Collaborative Team-Based Primary Health Care

Team-based care is a model of health care delivery where many health professionals work together to support a patient’s needs. When health care providers work in teams, they can build on each other’s unique combination of knowledge, skills and experience offering better coordinated care to their patients.

The College of Family Physicians of Canada (CFPC) has endorsed the Patient Medical Home model of primary care, where physicians, nurse practitioners and allied health professionals work together to meet patient needs. It has been described as the place patients “feel most comfortable presenting and discussing their personal and family health and medical concerns” (College of Family Physicians of Canada).

The Government of New Brunswick is investing in team-based primary care by:

• supporting the work of the Regional Health Authorities (Horizon Health Network and Vitalité Health Network) who are building local family health teams in communities across the province. 
• supporting the work of Family Medicine New Brunswick teams.

The role of the patient is changing. Advances in technology allow patients to take a more active role in making decisions that affect their health with increased access to “official” health records and the wide availability of apps to monitor various symptoms and conditions.

New Brunswickers are able to access lab results, medications, immunization records and imaging reports through https://myhealth.gnb.ca

Every day New Brunswickers receive primary health care services from a variety of health care professionals in their communities.  Some examples include visits with:

• Family Physicians and Nurse Practitioners
• Clinic Nurses
• Pharmacists
• Physiotherapists
• Dietitians
• Mental Health Practitioners

While access to primary care is important, safe and effective care requires deliberate organization of patient care and sharing of information among all the participants – patients and service providers.

New Brunswick’s Primary Health Care system has traditionally relied on family physicians taking overall responsibility for directing and coordinating the care and management of patients.  In recent years, nurse practitioners have taken on this role for some patients in New Brunswick.

Most recently, team-based models of primary health care have been identified as the gold standard for complete and continuous care.  Teams are a helpful way to address the increasingly complex needs of patients and the shortage of health care professionals New Brunswick is currently facing.

Building collaborative primary health care teams is a work in progress. Each team is unique and may include a number of different health professionals, working together to provide high quality care to patients.

Patient role

Patients are at the center of team-based care. Health care professionals see you as a partner and will work with you and your family to make the best decisions about the right care for you.

As a patient, your role in the team will be:

• contacting your care team first for routine primary health care needs
• sharing your health concerns  
• asking questions if you do not understand something about your care plan (making notes before your appointment may help with this)
• keeping an updated list of medications
• asking for instructions to be written down if that’s helpful to you 

Primary Care Provider role

Family Doctors and Nurse Practitioners are the health professionals most commonly recognized as primary care providers in the province of New Brunswick and are essential members of the primary health care team.

Some examples of health care professionals who may be on your primary health care team include:

• Family Physician
• Nurse Practitioner
• Medical Office Assistant
• Dietitian
• Licensed Counseling Therapist
• Licensed Practical Nurse
• Occupational Therapist
• Pharmacist
• Physician Assistant
• Physiotherapist
• Psychologist
• Registered Nurse
• Respiratory Therapist
• Social Worker

Every patient in New Brunswick should have a family physician or nurse practitioner who:

• Is their first point of contact within the system.
• Practices as part of a team.
• Is available to them within five days of their primary care need.
• Uses an electronic medical record, shared within the members of their team.
• Provides them with after-hours access, as part of their team.
• Regularly involves other community-based allied health professionals (like occupational therapy, social work, and pharmacists) in their care as needed.
• Provides access either virtually or in-person. The modality must be clinically appropriate for their need; if that is satisfied, the choice of access should be whichever is most preferred by the patient.
• Provides equitable services in their community as are provided elsewhere in New Brunswick in communities with equitable needs.
• Practices patient centred care/co-created and customized to each community.
• Provides physical space suitable for education, learning, and ongoing training.
• Follows outcome-based system evaluation and performance measurements.