New primary care social worker program in FNW region replicates successful ”Nurse Debbie" model

Feedback from GPs and the success of a joint program of the Fraser Northwest division and Fraser Health have led to a new team-based care pilot project in the region. 

As of March 1, 2018, the division’s GPs have exclusive access to a Fraser Health social worker, who can assess and intervene in complex situations that may include challenges such as barriers associated with the social determinants of health (e.g., culture, education, poverty), disability and loss of independence, high-risk behaviors, and compromised ability to remain at home.

The social worker can assist patients to access community resources as well as mental health and substance use resources and services available through Fraser Health and community non-profit organizations.

Eligible patients must consent to receiving support from the social worker, be 19 years or older, and reside within the geographical boundaries of the Fraser Northwest division.

The division and health authority developed the program in response to local GPs identifying social work support as one of their patients’ greatest needs. It is the partners’ next step toward improving local access to allied health resources in the community.  

The program builds on the existing Community Primary Care Nurse (“Nurse Debbie”) model that is expanding within the Fraser Health region. GPs can even use the same referral form created for that program, which is available and active on Pathways.