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

In this episode, Morgan and Sarah continue their discussion of the first stage of the learning pathway: Where to start with team based care. Our hosts focus on the importance of thinking about both service design and team readiness when transitioning to team-based care in primary care clinics. They emphasize the need to consider the existing services in the community when designing or redesigning a team. Sarah and Morgan also highlight a number of resources available for primary care teams in the first stage of the learning pathway, highlighting the Team Readiness Checklist as something for listeners to try out 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

Past Podcast Episodes that may be of interest:
For links to the job descriptions and role material described in this episode explore stage 1 of the team based care learning pathway
Find the Team Readiness checklist here to try it out in practice

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: Is your primary care
clinic getting ready to shift

towards team-based care?

Are you wanting your new
team to complement other

services in your community?

Are you looking for tools to help you
design your primary care team structure?

Yeah, me too.

Sarah: there's a lot involved in,
the initial stage of the learning

pathway for team based care.

And we split everything into two
episodes for the purposes of the podcast.

So last episode we focused
on the importance of getting

to know your patients.

And today we really want to talk about
service design and team readiness.

This includes everything from
deciding what services to include

in your team, to space, and
figuring out how you work together.

to this big question of, , are you,
are you ready to work together?

What do you need to do to
get there if you're not?

Morgan: Yeah.

These are important things to think about
as you're getting ready to create a team.

change a team.

Sarah: And Amy Huff, who led the
creation of the pathway reflected

on the importance of supports for
really setting teams up in a good way

this stage helps you.

Prepare for that.

and think about things like,
patient-centered care, the quality matrix,

considering cultural safety and humility
in, your, team training and design.

Sarah: She also provided, a great
summary of, some of the resources that

are accessible through the pathway.

I'll just let her speak to this.

amie_1_12-20-2023_110634: So we've added
resources like, health match bc, sample

job descriptions, RNs are certainly the,
team members we get asked about the most.

We've, we've added some sample,
primary care nurse postings there.

And the role descriptions for
different clinicians, from dieticians

to physiotherapists, occupational
therapists and psychologists, and more.

Morgan: I think all these supports around
role descriptions and postings are very

tangible and important resources to have.

The pathway links to a
lot of the ones in BC.

And I think most provinces have
similar resources available for

primary care clinics and teams.

And a really important piece that links
back to our first episode is perhaps

less about the paperwork, but more about
thinking about how you want to design your

team and how it can integrate in with the
community that you're a part of, and also

to align with patient needs, of course.

But we want to talk about more
about that community alignment.

Sarah: That's right.

And, you know, really.

Coming at this as not a clinician,
when I was first thinking about,

well, what do you do to set up a team?

Honestly, it didn't even occur
to me to think about what's

already in the community.

I went straight to, like,
who's on the team, what's being

covered, sort of what's happening.

And I think that lens of what's around
you, what's in the community, and

how are you going to integrate into
the community is just so important.

Morgan: Sarah, I think that's a
pretty natural thing to think about.

Particularly for, private offices that
are used to thinking about the services

that they provide for their panel of
patients, community health centers,

uh, by their very sort of reason for
being, think about it differently.

And so learning from CHCs is a
great way to think about this.

It is about the partnerships
between your group and others.

And to think about how to make
things more accessible for people.

Sarah: I think, you know, really
talking about what's offered in the

community is obviously important here.

And You talked about this idea
of not duplicating things,

Morgan: Sarah, you're right.

I think not duplicating
is really important.

I mean, right now we have such a
crisis in primary care that if we

start creating redundant services,
we will have gaps in other areas, and

people who aren't Working to their
full scope of practice in other areas.

So I think really considering what
are the services around you, that

your practice and your population can
access, and then complimenting that as

you expand your team, super important.

Sarah: and I think as there's shiny
new things that can be offered,

particularly when we're thinking
about teams and like, oh, well, so

and so down the street has a mental
health, person working one day a week.

Like, we need that too.

let's jump on that bandwagon.

That happens sometimes,
maybe, the first step.

is going out and talking to community
services and seeing what changes they

could do to support your patients.

Maybe it's not an actual gap
before you try to expand your team.

Morgan: Yes.

Yeah, I think that's a really good
point, is that there's potentially

some services that you can access or,
, invite in that are, more for in reach

into your clinic as opposed to hiring
somebody from outside the community.

I think those are really important
points to think about in that sort

of step wise growth of a team.

And through that, you're going
to figure out what the different

roles are that you need.

In your team, and then how they
will start to work together, but

also how they connect to different
resources in the community to

Sarah: And I know I said I wasn't
going to talk about team mapping

because it's not all about team
mapping and we've made, I've made it

like three episodes into this season.

Morgan: including the intro.


Sarah: but I think when we're thinking
about roles and connecting with

existing community services and what's
out there in the community and how

our team's going to be integrating
to meet those patient needs.

A tool like team mapping
can be really useful.

Morgan: absolutely

amie_1_12-20-2023_110634: So.

Things like shared goals.

How are we gonna work together?

You know, of course, I, I put, the issu
team mapping process as, as number one up


I, I've been part of that
process, it'ss really great, um,

to, to, look at role clarity.

know, we talk so much about role
and scope and there's a real,

you know, sort of still a lack of
understanding of each other's roles.

Sarah: And I think, as we've already
mentioned, there's a ton of great

resources related to this stage of the
learning pathway and it really covers

a lot when you think about, you know,
how are you going to communicate as a

team, we've got the roles, discussions,
who's going to make up a team To meet

the needs of a population, there's
another really important piece here,

in this, uh, stage of the pathway,
and that really is team readiness.

amie_1_12-20-2023_110634: the stage
also helps you look at team readiness.

Are we ready to work as a team?

Do I have things set up?

do we have things set up, like space?

Is there space for us to work?

Where will we work?

if we're not co-located, what's.

The plan to communicate.

Sarah: And I love diving
into this question of, are we

really ready to work as a team?

This is a big change.

Morgan: It's a big change.

we're onboarding into our team, Sarah,
several people right now this week.

it's exciting, it, has lots of
potential, and it's also, a lot of,

positive stress and, uh, effort.

I think, it'll be worth it, absolutely.

And for the new team members, when
they listen to this, we're super

excited to have you on board.

And, you know, I think for people
who might be in practice and,

and working incredibly hard.

They need to know that there's that effort
and that balance and know that they've got

the capacity before they make a big jump.

Otherwise, it could be really difficult.

more than a dozen years ago, a new
nurse was joining our practice and

was joining particularly my practice.

And I was in a CHC, a different CHC, where
I had technically protected time work

with that new person and bring them on
board and introduce them to my practice.

And I wasn't losing money
as a fee for service doctor.

But to find the time,

Sarah: Mm hmm.

Morgan: given the patient demands of a
full practice panel, was really hard.

Sarah: And I think, something
that we hear repeatedly is the

challenge of making the time.

one of the things that I wanted
to highlight here as a, as a great

resource, thinking about, again, the, the
challenges of time and how these things.

And sometimes there can be things you
can do as an individual, to get a sense

of what that readiness might look like.

There's a team readiness checklist
as part of the, pathway that

I think is really interesting.

it's a 10 item checklist.

It can help people get started.

Or if, like Morgan in your example,
you know, you've, you've started,

but you're continuing with the day
to day work and maybe the time to

sit back and think about the team
has kind of fallen off a little bit.

I think it's also a great tool for
getting restarted in this space.

and it's just a simple checklist that
asks a series of questions, that can

get you thinking about, you know,
are you ready to work as a team?

Are you ready to change?

And it's not always the best time.

So putting that out as well, right?

Morgan: Yeah.

it could be in a little while.

And what I found with that checklist
is that it actually makes the process

easier if you've gone through it and
started to prep some of those things.

So it's not just an assessment,
but it helps you get ready.

If that's your intention.

there's sort of two benefits to that.

each checklist item is a different
question and sort of just go

into the weeds a little bit.

it does identify gaps, either knowledge
or what you prepared, like, Oh, I knew

I needed to do that, but I haven't yet.

Maybe I should.

So, if you've already got a team, like
does every team member know their role?

And the role of other team members.

I think that's an important thing.

If you don't have a team yet,
you know, it's about do you know

what the role is going to be?

do you know how to make decisions
around care for patients?

Who's responsible?

And what is the, the
handover parts to that?

That's something to consider.

And it's one of the questions.

There's a question around
quality, uh, assurance mechanisms.

I hate the words quality assurance, but
the idea of how are you working together

and, and, you know, where are those
checks and balances across the team,

where necessary when working together,
and sharing care for a patient so that

things don't fall through the cracks.

Sarah: And I think, what the checklist
does really well is provide a little

bit of a framework for teams or leaders
within teams to work through to support

thinking through the processes that are
going to move culture change forward

and specific questions that target some
of those big coordination questions.

Morgan: yeah, I think, these
are big questions, Sarah.

and even just sort of going through
that list, I'm already working in

a team and I'm like, my heart rate
went up a little bit, like, Oh

yeah, there's a lot to do there.

in terms of, uh, what to do, if you
want to do anything after listening to

this episode, going into that checklist
is a great place to start and picking

one of those things that might be a
gap and just, jotting down some notes

about how you might address that.

You don't have to address it
yet, but even just articulating

what that gap is for yourself, it
would be a great, place to start.

Sarah: So what are our Calls
to action for this episode.

Morgan: well, I think that was it.

I want to pick one thing
from that checklist and start

to plan what that could be.

If there are other things in the
pathways that you can look at as

well, there's lots of resources there.

We just picked this one to today.

but go in there and have a look
and see which one might be most

appropriate for what stage you're at
and what you need to look at next.

Sarah: And if you're looking for
something and you can't find it, it's

missing, reach out to us and let us know.

You can email ISU at familymed.



We're always really happy
to hear from people.

We love feedback.

So let us know what you think.

Let us know what you need and
we'll work on making it happen.

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
this episode of team up and we will

talk to you in the next episode