Care conferencing enhances partnership between GPs and home health staff

Care conferences are bringing family physicians and Richmond Home Health staff together to exchange information and collaborate on care plans for their shared clients. Jane Pratt, an occupational therapist who is part of Richmond’s Home Health team, is excited about the new initiative and feels it’s long overdue.

“For clients in the community, their GP is their main anchor,” says Jane. “When the GP is part of the community care team in a care conference, our findings and concerns are heard, and we can jointly come up with a care plan and a way to move forward.”

GP/interdisciplinary care conferences generally take about 15 minutes, either in person or by teleconference. They are scheduled in advance with the GP, to ensure all participants have dedicated time to focus on the client. The goal is to help the client stay in their home as long as it’s safe to do so, with appropriate supports.

Natalie Choy, a registered dietitian with Richmond’s Early Supported Discharge program, knows firsthand how complex clients’ health issues can be. Her clients are living with heart failure, stroke or Chronic Obstructive Pulmonary Disease and need help transitioning from the hospital back into their community.

“I see care conferencing as an emerging partnership between Home Health clinicians and GPs,” says Natalie, who has joined several GP care conferences since the initiative began. “There are many professionals who can bring their expertise to a care conference – we have a nurse, occupational therapist, physiotherapist, registered dietitian, respiratory therapist and speech language pathologist.”

While most health care providers feel very positive about the practice, GP care conferencing is still in the early stages.

“I look forward to the time when care conferences will be the norm, not the exception, in our practice,” Natalie continues.

“Some clinicians feel there is not much difference between a care conference and just alerting the GP for issues like a change in medication,” explains Jane, who visits clients in their home for safety assessments and to make recommendations for alternative functional strategies and use of equipment. “But I feel conferences are for larger functional issues that we’re seeing in the home that the GP would not be aware of, such as physical and environmental barriers, non-compliance or inability to cope.”

So far, the health care providers participating in GP care conferencing have seen how the practice helps with proactive coordination and continuity of care, avoids the repetition of any interventions, and gives each other insight based on personal expertise and experience with the client.

“I feel it’s so fundamental to my job,” says Jane. “I’m here to visit clients and do my best for them.”

GP care conferencing in Richmond, Vancouver and on the North Shore is supported through the Integrated Primary and Community Care initiative at VCH.

For more information about GP/interdisciplinary care conferencing in Richmond, contact Teresa Suranyi at 604-233-3144 or Teresa.Suranyi@vch.ca.