GP-RN partnership in Maple Ridge supports overall patient health

Dr. Ursula Luitingh, Family Doctor, Maple Ridge

I’ve been a GP practicing in Maple Ridge since 1992. When the government started to realize that there are problems with unattached patients, and when I saw unattached patients coming to walk-ins and not getting proper care, I saw an opportunity to work with the Division to collaborate with partners and colleagues to move those numbers down and provide the care these patients need. This is a project where I thought we could really apply a solution as a community, using local talent.

One of our initiatives was aimed at improving capacity in a physician’s office. We do a lot of paperwork, patient education about their care, and generally ticking boxes to make the patient’s journey more enjoyable and informed. A lot of the time, a patient’s health is impacted by other things: their finances, loneliness, their ability to communicate about their care needs, and accessing support systems. When it comes to dealing with our complex patients, with heart failure, diabetes, COPD, a lot needs to be done to care for them.

As part of A GP for Me, we brought a nurse into our practice. The nurse has been very well-received by the patients and the MOAs also like her. It has created a good working environment and has helped patients to improve their overall health by getting involved in the community, finding the resources they need, getting exercise and building stronger connections with other seniors.

The nurse identifies the overall needs of a patient and connects them with the resources in the community. She talks to the patients about their lifestyle, how they eat, and what services they know about. Her role is integral in meeting patient needs.

There are not enough people to fill the gap between what I can do as a GP and the things a person needs in the community. I have the confidence the nurse has the training and clinical expertise to work with the patient to make sure they understand and can follow their care plans.

The most significant change I’ve seen is when a patient in his 50s had a stroke, and she worked with his family to help address his needs. He couldn’t go up the stairs, and his wife was taking him to the community centre to shower. The nurse identified this as an issue and worked with the family to identify related concerns, including finances, with the patient. She looked into the system to see where he could receive support as a stroke patient.

This is significant to me because this means the total health needs of a patient are being met. I know that I can defer things to her and I don’t need to worry about whether the patient will know what to do and whether they will follow the instructions. After I tell a patient their results, she has the time to talk to the patient about whether they saw their diabetes nurse or if they’re using their puffer properly.

Long-term, this is becoming a partnership. We are also proving the business model and finding that having a nurse in practice doesn’t cost the practice any more to provide this improved care.