Our Health is OUR Health ~ PCN is here to help us

By Pam Jones, Editor.

Primary Care Network and What’s In It For You

dr-siray-imag2484Our local Primary Care Network (PCN) is celebrating its 10th Anniversary this year and has some important updates to share with you.

Sounds exciting; anniversaries are usually worth celebrating! But wait a minute… What is PCN? How does it affect me? Basically, why should I care? Let’s take a closer look while I attempt to demystify this part of our mystical medical profession and services.

Traditionally, we have a ‘family doctor’ and, literally, everyone in our ‘family’ goes to see this one doctor. We then expect him or her to keep track of all the bits and pieces and details about us and our health – not just you though, all two, four, or maybe eight members of your family. But hang on, while we might only have one family doctor, that doctor certainly has more than one family!

Good grief, so how many people is each doctor expected to track and REMEMBER all of these details for? I’m sorry, my math skills don’t go that high, but it’s A LOT! In fact, the PCN region encompasses 130 physicians and about 110,000 patients.

But it’s also not just about tracking and remembering, there’s a ton of smaller tasks that must be done on a regular basis too that there just isn’t enough time for with the increasing number of patients per doctor. Things like weighing and measuring, taking our blood pressure, and other routine procedures.

Medicine is changing – a lot – and it’s in realizing that physicians can’t do it all alone anymore that has spurred a greater movement towards a team approach. This realization is what has evolved PCN (Primary Care Network) and it’s the changes in how your medical needs are being (and will be) met that make this information both interesting and valuable to you.

Dr. Brian Siray, from the Foothills Family Medical Centre in Black Diamond, sat with me and shared the concept of the PCN. He explained how it operates and how it provides a better health care system for all of us. Our rural PCN area, which is mainly south of Calgary, extends all the way down to Claresholm, plus it covers east towards Strathmore and then, oddly enough, does a loop as far west as Lake Louise. Dr. Siray is the Black Diamond representative on the PCN for our local clinic and he then gets together with the representative doctors from other area clinics once per month to make decisions.

Initially, the PCN had government funds that each area would decide what to do with. They have now evolved into a much more organized approach to the management of funds and how they can be utilized to more effectively assist with chronic disease.

PCN is in place to assist Primary Care Physicians, (aka: our family doctors who work in each community), gain access to funding that will help to create more of a team environment. In the Foothills Family Medical Centre this has taken on the form of four team members specializing in different areas.

Their titles are: Panel Manager, Chronic Care Manager, Referral Specialist and Chronic Disease Nurse. The main idea of a team approach is to be focusing on preventative care rather than just reacting to someone who is sick.

So let’s take a closer look at what these four positions look like and how they contribute to a team environment in order to assist our family doctors.

Panel Manager

In the Foothills Medical clinic, the Panel Manager is a person who actually manages the patient records and keeps them up-to-date. There are many patients on a doctor’s list that the doctor might not have seen for five years because they are healthy so the question becomes are they still a patient of this doctor or not? It is part of the Panel Manager’s job to touch base with these patients and encourage them to make an appointment for a general review to make sure that things are in order, updating the clinic’s computer, getting the social situation: are they smokers, drinkers, are they at risk of developing diseases – the idea again is to be focusing more on preventative care rather than reacting to someone who is sick.  This is also applicable to children who have now become adults. They came to the doctor with a parent, now they’re adults, are they planning on coming to this doctor or have they in fact moved away?  Dr. Siray explained, “We’ve moved away from the old traditional way of you going for an annual check-up and switched to what we call a Periodic Health Review.” The Panel Manager is instrumental in the successful implementation of this model.

Chronic Care Manager

“There are certain medical conditions, things like diabetes, hypertension, COPD, psychiatric diseases, addictions, and more, that as family physicians we are by the government to do what we call Annual Chronic Care Plans for,” said Dr. Siray.

Creating an Annual Chronic Care Plan means that you sit down with your physician and review what illness you have and what your goals are for the next year to allow you to stay healthy or become healthier. “Our Chronic Care Manager has the formidable task of keeping all of those people coming for their follow-up visits and their annual reassessment of their Chronic Care Plan. It’s quite an undertaking and basically a full-time job. So that is something that is part of the team at our clinic,” Dr. Siray continued.

Referral Specialist

This is the third member of the team and the person that does all of the physicians’ referrals, co-ordinates all of their referrals and all of the testing being done, makes sure they’re getting the results and makes sure people are getting in to see specialists – so again it’s a full-time job co-ordinating that linkage with specialty services. The current buzz word ‘linkage’ has a lot of work attached to it. How do family physicians link to the specialty services more effectively? The Referral Specialist takes the time to help ensure that more appropriate referrals are being made which in turn should help to reduce some of the long waiting times we have seen in the past.

Chronic Disease

This is a specialized nurse who is a registered psychologist that also understands chronic disease conditions like Diabetes, Hypertension or COPD. They sit down and have more time to talk with patients about changes in lifestyle, changes in how they are managing their diseases and conditions. The goal in having this person is to use techniques to try to fine tune and motivate people to want to make changes. It is almost impossible for physicians to achieve this in a short ten or fifteen-minute appointment. “This is a new area that we’re going into and we’re quite excited about that because we think we can do a lot better job if we have a lot better help in that area,” said Dr. Siray.

At the end of the day, our health is just that – OUR health and it is incumbent upon us to take charge of our health. Our doctors can only do so much and we have to take the responsibility to help them by staying educated and talking to them and their team.

Sitting in the waiting room at the Foothills Family Medical Centre is also an education – the flat screen television on the wall shares a variety of tips and general information; take advantage of it and listen to the guidelines it is providing.

As 2016 draws to a close, consider adding your health to your prioritized list of things to improve in 2017.