Since February of 2023, our pioneering PCN programs – social work, clinical counselling and clinical pharmacy – have seen over 1,800 referrals from over 130 Surrey-North Delta Family Physicians.  

As referrals continue to climb, it’s clear that these programs are meeting a need. But beyond serving clients, Surrey-North Delta PCN programs are designed with a unique purpose: to extend Family Physicians’ and Nurse Practitioners’ capacity to care for their patients by addressing factors that are impacting patient health within a team-based care model.  

This means that PCN allied health providers in Surrey-North Delta operate in close partnership with FPs and NPs to create meaningful care plans for patients, communicating with them throughout the process, conducting care conferences when necessary and providing a summary of the support provided once the process is complete.  

This focus on breaking down silos and working as a team with referring FPs and NPs has led to better outcomes for patients and a better experience for referrers.  

We spoke with a cohort of “super-senders” to find out what they think of these PCN programs, and why they refer as often as they do.  

 

Dr. Felix Yang  - Knowing Each Other's Name Helps with Collaboration

Before PCN, access to social workers and counsellors was not easy or reliable. Because of these access issues, I was counselling my patients and providing other supports that weren’t necessarily within my scope, which was taking a lot of my time. 

The Surrey-North Delta PCN programs provide a remote team to support us with things like counselling, PWD forms and other issues, which allows me to focus on what I can do best for my patients as their physician. I’ve found this extra support for patients and FPs makes a difference for patient care and helps to alleviate my patients’ stress.  

Comparing the SND PCN programs to other options, I’ve found that not only is the wait time much shorter, but it’s also a more personal experience. When I make a referral, the individual AHP will often connect back with me – there's a name. Knowing each other’s name helps with collaboration. 

In terms of referrals, my staff have all been trained on Pathways Referral Tracker for ease of submitting the referral.  

 

"My feeling is that anyone who is aware of the service must be using it, because it is so helpful. There isn’t much else out there that compares." - Dr. Jawanda

 

Dr. Amritpal Jawanda - PCN Social Work Has Deepened My Knowledge of Available Services

As a new physician in the community, I’ve found the PCN social work and PCN clinical counselling services to be quite helpful. Before, it was difficult to know where to send patients who needed these services. Referrals felt a bit like a shot in the dark and I wasn’t kept in the loop. 

With PCN, I receive feedback from the AHP about the interventions that were offered, which not only helps me to follow up with my patients, but has deepened my knowledge of available services so that I can better support other patients in similar situations. 

We have two physicians who have just joined our clinic, and they are now using PCN as well. My feeling is that anyone who is aware of the service must be using it, because it is so helpful. There isn’t much else out there that compares. 

 

Dr. Larysa Makhovska - PCN Services are Quick and Easy to Access

I’m very happy to have PCN allied health providers to support my complex patients. It has helped me and it’s helped my patients. Most of my patients don’t have extended health benefits, so supporting them with issues like mental health challenges was quite difficult. Waitlists for services were long, and many referrals were rejected due to the level of care needed.  

I’ve found PCN services to be quick and easy to access. I can connect with the individual AHP to share and receive feedback about my patient and I always receive a comprehensive review, especially from the clinical pharmacists.  

I would definitely recommend PCN services to my colleagues who want to address their patients holistically. It’s been a big help for us, and has actually helped reduce my psychiatry referrals. 

 

Dr. Amina Jabar - It Has Freed a Lot of Time for Myself and My MOAs

PCN has made my life so much easier. Especially when you are new to practice, you might not be aware of the services that are available. Before PCN, I spent a lot of extra time looking for low-cost counselling options for my patients, trying to find social supports for them myself and reaching out to community pharmacists for information to support my patients with complex polypharmacy needs.  

Now, I can easily refer patients to PCN using Referral Tracker; they receive excellent support and I receive detailed communication about which AHP is seeing my patient and what their care plan is. The information I receive from the PCN team actually broadens my knowledge base, which I appreciate. It has freed up a lot of my time, and not having to track down referrals has freed up my MOAs’ time as well. 

I use PCN services almost daily as part of my patient plans. They provide proper, competent care, and my patients come back happier and better. 

 

"I can connect with the individual AHP to share and receive feedback about my patient and I always receive a comprehensive review, especially from the clinical pharmacists." - Dr. Makhovska 

 

Dr. Suman Sharma  - It's a Team-Based Care Approach

I’ve found that younger people are more open to the idea of counselling. But for many of my patients, if they have to find a counsellor on their own, they won’t go. Before the SND PCN services were available, if I referred a patient to a mental health service, I didn’t know if the patient was seen or not. With PCN, I know if the patient has booked and I receive a patient summary once they have received the service. It is a team-based care approach. 

My patients get a lot of benefit from PCN - I'm especially happy with the PCN counselling services.