A new member has been added to the primary care team in Kimberley — a social worker dedicated to Kimberley patients.
Doctors and patients in the East Kootenay are welcoming the expansion of an innovative program that brings doctors and social workers together to provide care for patients with complex needs.
In the past, physicians in the region had limited access to social workers. Through the primary care social worker program, family doctors can now request a consultation for patients who may require extra support. The social worker meets with a patient and doctor to discuss the patient’s needs, coordinate referrals to other community and health services, and provide the patient with additional support where required.
The program began in 2014 as a pilot project of the EK Division. It was a key component of the region’s A GP for Me strategy, aimed at improving access to primary care across the East Kootenay. Following the success of the pilot, the EK Division partnered with the Ktunaxa Nation to secure ongoing funding for an expanded program. Starting with just three social workers serving Cranbrook, Creston and the Elk Valley, the program has expanded to six communities, including one social worker dedicated to patients in Kimberley/A’qam. Social workers are permanently employed through the Ktunaxa Nation, and work in doctors’ offices and Band health centres.
“Kimberley was a bit more complicated during the pilot phase because of lot of Kimberley patients have Cranbrook doctors, said Erin Gawne, who has been working with the East Kootenay Division of Family Practice to raise awareness of the program. “Some Kimberley patients have had access to the social worker. But since our partnership with the Ktunaxa, Kimberley doctors have gradually been coming on board. Now there is a social worker dedicated to Kimberley doctors.”
“We know that social determinants like poverty, disability, housing, and employment have a direct and profound impact on patients’ health,” says Dr. Shaun van Zyl, a family doctor in Kimberley and a member of the East Kootenay Division of Family Practice (EK Division). “By helping to coordinate patients’ social, financial or behavioural needs, having a social worker on my team allows me to more effectively focus on my patients’ medical care. It’s definitely making a difference in the quality of care we are able to provide in our community.”
“When a person is struggling with social issues, their health is greatly affected,” said Debbie Whitehead, Director, Social Investment at Ktunaxa Nation Council. “Through the social worker program, we are able to provide our citizens with the best primary health care, while supporting doctors and nurse practitioners with patients whose social needs are a barrier to their health.”
The East Kootenay region is one of the first places in B.C. to integrate social workers into primary care teams. It is an example of the work that is underway across the province to transform the primary care system through the introduction of integrated, team-based care.
It will take time to realize the full impact of the primary care social worker program, but initial results show it has had meaningful benefits for patients and health care in the region. Results from the pilot program show that over an 18-month period:
• Social workers conducted 3,338 visits with 626 patients, resulting in 783 referrals to other community services. The top three services provided by the social workers included: advocacy (financial, disability, housing, food), coordination of health services, and counseling.
• Approximately 6.7 emergency room visits per month were prevented.
• Physicians referring more than five patients to social workers were able to free up three additional appointments per week for other patients.
“Perhaps the greatest testament to the program is that when funding for the pilot program came to an end, there was an outcry from physicians who felt it had become an essential part of the care they provide to patients,” said Tara Ross, the social worker dedicated to serving the serving the Kimberley/ A’qam area.
“The issues I assist patients with are primarily around finances, disability, housing, and employment,” said Ross. “These are issues that greatly affect patient health, but are outside the scope of the care that family doctors can reasonably provide.”
An example of how social issues can affect one’s physical well-being is in the case of a person struggling with financial stability, who cannot afford the medication prescribed by their doctor.
“If they need to apply for Income Assistance, it can only be done online. This is a huge barrier to many people who don’t have access to a computer, or who may not be computer literate,” said Ross. “In these situations, I help the patient to apply for Income Assistance, so that they can afford the medication they need.”
Anyone living in the Kimberley/A’qam area who feels they would benefit from the primary care social worker program are encouraged to discuss it with their family doctor. Physicians requiring more information should contact the East Kootenay Division of Family Practice at (250) 426-4890.