getting to know patients,
  1. Utilizing EMR data for demographic insights and chronic condition trends and
  2. Conducting patient surveys to uncover needs.
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
Here are a few of the highlighted patient experience survey tools from a recent review by the ISU:
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 hearing a lot
about team based primary care?

Are you wondering where to
start and you haven't yet begun?

Or are you wanting to help a
friend with their first steps

into team based primary care?

Yeah, me too.

Sarah: Great.

So I'm excited about this one, Morgan.

Getting a team is about getting
the right people on the bus.

Morgan: Well, , that's
what we all think, right?

But it's not the first step.

It is an important
step, Sarah, absolutely.

But I think actually thinking about your
patients might be the first step when

thinking about how to create a team.

, thinking about who are you supporting,
thinking about, how many patients

are already part of your panel,
how many you might need to add.

in from your community.

And then once you know who your
patients are, are there specific gaps?

Is there information that you
can get from your patients?

to help guide what those gaps might be.

And I guess also if you are
getting new funding, sometimes

that comes with a new mandate.

So, understanding what that is in
relation to your patient population,

those are probably some of the first steps

Sarah: it feels to me, Morgan, like this
is a step that can really easily get

missed, especially when there's lots of
excitement about new opportunities and

new team members that you could possibly
bring in, new parcels of funding.

But I think you're right, bringing you
back to the patient, thinking about who it

is that's going to be accessing services.

And also, what's already.

In your community, outside your door,
who are you already working closely with?

Maybe you don't need to bring in,
say, a physiotherapist into your team.

If you have a physiotherapist right down
the street that you know really well,

Morgan: yeah, you just need to
work, work more closely together.

I think that's a really good point
and understanding what the gaps are.

And if you already have a small
team, understanding these gaps.

You might be able to build a capacity
internally without adding in anybody new.

But if you're starting from scratch,
I think starting with your patient

population is really the place to be.

Sarah: And this all falls into stage one
of the learning pathway, which is really

this, where to start with team based care.

And there's a lot to think about
when we think about getting started.

so we've kind of split this into
two steps in our own thinking.

We're going to talk about.

So step one, getting to know your
patients in this episode and step

two, which is more service design
focused in the next episode,

amie_1_12-20-2023_110634: So
really stage one is all around,

Who, who are we serving?

What is our, what does
our panel look like?

Who are our, who are the patients,
that we're serving in this clinic?

And this can apply to any clinic.


That's gonna really determine
who's gonna make up your team

Morgan: So that was Amy Huff
from Health Quality BC.

Amy's led the development of the learning
pathway that we're referencing throughout.

This season of Team Up, and it's
available on teambasedcarebc.


So we're going to be hearing a
little bit from Amy throughout the

season in all the episodes as we dive
into each of the different stages.

Sarah: So Morgan, what are we going
to be talking about in this episode?

I think really it's , two main
things that we're thinking about.

The first is utilizing EMR data.

Electronic medical record data
for demographic insights into the

population that you're serving and
different chronic condition trends.

And then the second is the
idea of conducting patient

surveys to uncover needs,

Morgan: Yeah.

And Sarah, both of these assume that you
have access to a patient population.

You're not a brand new clinic.

So if, you're an existing clinic and you
have an electronic record, it is a good

way to get some initial ideas and you,
you'll have a sense of it already based

on just being in practice, of course.

Sarah: And for people who don't
know Morgan, you, you kind of

like electronic medical records.

You have a little bit
of a background here.

Morgan: I do, I've been involved with EMRs
since, um, well, since my residency a few

years ago now, And help with standards
and a bunch of other things along the way.

Using EMR data has its pros and
cons, But is a great place to start.

And even some really simple EMR reports
can give you some really interesting

insights into your practice that can
help you think about how your team

needs to be structured, the kinds of
skills you might want to have in the

Sarah: So as someone who's
never been, into the back end

of an electronic medical record.

What kinds of things would you
run when you say EMR reports?

Morgan: So really simple ones.

Like, if you just run a report about the
age groups of your patients, so , the

age bands , of your population, how many
are kids, how many are young adults,

how many are elderly, that gives you
some information, about sort of where

you're focusing, the kinds of skills you
might need and the kinds of interests in

your team that you might want to have.

Chronic conditions is another area.

If you run some reports
and figure out how many.

diabetics you have, how many people
with congestive heart failure, how

many people with kidney disease,
that might lean you in a different

direction than if you had those in
larger numbers in your population.

Then mental health, anxiety,
depression, you might think of

your team in a different way.

And those are fairly quick in terms
of being able to run those reports.

And a lot of electronic records have
reports like those that are pre built.

So you can use reports that
look at your problem list.

Or you can look at reports that look
at the sort of the visits and how many

visits do you have for different reasons.

And of course that can vary a
little bit depending on the season.

Sarah: And I guess thinking about
those kind of seasonal things is

also really important when you're
looking at your past data to figure

out what your future needs might
look like over the course of a year.

Morgan: Yeah.

As you're planning what your capacity
is over a year, you definitely want

to think of those ebbs and flows.

but if you're doing something simple
and you can't run a report and you

just want to look at, say, your
schedule or your billing record for

the last, 30 days, just always keep
in mind that it will be different

depending on what season you're in.

you know, sort of the winter months,
you're going to be in flu season,

so you're going to have a lot more
upper respiratory tract infections

than you would have in July.

If you're doing something a little
bit, a little bit more complex, then

you can, look at a whole year at once.

So that's, The idea of doing some EMR
data reports, I think one thing, if you're

going to get serious about it is to think
about cleaning up your we call panel data.

So there's a data quality issue as well.

And that's something that
maybe we'll talk about later.

But that's just just remember that
Your reports are only as good as

the data that you have in your EMR.

Sarah: there's a great resource there
as well, Morgan, that I'm thinking

about now that, the practice support
Coach program and this is for British

Columbia specifically, but they've done
a restructure and they now have panel

management coaches So if this is something
that you know You need support with

there's also resources around to do that

Morgan: And I don't remember the
acronyms for other provinces, but

there are absolutely other coaches and
support services that can help you with

cleanup your EMR data in order to help
with things like quality improvements.

And this is absolutely
part of that process.

So you can reach out and get help
from your local support team.

And then Sarah, the other topic you wanted
to bring in was, uh, patient surveys.

Sarah: Right.

So this idea of patient surveys and how
that can help you think about uncovering

needs when you're at that point of
getting started in team based care.

So, why ask patients?

And again, this is easier if you
have an existing patient panel

that you're going out to ask.

Although, you know, there are
often community engagement steps

that are happening if it's,
you know, in a new community.

So there's, there's often some
patient feedback that you can find

if you're a new clinic as well.

But I think patients should
always be at the center.

Patients perceptions and experiences
are different than providers, can

really easily get skipped over.

and I think if they're included
at the beginning, it's easy.

easier to continue to include them
over the course of a team, and patients

are key members of primary care teams.

so this, I think, is a great way for,
for building that patient engagement

into the way your, team functions.

I really think, though, that, you know,
what surveys do well is, focus on needs.

rather than solutions.

Morgan: That's a good point.

Sarah: and then the other thing that
really jumps out to me here is a quick

survey is better than no survey, and
the flip side of that is sometimes

a really long survey can do the
opposite of what you want, I don't

think is a great way to engage folks.

So it's about finding kind of that
middle ground, something that's

Useful, targeted, and isn't going
to be a huge heavy lift for people.

Morgan: I think feasibility
is really important.

You know, there's a lot of change
happening and, could you ask every

patient that comes in for the next week?

three or four questions, gives
you some, some data to base your

next, planning off of, and might
be quite feasible to do for a week.

whereas surveying every single patient
and trying to do data collection on what

could be several thousand patients in a
practice, is not feasible for, Most, if

not all, almost all practices, . So better
to keep it feasible than not do it at all.

Sarah: That's right.

And, not to put any spoilers out
there, but we're currently actually

working through a review process.

So we're going to have a recommendation,
for British Columbia soon.

But we've done a lot of work figuring
out what some of the top tools for

measuring patient perceptions of team,
are and, the patient, perceptions of care.

So we'll put some links in the
show notes to those top four tools.

And they, they range, in size.

There's some that are Canadian focused,
some that are more international, but

I think it's really great to take a
quick look at the kinds of things that

these surveys will be asking, which
is, you know, a lot of feedback about,

what's working well, what patients
might want to see more of, if they

know who's on their team, there's some
really general questions like that,

that can give you a good sense of,
how well your team is working and how

well your team is being communicated.

Something that we've really been learning
a lot about is The kind of communication

of team based care to patients is really
something that, needs more attention.

And there's a lot of resources that I
think we can link in throughout the season

that'll bring that to the forefront.

Morgan: And Sarah, that's a, that's
a really good point, actually.

tying some feedback questions
to, information to your patients.

We're thinking about making some
changes and we want to hear from you.

So it's, doing a little bit
of foreshadowing, isn't it?

, to your patients that, you know,
there's change and team members are

going to be joining potentially in
the near future, we want to know from

you, what are some of the gaps that
you would like more support with?

it's not necessarily a promise that
those things would happen, but it,

it also foreshadows that there may
be some shifts and new team members

coming on board, which hopefully gets
some excitement from the patients.

Sarah: We'll link to some of
these existing tools, in the show

notes and we'll also update this
when we do have a final patient

experience tool recommendation.

So if you listen and the
recommendation isn't there, make sure

you check back, watch this space.

, we'll keep that updated.

Morgan: So Sarah, in, in wrapping it,
we've talked about sort of two big things.

I think I kind of exposed my bias at the
beginning, but in terms of where to start,

I think I would recommend keep it simple.

If you're just thinking about
this and wanting to get an idea of

what the potential needs could be,
I would start with your EMR and

look to see what canned reports.

So what's already prebuilt into your
EMR that you could run or get a coach

to help you run just by pressing a few
buttons . That will help you understand

what some of the gaps might be and what
some of the demands might be that you

think you might need some help with when
going from a, small team or a, group

practice into a team based practice.

there's lots of other resources through
stage one of the learning pathway.

There's some great materials and
we've got links in every episode.

So have a look at that.

Sarah: And thanks so much, as always,
we'd love to hear from you, so please

do reach out to ISU at familymed.


ca with any feedback.

Getting not just patient survey
data, but our listener data is

always really interesting for us.

Morgan: Yeah.

So we'll, and we'll adapt.

if we get some feedback and questions,
we're definitely going to bring it

into the episodes of the season.

Thanks for listening to team up and
we'll see you at the next episode.

Sarah: 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 to
season six, and we'll see you

in the next episode of team up.