Burnaby Division of Family Practice

Shared Care


The Burnaby Division of Family Practice works with Shared Care (a Joint Collaborative Committee of Doctors of BC and the BC government) to support the collaboration between Family and Specialist Physicians and partners to improve the coordination of health care for patient populations. We are grateful for the work done by all our physicians, nurse practitioners, nurses, allied health, health authority, community partners and patient partners who have supported these projects. 


If you are a physician interested in joining or leading a Shared Care project, please reach out to our staff with your area of interest - new project ideas welcome! (please see contact details below).



Current Projects


Sharing Care with Community: Supporting a Patient-Centered Approach to Mental Health Care
Project Status:  Project End
The project goal was to develop, pilot, launch and disseminate the Mental Health Community Connectors (MHCC) approach to better integrate community, PCN and Mental Health (MH) care providers to support the mild-moderate MH needs of Burnaby residents. The aim of this initiative was to increase awareness of local supports, and provider confidence and satisfaction to support the MH of their patients/ clients.
A community resource directory was developed HERE listing MH resources, as well as local supports related to the social determinants of MH. 
A 4-hr training for front-line community providers, and a 1-hr training on how to use the Burnaby resource directory was also developed. More information can be found HERE


Adults with Intellectual and Developmental Disabilities (IDD): Improving Medical Visits for Patients and Providers Across the Spectrum of Care
Project Status:  Project End
The project aimed to develop unique sets of resources and engagement activities for providers and patients to enhance patient-provider communication, improve the coordination of care, and increase patient and provider knowledge of medical and community supports. As part of the project, the following resources were developed:
  1. ​pdf iconAbout My Health” form – summarizes patient’s health history and communication preferences.
  2. ​pdf icon My Healthcare Visit” form – supports patients to better prepare for, communicate at, and reflect on a specific medical visit.  
  3. ​pdf icon My Healthcare Visit Tracker” form – helps patients keep track of multiple medical visits.
  4. ​pdf icon Poster for medical office with QR code to download the forms above
  5. ​pdf icon Physician FAQ Handout on mental health and IDD – a summary of the Q&A from the panel discussion at the October 2023 physician hybrid event “Mental Health and Intellectual and Developmental Disabilities – Improving Burnaby Transitions in Care, Communication and Integration”.
Patients can also download fillable versions of the forms and access a digital repository of local resources from the Burnby PCN website HERE.


Addressing Communication and Language Barriers for the Provision of Culturally Appropriate Medical Care
Project Status: Project Phase
Communication barriers, especially those related to language, can lead to system inefficiencies and negative impacts on patient safety. Through partnership-building, leveraging existing resources, and training and engagement opportunities, this project aims to better support Burnaby residents, with a focus on families with language barriers, to experience better communication with their medical providers by increasing access to and utilization of appropriate interpretation supports. Additionally, the project aims to increase patient understanding of the healthcare system and increase both provider and patient confidence and satisfaction related to medical visits, especially when using language supports.
Strengthening the Transition from Acute to Primary and Community Care for Burnaby Patients with Substance Use Disorders
Project Status: Project Phase
The project team aims to implement a localized, longitudinal, integrated and holistic approach to better support the transition of care for patients in Burnaby with Substance Use Disorder (SUD) from acute to primary and community care. This includes modelling pathways between Burnaby Hospital, the Urgent Primary Care Centre, and community clinics, and strengthening physician capacity to provide care through trauma-informed training, and resource sharing. The project also aims to strengthen the community response and address stigma to better care for community members with SUD.
Sharing Care Collaborative: Developing Pathways Between Health and Social Programs
Project Status: Planning/ Needs Assessment Phase
As part of a broader vision to develop an interconnected system in Burnaby within and across sectors, this project aims to promote health and wellbeing by extending access to supports that address the social determinants of health. The project seeks to streamline referral pathways from Family Physicians and Hospitalists to appropriate community supports while simultaneously creating channels for community members to access the assistance they require, precisely when it is needed.  By exploring avenues to support acute, primary and community care providers to collaborate, the initiative aims to better empower physicians to address the social, economic, and psychological factors affecting patients' health.


Improving Access to Screening for Early Detection of Metabolic Conditions and Cancers
Project Status: Planning/ Needs Assessment Phase
Individuals who are not attached to a family physician or nurse practitioner have limited access to important preventative screening. This leads to delayed treatment and poorer health outcomes, including higher morbidity and mortality, resulting in increased health care costs. The proposed initiative will begin by understanding current pathways and barriers to access timely preventative care, identifying specific metabolic conditions and/or cancers to focus on for this project, and exploring opportunities to improve access to appropriate preventative care. By leveraging existing resources, building partnerships, and developing knowledge-sharing opportunities, this initiative will work towards improving equitable access to preventative primary care.


Improving Communications Between Family Physicians, Community Health Nurses and PCN Allied Health for Shared Patients
Project Status: Planning/ Needs Assessment Phase
Enhancing care for primary care patients involves improving communication between Family Physicians (FPs) and the larger care team. This project aims to bridge the gap between FPs, their local community health nurses (CHNs), and their local Primary Care Network (PCN) Allied Health (AH) clinicians to support team-based care in the primary care environment for their shared patients. By building awareness of each other's challenges, supporting face-to-face meet and greets, fostering better communication, and incorporating stakeholder feedback into these processes, the project will build a strong foundation for FPs, CHNs and PCN AH to work collaboratively together. 


Completed Projects


Pathology Consult Service
Project End: Feb. 2023
A consult service was piloted for Burnaby FPs/NPs to support access to pathologist- guided decision support for the diagnosis and treatment of patient hyponatremia (low sodium levels). The consult service is still available– the listing for this service is on Pathways: pathwaysbc.ca/clinics/2208
Click HERE for a handout for FPs/NPs answering common provider questions on lab processes.
Click HERE for a patient resource answering common questions on how to prepare for a lab visit. Downloadable handouts are also available in English, Arabic, Farsi, Simplified Chinese and Tigrinya.
Click HERE for a webinar with a Burnaby Lab Physician, a Lab Expert from LifeLabs and members of the community discussing common inquiries on lab testing and procedures.



Azra Bhanji
Shared Care Project Manager
Burnaby Division of Family Practice


Natasha Cholowsky
Shared Care Project Coordinator
Burnaby Division of Family Practice


Huyanne Le
Community Program Manager
Burnaby Division of Family Practice


Veronica De Jong
PCN Manager
Burnaby Division of Family Practice