When a client claimed that the wounds on her body were caused by equipment, the Richmond Home Health team decided to schedule a care conference with the client’s GP to share their concerns and work together on a care plan.

“We were concerned that the wounds were caused by self-harm,” says Christina Prociuk, a social work case manager. “Her story seemed off.”

Jane Pratt, an occupational therapist, says a colleague validated their concerns during a team huddle. “We immediately decided to get the GP involved,” she says.

GPs are part of the team

Working closer with family physicians is a growing trend in Home Health across VCH. A 15-minute GP care conference can be over the phone or in person, with the goal of exchanging information and collaborating on a shared care plan that is client-centered and integrates the expertise of the entire care team.

Last year, VCH teams held over 440 care conferences with family physicians.

The care conference they booked for this particular client included Jane, Christina, Emily Sy, a home care nurse, and the client’s GP.

“Talking with the doctor helped us put together a more realistic view of what was going on in the home,” says Christina.

Better health outcomes

“This client is complex in her physical and psychological needs and the care conference brought all of our findings together,” explains Jane. “For instance, the GP was unaware of the client’s history of self-harm. Now, her wounds have healed and we are more aware of the psychosocial make-up of her family life.”

Armed with new knowledge, the GP decided to meet with the client every six weeks in her office, without her parents, to encourage her to get out of the house. Emily and Christina also went together for a follow-up home visit and let the client know they were partnered with her family doctor.

Making the time

Scheduling a GP care conference with a group of people can be a challenge but Jane holds time in her calendar because of the value it adds to client care. “We’re using care conferencing at this point to discuss dilemmas,” she says. “A team approach helps along the way—I’ll make time for it.”

“For me it’s an opportunity to speak candidly with other professionals to express weaknesses and strengths and to come up with a plan,” adds Christina. “It builds a strong relationship with the GP.”

For any clinician who may doubt the practice, Christina says, “Just try it. It’s beneficial to the client and creates a better continuum of care.”

What do other clinicians think?

Three clinicians at Robert & Lily Lee Family Community Health Centre in Vancouver share their views on GP care conferencing .

For more information

For more information on GP care conferencing across the region, visit the Home Health Redesign section on VCH Connect. [internal link]