This Shared Care BC funded project, led by Family physicians Dr. Onuora Odoh, Dr. Brenda Huff, and Pediatrician Dr. Zaneta Lim, along with our partners, Dr. Robert Boushel (Director of the University of BC’s Kinesiology Department), and project partners Charlene Webb (Northern Region Indigenous Health Director), Dr. Eli Puterman, and Dr. Guy Falkner is to create an integrated care pathway to coordinate complex care for pediatric patients living in British Columbia’s rural, remote, geographically and weather challenged Pacific Northwest. This project hopes to inform and complement local primary care transformation work. The physicians’ care pathway development and quality improvement work that will be addressed through this project will be sustained by a natural incorporation into physicians’ workflow moving into the future.
With a commitment from physicians, we are creating new processes, testing them, and implementing over the duration of the project. We anticipate that there will be a natural progression to this adopted workflow in patient medical homes as well as through the primary care networks.
A common overall strategy to Coordinate Complex Care for Families Living with Obesity is needed to improve patient outcomes and reduce health care costs is lacking provincially, both at a practice and program level. Standardized definitions of services, treatment modalities, technologies, clinicians, and other necessary patient-care resources are lacking especially in rural and remote communities and regions such as the Pacific Northwest.
Through this project, the focus is to develop and provide necessary care pathway supports to pediatric patients and their families who are at risk for developing comorbidities stemming from obesity/metabolic syndrome. Healthcare professionals advise that the most effective and efficient supports for a patient with Metabolic Syndrome, Type 2 Diabetes, and Cardiovascular Disease (CVD) risk are a proactive, patient focused and structured dietary and exercise lifestyle modification treatment program that is led by the patient’s Family Physician and supported by appropriate medical specialist, in an inter-professional team care model that includes a registered Dietitian and Kinesiologist and exists in a primary care setting.
Currently, the BC blueprint for the Patient Medical Home is lacking these fundamental patient care pathways and structures. Through this project we are hoping to develop strategies to provide an evidence based local pathway to sustainable supports for pediatric patient and integrate these strategies as cornerstones for five primary care networks currently under development in the Pacific Northwest. The main outcomes of this project are for pediatric patients, families, caregivers, and providers to provide a pediatric care pathway to reduce the risk factors for Metabolic Syndrome, Type 2 Diabetes and other co-morbid conditions, which will improve health outcomes for pediatric patients. It will also inform and complement local primary care transformation work.
The physicians’ care pathway. This project will help to inform and complement local primary care transformation work.