Integrating Registered Nurses Supports Team-Based Care at Fraser Street Medical

We celebrate Canada’s National Nursing Week (May 8-14 2023) by visiting the Fraser Street Clinic where a Primary Care Network (PCN) Registered Nurse (RN) is contributing to a better experience for patients.

“It can be complex, providing care as a team,” says RN Jana Sunuwar, “but it’s very rewarding.”

Sunuwar is among a group of Registered Nurses who are co-located at family practices in Vancouver as part of the PCNs. Together with Medical Director Dr. Daniel Ngui and the rest of the staff at Fraser Street Medical Clinic, Sunuwar aims to provide better care for patients through utilizing a team-based approach.

“It’s very important to me that we aspire to be the patient’s medical home and the hub of where they receive services” adds Dr. Ngui. “Having a collocated, interdisciplinary team at the clinic is vital to promoting this.”

Vancouver Divisions of Family Practice and Vancouver Coastal Health have partnered to integrate RNs into community primary care clinics as part of the PCN in order to increase education and support for patients, build capacity for primary care providers, and support team-based care. The PCN RN also provides a strong connection to other PCN allied health supports.

Team Approach Facilities Expanded Capacity

Practicing medicine is very demanding and the more typical siloed approach often places limits on capacity. Dr. Ngui finds that through teamwork, the clinic is able to operate at a level that’s even greater than the sum of its parts.

“By having nurses, clinical pharmacists, and a highly trained chronic disease management staff, we’re able to maintain thousands of patients,” he says.

For RNs, the arrangement provides an opportunity to utilize their capabilities in a dynamic environment.

“Obviously as a nurse I would love to work to the fullest scope of my practice,” says Sunuwar, highlighting her enthusiasm for the project. “There are many overlaps between the support RNs and family doctors can provide.”

Sunuwar believes that the results could benefit both the clinic and those who utilize it.

“I hope that down the road we see happier, healthier patients in the community as a result of this model,” she says. “I’m optimistic.

Benefits of Roster-Based Management

Dr. Ngui believes that the roster-based management approach allows the clinic to better meet the needs of a wide range of patients, including those with chronic disease.

“We’re gaining efficiencies to better manage a roster or registry of patients, many of them with specific chronic diseases, such as diabetes” he says. “This was traditionally done by a single clinician, but now our chronic disease coordinator helps to identify lists of patients with clinical issues, nurses provide 1 on 1 patient support and chronic disease education, and pharmacists provide medication reviews. As a result, physicians can improve efficiencies when managing stable chronic diseases and gain capacity to take on new patients or deal with same day visits. It multiplies the quality of self-management education and the time that patients are given to address their own questions.”

One way that Sunuwar is able to assist patients is by facilitating better attention for those with care gaps.

“Patients may need more complex needs to be addressed during pharmacist medication reviews,” she explains. “Physicians need help with advanced care planning with complex care visits. I’ll go through patient charts and identify overdue lab work and review missing proven interventions. I’ll communicate with patients and send them their lab work or information to review ahead of their visits.”

“Certainly having a nurse in the clinic can prevent burnout for providers,” says Dr. Ngui.

A Challenging Role and Great Opportunity

“Every day I see new things,” says Sunuwar. “It’s challenging, but very exciting. We’re always looking ahead and trying to improve the workflow in the clinic, discovering ways to become more efficient, more effective, and provide better quality care for our patients.”

Dr. Ngui describes the process as a difficult, but rewarding, one.

“As a team we need to have a clear idea of what our common mission is and collaborate on team member roles and responsibilities,” he says. “It takes leadership to facilitate teamwork and dedication to strive for excellence. It’s important to have regular team communication and for everyone to be committed to the singular focus of improving care for all patients in the most efficient and effective manner possible.”

Thinking About Potential Role of Nurses

Sunuwar is adamant that physicians who utilize the services of an RN in their clinic should think big. She cautions against falling into a rut and failing to make use of the talents that nurses bring to the table.

“There’s a lot going on each day,” she acknowledges. “It can be easy to look at the PCN nurses as additional staff members and assign them administrative tasks and so on. I would prefer to look at the bigger picture and focus on ways that nurses can improve the quality of patient care. Physicians should be open minded to the different ways they can work with an RN.” Dr. Ngui also believes that great results await those who truly utilize their team.

“Clinicians often think about the path of least resistance, which is providing one-on-one support,” he says. “I would challenge that. Moving beyond one-on-one patient care is where the magic occurs. It’s worthwhile to take a step back and not just look at the tree, but the forest, and look for ways that team members can help physicians manage the forest and address patient care gaps systematically.”

Both Sunuwar and Ngui stress the need for more support if forward momentum is to be sustained.

“As PCN nurses, we are trained on so many things, but there are still limitations,” says Sunuwar. “We need more training and more resources, as well as funding systems that support team-based care and roster management.”

Beneficial to Clinics, Nurses and Patients

The doctor and nurse both spoke positively about the team-based approach, describing it as something that benefits everyone involved.

Dr. Ngui feels that positive team members enhance the experience for both patients and providers. Sunuwar feels that having additional team members offers more opportunities for patients to share their fears and emotions.

“My role is always evolving,” she says. “When you work as a MedSurg nurse, the role is predictable, but when you come to primary care, you have to believe in teamwork and be flexible. Even though there are specific roles, we always have to adapt to serve patients. I have a great relationship with the doctors and staff at the clinic. It’s a great opportunity when nurses get to have an experience like this.”

Dr. Ngui is clearly keen to expand the usage of the roster-based management approach.

“As medical director of an interdisciplinary clinic, I believe that a team-based approach allows many hands to transform heavy work into lighter work,” he says. “We’ve certainly dipped our feet in the proverbial waters of team-based care, but now, knowing that it’s a beautiful lagoon in a tropical paradise, you want to take the plunge!”