Team-based care: The best thing about practising on Gabriola Island

Residents of Gabriola Island banded together to build a leading-edge community health facility through volunteer efforts, fundraising, and collaborating with local partners and stakeholders when a lack of available clinic space began to impact the island’s ability to recruit new doctors and health care providers. That theme of collaboration continues through the very successful team-based care model now functioning within the clinic, which has exceeded all expectations for success since opening its doors in 2012.

The Gabriola Community Health Centre is owned, maintained, and administered by the Gabriola Health Care Foundation—a non-profit society formed by island residents. While the centre was built prior to the formation of the Gabriola Island Chapter of the Rural and Remote Division of Family Practice, the division and chapter have been instrumental in initiating a part-time social worker, telehealth videoconferencing equipment and support, development of the Health and Wellness Collaborative and the Palliative Care Working Group, and more. Island Health and other local health care stakeholders also support the centre.

Two of the clinic’s GPs, Drs Francis Bosman and Tracey Thorne, were part of the community effort to build the clinic. Dr Bosman feels that strongest part of the clinic’s foundation lies not within in the clinic building itself, but in the strength of its multidisciplinary team. “The best thing about practising on Gabriola Island is we’ve created a great team,” he says. “We have a social worker, mental health nurse, visiting psychiatrist, home nursing, occupational therapist, long-term care case manager, and community paramedic, along with a team of doctors who work together extremely well. We all ‘case conference’ around patients with problems and solve the problems as a team.”

Relying on the individual expertise of their team members enables Drs Bosman and Thorne to focus on patient care. Dr Thorne says, “Instead of me trying to be an inexperienced and ineffectual mental health nurse, I actually have a very experienced and wonderful mental health nurse I can go to. She can give me her skills, her feedback, and we can really work on improving someone’s overall situation.” Providing care as a team enables clinic staff to focus on a patient’s overall wellness—instead of putting bandaids on crisis situations, doctors and care providers can anticipate and prevent crises before they happen.

Dr Thorne also appreciates the different perspectives provided by her colleagues at the clinic. “As a physician it’s so fulfilling to work in a setting where you have colleagues who have a different scope of practice and a different skillset, because it can often be very myopic when you’re a physician. When we have our team meetings and we’re talking about the person, working with the team really helps me look at that whole person.”

Maureen Zdancewicz, the clinic’s former Community Health Nurse, appreciates the open lines of communication between team members. “I’d say it’s one of the best places I’ve ever worked because of the interdisciplinary team approach,” she says. “The doctors here make it easy because their door is always open. Collaboration is something that happens daily, and I think because of this our patients get better care.”

This team approach has been particularly helpful in caring for vulnerable and marginalized patients, and patients with mental health and addictions issues. The clinic’s social worker plays an important role in referring vulnerable patients to the clinic, explains Dr Thorne. “One of our social workers also works at PHC (the community social service agency on the island) and she will meet people there who’ve been reluctant to access medical care for whatever reason—historical biases or concerns they’ve had in the past. She builds relationships with them, and through the trust they have in her she can transmit that trust to me or one of the other physicians who she feels is the best fit.” Through this system the clinic has gained patients who need support from the medical system but have been unwilling to access it through the traditional doors. “We can access [these patients] now because they’re willing to trust our team members and those team members can bring them to us. And that’s a really wonderful thing.”

Vulnerable patients who have mental health and addiction issues can access services at the clinic from both a social worker and a mental health nurse, who collaborate on patient care, community outreach, and crisis intervention. Their work has made a significant impact on the number of people who turn up at the clinic in the midst of a mental health crisis. Realizing that they were seeing far fewer people in crisis, mental health and addictions nurse Cathy Fox reached out to the local RCMP to see if they had seen a similar change. “The amount that they’ve had to intervene or transport has dropped by 83% since the social worker and I started,” said Ms Fox. “So those are pretty fantastic stats!”

Dr Thorne agrees. “This reduction means mental health patients are getting treated and cared for by the appropriate people instead of having to come into conflict with the RCMP. Mental health shouldn’t be dealt with as a criminal issue, and that is not how the RCMP want to deal with it. This frees up their time to deal with other folks more appropriately, and it also means we’re taking care of people before they get to that crisis point of an RCMP call.”

While the clinic focuses on providing primary care services in its team environment, visiting specialists who provide secondary care services are becoming an increasingly important component of the team. Clinic physician Dr Maciej Mierzewski explains, “We have this great primary care home, but we’re trying to extend it to secondary care too. Gabriolans on the island have access to some of the secondary care specialists who’ve decided to visit us. This makes it much easier for all of us – much easier for Gabriolans because they don’t have to travel to Nanaimo.” Having specialists on site when possible is great for communication, says Dr Mierzewski. “This makes it easy for us, because we have face-to-face contact with a specialist and we can talk about the issues, we can talk about the patients, we can troubleshoot problems, it makes it basically way more efficient.”

The team environment at the clinic hasn’t just improved support and care for local patients—having a team to rely on has also reduced feelings of burnout for the clinic’s GPs, says Dr Thorne. “Burnout can be a really big issue in rural communities because physicians are on-call, they’re doing emergency, they’re doing mental health, they’re doing primary care, and they’re often doing that without anyone else to support them.” The clinic team makes her feel like she’s doing her job better, and like she’s part of a system of care. “We’re so grateful and so lucky to have all these other people working with us,” she says. “[The team] helps us realize that we’re part of an overall system – we don’t have to be the whole system. When you don’t feel like all that pressure is resting solely on you, it gives you a lot more freedom to work differently and to think more broadly.”

Team members feel the same way. Maureen Zdancewicz says “We’re such a special clinic because I’m working as part of a team—I have experts all around me for every need. We’re really providing holistic care for people in this community, and it’s working – we’re getting feedback that this is how health care should be.”

To learn more about the Gabriola team-based care model, watch the video “Gabriola Community Health Centre: Much more than a clinic” or visit