The Pacific Northwest Prehab-Rehab Metabolic Syndrome Cardiovascular Project – A Shared Care Initiative

The Pacific Northwest Prehab-Rehab Metabolic Syndrome Cardiovascular project is a family physician led, innovative, and cost-effective approach that aims at preventing Metabolic Syndrome (MetS) and Cardiovascular Disease (CVD) by informing and addressing it to patients within Primary Care services.

Achieving this at an early stage will improve patients’ outcomes and reduce eventual health care costs that are lacking provincially.  The project lead by Family Physicians Dr. Brenda Huff, Dr. Greg Linton and Dr. Onuora Odoh also addresses the issues of coordination in primary care and is patient-centered in achieving efficient prevention of common chronic diseases.

The focus of this project is to design and provide culturally-safe prehab supports for patients who are at risk of developing Metabolic Syndrome or are currently living with the chronic condition; hence providing rehabilitation supports to those suffering from Cardiovascular Disease.

For the “rehab” part of the project, the use of kinesiology, physiotherapy and diet has been put into action with a great partnership with UBC’s Faculty of Kinesiology, along with Dieticians, and local Dental Hygienists. These primary care supports will sometimes need to be complemented/coordinated with additional levels of care that may include specialty care components such as support, consultation and referral. In order to ensure these secondary components of care are in place to properly support patients in primary care homes we are working together with Endocrinology, Cardiology, Exercise Medicine, Pediatricians, Internists, and other Specialty Services to co design the secondary services for patients with Metabolic Syndrome and Type 2 Diabetes.

Our hope with this project is to create a strong collaboration and strengthening of the relationships between primary care providers, interprofessional teams and specialty care to design an innovative Metabolic Syndrome and Type 2 Diabetes care pathway process that can be replicated in other communities provincially, facilitates shared care planning, best practice approaches, and problem-solving sessions between Endocrinologists, Cardiologists, Exercise Medicine, Internists, and Primary Care Providers. We have to achieve improved understanding of each other’s role, what information needs to be shared more effectively from a patient perspective, to set guidelines about roles and responsibilities and how they will work together to provide care.